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17A-281 (5) Page No. of Pages j i SIDING SPECIALISTS INC. 781 Bridge Road !,,-)RTFf,^TT0N, W SS CH'USETTS 01060 (413) 586-4167 t PROPOSAL SUBMITTED TO t PHONE DATE STREE T � � } --,�. JOB NAME CITY,STATE and ZIP CODE, , Jf± JOB LOCATION i ARCHITECT DATE OF PLANS JOB PHONE i I We hereby subm .and estimates for: 42 ` 7;? ---- All / > l j, i 3 I 'i i EI I i L I r I i 1 HIP PrOPOSP hereby to furnish material and labor—complete in accordance with above specifications, for the sum of: dollars($ } f eeq ) Payment o be made as follow ' All material is guaranteed to be as specified. AI work to be completed in a workmanlike Authorized manner according to standard practices.Any alteration or deviation from above specifications Signature i involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents £` or delays beyond our control. Owner to carry fire,tornado and other necessary insurance. Note:This proposal may be withdrawn by us if not accepted within � days. ; Our workers are fully covered by Workman's Compensation Insurance. {i Arre taurr of Proposal — The above prices, specifications �„ l• j and conditions are satisfacry and are hereby accepted. You are authorized Signature to do the work as speci d. Payment will be made as outlined above. n r Date of Acceptance: h Signature TO Rmdm CNN I 1-894.225-M ��tiATlp�, O O s� °e Cris of 'W art4antvtun �Tx3saChn8t115 DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT 1errniu) with a principal place of business/residence / (phone#) ( city/ Zip) do hereby certify, under the pains and penalties of perjury, that: ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance Company) (Polio Number) (Expiration Daze) ( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired the contractors listed below who have the following workers compensation policies: (Name of Contractor)/// (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional shed ifnecenaryto include infocmafion peauaiaing to all 000trnc ors) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that while homeownen who employ pasom to do maintenance,cou&uctioa or repair work on a dwelling of not more than throe units in which the homeowner resides or oa the grounds appurtenant thereto arc not swe ally ooasidcrcd to be employers under the worker's oompasss4on Act(GL 152,sa 1(5)),application by a homeowner for a license or permit may evidence the legal status of an employer under the Worlcees Compensation Act I understand that a copy of this statement may be forwarded to the Dtpwuoccd of Tidustrial Aaadmts'Office of Inwr*noe for the covaxge verification and that failure to secure coverw sunder section 25A of MOIL 152 can lead to the imposition of criminal penalties consisting of a fine of up to$1,500.00 and(or k;rbonmart of up to one ysar and evil pemlties in the font of n Stop Work Or dez and a fm of 5100.00 a day against me a x For departmental arse Only Permit Number ; gr�0d Lot# J M� Signature of Licensee/Permittee / a SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone ME ff ..N, . .. Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WIJRKERS' COMPENSATION INSURANCE AFFIDAVIT'(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature hie New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: VL441,I^L-41 ,,I+' Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative ❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ Sheet❑ a. Use of building: One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? In. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION -©WNER AUTHORIZATIO,IV -TO BI*COMPLETED WHEN 8111°ams AGENT OR C NTRACTOR APPLIES,FOR BUILDING PERMIT l as Owner of the subject property hereby authorize b , to act on my behalf, in all matters relative to work autho rig`d by this building permit application. Signature of Owner Date 1 , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Signature of Owner/Agent Date Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ?YES_ No IF YES, describe size, type and location: r � u1jul' 01 W, SNO(1;13dSNl�Nidlln9 j0 1d30 Cit of Northampton i ding Department r 100Z 8 - ON 12 Main Street ff Room 100 nn mpton, MA 01060 7-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: { ' At �st�3A ,za y� r a � y SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ( - &' AK 4'6 Name(Print) 01 _ Current Mailing Address: �✓a c �� d Telephone Signature 2.2 Authorized A en OL am e Print) Current Mailing Address: D04 4!5�z Signature Telephone SECTION 3-ESTIm*ftD,e'oNSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of! Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 + 2+ 3 +4+ 5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: _.._ ?y Building,Commissioner/Inspector d'94ildlhgs' Dafe J BP-2001-0898 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: BUILDING PERMIT Permit# BP-2001-0898 Project# JS-2001-1625 Est.Cost: $35000.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: B & R Siding 026846 Lot Size(sq.ft.): 12283.92 Owner: KOLODZINSKI CHARLES&EDITH Zoning:URB Applicant. KOLODZINSKI CHARLES & EDITH AT. 129 OAK ST Applicant Address: Phone: Insurance: 129 OAK ST Workers Compensation FLORENCEMA01062 ISSUED ON:519101 0:00:00 TO PERFORM THE FOLLOWING WORK:S I D I N G POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Final: Final: Rough Frame: Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Si nature: Fee Type: Receipt No: Date Paid: Check No: "'Amount: Building 5/9/010:00:00 17659 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo