25C-124 (2) 1�i S y
TroposaI Vinyl Siding
Windows
Corbett Home Improvement Roofing
Northampton, MA 01060 Awnings
(413) 584-6571 Canopies
Gutters
�O
Shutters
PROPOSAL SUBMITTED TO AO/Y/ ` L( M PHONF� s 07/ DATE V V V
STREET Qq j L S/ JOB NAME
CrrY,STATE,amxt ZIP CODE,/ JOB LOCATION
DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
1�VcS L A'L W 3 '04 i v /�J. , w— L►
Vz. l o o c is c_' d �✓
sr, s s s o r 710 JWSL i
t 2 0 s✓ dG( Wq_ 40 W-4- 'J s' 4-e- -pyc
2_1'31y X 691/y I VJ 60 67 VV I
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CWe C Propose hereby to furnish material and labor-complete in accordance with the above specifications,for the sum of:
Dollars« 0 S�
Payments to be trade as follows:
All material is guaranteed to be ac specified. All work to he completed in a work-like manner according Authorized
to'tandanl practims. Any altercations or deviation from above specifications involving extra cuts will he Signature
executed only upon written orders,and will becomee an extra charge over and above the estimate. All
agreements contingent upon strikes,accidents or delays heyond our control. (honer w carry fire,tomado Note: This proposal may be --------- '
and other nec mary insurance. Our workers are fully avered by Workmen's Compensation Insurance. withdrawn by us if not accepted witlun days.
Acceptance of Troposal-The above prices,specifications
are conditions are satisfactory and are Itereby accepted.You are authorized to Signatur)� 8
(lo the work as specified. Payment will be con aadee as outlined above.
Date of Acceptance: VI I IVQ Signature
. The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual): V JI'
Address:
City/State/Zip: 1U P_40h! 71 , Mh- 6)060 Phone #:_(t113),5_,99(- 6 S7/
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 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. ' Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. g. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 1011 Electrical repairs or additions
3.❑ I am a homeowner doing all work right oC exemption per M(i L 1 1.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152. §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13.❑ Other
"Any applicant that checks box#I 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 their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance fur 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 up to $250.00 a day 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 verification.
I do hereby certify under the pains an
penalt" of perjury that the in formation provided above is true and correct
Sign ture: Date:
Phone#: —�
Official 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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
^(—
Not Applicable ❑
Name of License Holder:
/
�(J2 Qj7T¢
0e7 /—k j6)
e??d N
License Number
y-3--0(9
Address
Expiration Date
yi3 �8y G�-7,)
Signature Telephone
9.Registered Home Improvement Contractor:
Not Applicable ❑
Co/We-71- ome- am,,,Zdvone,✓r
%/l0 4G 9
Company Name
54 r.l PM
01066
Registration Number
Address
,,JJ
Telephon�7��
Expiration Date
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....... V No...... ❑ 1
11. - Home Owner Exemption
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 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing E-1 Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding[I]] Other[Q
Brief iptio of P opo
Work:
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
1. 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
4anelief. r as Owne horized ereby declare that the statements and information on the foregoing application are true and accurate,to the best of edge
Signed under the pains and penalties of perjury.
Tky%el( T7�k'4 Jr
Print Name
11-6-07
Signature of Owner/Agent 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
parking)
#of Parking Spaces
Fill:
volume&Location)'
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW YES Q
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 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? YES Q 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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, a avation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO —P
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
r City of Northampton Status of Permit:
^Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
lorthampton, MA 01060 Two Sets of Structural Plans
phape 413-587.-1240, Fax 413-587-1272 Plot/Site Plans
C�\ 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:
(3 81 2 811 �t— Map Lot Unit
G ll„ Zone Overlay District
Elm.St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
b6mi S JLm tin/ 2
Name(Print) Current Mailing Addre
Telephone �r►Q Q 7/ i
Signature v Q
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 (a)Building Permit Fee
2. Electrical (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)
Check Number J
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/inspector of Buildings Date
212 l3k1 W,,9T BP-2008-0498
GIs#: COMMONWEALTH OF MASSACHUSETTS
124 CITY OF NORTHAMPTON
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-2008-0498
Project# JS-2008-000745
Est. Cost: $2255.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Ed Corbett Jr 116069
Lot Size(sq. ft.): 7187.40 Owner: SHULMAN NAMOMI A&
Zoning:URB Applicant: Ed Corbett Jr
AT. 212 BRIDGE ST
Applicant Address: Phone: Insurance:
4 Reed Street (413) 584-6571
NORTHAM PTONMA01 060 ISSUED ON.111812007 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 11/8/2007 0:00:00 $25.003660
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
BP-2008-0498
212 BRIDGE ST
COMMONWEALTH OF MASSACHUSETTS
GIs#:
CITY OF NORTHAMPTON
Map:Block: 25c- 124 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Lot: Blo
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Category:
Permit# BP-2008-0498
Project# JS-2008-000745
_Est. Cost: $2255.00
Fee:Cost: $ PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
Const. Class: 116069
Use Group: Ed Corbett Jr
Lot Size(sq ft.): 7187.40 Owner: SHULMAN NAMOMI A&
zoninv: URB Applicant: Ed Corbett Jr
Applicant Address:
Phone: Insurance:
4 Recd Street (413) 584-671
NORTHAMPTONMA01060 ISSUED ON:11/8/2007 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET Building Inspector
Inspector of Plumbing Inspector of Wiring D.P.W. g p
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
g Driveway Final:
Final: Final:
Rough Frame:
Gas:
Fire Department Fireplace/Chimney:
Insulation:
Rough: Oil:
Final:
Smoke: Final: 47-�
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULA IONS.
Certificate of Occu anc sipitature
FeeType: Date Paid: Amount:
Building 111/8/2007 0:00:00 $25.003660
212 Main Street,Phone(413)587-1240,Tax: (413)587-1272
Building Commissioner-Anthony Patillo