24D-280 PERMIT NOT ISSUED ._____ OfIL .r1D -1x-Fi N1%
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.Z, The Commonwealth of Massachusetts F E B 2 2 2021
W Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 C1 "—----- (MUNICIPALITY
buil 1)IN;,INSPFCTICNS USE
„Fa A i°eill�-°,�.r'^°ems° Revised Mar 2011
Building Permit Application To Construct,Repair,Renovateotuo.•�
One-or Two-Family Dwelling
tion For Official Use Only ,tl
i Building Permit Number: g A- .i'•9 3b to Applied: U
if.),\,/
lir
Building Official(Print Name) 'gnature Date
: ITE INFORMATION w�
1.1 Property Address:,. 1.2 Assessors Map&Parcel Numbers
/E c C Rcsten.k Sia.e Ay 0 2.80
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: _ Outside Flood Zone?
Check if yes❑ Municipal 0 On site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Clot;Re MIV n y /1/d1T ain f ro- AlA 01061�
Name(Print) City, State,ZIP
I F4; e�il`r-eA y93- 3aso-/d 9a..
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition ❑ Accessory Bldg. 0 Number of Units Other .11-Specify /Q4p tace,M ft i n is of
Brief Description of Proposed Work2: /1 e M p.m-otd W i 4•Lik/s ac.,,d_i✓tS ti t L V 1.7y'--
A er 1 it.v 4v, r r);,,4o ei f c,.,,Ti► Gt_ • a..7 !J- vA ..✓C-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $ (
Check No. RO
6.Total Project Cost: $ a .5-,5�1 c,!> 'S Check Amount: Cash Amount:
0 Paid in Full 0 Outstanding Balance Due:
c IC tta1i6a 6 te0
it (
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
a?�d47 6• 4.6 • 1.k
k b License Number Expiration Date
Name of CSL Holder U
List CSL Type(see below)
No.and Street Type Description
n U Unrestricted(Buildings up to 35,000 cu.ft.)
` '. "'e z/A- <4 /44 '2/3 - 3 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
"//?•S�6- ?A I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
J 6 't' HIC Registration Number Expiration Date
HIC Comp y Name or C 13 i rant Name
3er
No.an4 Street , Email address
City/Town,State,ZIP Telephone
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 0 No -�
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
:T/v4, � ,r1 J? 2. . A.1
Print Owner's<Authorized Agent Name(Electronic Signature) Date
NOTES:
1. 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. 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.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
rrrir..ri
0 ' sic
Massachusetts .�._ >er.
DEPARTMENT OF BUILDING INSPECTIONS
a:',r,, 212 Main Street • Municipal Building yJ6 a�
f Northampton, MA 01060 ssyh, 3' ‘^`�`
- F_
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: LA t. i , > j i' , ./: ,:, , ,
The debris will be transported by:
Name of Hauler: -..Ao/vA > < Li>n-,ber-'
Signature of Applicant: Date: da . O. t
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.gor/dia
11 urkrrs'Compensation Insurance Allidas it Bu ildersiContr ctars/Electriria,i iPluothers.
10 HE FILED%%rrrr THE PERMITTING AtrrHCNtrl't'.
Applicant Information Please Print I.rtziblti
Name 4 Hustttess Organtaation Indnidual j: - </L,jk e 1t` /Um, G.4 P .)md'
Address: ? 6-4atde.� s�
City/State/Zip:S. [Q e e Nr►z� /WA d 13 7 y Phone#: 1//2- S'8 6 -
Antrim an employer?Cheek thy appropriate hull:
Type of project(required):
1.0 I am a. Ina w 191 etepluyves gun and Cyr part-tnne I. 7. 0 New construction
V9I am auk prupnctur or partnership and hate nu employees working for nee in IL 0 Remodeling
any wpscaty.[Nu workers'comp.ucsuranr mongol l
9. ElDemolition
30 I am a h unnwmacr doing all work myself.Jto workers'comp.insurance required"
10 0 Building addition
4.0I am a hutnnww rue and will be hiring omits:mom to conduct all work on my peoperry_ I will
ensure that all c+mtrrcwn either laic workers"congrcauaeion insurance or art ache 11.D Electrical repairs or additions
prupriKrctn w all no ennplwec k' 12.0 Plumbing repairs or additions
SO I am a general contractor and I Isase bided the sub-contractors Eitd ea the ruerlied share 13.0 Roofrepairs
The sub-contractor.hike sadism...!workers'comp.ingounne.t Them: employees
&El We an:a corporation and its officers hake exercised their nein of exampu Ul.per h1 e. 1 Other�%tithd(J1
152.§I(4).and we bake no ctteplurees.['_5u workers'cuanp.insurance rop mete.)
'Any applicant that eh x•ks beta=I must also fill out the kctwn below show a their wurker.'compensation polic-y information.
Irenneuw ncrn w In,submit this atf,da%at indicating they arc doing all work and then hire outside contractor,,must submit a new affidac it oadicatml such.
:Contractors that check thu boa roust attached an additional sheet shimmy the noun of du:autrcuotr:kuxs and state is holier or nut those%mutes hake
ciripkIsees. I t the sub-contractors lake ernplunes.die)must pros idc their wurkers'uurnp.policy naobm.
I un►an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address. City State:Zip:
Attach a copy of the workers'compensation police declaration page(showing the policy number and expiration date).
Failure to secure coverage as requirtnl under MCiL c_ 15_*25A is a criminal violation punishable by a tine up to SI.500.00
aodior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance
coverage verification.
I do hereby certify an,er ter ns and penalties of perjury that the information provider!above is true and correct.
Swnature: Ir, Date: 01. d •a 1
Phone r:: ///1-d`JK.-Y?!1,
�aararaa�arrr --
Official use only Do not write in this area.to be completed by city or town official
('its or Torn Permit/License
Issuing Authority (circle our):
I_ Board of health Z.Building,Department 3.( ittfToenit Clerk 4.Electrical inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
a ,v S ...�....aic,� Massachusetts ... 'c,, *
d !# ( 4+ '' DEPARTMENT' OF BUILDING INSPECTIONS y1 rje
9v,, ;�
w w,, 212 Main Street a Municipal Building
+�rl r r amp i'j,��Q
-.-• Northampton, MA 01060
/ r HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I, G' ,or insert full legal name), born 6 Ica•63 (insert
(
month, d'f'►�year), here, depose and state the following:
1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a
parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption,
does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s)who owns 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 home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for
and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work
on my parcel, I am not engaged in construction supervision in connection with any project or work involving
construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any
provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my
parcel,I acknowledge that I am required to and will act as the supervisor for said project or work.
Signed under the pains and penalties of perjury on this .1_44lay of te 6 n..r4sl , 20 .
Aki
(Signa ir
') 3 > v s-ri _ (Wtor-J._
JCORBETT
` `` '`i. HOME EXTERIORS HIC #160143
X 413-665-2286 • 413 s86 871 z•corbetr®woodscomputer.com 4.
CSL#78297
38 Graves Street,South Deerfield,MA 01373
WINDOWS•SIDING•GUTTERS•ROOFING
"Locally Owned and Trusted Since 1966"
Serving the Entire Pioneer Valley
CONTRACT
Date A&cC-11, &vL.- /? 20 %II
This agreement,between C L i. s a e, /dd vU f/1 1/
r _ _,J' Owner)
of 5i v s)A...c,3) /b 1 (Ad s) , and
JCORBETT HOME EXTERIORS. SOUTH DEERFIELD, MASSACHUSETTS
Phone 'l/.7- 3a0 /6C-2,
SPECIFICATIONS
24 4tL C V)ell Z. t eiv►rit i IV)i domis 66) /,�vA , ,-t 1NJOf
iCL'LLJ 419O wf.,,J ii{roLa )e .
4LL u.,.let eti✓1 q!i ), At di 411 itt[/i,/Iy i u '-- -r/ no a1aC,
�.fCi‘ inr.( t'/V41l.it- —'
( dô la.;„.A
on the premises located at /6S- C 2G-C(.ec ,S),IiA /hL/*r,/)•\ a total cost of c S S~v- Gb
With this order owner pays down the sum of$ $4--ci. ad
Owner agrees on completion of said work by the Contractor to pay the sum of $ /700., v0 dollars
($ )•
Owner agrees that in the event of any breach of this agreement by him after acceptance he will pay 70%of the total contract
price because vinyl replacement windows are custom measured and made for owners home and will fit nowhere else.
Performance of this agreement is made subject to labor strikes,fires,wars, acts of God, and the Contractor's ability to obtain
material.
This Contract constitutes the entire understanding of the parties, and no other understanding, collateral or otherwise shall be
binding unless in writing signed by both parties.
WINDOW GUARANTEE
Manufacturer's glass is guaranteed for life from date above not to fog up between the panes of glass. All other parts will be
supplied free of charge for life. Service will be free of charge for 1 year from date above. Guarantee does not cover broken or cracked
glass after one year from date above or y damage resulting from neglect,abuse,or acts of God. Condensation build up on the glass is
caused from high humidity levels an' �sr ventilation within the home therefore there is no guarantee that this condition will not occur.
In witness whereof,I have h- - gned my name this /.e? rli day of C, , l eA, 20 GI
Sci)c---__
�_ )
by ,- —I,
•.ntractor o ••uthorized Agent) (Owner)
(Joint Owner)