12C-109 1 ' BP- 2010 -0109
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)
Categor BUILDING PERMIT
Permit # BP- 2010 -0109
Project # JS- 2010 - 000125
Est. Cost: $1800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin JOHN CORBETT 160143
Lot Size(sq. ft.): 10236.60 Owner: BASSETT VALERIE A
Zoning: URA(100, //) RI/WSP Applicant: JOHN CORBETT
AT. 62 RICK DR
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586 -8712
LEEDSMA01053 ISSUED ON :712912009 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT 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 7/29/2009 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 Perrnlf
Building Department Curb CutlDnvevay Permit
212 Main Street Sewer/Septr�Ariailabtji
Room 100 Water/Well A'" 11abili ty
Northampton, MA 01060 Two Setts of Stnctural�?lans '' r
phone 413- 587 -1240 Fax 413- 587 -1272 Ptat[Slte 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
Map Lot Unit
A z C- Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signatur Telephone
SE ON 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 Piule(Aiun
6. Total = 0 +2+3+4+5) Check Number
This Section For Official Use Onl
Permit Number: Date
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
4.
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 d
p arking) a..� _-
# of Parking Spaces -•w
Fill: _. ......
(volume & Location)
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: = M 4 5
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW „ YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:t
- .....dv.., ,. . -.., .-1
C. Do any signs exist on the property? YES 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 0 NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
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 ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding [0] Other [0]
Brief Description of Proposed-
Work: ._- - lt- ° �i �3-L� y/ y L L�✓c-
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
as Ow er /Authorize
Ag€�JjBreby declare that the statements and information on the foregoing application are true and accurate, to the best o`FrRy Tnowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Sign of Ow r /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
/C ( Z) 7 J- 9 7
Address Expiration Date
L S 1 X 7
5 1ure Telephone
S. Registered - Home fmproverriienf Contractor ; Not Applicable ❑
f 0/4 -�
Company Name Registration Number
WINDOW WORLD 6/,14, /0
Address 56 9in St ree t Expiriftion Date
Leeds, NIA 01053
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...... ❑
. .;
IL. Home Owner` geri ptian
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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office bf Investigations
600 TEashington Street
Boston, MA 02111
www. rnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /EIectricians/Plumbers
Applicant Information Please Print Leaibly
Name ( Business /Organization/Individual): MINDO-W WAR
Address: 56 Dimock Street _
1-:�eeds, MA 01053
City /State /Zip: 5 8 ione #
Are you an employer? Check the appropriate box: Fonstruction oject (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
2k. employees (full and/or part-time).* have hired the sub - contractors c
I am a sole proprietor or partner- listed on the attached sheet. odeling
ship and have no employees These sub - contractors have . molition
working for me in any capacity. employees and have workers'
insurance.: 9. ❑Building addition
comp. [No workers' comp. insurance
required.] 5• ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing aII work officers have exercised their 11. ❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13•❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also 511 out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all 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 the sub - contractors and state whether or not those entities have
enployees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration 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 S 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 certify under the pains and penalties of perjury that the information provided above is true and correct.
t
Sienature:
Date: i o
i
Phone n 7 r t.—
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. or
Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
WINDOW WORLD HIC #104000
56 Dimock St.
Leeds, MA 01053
7� I Telephone 586 -8712
7 CONTRACT
Date 2 / d 20 d F-
This agreement, between C-.- 5 5;
(Owner)
of - - _ �/Z �� �, rc �t.� 9- , and
(Address)
WINDOW WORLD OF LEEDS, MASSACHUSETTS. _
Phone �S
� n � I ' L SPECIFICATIONS
� c u -'l
t p1i Ls S cJ /v 75 4414 �
410
on the premises located at Z C.)t ! a total cost of f gd 4 OCR
With this order owner pays down the sum of $
Owner agrees on completion of said work by the Contractor to pay the sum of $ /_ I F - 41 . d C3 dollars
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 are custom measured and made for owners home and will fit nowhere else.
Performance of this agreement is made subject to labor strikes, fires, wars, acts of God, and the Contractor's ability to obtain
material.
This Contract constitutes the entire understanding of the parties, and no other understanding, collateral or otherwise shall be
binding unless in writing signed by both parties.
WINDOW GUARANTEE
Window World's glass is guaranteed for 20 years 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 1 year from date above. Guarantee does not cover broken or cracked
glass after 90 days from date above or any damage resulting from neglect, abuse, or acis of God. Condensation build up on the glass is
caused from high humidify levels and poor ventilation within the home therefore there is no guarantee that this condition will not occur.
In witness whereof, I have hereunto signed my name this 1 , 1e of 20
by
on or of Authorized Agent) (Owner)
(Joint Owner)