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25A-075 (5) As k10__VJj& 60 ro osaC Vinyl Siding Corbett Home Improvement Window Roofing s Dors Northampton, MA 01060 Aw ings (413) 584-6571 Canopies 'cam l 1� o 6 9 L o(07 X5°4 but ers PROPt.>sAL SUBMITTED TO vj A Al rQ /V>♦7 Z PHON Q6 DATE �' / V-7 _:57R 11- 7 SI7[EET e 'P v� JOB NAME CRY,STATE,alai ZIP CODE JOB LOCATION DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: U .t! /N L✓: Za e ov eve -4_ G �s 3� d 433 7KA S 3 3 &A b cWe Tropose hereby to furnish material and labor-complete in accordance with the above specifications,for the suns of Payments to be made as follows:Me) All material is guaranteed to be as specified. All work to he completed in a work-like manner according Audlorized to standani practices. Any altercations or deviation from above specifications involving extra ousts will he Signature _ executed only upon written orders,anti will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. (honer to carry fire,tornado Note: This proposal may be and other necessary insurance. Our workers are fully covered by Wurkmten's Compensation Insurance. withdrawn by us if not accepted witlin Acceptance of ,PrOpOSAf-The shove prices,specifications are conditions are satisfactory and are hereby accepted.You are authorized to Signature do the work as specified. Payment will made as Ithried above. Date of Acceptance: � ` Signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigation.s 600 Washington Street k1V Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/organization/Individual): V kd4-Jr Address: City/State/Zip: IV ore Al }ri,✓1x114- 61060 Phone #: (913),s8!Y--6 x71 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am&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. 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 required.] officers have exercised their ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption her R1GL, I L❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we ha v,: uo 12.❑ Roof repairs insurance required.] t employees. [No workers' 131-1 Other comp. insurance required.] *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 outside.ontractors must submit anew affidavit indicating such_ $Contractors that check this box must attached an additional sheet showing the name of th, sub-,:onu actors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for m r employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self-ins. Lic. ti 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 an penalt' of perjury that the information provided above is true and correct. Signature: Date: Phone#: —� - 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. b:lectrieal Inspector 5. Plumbing Inspector 6. Other Contact Person: _____ Phone #: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su rvisor: n /J Not Applicable ❑ Name of License Holder: l 2 J r 06 7 Lk5-6 License Number 41 o(0 q-3-0 8 Address Expiration Date Signature Telephone 9.Realstered Home Improvement Contractor: Not Applicable ❑ C©213e.7F7- Aerie �i�o.�a� /I4 o6 9 Company Name Registration Number Address Expiration Date Telephon�%�c� ByYOs7/ 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 result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... No...... ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellines 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 108.3.5.1. 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 buildine 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement-windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[:J Siding[O] Other(CA Brief Work esc DuPro7s�/ � � l�l✓s �l ZV. Cr Ss — Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.If New house and or addition to existing housing, complete the following: 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 FOR BUILDING PERMIT I, , 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 4anelief. as Owne horized reby declare that the statements and information on the foregoing application are true and accurate,to the best of edge Signed under the pains and penalties of perjury. Jr Print Name Signature of Owner/Agent Date 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: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (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 O DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES o IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES O 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 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,a avation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO J;�). IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permlt " Building Department Curb Cut(Drivewiy Owrrilt 212 Main Street Sewer/Septic AvallabiNty Room 100 T _ _ __ WaWAAWD Av011ability Northampton, MA 01 0 is W;tructural Plans"'" p �� � phone 413-587-1240 Fax 413= 8� 2 -- flloUSite��la►9 Other Spedty' APPLICATION TO CONSTRUCT,ALTER, REPAIR;REN T dR OLISH-CONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION r, r 1.1 Property Address: Th s section to be completed by office 6 C /_ 6l, e- 74Vej Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: U i yi6^/ tQ reSNv 4;-. Name(Print) Current Mailing Address: Telephone 7 CJ, !^ ba Signature 2.2 Authorized Anent: k",p 7- (bo ere-rr J IZ Rf Pd S-� I l4d MA © Q 6 0 Name(Print) Current Mailing Address: S7i Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit 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=0 +2+3+4+5) 02 OaL Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date BP-2007-1139 GIs#: COMMONWEALTH OF MASSACHUSETTS 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-2007-1139 Project# JS-2007-001825 Est.Cost: $2426.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Ed Corbett Jr 116069 Lot Size(sg. ft.): 5314.32 Owner: BRESNITZ VIVIAN Zoning:URB Applicant: Ed Corbett Jr AT: 59 COOLIDGE AVE Applicant Address: Phone: Insurance: 4 Reed Street (413) 584-6571 NORTHAMPTON MAO 1060 ISSUED ON:512212007 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 5/22/2007 0:00:00 $25.003454 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 59 COOLIDGE AVE BP-2007-1139 GIS#: CO1� ALTH OF MASSACHUSETTS Map:Block:25A-075 t7Y OF NORTHAMPTON Lot: -001 PERSONS CONTRACT iAG WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2007-1139 Proiect# JS-2007-001825 Est. Cost: $2426.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Ed Corbett Jr 116069 Lot Size(sa.ft.?: 5314.32 Owner: BRESNITZ VIVIAN =a*- ¢U^1; Applicant: Ed Corbett Jr AT. 59 GOO'-.iDGE A E Applicant Address: Phone: Insurance: 4 Reed Street (413) 584-6571 NORTHAM PTONMA01 060 ISSUED ON:512212007 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: ©k G-j •t9 7—&tn THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULAXIO Certificate of Occu anc �� si nature: FeeType: Date Paid: Amount: Building 5/22/2007 0:00:00 $25.003454 212 Main Street,Phone(413' -1" (413)587-1272 Building Comm:e :er tillo