02-019 (7) � PELLA PRODUCTS, INC.
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--- --. --- -- DON SCHABACKER
Location__
Phone: 413 736-9239
_— FAX: (413)736-3390
---
oate_ _ Pager: (413)292-2826
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Bundling '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE kr1T11DAVTr
—
(licensee/pecrmittee)
with a principal place of business/residence at:
(phone#)
(street city/state/yip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) —--- (Expiration Date)
I ani a sole proprietor, general contractor o homed e- circle one and have hired
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the contractors listed below who have the following worker's compensation policies:
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(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (lnsurance Compaay/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Compary/Poky Number) (E,\pLmboa Date)
(Name of Contractor) (Insurance Compa2y/Policy Number) (ExT,,i.ration Date)
(attach zMiticeil sheer fnccc zu to include infocnulion pertaining to all ocatred.ors)
O I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:ptc:sc be aware that while homcotAvcrs who employ pc-s m to do U injc .n•Y cro:r3trtcien or repair work,on a dwelling of
not mote than tJmo units in which the bomoowncr resides or on the grounds appurtennni tbcrdo arc no(gcrxralty ooasidcrcd to be
employers under the workces companafion Act(GL152,=1(5)),application by a homcow-=for a 6CM54 or pt'�may evidence the
legal ctat"of an employes under the Workode Compensation Act..
I undcntind th:t a copy of this anfcmcnt may bo forwarded to the DcparTarnt of Industrial Ao admty Offs o of I--for the
coverage vmficatioa and that failure to secure oovtt tinder scction 25A of MGL 152 can Icad to tho imposition of criminal pencils es
consisting of a fine'of up to S1,500.00 and/or u� of up to oat year and civil penalties in d)c form of a Stop Work Ord"—and a
fins o(5100.00 a day against me
4 —only
For dcputn' l
o Permit Number
_Lot#
Signature of Liccnseelpermitfee �e
SECTION'8 .CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : LAr -
License Number
a t r.
Address Expiration Date
Signature Telephone
9Reg�s"tgre� tl�ri p eme "tCbtt ntr�acCtir< �xft °� x° Not Applicable ❑
.. ::,
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....... Ef No...... ❑
11.,: orne wne eji n
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 buildinlZ 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' ;.. ompensation) 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 Loc Zoning Laws and State of Massach setts General Laws Annotated.
Homeowner Signature
SECTION 5 DESCRIPTION�OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ Siding[ ] Other [ ]
Brief Description of Proposed Work: U-Wa12: "' rr:-. 0L CK ON 4r? ,7 rL':". "o °
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
a"f INeW:hoi se.atid nr cldition exlStin' hou in cnrn"1et� tt e.followin
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?
t
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 -,OWNERAILITHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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I,
ZA & as Owner of the subject property
hereby authorize __. to act on
my behalf, in all m ers relative to wo authorized by this building permit application.
Signature of Dwner4 Date
IA; (J �' 1�c3 � 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 p�ejrjury.
Print Name
Signature of Owne 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: r *_ ", L: R: T�
�C�'
Rear � •, ' S�
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking) ��1, v
#of Parking Spaces
-
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding,ever been issued for/on the site?
f
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:
City of Northampton
® rr e artment
L�, 2[f Street ,. .
100 a
APR N rtha MA 01060 g.
.i i�l (� "' � w
phone 137 Fax 413-587-1272 hot/ Ite i
. Qt1,�er�Speolfy
OAt!! TO 1COtJ '1 E7CT, AL ER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION-1 - SITE INFORMATION
This section to beaGompleted b offtce
1.1 Property Address: f
/� A Map Lot� � f i
�S� (3I O 4 �, Zone `;Overlay Distrtct �
t��IV �; 1w; ,�
Elm`St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
i 2.1 Owner of Record:
LA u rec A/ -AyAl c4ore eft /v. s /P-,/?
Name(Prinp, Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION.3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by permit applicant
1. Building �2 _ / "� 0C"—' (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
This Section For Official Use Only
Building Permit Number: Date Issued:
Signatures
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0824
APPLICANT/CONTACT PERSON CORBETT LAUREN A
ADDRESS/PHONE 589 NORTH FARMS RD (413)584-5440 Q
PROPERTY LOCATION 589 NORTH FARMS RD
MAP 02 PARCEL 019 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid C_
Typeof Construction: CONSTRUCT 40 X 10 DECK
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
INF99MATION PRESENTED:
Approved 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 ssion
42 --002-
Signature of Building Official 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.
BP-2002.0824
589 NORTH FARMS RD
COMMONWEALTH OF MASSACHUSETTS
GIs#:
M CITY OF NORTHAMPTON
ap:Block:02-019
Lot: -001
Permit Building
•
ADDITION BUILDING PERMIT,
Category.
Permit# BP-2002-0824
Project# JS-2002-1374
Est Cost: $14000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group.
Lot Size(ss ft.): 128937.60 Owner: CORBETT LAUREN A
Zoning:RR Applicant.• CORBETT LAUREN A
AT. 589 NORTH FAPMS RD.
Applicant Address: Phone: Insurance:
589 NORTH FARMS RD (41-A) 584-5440
FLORENCEMA01062 ISSUED ON.
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 40 X 10 DECK
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: C!L $
Driveway Final:
Final: Final"((e-:;,
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough:
Oil: Insulation:
Final: Smoke: Final: Q!C G/9•pa
THIS PERMIT MAY BE REVOKED BY THE CIT OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
367 $50.00
Building
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo