43-014 K&B CONSTRUCTION Estimate
21 EAST BUCKLAND RD
SHELBURNE FALLS, MA 01370 Date Estimate#
10/24/2013 136
Name/Address
SHARON HALL-SMITH
41 PARK HILL RD
FLORENCE MA 01062
Project
Description Qty Cost Total
BID PRICE FOR STRIPPING AND REROOFING HOUSE AT 41 25 350.00 8,750.00
PARK HILL RD FLORENCE
PRICE INCLUDES MATERIALS/LABOR AND PERMIT
GROUND TO BE COVERED DURING DEMO
STRIP 2 LAYERS OF ROOFING DOWN TO WOOD
NEW STEP FLASHING AROUND CHIMNEY
INSTALL 8 INCH DRIP EDGE COLOR BROWN
INSTALL ICE AND WATER SHIELD 6 FEET
INSTALL UNDERLAYMENT REST OF ROOF
INSTALL 35 YR IKO ARCHITECTURAL SHINGLES/LIMITED
LIFE TIME COLOR TO PICKED BY HOMEOWNER
NEW ROOF BOOTS AROUND PIPES 2-4 INCH
INSTALL RIDGE VENT ON ALL PEAKS TO BE VENTED
PRICE GOOD FOR 30 DAYS DUE TO RISING SHINGLE
COSTS
ANY QUESTIONS FEEL FREE TO CALL BRUCE AT
413-834-3331 24 HRS A DAY
BID PRICE FOR GUTTER COVERS 1 650.00 650.00
BID PRICE FOR INSTALLING 12 INCHES OF CELLULOSE 1 1,100.00 1,100.00
INSULATION WITH PROPER VET ALONG EVES
LIC#069157 HIC#126477
Total $10,500.00
The Commonwealth of Massachusetts
_ 5__ Department of Industrial Accidents •
=..1.4t.1 .,
A Office of Investigations
°::f
—' rr tt 600 Washington Street
fl::: ,
Boston,MA 02111
,• www.mass.gov/dia
ow-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information - Please Print Legibly
Name(Business/Organization/Individual): J/C8 h' 3„,375(....,..f,',,,.. .
•Address: 4-( ets 1` if„�t( t kV. • •
)� G
City/State/Zip: ..5' 44_6 vim f,-`)(5 /44f-- �P one.#: q(.9 Sd 9 3,}}�
Are you an employer?Check the appropriate box: • Type of project(required): -1
10-I am a employer with - 4.. 0 I am a general contractor and I
6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling.
+ ship and have.no.employees These sub contractors have g. Ej Demolition .
working for me in any capacity. employees and have workers'
g Y P tY 9. ❑Building addition
[No workers'comp.insurance comp.insurance.$
required.] 5. 0 We are a corporation and its 14:0 Electrical repairs or additions
3.0 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
124 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13 ig Other, ,))�/� ,,`-
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.
xContractors 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: /'e9iv�r Gc-t '1.
Policy#or Self-ins.Lic.#: 6 //V J c1 6./4 `LJ Expiration Date:- p/ -��Y
Job Site Address: 4 / 1444/1.-6( h 1/ /, City/State/Zip: /42'/2G---- '
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$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.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: 2�v-■_— Date: /1/1 /1-)
Phone#: 41- 1.9 V 3:9J! -
Official use only. Do not write in this area,to be completed by city or town official.
f
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: i Not Applicable ❑
Name of License Holder: 8 L i b1 ?_,.fit 6 6 c /s 7
License Number
64st- ilu fl-O 54,z,/ „rte P4-/h M . 0l j2ey
Address Expiration Date
If/3 T3G-/ 3 )3 i
Signature Telephone
9.Registered Hoime lmproveinent Contractor; "" Not Applicable ❑
Company Name Registration Number
l i L.cr n s rb-1 6 t r/l Z/
Address / / j,, > (lS Expiration Date
L E 4"4l 41,0.t t4/) ii4 _c uit/g t Telephone 7/. ��`j: ji'/
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 permit.
Signed Affidavit Attached Yes ,z No ❑
11;----Lime:Owner.Exemption
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
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E] Siding [0] Other[0]
Brief Description of Proposed
Work: cInp y 126 0.e,. /, v./
Alteration of existing bedroom Yes /\ No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes ,( No
Plans Attached Roll -Sheet
. w o o , w6a r g q :
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 constructio . Dimensions
e. Number of stories? A
f. Method of heating? MIMI Firepl:ces or Woodstoves Number of each
g. Energy Conservation •mpliancr Mas•check Energy Compliance form attached?
h. Type of constructio
i. Is construction wi in 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of base ,ent 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, eI=QIGC Pt 4 /' S7 -- ,as Owner/Authorized
Agent hereby declare that the sta ments and information oh the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
lip—N._ l l // 7/k)
Signature of Owner/Agent Date
Section 4. ZONING 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
Sa
1
Lot Size , _. . � _,_m �... J'
Frontage .�,
Setbacks Front `i
Side L: i R:,'...... ... 1 R: ..._.... . ' _
Rear i
,
Building Height
Bldg.Square Footage r"" ' °i % i
Open Space Footage %
(Lot area minus bldg&paved t _
parking)
#of Parking Spaces ° -~ -
Fill: 1
(volume&Location) _A
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO I)
IF YES, describe size, type and location: +
1
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Ike
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 (3 NO
IF YES,then a Northampton Storm Water Management ermit from the DPW is required.
£lower''------- part A r wyy ',
City of Northampton ��#usof Pe ; �i! ' ��
-,1 I, ilding Department r • u� vewa ;r
,212 Main Street Sewed �: �°a:rrtyN�
i Room 100 et e,1,A It tiil►t` � w r�',
J i. PU 1 9 2013 ti����i � l
N hampton, MA 01060 ' � t ot4StructuraI 9
L___ _ phone 13- 87-1240 Fax 413-587-1272 PJoVS e I
Electric F r c � t P on t P - s
n uections a
APPLICATION TO CONSTRUCT,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
-! I / n G( �j-, J �I_ Map Lot Unit
Flog C.-6e ,4 D�G�,�. Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
•Signature
2.2 Authorized Agent:
(312vGC I�v�;2 / a- ��s7 �i�4' .,•3 i yt e�f d'c./''�l rf.44.
Name(Print) Current Mailing Address: 6113)? .
Ij 1,1/
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) �dr�>U. G'� Check Numbery�� �J� --
This Section For Issued:Official Use Only
Building Permit Number: Date
Signature:
Building Commissioner/Inspector of Buildings Date
41 PARK HILL RD BP-2014-0632
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 43 -014 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2014-0632
Project# JS-2014-001072
Est. Cost: $10500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BRUCE DUBRULE JR 069157
Lot Size(sq. ft.): 27007.20 Owner: SMITH WINSTON A&SHARON E
Zoning: Applicant: BRUCE DUBRULE JR
AT: 41 PARK HILL RD
Applicant Address: Phone: Insurance:
21 EAST BUCKLAND RD (413) 834-3331 WC
SHELBURNE FALLSMA01370ISSUED ON:11/19/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 11/19/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner