29-344 'Troposaf
44 Corhett Home Improvement
Northampton, MA 0 1060
(4 13) 584-6571
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m DEPARTMENT OF BUILDI�C INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. C11060
WORKER'S COMPENSA'T'ION INSURANCE A-FFIDAVU
(li censcr/pernl�ttcc)
��itil a. prizlcipal place of businesslresidence at
MA OJOCO
(stse�t/ci ty/nat�!r�p)
u hereby certify, under the pami and penalties W,p-�r�uly
131n an employer providing the followins, ,�ur ers cunlDt:ns a;un coverage for my
employees work-irg on this job:
(Insu,=ancc CompaEy) (Policy Naoibcr) (Expiration Date)
j r Lu-1 a soie proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the follo,,vi_ng workers compensation policies.
-- ---------------
(Name of Contractor) (Insurancc Cornpan),/Poliq Nlllnbcr) (Expirution Date)
(Name of Contractor) (Lnsurancc Con u�.../P�!.��� NIlmtx'r) (Expiration Date)
(N 1n-'C of Contractor) Jrtsuraac Comb_fly/Po' ,.r N�t:ntxs) (Lxpiration Date)
(Name of Contractor) (Insurance Comnalt} p i y NlunbXr) (Exprrati oa Date)
(attati,ad'1itiocial�xCl ifncccsury to ndu c nfocrnatioa Pcrta u rig tc all ar7aaon;
I <u>a a sole propnetor turd have no one work-Mg for 1ne.
O I am a home owner performing al( the work IlIvself.
NOIT;:p!c ac be a rare l aiµtile lxxxo tiixta tvho cnploy{ w;s to:i a n cianc� v s n iai cpau«ock n a d tc11 ag of
I1CA nroc-c th=Lluce units in tritidl the ha:rou'rxt rraidca Cr on t_tic grcun!�zr furictLUd tlwcto arc,xt telly coatidc:td to be
m.pro}va urY cr the«o isi s c Yrpvnatim
Act(GL152 sa 1(S)),r.{ licaticr,try a han.o vn fora xnsc or permi:nay cv dam the
lcgil ct v e of an oraployx under tho W«kce.Cocap_tioct Acx_
I undo.-sltnd that a copy of this ci.at.cu t a-y bo tocward«1 to tlw of l,"L t al A�'c. ,ty Offioo of for th7
covaab-c vmfrcatloo and that failtn-c to acatrc covcrago undcx SCCUOn 25A of MQL 152 can[cad to Lhc n xiziiioa of aiminal pcnaltics
crouaiating of a fine of up to S 1,500.0o m-Aloc izupr-'o Xzi of up to one}Tar a:)�j rit,1] Lies in ffc f6az of a Step Wert Or&z and a
of S100.w a dly 1&&Uzt me Ems'
/) For dcpu4mCa1 wo cXIIY
/e/ ry� 1�CTIIllt l�llnlr
` ,��I A44_ 71 02-, Map;l Lot 4
— - Se�aturc f Licans- e CMI-ittce ��
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by zoning I
f
This column to be filled in M
Ruilding Dcpartmcm
i
l,ot Size j
Frontage 1--- -- - --- - - __J
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 _ --�-- -- - — -----_----
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 tt
R. Does the site contain a hrook, body of water or wetlands? NO DON'T KNOW .
YES
IF YES, has a permit heen or need to he obtained from the Conservation Oom��issior ?
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 Y S, describe size, type and location:
SECTION 8 - CONSTRUCTION SERVICES
b 1 Licensed Construction Supervisor: Not Applicable ❑
`Jdn,r of License Holder -� ��.����.��. f �.L�,t���ji(` 1.7 „j t� L t+. 7 C
----
License Number
relepr,o,,e
9Registered HomeImrovertieiit Contractor 'ECM ,, �� " Not Applicable ❑
Company--Name Registration Number
r
:. . ....
Olt-
-
Expiration Date
n elepFone '- ---
'
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c 152. § 25C(6))
d ul.[r tte-' application. Failure to provide this attiu<::
�n �.he denial of the �ssu� � e o` I�� t'o i1Ir17 pE
:aavit Attached Yes y do.
l�lom � wnerE empties
The current exemption for"homeowners" was extended to include Owner-occupied Dwellings of one(1) or two(2) farmlic•;
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 them°
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 it two-year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptahlr to the Building Official, that he/she shall be
res >onsible for 1111 such work performed under the buildill�)crunit._
\ti actin( Construction Supervisor dour prase ncr on the joh site will I)r rcauired 110111 time to tinge, during and upon
oniplctlon of the work for which this permit is issued
\Iso he advised that r�ilh to 0iaptcr 1 ori r uinprn:;anon) and Chapter 1.� (I.labillIN of Employers
mp.w'ccs lot in)urics not resultine Ili llcutlt) of the you may be liable for pv.you,:
.01,1 Imc, to perform v�ork fur',ou under this pcnnit_
I he undersigned "homeowner" ccrtiti:S anci assuut respona11 1111, lot compliance with the State Building"Code, Cits of
�"urthanll'�ton Urdlnances, State acid I.o al L«nintt , arcs ,1nci State ,)I h1Lt S 1chu')ctts C;eneral Laws Annotated.
homeowner Signature
SECTION=5=-DESCR'IPTIONtOF:RROPOSED WORK(check all applicable
New House ❑ Addition ❑ Replace t Windows Alteration(s) ❑ Roofing
I Or Doors
Accessory Bldg ❑ Demolition[] New Signs ] Decks ( ] Siding Other
' Brief Description of Proposed Work: )"A-- l�!lie!'r _ 11f.r_U7 S
Alteration of existing bedroom Yes No Adding new bedroom _ Yes No
Attached Narrative ❑ Renovating unfinished basement _Yes No
Plans Attached Roll D - Sheet D
saIfNewho'tTis"e"and O�ratl`tlition t`o exisfingK:hoiasing'' completethefollowin' :
a. Use of building : One Family _'' Two Family Other
b. Number of rooms in each family unit:_ Number of Bathrooms___
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?
In. Type of construction
Is construction within 100 ft. of wetlands? _—____ Yes ___._._ No. Is construction within 100 yr. floodplain _-_._ - e
j. Depth of basement or cellar floor below finished grade
i
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
01WNERS,:AGENT OR;CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the su
hereby authorize
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorizer. Age-
hereby declare that the statements and information on the foregoing application are true and accurate, to the best c'
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date -_
4
�,� -- —�. n � Y"bf Northan�pfon �-
11 Sat s of Per It
!'
E3u01 i�mr, Deharttiir W Curb Cu
r-
MAY 2 3 1OC2. '2? Main Street Sewer/Septic la
4 i M "c,y
q.
E 00111 100 Wat' elW I
-- than pton. MA 1 6 fist c a a
Ni
Other Specify
APPLICATION TO CONSTRUCT. ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWC FAM!I-v P't"YE'. -
SECTION 1 - SITE INFORMATION
;.1 Property Address This section to,be,completed by office
9z 4L6-i1k Map- Lot Unit
Zone—_ Overlay District
Elm St. Districl CB District_ _
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
Z1 Owner of Record:
2-0 7s
2.2 Authorized_Agent:
SECTION 3 ESTIMATED_C-ONSTRUCTIO_N COSTS
, ± r Official Jae CMIN
�o �plet�d by �e,r,r --
�,' r�� ildir F r'� mit Fee
I i
1otal Cost of
stuff ?ion from hl
Building Permit Fee
I,
This Section For Official Use Only
Building Permit Number:_
Signature: ---- -
Building Commissioner/Inspector of Buildings Date
94 AUSTIN CIR BP-2002.1056
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma :Block: 29-344 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2002-1056
Project# JS•2002.1693
Est. Cost: $6500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Ed Corbett Jr 116069
Lot Size(ssq. ft.): 19732.68 Owner: EASTMAN GLENN A
zoning Applicant: Ed Corbett Jr
AT- -94 AUSTIN CIR
Applicant Address: Phone: Insurance:
4 Reed Street (413) 584-6571
NORTHAMPTON MAO 1060 ISSUED ON:5130102 0.00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL SIDING & REPLACEMENT WINDOWS
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: ,o H g'a 3
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. - �s
Certificate of Occupancy psi natur
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 5/30/02 0:00:00 1588 $25.00
212 Main St-A r,•?'hone(A 13)587-1240,Fax: (413)587-1272
T u.z " i,.sioner-Anthony Patillo