12C-112 BP- 2011 -0511
GIs #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0511
Project # JS- 2011- 000833
Est. Cost: $3328.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN CORBETT 078297
Lot Size(sg. ft.): 10497.96 Owner: JOHNSTON RENA E
Zoning: URA(100) / /RI /WSP Applicant: JOHN CORBETT
AT. 87 RICK DR
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586 -8712
LEEDSMA01053 ISSUED ON :121212010 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 Sisnature:
FeeType: Date Paid: Amount:
Building 12/2/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
City of Northampton
Building Department J
212 Main Street ,
D ip Room 100
Northampton, MA 01060
�c
phone 4f3 -1240 Fax 413 - 587 -1272
SM. w"10'.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION -M1 -SITE INFORMATION
1.1 Prooertv Address This section to be completed by office
Map" Lot Unit
A — Overlay, Distnct
iiiinziI District CB District
.SECTION -2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
R yo'- A - 7 � �--
Name In t) Current Mailing Address:
/ `f l 77C
Telephone
Signature
2.2 Authorize Agent:
' — T - c> L H' c�' S == z c C Lc Xi Alf -'4
Name (Print) Current Mailing Address:
Sig re 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 = (1 + 2 + 3 + 4 + 5) jr �— — Check Number
This Section For Official Use Onl
Date
Building Permit Number: 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 I --
Side L: .___f R: L: =, R:
Rear
Building Height --
Bldg. Square Footage - - 1 % 7_
Open Space Footage %
(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 Q 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 #,�
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , 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 0 NO Q
IF YES, describe size, type and location: WV
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 Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
. - A
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement_WJndows Alteration(s) ❑ Roofing ❑
Or Doors PT-1
Accessory Bldg. ❑ Demolition ❑ New Signs [r-3i Decks [0 Siding [O] Other [a
Brief Description of Propos _
Work: .-1- Sf At Gd, 1 6 ) V) E:' z L (/tom. e f C_ C/ V�I 25 ci
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a . iteew, hciulsanir ..�a�+d1�s�ii�s7na:.oi�el` ianiifia:
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - T 6:B E 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
I, -,-j — � `— lam , as Owner/ thorize
AZe ereby declare that the statements and information on the foregoing application are true and accurate, to the best of edge
and belief.
Signed under the pains and penalties of pedury.
Print Name
en
Signatu Owne Agent Datdf
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Constructio Supervisor Not Applicable ❑
Name of License Holder t� G �1 r�' C r t' t l _ 6 7 �p�
License ` Number Address Expiration Date
nature Telephone
9.•tlisterrll lrtbrorrtertt'Corifot+at � .�, �,. Not Applicable ❑
/60/�c - --'7
Company Name Registration Number
WINDOW WORLD Z-J�Az/1�
Address Expiration a et
Leeds, MA 01053
r,_gZlz Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L, c. 162, § 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...... ❑
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 buildine 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
T
The Commonwealth of Massachusetts
Department of Industrial Accidents -
Office of Investigations
_ 600 Washington Street
Boston, MA 02111
www.mass gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumb.ers
Applicant Information Please Print Legibly
Name ( Business / ganization/Individual) . pW WORLD
56 Dirnock treet
Address: T o MA 01058
586 -871
City /State/ap: Phone. #:
Are you an employer?. Check the appropriate'box: Type of project (required):.
1. El I am a employer with 4.. E] I am a general contractor and I I 6. New co
employees (full and/or part time). # have hired the sub - contractors
2" 1 am a sole proprietor or partner listed on the attached. sheet. 7. ❑ Remodeling
ship and have no =4)loyees These sub - contractors .have. .8. [ Demolition
working for me in any capacity.Ioyecs_and3iaye workers'
' 9 Q Building atldifiion
No workers-' comp insurance. comp. ; .
required:] 5. E3 We are a coipoiation and its 10.0 Electrical repairs or additions
3. El I am a homeowner doing all work officers bavez�xeroisecl their 1 LEI PIu nbing repairs or additions
myself [No workers' comp. right 6f exemption per MGL 12. Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
Y (N 13. Other
emp loyees. o workers'
comp. insurance regdired j.
'Any applicant that checla box #1 -roust also fiIl out the section bolo av showing t a +orkers'. compensation policy information.
t Homeowaeri wbo submit this affidavit:mdicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must.attaehed an additional sheet showing the name of the sub- contractors grid state whether ornotthose-entities have
employees. If the sub - contractors have employees, they must provide their warmers,' conv- policy number.
l am an employer that is providing workers' compensaifan insurance fog einptgyees Belnw it the policy ¢nd job site
information
Insurance Company Name:
Policy # or Self =ins. Lic. #: Expiration Date.
Job Site Address: City /Stafe/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the p9licy number and expiration date).
Failure to secure coverage. as required tiifier Section 25:4 'of MCTL a 15z can leid to the '
�o ' sitton of " penalties -
es of a
_ .
fine up to $1,500.00 and /or one- -year m3pnsonment; as well as civil penalties is the form ofa STOP WORK ORDER and-a fine
of up to $250.00 a day against tlic violator, Be advised that a copy of this statement may be forwarded to the Office of
InvestlQations of the bIA for insurance coverage verification _ ..
I do hereb }• certify under the pains -and penalties of perjury that - the inf ormation rovided-abavp- strue_and- iorrect -___
f p
Sinnature: L->z.-I !!r bate :
Phone
Official use only. Do not write in this area, to be completed by city or town officiaL
`City or Town: PermitUcense #
Issuing Authority (circle one):
J. Board of Health 2. Building Department 3. City /Town Clerk .4. Electrical Inspector 5. Plumbing Inspector
6.Other �.
Contact Person: Phone #: