17A-261 (2) 3propofsaY
SEXTON ROOFING CO.
Tamko Roofing Systems U.S. INTEC BRAI
Gold Club #6822
(413) 534-1234 P.O. Box 6327
800-524-ROOF HIC #118239 Holyoke, MA 01041
PHONE -6-1546 DATE
SUBMITTEDTO & 5
STREET 6 0 KI I "S JOB NAM?("`10Vt_'
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CITY
STATE F-1 0,'i F_ JOB LOCATION
ZIP CODE
SEXTON ROOFING HEREBY SUBMITS SPECIFICATIONS AND ESTIMATES FOR:
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.;qe proyj�hereby to furniph material and-14bor-c,orrieletp-irl accordance with the above specifications, for the sum of:
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, j ---- dollars $
PAYMENT TO BE MADE AS FOLLOWS
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All Material is guaranteed to be as specified.All work to be completed in a workmanlike manner Authorized
according to standard practices.Any alteration or deviation from above specifications involving
extra costs will be executed only upon written orders,and will become an extra charge over and Signature
above the estimate.All agreements contingent upon strikes,accidents or delays beyond our con- Note,This proposal may be
trol.Not responsible for water damage during construction.Owner topay responsible legal fees for
non-payment,and applicable interest. withdrawn by us if not accepted within days.
001 The above prices,specifications and conditions
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are satisfactory and are hereby accepted. You are authorized to do the
re satisfactory Ctory
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work as specified.Payment will be made as outlined above.
work S specified.
a of p Signature
Date of Acceptance ptance.
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFMAVIT
CO r
(li cellserJpermi ttee)
with a principal place of busiuessJresidence at:
v � ►Yor _ ct ox Si, ko d"qe MA , (phone#)
( city/Aafr/aP)
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:
A.— 'r.,,6, T,4-,,G,
(IILSUI'3nce Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
f.
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (InsZtraace Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml short if mcc to includc iafoctniIIon pertaining to all ooatmd f3)
i
( ) 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 aw-. c that whirr hoaxowncra who cmplay paTo=w do ma iztn,.jc was ruction or repair work on a dwelling of
not more than thtco units in which the homoowncr residc3 or oa the grounds appurtenant th tk t arc not grncra coaridcrcd to be
cmployca under the vm6, 's cation Act(GL152,ss 1(5)),application by a homeoavcr for a liccn:x cc permit may cvidcnee the
Itg21 rtatup of an employer under the Wockcet Compamaiion Act.
I undasund dul a oopy of this rtatemcnt may be forwarded to tho Departm a of Dial Accidrn&Ofoe of 1""'n-for thn
coverage va ificatioa and that failure to sxun oovecngn under soctioo 25A of MGL 152 can lad to tho"imposition of aimfiw penalties
oomisting of a fine'of up to 51,500.00 and/or imprisoarncni of up to one year and civil pcaattia in the form of a stop Work Or+da and a
firm of s 100.00 a day against tot
For degut�u1O only
Permit Number
(o –A2-l I WP4 — --Lot#
Signaature of Li a n ee/Pernu e
4 • , F
G
l
X
ECTO�1 ��NS7RUCTlON,SERVICE§,v
4 :, 3 s
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
IN
e m m r emen n Not Applicable z
Co
Company Name }� Registration Number
Address{{ Expiration Date
t4d I G h e Telephone
SECTION 10, WORKERS' 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 affida
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
r,
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie
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(
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
M"P." 10 O�F�PROPOSED WORK 'c eck a�a A'l cable
IL
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ j Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:_ 'SA V i D O �-Ii O a,A 1 vr--\J h a a
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
I N;e s d or d"d t' n to ez§isti "�,o srn orff le. a BVIt,k:
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?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes 1`
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
SEC '6*46/NER AUTHORIZATION TO BE�COMPI.ETED WREN
QIf NERS i IVT., CQNTI�ACTOR'ApP1:lE$TF9 IOUII bING PEIt1 1T,
1. as Owner of the subject propert
hereby authorize to act
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, 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
� o —
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/Find' g 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:
f ,� _ ./�
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MD 0n jz of Northampton
l'1 l5 ing Department
2 Main Street
JUN t z Room 100
or h mpton, MA 01060 s f
3-5 7-1240 Fax 413-587.1272loS to
DEPT OF BUILDING 0NS
NORTWIMPTON,MA 01060 � `
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section tobecompleted by office
1.1 Property Address: w
-Unrt
r
ZoneOyerlay�Dstr�ct
".Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: P
4, k Al
Name(Prin ) Current Mailing Address:
Telephone '
Signature
2.2 Authorized Agent:
< Y C%. rioo��•�°�. Cd � �0 yaw�'�6
Name(Print) Current Mailing Address:
ev
Signature Telephone
SEC7104 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
00 com feted by ermit applican t
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
Buildi,ng;Permit'Number: Date Issued:
Signature:
Building-,Commissioner/inspector of Buildings Date
1
Al BP-2001-1032
GIS#; COMMONWEALTH OF MASSACHUSETTS
tAI;, CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofma BUILDING PERMIT
Permit# BP-2001-1032
Project# JS-2001-1835
Est. Cost: $5860.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: SEXTON ROOFING CO 118239
Lot Size(sa.ft.): 10759.32 Owner: DELISLE WAYNE L&DIANNE M
Zoning:URB Applicant. SEXTON ROOFING CO
AT. 83 OAK ST
Applicant Address: Phone: Insurance:
573 NORTHAMPTON ST (413) 534-1234
HOLYOKEMA01040 ISSUED ON:6112101 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 6/12/010:00:00 11696 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo