16A-028 6 CHESTERFIELD RD BP -2010 -0356
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map :Bloc 16A - 028 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categoog: BUILDING PERMIT
Permit # BP- 2010 -0356
Proiect # JS- 2010- 000477
Est. Cost: $7350.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ED CORBETT JR 067450
Lot Size(sq. ft.): 152895.60 Owner: DUNPHY THOMAS J & KAREN A
z oning : URA(100) //WSP Applicant: ED CORBETT JR
A T: 6 C HESTERF!r- Q RD
Applicant Address: Phone: Insurance:
4 Reed Street (413) 584 -6571
NORTHAM PTONMA01 060 ISSUED ON :101512009 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 T E CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS
Certificate of Occu an 11� Si nature:
FeeType: Date Amount:
I
Building 10/5/2009 0:00:00 $35.00
212 Main Street, Phope (413) 587 -1240, Fax: (413) 587- 1272
Building Commissioner - Anthony Patillo
a
f •
BP- 2010 -0356
GIs #: COMMONWEALTH OF MASSACHUSETTS
µ 'tA -.ts V 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 -0356
Project # JS- 2010- 000477
Est. Cost: $7350.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ED CORBETT JR 067450
Lot Size(sq. ft.): 152895.60 Owner: DUNPHY THOMAS J & KAREN A
zoning: URA(100)HWSP Applicant: ED CORBETT JR
AT. 6 CHESTERFIELD RD
Applicant Address: Phone: Insurance:
4 Reed Street (413) 584 -6571
NORTHAMPTONMA01060 ISSUED ON. 101512009 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 10/5/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
pertment us* only
City of Northampton Stptus of Permit:
Building Department Curb Cut/brivewey Permit
212 Main Street Sower /Septic Availability.
Room 100 WatarMell Availability
Northampton, MA 01060 Two Sets of Structural Plaits
phone 413- 587 -1240 Fax 413 - 587 -1272 Plot/ate Plpne
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
� c he���>✓ �� Map ._ .._ ��2- L�..�.. Lot � Unit
Zone Overlay District
Elm 8t. District.-- CO District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Current Mailing Address:
Telephon
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature T eiaplione
SECTION 3 - ESTIMATED CONSTRUgTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by pe rrult a lcant
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) ~ - - -_- _ - _ Check Number
This Section For Official U O nly w
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
Rai F
f
Section 4. ZONING All Information Must Ile Complelud Peunll Can tie Uenled Due To Incomplete Information
Existing I iopused Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front_
Side I.:
Rear Building Height
Bldg. Square Footage
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 heen issued for /on the site?
NO O DON'T KNOW 19 YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO a DON'T KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of wa(vi (ii wetlands? NU 0 DON'T KNOW 'P YES O
IF YES, has a permit been or need to be obtained hone the Conservation Commission?
Needs to be obtained O Obtained 0 Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of slpns intended for' the property ? YES O NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grad)rlll, q>u;avahon, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NC)
IF YES, then a Northampton Storm Water Mannllornorit Permit from the DPW is required.
SECTION 5 - DESCRIPTION OF PROPOSIU ItYORK IShI1111.A11.I1W1919010)
New House ❑ Addition �] Regleoement 1P I
Windows Alleretlon(e) J Roofing F-1 Or oorr
Accessory Bldg. ❑ Demolition New 81gn• JC ::IJ C)euk• J(;'] 81ding [nJ Other [EA
Brief R� ri ti of Propos �► f - /
Work:
�_t! � A /^�Gt (� . W / ?h....r�iQ�!J` -f-ITR6
Alteration of existing bedroom — _____ - ._..__ _ No Ad llnij now bodmom you _. No
Attached Narrative Ilenovallntt unllnlahed hasaouarlt _ Yes
Plans Attached Roll - Sheet
6a. If New house and or addition to 1xistinn h ou si ng, camalstit h2 follow
a. Use of building : One Family Two Farnlly Olher
b. Number of rooms in each farnlly unit: _ Nunlhnr nt Iirrthmortm
c. Is there a garage attached? ._
d. Proposed Square footage of now conslnu,lir.m I )III till rrinilit
e. Number of stories?
f. Method of heating? ------ .- - - - - -. _ _._.._....... I Irnpilums ul Wooelaloves . Number of each _ _ --
g. Energy Conservation Compliance. _. MnsHcholck I nority t;nnlpllrulce loran ottar..hed?
h. Type of construction
i. Is construction within 100 ft. of wetlands? You No. IM r;unstmOlon within 100 yr. floodplain __. Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Toning re {.1ulallrnlNY you No.
1. Septic Tank City Sewer _. _ Prlvnle well t :Ily wnlrrr r)uliply _
SECTION 7a - OWNER AUTHORIZATION - TO 95 CiOMP"TOD I HHN
OWNERS AGENT OR CONTRACTOR APPLI118 POR "URDINO P hI11I11
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work nulhoilierl by Ihls hullrllntl 11omidi rlplrllnallon
Signature of Owner 141111
as Owne horized
an ereby declare that the statements and Inforrnatlon on Iho lmogning oppllnellnn area Iruo and ercurate, to the best odge
a elief.
Signed under the pains and penalI of perjury.
Taamz ` l �w . __ C____ _
Print Name __-_..__.----__----
-•r
Signature of Owner /Agent I Inl�
4
f
SECTION 8 . CONSTRUCTION SERVICES
8.1 Licensed Constru u ervi Not Applicable ❑
Name of License Holder /e (' 06 7 7,
um, be
N' 4dl e C t o 6 p
Addr
W91ratior ate
Signature Telephone
Not Applicable ❑
()1z6 0 t Jl /0 Lo 9
Company Name
Address / iration Date
Telephon�
SECTION 10 WO;RMRS`'COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 132,1 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...... ❑
wner°
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings> one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess,# 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 izatends 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 do 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
i
' The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
lip Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/(' ontractors /Electricians/Plumbers
Applicant Information Please Print LeLdbl
Name ( Business /OrganizatiorAndividuai) :� J(`
f Address: y R . 0
City /State /Zip: I�102��Jj✓ )W - 0)064 Phont #:� ��3��8y 6 571
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a7 employer with 4. ❑ 1 am a general contnictm and 1 6. ❑ New construction
employees (full and/or part - time).* have hired the sub - contractors
2. D4 I am a sole proprietor or partner- listed on the attached sheet. + ?• 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. ❑ 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 ol' exemption per MG L. 11.❑ Plumbing repairs or additions
myself. [No workers' comp, c. 152, p 1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers'
comp. insurance req 13.❑ Other
*Any applicant that checks box #I must also fill out tho section below showing their workors' annljensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hiry ontsidt- � ontractors must submit anew affidavit indicating such.
, contractors that check th b ox must attached an additional sheet showing the name of tI)L' sub•oinuactors and their workers' comp. policy information.
Iam an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob 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 up to $250.00 a day against the violator. Be advised thus a copy of thi, 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 — oj'perjtiry that the in/ormation provided above is true and correct.
Si nature:
_ tote: 9 /9 0
Phone #: =� -
Official use only. Do not write in this area, to be completed by cit or town official
City or Town: Permit/Liccuse #
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 #:
fjrapusal paye Nu Ut
CORBETT HOME IMPROVEMENT 1024
WINDOWS -SIDING - ROOFING
4 REED ST
NORTHAMPTON, MASS 01060
(413) 584-6571
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Please make checks payable to: Corbett Home Improvement
111v j3ropusr hereby to furnish material and izibur complete in accordance nitn
or the sum of '13 � PUS/ - �j oI
QTL 0
[his pruputw m c mihubiwri by i it
nut 'Iu�Lp!ud will IIII
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