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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