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38C-007
. . l rvpvsaI Page No. of Pages CORBETT HOME IMPROVEMENT - 1013 WINDOWS - SIDING - ROOFING 4 REED ST NORTHAMPTON, MASS 01060 f-1 J /(a(9 Csc O67 y� �i PROPOSAL SUBMIT TO DAT fJ /fPey f e 4 ri Q.8 ay ADDRESS 4S0 CAO ue. S : P 8b-:,2 8 yi A fril Mt /11/4 _...--■------- DATE OF PLANS JOT NAME AND LOCATION ARCHITEC' - Ion r � __. JO PHO co We hereby t submit�ecifis and e�ates� �e�to at terms and conditions as set forth on both sides. as follows P A J sub f li p� art,1 S O1 r JyQuJ f �,.1 3 y r` 6 41 ? 5,4OIL 4/vy 4 %x, / /444,-WS go}- g. i ce O LtI ..5 / 19 /i,Ml,v,/M FAe. -.c/ dv6i= eiA feu/ U-e• j . > /,,wy.< New 4 c ._ �„ $ a / ( /C/4 x 5, flc1 ±G AUCl tc /11-L 7 4s4' Di 6s4L Aga' P-egmi i f - !5. Si-//EIKEA)001 Please make checks payable to: Corbett Home Improvement (Read Reverse Side) tie I Jrnpose hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: 1 /3 DeP as / s (a C." dollars ($ c,5 C 0 ) \,i i 773 �s; ,,� JS 0 NOTE: This proposal may be withdrawn by us if Authorized not accepted within days. Signawr / A ccr ltrb: The above prices. specifications and i conditions are satisfactory and are hereby accepted. You 1 Signature .�,- 0./ are authorized to do the rk as soeci i d Pay nt wit he made as outlined_above, '– Date C/ __ 1 J _. ° / Signature The Commonwealth of Massachusetts Department of Industrial Accidents = _ Office of Investigations 600 Washington Street Boston, MA 02111 " www.mass.gov /dla Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �1,,, Pleas e Print Legibly . • Name ( Business/ Organization /Individual):0-t.IQ ✓ 4 (Y 7e /WVf�T tra W ig l Jr Address: y ky.e_01 City /State /Zip: /U0P441ampri7l.'✓ /1?l9- 4)060 Phone 11: &/3J5Y 6 5 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 6. 0 New construction employees (full and/or part - time).* have hired the sub - contractors 2. C2 I am a sole proprietor or partner- listed on the attached street. t 7 . ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g Y P tY• 9. 0 Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MG I.. 11.0 Plumbing repairs or additions myself [No workers' comp. c. 152, § 1(4), and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] Any applicant that checks box #1 must also fill out the section below showing their workers' cuninensation policy information. t Homeowners who submit this affidavit indicating they are doing all wink and then hire via side i untractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of thy• sub-.onractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance /or 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains a ' penalt ' ' of perjury that the information provided above is true and correct. Si. nature: / - • pate: 9 �9 -0 7 Phone #: c3 - 1, Official use only. Do not write in this area, to be completed by city or town official City or Town: ... Permit /l,iccuse # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: _______,_.__._ _.. ____....._ Phone #: SECTION 8 - CONSTRUCTION SIRVICIS 8.1 Licensed Constructlpn Slug Menet • . Not Applicable ❑ ,�1 4✓ Name of Llpense Holder : 41 a1t'i - �,.,I ,( - r Li 'urt *C .. . , 010 0 9 4 Reed s+ N' 1 o( ) a Address �►. _ b ` ', Oki 11$ Lit / Signature M /p 41 9.'Reolstered Hann, Imi2 v m0011 t 0d ,1; 40000# Not Applicable El r CO2 7�" colt c! 1 ' • Company Nam I , 1.6. - r , • . _ "q A'd s-4 iv i _. A _.. 01..6 p ..._.._ _.•....._....• � � ► 1� ?: _ Address II ' lrelion mita Y , :ca� _ tslwphan _ ._.± L. � SECTION 10 WORKERS' COMPENSATION INNURANOM APOIf AVItily.0,L 0, illy $64(11)) Workers Compensation Insurance affidavit must be umnplsted and submitted wills Oils application. Pelluru to provide this affidavit will result in the denial of the Issuance of the buyirbilpaffillL _ Signed Affidavit Attached Yes I ..g It Home Ow,pv.ifiggmtign The current exemption for "homeowners" was extended to htultide 11,7ptIItJlhlYajbulliWzJr cpono (1) or two(2) families and to allow such homeowner to engage an Indlvtdudl Ibr hire who t uws riot possess it license, provided that the owner acts :5 r ' . rvi 1 r l/ f . :i , 1 , , I , 1 I, . Definition of Homeowner; 'arson (I) w o own a parue o M on wisitlh Ise /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or tialiwltud Nll'tlultirus summary to much use and/ or farm structures. A ! e , ii , i . n i ' I 1 . • i ' 1 1.1 1 . , , 11 . 1 w • . Such "homeowner" shall submit to the Dui d ng t:) lu on a lbrni rumen a tie to the 131i1 ding C)ftlelal, that he /she shall be pesoonsibie for aU such wW'h *mild under thiligidiliii pima, . As acting on tr your presence on the jot site will t o required h•oni tittle to time, during and upon completion of the work for wh alt t ifs purtnil Is INNtlatl Also be advised that with reference to Chaplet 152 (Workers" I'oitiptwl(Hatltai) alld Chapter 153 (Liability of Employers to Employees for injuries not resulting In Magill) 01'1110 MaNNaclnssutis I lulnital l awN Annulated, yet! mqv be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility hit compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and Mule of Masuilulnlsettu Clenerul Laws Annotated. Homeowner Signature _ — _ _ __...__._____. • SECTION 5- DESCRIPTION OF PROJOSED WORM Wheals all apullttOhjrt) New House ❑ Addition ( ] Replacement Windows Alteration(s) ( Roofing Or Donis f I n I l T•" Accessory Bldg. ❑ Demolition NOW 601s H.:11 Pecks 11...j Siding [ItJI Other 11111 Brief D scriplion of Proposed Work: �O 0t1e,� �- L w erg, R001 Gs 1,4 3o s ! Zs Alteration of existing bedroom Yes No Adding new Iambi null You No Attached Narrative Henovulitip uttllnishud basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addlt pn to exlstino housing,. complete the tollowlno., a. Use of building : One Family Two Family _ Other b. Number of rooms in each family unit: Numbut of fiethionnrtr c. Is there a garage attached? d. Proposed Square footage of new construction. 11Unenslone e. Number of stories? f. Method of heating? I [Timms o1 Wontlittown+ Number of each g. Energy Conservation Compliance. IVInttschrtnit t nenlfy i:unrpllatu,e form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yin) I In lu +,unstrncilnii within 11111 yr tloodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? You 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 1, as Owner of the subject property hereby authorize to act on niy behalf, in all matters relative lo wont aralluulinit by Ihh I ++illrilnll Innnill ohliIi +rllun Signature of Owner Daly 1, if ki>J /__1t.!__._. as Owne hXtt�orizec'f) son ereby declare that the statements and Inforrhatiun nit the t nsrgaing t ►Itltlit:,allon urn True and accurate, to the best of�rty'kttt7Wigdge and relief. Signed under the pains and penaltie of perjury. ....._..Jr Print Name !, D Signature of Owner /Agent I lulu • 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: - -- ._ I,: __.._ It: Rear Building Height Bldg. Square Footage '! b Open Space Footage 'V (Lot area minus bldg & paved parking) # 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 0 YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW 0 YES 0 IF YES: enter Book Page and /or Document # ‘9, B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES 0 NO t 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, a ;ovation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ______ Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Paint 212 Main Street Sewer /Septic Availability, Room 100 Wster/W @II Availability, Northampton, MA 01060 Two Sets Of Structural Plans phone 413 -587 -1240 Fax 413 -587 -1272 Plot/Site Plans 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 / 5 6 G IZOVt, S-� Map Lot Unit Zone Overlay District Elm 8t. District,.-- _ CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 13i I t 19.5' .-- _ __.___ _ --- - - - - -- Name (Print) Current Mailing Address: — — — — Telephone ,-� Signature _ S r p2$ 2.2 Authorized Agent: . • R . a "Tr ter- - _ •(< Li _ Rf)-ed s-t . - PIA ©)% _. Name (Print) Current Melling Address: Cyi J < 58 6--s Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COTS j Item Estimated Cost (Dollars) to be Official Use Only _ completed y permit 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) 5560 Check Number This Section For Oflciel Use Only _ _� Permit Number: Date Building .___._____ Issued: Signature: Building Commissioner /Inspector of Buildings Date 150 GROVE ST BP- 2010 -0355 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38C - 007 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 -0355 Project # JS- 2010- 000476 Est. Cost: $5500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ED CORBETT JR 067450 Lot Size(sq. ft.): 20821.68 Owner: PEASE WILLIAM A & MARGARET A Zoning: URB(100)/ Applicant: ED CORBETT JR AT: 150 GROVE ST Applicant Address: Phone: Insurance: 4 Reed Street (413) 584 -6571 N O RTHAM PTO N MA01060 ISSUED ON:10/2/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:SHINGLE ROOF OVER 1 LAYER 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: /B 'VI/ Cf Ir4of THIS PERMIT MAY BE REVOKED BY THE CIT OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: / ` FeeType: Date Paid: Amount: Building 10/2/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo