35-075 Troposaf
Northampton, MA 01060
(413) 584-6571
62 VS
PROPOSALSUBM=DTO PHONE, DATE
DATE 01,PLANS —I0B PHONT
We hereby subinit specifications and estirmites for:
i (,We Cpropi]iSe hereby to furnish inaterial and labor-complete ill accor(jallce with the abovespecifications,for the sum of-
Dollars 6
All oUtCrial is guaranteed lobe as specified Ali work to he completed in a work-likv inaruter according Aufliorilfl
tostandard practices. Any altercations or deviation train above specilitatiolus Involving extra costs will bt Signature
executednulv ufx,n written orders.and will become an extra cluirp,over 211d�th,ve the estijuale. All Note: -nns proposal May he
ugrreinents contingent uponstrikes,accidents or delays hevond our cojurtil. Owner to(�im,fire,tornado
and other necessury insurance, Our workers are fully covered h%,Workinen's Compensation Insurance. withdrawn hy its it not accepled withi 11 day,
,kcceptance of Troposal--flie above prices,specifications
-ire conditions are satisfactory and are hereby accepted. You are authorized to Signature
do the work as specified. Payment will be ina(le as outlined above.
Date of Acceptance: Swil t
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K E �ii� of kTorfl1a111Ptoil
�lcssn[hnLrlle _
3 —
o DEPARTMENT OP DUrLDr�\,G 1NSPECTIO!<'S
212 ?thin Street ' Municipal BkllldinC
Northampton, Mass. 01060
VT'ORICLIZ'S COMI'LNSATION LNSU-RA CF AFFMAVIT
(licczs�Jfr_rn)tr�) - —
,,virh z pimcipa-1 place of businesslrlesidence at
(s[TC- yc tY;Staic 7p)
do hereby certify, under the pa_ns and peualties of perjury, that
( ) I am an employer providing the following worker's comncnssuo;, cove zSc for Inv
eruplovccs worming on uiis job.
(la=-,-,Dc-- Coor n ) (PCLC- N ��r) -- (T :piruor Due)
I amt a sole proprictor, general contractor or homcovvoer (curie one) iDd have hired
the cones actors Listed below v,,bo hive the 'IOUOy,lnQ CDDDensz-Jon po!!cies
----(i^�aIL: of Copt-c,or1 (ln�nn� Cotnpv��ii'ct,c, ?:rirn�•.r; (T:x;�ir�',;on I�atc)
(t �e 01 Contractor) -- (Ins-,u2ncc• Com0a2`vP0'jc-" err) (—L.\ ir,i i o n Date)
(Name of Colunc-lo,-) — (Iasumncc C0mP2.C)'/P0Uq NmPb—') CExpir t on Darc)
01 2,Mc of Contractor) (Instranc-- Compa -y1P0hcy Numb:r) Zspir-anon Daic)
(eox�:d�;;ociJ c'.xc ifoce�..-� to mein�nrofn,_ioa pert"�to.L
1 am a sole proprietor and have no one worl,=g for me
( ) I am a home owner performing all the work myself.
NOTE.pl:s b cwx t Lu t c be o v,Nb flay pc:ov w G c1 ,,—:: X)c rc-Ru I.orx
ncx UZ-0-L--Lrro in a-t cb the bocmo-.+ver r>ydo or oa the g DUL z,7—ten:-ttran—Die G�_lly 0.Cc1.6 cd Lo be
c�tploycz uaGe Lh_.. :o�,,•• •-._liea Ari(GLI 52-n 1(5)� homeo,v Ier pa-rnrt n::7 c Idcnoc the
cp nznu or eo-'Ploy-uadc ho W—k4 el C Ocap--16o. AeL
1 undart.und tha a oopy of th,.Qat.cmcm m..y bo to tbo D,,p tma:t of Off—of Laurzooe for th,
co o i vvific�iroa&ad t1u L-ilu-c to eecurt'eovcr�t�under soeuoo)5 A of MOL 157 tin lad to the Lagxndioo of mmma,pcn-+rti�
ooasisrztg of c Gnc of uP to S 1-5C0.po and/or i�of up to oa ycsr cad C,j pm,.1'Ui i t5 form of.Slop Wort;Order.ad.
fimo(SI00.0o,d_y cplwna),--
Permit NumUes
p:;
SiCnatun of LICCmsC c=Ucc e F
. .
. .
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suppryisor, Not Applicable 0
Name of License Holde Z�X,/
License Number
q 4�� -D L,
Address Expiration Date
Signature Telephone
Company Na e Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will reSLI(t
in the denial of the issuance of thebuilding permit.
The current exemption for'humeopozern'was extended to include one(1) or two(2) families
and m allow such homeowner nu engage au individual for hire who does not possess ulicense, provided that the owner acts as supervisor.CMR 780,�Sixth Edition Section 108.3.5.1.
of ��c b�����d� ��d mnm�� onwh�h �c�
� y�zmo�(� v�m own oo�uzcu com�uuu
� �
is, orio intended to be,u one oz two family dwelling, attached or structures accessory uaouo d/o r far-`
Str=tffes. 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 ou the job o b o, D6 c required fr otine\odme. during and upon
completion of the work for which this permit ioissued.
Also bc advised that with reference to Chapter l52 (Workers' Compensation) and Chapter l53 (Liability o[Employers /^
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable forperynn(y)
you hire tu perform work for you under this permit.
The undersigned'1zomeowncr''certifies and uuaomoo 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
.
'
ma
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
Windows Or Doors
A,(,_essury Bldg. D DemolitionD New Signs Decks Siding Other [
bedroom _____Yes No Adding new bedroom ______Yes No
wa'smve Renovating unfinished basement —Yes _______No
Poll Sheet
na It New house:�and:or:addition�to:existigg:�h:ousi:ng,::com:olete::the::following:
oo,ding : One Family_ __ Two Family________ Ot e,________
— z ,uomsm each family unrt: Number ofBathroom
`..... ^ jowgeottochcd7_______
5quao �o�gec�n�wcon�u��n� Dimensions
o/ 5tnncs,
o| ,catngr Fireplaces or vVooUstoves Number of each
�. -.nmvauxx/ Compliance, Maabeck Energy Compliance fonnattached7 ______�___�_
^ .`� coxstroctinn
witk\x 100 'It. of wetlands? Yes No. ls construction, within 100 yr. MooUp|ain ____�Yes _No
^ �,�^,/n-�x,, o/ c(AarOoo/ he(owOn<shcdgradc _____
^oo|om' mLhe, dui!dmg axd Zmwog regulations? Yes No
,'. '.. -un^ ____ City Sewer Private well City water Supply
______
SECVION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the sub)cc,
x�adve to work author zeU �� ��� buV�/ng permit iii aU matters
Date
?
�
as Owner/Authorized Agtf-
information on the foregoing application are uuc and accurate, to the best n/mv knowledge and
u�c pains and penalties cdper)ury.
. .
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Section 4.
INFORMATION MU |ST BE COMPLETED, or PERMIT CAN BE DENIED
DU;E TO LACK OF INFORMATION
Exisfin- Proposed Required by Zoning
Buddi".Department
Sctbacks Front
Rear
Tvii Space Footage "I lo
�
Has a Special Perm d/Vahonce/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, dote issued:
IF YES: Was the permit recorded at the Registry ofDeeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
.. Do�sLhc �itecon�oin o brook, body ofwaic/ or wedonds? N� DON'T KNOW
YE5 ______
IF YES, has permit been or need to be obtained from che Conservation Commission?
Needs to be obtained ____________0btained QabeIssued�
� Do any signs exist on the property? YES NO
IF YES' describe size, type and
D. Ar there any proposed changes to or additions ofsigns intended for the property ?YES ___
No
_�-
'
IF YES, describe size, type and |ocadon:
Department use only
City of Northampton status of ?eianit f
Building Department Curb Gut/Dnveway i',er�n>
212 Main Street Sewer/Sept c=,AVibblft y
Room 100 water/-wolu- Silabjlity�-
Northampton, MA 01060 Tyro Sets of`Structural Plans
`phone 413-58Y-1240 Fax 413-587-1272 Plot%SiteiPJans
Other Specify :. m
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot Unit
Zone Overlay District
/f G'
Elm St.District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
'vanit- Print; Current Mailing Address:
_ Telephone
2.2 Authorized Agent:
(3 ACS
Current Mailing Address:
signature Telephone
77 SECTION 3 - ESTIMATED CONSTRUCTION COSTS
-- -
;teT Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant i
(a) Building Permit Fee
rtrica! (b) Estimated Total Cost of
Construction from 6
n��1,'oing Building Permit Fee
t�Iecnanical ,'HVAC)
-ire r1rotection --
jtai = (: + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
3,, imu Permit Number: Date Tssued:_ -- -z
Building Commissioner/Inspector of Buildings Date ,_
854 RYAN RD BP-2004-0611
CIS#: COIV11VIONWEALTH OF MASSACHUSETTS
Map:Block: 35 -075 CITY OF NORTHAMPTON
Lot: -001
Permit: Built inQ
CateQOrv: BUILDING PERMIT
Permit# BP-2004-0611
Project# JS-2- 04-0862
Est. Cost: $2250.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Ed Corbett Jr 116069
Lot Size(sa.ft.): 95896.40 Owner: ANSALDO ROBERT T&PHYLLIS A
Z�ni�� "lz ,�;,nsCn��t• Fri f'�rhp}t 7r
AT. 854 RYAN RD
Applicant Address: Phone: Insurance:
4 Reed Street (413) 584-6571
NORTHAMPTONMA01060 ISSUED ON.11118103 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:Lr A- /of-10 a3 --&V
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATION
Certificate of Occu ant Si nature:
FeeType• Receipt No• Date Paid: Check No: Amount:
Building 11/18/03 0:00:00 2105 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anfiony Patil'