25C-109 (2) 36 GRANT AVE BP-2017-0461
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C- 109 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit# BP-2017-0461
Project# JS-2017-000763
Est.Cost:$7500.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group STEPHEN CAMP 082531
Lot Size(sq.ft.): 8799.12 Owner: STRECIWILK ANNA&STANLEY&
Zoning: URB(101)/ Applicant: STEPHEN CAMP
AT: 36 GRANT AVE
Applicant Address: Phone: Insurance:
46 EAST ST (413) 527-7124 (1 WC
EASTHAMPTONMA01027 ISSUED ON:10/7/2016 0:00:00
TO PERFORM THE FOLLOWING WORK 30 VINYL REPLACEMENT WINDOWS - ENTIRE
HOUSE
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 ft 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 10/7/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
- _ Version1.7 Commercial Building Pcrmit May 15,2000 SO
Department use only
i City of Northampton Status of Permit
OCT — 5 Building Department Curb Cut/Driveway Permit
,1 212 Main Street Sewer/Septic Availability
DEPT OF• � Room 100 Water/Well Availability
"�" • " - Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
G_____Kt-
.
Map Lot Unit
� _ �� `/� Zone DistrictOverla District
rctct
614/9 /
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner offR�t Record:
- 4 V -57)-1,-eC/ G-'l l/' )o'/ 716/41.4/5 .e„/?r Fed- /92.44 t499 vs&
Name(Print) Current Mailing Address: ill k 0/3 r/
26 2 -27s's- C-14 ? -2/ 7/
Signature Telephone
2.2 Authorized Anent:
5+99/a412 'APL 'f,C 2-40.4)i- 57-/a--71--
Name(Print) Current Mailing Address:
M.i
Signature Telephone 5-2- 1 - 7/g Z/
T
SECTION 3-ESTIMATED CONSTRUCTION COSTS /
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 7 5-ct,. v0 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee ,y
4. Mechanical(HVAC) yC
5.Fire Protection 1 �J
6. Total=(1 +2+3+4+5) 7500. en Check Number&/4o
This Section For Official Use Only
Building Permit Number Date
Issued
Signature /�
/l . „sine
�/
e /i- /--/a17
Buil. • •mmissioneranspector of Buildings Date
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations 0 Existing Wall Signs 0 Demolition 0 Repairs Additions 0 Accessory Building 0
Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing 0 Change of Use❑ Other❑
Brief Description Enter a brief description here. (A /4,9/ n
Of Proposed Work: /) , !J€47/46€/.44.4 �yyPt rJ ed Aa4e
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 0 A-2 0 A-3 0 1A 0
A-4 0 A-5 0 1B ❑
B Business 0 2A ❑
E Educational 0 2B ❑
F Factory 0 F-1 0 F-2 0 2C ❑
H High Hazard 0 3A 0
I Institutional 0 1-1 0 1-2 0 1-3 0 3B 0
M Mercantile 0 4 ❑
R Residential 0 R-1 0 R-2 ❑ R-3 0 5A ❑
S Storage 0 S-1 0 5-2 0 5B 0
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
ip 1„
2"
3m 3°
Total Area(sf) Total Proposed New Construction(sf)
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 0 Private 0 Zone Outside Flood Zone❑ Municipal 0 On site disposal system❑
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No 0
SECTION 11 -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, TCL✓MrC✓ (ALN ,as Owner/Authorized
amt hereby declare that the statements and information on the foregoing application are tme and accurate,to the best of my knowledge
an belief.
Signed under the pains and penalties of perjury.
S1 / ✓C, e
Print Name
Signature of Owne Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Su�?rvisor: Not Applicable�yCI
/i✓ p
Name of License Holder: 7ha,- it D 2 srf?
/
License Number
lid 1'45 i- S-t-vael- f A, rh.t //-2) - / 7
AddressExpiration Date
127- 7/ 2 /
Signature U Telephone
SECTION 13-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 uilding permit
Signed Affidavit Attached Yes No 0
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 3 `111.14 c✓u-w/ /9-7e-
The
r6'eThe debris will be transported by: y-✓vGA—
The debris will be received by: ea 1t-7/
Building permit number: ,
Name of Permit Applicant y/� /„/ /eP
Date Signature of Permit Applicant
. •N The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
"?ze— www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): SIW
Z74.6
/y
G�" v
Address: (��6 G'45r* S &S
City/State/Zip: 4P / a AD 22 Phone #: -f2 7 " ,/ Z +�
Are you an employer?Check the appropriate box:
contractor and I Type of project(required):
4. I am ageneral
1I am a employer with ❑ ❑
employees(frill and/or part-time).' have hired the sub-contractors 6. New construction
listed on the attached sheet. 7. 0Remodeling
2.❑ 1 am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ 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 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other/,f''t,.,../ L"17 pwys
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tConuactors 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. ACe.
Insurance Company Name: AC.<'_ 4.zitc 4'i (.nti,�.✓�,< 217. C-O- / /
Policy#or Self-ins. Lic. #: > (� /c/j� 221 —�jTi C ( (' 2i Expiration Date:Jr j /( 2
Job Site Address: Yv=J L ` r-24/m� t7 (L– City/State/Zip: 422,/ p/U(e9
Attach a copy of the workers' compensation policy declaration page(showing the policy number an 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$250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certify under thepains andd penalties of perjury that the information provided above is true and correct.
Signature: r Date: 457 —1—/ to
Phone#: c. -
Official use only. Do not write in this area,to be completed by city or town official.
City 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
6.Other
Contact Person: Phone It:
Stephen Camp Construction
46 East St.
Easthampton, Ma 01027
(413)527-7124
Submitted To : Stan Streciwilk Phone-262-2785 367-2171
Address : 304 Turners falls rd. Date—9-12-2016
Montague, Ma 01351 Northampton,mjob 30 windows
(3 '" 7.'1- fiG'�
We hereby submit this estimate for—Window Replacement
The job is to replace existing windows with new vinyl replacement windows.
I will remove the storm windows and install the vinyl windows.
I will insulate, caulk and re-install the interior windows trim/stops to complete the job.
(customer will do all painting necessary)
I will supply the building permit.
Price= $250.00 each x 30 windows=$ 7500.00
50%to order—balance at completion of job
Contractor Supervisors License number 082531
Home Improvement contractor Registration number 135204
I propose to supply materials and labor-in accordance with above specifications.
This proposal may be withdrawn
By us if not accepted within 30 days
AuthorizedSignature •
Acceptance of proposal Signature j _,. -