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17A-250 (5) R0 OS PROP.OS%L., UBIJhITTED TO { -� ORKTO BE PERFORMED r. x PHO E, O G MSAN 'M m . R �t AII,4matenal is. uaranteed to be asapeclfled,.and the "above work to be performed to accordance�v�lt he drawings and speclfi ^",''its" ^„ k �' -.-,_ x_� ..:., a" raF� F � ' i iri r+r;, y S "' r r •ak c'.r, dons IS tted for above work and'completed in a substantial workmanlike manner for the sum of Dollars with paymerO is a made as follows.' .. y1 Z tike S k Respectfully submitted Any alteration or deviation from above specifications,involving extra costs Will be executed only upon written order,and will become an extra charge Per over and above the estimate. All agreements contingent upon strikes, ac- cidents,or delays beyond our control. Note—This proposa ay be withdrawn by us if not accepted within days. A 'FA CCE Af CE C N thee ,oYe races IffifficatiMons ancorditlonys are satisfactory and pare here y "accepte o nt ,t o zed o o the work aS SpeClfle anents wlq be made l�S Outlined above y _ Signatiire� , Date R�L.C-ee To a� Signature GAi kum NC 3818-50 PROPOSAL MADE IN USA Z11 s.�.d..:,��•� .'° �'�x}:;s`�� ; ti2 y"1.+..�':,, '� ,a+��y.'l ,;i . 'ti _, f \c';+,r "� a- .y .� ;�c�. ' .. 1 t. i1. '-`_ • S k . E Crif of "Noriliamploll g E eaaAchnrctta _= — K DEPARTMENT OF BUILDr1\C INSPECTIONS — 212 Main Street ' Municipal Building NlorthampLon, Mass. 01060 W0jUtI:R'S COMPENSATION INSURA-ICE AFFIDAVIT (l i c;.ns::J peruli t t tx) v"ith a principal place of business/residence at: — �1 hone;-) - -- -- (snit/ci i J/stale/z�P) do hereby certify, under dllc pains and penalties of perjury, :1121 ( ) I am an employer providing the folio%ving workers cotnncnsauon cove:agc for Illy etuployees working on this job QIQ4-1 Y\,, �4 ---- (La=--mcz Corn:_V) (Poke-. Nu=Lxr) (T zv:ruon Date) ( 1 I am a sole propr;etor, general contractor or homeowner (circle one) arld have hired the contractors hste belo•ty who have the follovvug workers coctnensadon policies: (N=Ic of Co.^.!:".1CI0:! (InsLrancc Comoail i-Po6c-, i ) ?�uIr1LY; (- ) -- (Na me of Coutrzczor) --- (Insuanc ComowavRo!im, Numbczr) (L»ir tion Date) (Name of CO=CIO ) (Insarance Comparey[PoUq-Numbu) (L-xpirtion Date) (i ame of Contractor) (Insurance Compury/PoUcy Number) (Expiration DalE) (mach additicca!Ehcci ifoccc-s .;to mc'uc--WfonM1-t,00 pertnicaos to ell ooma�on) ( ) I am a sole proprietor and have no one workdng for me. ( ) I am a home owner performing all the work myself. NOTE:plc=.se be aanrt th.i-trio homeo+voen who employ pciotn to do m-2 rro-,•ncc cmm=r, oc er repair work oo a d..cll^g of not mocc tban throo halts in Winch the bomo�r=d,=oc oc the grouads appurk=m thccco arc oo(gcnc-ally oocrdatd to be employers A' tba warms ocmpCS--�icn Act(GLI52-s3 1(5)�applieiboo by a homcoa-=for a Gecn-oc patnrt ttuy cvidcocc the Iegi1 ctnuu of an amp loyer under tbo Workoet Com,00s lioa Ae< !!+,, I undcratzid th+t a oopy of thi.chlcmml may be focwordnd to tbo Doportmma of Industrial Acadoa&01L o of In-u-om for ttw covaagc vaificxtioc and that f ih rr to&came covangc,ID. C soaioa 25A of I.IoL 152 can Iced to tba impoaitioa of cumin%!penalties oomis6ng of a fmc of up to S 1,500.00_&Or iststaiso�of up to ooc year Lod civil pm+ltio is the form of a Stop Worlk Order od a fim of S 100.00 t day apiast me For.q.TtnxGW trio only Permit Number Map° _ Lot S LicciiscrJPcrrni SECTION$-CONSTRUCTION SERVICES 1 Licensed Construction Supervisor: Not Applicabfler❑P Name of License Holder : !O-A= QA,1� ���lr►1�► In License Number Address Expiration Date Signature Telephone :: F f Vzo.vn Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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. ,OJMJigned Affidavit Attached Yes....... ❑ No...... ❑ 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 �WCTIION 5- DESCRIPTION nr onnonec ch ck all appliga bfe oe New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition[] New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: Altsoell I Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 6a; .f 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 SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT'OR CONTRACTOR APPLIES''>:bR 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, , 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. ned under the pains and penalties of perjury. Print am Signature'of Owner gent 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 o `Northampton OR 2 7 i1 lD Department 2 ain Street DEPT OF SUi ' G INSPE S Ro{ m 100 fb°�Rtt ,� ton, MA 01060 phone 413-5 40 Fax 413.587.1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: This isectiott ty r�4fi ,r One Elm St. District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: l V1,C. t, Name(Print) C rre V Iing.Addr s: 1 Telephone Signature 2.2 Authorized Agent: l_ 1 �� n4'c- i6 �1c, ca,fJ�!L- Na Print) _ Current Mailing Address: 4 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit 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) 1 ! Check Number o This Section For Official Use Only Building Permit Number: aD ` Date Issued: hook Signature: Building Commissioner/Inspector of Buildings Date i i a I IN 104 LAKE! T' BP-2000-0943 GIs#: , . COMMONWEALTH OF MASSACHUSETTS � MV:Mock:I7A-249 CITY OF NORMPTON =Lot.-001 P-:c t: Buildina CategM:rooftz BUILDINGPE MT Permit# BP-2009-0943 Project# JS-2qO -1'731 Est.Cost:101ft Fee: 2 .00 PERMISSION IS HEREBY GRANTED TO. Const.Class: Contractor: License: Use Group: CDT CONSTRUCTION 130152 Lot Sitze[sa.fQ: 17772.48 Omer: CAPUTOVICTOR F JR&DEMISE M Zoning:IM Agekant: CDT CONSTRUCTION` A7': '104 LAKE ST .Applscant Atress: Phone: Insurance: 158 NORTH MAPLE,ST (413) 585-8677 Workers Comp1©n FLORENCEMA01062 M§ ED QN,412MO&_00.-DD TO PERFORM THE FOLLOWING WOR.g:SHINGLE ROOF OVER L`LAYER POST THIS CARD S0 IT ,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: d :3•d.0 THIS PERMIT MAY BE REVOKED BY THE CITY NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS, ertifiG #e of QQc u Si mature: Fee Tva� Receiut No: Date Paid: Check No: 407 Amount: Building 4/27/00 0:00:00 1885 $25.00 r - "t 4 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo