17C-064 4W. O FORM 3850 , ]HIPLIUAIL
PROPOSAL
Date . � ^
�`�
:. /S �h 5� % C�!'S Sheet No.
Proposal Submitted To: Work To Be Performed At:
Name i F_ ;- PV3
Street ��.�Y��V/` S�_ Street /C)
City State City � /,_,V_�i c State
Phone Date of Plans Architect
We hereby propose to furnish the materials and perform the labor necessary for the completion of
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All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and
specific ns ubmitted f abov work and complete in,, a substantial workmanlike manner for the sum of
1 1)) t
I Dollars 1$ � C) 1.
with payments to be made as follows: Dpr, J-hov5,0v^ _ Ebwtil. Er yc t �?a>v Caw f74 b,
Any alteration or deviation from above specifications involving extra ((/ '`
costs,will be executed only upon written orders, and will become an Respectfully submitted �, all—' L^Q_
extra charge over and above the estimate.All agreements contingent f
upon strikes,accidents or delays beyond our control. Owner to carry
fire.tornado and other necessary insurance upon above work. Work- Per / I
I men's Compensation and Public Liability Insurance on above work to be
taken out by Note-This proposal may be withdrawn by us if not accepted
within days.
ACCEPTANCE OF PROPOSAL
4
The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified
Payment will be made as outlined above. A
Signature
Date 411gllvclao Signature G
� Y
C3/rl�0 —�
F. ?� Ciih) of �,Torflj t11iptoll V -
Q E �csanrtlncrtla 3 --
OEPARi-MENT OP BUILDING INSPECT)O S 3
212 Main Strect ' Municipal Buildinn
?Northampton, A,'ass. 0]060
��'ORIC1 IZ'S CO)ITLNSATZON YNSURANCT AFFIDAVIT
pi-u1c1pal place of business/residcncc at.
(szr - c�tr/st�i��ap)
do hereby certil y, under the hain5 and pellatties of pcTlry, �h2!
cmployci providill- die fo�]OwlmJ "voik-u'S Coll)DCnS2L10i1 covergC for Illy
etuplovccs v11,or:11ns, MI MIS job
(lnsu M Corer ) (Pc Li c; }:tu�ir)
I a�sole proprtct general Conu-ac�or or hoIlieO'vDc (cLCie one) grid have hired
the cones actors fisted bet w v,'t;o hzvc the foLlo"WIPP, -0,,Orkef s coma n---jon poilcies:
(i1IlI➢c Oi t.0:`.L�!ClO:I --t111�i!f�717C:. t.,01l1USi1}'�PGIJCt ?�Ui]lrC;) (!:?: )li7:::Q? Dale)
- (Name of Contractor) (insl;dncc: Comoamv?olic-,
(Name of Conlncior) (Laampc Company/Pot�cy Numb } ( vpir.:uol1 Datc)
(NaJn(-- of COnnaemr) (Insttmnc-- COIJIDaBy/Policy Nujn!?.I) T.��irlfion Dom)
to mfc m-6cn pert�-.n.n�to.11
1 aw a sole propnetor and have no one Worker g for me-
( j I am a homic owner perforrnu30 all tl)e wor}c myself.
NOTE:plea tK ubo cnplay pcou:to 6 rv", it or o .d.•c11 of
co((h:o(c 4._r.U-7c_ of oa the p au>'`i zppvttca,- c.c rrx �..::Uy a�c:!:d:cd to tti
loye s unG Ix ..aicfz cc m Alt(GLI SZ�!(S)) :{pl e ion try a t o:n �a�c fcr e t e({:omit n::y-ids 1e
Icg-1 0 -a"of-a c"PIOVK.0&< d,. WO( q�l Comp«7�.f_ioo Ac
1 uc>dc.^s;�d(ha>copy of thi.a r ,n my to for--Jed to tbo f l�id hood--Offioo of I--i--dm
coven sc vcnf c oo n.-:d Uu L Jac to scatrc cUV,:�&c under socaion 25A of MGL 152 can lad to the u^yoositioo of c im nil pc ull c�
cocnu'.i-zb of a fin-of up to S 1}00.00 ar-lrcx iz�atioaaax�ri of up w oo,Y,:r c.i ci,i1 pm.t�.L,tx form of a Stop Work Order'-°d n
ft,~of 5100.00 I day&g im ar_
For d�.:ui,�sl u,c only
perYnit Ntuzlbcr �_—
e,'
r1 i
ISM'f`1CIN 8•CCINS' R4q"iC►N S>=RVICES
r"""3 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
.E E.?haEE...allow 3E` I ° Not Applicable ❑
Company Name Registration Number
L4;
Adder Expiration Date
' I Telephone O
1Q CWER ' flMTN f IDVIT(
M.GLc.152,1 2EC1 IC � i " 506})
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...... ❑
MEN
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
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: StI91 12 12—on koo�lsn'
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll o - Sheet❑
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. Mascheck Energy Compliance form attached?
�. 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
S�C7101V 7a-OWNt- AUTH RIZATiON }:6E CO b WHIEN
OWNI R AG N+ ",bit flCsj""I A it,APPO1 "MOOR 1§01W l d PERM1T
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
as Own %thorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to
knowledge and belief.
Signed under the pains and penalties of perjury.
ALen-n L
Print Name
Signature of Owne Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW 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
YES
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
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION.1 " ITE-IIdFOFtMAT101t
1.1 Propert Address:
P
J
t
Zone f� ri+wY k
ROPI>iRTV OWNERSHIPIAUTHORIZEO AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
1111 - TIMAT>EI?GONSTRUCTION'COS'�
Item Estimated Cost(Dollars)to be else Ont .
Y
completed by ermit applicant
l. g ���n� �a) Building Rerrnit Fee "
2. Electrical (b) Estima'ted Total Cost of
Co nstrction:fram "5
3. Plumbing Building Pjkrmlt Fee,
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2 + 3 +4+ 5) CheckNumber
This,Seipni=:1•or Official Use OrrN
Buildin&.Permit,,Number* Date issued.
Signature:
lauiiding Commissioinerllns ec#or of t3crildir<gs pate
y.�
167 CHESTNUT ST BP-2001-0056
am GIS#: COMMONWEALTH OF MASSACHUSETTS
fr iVlan:Block: 17C-064 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0056
Project# JS-2001-0093
Est.Cost:$4000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group: Wayne Ducharme 118101
Lot Size(sa.ft.): 14984.64 Owner: KMETZ LEWIS J&FLORENCE R
Zoning,_URA Applicant. Wayne Ducharme
AT.• 167 CHESTNUT ST
Applicant Address: Phone: Insurance:
15 GaugLh St (413) 527-8940
EASTHAMPTONMA01027 ISSUED ON.•7117100 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. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/17/00 0:00:00 320 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo