43-072 (5) BP-2007-0233
GIS #: COMMONWEALTH OF MASSACHUSETTS
Yue 6fi ` CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2007-0233
Project# JS-2007-000352
Est. Cost:$10903.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
use Groun: SEARS HOME IMPROVEMENT PRODUCTS INC 148607
Lot Size(sp. ft.): 16552.80 Owner: DEVANANDAN MARTIN&MARY E
zonae: SR Applicant: SEARS HOME IMPROVEMENT PRODUCTS INC
AT: 112 DUNPHY DR
Applicant Address: Phone: Insurance:
1024 FLORIDA CENTRAL PKWY (407) 551-5962
WC
LONGWOODFL32750 ISSUED ON:8/30/2006 0:00:00
TO PERFORM THE FOLLOWING WORK:I NSTALL KITCHEN CABINETS &
COUNTERTOPS
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 8/30/2006 0:00:00 $55.00M0
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
Department use only
City of Northampton Status of Permit:
r, p h-r
laullding Department Curb Cut/Driveway Permit
rr,I IC y l' 1212 Main Street Sewer/Septic Availability
NogRoom 100 Water/Well Availability
hl am ton, MA 01060 Two Sets of Structural Plans
A,\u 2a pLone 41X-587-1240 Fax 413-587-1272 Plot/Site Plans
J Other Specify
7 APPLICATIONTPVONSTRUCT,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
//9 bkA/pflyf✓E Map Lot Unit
N L o eei✓c e- mA 0 /6 6 Z Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
(Y1/9"KT;r �cV 4w17A01 //2 DuA/Pil y b2,
Name(Print) ff � Current Mailing AddreS ,37
�KCU.wcv. J�L�ZW�-r�--.-�/7r1.4J ) Telephone/3
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 permit applicant
t Building (a) Building Permit Fee
;0903
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) /0y 903 Check Number 1170 ( s-
This Section For Official Use Only 7/
Building Permit Number: Date
Issued'.
Signature:
Building Commissioner/Inspector of Buildings 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: It:
Rear
Building Height
Bldg. Square Footage
-Open Space Footage %
(Lot area minus bldg B paved
parking)
Si of Parking Spaces
Fill:
(volume&Lotion) - _
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW 0 YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW ® YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
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 O
IF YES, describe size, type and Location:
E. Will the construction activity disturb(clearing, grading,excavation,or fining)over 1 acre or s it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
•
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) I7I Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [O Siding[CI Other[D]
Brief Description of Proposed
Work: RPPcgcemea/T j1r7Y ae.JC1190.i -f ey eke-2TdPS
Alteration of existing bedroom Yes No Adding new bedroom Yes -X 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
nifieriN l2V f}f✓�f)k) ,as Owner of the subject
property
hereby authorize Se�il c Heine /2)PEUJewtaur' -QP_DDUCTsf��1C
to act on my behalf, in all matters relative' to work authorized by this building` permit application.
Y{'�A QAG✓Ificycz-Yrivl�L� SP4 ,&tip
Signa ur,of Owner Date X
I, 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.
P1A&c 4t- -k
Prin Name
? 9 r
L! Ne-116-- h as O6
Signature of 0 er/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: 4 LFBED Aly 1118 A) are , Not Applicable ❑
Sepe5 14e me" ;t) eV meNl ?gap ucr5 /()lC , i S 6 0 4
Company Name Registration Number
/0,0-r-1 Fine.DFS CatfiaAL. Pkwy /0Il11,0-007—
Address (yo;) Expiration Date
/L`) tA14-U7cCt> it-t- Telephone 5-7C• 2,
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 Dwellings of one(I) 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 workfor 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
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Fir :-___-.- -7E.'9 PAX G=. . 722 Et 9: tae-. 70 200E F:
The Commonwealth ofitlassachuseas
Department of htdttsfrial Accident
aOffice of Investigations
600 Wash ing1on Strep:
\irk Boston, MA 02111
Ivww.ntays.gov/dirt
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
'r. :: (awinesilors,n;z,;:nriand:'ddeaq: SELTF,Q.S H 0)E (Ma�'n!'G P2r._Dt_t-rS. lar L,
Address: ftr0Z4 LtP�1kA CF/h.T )91_ PMkKt3iii
City/State/Zip: Lund(&th EL .-3,2_756 Phone #: 467- -gJe4'.
Arc you an employer?Check the appropriate hot . Type of project(required):
1.g I ani a employer with 4. ❑ 1 em a general contractor and I
6r ❑Naw construction
employees(full andior parttime).` have hired the sub-cantractors
2.❑ I am a sole proprietor or partner- listed un Che artached,sheets 7. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me it my capacity. mixers' comp, insurance. 9. ❑Building addition
[No tonrkers' comp. insurance 5. ❑ Vr't are a corporation and its
required.] officers have exercised their I15.9 Electrical repairs or additions
3.❑ l n n P.homeowner doing all work right of exemption per\IGL I L❑ Plumbing repairs or additions
myself[No worker' comp. c. 152.$1(4),and we have no 12.9 goof repairs
insurance.required.1 t . employee.:. [No workers' U.❑ Oahe:
_ camp.insurance requirethl _
'Asa e:riusietha,check.box PI must nls>011 wit tlmru:un betess SSLINVilljt.'<ir uvd:ri con:penusion policy inrrinatinn.
t schmh this eId•vi:hidithrine they arlotus as au cod:am bite ouard.umt-_wrs must ipbmieo.<w Find:wit irdicatht suds.
$ec.,co-nthA:cne;h:Mites must.rsted on Additional 9wus:ou1er,tamem.e ofncmk-cua:rntnrs ar.d their worker?comp.policy Information.
/am on employer that Is providing workers'compensation insurance for my engaloyees. Below is the policy and Job she
Infnnnalion.
Nur-Ince Company Name: Yat )EMd 171 1d.49.4,(aiAf LE ('n e� 11oF %/1 „mt.,/�f1
Policy b or Sel6ins.Lia IS: C- ',`(E 4rO c)a-�+ � Expiation Date: ,,,./24/L,,, //LA;4'41
Job Site Address: //a �(./Nf7it l _De City/stntc/7.ip fwee7O'C m 010 6 Z
Attach a copy of the workers' compensation policy declaration page(showing the polity number and expiration date).
Failure to secure coverage as required under Section 25A o f MOL c. 152 can lead to the imposition of criminal penalties of
fine up to 51,500.00 nny'or ono-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a bre '
of up m 5210.00 a day against the violator. Be advised the a copy of this staxmen:ma;be forwarded to the Office of
'investigations of the DIA for insurance eovcrage verification.
i do hereby certify a Iden the p s andpenaliies of perjury that the inf motion provided above ix true and correct
Si:,a::::e• l --- — Date: Si- —2-'I— rib
Phcn:c{. `{D-7-,43'51
Ofiiclaase only. to nut;Mtn'In th isareg ro be complexed by city or in in official
City or Town: _ • _ _ Permit/License#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3, CIt5rinna Clerk 4.Electrical Inspector 5.Plumbing Inspectur
6.Other
Contact Person: Phonier
Ee cr. 3;30/2005 11 :30:27 s01
•
a7S
HOME IMPROVEMENT PRODUCTS
May 2006
LETTER OF AUTHORIZATION
I, A. W. Nyman, Jr., Assistant Secretary for Sears Home Improvement Products, Inc., give permission to
Corestates,Inc. and its' associates,Karen Kirklys to be able to submit permits and licenses,pick up permits and
licenses,make changes to permits,licenses and plans and initial changes made by the building department on behalf
of Sears Home Improvement Products,Inc.
I also give permission to Corestates, Inc. and its' associates, Karen Kirklys to purchase permits and'or licenses
with a company check, personal check,personal credit card or cash. This authorization is valid through December
2006.
certify that the above information is true and correct.
0.S.2171111,
[ant Secretary
Scars Home Improvement Pro,ucrs,
STATE of Florida
COUNTY of Seminole
SWORN TO AND SUBSCRIBED BEFORE ME THIS 22nd day of May,2006,by Alfred W.Nyman,Jr.,Assistant
Secretary for Sears Home Improvement Products, Inc. and who is X personally known to me or has
produced a Valid Drivers License.
NOTARY PUSUC.STATE OF FLORIDA
2 *Deborah P. Phillips
Commission it DD520380
Print Name: Deborah P. Phillips Expires: AUG. 13, 2007
Notary Public,State of Florida Bonded Thru Atlantic Bonding Co.,Inc.
MY COMMISSION EXPIRES- Aug. 13,2007
ecfrirvinomefeala oi_ G cue��.ls
�oyscz
Board of Buiidtng Regular ons and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration; 148607
Type: Public Corporation
Expiration; 10/11/2007
SEARS HOME IMPROVEMENT PRODUCT
ALFRED NYMAN JR.
1024 FLORIDA CENTRAL PKWY
LONGWOOD, FL 32750
Update Address and return cart Mark reason for change
nrs CAI „ sm+-oaaswcaese ❑ Address flRenewal 0 Employment rl Lost Card
a &ewneoanasa/c% /✓a�iwmafuaaa
Board of 11vtitling Rtgais}ions and Staadarda License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date, if found return to:
(V75. Re8lstration: 148607 Board of Building Regulations and Standards
Expiration: 19/11/2007One Ashburton Place Rut f 301
Type: Public Corporation Boston,Ma.02108
SEARS HOME IMPROVEMENT PRODUCTS INC.
ALFRED NYMAN JR. '
1924 FLORIDA CENTRAL PKWY pa.�. �
LONOWUDD,FL 32756 Administrator Not valid without signature
c 3;'3Y2a22 11:55
4071767-55375 PcRii,iT$ LICENSE :SPI -
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LOCKiCN COMPANIES
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THIS CERTIFICATE Is ISSb D f { t4ATTEa OF 12150:(11,710N :
ONLY AND CONFERS NO RIGHTS UPON THE CERTIF'„ATE
525 V7,IArrs„X,Suite 6:3 HOLDER,THIS CERTIFICATE D>ES NOT AMEND, EXTEND OR
CH:CAGQ 2.62,551 .A7..TEti.'Ct1E C9'_LERAGE AFFQHPED$XSHE PO.1d41EiCSELO_PL I
032)2525530
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•
CORE STATES LETTER OF TRANSMITTAL
ENGINEERING
Date: August 28,2006
1191 Rsam rvu as 297 Semdn Fang 379 Campa Dm 53 Crown Steel Ora Hama Sew, 56C,alvd beware 7251 Pao.Mwle.e HY&aroma Pk 016
srwz „�.,, M>.e.nwn MA 01,30 Sete 500 S.Mzm ens Project Name: Sears
DMUM,G93006; mmn.vn Sdme11M,W06813 Canada en srs 9.578 .Mo 59116 cn.w..lc z�c 1187:0-211_75633519 Pro'ect Number:SRS-5538
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foxFaxxFax 13save Fax 7R-667-9001 ra,wssvae, alaew5z3 Fax 704'927-M61 Fax 813-420-1759 Task Number
681 Site Location: Florence,MA
To:City of Northampton
212 Main St.
Northampton,Ma 01060
Attn: Building Inspector's Office
Phone:413-587-1240
WE ARE SENDING YOU:
Plans ^ Reports Letter Specifications Photocopies
Prints I i I Other:
VIA:
X Overnight US Mail Courier Pickup n Other
COPIES DATE OR NO REV DATE DESCRIPTION
1 Building Permit application
1 _ Check for Permit fee of$55
1 Contract between Sears and Owner
1 HIC License
1 MA Workers'Comp Insurance Affidavit
1 Sears Letter of Authorization
1 Self-addressed, Pre-paid FedEx envelope
THESE ARE TRANSMITTED AS INDICATED BELOW
X For your use As requested ri For your input n For review&comment
Other
Remarks:
I've enclosed a self-addressed package for your convenience to mail the building permit to me.
When the permit is ready, please call me at 978-462-5788.
Thank you,
Margaret
COPIES TO: SIGNED: b't euJ`p„cw- Aka:
Margaretiillis �"_""
engineers • constructors • project managers • program managers