24A-018 (11) BP-2008-1149
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-2008-1149
Project# JS-2008-001695
Est. Cost: $3430.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WESTERN MASS MASONS 133234
Lot Size(sq. ft.): 1 1238.48 Owner: SULLIVAN KAREN
Zoning:URB Applicant: WESTERN MASS MASONS
AT: 119 PROSPECT AVE
Applicant Address: Phone: Insurance:
147 MIDDLE RD (413) 540-1959 WC
SOUTHAMPTONMA01073 ISSUED ON:6/20/2008 0:00:00
TO PERFORM THE FOLLOWING WORK:REBUILD CHIMNEY FROM ROOFLINE
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 6/20/2008 0:00:00 $25.003203
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
r [
Department use only
"City of Northampton Status of Permit:
.......„...„,,q1- \- Building Department Curb Cut/Driveway Permit"
-�,� `� 212 Main Street Sewer/Se tip 4vaiiabili
% p_ . ty -
((_ Room 100 WatecJWeil-Availability
vv Northampton, MA 01060 Two Sets of Structural Plans
('pl�t��e 413 5871240 fax 413-587 1272 Plot/Site Plans
" a
,�� ,5 Other Specify
1 \'"" APPLICATION Tb CQN$TR�T,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
`C `I n\ c
SECTION 1 - ITE INFORMATION
\" This section to be completed by office
1.1 Property Address: _
7,? ^, �� Map Lot Unit
///� Zone Overlay District
Elm St.'District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT f
2-1 Owner of Record: // _
14 ,ra,Z c74i L( r U C. r i! ` /Drai,c-/ h€
Name(Print) Current Mailitg Addre s:
Telephone
Signature
2-2 Authorized Agent:
I'ed'e._ (�.'ex-I4 - 51'3 cG//(.9 t /,&> S 0
Name(Pent Current Mailing Addresk
--, �01 7-/Pc Q
Signatu Telephone
SECTION 33-ESTIMATED CONSTRUCTION COSTS 1
Item Estimated Cost(Dollars)to be I Official Use Only
i
completed by permit applicant
1- Building I (a)Building Permit Fee
2. Electrical
(b) of Estimated
Construction Total fromCost(6)
3. Plumbing I Building Permit Fee
4. Mechanical(HVAC)
5 Fire Protection
6. Total=(1 +2+3+4+5) j 3`ft'G-c o T Check Number .,.,2,p3 i
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building,Commissioner/Inspecto?ofEuldmgs Date
,
Section 4. ZONING I All Information 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 1 i
Setbacks Front 2 ,
Side L:' ' R:•_______ L: a RI—
Rear
Building Height
3
Bldg. Square Footage % # i
Open Space Footage + -, % _ - ---
(Lot area minus bldg&paved _ __; — -
oarldne)
#of Parking Spaces
Fill: -.__.�.-_.-__- _.___..,�____-.._—_
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES Q
IF YES, date issued:-
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Pagel and/or Document#
3
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Date Issued:
C. Do any signs exist on the property? YES (3 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation, or filling)over 1 acre or is it part of a Lunniiull plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management-Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House n I Addition Q Replacement Windows i Alteration(s) 7 i Roofing I I I
Or Doors El 1
Accessory Bldg. E Demolition New Signs [E:1] Decks [ Siding IrT Other fp]
Brief Description of Proposed Aix,
Work: G, .�ige J f/`l
e 4, •
Alteration of existing bedroom Yes No f Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes Nc
Plans Attached Roll -Sheet
6a. If New house and or addition to existina housina. complete the followina
a. Use of building: One Family Twc 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-.T O 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. p 0'7(./c i/Nei< / , 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.
/f Print Name • • /x. ---- 6.--40?v ^a0P
1 Signature of Own._:nt Date
SECTION 8 -CONSTRUCTION SERVICES 1
8.1 Licensed Construction Super iisor: I Not Applicable 0
P ^ 3/
Name of License Holder: 0,04(/I �/ ��)< � �/`/L C�
License Number
26 /-07 l0
;dcress - Expiration Date
Sign Telephone
t--.Recristered Home fmnrovertierrt_Cpntractor _.. ' w Not Applicable ❑
Ac s/erA, /441.1 ,I4Io . /3.3?3y
:omoanv Name Registration Number
LSD 01i.f
.ddress Expiration Date
Telephone
ECTION 1:0-WORKERS'COMPENSATION INSURANCE AFFIDAVIT EM:G:L.c.152,§25C(6))
'orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the buildin ermit.•
fined Affidavit Attached Yes No 0
LI Olne Owner gempf Jii
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
* '" The Commonwealth of Massachusetts
Department of Industrial Accidents
'1": -- � Office of Investlgations
600 Washington Street
Boston, MA 02111
__Y.''.m, www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): )&f t 1 j . /(4 c ' 7
Address: So 3 vi�� 1r 1
City/State/Zip: >� � /L� ✓✓ Phone-: LS , ?--(Pc-'
Are you an employer?Check thf appropriate box:1. Type of project(required): i
a employer with �—
employees (full and/or part-time).*
�- 0 I am a general.contractor-and I
have hired the sub-contractors 6. ❑New construction
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. El Demolition
working for me in any capacity. employees and have workers' 9. ❑Builriino addition
[No workers'comp.insurance comp. insurance.:
required.] 5. We are a corporation and its 10.❑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 G�,-.ram.
i comp.insurance required.] /
*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 sire
information. .-. \
Insurance Company Name: ( ' ."7Z , 7 l _
Policy#or Self-ins.Lic.#: P? (.5 't-p Expiration Date: /{/0'1-a 7
Job Site Address: LL 7 p`c:y • City/State/Zip: / . .i Lc.
Attach a copy of the workers compe sation 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$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 DL4 for insurance coverage verification.
I do hereby certi der the p ns nd penalties of perjury that the information provided above is true and correct.
Signature: Date: -plc/ o A
Phone#: so'-?`CO c
use only. Do not write in this area,to be completed by thy or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.BuiIding Department 3. City/Town Clerk 4.Electrical Inspector Plumbing Inspector
6.Other/ Official
Contact Person: Phone#:
.
HOME OWNER EXEMPTION ACR 'OWLEDGEMENT
The State of Massachusetts allows the homeowner 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 a two-year period shall not be considered a
home owner."
The buildings department for the City of Northampton wants 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 to me.
Date
Address of work
location
'LICENSED REGISTERED INSURED
WESTERN MASS
_ • .
•. _
383 COLLEGE HVVY, SOUTHAMPTON, MA 01073 • (413) 527-1800,540-1959
WWW.WESTERNMASSMASONS.COM
QUOTE
To: KAREN SULLIVAN Date: 12-13-2007
119 PROSPECT AVE. Quote# 43788
NORTHAMPTON MA. Project: CHIMNEYS
Phone: 586-3856
Description of Work To Be Done:
1. FRONT FIREPLACE CHIMNEY WILL BE TAKEN DOWN TO THE ROOFLINE AND REBUILT.
THE CHIMNEY WILL BE REBUILT WITH NEW BRICKS, FLUE AND LEAD FLASHING. A
CONCRETE CAP WILL BE FORMED AND POURED AT THE TOP.
MATCH BRICKS AS BEST AS POSSIBLE . DISPSOE OF ALL OLD MATERIAL.
TOTAL$ 3450.00
2. BECAUSE OF EXTENSIVE BRICK SPAULDING ON THE REAR FIREPLACE AND THE
CHANCE THAT MOISTURE IS ROUTING THE FRAMING, THE BRICK ON THE CHIMNEY
WILL AlL HAVE TO BE TAKEN DO'v"JN AND REPLACED.
THE BRICK WILL BE TAKEN DOWN TO THE GRADE AND REPLACE WITH NEW BRICKS,
LEAD AT THE ROOFLINE AND A CONCRETE CAP FORMED AND POURED AT THE TOP.
DISPOSE OF ALL OLD MATERIAL.
TOTTAL$6475.00
PLEASE AND RETURN FOR SPRING BOOKING 2008.
WE HEREBY PROPOSE TO FURNISH MATERIALS AND LABOR- .t
IN ACCORDANCE WITH THE ABOVE SPECIFICATIONS,FOR THE SUM OF:
This quote may be withdrawn from us if not accepted within 30 days. I 1111,0d.
Quote Prepared By: David Osiecki 1,1 l
I ERMS:Any alteration or deviation from above specifications involving extra costs wi l be executed oily upon ,wmien orders.arid will become an
extra charge over and above the estimate.By signing this quote you agree and understand ail the above terms and s that apply to this job.
Any changes that are to be made,must be discussed prior to construction and agreed upon by contractor and may also efie to the final price.
PAYMENT TO BE MADE AS FOLLOWS:One half of quoted amount is due when job construction has begun.Rernair Ong balance of bill will be paid
in full when job is complete.A Finance Charge of 1-1/2(18%annual rate)per month will be added to any unpaid balance over 30 days. ``CZ I
ACCEPTANCE OF PROPOSAL:The Above Prices,Specifications And Conditions Are Satisfactory And Hereby Accepted.You Are Authorized To Do
li
The Work As Specified.Payment Will Be Made As Outlined Above.
Signature: Date: j Signature: Date:
w ,�, �•!, 1, "z` III
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