06-004 (8) Date '` , Homeowner Information
Narrtew Email a C ki
Street �, . � stal _ e.,
Phone
c (circle)AI.T# .1�.'4�.�.�r.. ..�,._r ..��_ HV� t Tn UPd8t .,.AW4^
l[9lfitG Type Color �: Style VX-1A1&tC
Removal of Existing Soling es ONO Wrap E*Oncal es ;-INo
Removal of Garage Siding "Yesmo New Gutters ulryes 1041 co �
Dumpster W ONO New Down 1."'PYess
Window Trim €3 3 / 4 S Ot^LrA Old€;fullers RomoveJFte�rnstail Exist" C- C?ts e
Coif OEtat OPVC i Performance Colof,Wjoro G"prvtectttx+ f]Yes
Gable Vents gees ONO Storm Door l..lYes Entry ter
`> 0-- Type �,a.._,
SOMt Covered Was ONO Color Entry hoar 6-Y J6
Soffit Vented 5r'+es ONO #--_ Type.._,m.= � Color— �_..
Fascia Covered Ores Color_ Shuhm Gres 10
Raked C "red Nos ONO Cokw fflaks 0 Panel fie" Louverilid
Contras"Camara es No Color Porch Color v..
Repair Rotted wood (not she64wv LOYes ONO Porch tried*Wads dyes Color
Replace Sttelasting --
_....,,,,.,._. Windows Glass Screens lolor GRIDS Fixtures
Ofton Cry. Smad !� 2 Pow ",— half Inside Exte S Sh+lt
I
Do Not Do We do not do any pwinfi%'Of at****)
WORK SCHEDULE
Cc n b0On the work or onfer V*MOW**bel0re Wo fwd 0ty taslow0ap trot MWw 01 lift Aprsnnent.tir+k� ad«ae1 tie qrw ewe+ an+o1 ab"
(full) de*oa�wad try dim b*yturl C�lrOaaft 0onlyd,Ow w w%Will be c0mpn016d by n owww r tcl6
c:0 tlwe dates lire appra�e�e and aft sard6 daunt 00100 we rrct■.cvdable by 00 C arrw incArafewn. so vr**% At%M Gad ~&Q"
rnalerraa,esxodents,arld as otfwr detains beywb ft conlml.st6rt not#»rcrrtr0erae as d
WARRANTY The Gor> or warrtrdt thee trw work f mvilhed heraur4sr be well kom 0010016 rn am r lax t d OM� $"11,w "?t
wo tfwe rectssrerraft of aws Agrawroeret in awe ever0"d0aW n wWWW*hV or nulertlge,or dvntge owisad by Ow C0*601N,its ex xora ti 6u 41, ew
after=Mletioll of any lob,Ins u*V d"nW..tree CO+*seCW Nees 0 all own OW",kirOWAM rser6srty,r*W,correct,ntplac*.w ct6+we to be rornedod w,)&— w-Pi- I'
dornsp tx such dated to m trod vfwtor� The 00"00wt0 tiles*WW" In cOrww~MM the 49POW-Upon*V"
YHl agrees to perform the work,furnish the material and labor specified above for the total sum of,
t t t Ns"*of awe s M try a�.d
{� ( } 0prrrpttt+on M r twn ors~too ho"ff*w.+rW*--q*Q*040 M"m"tm""
*Vow)a'ems.0wo owsod all the WW oaaa.er VMS w 00 0"Woo"of M arpo w"o.
,✓�E� {s. .._ ., 1�, .,,_ _..)st►a t be m00o +rttr»rth+x�on tw w arewn WON asww"aeries 00—Y o6 or0a
of Work undo Its"oar** na Wwis&W 4091offfol".
Acceptance of PrOposat f have rear!both sides�this doaxrnernf aruf as tom.1�ec;�Gatiotas and conditions stated.1 d that upon
signing,this proposal tfeoomaes a binding contract.You an authorized to do the work as specified.Payment will be made as outlined above
You may cartcei this agreement if it has bW signed by a patty thereto at a place other than an address of the Seller,which may be his main office or
branch tt»eof,provided you notify the Serer in writing at his maim office or taranch by ordinary malt posted,aY telegram sent or toy delivery,not later than
midnight of the third business day following the signing of this agreement.Please refer to the Notice of Car"Uatton below contents of which are referred
to agave and incorporated hereon by reference.
DO NO, rSJGN THIS CONTRACT IF THERE ARE ANY BLANK SPA
/ _
Da#e_. atwo_- -r"
The Commonwealth of Massachusetts
02 Department ofindustr&ZAccidents
Officeo f Investigations
e
I Congress Street,Suite 100
Boston,MA 02114-2017
www.inass.a
govldia
Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
nandividual):_
-Name (Business/OrgInizado _MTNWXM?_ni
Address.: '3Z -ndu:s+-r-:,,e0 Drive up."I
City/State/Zip: (1Y 1Cc mpbh DLO Phone#: -52
W _�L_, �
Are you an employer? Check 6e appropriate box: Type of project(required)-
1. I 4. ❑ 1 ain a general contractor and I
D/ am a employer with F
employees (fall and/or part-time)." have Bred the sa•co armctors 6. ❑New construction
1 7, remodeling
2,E] 1 am a sole proprietor or partner- listed on the attached street
These sub contractors have
ship and have no employees 8. 7 Demolition
'working for me in any capacity. employees and have workers' 9. F-1 Building addition
[No workers' comp- insurance comp- insimance., 10.7 Electrical repairs or additions
required-) 5. 7 We are a corporation and its
3.0 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. (No workers' comp. right of exemption per MI GL 12.7 Roof repairs
insurance required.] t c- 152, §1(4),and we have no 13.17 Other
employees. [No workers'
comp.insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit 2 DCW affidavit indicating such.
.Contractors that check this box must attached an additional sbeet showL:g th,-namc of the sub-contactors and state whether or not those entities have
employ=. If the sub-contractors have employees,they mustprovide their workers'comp.policy number-
lam an employer that is providing workers'compensation insurance for my employees. Below is&epolicy and job site
information. E 4t
Insurance Company Name: Tnwrano. ai_
Policy#orSe1f-ins, Lic.#: (O tob 1-6-1 Expiration Date
5 /257 Z2_015-
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(shovc,ing the policy number and expiration date).
Failure to secure coverage as required girder Section 25A of_MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-dear imprisonment, as well as civil penalties In the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised dw a copy of this stal--ment may be forwarded to the Office of
Investig
gations of the DIA for insurance coverage verification.
I do hereby certify. r th wins and penalties 49fperjury that the information provided above correct
Sio-nazure: Date:
?hone,#: 41 13-.
Official use 9114Y. Do not write in this area,to be comp:ewdkv C4 Or A.,W12 offwlal.
City 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 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS 8 9 14-"2 3-f5-2af6
{ G&--7ZAA-7 XI-Dty,A Rf License Number Expiration Date
Name of CSL Holder U
E2- -rAfDLf57-R1AL 7/�i'yC List CSL Type(see below)
No.and Street Type Description
U Unrestricted(BU dings to 35,000 cu.ft.)
ICiOi?T H�3 i�t PTD�i/.MISS. Of Dfv0 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone D Demolition
5.2 Registered Home Improvement Contractor(HIC) /6 ASS I-f-
YAAIKEE AOME7 -ZMP'G0VCM«r -- HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
82�N.DLJS
No_and Street Email address
NDr�Th,4rlPTDR./� MASS: OiGXG3 rfl3�3tf!-.�Z55
City/Town,State,ZIP Telephone V
SECTION 6: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.........-❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT j
1,as Owner of the subject property,hereby authorize YAK NlCHj9' NOME:E�tc'3�Vi=i+jlitLi T
to act on my behalf,in all matters relative to work authorized by this building permit application.
nA -pAi TfZACT
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By enterizrg my elow,I hereby attest under the pains and penalties of perjury that all of the information
containe th' plication is true and accurate to the best of my knowledge and understan ding
Print s or Authorized Agent's Name(Electronic Sigpature) D E
NOTES:'
An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at i
f wtivw.mass.,gov/oca Information on the Construction Supervisor License can be found at www.mass.aov.'das
r2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.fQ Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhalf/baths
Type ofheadng sysrain - Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for`total Project Cost"
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement Windows I Alteration(s) Roofing
Or Doors D L_
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [M Siding Other[❑]
Brief Description of Proposed
Work: revVxsv� } r-eD .e �Jidt�1` _.
Alteration of existing bedroom Yes fo Adding new bedroom Yes / No
Attached Narrative Renovating unfinished basement Yes ---No
Plans Attached Roll -Sheet
6a. If New house and or addition to exist!n housirt com i to the full®win ':
a. Use of building : One Family Two Family__ Other__._--
b, dumber of rooms in each family unit __ lure bsr cf
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
I, (f-7 as Owner/Authorized
Agent 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. I
Gtr ra,v�Y-2e2�✓!LPraV
Print Name
Signature wner/Agen 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 tilled 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 DONT KNOW YES
IF YES, date issued:!:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 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:
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 a
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
> rk�nt use only
City of Northamptont�at iermt
Building Department Curf� ury
r-- I 212 Main Street ta b tlty
i p
Room 100 WaterMCeN9Avatl
MAY — ' Northampton, MA 01060 1•va�stit5trut"ttiral Plans
DUI ply 413-587-1240 Fax 413-587-1272 PiftStt � ' --
EleC
pton N TO ONSTRUCT,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 lJnit
W Zone Overfly District
Elm 5t.DI+trict Ca District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
AT"e- or- e,� ��rre0.�s1 ,_ 58a c is D/953
Name(Print) Current Mailing Ad ss:
Telephone 4t3— —o �i
Signature _
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building S on t"N. y'-A (a)Building Permit Fee
2. Electrical D (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) � Li Check Number �7&� 2 --�
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
582 HAYDENVILLE RD BP-2015-1065
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 06-004 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit# BP-2015-1065
Project# JS-2015-002017
Est.Cost: $28489.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: YANKEE HOME IMPROVEMENT INC 89442
Lot Size(sq. ft.): 32800.68 Owner: CORREA ARLENE&GORDON SHAW
Zoning: SR(100)/ Applicant: YANKEE HOME IMPROVEMENT INC
AT. 582 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
82 INDUSTRIAL DR UNIT 2 (413) 341-5259 O WC
NORTHAMPTONMA01060 ISSUED ON.51412015 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE SIDING
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 5/4/2015 0:00:00 $35.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner