13-017 27 ROCKLAND HEIGHTS RD BP- 2011 -1114
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map :Bloc 13 - 017 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit # BP- 2011 -1114
Project # JS -2011- 001790
Est. Cost: $2351.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group_ LOW E'S
Lot Size(sq ft.): 24393.60 Owner: KRASIN- SAVENKOVA BRUCE W LUDMILA V SAVENKOVA -KRASIN
Zoning: SR(100 )//RI Applicant. LOWE'S
AT. 27 ROCKLAND HEIGHTS RD
Applicant Address: Phone: Insurance:
282 RUSSELL ST (413) 588 -0270 WC
HADLEYMA01035 ISSUED ON. 6129120110:00:00
TO PERFORM THE FOLLOWING WORK.- REPLACE ENTRY DOOR
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 6/29/20110:00:00 $40.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
-K
T e C mmonwealth of Massachusetts
FOR
((�°°ar of uilding Regulations and Standards
JJN
iMa�' tts tate Building Code, 780 CMR, 7` edition MUNICIPALITY
USE
lica 'on To Construct, Repair, Renovate Or Demolish a Revised January
NORTHAMPTON, AU o oso O e- or T wo-Family Dw elling 1, 2008
This Section For Official Use Only
Building Permit Number: Date Applied: Q
Signature:
Building Commissioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
1.1 a Is this an accepted street? yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area (sq ft) Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private ❑ Zone: ! Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner' of Record:
.t.�GE- SA V l r oy I� ocl'`t 9 ;l b�-fC
Name (Print) Address for Service
C,00
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner -Occupied ❑ 1 Repairs(s) X I Alteration(s) Addition ❑
Demolition ❑ Accesso Bldg ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work b(..y d 1�
lUa� -ec�t
SEC 4: ESTIMATE CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ � 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑ Total Project Cost (Item 6) x multiplier x
3. Plumbing $ I. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression) Total All Fees: $
/ Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ p paid in Full ❑ Outstanding Balance Due:
y�5 3a iL17-3
SECTION S. CONSTRUCTION SERVICES
5.1 Lkemed Cnetstfrtiction Supervisor (CSL) oq C t 15Z �
�l�` ;:)0 -06:r0 Li cense Number Expiration Date
Name of CSL. Hold 1 Ust CS1, Type (seen below)
1 Dexcsi taon
nre
U U stricted (up to 35.0w Cu, Est,)
R fteMated 1 &2 Fatnil Dwellin
5 I g� � M M:,sott of
RC tteeideotiel Roofialz Coverin
Telephone WS ltasident Window and
SF I Residential Solid Fuel Burnin A liana lnstallution
D Residential Duttolition
S. aco, , i�" o► rovemen Co ► rnrtar {HI.1) I mo t' C�
- G� c�, t
14 C�tnpan N C Reowint [tame a Itegistra 'or< tuber
Ex*.ItionDate
J� SignAwre Telephone
SECTIO 6, W ORMS" COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 157. 2SC(d))
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 d
SECTION In: OWNER AVVIORIZATI N TO RE COMPLUED WREN
OWNER'S AGENT OR CONTRAC'T'OR APPLIES FOR BUILDING PERMIT
I, LICC e, � lQKd v , as Owner of the Subject property hereby
uuthohic. L S aol-te-e, C�,�� } �� to let on my behalf, in all matters
r w
relative to work authorized by this building pettnit application.
- signature of owner Dale
ON - >✓R Olt AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the state information an the foregoing application are true surd accurate, to the best of my knuwlr dgc and
behalf.
T
Print tv C) 2 2� � t
Sin ner or Authorized Agent Date
( Signed er the p ains and penalties of 'ut
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires ate unregistered contractor
(not registered in the Home Improvement Contractor O UC) Program), will -t have access to the arbitration
program or 90=nty fund under M.G.L. c. 142A, Other important information on the HIC 1?togstim and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations l I0.R6 and 11015, respectively.
2. When substantial work is planned, provide the information below:
Total floors area (Sq. Ft,) (including garage. finished basement/Attics, decks or porch)
Cross living area (Sq. Ft,) Habitabic room count
Number of fiireplaces _ _ Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating systein Number of decks/ porches _
Typc of cooling syste - _ Enclosed Open
3. "total Project square footage" may be substituted for "Total Project Cast"
d << 9120 885 M OSI ML Sava) wOL 02-90-LL02
[00/[00'd 911^# �rt�P,l llb�.r' 7 /R';
M JA Us ffiTAL LED SALES P 112
Departnwnt of Industrial A ccidents
6fflee qf Invesdgatiomi
600 Wa.Mington.SWeet
Boston, M,4 02111
Workers' Compensation Insurance Affidavit: Builders[Con tractors/ F.1 ectri cia n s/P1 u nibers
Applicant Information - Please Print 1,egibly
Name (13u%iness/()Tga,nizationfliidividuil)' a
Address Lto
I- '-floor
City/State/Zi_p:_b"_flk, 0 11 0 P 1) one (q)
Are you an employer? Check the appropriate box: Type of project (requiretl)=
I. ❑ I run a employer with _ 4. 1 am a general costa actoTand 1 G. El New constniction
ciriployce-s (full and/or part-tirw).* have hired the sub -contractors
2, 1 am a sole propriclor or patiner- Wstotl on (lic attached sheet. 7. E] Rcn - K)dclitig
ship and have no employees These Sub -contractots have 9- ❑ 0 c , "Olitioll
working for the in ally capacity, f employees sled have workers, 9. ❑ Building addition
[No workers' 00tup. insurance comp, insuraoce.1 10.L] Electrical repairs or additions
rl�qtij red, 1 5, ❑ We are a corporation and its
3. 1 alp a hotncowfkcr do4 all work officers have exercised their l I.E] Pilinibing repairs oi
myself. [No workers' comp. tight ofcxernption per MGL 12,❑ Roof rupair%
insurance required.) t
C, 15 2, X 1(4), and we have no
employees- (No Workers 13.LK Other_
comp. insww1ce
' tatty applicant that k:ltec6 box 91 nium ahAJili out the soctionbel')w showing
11iciz wxkcrs'conTcn%&tion policy ipformation.
Hotwowncvq who submil this affidavit indicating they are doing, all work. and then him outside contractors must submit a nv%n affidavit indit;atizig such.
lContracton that check this box must attached an additional sheet showing the name, of the SUb-contruclon and state whether or ritA those entities have
CMPl0yCCR_ lfthL IlUve employees, they must provide their warkevi'cotap. policy number_
f am an emplejwr that is providing wotktrx'eompensad7 qn insurance for nq mphayeas.
Insurance Company Nwm,
Policy # or Self-ins, Lic- #_ , PV C Expiration Date:
... . /I
Jot) Site Address:__
Attach a copy of the workers! compensation policy declaration page (showing the policy number and expiration (late),
Failurc to secure coveragc as required under Section 25A of MOL c. 152 can lead to the imposition of crintirutl peruilties of a
fine up to ax1for one-year iniprisoranent, w well as civil perwhies in the form of a WORK ORDER and a fine
of up to $250.00 a day against die violator. Be advised that a copy of this staletinerit may be forwarded to the Officc of
Investigations of the DIA for J,_ ar= coverage verification,
I do hereby earfify it e r pains abies p
oftrjury that the information provided above is true ndeorreer.
Pate:
I'hctrtc #: C 44 4f131 8 5
Official use only. Do not urile in thin area, to be compkfed by efty or lawn offidat
City or Town: #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Ck-rk 4. Electrical Inspector 5. Plurnbilig TnsPMt
6. Other
Cijatii et Persoill Phone
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