31B-207 (4) 98 STATE ST BP-2020-0230
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.-Block: 3 1 B-207 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2020-023.0
Project# JS-2020-000382
Est.Cost: $1125833.00
Fee:$753.00 PERMISSION IS HEREBY GRANTED TO.-
Const.
O.Const.Class: Contractor: License:
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Use Group NORMAN JACQUES 060189
Lot Size(sq.ft.): 5924.16 Owner: KITTO ANDREW '
Zoning: URC(I00)/ Applicant: NORMAN JACQUES
AT. 98 STATE ST
Applicant Address: Phone: Insurance:
185 SHEARER ST (413) 531-3561 WC
PALMERMA01069II� ISSUED ON:812812019.0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD MASTER BATH, RELOCATE 2ND FLOOR
BATH AND RELOCATE LAUNDRY TO 1ST FLOOR
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 Debartment Fireplace/Chimney:
Rough: Oil: Insulation:
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Final: Smoke: Final:
THIS PERMIT MAYBE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy. Signature:
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FeeType: Date Paid: Amount:
Building 8/28/2019 0:00:00 $753.00 '
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212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2020-0230
APPLICANT/CONTACT PERSO NORMAN JACQUES
ADDRESS/PHONE 185 SHEARE ST PALMER (413)531-3561
PROPERTY LOCATION 98 STATE ST
MAP 31 B PARCEL 207 001 ZONE URC 100 /
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIREDi DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
Typeof Construction: ADD MASTER BATH RELOCATE 2ND FLOOR BATH AND RELOCATE LAUNDRY
TO I ST FLOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 060189
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HHI AS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: I Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With iSite Plan
ZONING BOARD PERMIT REQUIRED UNDER: §.
Finding (Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
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Permit from Elm treet Commission Permit DPW Storm Water Management
Demolition Delay
Ze-Zol9
Sign6&e of Building Official Date
Note:Issuance of a Zoning per it does not relieve a applicant's burden to comply with all zoning
requirements and obtain all reuired permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for mo e information.
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} Department use only -
� r City of Northampton Status of Permit
fry % Building Department Curb Cut/Dndeway Permit t
(� 212 Main Street Sewer/Septic Availability 2
.`
t XG Room 100 WaferlvVell Avadabibty
Northampton, MA 01060 Two,`Sets of.Structual Plans
phone 413-58711240 Fax 413-587-1272 Piof/slte Plans ,
Other Specify M
APPLICATION TO CONSTRUC�,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION I_ ,
This sectiono,, be,completed.by-office
1.1 Property Address:
ST7�TC �T �dd'e.-►- �7oi- !�'4 . Ma of d�0 Unit
zone
IOverlay District.
•EIm St.District' CB District
SECTION 2-•PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address;-23 3_ 3 15
Arpk4f.-> Telephone
Signature
2.2 Authorized Agent: / �� S/gC4AFX T -
�,Qc rc'� -A1T' i PJc. 1301 Lo�.ns �.�/�- A u,e.rE — fA- 0/0 J
Name(Print) Current Mailing Address:
Signature Telephone
SECTI N 3-ESTIMAT CONSTRUCTIONCOSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit 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 l
6. Total=(1 +2+3+4+5) (��f3�, Check Number
This Section for.Official Use Only
Building Permit Number:. Date
- - Issued:
Signature:
Building Commissioner/Inspector of Buildings i Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due Toi Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
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�........_..�__._._.._. _....,. ...,. ......._.......-._....,._.-._...�..._ .vim-._ i..M._..1.....,,<__....._.__.__._...�....,,_..__.;
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Lot Size
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Frontage
Setbacks Front
Side L t� _ R v _ L:?�, 1 R:!
Rear . ___` ~,
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Building Height
l._--.,....,.,,
Bldg.Square Footage " %
Open Space Footage _ . %
(Lot area minus bldg paved
parking) I
#of Parking Spaces f--•---` -�w� - --�
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Fill:
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volume&Location �._. _..._....__..._ .,.:
A. Has a Special Perm't/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW Q YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW Q YES O
IF YES: enter Book ? Pages And/or Document#';
B. Does the site contain brook, body of water or wetlands? NO Q DON'T KNOW Q YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Y`^„ R6f `
Needs to be obtainedQ Obtained Q , Date Issued: i
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q
IF YES, describe size, type and location:
E. Will the construction act'vity disturb(clearing,grading,excavation,or filling)over i1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES,then a Northam Dton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s)I Roofin
Or Doors E3 I g
Accessory Bldg. ❑ Demolition ❑ New Signs [E:3] Decks [[] ! Siding[E3] Other[O]
Brief Description of Proposed
Work: At�.P rata s4rt+r ezeio L*M- d AJV3 t=wo9-r-OLL Myo rk AA V3 1lr-Aocst,-*-A4L1, 1D1 -r` -t-, 1 fir •
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative JCC- • Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.If:New house and.or addition t0�existina hous�ng,.'completeal a followtnq:
a. Use of building: One Family Two Family Other
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b. Number of rooms in each family unit:l Number of Bathrooms
G. is there a garage attached?
d. Proposed Square footage of new co?Istruction. Dimensions i
e. Number of stories? 1
f. Method of heating? Fireplaces or Woodstoves Number of each
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g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
T—
I. Is construction within 100 ft.of wetla�ds? 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 land Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
:SECTION 7a=OWNER AUTHORIZATIQN--TO,BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES'FOR BUILDING PERMIT-
I, SC�C� wa�.l� �4yt�2 t •i-10°`� �� /�-1'P�dk 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.
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Signature of Owner Date
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I, PdYU/'c40 utak-Serol(-oens-S (D Li A 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.
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Signed under the pains and penalties of perjury.
Print Name
Sign re wner/Agent Date
SECTION;8-CONSTRUCTION SERVICES'
8.1 Licensed Construction Supervisorl: Not Applicable ❑
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Name of License Holder: h 1cwwa� • AFS S A (Q(� ��
License Number
VSs ff e s`r Auq&mac- wA- 0/0 6ci 0,0
Address Expiration Date
Si ,lure Telephone
Sr
9.Regsteired;Home-iennrovementContractor !Not Applicable ❑
G�1-C-7tP4Is s !we ��03a
Company Name Registration Numbler
SS- -514G ed-f- S'►- ,l-�l &r- g4- 0/o(0 7-/3 -,20010
Address Expiration Date
Telephon
_ f
SECTION 10-WORKERS'COMPENSATION`INSURANCE AFFIDAVIT(M.G.L..c:1521§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...... ❑
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�- City of Northampton
Massachusetts
� ,ta .5r DEPARTMENT OF BUILDING INSPECTIONS
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212 Man Street • Municipal Building
y �
\ ® Northampton, MA 01060 UfsNjY flr7i~�
AFFIDAVIT
Home Improvement Contractor Lave
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing impiovements or renovations on detached one to four family homes.Prior to
performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requirels that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building'be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity fnust be registered.
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Type of Work: Est. Cost:
Address of Work: �! 1.ST.4ne- .ST putt' /270 &4,d
Date of Permit Application:
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I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
_Other(specify):
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OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.1 SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of eijury:
I hereby apply for a building permit as the agent of the owner:
Date Contractor Name iHIC Registration No.
OR:
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Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
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Date Owner Name and Signature
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City of Northampton i
Massachusetts �4'`„
DEPARnWiT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060ssj',
Massachusetts Residential'Building Code
Section 110.R5.1.2
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 sucih use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section 110.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
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the licensing provisions o 780 CMR 110.R5, provided that if a homeowner engages a person(s)
for hire to do such work, ten such homeowner shall act as supervisor.
Such homeowner shall sumit 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 eference 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 1perform work for you
under this permit.
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• City of Northampton
f Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS }�
212 Main Street •Municipal Building
Northampton, MA 01060
Debris Disposal Affidavit
In accordance of the provision 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 solidraste disposal facility, as defined by MGL c 1111, S 150A.
The debris from construction work being performed at:
� ST�fiL� STI
(Please print house number and street name)
Is to be disposed of at:
5�'��(Please print print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
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Sign ure of Per icant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
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The Commonwealth of Massachusetts
s
Department of Industrial Accidents
I Congress Street, Suite 100
t Boston, MA 02114-2017
www.mass.go>v/dia
NI%orkers'Compensation Insurance Affidavit:Builders/Contractors/Eleetricians/Plumbers.
TO
BE FILED WITH THE PERMITTING AUTHORITY.
Annlicant Information Please Print Legibly
�
C. Ars (.AJ . I PJ C-
Address:
(Business/Organizationlindividual .. —
Address: hdi S— SII�KtPC.-
City/State/Zip: i+
tc-rC7L. �A _ 0100 Phone#: 6113� S31 s 1
Are you an employer?Check the appropriate box: Type of project(required):
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1� I am a employer with emplgyees(full and/or part-time).- 7. ❑New construction
2.0�11 am a sole proprietor or partnership and have no employees working for me in $.Remodeling
any capacity.[No workers'comp.insurance required.]
9. 0 Demolition
3.E]I am a homeowner doing all work mysielf.[No workers'comp.insurance required.]T
10 Q Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
Electrical repairs or additions
�0
ensure that all contractors either have workers'compensation insurance or are sole 11
proprietors with no employees. 12.0 Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13 ❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
141®Other
6.F�We are a corporation and its officers have exercised their right of exemption per MGL c.
152,$1(4),and we have no employee.[No workers'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.
*Contractors that check this box must attachean 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 4vorkers'compensation insurance for my employees. Below is the policy and job site
information. I�
Insurance Company Name: A4U,A rAWI 10K CA L9J 4L-r.!WS '
Policy#or Self-ins.Lic.#: 3 k o 3 Expiration bate:
Job Site Address: C7 .S7n ST City/State/Zip: `Zr `'PP4J
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of ithis statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify unde rte pain and per perjury that the information provided above is true and correct.
Signature: Date:
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Phone#:
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):
L6.
ard of Health 2.Buildinlg Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
ther
tact Person• Phone#•
• ® DATE(MM1DDlYYY1�
CERTIFICATE OF LIABILITY INSURANCE 08/02/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certai,r policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Sean Rooney
Sean Patrick Rooney,Sr.dba PHONo.Ext): 413-887-8817 FAX No
877-771-6087
IAJRooney Insurance Services A DDDD RIESS, sean.rooney@farm-family.com
2341 Boston Rd. INSURER(S)AFFORDING COVERAGE NAtC rf
Wilbraham MA 01095 INSURER A: Farm Family Casualty Insurance Company 13803~
INSURED INSURER B
Jacques Enterprises Inc INSURERC: —
185 Shearer St INSURER D,
Palmer, MA 01069 INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED'.NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED IHEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADI�LTBUBR POLICY NUMBER MOMIIDDDY ErM FF MM/uDD EXP LIMITS
LTRINS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S '-900 QQO
CLAIMS-MADE OCCUR PREM ISEE
NIEREdccu ice S 100,000
MED EXP(Any oneperson) S5 O _
A X I Business Owners Policy 2001X1402 04/18/19 04/18/20 PERSONAL&ADV INJURY S 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE_ S 2,000,000
X POLICY ECT 0 LOC PRODUCTS-COMPIOPAGG I S 2,000,000
f (OTHER: s
AUTOMOBILE LIABILITY Ea a�deerritSINGLE LIMIT S
ANY AUTO BODILY INJURY(Per person) S 250.000
A ALL AUTOS OWNED �( AUTOSULED 2001 C6420 03/28/19 03/28/20 BODILY INJURY(Per accident)I S 500, 00
NON-OWNED PROPERTY DAMAGE S
HIRED AUTOS AUTOS Per accidentI 100,000—
S
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
EXCESS LIAS CLAIMS-MADE AGGREGATE S
DED I I RETENTIONS S
WORKERS COMPENSATION STATUTE ER
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE Y I N EL EACH ACCIDENT S��QQ�QQO
A (MandatoryOFFICERIM15MBER EXCLUDED? ❑NIA 2001W8563 02/09/19 02/09/20 fE.L.DISEASE-EA EMPLOYE S 10Il-01110--
(Mandatory In NH)
(ryes,describe under E.L.DISEASE-POLICY LIMIT 5
DESCRIPTION OF OPERATIONS below
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DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additlonai Remarks Schedule,maybe attached if more space is required)
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Cinemark THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POL17 PROVISIONS.
AUTHORIZED REPRESENTATIVE
Sean Patrick Rooney,Sr.
0*1988-2014 AGORD CORPORATION. All rights reserved.
ACORD 25(2014101) ;She ACORD name and logo are registered marks of ACORD
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Division of Professional Licens CrelYjA9 51l1.,t1UDL'1 13 l)ttlVhK,!b
�. s ! _ N u, LICENSE t 1
Board of Building Regulations and Standards _ a `,
Const r�ctibrl'Spervisor ' d
1 f L13-012019 S3463353-3
CS-060189 ,' : Expires: 07/30/2020iao12o2a-� 07/30/'1969
NO _
NORMAN R JACQUES>z4- t $ i j e t
185 SHEAREWSTREET' �. zN0 kIAN ROBE T3
.t fit{
PALMER MA 01069 3 �+ a, '' 6186 HEAl�ERST ;
t:�fr,4.3.tt1� PALMER MA091432. `
seiEs'BLU { -
�4r
Commissioner cil . 0,7/30/G9.
{
r u�o ell;
Office of Consumer Affairs&Business Regulation Registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. if.found return to:
TYPECorporation Office of Consumer Affairs and Business Regulation
Registration- ; Expiration 1000 Washington Street-Suite 710
E160328 071312020 Boston,MA 02118
JACQUES ENTERPR1SESs INC"
AN JACQUES t_ -'
NORM nature
out sl
185 SHEARER STREET ' NO th 9
PALMER,MA 01069 Undersecretary, j
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rn
U S.pepartrciert pf'l�tx7r,.
,' C1ccuSk?t+ona{Safety an.1,.Heatth Adrn n sisal+o,
` d,/L /1/ �� earth
SDtlt QGCUIS�"r.7f,Ai'�J2 qT}!._ .
s scacresst�lly completed a 1tN
', 7rain+ng ,rse in
&n S
Health
R 'Constructioale
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Information and Instructions
Massachusetts General Laws chap�er 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every,person in the service of another under any contract of hire,
express or implied,oral or written.?'
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint)enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein:or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair iwork on such dwelling house
or on the grounds or building apptirtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into anv contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and.if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Co�}I?anies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not regttiired to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. )3e advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of in$urance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. should yoti have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call)the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit Is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill on in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the per7t/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city of town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
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The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel.#617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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City of Northampton
} t Massachusetts �w�s` --
^« k DEPARTMENT OF BUII,UING INSPECTIONS1
212 Main Street • Municipal Building
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N60
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Northampton, MA 0 10
Fee Calculator for Residential Properties
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Location • '� � :��'�=�,�;-- �,--� ��,.�-�-�:�f,,;..��.,..� �� � .
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Square Footage Amount
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Basement @ .20
1sT Floor @ .50
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2nd Floor @ .50
'/2 Floors, Finish Attic, Garage @ .20
Deck / Porches @ .20
Total : 73,-
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JACQUES BUILDERS
fir DIVISION OF JACQUES ENTERPRISES, INC.,
185 SHEARER STREET PALMER MA O 1069 (413)283-5750
ESTIMATE
Date: August 1, 2019
Name: Andy Kitto Page 1 of 2
Address: 98 State Street
City, State: Northampton, MA
Phone: Andy.Kitto(c-)-gmail.com
We hereby submit specifications and estimates for. Second Floor Bathroom Relocation
Job Scope: New master bathroom and closet area with new access to master bedroom
• Rebuild staircase balustrade with oak handrail, new white balusters, extend existing newel post for new
height requirement. Build two new newel post to mimic existing post. Balusters will stay at existing
spacing due to predrilled holes in existing treads(need to be approved by Building Department)
• Redesign front bedroom into old bathroom floor plan with closet.
• Redesign rear bedroom with new second floor full bath, relocate laundry facilities to first floor.
• Build new soffits in dining room and kitchen to accommodate new plumbing as needed.
***NOTE: Jacques Enterprises, Inc. is starting this project after Mr. Kitto has!had the rough demo and
hazardous material removed at his expense by a licensed and insured sub-contractor, Jacques Enterprises
Inc. assumeno responsibility for their workmanship or any debris left on site.iNew dust containment will be
installed before work starts and maintained throughout the project. We will leave work area broom cleaned
when completed. Please note-tape from containment may peel or damage some surfaces,
Jacques Enterprises, Inc. assumes no liability for said damage or its repair.
• Carpentry: All related interior framing for new partitions per existing plan will be included-in this estimate.
Any changes to the existing plan will need to be made before the installation is scheduled for proper materials
to be on site. This will need to be done in writing, signed by customer and paid in full before change will be
completed. All new partitions and existing exposed framing will be sheet rocked, taped and sanded ready for
finishing. All doors and related millwork will be installed and ready for finishes. Stair banister will be installed
and ready for finish. All new finished materials, sheetrock, doors trim, moldings as well as some existing
surfaces will be given a new coat of paint, stain or clear finish as required. All bathroom cabinetry and closet
shelving will be installed and pre-finished as needed.
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• Insulation: All enclosed exterior spaces will be insulated with foam insulation as well as fiberglass as
needed. Note:the existing attic space that is accessible from hall access is not included. Homeowner
to contact Mass Save. '
• Tile: Install ceramiclor porcelain floor tile in both bathrooms in straight or funning bond (like brick) pattern.
Standard 12"x12"installation. Master shower stall tile included.
Tile Material Allowance is$2,200, Master bath shower glass allowance$3,500
Bath vanity allowance 1 single, 1 double,with countertops$2,500
• Plumbing: Install new water feed lines from source in basement to first floor laundry and second floor master
bath with second floor I full bath in new Pex piping with all required shutoffs. All new drain and vent piping
required for two toilets; one Bidet, one standard vanity, one double vanity,two shower stalls and one laundry set.
Fixture Allowance$7,500- Items required: 2-toilets, 1 - Bidet, 3-vanity faucets, 2-shower valve assembly's
and 1 -corner/neo angle shower stall acrylic material with door unit attached.
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• Electrical: Up-grade electrical service in basement to 200 amp panel. Feed new laundry room with lighting,
rewire two new bathrooms with bath fan light combo, sconces and GFCI receptacles over sinks. Master closet
flush mount light, master hall flush mount light. Install hardwired smoke detectors from existing system to each
bedroom as required With all new heads. Electrical fixture allowance$3,200 Items required: 2- Panasonic
ultra quiet fan light combo, 3-sconces, 2-flush mount LED approximately 12" round
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One 20 yard roll off ddmpster or trailer from McNamara Waste Management
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Page.2 of 2
DESCRIPTION
TOTAL
Total estimated cost for second floor bathroom relocation as described in above specifications $115,833.00
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We propose hereby to furnish material and labor complete in accordance with above specifications:
One Hundred Fifteen Thousand Eight Hundred Thirty-three dollars only
Payment to be made as follows: j
Deposit on contract$38.,333 Due 8-5-19 (Initial ), Second payment Rough!Inspections Due 9-3-19 (Initial )
Third payment due sheetrock installation$28,113 Due 9-16-19 (Initial ), Fourth payment finish based on
allowances$11,055 Due 10-7-19 (Initial )
First payment is a non-refundable dl posit to secure scheduling.
Final payment is due upon job completion.
Any additional expenses incurred such as permits, fines and fees will be billed accordingly.
All work to be completed in a workmanlike manner according to standard practices.
This is an estimated cost based on time figured Any change in quantity,quality and/or style will be billed as an extra charge.
Note:This estimate may be withdrawn if not accepted within eight days
All Materials Installed are the property of Jacques Enterprises,Inc.until final payment has been paid and release is signed.
Until such time,any and all materials used maylbe removed and returned to vendor to satisfy outstanding debt plus labor and materials required to do so.
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Acceptance of Estimate:
The above prices,specifications and conditions are hereby accepted. You are authorized to do work specified. i
Payment will be made as outlined.
We authorize you to use any and all pictures taken of this project for business use at no charge.
We agree to all terms as listed above. Any changes made to original contract will require a change order and will)be paid for separately.
Work will stop until change order is signed and(paid for
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Signature: s D-c i C1
Signature:
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JACQUES BUILDERS
A DIVISION OF JACQUES ENTERPRISES,INC.
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1 85 SHEARER STREET PALMER MA O 1069 (413)2834-5750
Authorization Form
Date:
Project Name/No.: Se Wrc moot row-, 10� ova
Owner: AAA(tiN I'P*
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Contractor: Jacques Builders
Specifications for Project
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I, r8 W V6 hereby authorize Jacques Enterprises,Inc.doing business as Jacques
Builders to obtain any and,
all permits necessary for the above described project at the ab ve disclosed location.
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Signatur f Jner/agent
Estimated Project Cost: I l 5 g 33.o 0
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