17C-167 (9) WESTERN MASS MASONS
NOW
LICENSED ,. INSURER
147 Middle Road
Southampton,MA 01073
(413) 540-1959
WW W_WESTERNMASSMASONS.COM
QUOTE PATE-11.41-05
cu]"-rp 44 Q9 [A
TO: LEE GOSS
n n_4? urr u c�
TE, , s 3..
FLORENCE MA.
cQ c_1n7
BECAUSE OF EXTENSIVE DAMAGE TO THE CHIMNEY FROM WATER,THIS
CHIMNEY SHOULD BE TAKEN DOWN TO THE ROOFLINE AND REBUILT
WITH NEW BR CKS,FLUE AND LEAD rLASHINU
TOTAL$3250.00
Quote valid for 34 days.
Quote prepared by: David Osi—cki
tlomeovmer_will_pay-mason-contractor one had of-total aniount of bttl-when job
construction has begun, remaining balance of bill w1ill be Maid in full when iob is
compieted.
By signing this quote you agree and understand all the above terms and conditions that
apply W dusjvb. Any changes liial arc W oe IIlaue, 'Dust be utscusbcu prior to
construction and agreed upon by contractor and may also affect the final price. A finance
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�, DEPARTMENT OF BUILDD�G INSPECTIONS /=
INSPECTOR
'212 Main Street • Municipal Building
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sups.:-„isor. The state defines "Homeowner” as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a dine or-two fWm7y- -
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
home owner."
The builaing depa tment for flee City of Northampton wants-any person(s)-who--seek-to
use the home owner exemption, to act as their own construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and regulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfill),
sonotube holes (before pour) a rough building inspection(before work is
concealed) insulation inspection(if required) and a final building inspection.:The
building department requires these inspections before the work is concealed,failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work(electrical, plumbing& gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections.Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued-tom me
Daze
Address of work
location
tiE GiI 3 of �\Tarf1jc311ipjall
DEPARTMENT OP BUILDIZG INSPECTIONS
�I
212 Main Strcet Municipal Budding
c
I
Northampton, Mass. OIOGO
I
I
WOR10ER'S CONOENSAITO.N )J ISURA-NCE AF FD),-' A,
I
I -
I,
01 ccns--t/permi tfcc)
%vitb a principal place of businessfresidence at: -- -
_ - (phoney.)
(sa•�.t/cf i,JlstatLf�p)
do hereby certif} under tl)c.painsd penalties of perjury, hal
( ) I am an employer providing die folio 'n,,, -vorkCr'5 comocaSabo, coverage Lor im
eluplovec:s worlang on tills job:
(i
Cs'anc Conr m.) CPclic: Nu• r) (T=:pirtior. Dane)
I .
( ) I am a sole proprietor, general contractor or homeo'* rner(circle one) and have hired
the coca-acigrs listed below wbo have the follotvine worker's coE-:oen—saaon pokies:
i
I
`t amc 0' Coninaor) (InRranc„• Company t�Ouc:i NluII1C<:) bale)
(Name of COntraor) (lnsaraz-Z COMI)an,,•lPOUc- Number) (%»ir lion Date)
(Name of Connaad;) (Lasurancc Com
• 1=3'[Pol,•q• N:1sb:1) (Expiraen Datc)
(Nzme of Contractor) gmall—aa(-- Comcary/PoUcy Numbcr) (Expi-zdoa Date)-
(aIIS.1:d:rs::ocaJ�eC.iln�-.•ti. mcuC=inf«miZoo to JI -
i
j O I
am'a sole proprietor and have no one working for me.
I ( ) I am..a home owner performing all the work myself.
I NOTE:ptcsc ix corsrt Ti x:..•t Jj hCC c='vcn tat'p Cloy P.ora t.o d�c• cst�aa c rc as••-crib oa d..Tr -Z of
trot mecz tb.:-[sr_--is«'seh the homoatwc I=da«oa the IIoua6 zppurtea tbern�z nub�rrty occ d-ni w be
cxpioy'uaG=the-vr =- Acs(GLt15la 1(5)).�pti i6ao by a homtAa�fc c li�^v or pcvit r>_y the
Legs!e.-�.•of:.o aployx under dto Works "Comp•ama.fioa A,,
a copy orthu otc=n=m...y be fob xded to the DcPan r_t orL'6'nc!Acvdca�Office or 4zw+ for th.
—v--p^r-eirCtioa and U,--L Liltze to uiyrc eovR�o =cdoa 25A of h{QL 132 ou tcd to the u..^�oa of cimiCA per_al =
of a rise of up to S 1300.00 andlor orup to ooc Y-= e.-,d ei.ir pcu.tie,,a be rorat of.Stop Wort;Ordc and a
fig of S 100.00 a d_y tit+R me
F«dq.eaza:--J use mJy —•-'
Pcrmit Numb=
Lot
Sl�yIleZtur>_of Li�/perrmiu c ¢'
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Ul 1/ l,/s.r z G
License Number
Address Expiration Date
Si t re Telephone
a:�� +-..� rem. sa r. a'.. f- w� a -. .
9 k2ei istera0 ome,,l%nbrav, ff 6antrac a = �. � .` v im, Not Applicable ❑
We,31�.ti .,"fl errs l3 LIP-3 y
Company Name Registration Num— a 6 r`-- ----
r-,aa-5-o
Address Expiration Date
Telephone_ ,f4i
SECTION 10-WORKERS'COMPENSATION INSUI;tANCE-AFFtD/VIT'M G.L c. F52,;§25C(f))
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...... ❑
EZ 512
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
t
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑: Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [17-1] Decks [Q Siding[[3] Other[a]
Brief Description of Proposed f
Work: Ci`I M•vbl ' `C�a .'
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
.-a�s .y �;:*7.:mss �: ._ � ��, a" ,_ ._"�-s:w.r cs:�i.-<"`r=°r'?z":'";°��.)�'"`•::` "" :"'";,�°-„v` '�"'p""�"r;'
6a.�€�[��tnf�haose�°a�x �; �tQ�a�excsttnc>�Cia�stnc�,ca�p�et�t�i�aEfaur�IC�q:
1 Ica of hi iilrlinn (lna FAnllly 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. Masscheck 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 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 7a-OWNER AUTHORIZATION:-TO BE COMPLETED WHEN"
OWNERS'AGENT.ORCONTRACT6' APPLIES FOR_BUILDINC PERMIT-
1 as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
�,,¢�j 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 perj.Yry. '
Print Na
Signat a of Owner/Agent Date
° .
'--
Section 4. ZONING All Informati6ti Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
(volume-&Location)
A. Has a Special Perm it/Varanno/Findi ever been issued for/on the site?
Ni 0 DON'T KNOW 0 YES 0 �
IF YES, date issued::
IF YES: Was the permit recorded ut the Registry nfDeeds?
�� VV
NO �� DON7KNO YES
IF YES: enter Bonk Page; and/or Document#!
'
�� ��
B. Does the site contain a brook, body of water orwetlands? NO v���� DON7KNOVV v�� YES v��
IF YES, has permit been or need to be obtained from the Conservation Commission?
' Needstubmobtaimed �—
\ Obtained �~\ Date
v�� v�� '
C. Do any signs exist on the pruperty �� ��� YES �~� NO v��
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YE8 x~� NO 0
IF YES, describe size, typo and location:
E Will the construction activity disturb grading ur filling)over 1acre or is it part ofo common plan
thowi||dimmrbovo,1uom? YES r NO K }
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton St e t
Building Department
212 Main Street
Room 100 y er aifiaC�rpF T ms,µ
AN
Northampton; MA 01060 I�tans�
phone 413-587-1240 Fax 413-587-1272 tatlSttn
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFOR_MATION
1.1 Property Address: This sectiorr to he completed bx afffce
�!v/l nc� hZorte Overlau Distncf
��EIm,St Drstnct R ; yCB Distract
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT,
2.1 Owner of Record:
A&& Gads
Name(Print) Current Mailing A ress:
Telephone
Signature
2.2 Authorized Agent:
Name Current Mailing Address:
S 110
SignaturV Telephone
SECTION 3-,-ESTIMATED'CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit flee
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) 3 'Cl- C-G Check Number
This Section!For Official Use Only
'.Date;:
Building Permit Number. Issued':
Signature: r
i
Building-Commissioner/Inspector of Buildings Date
2. BP-2006-0865
GIS#: COMMONWEALTH OF MASSACHUSETTS
167 CITY OF NORTHAMPTON
Lot:-001
Perrnit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0865
Project# JS-2006-1332
Est.Cost: $3250.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: WESTERN MASS MASONS 133234
Lot Size(sa.ft.): 31798.80 Owner: GOSS LEE W&PATRICIA A SCOTT
zoning URB Applicant: WESTERN MASS MASONS
AT. 42 HIGH ST
Applicant Address: Phone: Insurance:
147 MIDDLE RD (413) 540-1959 WC
SOUTHAMPTONMA01073 ISSUED ON:31612006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REBUILD CHIMNEY
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
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:
FeeType: Date Paid: Amount:
Building 3/6/2006 0:00:00 $25.002416
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo