12C-123 e .
BP- 2010 -0359
GIs #: COMMONWEALTH OF MASSACHUSETTS
r 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 -0359
Protect # JS- 2010- 000480
Est. Cost: $4500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ED CORBETT JR 067450
Lot size(sq. ft.): 10846.44 Owner: BOOTHROYD MICHELE A
Zoning: URA(100) / /RI/WSP Applicant: ED CORBETT JR
AT: 111 RICK DR
Applicant Address: Phone: Insurance:
4 Reed Street (413) 584 -6571
NORTHAMPTONMA01060 ISSUED ON. 101512009 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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
4
Department use only
City of Northampton status of permit:
Building Department Ourb Cut/prlvewby Ppmtit
212 Main Street OtWor /rIleptic AvallabIll
Room 100 Wottr/Well Ave(lability
Northampton, MA 01060 Two Sets of Structural OIans '`
phone 413 -587 -1240 Fax 413 -587 -1272 Plot/site Plans
other speolty
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFOR
f t ITS section to be completed by office
1.1 Proraerty Address
A M 2 Map .___ -___ -- Lot Unit —
Zone Overlay District
-_ Elm tat. District District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AQENT
2.1 Owner of Record
M I ch e_ Ili & 0 _ 4-k (-0(4 _ _ _
Name (Print) �^ Gurrenl Malling Address: �^
-- -
Telephone
Signature
2.2 Authorized Ascent:
Epfijft1qp - T Reed --s
Name (Print) Current Malling Address-:
--------------- -
Signature I olephone
SECTION 3 - ESTIMATED GONITBUGTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
comp leted by erm 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 = 0 +2+3+4+5) OD _ _ Check Numbe
F°ur Ioil Ulrs
Building Permit Number: Date
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
Setbacks Front
Side
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
ft of Parking Spaces
(volume & Location)
A. Has a Special Permit/Variance/Rnd( ever been issued for/on the site?
�l ��
NO DON'T YES �� �� ��
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds/
�� �� ��
NO �~� DONTNNOVV ��/ YES \~�
IF YES: enter Book Page and/or Document#
B. Does n brook body of or NO v�� DON'T KNOW Y[� v~~�
� ' v.�/ v�/ \^J
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained x�� Obtained �~� Date ^�/ \�� ' '
C. Do any signs exist nn the property? Y[5 �� K ) NO �C)
|F YES, describe size, type and location:
D. Are there any proposed changes to or add||h,ns of signs Intended for the property ? YES x�� NO /—�
x�/ \�~/
IF YES, describe size, type and kua\ Ion �
E. Will the construction activity disturb (clearing, gra eveUon.ov filling) over 1 acre orioit part ofo common plan
that will disturb over 1acre? YESK > m0
��
|F YES, then e Northampton Storm Water K4mouUvn/on| Permit from the DPW |urequired.
'
^
SECTION 5- DESCRIPTION OF PROPOSED WQRK icheak allisWIJUMI)
Now House F Addition Reglacenimil Inclows Alteration(s) El 5Z]
Or ools Roofing
Accessory Bldg. Demolition Now Sigiis .11 Decks I[..] Siding [0] Other
Brief Description of ropased
Alteration of existing bedroom _Y08 No Addiiiij mow bodfoom Yes Yes No No
Plans Attached Roll - Sheet
Sa. If Now house and or-addiflon to existing hgU1ftHL=p1stv the tQ11pw1na;
a. Use of building : One Family -_ 'rwo Ffirolly 01111,11
b. Number of rooms in each family unit:.. III HImIlhim)[Im
d. Proposed Square footage of now construction... F)IFTIonsionh
e. Number of stories?
f. Method of heating? I imphicos ot Woodslovas Number of each . - ...
g. Energy Conservation Compliance. Mmirwhfick 1'.-Ainigy Compliance form attached?
i. Is construction within 100 ft, of wetlands? yoli No hi imistrucilon within 100 yr. floodplHin Yes No
j. Depth of basement or cellar floor below finished grfldo
k. Will building conform to the Building and Zoning rogulatiorm'? YoH No.
1. Septic Tank City Sewer P1 woll Cily W1111131 �`Itll)[Ily
SECTION 7a - OWNER AUTHORI?ATION - I ION
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING RAW
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authoilLod by thiii buildinil purmil iipl.
Signature of Owner Date
4 an erebydecilare that the statements and information oii t1m limiljoInIj tipplionflon ma true and aoe.umte, to the best ofTfty-kTr0WIFdge
ael
Signed under the pal is and penaltior of perjury
Z�?�' _ Ta'eil)V J',r
Print Name
SECTION 8 - CONSTRUCTION SERVICES
1 Li - Not Applicable ❑
��7 y��
Name of Ucense Holder i
,q '^• IWI
Address _• .....,...—
raU
Signature Telephone
Not Applicable ❑
Company NFme -
Address xp ration ate
SECTION 1¢ WOW RS``COMPENSATION INSURANCN AFFIDAVIT (M.G.L. o,10�, SC(e))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the deniat of the issuance of the buIldln2 permit.
Signed Affidavit Attached Yes........ ` No ...... ❑
arne w" HOFE. dMp ion
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,a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edifign Slition 10811
Definition of Homeowner Person (s) who own it parcel of land on wh1oh lie /she resides of 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 h
Such "homeowner" shall submit to the Building Oftiois , on a tbmi acceptable to the Building Official that belshe shall be
responsible for all such wgrk yer1bCMgd under t
As acting _Construction Supervisor your presence on the job alto wl I 6 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 Otinural 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 Mussucliusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
UT Boston, MA 02111
www.mass.gov 1d1a
Workers' Compensation Insurance Affidavit: Bull ders/C o ntractors/Electricians/Plumbers
Applicant information Please Print LeLribl
Name ( Business /Organization/Individual):
Address: __ --
City /State /Zip Ah- 0)060 Pholiv /1:� 9— to 7 7/
Are you an employer? Check the appropriate box; Type of project (required):
1. ❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6, ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
2. C4 I am a sole proprietor or partner- listed on the attached sheet. + ?• ❑ Remodeling
ship and have no employees These sub - contractors huvc 8. ❑ Demolition
working for me in any capacity, workers' comp. insuruncc, 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ 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 her Mod-, 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we huvc no 11❑ Roof repairs
insurance required.) t employees, [No workers' 13.❑ Other
comp. insurance required,]
'Any applicant that checks box #1 must also fill out the section below showing their workers' cumpensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire uinside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing iho name of thr sub- roniractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance Jar my vinployees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #: __- 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 its 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 it copy of th statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification,
I do hereby certify under the pains and penald oj'perjury that the hi provided above is true and correct '-
Sig ture: _�__ _ tte Q�'r / Q�
Phone M -�
Official use only. Do not write in this urea, to be completed by clo or towil ojjlclaL
City or Town: Permil /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
P roposal P No. of Pages
CORBETT HOME IMPROVEMENT 1
WINDOWS -SIDING - ROOFING
4 REED ST
NORTHAMPTON, MASS 01060
(413) 584 -6571
pHON�
'DATE OF PI ANS
-jr, nr-ino
JOa PHONE
We submit specificc and estimates, subject to all terms and condition as set forth on both sides, as follows
-- �Cc. -'- 1 'rA 4 " ' t_orb e�,v�s� � o ✓ "0(
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Ak I 'vv ' t„ Dg ' ( 1 1 a4-e-
�10 A-o�
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Please make chec payable to: Corbe Home Improvement (Read Reverse side)
111r I'JCDp05P hereby to furnish material and lab r— omplete in accordance with abo pecifications,
for he sum of _d / A ,e�+4 f�✓ dollars (� _._C�
NOTE This proposal may be. withdrawn by us If
Signa rued - --- -- _ -
no �7corind within _ days. Signature
�CCC�ItC1: The ahove prices specifications and
-nd .ions are satisfactory ird are hereby accepted You Signature _
ire cull oozed to do the worn as specified- Payment will be
^rndn as "'thned ahove
111 RICK DR BP- 2010 -0359
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map.Bloc 12C - 123 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 -0359
Proiect # JS -2010- 000480
Est. Cost: $4500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor. License:
Use Gro up: ED CORBETT JR 067450
Lot Size(sq. ft.): 10846.44 Owner: BOOTHROYD MICHELE A
Zoning• URA(100, //RI/WSP Applicant ED CORBETT JR
AT: 1_11_ RI_CK__ DR
Applicant Address: Phone: Insurance:
4 Reed Street (413) 584 -6 571
NORTHAMPTON MAO 1060 ISSUED ON. 101512009 0:00:00
TO PERFORM THE FOLLOWING WORK.- & SHINGLE ROOF
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: 7 A �!� • 7 -Q
THIS PERMIT MAY BE REVOKED BY THE ITY OF NORTHAMPTON UPON VIOPPON OF
ANY OF ITS RULES AND REGULATION
Certificate of Occupancy Si nature
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 Corrunissioner - Anthony Patillo