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12C-103 A BP- 2010 -0357 GIs # COMMONWEALTH OF MASSACHUSETTS 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- 2010 -0357 Project # JS -2010- 000478 Est. Cost: $6425.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin ED CORBETT JR 067450 Lot Size(sq. ft.): 62290.80 Owner: STAPLES GEORGE W JR & ROBIN MARIE STAPLES Zoning: URA(too )/ /RI /WSP Applicant: ED CORBETT JR AT. 36 RICK DR Applicant Address: Phone: Insurance: 4 Reed Street (413) 584 -6571 NORTHAMPTONMA01060 ISSUED ON :101512009 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACMENT 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: 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: FeeType: Date Paid: Amount: Building 10/5/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo Department use only City of Northampton Status of Permit: Building Department Curb CuVDriveway Permit 212 Main Street Sewer /Septic Availability Room 100 WilterNV011 AVellabllity Northampton, MAO 1060 Two Sots of Structural Plfltns "$' phone 413 -567 -1240 Fax 413- 587 -1272 Plot/Site Plane other Splt APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SI IN 1.1 Property Address 'fhfs section to be completed by office 3 � 2 Map _ Lot Unit Zone Overlay District IIm et. District_ CS District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2,1 Owner of Record _ obit 54 le--s Name (Print) Currmit Milling Address tcilephonci Signature 2.2 Authorized Ascent: Name (Print) rhment Malling Address. Signature Telephone SECTION 3 - ESTlMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to tug Official Use Only completed by ernil n Iloartl _ 1. Building (a) Building Permit Fee 2. Electrical (I)) Estimated Total Cost of _.... _...._._._.._..___.__._.._ . _ ._...- .Q uriatruotlon trom (t3) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 8. Tots! = (1 + Z + 3 + 4 + 5)� Chech __,. ____ .._ ..... _ ...... _..T.l!!,M "puflun F q Offlalpl Uga Only_ Building Permit Number: Data Signature: Building C)ommissloner /Inspeclor of Bolldingu Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing I'roposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side [.: - -- R:. - _ I K:.— Rear Building Height Bldg. Square Footage % Open Space Footage 'Vo — (Lot area minus bldg & paved p arkin g) # of Parking Spaces Fill: (volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO O DON'T KNOW Y1 =S 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW l) YES O IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW 1P YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained o , 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 addle ions uI siµrrs intended for the property ? YES o NO O IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, gradinl,l gy;avation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES, then a Northampton Storm Water Managwrient Permit from the DPW is required. t . SECTION S- DESCRIPTION OF PROP0819 WQRK (gltJgl{ all 1WU#41g) New House [] Addition [ Replaoernenindows Alterstlon(s) ❑ Roofing ❑ Or dams Accessory Bldg. ❑ Demolition New Signs Jr:: ]J pecks J[:`a Siding (0) Other JIB Brief D script'Q of Proposed Work: 577 IL 15 �! lN [l� /i9CC/►1C ._. / OG W — L s _. Alteration of existing bedroom _Yes _ ._ _ No Adding rrew bo(hoom Yes No Attached Narrative RenovFrtinll unllnishmd hasertronl Yes No Plans Attached Roll - Sheet 6a. If New house and or addltlon to sxlMtltEal „► ) jCl rs tttlal l 5 1 11 1lYlgp a. Use of building : One Family -_ _, -- . ... . Two Family (Mim b. Number of rooms in each family unit:_ _ ._ Nunibrcr nl Iallunurnri c. Is there a garage attached? d. Proposed Square footage of new construction., _ L)hnanr. {Icnrrr e. Number of stories? f. Method of heating? -- ..__._..__.._ _.. _ I iieplrrcos or Wnadstoves Number of each g. Energy Conservation Compliance. _ Milli sr:hocIt Enwily Compliance form attached? h. Type of construction -_____ -, i. Is construction within 100 ft, of wetlands'? _ Yoa No la r;uristnnrllc.m within 100 yr floodplain Yes No j. Depth of basement or cellar floor below finisher.' grtrder k. Will building conform to the Building and Zoning rallulHllrnr�i'e Nn I. Septic Tank __ City Sower Private wall r !ity wins +r Hupply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETE() WHEN OWNERS AGENT OR CONTRACTOR A PPLIES FOR BUILDINO frl6alYlIT I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authori,ed try thin Iruilrlinll lierrnit npfrlic:allon. Signature of Owner 11cih� ��� � . -� r -. _ __ ____, as Owne horized 4 elieereby declare that the staternenls and Inforrnallrr un Ihi, ImOlpiIny Oppilratlnn tiro Irua anti accurate, to the best odge f. Signed under the pains and penaltla of perjury. J . 0� ' __ __�1r.. Print Name — _ - -- -- Signature of Ow /Agent I rein SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Constru Not Applicable D Name of License Holder: � Address t:xgireUOn ete Signature Telephone " Realstered `Ho'rt�nlnroveitient "ContictQr „ „ } „k {�;w,�ag.,, Not Applicable ❑ © (Z 13ei 4►'i'!��MoIC P. A/7 Company Name Renistration AUim� --� Address ` Aption Date Telephon � ,i'vS`1 SECTION 10- WOR1MRW'COMPENSATION INSURANCE AFFIDAVIT (M.01. x.152, J 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. orvo 1 Signed Affidavit Attached Yes.....:. ` No...... ❑ 1: 0_ r Exempt, The current exemption for "homeowners” was extended to include Owner - occupied Dwellines> (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess. is license, Provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 18.3,S Definition of Homeowner Person (s) who own a parcel of land on which he/she resides or i4tends 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 Period ,!hall not bg considered a homeowner Such "homeowner” shall submit to the Building Official, on a fbrm acceptable to the Building Official that he /she shall be responsible for all such work per[2rmed under the building 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 ' ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investig ►utlotts 600 Washington Street Boston, MA 02111 www. tnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Le 'bl r Name ( Business /Orgg anization/Individual): A me :DW 6 Jl` Address: 91 City /State /Zip: /UQi249 .!✓ /-V- - 6)Q60 Phonc #: _(y 13).��5� — tD S7/ Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ 1 am a gcmeral contractor and I 6. ❑ New construction employees (full and/or part - time).* have hired the dub- coninictors 2. C4 I am a sole proprietor or partner- listed on the attaclwd sl ivet. t ? E] 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. [1 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 of exemption per M(i l-. l 1.❑ Plumbing repairs or additions myself. [No workers' comp. c, 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 11❑ Other comp, insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their wurkers' compensation policy information. t Homeowners who submit this affiduvit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. lCon th c this box must attached an additional sheet showing the name of the sub- rowriictors and the workers' comp. policy information r� Iam an employer that is providing workers' compensation insurance fur t,ry employees. Below is the policy and job site information. Insurance Company Name; Policy # or Self -ins. Lie. t�:_ tsxpiration Date: Job Site Address: ------ . City /State /Zip: 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 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 pen ilties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised tint a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains a penalt laq of per/u . that the Infi)rmation provided above is true and correct. Signature: Date: ©C.l — / 09 Phone #: C Official use only. Do not write in this area, to be completed by city or towtr official City or Town: Pcrtttlt /I ,Icensc #t__ Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City /'Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: -__ -- _--- ___ - -___ _ Phonc #: r o p o o l Pag No of Pages CORBETT HOME IMPROVEMENT 1033 WINDOWS -SIDING - ROOFING 4 REED ST NORTHAMPTON, MASS 01060 Cc t� fl ) (o 1? (413) 584.6571 �S L # 0 !07 `VSv rst oTO NE 6- bSaS DATE OF PLANS lOe NAMF AND LOCATION ARCHITECT - -' JOB PHON VV- hereby submit specifications and estimates, subject to all terms and conditions as set forth on both sides. as follow u_ /t5 NA- U 1Vw3 0d4 L lIv,� A' ww'ZIj. � /l � r � ✓ ' 1,,�__ Ga � , -IL ao �yx y9 Pvi 5 a Y,)- U Yael X_37/? --_ 1 V �Rc4 /^fG�uc�es I�� � f 1114 — 1 f yD %yX 9 VA P lease make checks pay to: Corbett Home Improvement (Re Reverse side) P 13 r o P 0 gj hereby to furnish mater nd labor — complete in accordance with abo sp cif u ( or the sum of O & 107 dollar ($ ) _�23_ NOTE This proposal may be withdr awn by us if Authorized not accepted within days. SIgnaI ACCCPtC*1. The above prices, specifications and conditions are satisfactory and are hereby accepted. You Signature — xe authorized to do the work as specified. Payment will be made as o lined above. � n Date ._ - � '.7 [�'� Signature 36 RICK DR BP 2010 -0357 GIs #: �''�' $''WEALTH OF MASSACHUSETTS Map:Bloc 12C - 103 CI'T'Y 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- 2010 -0357 Project # JS -2010- 000478 Est. Cost: $6425.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Consr. Class: Contractor. License: Use Group: ED CORBETT JR 067450 Lot Size(sq. ft.): 62290.80 Owner: STAPLES GEORGE W JR & ROBIN MARIE STAPLES Zoning: URA(100) /,IRI /WSP Applicant: ED CORBETT JR AT 35 RICdK DL' Applicant Address: Phone: Insurance: 4 Reed Street 413 5 84 -6 571 NORTHAMPTON MAO 1060 ISSUED ON :101512009 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACMENT 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: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke• e Final: 1 A L, d I qd q0 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occu anc Signature: " "�� ""'� - °�`'� �`�'''� FeeType: Date Paid: Amount Building 10/5/2009 0:00:00 $35.00 -V I Z�/o 40 9 r 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo