12C-109 (2) 4 vw BP- 2010 -1097
GIs #: COMMONWEALTH OF MASSACHUSETTS
ock: 12C - 149 orb CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate BUILDING PERMIT
Permit # BP- 2010 -1097
Proiect # JS- 2010- 001614
Est. Cost: $2000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN CORBETT 078297
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 :61312010 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 6/3/2010 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 Cut/Driveway= Permit
212 Main Street Sewer/SepticAvailability
Room 100 Water/Well 'Availability
� Northampton, MA 01060 Two Sets of Structural Plans
phone 41 y -58 1240 Fax 413- 587 -1272 Plot/Site Plans
S Other Specify "
,APPLICATfON TO CONSTKUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEQTION'1 - SITE INFORMATION
1.1 Property Address This section to be completed by office
R f J ' O t- Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Current Mailing Address:
sS2;B'
Telephone
Signature
2.2 Authorized Agent:
5� i �2 a G i� s 1 G - c >! A41 f4
Name (Print) Current Mailing Address:
7
Sig re Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building de��l (a)' Building Permit Fee
2 Flertrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= 0 +2+3 Check Number
This Section For Official Use Onl
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings 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
p
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW Q 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 #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
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.
r
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable
New House [D Addition ❑ Replacement indows Alterations) ❑ Roofing ❑
Or Doors );+-
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks (M Siding [01 Other [❑}
Brief Description of P�lpesed / -
Work: - LAcV�L �'��rCL°I'n�l[�tW O
j VG �/LCv e_ i v
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 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
I , 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 Owner/ ed
en )hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my kno e ge
an =e ief.
Signed under the pains and penalties of perjury.
tA-
Print Name
Signat Owner/Kg-en-D) Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder : �J �1/ l®Rri" J e` -'-C� ���7
License Number
Addres Expiration Date
P 6 ature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
' l O / Y- N
Company Name WINDOW WORLD Registration Number
56 Dimock Street
Address Leeds, MA 01053 Exp r, a ion Date
58 -8712 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...... ❑
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 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 residting in Death) of the Massachusetts General Laws Annotated, you may be liable fui peisuu(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 o f Industrial Accidents
Office of Investigations
600 Washington Street
- ' Boston, 314 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /EIectricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business / Organization /Individual): WINDOW WORT p
56 Dimock Street
Address: Leeds, MA 01053
586 -871
City /State /Zip: Pone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction
2.)< 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. eiuployres and have workers'
[No workers' comp. insurance comp. insurance.
$ 9. Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. officers have exercised their I am a homeowner doing all work 11. ❑ Plumbing repairs or additions
myself o workers' comp. right per
y � k' ht of exemption MGL p 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 131 Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill 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.
Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. 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 $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 nh 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 peijury that the information provided above is true and correct.
Signature: Dater /G
Phone #:
Of 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 #:
WINDOW WORLD
HIC #160143
56 Dimock St. CSL #78297
Leeds, MA 01053
Telephone 586 -8712
CONTRACT
Da te �j �v 20 / C
This agreement, between f /�da - -�-�`1 `�--- Y�J t'�✓ E l t
n (Owner)
0
of �a � - " C. < L th t' l` 4` G ye _ , and
(Address)
WINDOW WORLD OF LEEDS, MASSACHUSETTS. _ _
Phone t - 5 395 3 O S
SPECIE CATIONS
Window World will
�.c o %v c,
�` Lv
V- !`- L
,fit±
6 Y-
e/ t
on the premises located at i C lC F"" a total cost of �000
With this order owner pays down the sum of $
Owner agrees on completion of said work by the Contractor to pay the sum of $ 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
1 0 1 0mimodiUs 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 one year from date above or any damage resulting from neglect, abuse, 9r acts of God. Condensation build up on the glass is
caused from high humidify levels and poor ventilation within the hho ?e therefore there is no guarantee that this condition will not occur.
In witness whereof, I have hereunto signed my name this day of G
by
on t ut orize Agent ner
(Joint�5( wnerj - -- - - - - - --