38A-001 (2) V
_* _ �J lee • a . / / 4 ' f I
1 a = �,
Office of Consumer A:ffai s and Business Regulation
-1_f_ 10 Park Plaza - Suite 5170
,.. `_s Boston, a.,ksachusetts 02116
Home Improvei ontractor Registration
=- �� 77: Registration: 103713
ri Type: Supplement Card
$ _
Expiration: 7/14/2012
NORTH EAST SPECIALTY COR'v >,,
KEITH DEVIN " 2 , � = =
1 48 �, ‘fli D OTY CIRCLE ' L . �_ w
WEST SPRINGFIELD, MA 01089 , -= - : - ,.J
-1..\: Update Address and return card. Mark reason for change.
Address Renewal Employment 11 Lost Card
DPS -CA1 0 50M- 0,4/044101218 ❑ ❑ ❑
77te -6 a/✓gaoaacicuaella
Office of Consumer Affairs & Business Regulation License or registration valid for individul use only
, 4 4 11 l HOME1MPROV ENT CONTRACTOR before the expiration date. If found return to:
C ea 5 ti Office of Consumer Affairs and Business Regulation
e U e Reglstration Type:
�� —_- lO Park Plaza -Suite 5170
Exp -r s
' Supplement Card Boston, MA 02116
� _ :, .
NORTH EAST ,; - ,�j �I =- •=--•. ORATION
NESCOR , € _ � __ __
KEITH DEVIN 'AV 4
�T
148 DOTY CIRCL• ,;� o
WEST SPRINGFIEL4["�ff`0'(089 Undersecretary Not valid without signature
•
■
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MAR /14/2012/WED 02:U4 PM FAX No, P. 004
../._ �-" ^ NSCO.1 OP ID: MS
ORf7 D AT E (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 03/14/12
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms end conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER CON ACT
413- 737.5359 NAME:
J Raymond Lussier Ins Agcy Inc PHONE --- _ ...•. -�' -- " -• FAQ —_ ..__ —�_._.
181 Park Avenue, Suite 8 413.732.2027 No Exf)„ _ .._ . ..., ( A/C , NoL•. ._.__... —. ._.
PO Box 489 E -MAIL
AbbRE _ _ . ....._._... _ .. _ -...
West Springfield, MA 01090 -0499 ,
J Raymond Lussier Ins Agcy Inc INSURER(S)AFFORDING COVER s_--,,, _ ,. NAIL #�
INSURER A ; Safet�r Insurance Company„ • 139454 •
INSURED - Northeast Specialty Corp dba INSURERB;A.I.M. Mutual ins. Co.
Nescor wSURERC :Northland Insurance Co. I
1 48 Doty Circle M_...._-.. ....__._.........!_. r _.....__ _. - --
West Springfield, MA 01089 INSURER D I
INSU ER F : I
COVERAGES CERTIFICATE NUMBER: _ REVISION NUMBER:
THIS IS TO C R 1'IFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS O.F SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID. CLAIMS. _ _ —.--,----------
INSR, - IAODLSU� 6 - POLI M M / DD, EXP LIMITS
LTR i TYPE OF INSURANCE i POLICY NUMBER {MM /17p(YY1'Y) (M M /DD/YV�Y)
GENERAL LIAEIL{tY I EACH OCCURRENCE I —$ 1,000,000
1
G I X_1 COMMERCIAL GENERAL LIABILITY WS145401 03/15/1 03/15/13 CAMAGETCSRE'F1TEp 29 fA.ISES (Ea- 542y¢s,nce),.,. 100,000
' ' CLAIMS -MADE ' X OCCUR MED EXP�An person) : -! $ EXCLUDED
PERSONAL B ADV INJURY ! $ _ 1,000,000
I rGEN AGGREG ATE $ 2,00o 000
GEN'LAGGREGATELIMITAPPSPER: ' PRODUCTS $ 2,000,000
PRO -
. LIE . 1 $
. __......_ __.
X POLICY (FM LOC
AUTOMOBILE LIABILITY I ' COMBINED SINGLE LIMIT
_ —,_ - :..(Ea acci ---... „ _ . _.. ,000,000
A i ANY AUTO I I 2433825 03/11/12 i 03/11 /13 BODILY INJURY (Per person) i b
' ALL OWNED ' SCHEDULED �
/.`,... I • BODILY INJURY (Per accidenq $
- AUTOS I AUTOS
NDN -OWNED :..._... �- - -.�_ . __._�..._.._..._
PRn D
i x 'HIRED AUTOS X AUTOS , I (Pali 3e RTdeY nt�, AM AG E __— ,. _ $
_ I :$
UMBRELLA LIAR ' OCCUR I I EACH OCCURRENCE
I f EXCESS LIAR CLAIMS -MADE) I 1 AGGREGATE $ ,• —_
CED • . RETENTION $ ; 1
I WORKERS COMPENSATION i I I w I WC STATU- 1 1 0TH -1
AND EMPLOYERS' LIABILITY YIN
�i)8Y L1MIS.. FR
- B ANY PROPRIETOR /PARTNER/EXECUTIVE — , VWC6003862011 07/09/11 07/09/12 E.L. EACH ACCIOE : 3 100,000
• OFFICERJMEM6 N /A
ER EXCLUDED? I r— • '— "—
(Mandatory 10 NH) E.L. DISEASE-EA EMPLOYEE) $ 100,000
f es describe tinder I ' "—
D OF OPERATIONS below I I : E,L. DISEASE - POLICY LIMIT ' $ 500,000
•
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, I i I
DESCRIPTION OF OPERATIONS /LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
CERTIFICATE HOLDER _ CANCELLATION ,
CUSTOME
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL Be DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE •
I 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) . The ACORD name and logo are registered marks of ACORD
May 13 12 10:40a . JOHN SFR1•42O 203 2S1 4477 p. 2
NORTHEAST SPECIALTY CORPORATION dlb/a NESCOR W�_ — -
MA License #103713 All home Improvement rontraptprg and subcontractors
engaged in home improvement CCntraCting, tatieSs specifi-
148 Doty Circle • WEST SPRINGFIELD, MA 01089 catty exempt from registration by Provisions of Chapter 1.42A
1-888-NESCOR-1 1.8886372671 of the general laws, must be registered with the
413739 -4333 Commonwealth of Massachusetts. Inquiries about registra•
www.neSCOhdirtllrla,eom dot and status should be made to the Director, Home
Improvement Contract Registration, One Ashburton Place,
Submitted f Room 1301, Boston, MA 02108 (817) 727.8598
To. e:,4,0 _— - - -
a.:z.I . r . PIT Q 0
f,,l . rt -(A.M i dLi /'? A . Jp6 u , .ME.-...., _. _ 4..m e —
p� xa pATt: JOE LOCATt�N
lima 5 . : f...,.,j_^..._ 5 it ESTIMATOR . ` , �M
We hereby Submit speCifioattione and estimate& for soda to be performed and materials ro be rued:
Mk1c.11SOCF > i 1 --M0.1 MA/ eg. t'"tlt c 2, Q. e '7" ifr A Z1 tr
A.! P G N3 Z O T. _g.- d7 9 PF l 1 1) C E.1' • Id eSA3 -i M t Pi �6 „ _ !-r ik. CIA
41140 EY . 14 EV? ii-A ids. . c-t M 0 C `- ,. %' 08e- - _11M00
13i4 ( t 6i. it rr7..? x 2 ' P(.2-6--T. ± r .At . e a 4 aaate_C--1-_. A,
Do no: do: Conatruetiar related !Winks:
'� F sal i✓ I�.. k t i 4 h-i 1e.":7
WORK SCHEDULE
C_.!._Mr wit het begin the wt:tft or aroer u:c .rotorslc bsfc'e the third day !:!:wing the c; ins of this Agroam:nt, ».tor; ;air horcl^, Convector Ai! erg: -'he •rxk cn r coca:
._ (date). Berrino delay caused by cirCltrelencee beyond Contractor's control, Ins work will be completed by -.. _(date). The Owner hereby acknewleoges
eneigreoe that the odbodl. ".p rotes ore sporoximats and that such delays Instate not avcdabte by the Contractor incuding, but not limited to strikes, Ac!e of sloa 'Manages of mater,
ale,accklente, arts el other delays havond Ito censor, shell MI ba ooniidared 48 viotar era of thi. AgreornWri.
WARRANTY
The Contractor w lrr..;ttc that tad work furnished nersundor ahsf be tree kW dofoae it materials and workmaneh!, fora m o o d of Lle. following complain and shalt comply
with the req.lrerra +t3 ct tn' Agreement. In the event any deleCt in wearrnanahio Or matedlda, or damage ceoaed by the Conlr.otar. kg oubcontrectos employees or agan:a. 13 *covered
altar completion of any j.•b, l.gvdi &e*, eo, the Conlr*CIQr than, at its awn lapels., Ionhwilh remedy, rink trr'r e.cI, rektzp., or a suite to be remedied, repaired os replaced, oath oem•
e e o r WCh on` in re t date and workmanah ,The tore on w er a nlMe shell etrtvNa enY Inspect.. Nr! ^.w ad�reneetbn with the aoreed.0pen wont.
8 ropos<3 hereby to furnish material and labor • compile In accordance with above sae pions, for the aunt of;
Penitent t be a w a i t IS WNW
A i Ai .% (a R _ upon s.Qnrtg c rtiva t NORTHEAST SPECIALTY CORPORATION ti/b/a NESCOP _-
Name d ContracrorrD.slanat.d tleOetranf
. 4 ,x, 0 C l � . ^) up on completion of , Any 16414617-: AL; 143 DOTY CIRCLE
17T74 . V.. tL stiraet Addroes
„ 3_, -ta ($__ i gi ) upon completion of WEST SPRINGFIELD. M.A 91 069 413 - 7394333
"-1 141 ' C!tyrSite Phone
'E 4 1 shall be made forthwith upon 103713
cCmdotlon of work under this contract, Rogialeation No J
Notke: No agreement forte improvement contracting wo& s'tatl requite a down Jvarre_ot Sete 1
a.n _ A__0
payment (advance depoot of more than one•thir7 of the total contract price or the 1�
total amount l el dopoei?e or payment. which the earl eCtor must make. In edvenbe, Authedaad naI ve � ' 2 ^V
to order anchor otherwise obtain delivery of special order materiels and equipment, �!r►
Acceptance of Proposal t have read both aides of this document and %CCapt the prices. apaclfcat!oxu and conditions stated. I understand tnat upon
signing, this proposal becomes a binding ontract. You are authorized to do the work as epec:fied. Payment will be made as outtned above.
You may cancel this agreement it it has be en signed by a party thereto at a place other than an addree8 of the seller, which may be his meet office or
branch thereat, provided you notify the Seller In writing at tile main office or branch by ordinary mall posted. by telegram Sent or by delivery, rot later then
midnight of the third buoineee day following the signing of this agreement, Please refer to Me Notice of Cancellation that accompanies was contract; con-
tents of which are referred to above and incorporated herein by reference
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
eb.•
signature 610'11 Signature Data signature ��� .: �' •• R - Data 9
` v. +.w✓
City of Northampton
i '"'
/ f ‘.\,- s *. Massachusetts ' r --. c iz
DEPARTMENT OF BUILDING INSPECTIONS r b ?' ...
{'� ; 212 Main Street • Municipal Building 3 yt '
a `: .
' _ Northampton, MA 01060 Pit 1,
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his /her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he /she resides or intends 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 in a two -
year period shall not be considered a home owner."
The building department for the City of Northampton wants any person(s) who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection
(before work is concealed), insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
y
The Commonwealth of Massachusetts
, — Department of Industrial Accidents
9 > • Office of Investigations
1%
— 600 Washington Street ,
-- , Boston, MA 02111 {
"° , www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): 0 - C�s�f ,l a ' st_cl
Address: , (t-{- pocl C 1/4s - de_
e_
City /State /Zip: W. ' 0 ( WI Phone #: 4(3 r i ` k L r (C �
3 - i ES
employer? Cheek ^ the appropriate Are ou an em c\ ro
p Y pp p box: Type of project (required):
1 .m a employer with l 2 4. n I am a general contractor and I 6. New construction
employees (full and/or part- time). * have hired the sub contractors
listed on the attached sheet. 7. 1:1 Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. 1111 Demolition
for me in any capacity. employees and have workers'
working Y P Y 9. - Building addition
[No workers' comp. insurance comp. tnsuratice.$
required.] 5. fl We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
3.17 I am a homeowner doing all work g p
myself. [No workers' comp. right of exemption per MGL l2. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
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' compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: \i C k ( ? -0( ,, Expiration Date:
Job Site Address: ,'"- 0t a Tt'r`)..C\ City /State /Zip:C C;fv tIAB
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 he pains and , enalties of perjury that the information provided above is true and correct.
Si• ature: Date:
c
Phone #: t — S30 ( k
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 #:
r
I
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
o
Name of License Holder : �1Qc� 1 t %.......) � 1 9'3'
License Number
Add -s- Expiration Date
,�._ W 30 I
"ignature Telephone
-m .:w,Hr ^ter. �w . "a m w as:,
(\.) 0 'Vc26.6,\A 'C egiiitered lmpeovem e'ilfbtiiiiF ctor gg ; a w r: d Not Applicable ❑
Company Name Registration N mber
1 q C,sc\E (.0( _ ���1 ONO (De* 7/r 1 /7--
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG L. c. 152, § 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 Attache6`YXl No ❑
. ROM& Owner .xeMPtion
11
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (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 Edition Section 1083.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he /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 home in 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
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) n Roofing ‘\F:1)
Or Doors ED
Accessory Bldg. n Demolition ❑ New Signs [D] Decks [C] Siding [D] Other [D]
Brief Description o ropos � rE't C r s C' j �� _S
Work: ''UU�� '�'[_
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa If`zNew;rhouse and or <addition -to existinct housi com the fotlowinq:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each '
g. Energy Conservation Compliance. Masscheck Energy Compliance 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 City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED ".WHEN
OWNERS AGENT OR CONTRACTOR, APPLIES FORBUILDINGPPERMIT
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
, as Owner /Authorized
Age t hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Nam'
Sign.ture of Owner /Agent Date
1
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by'Loning '' {y Ma"
This column to be filled in by
Building Department
Lot Size L --- '----
Frontage -- ,- -- --_— ,
Setbacks Front
Side L:- ; R:--- L:` i R: j ,
Rear
Building Height
Bldg. Square Footage i % i 1
Open Space Footage % _
(Lot area minus bldg & paved
r
parking)
# of Parking Spaces -- '
Fill: , ;
(volume & Location) --
1
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book i Page' ' and /or Document # '
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained I Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES f NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Depa rtment use orl
City of Northampton Status :rf Permit
Building partment Curb CutlDrly w'' rrni-t l - -- �' ; ,
L -6 012 rb , pti� :x �'
iliti 2 212 Main De Street Sewer /5e ttc A�rallabi[I
( e: AAd 3 W M +% i 5 b§
\ Room 100 Wa ter/Weli 4 atlabl € ity V h -, ,,,
�T�I�N:i x" s `p �^' ,r -a`5 .1i s v x.1. -4 ; .. „ S . �`''�-
Eas,aF nao ; o 6o rthampton, MA 01060 Two Sets Struct , r ' *k �� .,
No ' - 413- 587 -1240 Fax 413 - 587 -1272 Pler�l ans���
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This sect to be completed by office
3' r 04- p
M a * '' Lot '� , '` � �'
Unit ;
�Qt��� Zone O verlay Distrre
f 3 - 114 } _ S# . tl 4
Elm St Distract ". CB Disttict`
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT - _
2.1 Owner of Record:
(ern •SSSQ
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
3 (3t-I Il ic- ti'•_, Cr _5(c kc
Name (Pri ) Current Mailing Address:
y :---s" ... ------- 7 . Th
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Ed Total Co
Construction o fro (6) st of
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) �� � Check Number 3
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
38 BURTS PIT RD BP- 2012 -1084
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38A - 001 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -1084
Project # JS- 2012- 001866
Est. Cost: $27575.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KEITH DEVIN 99931
Lot Size(sq. ft.): 10018.80 Owner: SASSO DEA L
Zoning: URB(100)/RR(0)/ Applicant: KEITH DEVIN
AT: 38 BURTS PIT RD
Applicant Address: Phone: Insurance:
148 DOTY CIRCLE (413) 846 -4918 WC
WEST SPRINGFIELDMA01089 ISSUED ON:6/7/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:ST�P§ FI GLE OOF $� SKYLIGHTS
of - Q'vlS, .:c
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 6/7/2012 0:00:00 $35.00 C) /, - 1 "33
IN �
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck— Building Commissioner