17D-055 (9) ;C'.918-Sf;A�l S•
Carbonless .dJom NC 3818-50 3 PA.0
PROPOSAL
w%'7w R�(]EF3 P1 28 q MARTIN�I `` CTtSTOM MASONRY �
' 1� JS 71,� .� � 3GS24 t'l,t'7R 1.IiV 'l.liolvt•1 I�StS��'.�'.OL'I L'C). `O•
13 ) 502-3595- 103 SHERIDAN STREET ff
4� 3 y92-35t78F CHICOPEE, MA 01020-2725 Q� t
LT*CENSED REGISTERED INSURw
1t /24/OS'
PROPOSAL SUBMITTED TED TO: INORK TO BE PERFORMED AT
IN tit t )v'7, t}
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I P.O, Box 448 1� 6 �t±���r ���• �lo �to�� � 0146C9
�d--------- DATE OF PLANOr
f
Leeds MA 01053
t=t:`t�te.iv��. ARGHfTECT
( 913 )5£4-2546
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:! material is art nt d t0 b8 as Spaciti6d, anc;! the r��V� t to be N4 YVM
vatic=r: submitted for abpve work end cb,mpleted in;a std atr�t�l vtR�rltm ke�c l�r'��i
w>wy n Hundred aril ?.ift: I1C� QO 100- ��r:'`�}e..ai.. 0 kr8
�u,#h payments kc be fYtad+Tr+as!foilows. -
1 /3 or $2, 066.' as s mater
the balance due upon sul� ntia completliPpIA
Respectfutfy submi
;ry veration or d-xrration from above specifications ir-,M rng extra costs
will be execrates only upon written order, and will became an extra oharge Per
fi cu— and above the eatlmate. AN agreernertts cordingent upon strikes, ac-
cxierrts or dead s bevend our control
l4aRte This prupo S&I may be• :thdraw
STAFF: COMPLETION: by us R not accepted within 1`tdays,
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The ort�, C1flOP"rkr aria of its are sa ry srrd ; i t is r
s Py e ie ecffed. nt i s tk
Oatuf`01
,ate Signature
HOME OWNER EXEMPTIOIN ACKNOWLEDGEMENT
The State of Massachusetts allows the homeo er the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends 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 is two-year period shall not be considered a
home owner."
The building department for the City of North4mpton wants person(s)who seek to use
the home owner exemption, to act as their owrl construction supervisor,to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires tl�at the building department be called to
inspect work at various stages, which include!oundation/footings (before backfill),
sonotube holes (before your) 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 failureito 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 '$ecure 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 reque ting exemption)
I will call to schedule all required building insp ctions necessary for the building permit
issued to me.
i
Date
i
Address of work
location J
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
�. 600 Washington Street
_ Boston, MA 02111
' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ��� / �,+ �//,� Please Print Legibly
Name (Business/Organization/Individual):0��'�/ /w (`?(��� f j// IV" `�'1 _
Address: b3
City/State/Zip: 91 Q,iil/ c—o 141 1-0 Phone#: l �� � Z ' 3 7i
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. E] I am a general contractor and I
6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers'comp.insurance comp. insurance.$
required.] 5• ❑ We are a corporation and its 10.❑Electrical,repairs or additions
officers have exercised their 11. Plumbing repairs or additions
3.❑ I am a homeowner doing all work � p
myself. o workers' comp. right of exemption per MGL
y [N p 12.E]Roof repairs
insurance required.] t c. 152, §1(4),and we have no ,—,/
q ] employees. [No workers' 13.L 7 Uther M IBS 0 6n
comp.insurance required.] I C�t s
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address: 11b 5511 C-_ r1� ,+i.K.� ,i��X I)JI)bD City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investisations of the DIA for insurance coverage verification.
I do her, e�rtify un the pains and penalt' of perjury that the information provided above is true and correct.
Sianatu Date:
Phone:`• CwC(I-3) S�
Oyficialuseonly. Do not write in this area, to be completed by city or town offcciaL
Citv or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
b. Other
Contact Person: Phone#:
i
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Not Applicable
Name of License Holder: n W J
License b
161 S A-C-ku o Kau 57�1.c t- L if CA) t,�G l'� �� �-O ?Nu 5 v
A Expiration Date
Sig a Telephone
9.Re isterecl Hame'tm rauerrienfiCoirtraGtar Not Applicable ❑
Co'mPlarij Name Registration Numb r d V/o 4 t 6-? '� 0"- OAv s"rncsf c1b twc-tF.; t L)
Address Expira i n Date
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 affidavit will result
in the denial of the issuance of the building it.
Signed Affidavit Attached Yes....... No...... ❑
I1. Home Owj er,Egemption
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 hide 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)Rand 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 4 form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the buildiog permit.
As acting Construction Supervisor your presence on the jo 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$tate of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION Of PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows I Alteration(s) Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (M Siding[O] Other([�]
Brief Descri ion of Proposed 1
Work:__
X TG N 9 ✓L112'�i�u v� L'ff/kk IL6y �z 1 �D Copy
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and,or addition Ad:existing housing,.comglete the following:
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. 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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , 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
I, r (/1•t(�Z 'S V0 ki- ►K) 6 9Z44*1f//V ��5 �`�'I �yas 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.
P' Name
%—2-1 11 [a
Signature wner/Agent Date
i
Section 4. ZONING Alt Information Must Be Complete . 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
Side L:. __......_ R. _._..._..,_ L: _.,r.., 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 er been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:'.
IF YES: Was the permit recorded at the Reg' ry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page an or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW (D YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , 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 ci signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, cav on, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Repartment use onty
b
City of Northampton status ofPermlt
'Building Department Cr} Gutltnwrey PercnrEh Y
212 Main Street Sewer�SeptrcAaatab�tie
Room 100 �bieiizF N4i Auailstuitty
Northampton, MA 01060 Tuu�Sets af;StructuratPlar;
413-687,1240 Fax 413-587-1272 Platlslte'Prans '
P
, hs
r
Other Specify .*
AP jLICATION 0,-OagS1'RUC LTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION -SITE INFORMATION
1.1 PropertV Address: This section to be completed by office
4v t Map Lot Unit
ll
A0 Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
lit, S'17?ATd &k-
Name(Print) Current W51ing Address:
Telephone
Signature
2.2 Authorized A ent:
l o d
m (Pr CuirentNailing-A dld-r�es�s(:��G- �44A A x�0 10
21-0 f
Telephone
SECTION 3-ESTIMA ED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by.permit applicant
1. Build (a)Building Permit Fee
2. Electrical V (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
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
i
BP-2009-0603
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category BUILDING PERMIT
Permit# BP-2009-0603
Project# JS-2009-000866
Est. Cost:$5750.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARTIN CUSTOM MASONRY 132824
Lot Size(scl.ft.): 8145.72 Owner: MARK CHRISTINE
Zoning:URB(100)/ Applicant: MARTIN CUSTOM MASONRY
AT. 116 STRAW AVE
Applicant Address: Phone: Insurance:
103 SHERIDAN ST (413) 592-3595
CHICOPEEMA01020 ISSUED ON.1211212008 0:00:00
TO PERFORM THE FOLLOWING WORK.-EXTEND HOUSE CHIMNEY FOR 3RD FLR
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 12/12/2008 0:00:00 $25.00110
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
i
.�
a
_ _
�. ;
116 STRAW AVE BP-2009-0603
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.-Block: 17D-055 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0603
Project# — JS-2009- 00806.
Est.Cost: $5750.00
Fee: $25.00 PERMISSION.IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARTIN CUSTOM MASONRY 132824
Lot Size(sg.ft.): 8145.72 Owner: MARK CHRISTINE
Zorint;:.JR3(100T Applicant: MARTIN CUSTOM MASONRY
Ali: I'I0 J i i%/-%Vy"N`st_
Applicant Address: Phone: Insurance:
103 SHERIDAN ST (413) 592-3595
CHICOPEEMA01020 ISSUED ON:1211212008 0:00:00
TO PERFORM THE FOLLOWING WORK.-EXTEND HOUSE CHIMNEY FOR 3RD FLR
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:
Drh,eway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: &4& a �f 4 ' d 9 ✓ ie'�o
THIS PERMIT MAY BE REVOKED BY THE CI,. OF NORTHAMPTON UPON VIOLATJQN OF
ANY OF ITS RULES AND REGUL IONS.
Certificate Of Occu anc s► nature•
FeeType: ate Pa>;d Amount:
Building 12/12/2008 0:00:00 $25.00110
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo