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23D-018 LICENSED REGISTERED INSURED WESTERN MASS MASONS 383 COLLEGE HWY, SOUTHAMPTON, MA 01073 • (413) 527 -1800 WWW.WESTERNMASSMASONS.COM QUOTE To: CHRIS MCKEEVER Date: 10 -08 -2009 540 ELM ST. Quote # 78943 NORTHAMPTON MA Project: CHIMNEY Phone: 584 -0532 Description of Work To Be Done: BECAUSE OF WATER DAMAGE TO THE TOP SECTION OF THE CHIMNEY, AND THE FACT THAT IT HAS ALREADY BEEN REPOINTED ONCE BEFORE, THE CHIMNEY MUST BE REBUILT. THE CHIMNEY WILL BE REBUILT WITH NEW USED BRICKS, TOP SECTIONS OF FLUE AND LEAD FLASHING. THE SECTION TO BE REBUILT WILL BE THE TOP 6'. FORM AND POUR A CONCRETE CAP AT THE TOP. APPLY CLEAR SEALER TO ENTIRE CHIMNEY DISPOSE OF ALL OLD MATERIAL. PULL PERMIT FOR THE JOB. * ** PLEASE SIGN AND RETURN FOR SPRING 2010 BOOKING. WE HEREBY PROPOSE TO FURNISH MATERIALS AND LABOR - $ 2950.00 IN ACCORDANCE WITH THE ABOVE SPECIFICATIONS, FOR THE SUM OF: This quote may be withdrawn from us if not accepted within 30 days. BBBONLSNE RELIABILITY Quote Prepared By: David Osiecki PROGRAM TERMS: Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. By signing this quote you agree and understand all the above terms and conditions 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 effect to the final price. PAYMENT TO BE MADE AS FOLLOWS: One half of quoted amount is due when job construction has begun. Remaining balance of bill will be paid in full when job is complete. A Finance Charge of 1 -112 (18 % annual rate) per month will be added to any unpaid balance over 30 days. ACCEPTANCE • F PROPOSAL: The Above Prices, Specifications And Conditions Are Satisfactory And Hereby Accepted. You Are Authorized To Do The Wo• 1 red. Pal • t Will Be ...e As 0 • ned Above. Date: Signature: Date: 6 O 40 Th nk You For Choosing Western Mass Masons! HOME OWNER EXEMPTION ACKNOWLEDGEMENT 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 building 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 • The Commonwealth of Massachusetts Department of Industrial Accidents All 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 pusinesslorganizaiionfindivid.o: 41 67( r„., _,// , ,,‘,/,1-1 n Address: 3P3 c-1(r City/State/Zip: c.c.x.-gc- 71 Cieef?i Phone.#: Sa9 Are you you an employer? Check the appropriate box: Type of project (required): / 1. r_a-ra a employer with 4. 0 I am a general contractor and I 6. New co 'on have hired the sub-contractors employees (full and/or part-time).* listed on the attached sheet. 7. Remodeling 2. 0 I am a sole proprietor or partner- These sub-contractors have ship and have no e...wloyees 8. D Demolition working for me in any capacity. employees and have workers 9. Buildiiii addition comp.in.sm-xnrp [No workers' comp. insuiance - - required.] 5. 111 We are a corporation and its 100 Electrical repairs or additions ' 3.0 I am a homeowner doing all work officers have4xercised their . 11.0 Plumbing repairs or additions myself [No workers' comp. Hen of exemption per MGL 12.0 Roof repairs . insurance required.] t c. 152, §1(4), and we have no ,_.., 13.11 Other employees. [No workers' comp. ce requited.1 *Any applicant that checks box #1 must also fill out the section beicrWshowing their woricers' compensation policy information_ t Homeowners who submit this affida;it incficating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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' ccrmp. policy number. am an employer that is providing workers' compensation insurance for my employees. Below is the policy curd job site information. Insurance Company Name: 6;6r, e • f',`// Policy # or Self-ins. Lic. #: 90 Expiration Date - Job Site Address: 7 ?If 0 L5 4' - 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 raider Section 25A 'ofMG-L c. 152 can lead to the iirgiositiOn of criminal penalties of a fine up to 51,500.00 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 Inleatikitimis of the for insurance coverage vflcon.' I do hereby cc nil the and penalties ofperjary that the informationprovided_above_ittrue_andiorr_ect__ Sitmature: • (3 • Date: Phone j)-1-1/‘ i •• _ Official use only. Do not write in this ai-ea, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Ap Name of License Holder : ("� 'cc ��� c V) License Number 30P3 cal I / Address Expiration Date Z /J Sig fre Telephone 9, Rpclisteiti l ame_lm ffientai ntract `... ` ..; .`. , a_` - L; ; ...... Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GL. 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 build, permit. Signed Affidavit Attached Yes No ❑ FIV4ittOnlettlWneVEXeMptiOn 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing j Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [ 1] Decks [C1 Siding [0] Other [0] Brief Description of Proposed ) f Work: ' ` G. , /o if ,'- ms s..✓ � Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 0 If'Nji* oiis arf lad ft air fio cistiiri ou "iilaiiiiil ittii the fottowh a: 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 , 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 0 44/ 1Z ! Cc / <1 , 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. Print Nam Si .f g ent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed uired Z oning Th is colu b y to be f in by Building Department Lot Size i __ ._ a Req Frontage 3 1 Setbacks Front = 4 Side L:L i R: L: R:[ . ' r _] Rear = E a Building Height = , J Bldg. Square Footage [ I 1 1 % i Open Space Footage % (Lot area minus bldg &paved € I ! I 1 1 parking) # of Parking Spaces ` I Fill: € �. _u. m, (volume & Location) I sl g ; • A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW 0 YES 0 IF YES, date issued:I I 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 # B. Does the site contain a brook, body of water or wetlands? NO 0 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 0 NO Q I 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 activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. w City of Northampton y i� Building Department 44x 212 Main Street ®< ..' Room 100 Northampton, MA 01060 q J bi pone 413- 587 -1240 Fax 413- 587 -1272 :4 1:1W 1 :ter, APPLICATION TO COJLSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 7 6 S/ Map Lot - Unit / Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Cam, rL$ /0` V cc (ye_ r ` /c) 4 ,ter Name (Print) Current Mailing Address • `.5 CZ57.1d Telephone Signature 2.2 Authorized Agent: a,L/(, Name (Print) Current Mailing Addres . Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS 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 6. Total = (1 + 2 + 3 + 4 + 5) pZ y t-'0 c% Check Number 3 3 /~' ' This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/inspector of Buildings Date 540 ELM ST BP-2010-0769 GIS #: COMMONWEALTH OF MASSACHUSETTS Map :Block: 23D - 018 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- 2010 -0769 Project # JS- 2010- 001150 Est. Cost: $2950.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WESTERN MASS MASONS 089376 Lot Size(sq. ft.): 7100.28 Owner: MCKEEVER CHRISTOPHER J Zoning: URB(100) //WP Applicant: WESTERN MASS MASONS AT: 540 ELM ST Applicant Address: Phone: Insurance: 383 COLLEGE HIGHWAY (413) 540 - 1959 SOUTHAMPTONMA01073 ISSUED ON :3/5/2010 0 :00 :00 TO PERFORM THE FOLLOWING WORK: REBUILD TOP OF CHMNEY 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 3/5/2010 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo