36-255 Page No. of Pages
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NEWMAN'S CONSTRUCTION
697 Bridge Rd.
Northampton, MA 01060 1063
413-586.1093
PROPOSAL SUBMITTED TO PHONE DATE
STREET JOB NAME
Rco O 1= c o Q VZ, o v I..
CITY,STATE and ZIP CODE JOB LOCATION
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
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We Vrap Mr hereby to furnish material and lab omplete in accordance with above specifications, for the sum of:
C)E3 dollars($ 9 )
Payment to be malb as follows: C�(
C� 1> k-7 CC)L,-r
All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized
manner according to standard practices.Any alteration or deviation from above specifications Signature
involving extra costs will be executed only upon written orders, and will become an extra
charge over and above the estimate. All agreements contingent upon strikes, accidents Note:This propos I ay be T
or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. withdrawn by us if not acce d within `t days.
X-�--,,fttttro ur workers are fully covered by Workman's Compensation Insurance.
rra of Proposal —The above prices,specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified./Paym t will bQ made as outlined above.
Date of Acceptance: 7 r l Signature
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lrxil-:NI 'll"TIO-NIT �OINVTEDGEEINMEN7
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h,o Le rzLz Wider 7 OC N,-FZ 10,3.4 to
acz az hif"ztr CoLs---ucrior, S,:To .- The- S-zat C4 fzes Ez, -Per:,
O-n(s)
wLo.o-,-zs a parcel on whicill he!she resides or i.,was to be, a one ortwafamz�
=acLed Gr.d,et-ached. stn-',C-.i-,res accesssoiy to such u--.-andlor 5-=,, 'Al
r1sidered a
pers,or.W—,-G Constructz More tLan ore home L a nwc-yeaurpenoc: sL--E r-ot be cc
i,home o-,mer.-
T--he b m-e:-f.-F-vl:e C I—Lyof per-s-Cra(s) -who seek to
e E6 ricer ex, �=tzof, to a= Lae=Gwr,
tLat- by doing sa you become responsible for compli.an Ce With state b allding codes
and reTalafcrs ant be a I I ed
.71,-=pecmon Frcce--S-requ-res that the buLding cep
to wori ar van,cus stp—gts, wLch bacIdUl).
2--notubt holes rbefore vour)- a rough buSdinz'hasnectfon-(before worn is
ir�ize-ctiau (if rewired)a- n fung? h din_gi=eCdO-n- Tae
zi =before-the wori is conc-ez*, failure to
r.-,rL es these-inspections
secure taese imsLections can result in failure to obtain a ce.-tificate of occunancy
Y tLe h=,eo-wmer h'±-es 01±,!:-trades to per.or=work plu--,b ing&-gas) �e
ho be r---p cr-mibl e to l c e sr--e tL=tLe trZ es bL-ed tLeLZ pro ef-
din e I-z -d =th their q
per.==in ou to the buLT zp issued, a th + ey get eir re uired
L'Ispections.FaErure of the individual t-ad.es to s4zzre the permits and inz:pectic= as
c �ET -I- zj2 , r
z-z D-17 Y 11 e�p r qjf t-7 su ch time as Le p rop er enm�=- and i=� ect:0 f S are
made
U--d,,era-,=;md the 2:ove-
(Hom—e Owe nerlrf---ident2s siggmatur--requesting exemption)
c;a:l 1 to ScLedu I,-all're ed C
�4= � il-12.1 1_2 ne-c--sary for the buLdizg-
Issued to me-
Date
` Of`ce of In vestigations
° 600 Washington Street
- Boston, 111A 02111
www.mass.gov1dins
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
onl3cant Information Please Print Legibly
Name (Busines i'Or2anization/Individual): CJries )Qewr4a ,
A a,a_
nuui�SS. �
City/State/Zip: ��� K,{ Phone -
-re you an employer? Check the appropriate box: Type of project(required):
. I am a em to ez`with 4. ❑ I am a general contractor and I
P Y 6. ❑ New construction
employees (ful] anv'or par*-time).T have hired the sub-contractors
2.❑ I an: a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity.
employees and have workers' 9 ❑ Building addition
[_No workers' comp. insurance comp. insurance.t 10.❑ Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
3.❑ I am a homeowner doinJ all worts officers have exercised their 11.❑ Plumbing repairs or additions
M self. [No workers' comp. right of exemption per 1IGL 12.0 Roof repairs
insurance required.] ' C. 152, §1(4), and we have no 13.❑ Other
employees. [No workers'
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their worlcers'compensation policy information.
Ho meowners who submit this affidavit indicating they are doing ail work and then hire outsidecontractors must submit a new affidavit indicating such.
or.rrac�c r,tl;at 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 ire sub-contractors have employees,they must provide their wor-kers'comp.policy number.
I ain an employer that is providing worlters'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-its. Lie. : 1....y Lo n>-22 Expiration Date: `J- - IC)
Job Site Address: 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 under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for insurance coverage verification.
1 do hereby cerz -unde. the- rrl pear tie afpe=jFFry ti az the information provided above is true and correct
1�!arlature: Date O
Ph_c Le
%iciaLasse_onL 1?un%z r l irzlhis a_ tc�e_cnmol�ted by citt or town
Cite or Town: Permit/License 7 (�
lssuin2_authority (circle one):
13O�:� �?Heal tn _ �L�i=I n_ Df:11 i"c:i �. � J �u Clenx- - Eieci?;L11 llS;tt r - �.umbin; Inspe�t�r
ji fi. tLer I�
M A
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ j
Name of License Holder: �iY t�j S. n, �[�rT ck A--) C� w LA G
T License Number
L I) Er 1P 12J. Me)r-+ha r-n picc,. (� n GIuaO '1- 1- 11
Address ^—r–� Expiration Date
Signature Telephone
9.Registered Home lmproyerhent C'ontracto. Not Applicable ❑
Company Name Registration Number
0-4 (2±j 5-Z! ICS
Address Expiration Date
NC)44 kLI n,I U44� Telephoned/-,)f-Et,—cz
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§1 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...... ❑
sn
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-vear 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 AJteration(s) ❑ Roofing
Or Doors r7
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding (0] Other[0]
Brief Description of Proposed f
Work: Xtx 1 �= G-'
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If Nevi house and or addition:t, existing 66sinq:.complete t e:followinq:
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 Wcodstoves 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
[�to, -) , 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 Rame
O
Signature of C er/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
Lot Size
�►rr
Frontage _._,. . ,,, _.._-_,_..__..__.. __, _._.._.. __ ._.__...... .._._, _. ._._.....,_,
Setbacks Front _.
Side L:', __._.... R: . L _. R.
Rear
Building Height
Bldg. Square Footage _.. % ___.; _._.....
Open Space Footage ° ---
(Lot area minus bldg&paved
parking)
#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 0
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 Page and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW (DYES 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 0 NO 0
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 0
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 distut over 1 acre? YES 0 NO C)
IF YES. then a Northampton Storm Water Management Permit from the DPW is required.
f �
"Departmentuse only
r
Eigof Northampton status of e t
Bd4ding Department Curb,GuffDily� Pei nrt
212 Main Street SeWerfSeptrcvaiFabrin
ROOM 100 WaterlFlV61FEt arfa6�l�fy
ortharripfpn, MA 09 060 Tvuo Sets of Strueturat'Plans
� 3-587-124vQ Fax 413-587-1272 P`i f ate Plans
}�0 \ (Oth
er Speafy
A�' LICATIO Td CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIONI -SITE INFORMATION
This section to be completed by office
1.1ff Property Add ress::
C � Pl L � dap Lot Unit
Zone Overlay District
Elm-St District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ae KS Jlv
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
r , one e )Q fir, y�1Cl
CU r'`US J ��L r�IGL r� s.,���-5 -,
Nam (Print Current Mailing Addr
f� !3�192
Signature 4 Telephone
SECTIC 3-ESTIMATED CONSTRUCTION COSTS 7
Item Estimated Cost(Dollars)to be Official.Use Only
completed by permit applicant
1- Building Q ® 00 (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) Check Number
This Section For official Use.Onl
Date
Buildirg Permit Number: Issued:
Signature:
--- -- --
Building Commissioner/laspecf�r of ui mgs -' Date
BP-2009-1108
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-1108
Project# JS-2009-001605
Est.Cost: $9850.00
Fee:$35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CYRUS NEW MAN 142807
Lot Size(sq. ft.): 74923.20 Owner: KELLY STEPHANIE B
Zoning: SR(100)/ Applicant: CYRUS NEWMAN
AT: 65 MAPLE RIDGE RD
Applicant Address: Phone: Insurance:
697 Bridge Road (413) 586-1093 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:613012009 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 LAYER
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 6/30/2009 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo