17C-141 (5) CHARLES T LAVECK
HOME IMPROVEMENT
413-527-5604
TOTAL ESTIMATE
DEPOSIT UPON ACCEPTANCE OF CONTRACT ccj
PARTIAL PAYMENT"
BALANCE DUE UPON COMPLETION 3 JD
THE ABOVE SPECIFICATIONS ARE ACCEPTED AND I/WE AGREE TO
PAYMENT TERMS,ANY EXTRAS WILL BE IN WRITING PRIOR TO
RTING, WORK MAY BE BEGIN AT ANY TIME
DATE .
ALL MATERIAL AND LABOR PROVIDED;ANY EXTRAS WILL BE IN
WRITING PRIOR TO STARTING,WORKMANSHIP GUARANTEED
—CHARLES T LAVECK 3/i 0/02ANY
QU STIONS PI- ASE CALL , CHUCK 413-527-5604
THANK YOU
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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WOR MR'S COMPENSATION INSURANCE + + AVIT
(licenseeJpelmi��ee)
with a principal place of business/residence at:
(phone#)
(stseet/city/stalr/ap)
do hereby certify, under the pains and penalties of pequry, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Comfy) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (F-\pirmtion Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ffneecuary to include infocma m pertaining to nH ocatma r3)
I am a sole proprietor and have no one wonting for me.
I am a home owner performing all the work myself.
NOTE:please be aware that while homcoAvo=who cmplay perzow to do maitrtcaincc,coasu�oa cr repair work on a dwelling of
not mote than threo units in wfzich the homooevn<r raids or oa the gonads 1PPutttnant tbcrcto arc no(gcocralty ooaridcrcd to be
employers under the wroc�s ccarpsatioa Act(GL152,a 1(5)},application by a hancowncr for a license cc permit may cvidcnoc the
legal status of an employer under the Workoes Compeolejon Act_
I understand that a copy of this 1-t-f mt may bo forwarded to tho Dcpartmmi of Indaxtid Accidm&oflioa of Inwranoo for tha
covcaa ve ificafioa and that f Ldure to seatre oovnago uudcr scctioa 25A of MOL 152 can Icad to the imposition of aimkW pcnaWes
oomisting of a fine of up to S 1,SOO.00 anNot kvris�of up to one year and ciQ pcn&Wa in the form of a Stop Work Order anti a
firm of x 100.00 a day against mw
J? For&urtm-W use oody
Pcrmit Number
z ll I C�� Nfap# Lot#
Signature of LiccnseelPermi e
f
SEGTIbN 8 CONSTRUC7IQN SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
_:�. � «., �, wa NotApplicable ❑
R redH me.lm" r"v.emen ,° n rac r ..�.,.. .. . ,�� PP
twe 1-21
Company Name Registration Number
Address Expiration Xate
��✓�Z�i�S ��` ''� 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 result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
0 . ba M-11 I
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 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
ig ;°�'
SECTIONiD�l (P+ li" OF�PR PW5 \II/bR3 check I ',aDI licable
�3
New House ❑ Addition ❑ Replacen eQt Windows Alteration(s) ❑ Roofing ❑
Or Doors /RJ\
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: t�c�'� s ,� �� v ii✓ gl-C �t2 ��r.� ��J
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
6a If Ne fio a'rid or tld�ti ri to ezi:strng no icing, com"plete MR,:
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. Mascheck 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 OVIINER AUTF]ORIZATION TO BE COMPLETED WHEN
OVYNERS AGENT=OR CONTRACTOR AP,.F'LlES�.1 OR:6UILDING PERMIT
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 Agent
he eby declare that the statements nd 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.
1.--ies
Print Name
Signature of Owner/Agent Date �`
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF 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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D Are there any proposed changes to or additions of signs intended for the property ?YES_
No
IF YES, describe size, type and location:
r iw
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587.1240 Fax 413-587-1272 I I ;rte 9
e��Sp N
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
Jhis section to be'completed by office
1.1 Property Adddrres�sf �a �
MaP Loth �, nr
/ Zone Overlay Distr ct
Av
�C . �.
Elih'St:District CB'District
SECTION 2 - PROPERTY OWNER SHIPIAUTHORIZED'AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
%���%�- jl��--z� .mss%��r,� -f� �"�,✓
Nam ri Current Mailing Address:
j 'S ,
ianature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS-
Item Estimated Cost(Dollars)to be Official Use Only
comp] ted 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 = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature;
Budding Corxlmissioier/Inspector ofBuldrrgs_ Date„
T
HIGH ST BP-2002-0839
GIs#: COMMONWEALTH OF MASSACHUSETTS
, :Blogk: 17C- 141 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildinl?
Category:windows replaced BUILDING PERMIT
Permit# BP-2002-0839
Project# JS-2002.1399
Est. Cost: $3690.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: CHARLES LAVECK 121419
Lot Size(sq. ft.): 5488.56 Owner: PELTIER JOSEPH N
Zoning: URB Applicant. CHARLES LAVECK
AT. 132 HIGH ST
Applicant Address: Phone: Insurance:
25 DAVIS ST (413) 527-5604
EASTHAMPTON MAO 1027 ISSUED ON:414102 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WONDWS
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/4/02 0:00:00 2476 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo