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12C-113 c ' k1?R BP- 2011 -0245 GIs #: COMMONWEALTH OF MASSACHUSETTS ` 11+f1p:Bloc k: 12C -113 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate BUILDING PERMIT Permit # BP-2011-0245 Project # JS- 2011- 000409 Est. Cost: $2691.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN CORBETT 078297 Lot Size(sq. ft.): 10018.80 Owner: GLENN ROBERT A Zoning: URA(100, //RI/WSP Applicant: JOHN CORBETT AT: 78 RICK DR Applicant Address: Phone: Insurance: 56 Dimock St (413) 586 -8712 LEEDSMA01053 ISSUED ON. 911712010 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS 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 9/17/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner SIR � ,, ✓ Department use only City of Northampton Status of Permit:" Qwflding Department Curti "Cut /Driveway Permit '�M12 Main Street Sewer /SeptieAvailability Room 10,0' Water/Well. Availability Northampton; MA 01060 Two Sets of Structural Plans phone 413- 587 -1240 Fax 413 - 587 -1272 Plot/S1te-Plaris Other Specify APPLICATION TO CONSTRUCT, 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 R ` i Map Lot Unit Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record p Name (Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: . �B'G 2 7! �— Sign e Telephone ECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2 Flectrical (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) G jn�, Check Number This Section For Official Use Onl Date Building Permit Number: 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: R Rear Building Height " Bldg. Square Footage Open Space Footage % _. (Lot area minus bldg & paved p # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DON'T KNOW 0 YES 0 IF YES, date issued:" IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 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 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 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 0 NO 0 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 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Y SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable New House ❑ Addition ❑ Replacemen Windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding (0] Other (OJ Brief Description of Propo Work: -' 2t A L-L— �7'� L/c A.Y [J .-i I i y PA L:1 < r Alteration of existing bedroom Yes No Adding new bedroom Yes 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 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 as Own uthorize en ereby declare that the statements and information on the foregoing application are true and accurate, to the best of my novledge and belief. Signed under th pains and penalties of perjury. 1 7.1,t�� �s rSCZII Print Name Signature of Owne A Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction S upervisor . Not Applicable ❑ Name of License Holder: G% VL A,4— ` / 45 License Number / Address Exp tion Dat ature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Z 4;e Company Name WINDOW WORLD Registration Number 56 Dimock Street �--- Address Leeds, MA 01053 Exp' tion Da ire 586 -8712 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...... ❑ 11. Home Owner Exempti ©n 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 La)vo Annotated, you may be liable ful peisuu(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 �w The Commonwealth of Massachusetts � Department of Industrial Accidents Office of Investigations F= 600 TEashington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): WINDOW WORLD Address: 56 Dimock Street Leads, MA M 053 City /State /Zip: 586 -8712 Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ,employees (full and/or part-time).* have hired the sub - contractors 2* 6. New construction I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling These sub - contractors have -ship and have no employees 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. $ 9. Building addition ❑ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ officers have exercised their I am a homeowner doing all work 11.7 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. , Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am 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. Lic. #: Expiration Date: Job Site Address: City/State /Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of nP in $250 00 a clay against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage v erification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. /S /0 Signature: Date: Phone #: Of use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 719 4 WINDOW WORLD MC #160143 56 Dimock St. CSL #78297 Leeds, MA 01053 Telephone 586 -8712 CONTRACT _ Date Se:P i trAt(L 20 ) U This agreem between & I; � � e► a n of / I )GIB b(Z 1 - Ldoe.nct. MR ner) ,and (Address) WINDOW WORLD OF LEEDS, MASSACHUSETTS. Phone ',� o J - 1006 SPECIFICATIONS Window World will Z ZALL ( !)jZI ' y L (Z {AL - &pjP.��-:tslirv(vH1S tA -,,; 7A s -•,au) /,s' A) L li��Y1 �')n�t w,`t.L �d��_ r / �.�.;,rst• � ACT a��r�jD �le�rt,`ort. 49.46& LPL 1,k& rte L H 1T� w1 :Ck �2 jet L. / .z , e- U ,4:z a Y on the premises located at '7F a j c i e r i V & f l &A r„ e � a total cost of abl 9 l L7'Ci With this order owner pays down the sum of $ S'6 (>, v 1 Owner agrees on completion of said work by the Contractor to pay the sum of $ f J, /j/j 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. A14��- 00% s WINDOW GUARANTEE eaP Yd!!1%fs glass is guaranteed fos.ZA rs 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 any damage resulting from neglect, abuse, 9r acts of God. Condensation build up on the glass is caused from high humidify levels and poor ventilation within the homFterefore there is no Euarantee that this condition will not occur. In witness whereof, I have hereunto igned my name this f day of ter' by 6)"Onffa oyAtaorized Agent) 7 11%er ) - - - - - -- Inint7Won - R - r - --