31A-021 9 SANDERSON AVE BP-2016-1477
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:31A-021 CITY OF NORTHAMPTON
Lot: -001_ PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: induws replaced BUILDING PERMIT
Permit# BP-2016-1477
Project# JS-2016-002531
Est. Cost:57856.00
Fee: 840.00 PERMISSION Li HEREBY GRANTED TO:
Const. Hs: Contractor: License:
Use Group: JOHN CORBETT J2 078297
Lot Size(sq.ti.l: 5357.88 Owner: KUSIAK U:_:P. Y TRUSTEE
Zoning: URB(l00)/ Applicant: JOHN CORBETT JR
AT: 9 SANDERSON AVE
Applicant Address: Phone: Insurance:
38GRAV'ISST LI 31665-22860
SOUTH DEERFIELDMA013731SSUEU ON:6/13/20i 0:00:00
TO PERFORM THE FOLLOWING WORD: NSTALL 20 REPLACEMENT WINDOWS
POST THIS CARD SO IT IS VIS113LE i ^.OAI P.:: STREET
Inspector of Plumbing Inspector of Wiring 1/.10D. Building Inspector
Un dergn mad: Service: Meter:
Footings:
Rough: Rough: Foundation:
hrn.r. Final:
Final: Final:
Rough Frame:
Gas: Fire Depart went Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOLLID BY THE CI'h1: OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy _ i mature:
FeeTvpe: Date Paid: Anionitt
Building 6/13/2016 0:00:00 41044
212 Main Street_ Phone{4:1) / -1240,Fax:(413)587-1272
Louis I IashroucL—Eo i I:Ing Commissioner
`,1 Department use only
.��, �.' � City of Northampton Status of Permit:
, P \ Building Department Cum Cutkhiveway Permit
Q. 212 Main Street Sewer/Septic Availability
�� Room 100
Water/Well Availability
�` Northampton, MA 01060 Two Sets of Structural Plans
_ - phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
p5'` Other Specify
'`•UCATION 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
7 SA ;nAtit AVB- Map Lot Unit
/I,Iorayk•-rp)on Zone Overlay District_
Elm St District ,, CB District^
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
27 Owner of Record:
. . r
Name(Pint) Current Mailing Address:
Telephone
Sgnature
2.2 Authorized Agent:
—, ,
Name(Print) Current Mailing Address:
1%
� Si, -vis sic l io
Sig .9- _ Telephone
SECTION 3-ESTIMATED CONSTRUCTION COS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Budding Permit Fee
4. Mechanical(HVAC)
5_Fire Protection
6. Total=(1 +2+3+4+5) _ B+ $S6, v0 Check Number C/
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: ., ____,
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING AB Information Must Be Compk ited. Permit Can Be Denied nue To Incomplete Information
Required by Zoning
111.11111
This coDe arbe rated in by
Building
Department
IPMIIIIIMIIIMIIIIIIIIIIIIMIIMIMIIIIIII
Front
Side Mal.
Rear
Bldg. Square Footage _�
lia
DinOpenr Space Footage
{aptarea bldga paved
kin_
#of Parkin:Sraces
IIIIIIIIII 11.111111.1111111111.1.
Fill: ---
volume&I Mesion
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
8. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained a Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 O
IF YES, describe size, type and location:
E. MU the construction activity disturb(c�l"e'�aring,grading,excavation,or aging}over 1 acre or is it part of a common pian
that will disturb over 1 acre? YES () NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House (l Addition D Replacement�Windows Alteration(s) n Roofing n
Or Doors gi
Accessory Bldg. Q Demolition [1 New Signs (CD Decks jp Siding[al Other[CA
Brief Description of Proposed •
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a 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 stones?
f Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h Type of construction
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 la-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
,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
.1111.11.111.111.1111.111011111111.1111.1111C-
ge e�rd¢bY declare the best of my,as Owner' uthonzed
re that the statements and information on the foregoing application are true and accurate,to edge
and belief
Signed under the pains^ and penalties of perjury.
.�nHnJ C o/E..., . .
Print Name —......�.....
‘' /3 ‘/(
Signet"OwneQAgen Date
SECTION B•CONSTRUCTION SERVICES
8.1 C.. ; S,, rvi Not Applicable ❑
Nemo of License Molder: . .+ t/
r
License Number
?. Sr 7. get LI S .26 ' Sr
Address
Expiration Date
Rr. a I ^.t'b't/. " . 713 ..
Sig ter- - Telephone
R. ' sr• . r0 ,.. , . . ,it • Lt1IM _ Not Applicable ❑
.) Gi��cM--Hemi t�rris
/LS
Company Name Registration Number
ere 1 • A
Address Expiration Date
_..... TelephoneA . . . . -, a,
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 4
12. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 118.3.5.1.
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 sinactures 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 suhmit to the Building Official,on a tixm 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 he 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
Employers 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
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 9 AVe-
The debris will be transported by: 77e.;z,ti
The debris will be received by: Vausy Jiecyct
Building permit number:
Name of Permit Applicant 71"
fl v 1C 7j t
5J 14 { 71 !
Date Signature of Permit Applicant
the tommonweaun of massachuseus
Department of Industrial Accidents
I.
11111•19
ce of Investigations
. '
1 Congress Street, Suite 100
Boston,MA 02114-2017
•"'^��a"'zi4 www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(liminess/Organizatioalndividual):
Address: .7,Y le/wire .C)
City/State/Zip: S. j}2.ee.r`rrerj M4 p.)r'1)S Phone#:5/J Sire fi7/
Are you an employer?Cheek the appropriate box: 'type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
Zjeff I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have R. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building,addition
[No workers' comp. insurance comp. insurance.:
required.] 5. C] We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MOL
12.0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' I3.0 Otherthp Car.rat,.".Grl. AFI(<S
comp. insurance required.]
*Any applicant that checks box fi I must also fill out the section below showing their workers compensation policy information.
t Homeow,a. who submil this affidavit indicating they are doing all work and then hire outside contractors must.submiit a new affidavit rodicaing such.
leontracmry that check this box must attached an additional shv t showing the name of the sub-wntractom and stale whether or not those entities have
employees, If the sub-contractors have employees.they must provide their workers'comppolicy number.
/am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job she
information.
Insurance Company Name:_
Policy#or Self-ins.Lie. #: Expiration Date:__
Iob Site Address: City/StatetZip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MOL c. 152 can lead 10 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 a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerrrfp u er , and penalties of perjury that the information provided above is true and correct
Signature: roy".
/ Date: 4°. l 7•/ e
Phone#: I$. 4-496
Officioi 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 S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"-..every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGI,chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGI,chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)nanie(s), address(es)and phone number(s)along with their certificate(s) of
insurance. Limited Liability Companies(LIE)or limited Liability Partnerships(I.LP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the n..ropriale line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the nem-lit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitdicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your coop.lation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 7-2613
www.mass.gov/dia
City of Northampton
:t jr��"��- Massachusetts � i /s. ��'
s V <e
d 1f..F 1)212 nIrOF H•IMOIIPG a i-
212 Main Street • Municipal Building V 1
N y' NOrthaepton, MA 0£060 x.s,rn 4,..
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION AC((,. • . . k'. .
The State of Massachusetts allows the homeowner the right under 780CMR 108.14 to act as his/her
construction supervisor.The state defines"Homeowner'as, "Person(s) who owns a parcel on which
he/she resides or intends 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 home owner."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages,which include
foundationifootinus(before backfill). sonotube holes (before pour rough building inspection
(before ork i •reale•. sulatio 1s,cti e.. if re.u.r • and . 1. el building inspection.
The building department requires these inspections before the work is concealed,faille* to secrt.
these inspections _ 1 r_ _t 1 -i 1., .. o• a"1 _ . l. __.' •f .� •.;1 _ 1 ' :1' u _ 1 •..
inspected
If the homeowner hires other trades to perform work (electrical, plumbing & gas)the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DEtfEL Y the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
s- 7.-1
I- ' 1 j CORBETT
HOME EXTERIORS HIC #160143
s a
13m5-22116•a 1M864712 CSL #78297
4
l Ll y )i cm I 3 Grecs Skeet.Skeet.South t n0.MA 01373
x 1 WINDOWS•SIDING•GUTTERS•ROOFING
l 'Lot-Ally Owned avid'ncd
d uvSiwe 1966'
3 m �l A J it j I amnion the Entire Pionccr Valley
'Y. A s ► t CONTRACT
Fl Date rC{!'cru �1 20 //•
This agreement, between A n v-“ (r v - t et
of Syr if tn_MJcnt Nyr-IilArpl or. _. and
(Address)
JCORBETT HOME EXTERIORS. SOUTH DEERFIELD, MASSACHUSETTS
Phone .SXI '[33
SPECIFICATIONS 5 '7 It FL-
_.... - • . ti.. - Cn1L rJ b'.✓a G/ii-) LOW - Z
Ctnj We. JLas ( c<n,( rc•c, r. r,Urt`) irm r/et aril II
till LJir`, /n, is 1•r, LI 6 • ki.41 c '�kl i ) • "niC /Dr
on the premises located at 5 S-4E1.4 er; a total cost of / irf6• a()
w ® _
With this order owner pays down the S1of f_,•e d cop_ cr D
Owner agrees on completion of said work by the Contractor to pay the suns of S s .S r F. r•rt t ._dollars
fS )
Owner agrees that in the event of any breach of this agreement by him after acceptance he will pay 70%of the total contract
price because vinyl replacement windows arc custom measured and made for owners home and will fit nowhere else.
PMwrnance of this agreement is made subject to labor spikes, fires,wars, acts of God,and the Contractors ability to obtain
material.
This Contract constitutes the entire understanding of the parties, and no other understanding, collateral or otherwise shall be
binding sinless in writing signed by both parties.
WINDOW GUARANTEE
Manufacturer's glass is guaranteed for life from date above not to fog up between the panes of glass. All other parts will be
supplied free of charge for life.Service will be free of charge for I year from date above.Guarantee does riot cover broken or cracked
glass after one year from date above or any da age resulting from neglect,abuse,or ads of God.Condensation build upon the glass is
caused from high taunting levels and pour lila/ion within the home threfore there is no guarantee that this condition will not occur.
m witness whereof,[have h• _si to s si my name this_.. a a n'day of /4/°-Q) L I . 20 /4
by I
r
�•::/ `tel,—ys v �i a'"��r< I/v
apse "A. .riri Agent (Owner)
(Joint Owner)