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25A-081 (2)
I • r o lni s 11 Page No of Pagos Oe ll S3S - oo 57 CORBETT HOME IMPROVEMENT 10 2 7 WINDOWS - SIDING - ROOFING 4 REED ST NORTHAMPTON, MASS 01060 1 )1k4,9 (413) 5314-6571 I r - 1 JBMI! '.tn to n �T ■ DATE f� I.vue k 9 PPI F s PHONE DAI F Pi ANS Ak 0 - — 4 hie'v. t AL`i O A .11ITEC;T SOe PnON� OZe her by sir wit specifcatiors and estimates . subject to all terms and conditions as set forth on both sides as follows Tti L c— 9 N/A orIAc vl■Joi) Nw3 ao81,1Q }-49 1,3 o W s. 6LSo - I/464A L( a, //tiyZ 041 r /6ocse, 6// D u L )- ivArys tee. In // Gar, ds , /U 0 oKi ds a J ,Sr,(,/. Ch e fs. )3 and QSx5 3a x53 %3/ / 07 rte" R a e x 3/ s i / a. 4 3 7 J3/ ( L LL it*O/JLL UUN�I �► q— p� w, .' L t w- 6 fl R(-bN. f ps. d.J 116• I 1 3 `% //OTO Q 1, L 3) /3/x /3 /y 1I/ Please make checks payable to :EDWARD CORBETT (Pearl Reverse Sl Ijlr 13roposc ehy to !slot material and labor complete in accordance with above spcciftcatjoonns for the - um of 7/ dollars (S 1 /30 _ V x/,506 Dy451.7/. 54) - _,p ytom . _ NO a TF This proposal m hdraw,.jy s t 9/M' A �, 3/ z ( u not accepted within days_ Slgnatur- :cri ptrii: The above poses specifications and A o (/� - .ondihons are satisfactory and are hereby accepted. You Signature a/ AL.,/,/ r t��,! are e authorized to do the work as snecdied. Payment will be !'uric as outlined above Sat. _ C r_f -a _ a- n 7 __ —___ _- ____- -._ —_- Signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigutioiss =i ;i ce _ 600 Washington Street �l = Boston, MA 02111 •" .�.. w ww. mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): .110: r✓.' P it ' 197..isitt &t e - J • + 3r Address: y Rol f City/State /Zip: /UO A v4/ /1919- eI06G ..__ Phone 8: 6 s7/ 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. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors 2. Is, I am a sole proprietor or partner- listed on the attached sheet. $ 7 . ❑ 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 officers have exercised their 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work right of exemption per MI_ t. 11. 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' comp. insurance required.] 13.0 Other Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outsidr contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the mime of thr sub•conitractors and their workers' comp. policy information. • I am an employer that is providing workers' compensation insurance Or ntj 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 penult ' of'perjury that the information provided above is true and correct. Signature: g Date; ! - Z- 6- ©mil Phone #:(94 -- 539 6 Official use only. Do not write in this area, to be completed by city or town official. City or Town: _ Permit /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 Person: Phone #: 4 SECTION 8 - CONSTRUCTION SERVICSS 8.1 Licensed Construction §un rvIsor: Not Applicable ❑ Name of License Holder : S ri-. or- ` s 4 14.6c) Numb.. 4 R'eed S AJ 1 `4/ 34 /3 - OP.1 6 0 . , Address / Up ratJOh Date -../ 7 ... ( L570 Y'..'. . " 7 :i Signature Telephone 9. Registered Home imoro ement ContrectOW04 A vie MIg Not Applicable ❑ C () 2 de / r.► � , �v vrr r' ' _.__.. _...___,.. l� l 6 6 9 Company Na / / / Rattlt _ stt Address Expir ate Telephon -7 4► 7/ — SECTION 10 WORKERS' COMPENSATION INSURANCI APPIDAVIT (M,ILL a,16*, O 150(6)) I 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 7 No ❑ 11: o e PC6110 oj1 The current exemption for "homeowners" was extended to include fawner - occupied Dwelling (atone (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possessa license, provided that the owner acts as supervisor, CMR 780. Sixth Edition Section 108.A.5.1 Definition of Homeowner: Person (s) who own a parcel or land on which Ire /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 bumf in a lwo -ygpr 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 bul dingperq` ( As acting Construction Sutletvlsor your presence en the Job site will he required 11•ont 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 tlenural 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 fur compliance with the State Building Code, City of Northampton Ordinances, State and Local zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature a SECTION 5- DESCRIPTION Of PROPOSED Mad New House ❑ Addition [._.] Re r iaoenion Indowe Alteration(s) 1 f RoOfIn 11 g 01' Dome Accessory Bldg. ❑ l Demolition New 81gne [t :1 Decks [[;:] Siding [p] Other [pj Brief D cri ti of Proposed Work: 85i4�L 15 rv J2p)4ceMe,J Uh w/ f}RG on/ Alteration of existing bedroom ____ No Adding now bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to exhltlna housing tha rn gain , a. Use of building : One Family Two Family C)Ihor b. Number of rooms in each family unll:_._ Number nl l i tlrruunrn c. Is there a garage attached? d. Proposed Square footage of new construction I ifiiiiinsionii e. Number of stories? f. Method of heating ? I iinple osur Woodsloves Number of each g. Energy Conservation Compliance. -__ Ivinsschru loony I:onrpllanc:e 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 I. Septic Tank_ City Sewer Private well i:7Ity water Supply ._ SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING F ritiM1MIT , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building pernlll uglification Signature of Owner (loin I , �j / V. - - __ - -- _ as Owner horized en ereby declare that the statements and Information on the Inregoliig al elicallon me True and aoc:urete, to the best of • rr :dge an-Cr-belief. Signed under the pains and penaltie of perjury. Print Name .3 Signature of Owner/Agent I hilr, Section 4. ZONING All Information Must lie 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 I.: R: I It: Rear Building Height Bldg. Square Footage % Open Space Footage Vo (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 0 DONT KNOW O YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water of wetlands? NO O 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 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO Q IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, t)rE3tlhrll 0 ;avation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q 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/Drivewev Permit 212 Main Street Bawer /Septic Availability, Room 100 Water/Well Availability, Northampton, MA 01060 Two Sets of Structural Plans 413 -587 -1240 Fax 413 - 587 -1272 plot/Slte 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 a7 Co o / I d y Au' Map _ Lot Unit Zons Overlay District Elm St. District___-_ CB District SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: - - -- - -- - -- - - - - - -- Telephone Sc9y 9 im Signature 2,2 Authorized Ascent: Name (Print) Current Mailing Address: ( < fir' V.- lD S 7/ Signature Telephone SECTION 3 - ESTIMATED CQNSTRUCJION COST$ Item Estimated Cost (Dollars) to be Official Use Only completed by 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) /3 f Check Number This Section For Official Use Ong _ Data Building Permit Number: __ ...__..._..._..__. Issued: Signature: Building Commissioner /Inspector of Buildings Date • 40,S BP-2010-0358 GIS #: COMMONWEALTH OF MASSACHUSETTS . WFr: " 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 -0358 Proiect # JS- 2010 - 000479 Est. Cost: $4300.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ED CORBETT JR 067450 Lot Size(sq. ft.): 6621.12 Owner: SHULMAN -RYAN MARA & LUKE F Zoning: URB(100)/ Applicant: ED CORBETT JR AT: 27 COOLIDGE AVE Applicant Address: Phone: Insurance: 4 Reed Street (413) 584 -6571 NORTHAMPTONMA01060 ISSUED ON:10/5/2009 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