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35-209 (2) NtA .AA flings Ilia' We Ile 1'c1)y."1jh1l'1 t Q111A)•� ��T�-� 4 e GI 3 Of NO; -= V, f DEPARTMENT OP t3UlISJR,,;G iNSPL'CI IONS — — 212 Main Street Municipal Building, Northampton, Mass. 01060 WORICER'S COMI ThNSATION INSURANCE; AFMAVIT (li�ttsccJper[nl tttx> %with a pnncipal place of business/residence at ` '`�--- ? D�4(lJ_ (j hone }_��3 =-(057 do hereby certify-, under the pains and penalties of perjury, _hat ( ) I am an employer providing the follo%vuw %voikerjs comnensaton cove:.ge for my cu)plrwces �VOI'rArl on falls job (it:n;r,�ur Coral t�) iPn,t<-� Numlr_r) (� ipirnor D�;.^) ( } 1 lint a sole pr oDr'ictor, gcIlci dl Conti uCIOr or holneov"me. (Cu cle One) alld have tliled the contractors listed below who have the followUI�I workel"s comnen--,-non nohcles. (211anic of Con! cto:) (trtsurancc Coleman}/Pnhc ?vTram_--:) (Iapirnuo❑ Dmc) (Name of Contractor) QnstlnInc., Comm 1%'TP0hC-, NUIDD T) (-Equimoon Date) — --— (Narne of Contractor) (Ins�ran<� Comj��n�rPol cti Nutt r.�:) (Expir io❑ Date) (Name of Contractor) (Iasllran Comha�y/Po1�cy Numlxr) (Expiration Dare) (r.ttach ukliti«tag s_`xct if ncccca:,;to irx�hx4 inl�x-t_ia;i on l.a to inuu In ell�i:-r�c-'o:z) VI am a sole propnetor and have no one worming for me. O I am a home owner perfonning all the ,York myself. NOTE::please be awatc t2uz w4,`._10 honYinvnc-wbo caipluy 1c.u-,ns to&et-_>micaaac�,c rcrwuon or rcv a work oa a d,cllutg of not moor LILtu t}mre UnAl in%kincb ttae hocir..owtxr resides or tar the p-cwcx3s appurteaar:f therm Wr tx:,t F,,--xzatty eoesieicral to be ez:tployrrs unde-T the%4wicxr's oa�iiat Aa(GL152,n I(5)),application by a homeowner fur e bccrm or permit—y-id—the legal ctnhie of an¢nployer under thn Workcl■Compao,aLiou Act I--i island that a cvyy of thin cxitrnx-rat—y bo forw_ted_tbo pc�xirtn�cnf of li�itri el Acn&.&OQiw of I�ursaco for thn covml e vcrifiestioo and that Utse to smut coverngc under scc ion 25A of MOL 152 ctn Imd to the imdion of mmmc l pca+tt- 000sinLng of a pint of try to S 1-500.00 aljcvc r of up to ooc year and civil pcnahia in the form of a Stop Work Ord r and a Lra of S 100.00 a dsy against Mc, Ftv dcpuvzmil uac on)y Permit Ntunber Map:,' Sign;thtrc of Licm1 cc/Pcrnrittcc TlI (I- \ SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: — License Number Address Expiration Date Signature Telephone 9'Fiee�st°erd iibmefmp`rrmett ion#ra"c o sm �:R << Not Applicable ❑ , .r 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. Signed Affidavit Attached Yes....... ❑ No...... ❑ 11. -'Home`OW,ner-Exemption 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 -- t, SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ ReplacementwWindows Alteration(s) ❑ Roofing ❑ Or Doors G®'' Accessory Bldg. ❑ Demolition❑ New Signs [ ] 1 Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed WorkTN�lt is vIrJK 1 (T)A V"'q- Witc(ofas w low —1 G lftss Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative n Renovating unfinished basement Yes No Plans Attached Roll❑ - Sheet 0 sa Ifr�Ne°v'��houseanch-orsadtliti�i� fa"existing:ho"�r�it�� `compfef 'tttie fbtl'owin�: 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? h. 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 FOR 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 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. Signed under the pains and penalties of perjury. Print Name Signature of Owner/Agent 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: of Northampton G 7f 8 Egil A n Department m Street DNra 0 100 'in, MA 01062 DEPT 240 Fax 413.587.1272 PECTIn APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECT_ ION I SITE INFORMATION `'This section to be completetf h off,�c 1.1 Property Address: ; s Ma ., l.oi x CPuba1 .',. X31 �JeS �w��or! � : Zane. Overld Disfr�ctax w * V Elm 5t D(krjtct' GB District SECTION 2'- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Ljewo 7A 9 kows 5.40,e- AS A 801Jf- Name(Print) Current Mailing Address: Telephone Signature 7 2.2 Authorized Agent: 001,w T� �P sf rU 14,L/ gin ©lobo Name(Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted 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) Check Number 5 This Section For Official Use Only Building Permit Number: Date Issued: Signature:.... Building Commissioner/Inspector of Buildings Date 531 WESTHAMPTON RD BP-2001-0014 GIS#: COMMONWEALTH OF MASSACHUSETTS rilftjfflock: 35-209 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:windows replaced BUILDING PERMIT Permit# BP-2001-0014 Project# JS-2001-0030 Est.Cost: $4600.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor License: Use Groin Ed Corbett Jr 116069 Lot Size(sq.ft.): 66646.80 Owner: YARROWS LEONARD&MARY L Zoning_ SR Applicant. Ed Corbett Jr AT. 531 WESTHAMPTON RD Applicant Address: Phone: Insurance: 4 Reed Street (413) 584-6571 NORTHAMPTONMA01060 ISSUED ON:717100 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWSW/LOW-E GLASS POST THIS CARD SO IT IS VISIBLE FROM THE STREET nspector 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: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 7/7/00 0:00:00 3591 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo