Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
02-019 (9)
(y Troposaf Vinyl Siding Corbett Home Improvement Windows 41 CPd s e- RDoorsg Northampton, MA 01060 Awnings (413) 584-6.571 Canopies &4f a�16 Q 6 Gutters PV�VTT �� Shutters PROPDS NL SIT M O 6Uf t"j PHONE 5—p Z/-'( Q TE O(J STTtF.ET JOB NAME CRY,STATE,sort ZIP CODE M4 k 6Z JOB LOCATION [DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: LL V IM (, G,,Y IM 0<5r, Scr-se.- - 0doiP o e'w 19 141"V'V eo a 766 w �S so 02 1 0, 3431 '�EA twill 36 a �,/e e4se".N j 5'o�0 i,b Lip M6) r^ we Cj�OpOSe herehy to furnish material and labor-complete in accordance with file above specifications,for the sum : \ Do rs Payments to he made as follows All nwtertal is guaranteed to be ac specifie+l. All work to he completed in a work-like manner according Authorized to slandard practices. Any altercations or deviation Gum above specifications involving extra costs will he Signature executed only only upon written orders,and will become an extra charge over and above the estiuwte. All agreements contingent upon strikes,accidents ur delays heyund our control. Owner to carry fire,tornado Note: This proposal may he W and other necessary insurance_ Our workers are fully covered by worknwn'.e(lrn pensatiun Insurance withdrawn by w if not accepted willun days. Acceptance of Troposa[-rite above prices,specifications are conditions are satisfactory and are hereby accepted.You are authorized to signature do file work as specified. Payment will e u le w cxlthroeo ahoy II S Z « �e--,W Spa b Date of Acceptance: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street UT Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): oV PTCdtT Sr Address: ko� g f- City/State/Zip: IV ole al j�/YJ 6,1060 Phony #: ��39LY—6 s7/ Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.CR I am a sole proprietor or partner- listed on the attached sheet_ ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. [] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right ol-exemption I)cr MG L. 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 15 §1(4), and vcc ha�c no 12.❑ Roof repairs insurance required.] + employees. [No worker~ 11M Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing al work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of thr;ub-rowiactors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance jur my employees. Below is the policy and job site information. Insurance Company Name:, Policy 4 or Self-ins. L.ic. ': _ Expiration Date: Job Site Address:_ _,_ c_'ity/State/Zip: Attach a copy of the workers' compensation policy declaration paf e (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 STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy oftlwi suitcutent may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains an penalt' •of periury that the information provided above is true and correct. Si nature: Date: 3- - 0 Phone#: —5; Official use only. Do not write in this area, to be 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 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: 77_ _ /J n U2 -ai17� r 06 7 L/v-C) License Number y-3-0 8 ��d N '�i•� S o t o a Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ C©R dP.7-f- A&Me- �i�-»r�avc�n ,.ter-' //6 4 6 9 Company Name e� O)o Registration Number 15-, /s%08 Address Expiration Date JJ ,) Telephon(`7�c3 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 Dermit. I Signed Affidavit Attached Yes....... sir No...... ❑ I 11. - Home Owner 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-vear Deriod 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement W' dows Alteration(s) El Roofing El Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding[0] Other[[I Brief Descri tion of-proposed Work: JAu— )O OW 11 FGC�'��4CQ/gGF/J li�lJn� dG�S w�G�w''� />}55 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa. If New house and or addition to existing housing, complete the following: 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. Masscheck 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 1 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 4anere as Owne honzed reby declare that the statements and best of edge f. Signed under the pains and penalties of perjury. Jr Print Name 34-00 Signature of Owner/Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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 O DONT KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO o DONT KNOW 10 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading;e avation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO �9 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only.; City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street SewedSeptioAvallability= Room 100 Water/Well Availability --_ \� ��`�oo�•? Northampton, MA 01060 TWO Sets of Structural Plans v Quo phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify_ APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 12 Ll.1 �!lQ Map Lot Unit f'�6 Zone Overlay District Firn St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: LAJ 611a/z 5,0,JT— s, Name(Print) Current Mailing Address: Telephone —5-9y° c�yyQ Signature 2.2 Authorized Agent: L)-kP-,Qz �a q Rfed /j '-6,.1 m6 cko c Name(Print) Current Mailing Address: N/3) s7/ Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed 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=0 +2+3+4+5) 361©Q Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 589 NORTH FARMS RD BP-2008-014 GIs #: COMMONWEALTH OF MASSACHUSETTS Map;Rl0ck: 02-019 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Catelzory: BUILDING PERMIT Permit# BP-2008-0749 Project=# JS-2008-001164 Est. Cost: $3200.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor., License: Use Group: Ed Corbett Jr 116069 Lot Sizelsq.ft.): 128937.60 Owner: CORBETT LAUREN A zoninv:RR Applicant. Ed Corbett Jr � TBa �;^R,N cngnnc, Rn Applicant Address: + Phone: Insurance: 4 Reed Street (413) 584-6571 NORTHAMPTON MAO 1060 ISSUED ON:31512008 0:00.00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS _POST `1'I-IIS 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 K THIS PERMIT MAY BE REVOKED BY THE CI OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGUL ONS. r,s_ Certificate of Occupancy si nature: FeeType: Date Paid: Amoilnt• Building 3/5/2008 0:00:00 $25.003741 212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo