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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 — I,nm oux lqqj UN L Uk '!A.',S 3 " I f If el_)y Ij M It She' it'Cal- ;b 'I I u 2St,, ,,Ies 1 1, all 1,, Illy Li, U ­I 'Afl IUA�?oAlqL `IJjq , I DDob� G0Gj /,q s _S WlAt o GRs, ) L 5cre S. J -- '_� 4414^k j I �- J'? ( 1- I V X ✓ / 7A r Y .' 5 Ce -I lic-ec-14 a fie IiNc�"l rah') /07 - 71 x _59 ����� 35 ' y3 /� viz ��� �3�iz 39 �% 3 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 'It t 1 �:� I llu'�ed l o� -.