44-06 00M I' BP- 2010 -0615
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
' � pek X44 tS6t;
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0615
Project # JS- 2010 - 000897
Est. Cost: $4775.00
Fee: $30.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ED CORBETT JR 067450
Lot Size(sq. ft.): 12022.56 Owner: FLYNN MICHAEL P & CAROLE C
Zoning: SR(100)//WSP 11 Applicant ED CORBETT JR
AT: 983 FLORENCE RD
Applicant Address: Phone: Insurance:
4 Reed Street (413 58) 4 -6571
NORTHAMPTON MAO 1060 ISSUED ON.•1211812009 0 :00 :00
TO PERFORM THE FOLLOWING WORK .-INSTALL REPLACEMENT WINDOWS /DOOR
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 12/18/2009 0:00:00 $30.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
-- - epartmen uss only
City of Northampton Stow of Permit:
Building Department Curb CutlpHvewey Permit
212 Main Street mt►wrlrleptia Avalletilpty
Room 100 WMter/Weli Avallobility,
Northampton, MA 01060 No S oto of Structural Plsn .�,,
phone 413 -887 -1240 Fax 413- 5H7- -1 Z l2 plausits pies
Other 8pealty-
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 P ? y s roperty Address
f l( eew c,— f Map . Lot Unit
Zone .—...___. Overlay District
qlm et. District Cs District
SECTION 2 - PROPERTY OWNERBHIPIAUTHORIZCD AGENT
2.1 Owner of Record:
Nome l ;unHnl Mrtlllnll Addreeg.
I HIHl111nnH
Signature
2.2 Authorized Aaent;
L 1 f4R 'T � �_ 1 'T _ �a (_ t. k' �.ar ,S C ._ 1 ' urn _.L'►'► _ a
Name (Print) Current Melling Address.
Signature I elepl(nne
SECTION 3 - ESTIMATED CON8T f jUCTION C08T8
Item Estimated Cost (Dollars) to be Official Use Only
oom feted b mar Tllt
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated 'Total Cost of
.- Constryptl2n from 8
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection /
8. Total = 1 +2 +3 +4 +5 �� �_ ..... Nuitiber /d
.4001011 P I' 019101 9 0e oltiy.
Date
Building Permit Number:
Signature: _ _..._.._._._- __.._.-- •- - -____ _.___.._ _
Building Commissioner /Inspoutur of Buildinus Date
c
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:- -_____
Rear
Building Height
Bldg. Square Footage `
Open Space Footage
(Lot area minus bldg & paved
p arking)-- _ -__.. - -- -- - - - - --
# of Parking Spaces
Fill:
(volume & Location)_--- -_ - - --
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO O DON'T KNOW YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Regist I of Deeds?
NO 0 DONT KNOW O YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW 10 YES
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? YF(. NO
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 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, gradlnt�e avation, or filling) over 1 acre or is 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.
Alterallon(s) F" Roofing
or oo
Now House F Addition
Accessory Bldg. Demolition El Now SlUite [( 060ke Siding [0] Other
Work: AIW 1,AIL-AN-0 —AXVL 01LOW 444
Attached Narrative 148110WIllol) 1111111114114011)111,01111 Yo%
Plans Attached Roll - Sheet
6a. If Now house and or addition to eglating housillgh WIN ths fg1lowina
b. Number of rooms in each family urill: Nuillbill III
d. Proposed Square footage of new construction.. Di I I I (If I K I OnH
e. Number of stories?
f. Method of heating? I II(II)III(ma of Woildtilovali Number of each ------
i. Is construction within 100 ft. of wallwidti? yoli H(i hi i:imWror 11mi within 100 yr Iloodplain Yes No
j. Depth of basement or cellar floor below finishod gitidil
k. Will building conform to the Building and Zoning tolpilHtiorlWe YoH No
1. Septic Tank __ City Sewer Privifle woll f:11Y willill f1upply
SECTION 7a - OWNER AUTHORIZATION - TO BE OOMeLITED WJINN
OWNERS AGENT OR CONTRACTOR APPLIES POR BUILDING PERMIT
as Ownerof the subject
property
hereby authorize
to act on my behalf, in all matters relfitive to work authoilzed by 11111i hLilldill(I INJI-IfIll III)r.111(lallorl
I Signature of Owner Halo
as Owrlo(AZo
CA ereby declare that the statemenle find Infornuillon (if I tl it I Im upoii i1j III ipliciiii(in 11111 IWO Ill III arioill to the bebt ofTn7trnWT6dge
Signed under the pains and penalt'i of perjury.
Pdnt Name
Signature of Owner/Ager�t
SECTION 8 • CONSTRUCTION SERVICES
18 Licens Constructio
f '; �7-''n Not Applicable 13 Name of License Holder: L J l �/e " 0(07 071
um
�P N
Address
tdxpua6 � ^
Signature Telephone
IReslsteredloell "riint+oyeent'Cotithrcto ( { ' : �, ;;, ,` ;;..,. " ",, .; Not Applicable ❑
))Ia 4 9
Company Name bar
Address expiration Date
Telephon
SECTION 10- WQRKERS!`COMPENSATION INSURANCE AFFIDAVIT (M.O.L, 0.152, 25C(B))
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...... ❑
Ig "nib
Owner ExemAtion
The current exemption for "homeowners" was extended to include Qwnlr occuvied Dwellings one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possesn,a license, provided that the owner acts
as supervisor. CMR 780, SIxth Edition Seetlo -n 1108,15.1.
Definition of Homeowner Person (s) who own a parcel of land on which he /she resides or *tends 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 mo[e than one home in a two -yegr 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 buildlppRermj(,
As acting Construction Suvervispf 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
' The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Streel
UT Boston, MA 02111
www. mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/(' ontractors /Electricians/Plumbers
Applicant Information _ Please Print Le ibl
Marne ( Business /Organizatiordlndividual): V Jr
Address: __ - --
City /State /Zip: A1 Or2 r Ma�y�/ /1'1f}' 4)060 P h o i i c #: ( 4 / /3)� 5 �8 z / —
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am wemployer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction
employees (full and/or part- time).* have (tired the sub- contractors
2. D4 I am a sole proprietor or partner- listed on the attached sheet. $ 2 Remodeling
ship and have no employees These sub - contractors have 8. [] Demolition
working for me in any capacity, workers' comp. Insurance. 9, E] Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3. ❑ I am a homeowner doing all work right of exemption por M(i i.. 11.❑ Plumbing repairs or additions
myself [No workers' comp. c. 152, pl(4), anti WC havC no 12.❑ Roof repairs
insurance required.) t employees. [No workers' 1311 Other
comp, insurance rtaluircd. ]
*My 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 till work and then hire uutsidc cuntractors must submit a new affidavit indicating such.
;Contractors tha ch eck this box must attached an additional sheet showing the name of ilic sub- cuntractors and their workers' comp. policy information.
511i�7i"�31S7�S 'iilf7iL�141'y01�I�1�i iC �i'S®TS� - 'I _ -
I am an employer that is providing workers' compensation insurance jor m y 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 policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c, 152 can (cad 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 up to $250.00 a day against the violator, Be advised that a copy of this slwcment maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains al4penall ' of perjury that the hilormation provided above is true and correct.
Si nature: __.._ _ _._ Date:
Phone #: -�
Official use only. Do not write in this area, to he completed by city or town ojficiaL
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City /'Town Clerk 4. h:lectrlcal Inspector 5. Plumbing Inspector
6. Other
Contact Person: __._ ___ _._ _..___ Phone #:
Corbett Horne Improvement
4 Reed Street
Northampton,Ma 01060
VJ(_?IiK 'rEiiFCiHMtD h
/ � f
YUUH WUHK UHDEH IVU. tilU Nv.
o �3
S D) ,j L G- STr�i P_ 41 L 01 c S wy 1?n, h use , vS W G L 3 /B P/,
/ivS ✓ /7jan/ - G E?`�'yail, /�YJ9L� /h,S - � c �} -y aCNk ✓C�1li%��ic
CIA 10 i Q ._ Z- _ Lr✓�l 0�.1 t �vy�? "7 i.r C (✓'74 f}�Ur�� ✓. �'or l� t�
U Ue r'� ps 0 � /��� ✓ ?e_r e,4 ,S / �=f r' � s �C� C)
C V�If {mil n �l✓rcN�i� �pii3iDCr� �eW l /�� / T��� vCi/> 1 >Crctr
r:, � � 1�K y �� V r,.> - r � �G.T � j � 5 , � � f4 I� oG✓ �-{- ,
W l!✓ Ol./5 t �a r7 P Q po / ( -N�173 LL 10 /NW ? 0,-",4 L NW 3 Do u � (, f �rj ? z-,/t c)O is
*t� Alf SC,—e.c U
1 N� Q r J fJ _ -YL/J' I /C�/N[ �! - lNi i✓ OG✓ W
1
/{t4
-3-
f rJ 1 f__ I�CkJ/1 S- lVaj J 7
.enal .s yuararrteed lv be as specified, and the above work was pertormed in accordonc, v4im ine Dui -. gs arcs I�� Jicat�:._
for the above wore, and was completed in a substantial workmanlike nianner for lh, ,yr�d ���
13 ����o5✓T J �3 Arse (�J4r�Ul _N�aJ- � o , Si�i t� �'G�I�U✓
�s Partial - Full tuvuice due and payable by:
Cull u actin s 13 vt�1i l'