42-152 HOMETOWN INVOICE
..,0,4 . S TRUCTURE S
� � 627 Southampton Road Order Date `
issomo'" sistamen Westfield, MA 01085-1329 Estimated Completion Date {`encl LiOL)
(413)562 -7171
Bill To 3tit &- 0c ,.c4 t-jL Notes
Address 14 T , 4'— cv 1 Lc; r'¢.
F k rv... e_ M 4 61 L 4.
Ph # 1 S S `i - }7b Rgliehone # ...5"8 3 3V...1
E -mail Address
❑ DuraTemp T1 - 11 A' V',M - '71-1 1 ❑ Vinyl
A In -stock Display Shed
❑ To Be Custom Built Body Color re ci Body Color
Trim Color Trim Color: White
Delivered Fu I ly Assembled (Includes fascia & trim around doors and windows) (Includes fascia & trim around doors and windows)
❑ Modular A ❑ Modular B Door Color rect Door Color
❑ Built On -site (Specify if trim on door is a different color) Corners
Corners re a SOFFIT CHOICE (For New England Style Only)
Size 14)- )r r} (% SOFFIT CHOICE (For New England Style Only) ❑ Venting Vinyl White
New England Series CI Solid DuraTemp T1 -11 Body Color CI Venting Vinyl Brown
❑ Exposed Rafter Tails Body color
❑ Keystone Series :II Aluminum Strip Vent Body Color Base Price $ — 7, (1 >
0
Style /U'-t) £r3 GeJ 51 Sk .d` Door Adjustment $ SL
Code 7' T Window Adjustment $
Shingles Windows Ramp W 6' x 4' ❑ 5' x 4' ❑ 54" x 4' ❑ $ id 0
❑ Dual Black ❑ 18" x 36"
❑ Earthtone Cedar ❑ 24" x 36" Loft ❑ 4' x 8' ❑ 4' x 10' ❑ 6' x 12' $ r d S
❑ Dual Gray ❑ 30" x 36"
14 Dual Brown 0- j;1' 36" x 36" Window Boxes ❑ Wood ❑ 18" ❑ 30" $
❑ Weatherwood ❑ 36" x 40"
❑ Harvard Slate ❑ Vinyl ❑ 24" ❑ 36" l
❑ Charcoal Gray Color
❑ ❑
Shutters riii Wood Color /Detail $ 6
Drip Edge: ❑ W on: Grids: ❑ W YPB ❑ Vinyl lt8
Single Door Double Door ( vv ) (? x9 (S k.d $ 6
Width 3' Width in $
Type T - E Type . r" 1° A
Transom Transom $
Grids: ❑ W JNB Grids: ❑ W 1538
Hinges: ❑ Std. )0Strap Hinges: ❑ Std. UStrap (subj to site evalua tion) $ Air J�) S it e Pre — pad size ) 5 x � �' -r
Overwidth Road Pennit Fee $ 1 ) ti r
Loading Illustration p rb rY 0 _— .- Er
Subtotal $ 7, 3 7 - 5
I Trailer Truck Sales Tax $ Y 0 `1. 3 e
a y. T OTAL $ '7, 7 7 9. 3 8 4.
r D_a Deposit $ -7. 7 7 g 3/5
I i t Balance $ b
1 I r 3 stomer Signature
30 -year architectural
2x- rafters 16" on
shingles over 1/2" CDX
center with col
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p roof sheet-
ties 4' on center
ridge vent
exclusive detailing, g.
with large roof overhang . ° °- � It
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a ,
double 2 x 6 header —
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over windows and doors p ressure treated floor
w�� system, 4 x 4 rails, j o is ts 12"
on center, 5/8" plywood
vinyl over 1/2 CDX plywood
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The Commonwealth of Massachusetts Print Form
i � , � Department of Industrial Accidents
1 Office of Investigations
... -; 1 Congress Street, Suite 100
: Boston, MA 02114 -2017
ww w.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): . ,' 11 S- c+ i S
Address: d S (,.fi\ „ o .
City/State /Zip: -)--Pt , 0)0Y-5-Phone #: Y/3 St° d r) /
Are you an employer? Check the appropriate box: Type of project (required):
1.PCP 1 am a employer with /O 4. ❑ 1 am a general contractor and I
have hired the sub-contractors 6. New construction
employees (full and /or part- time).
2.1 1 1 any a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub - contractors have 8. [1 Demolition
working any me in capacity. employees and have workers”
Y p Y 9. n Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. El We are a corporation and its 10.17 Electrical repairs or additions
3.n 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 12.n Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. Other 0(CCe .S - SO� -�
comp. insurance required.]
*An■ applicant that checks box #1 must also fill out the section below shoeing their vvorkers compensation policy. information.
Homeowners w ho submit this affidavit indicating they are doing all vw ork and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state kvh ether or not those entities have
employees. lithe 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
ii7 formation.
Insurance Company Name: il•Crks ,rc;Ack_
11
Policy # or Self -ins. Lic. #: T L)C- 3 3 O-) (o Expiration Date: 5 - d7-d613
Job Site Address: ) Ti nr Lit. City /State /Zip: lion/ C.e, f CVO6?
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.
1 do hereby certi y under the wins and enalties o ' )er'ury that the information provided above is true and correct.
SignaturE: Dater
Phone f: '113- 5(0 ) /) )
Official use only. Do not write in this area, to he completed by city or town official.
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 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL) 9 $/ g(o - _ d6/3
(n j'Z License Number Expiration Date
Name of CSL Holder
/�
List CSL Type (see below)
d (3;, Rocs
No. and Street Type Description
(1 � /�� U (unrestricted (Buildings up to 35,000 cu. ft.)
� �c }� ► / (�/ S b R Restricted 1 &2 Family Dwelling
City flown. State. ZII' M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
S L d- 7/-71 Insulation
'Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor (HIC)
Inc Registration Number Expiration Date
HIC qmpany Name or HIC Registrant Name
No. aid Street
Q-s4 k /) f: / s / / � � Email address
City /Town, State, ZIP 7 Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must he 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 l No ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. as Owner of the subject property, hereby authorize_ 14-cd k> ., .3 c
to act on my behalf, in all matters relative to work authorized by this building permit application.
WA
Print Owners Name (Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering niy name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of niy knowledge and understanding.
Print Owners or Authorized Agents Nanie (Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his %her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
ww w.mass.gov oca Information on the Construction Supervisor License can be found at www .mass. -dps
2. When substantial work is planned, provide the information below:
Total floor area (sq. ft.) Yo ' (including garage, finished basement /attics, decks or porch)
Gross living area (sq. ft.) Habitable room count
Number of fireplaces _ Number of bedrooms —
Number of bathrooms — Number of half /baths
Type of heating system — - Number of decks/ porches --
Type of cooling system — Enclosed Open — _
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
ILL'
AUUC - 2012 ,
The Commonwealth of Massachusetts
Board of Building Regulations and Standards
M assachusetts State Building FOR
pErN RrHArr.. ko o& MUNICIPALITY
--; Code, 780 CMR
USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Alan 011
One- or Taco - Family Dwelling
This Section For Official Use Only – 7
Building P 'i�'Ili''`i __ Date Applied:
� ig— •
Official (Pnn Name) Si Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 0 L)( )
1.2 Assessors Map & Parcel Numbers
- -i2 Tr an + 1 q rl - i /0''�nv /1 A
1.1a Is this an accepted street? yes 3e' no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
re 31 n - kn I '32 (0 70 -1 1 - 15 ' 4- /—
Zoning District Proposed Use Lot Area (sq ft) Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Prov ided Required Provided
3c o' +/ c: :`R: 'L'-- 36' - /
1.6 Water Supply: (M.G.I. c. 40. §54) 1.7 Flood Zone information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public t Private ❑ Municipal ❑ On site disposal system ,
i1 D Check ifves❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' of Record:
0,,. „4 W1% .`k d- 3,;-t_ 1311 Mtd6ros f to Knc_c_ IMP Ul v.).
Nance (Print) City. State. ZIP
I? Ti-R A L 55`) -?10 133 s'ILX C /\ . v Ma s s..e,
No. and Street I Telephone Nmail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner - Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. Ciff Number of Units Other ❑ Specify:
Brief Description of Proposed Work: de_ ii yv O 1: p re_ S s civi b k- q cC.es Sur? 6 J t ,
is
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
i (Labor and Materials)
I. Building $ G. ti-i0 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City /Town Application Fee
2. Electrical $ -
—
❑ Total Project Cost (Item 6) x multiplier x
3. Plumbing $ — 2. Other Fees: $
4. Mechanical (HVAC) $ — List:_
5. Mechanical (Fire -
Suppression) $ Total All Fee;: $
�� Check No /('heck ArnounT Cash Amount:
6. Total Project Cost: $ 1, ❑ Paid in Full ❑ Outstanding Balance Due:
,
File # BP- 2013 -0145 8 K
APPLICANT /CONTACT PERSON WHITE DAVID A & SUSAN MEDEIROS
ADDRESS /PHONE 12 TIFFANY LN FLORENCE
PROPERTY LOCATION 12 TIFFANY LN
MAP 42 PARCEL 152 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out )� /,(� �
( f �i
Fee Paid / Y C
Typeof Construction: ERECT 12 X 20 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Ap proved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER: §
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission - Permit DPW Storm Water Management
�e�•: ' nDelay
Signature o Buil g Of i_cial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
12 TIFFANY LN BP- 2013 -0145
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 42 - 152 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: shed BUILDING PERMIT
Permit # BP- 2013 -0145
Project # JS- 2013- 000238
Est. Cost: $6470.00
Fee: $48.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 30012.84 Owner: WHITE DAVID A & SUSAN MEDEIROS
Zoning: Applicant: WHITE DAVID A & SUSAN MEDEIROS
AT: 12 TIFFANY LN
Applicant Address: Phone: Insurance:
12 TIFFANY LN
FLORENCEMA01062 ISSUED ON:8/10/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: ERECT 12 X 20 SHED
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 8/10/2012 0:00:00 $48.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner