29-410 (Proposal—
Vim' Sidi n,_
Corbett Home Improvement rdk'
Northampton, MA 01060 Do. ,
Avkll�2'
(413) 584-6571 "allople,
("utter'
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DATE(+PLANS IIIBPIIONFOZ5,3_��Y
We herchy submit specifications and estinmics tor:
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ProPOSe herehy to f'urnish material and lahOU-COIllpleIC in accordmicc with the above specifications,for the SuIll of
Dollars CS 6 96u
Payments to he made as follows:V3 DePq S-Ir
All o.aerwl is guarantee([to he as specitied All work to he completed iii a w,,rk like mrnmcr o(Wung Authorized
k,slondord practices. Any altercations or deviation tram oN,,v 111""I"Irlp'Xtm cost's Wa11 he Signature
executed only upon written orders,and will he(orne an extra charge over and ahnwe the rsliniale, M)
agreements contingent upon strikes,accidents or,lel3vs hey,,11,1 our(."Iltr"I Owner "'arry tire (mlado Note: TIn.s proliosal may he
an(l other necessary insurance Our workers are tully coveted by workmen Compensation ITISUrunce withdrawn hy us it not accepted wilhill
Acceptonce of Troposaf The above liriLes,SI)ecificalwil.,
are(onditions are satisfactory and are hereby accelitcd You arc authorized to
Signalur
do the work as specified. Payment will he maile a.,outlined above.
Date of Acceptance: Signature
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DEPARTME11T OP DUILDD'�G INSPECTION
212 Alain Strcct ' Municipal BuildwU
NorthamPtor., Mass. 01060
WORIC ID'S CO�KPCNSATION LNSU-RA CF AFFMAVIT
'.riiil a p12ncipaJ place of business residence at
(SII�-t/ci(y/Stalc�Zi p)
do hereby cert-if , under the pains and penalties of perjury, 11
I zrn an employer providing tJhc following worker's comocns7�uon cove-fie for Illy
elupiovccs worljng on this)ob
i am a sole proprietor, general contractor or homeowner (c c!e one) a,id have hired
the con,ac,ors lis-ted below v,,bo have t_he `okvvMP vvrorker s cow Den don pokles:
-- ( �annc of Co�';ac,o�1 (In urine Comov��iPcuc, '�um'e=;) l_>:u,s,n;�r�. I�alc)
ConQnc,or) -- (lnsiranc Comoa]�/Poljc, Dane)
-- 1:_;i e n;Conn-acIGO, CLnsu a.LIcc Cori iav)-/PoLc, N,lsb t) C �p ruon Datc)
—O1 amc of Contractor) (LnsU=cc Comczay/PoLcY NumrI) (E.vpu-ation Dac)
i,eai=�'�:b�i:;oc>1 s'.-uc-t tf❑ct�ii.� t�m:!uck in(cxz�aoc: pm,:�aiu�to.11 o�cY_-�e:a:)
I am a sole propne-tor and bave no one worl=g for me
( ) I am a home owner performing all the work myself.
t'CITT ple b ewvt C l:'i-Jc boa> -n ubo cry p,l w w,-, L �� c rcaau•.or n.d.•cll or
x ao c 2 n L o �r n..dab tfx ba»o-.� rc do or oc chc g f n r_ been t o-x C�. lhy :dpi w tic
c loyc7 u�lc tyr.�.a-{;ct7 _, ,,cc A ,(GL152 v1(5)� -ppllativ try D 6o,T-olT fcr_Lczr--:a pcnnn n_y trc
IcgJ rt>aa<or—c.:?toy-uod—rho Works e.co¢ipoa_al;on^'c-
I uodo-ri..od cbc>oopy of Lb-cn-Lc i o y be roc—,id d w Lb,Cop—t—i of ind.w;rJ A dooti offiod of for the
cove -L, Ncr C:Iioo aid thu L•iltzm to smut LovcTtsc and soctioa 25 A of MGL 152 cw Im.d to the Lag= goo of almia>J pcwdbi
000ysmg of a riff of up to 51 500-00 anNor=Priw®crri of up to ooc yt3, ca'Ovd pm Pjn�tc form or o Stop Wor4 Ord-
fir^of S 100.00.ay t&A.inA OY-
For dcA.nm=��,�owl y
P�r�l
Lot °
e
Si�nacun �fLICU�sccJ}'crmiucc --
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su /rvisor.:/ ///J� �/ /�,.�} t Not Applicable
� ❑
Name of License Holde J N \ OJ�/- c:d 1 00990
J 9O
License Number
�( 4 -D 0-o y
Address Expiration Date
Signature Telephone
9. Re i red:Home>Imurovement Contractor r ;`, `` Not Applicable ❑
' ��l
Company Name Registration Number
Z2
Address /�//� Expiration Date
5 Telephone— ' 657
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.
Signed 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 whicb 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 fob 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
w i
5- DESCRIPTION OF PROPOSED WORK (check all applicable)
Addition ❑ Replacement Alteration(s) ❑ Roofing ❑
Windows Or Doors ]
Biay Demolition❑ New Signs [ ] Decks [ ] Siding FV Other [ J
I
Yrwy1
:jt,,room Yes _ No Adding new bedroom _ Yes No
Renovating unfinished basement Yes No
Sheet
Nevv house and or,addition to existing housing; com:otet�e:the tdllowing
one Family Two Family Other
each family unit:. Number of Bathrooms
a nacned,,
-Dotage of new construction. Dimensions
Fireplaces or Woodstoves Number of each
compliance. _ Mascheck Energy Compliance form attached-,
100 ft. of we-lands? Yes _ No. Is construction within 100 yr. floodplain Yes__No
_r cellar Moor below finished grade
the Building and Zoning regulations? Yes- No .
iTy Sewer Private well City water Supply
�h /a OWNER AUTHORIZATION -TO BE COMPLETED WHEN
RS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
to
alters relative to work authorized by this building permit application.
---- ---
Dates
as Owner/Authorized Agent
atements and information on the foregoing application are true and accurate, to the best of my knowledge and
ar,c perialties of perjury.
c
0 w * v#
Section 4.
A14- INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zonmo
This colunin to be filled in by
Building Department
-�cthaA'-s Front
Footage
oi Spaces
� Has Special Perm it/Voriancc/Finding ever been issuedfor/on the site?
NO DON'T KNOW YES ___________
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
ND DON'T KNOW YES
IF YES: enter Book Page and/or Oocument #
!� )ocs the site contain a brook, body of water or wetlands? NO _______ DON'T KNOW
/ES
IF YES, has permit been nr need tobz obtained from the Conservation Commission?
Needs tmbeobtained Obtained Date Issued:
� Oo any signs exist onthe property? YES NO
�F YES' describe size, type and location:
A there any proposed changes to or additions of signs intended for the property ?YES ___
No ��_
YES, describe size, type and location:
/ '
# Y etS�a ly r
City,of Northamptonst soy 4�
Building Department Cry a ve a '' ► �k,
r n 212 Main Street
And 2 Room 100
Northamp on, MA 01060
ptgne 413-5'87-12 0 Fax 413-587-1272 Pb rIN art �a
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
erty Address: This section to be completed by office
1.1 Prop
Map Lot Ur�ifi`
Zone Overlay District
Elm St.District Ca District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: I
jvlj
Name(Print) Current Mailing Address:
7
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item _ Estimated Cost(Dollars)to be Official Use Only
—completed.by permit applicant
1 Building (a) Building Permit Fee
Electrical (b) Estimated Total Cost of
Construction from 6
s. Plumbing Building Permit Fee
4 Mechanical (HVAC)
S. Fire Protection yr
6. Total = (1 + Z + 3 + 4 + 5) Qd-- Check Number J
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
105 SANDY HILL RD BP-2004-1071
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-410 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-1071
Project# JS-2004-1595
Est.Cost:$9900.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: Ed Corbett Jr 116069
Lot Size(sg. ft.): 12414.60 Owner: LUSSIER TIMOTHY S&WENDY E
zoning€:URA ADpticant: Ed Corbett Jr
AT. 105 SANDY HILL RD
AiyiicantAddress: Phone: Insurance:
4 Reed Street (413) 584-6571
NORTHAMPTONMA01060 ISSUED ON.413 0.00.00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOWS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
i
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Finale Smoke: Final: O K - 1$ O Z{
THIS PERMIT MAY BE REVOKED BY ZCIT F NORTHA MPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIOCertificate of Occu an i nature: �R
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 4/30/04 0:00:00 2259 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo