05-048 (5) Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
r Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 178722
Type: DBA
Expiration: 5/13/2016 Trtl 251877
DONE RIGHT CHIMNEY SERVICES
CORY MCGILL
P.O. BOX 1054
WILLIAMSBURY, MA 01096
Update Address and return card.Mark reason for change.
Address [] Renewal 0 Employment Lost Card
SCA 1 is 2OM-05/11
License or registration valid for individul use only
Office of Consumer Affairs&Business Regulation before the expiration date. If found return to:
ME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation
Ux'Vegistration: 178722 Type:
10 Park Plaza-Suite 5170
piration: 5/13/2016 DBA Boston,MA 02116
DONE RIGHT CHIMNEY SERVICES
CORY MCGILL c'
6 WHITE RD
GOSHEN,MA 01032 Undersecretary Not valid without signature
1 Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction SuperN isor
License: CS-107568 r
CORY MCGILL
6 WHITE RD
P.O.BOX 1054 ;
Williamsburg NM-91096
Expiraticn
05/24/2017
Commissioner
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work:
The debris will be transported by: �y � .C
The debris will be received by: Ti jlzcl%
Building permit number:
Name of Permit Applicant
g/1 /1
Date Signature of Permit Applicant
The Commomvecdth of Massctchuseth
Department of Industrial Accidents
Office of In vestigations
600 Washington Street
Boston,MA 02111
`'��_�, � ' ss�►vx:nurss.�}os>/�tia7
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please/ Print Le Jiib�rl
Nann '>cJ,
Addrew-
City/State/Li : wf le 6,•.t hone . E' (/0
Are you an employer?Check the appri#riate hox: Type of project(required)
i.❑ I am a employer with_._...__ .,,,.__.._ 4' ❑ I am a general contractor and I 6, E] New construction
inployces(full and/or part-tiinc).* have hired the sub-,contractors
listed on the attached slice(. 7, []Remodeling;
2. l am it sole proprietor or parttti;r- `I'lsesc sub-contractors tktvc
slip and.Irave no cmployces S. ❑ Demolition.
working for nie in any capacity. employees and Itave workers' t
p J. [� Building addition
[No w�orkcrs' comp. insurance comp.insurance.'
rc uired. ?. ❑ We arc a corporation and its lo.❑Electrical repairs or additions
cl �
3,❑ I ant a homeowner doing all work officers have exercised IhLir 111:1 Plumbing;repairs or additions
myself. jNo workers'cons , right of exemption per MGL �
P 1_ ❑ Roof repairs
c_ 152 §!
Insurance required] (4),and we lire no
�. d
employees. (No workers" f301llerh �f/ S>
coinp. insurance reguired.1
'Ally applicant that checks box�,I Must also lift out the seclicnt helovN'Jiming their wv(vkcrs'compon.sation poticN information.
3 Hopieowners wlw submit this affidavit indicating the%are doing ate work and then hire outsido contractors miist whinit a new affidavit imficating Stich.
-C onn;tctors that ch"k.this box must atiachc^d an atditional sheci sho%%ing the name of the stab-contractors aril state whethin or not tho'-,-c entities hava
emploNets. Ifthe soh-urnir.wfoty have cntplu�ccs.they must provide their worork-ms'comp,pohey number.
I am an entplo yer that is Irroviding)twrker's'comp ensation insurance for im,employees'. Below iv the policy amt joh site
ire fi�rmadon.
Insurance Company Namc:
Police #or Self-ins. Lic,#: _— .._. _ .-- Expiration Date:
Job Site Address t�`I u)4ty `1 G City/Statc/Zip: -eml 1W 0 0cj�
Attach a copy of the worker%'compensation policy declaration page(showing the policy number and expiration slate).
Filil tire to secure coven, e as required under Section 25A of MGL c. 152 can lead to Ilse imposition of criminal penalties of a
fine up to$1.5M.00 and/or one-year imprisoninciat,as well as civil penalties in(iie form of a STOP WORK.ORDER and a line
of up to$2500)a day against rite violator. Ile advised that a copy of this statement nta_N be forwarded to the Office of
Investigations ations of the DIA for insurance co\crag e verification.
1 dig herehv certtfj�atIF er the pails and penalties of perjury that the information prr�virlc:t!shove is true and c>srrec
_..._.. _ ...... ..._...�. �__ �...__..- ...._..�__. ._________— ...... __
/�
Phone : e 1
Of,icial use onlr. Ike not write in this area,to he campleted by city or tolV11 official.
Citv or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
/ Not eApplicable ❑
Name of License Holder: 0%y, /l�lG IJT� i-3 /��
License Number
Address V , xpiration ate
)6"re Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
I�l1YY gz> ,Il Am- �% ,6 a' ��al� �2/f✓C 17 O 7 i a�
Company Name Ll �� Registration Number
Ago A" 10 1�1.'�I l l ct[M{�c c � ���-7� 3 /�/lyt
dd/A ress —' Exoirgtidfi Date
Telephone t/ 3`ago-/3"
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....... y No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinas 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 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [0] Other
Brief Docri ti gn of Proposed ,
Work: 4 1-12 A- o7eW G��>n.ft�r` �Ll� StLG'1�c � ���GZ? � ��'f�t_ti�r l4i�tC�
�ti vny.O
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet � + ,c,,.�/
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
Ctir T- .`u=-� as Owner of the subject
property n A
hereby authorize
to act on my a , in all m tters relative to work authorized by this building permit application/.
l,� l
Signature of Own Date
I, ( `, as Owner/Authorized
Agee'n her e y declare tha 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.
/ N'1/
PrinNan�e—
— ��IA I�__"'/7 1
Signatu of wn /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 fi lled 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 0 DON'T KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
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, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
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 Permit
'aJ 1 6 2p1� 1 212 Main Street Sewer/Septic Availability
Oil
1 Room 100 Water/Well Availability,
to4ampton, MA 01060 Two Sets of Structural Plans
'phorje-4 3=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
,Qq A,, Jt ,/ �� � Map Lot Unit
"( #IWJ J`C�)? ) Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) f � Current Mailing Address:
Telephone
Signature
2.2 Authorized ent:
Name(P r�f t) Current Mailing Address:T
�(l -
3L/0- t3
SiyfatLw 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) 3, ' Check Number !
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
324 AUDUBON RD BP-2015-0666
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 05 -048 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:woodstove BUILDING PERMIT
Permit# BP-2015-0666
Project# JS-2015-001278
Est.Cost: $6904.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: CORY J MCGILL 107568
Lot Size(sq.ft.): 388119.60 Owner: CUTLER JODY
Zoniniz: RR(,100,/WSP(100)/WP(2o)// Applicant: CORY J MCGILL
AT. 324 AUDUBON RD
Applicant Address: Phone: Insurance:
P O BOX 1054 (413) 340-139n
WILLIAMSBURGMA01096 ISSUED ON:1211612014 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL METAL CHIMNEY &WOO DSTOVE
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 12/16/2014 0:00:00 $25.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner