11C-066 F� F LO REN C E S BP- 2010 -0082
GIs #: COMMONWEALTH OF MASSACHUSETTS
MapBloc 11C - 066' CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit # BP- 2010 -0082
Project # JS- 2010- 000088
Est. Cost: $20130.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES
Lot Size(sq. ft.): 20865.24 Owner: KOLODZIEJ PETER J & MARILYN J
Zoning: URA(100) Applicant: HOME DEPOT AT HOME SERVICES
AT. 83 FLORENCE ST
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 O
WORCESTERMA01607 ISSUED ON 712212009 0:00:00
TO PERFORM THE FOLLOWING WORK.-Siding and 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 7/22/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
Department use only
City of Northampton Status, of Permit.
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413- 587 -1240 Fax 413 - 587 -1272 Piot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, 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
Map Lot Unit
l Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owm of Record:
Name (Print) ,r Current Mailing Address:
n I j� C Telephone
Signature
2.2 Authorized t:
Name (Print) Current Mailing Address: �t
Signature Telephone
SECTION 3 - ESTI ATED 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) Check Number
his Section For Official Use Onl
Building Permit Number: Date
Issued:
Signature: Q
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 arkin g ) _.
_............._.._...
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT 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
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained I 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 Q NO
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 0 NO 0
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 ❑ Addition ❑ Replacement W' doves Alterations} Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (M Siding [0] Other (C7}
Brief Description of Proposed" i - �o
Work: �1 J 1 5d l
Alteration of existing bedroom Yes No Adding new bedroom Yes No Kb LA'c
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to4xisting 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
I, as Owner /Authorized
Agent hereby declare that t e s stem nts and in o ation foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under e p ns and ps pf perjury.
P�Name
-00- 4"n -- 7/2w
ure caner /Agent Date
4.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supp �ispr Not Applicable ❑
y r�
Name of License Holder
CQ, -7 License Number
I �L Address Expiration Date A Z., - r 7
Signature elephone
9. Registered Home improvement Contractor Not Applicable 0
Company Name
Registration Numb
3�rie>Pp
Address Expiration Date
�y 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 buildin ermit.
Signed Affidavit Attached Yes....... No...... ❑
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 1083.5.1.
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 fin peison(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
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his /her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he /she resides or intends 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."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
r
The Commonwealth of Massachusetts
Department of Industrial _Accidents
_ -� - -- ~
Office of Investigations
r L ` 600 Washington Street
Boston, M4 02111
E'
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual):
Address:
City /State /Zip: 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 6. ❑ New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have g. F Demolition
working for me in any capacity. employees and have wuikers'
[No workers' comp. insurance comp, insurance.$ 9. ❑Building addition
required.] ui 5• ❑ We are a corporation and its 10.7 Electrical repairs or additions
q )
3. ❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself o workers comp. right of exemption � ' per MGL P 12.7 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 131 Other
comp. insurance required.]
*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 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 isproviding 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 i11) to $250 00 a clay against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance c ov e rag e v erifi c ation.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
Of use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Nlas%itchuNetts - Delmi of Public ritfetN
Board of Building Re and Standards
U f
License: CS SL 98785
Restricted to: WS
IVAN KOSOBUTSKYY
72 STAFFORD ROAD
MONSON, MA 01057 ja
Expiration: 4127/2012
Trt: 98785
lee
Q
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 l rash ingion kree
x _ Boston, /ILIA 02111
\ s wit w.mass.gov/dia
Workers' Compensation Insur Affidavit: Builders /Contractoi /Electricians /Pitimbei
Applicant _ Please Print Le i bly
r
Name ( Business /Organization/Individual):
Address:
City /State /Zip: a � 3EO3!5 Phone .#:
AY10 an employer? Check the appropriate box: Type of project (required):
1. am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub- contractors 6. ❑New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have g, E] Demolition
working or me in an capacity. employees and have workers'
g Y P tY. 9. E] Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roo epairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ther C
comp. insurance required.]
*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.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors 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. #: (Lj� Expiration Date: f
Job Site Address: � N ow kYA 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 $1,5.00.00 and/or one -year imprisonment, as well a& GiVi
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 certi un r e p s an penalties of perjury that the information provided above is true and correct.
Si afore: 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):
1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
HOME>l k (Y1.MEitEF.COI+YI tkG: :
�. Sold lFvxWa1iedAnaloeralkdbr:
arpacb 1�ianae:.:Boatva. . , >►aue A� [. THI? Iomre'SerAlces,,Tnc:
Thttrnae.Ipa4 /E-'ti,,Dine: Sert'xCG,4 .
34SA e4�oaeaod �ftltt:,(Tntt 2, Wor-sler,. Mtn A.lk
Branch Number. 37, 1oCI FtY6.(8,OE1) $57 -}$2:. l aX.(98� 7$6 8823 "
'' leederal' ID • #�� *3ti4tHi6�0:1t'•L'#C')#'. TtiCt'7�C1i1027'
CT Lk*'.5it7 ZL kA oli 8 ro ne8� CO car itch: iw 126893 '
tootARR MAddress: 4€3 - ak 0Q
Rotrhasar YAM* h"w.
J ..,,
t Iltuppte Phoaer> Coil P bana .
Home Addr0sc
(If diffcxx* forth Installation Address) 3xyi . Zip FE
&m1111 Address (to receive projeeveom munieatioons and How Depocupdaoesy
0 11)0 NOT.wisb to %mcive Any wwketWg'emat78't7 *M The Home Depot,;
r tlon: Undersigned .( "cueeom+ar ^.); tail. 4te,cs'bt.dld�tr toe ;lCe}►'Arlie:nbdtrein'slaita�k .;kddre%, tobity,
and T Ac -Home Services, Inc. ("The Howe D.VW gees u1: Ctv*i, ta" d4iv nr, a��tigt�e `fpr'ttie "#�u lion'"') of
uli materrab dercAbed on. tbo below Ynd on t1w.,rw oed w. i c>;ated,'",0, ftp'Cortftact.by this
refereitoe,, along with any applicable State suopiaimerit 01, pttte�it,$�axipitMaty.:�ttaa ed'�dreto` all Wray C augC, ders (coltecttvely,
"Cmetriket")'
1Prntada:
Rouaiag Wmdawt4 " Irutuldt3at —
Lt J2 o21 �7 oc3uttert r Covei s OGnty boors' 5
`yqb Rt3ofing si ' Witedows LJ Inw Isdon
j]C uuers l:Covas K&tfy Doors f l ' Q !�✓ :.# s ° 2:_ hfir
ltw,Gng, LJ&ding U PTU.eoxv .l] Insab4btat
❑Gullets / Covers pantry Doom [�
It .g Siding Windows Insubadoa $
[JC,nuote t Covei9 �!47t Doors 1J• -
nsoi�m as4b nevatu a otr�,ict �;moittt atte ttpaveOn et'8�s+end�►tr ,
MMabtoPartfit�rsu►s noedepoettmate ,tit�+oAe�hMturtbaCotrlunent �� � �.0.
Customer agrees that, immediately upon cotttpletion of the work for each Produet:' C0ar0U*V -- IWW a; Completion Certificate
(omc for oath Pe9duct a, defined by an individual Spec Skeet) and: Pry ditY ba' *.& ditC, its , cab#.e, e(teb,:Cuaeomei�under this
Contract agrees to be jointly and severally obli.8trted and liable hereunder.. : '
The Homo Depot reserves the right to issue. a Chan -Order or, teb umme this COmtract ar:tuiy; iadaridtt i'Produc�g) Included here3ni at
its discretion, if 7Ne Horne
Depot or its authorized seivice provider detesttuites.that,it p xFctiO s .obliigateons,due to a,sttaictt,rat
problem with the home, envirotrmental hazards star as tbtosd: asbeetaa or jcad paint, safety totieems, .prising :enrc M Of because
work foquired to complete the job was not: iidcluded.in tht: COWS&rt '
Payment Sman,arX; The. Payment Summary Yinrrl o£ -tS, Coauecx. forth the;tatai
Contract amowit and payments required For the deWstts:af}d rnialpayrt>ertts iyy. a6' Cable);
You are entltkd to a c allied - iatt ca of the Couttaet lit :jdsb ine:yWf 'xlo #VE'ai rc 8 C4 Utlai'ertiaBtateStc
there ab one Completion �te for each Gated Fmduct o D�d, td 5.w*"ta)1 brc werk oa that Prwdttct .
is complete
In the event of tem)j nation of this Contrset, Custo ner .area to pay Ilbe How Depot tire, web of .tom, labor, aspen
and servieta provided by The H one Depot.or ,A,utb6Hled'ServiSe 1PrtMder tlte:'dattr ti'I'tca`am nsaft Pun any other
amounts set forth in V* Agreemnt or allowed • trader applicable lyw. TIC IaDDEPO`I' l►' AY WWWROLD AMOUNTS
OWED TO THE HOMC DEPOT FROM THF T7.1R. 41 T. PAVMZNT'OR'OtHER #1 YMENTS MADE, WITHOUT
LIMI THE ROME DEPOT'S O"MER REMEDM FOR RECOVERY OF SUCH AMOUNTS:
fs ce w4 Attth . Customer agrees and under,;tande that this A,ge eewcnt i6 2ht entire mVmc rent between Customer
and T' c Home l pot with regard u, the Prt'MiucLS and instaliatnm tiervicex and supersede 41 prior discussions and .agt'eem im, either
Orsf or writrem, relating to saki Prtnittctt and Installation. This Agreement. caumat be awiSned or amended =mpt by r writing signed ,
by Customer and The Home Depot. Customer acknowledges and agrees that Cwtomer•has read, understa64, voluntarily wxepts the
terms of aad has t'eceived a copy of thi6 Agreement -
Accep e b %bopi b :
customer's Si aft" 1?ate Sales onsultant's.S stole Date
2+ Telephone loo.
Customer's Sign4bre VF Saks 4bmsulrant License t1o,
CANCEL CUSTOMER MAY CANM TMS
AGREEMENT WITUO PENALTY OR OBLIGATION
AV T)91,TVbt:RTW- WRITTEN NOTICE TO THE HOME
DEPOT BY M1DN1GHT ON THE TJEl.1RD BUSINESS
PAY AFTER SIGNING THIS AGREEMENT_ TEE
STATE SUPPLEMENT ATTACHED IT.EIMTO
CONTA1145 A FORM TO USE IF ONE IS
SPE0FIC:ALLY PICESCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICC: ADDITIONAL TERMS AND WNAITIONf ARE STATED ON THE REVS 6 (41DR AND AAE PART Of TEM Coli7 tACT