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17A-301 1VLYLC. 11 Y1'r nr , J'V y $'iF'1 �1 L161 1.�.'1'2,N1. CI I • PI LVS l 4:14iS � ` S Fniinslied'and'Installed by: Branch Name: 'Boston • • Date: ` Ci .THD At- Ile7me-Serviccs,' lac: c' dlbta 2'he.Horne Depot. s�Flnrno Services • • • ‘..4.,. 345kcirecrovood $fa 3nit;2,: Woreeste MA 4160.7 Branch Number: 31 . X011 Feet � .� „6,57 5i 82;:.Fax (548) 756-8823 ttergj lP 75- 0 in ,I.M # CO2A3`3; 11,1 Cent. Lie# 16427 l Ch a 565522, lrrrprooextlent Coniittctpr Rcg # 126a93 installation Address: 1 ` . !1 :. ..- ���"J- jY ] • 1 'nrchaser(a):. ;'Waelc'Phone %Home Phoiio:'' , 'C 1 Phone: '' L0615.12_,..; S r * .: , fit 31,54 [ I . Home Address (If different foam Installation Address) 'City ,, State Zip E -reau. A'ddreas (tt, receive project contmurdeatiixis and ins Depot;uitdatee) - ' 0'1 DO NOT wish to receive anymarkx tiug =mauls foam The Ifarne:Depet t the hWnrs t formafi 3`rrviccc hie. ("The e Pro e of h e.proms lc3eatecl at the' abave'irrstaliatioti. 4Ate$s; agrees o buy. and It1�Ptmation� Undeisi gned ( "Cu 1�D e. ( "The Home Depot) ag td furnteh delr fir' arad grrixnge fcri^','Eh i4 aatailat �p :.e'Inistaliatloh'.') vC ail ipaieriala. on the belgw and oa the: r ioo4: -$1ee Slrgaci j, ea 1'4f*kucl?. t4cotpc'rtcted,iatc,.tht's.C4 t by'thss "Contract"): once,„ x I1Ir R nt, Su anq X+Pbga ( rofnratGe,.alon with any ataplieable State Su ]ernenr and o ,yore mtjaary, dt4lohad 1�rrr�atnd C Orders coticetrwel y, J°°#' ((■pmdaerareece) ,',' .,' "...• S•'ee'S .''t3 # '...,.. - ',Pie:tot:Amount III aefing .*Siding a. 'UVitae : We t!Tfigelatr#sd " ? ' 1 b OCnrtiera Covers a i boo>•a t ?. R . - � 2.z. ` ■Roofing *Siding 'Windows Y IDau1atteri,;. , C1Gutters 1 Cr 'zyea 11P.nelry Doors b .. (nktoofing Siding 0 Wiuiows 0rsula . hnou ' - latottore / Cevcrs 0Brttty DoarS u . .. ; . Erit-oofiog O'Siding *'Windows *'t nulsuon . _ .,i ]fitters /' Covgra ©Ei;4r5 . Minim:tup1$9/. DePo.s itotCma ',pmonaidnelpan;carecu n.84 tr #4 • fi ll ed tt !A4fyuun.. $ . Maine Pntnhaserl ratty not deposit more than• otlathC,rl oB'the �om#ractXnui�'it , � � ..� 2iistom agrees that, immediately opryn eon;pia'non, of rha fet 'each 1 Oduot 0 wijl xceucc +u Conxpletuvn CerriD6atc "one far each 'Product as defined by' au individual Spec Sheet) ,azwt pay atay;'bai8nue due.`:`M 4ipli64ble eireh Customer under.this Contract agrees 16 be jointly and severally obligated acid liable hcrcutider • . '' ' The Home Depot reserves e the right to issu a Change Orriut • r,tertuinere thie sxtj irp*icivial Pio'd (a) included herein; at . ,ts diSeretlon, if The Horne Depot or its euthdrttid setyiee.p[auid deumn9aiessdi<a'e Olpeicttsrr'i 1ts'bbiigationaxtue to ae utinal . rroblcnl with,the borne, environmental hazards such At to l4 bes e reed: pL 1 dth Okty Cor4e a pricing. arro Or. baesuse , . Fork required complete i he job was not iiacllld'ed m ehs,ConaaGt', e - . Payment'. Summary: The Payment Stitrlreary'# \ �x' 'itteiuded as part of•tlriS Cont net, sets forth...the total - 2ontract amorint aid payments required for the itel;ncits irlid:linalpal#rsente Fc4 t "tids"iigphasbi'e. NOTE TO C'[i T'CINIE t You are entitled to a com letely tilled -Ito copy o the CenZ'ract wt tat ale p4q .iii, b p'. lO slgn` a �`4m elan Certificate mote. :here is one Completion Certificate for each listed Product as di ed b r iid&• d t S>iac'' Bet #)before vvvnrlf on" her Pr itluet s complete. ;n the event of termination: of this Contract, Customer. algrecs tta'per Th 'horns, aepet't7rfs casts' 0f materials,: labor; expenses and services provided by .The Rome Depot:or Authorized r-vtce'Pro ides: throe�gh ille,.4 te• of *ern urafioa,.plus anyy other set forth in this Agreement or all under applicable law. T E. 04.411E RY :1'OT;MAE � rillifdll.•b AMO'17■T8 5N'E.D TO THE HOME DEPOT FROM THE lDLI'()SIT PAYMENT: OR. OTHE,R,`, PAYMENTS MADE," 'WITHOUT Lll41YTTnlC THE ROME DEPOT'S OTHER TiEMEDEES F034 RECOVERY OE SUCH A10bUNT$. iieeeptance and Authorisation: Ciustomur agrees and understands that this' Agreement is the entire agreement between Customer and The 'Flume Depot with regard to the Products and Iostalletien services and persodes. a'li prior diaeusaions end agreements, either tral or written, relating to said Products and Installation, This Agreement. Cannot be asSigued or amended except by a wilting signed ry Customer and The Home Depot. Customer aelmowlcdgcs and agrees that C.uttomer' has r4, utiderstands, voluntarily accepts, the cans of and has received a copy of this Agreement . \ccepted• y: / �_a.n N b r: .. lh ).1r: 1► 0 i . :us ∎∎• er's Si nature Date Sales Cortauni' lu s si t . bate _ _. Telcphdnc No, _ :ustorncr's Signature Date Sales Consultant License No. _ _ . ... - ;ANCELLA' 1 7: CUSTOMER MAY CANCEL THIS ” Ins app lienhte) ,GILEEMENT WTTRROUT PUNALTE OR ODLICATlON 1Y DELIVERING WRITTEN NOTICE TO TOE HO1'4E IEPOT )3V MIDNIGHT ON T1IE TFIfTtD• BFISi r'ESS )AY ArIER SIGNING TRR1S AGREEMENT: THE ITATE SUPPLEMENT ATTACIXED. 11ERE"I'O. _ '' :lONTATNS A FORM TO [1SE IF ONE IS ;PECTFTCALLY PRiESCR1BED BY LAW IN ,RISTOMER'S STATE. 'NOTICE: ADDITIONAL TERMS AND CQNDITIQN$ ARE STATED ON Tilt k1:VERSE SIDE nND AItE PART, OIrTLIYS CONTRACT '.16.09 C -5C - White - - .Biench't"lle ' Fellow — Cu . Pirik _<Sotms: Ctmsuttent - ' • 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 • I 11• - • • • - ' • • • • cess 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 - - - -- ------ pennits_in-conjunction to_theluiklingpermit .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. Address of work location • The Commonwealth of Massachusetts -- Department of Industrial Accidents ,1 1, _ " Office of Investigations - r . Jil P.i 600 Washington Street r j Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers Applicant Information Please Print Legibly Name ( Business /Organization/IndividuaI): I' VS ( / . Address: a i) 1l Yd7 �� i t� y City /State/Zip: Ofle Phone .#: Ga`775i'?5 --- Are you an employer? Check the appropriate box: Type of project (required): ' 1. De am a employer with (D 4.. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub- contractors 6. ❑New construction listed on the attached sheet 7. 0 Remodeling 2- 0 I am a sole proprietor or partner- ship ATrd have . no employees These sub - contractors have 8. 0 DemoMon for me in any capacity. employees and have workers' working Y P ty 9. E Building addition [No workers' comp. insurance - comp. rnsura e.l required.] 5. 0 We are a core Oration and its 10.❑ Electrical repairs or additions 3. am a�emeewner�eiaa aII work c r� ve exercised th it Bing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.D Roof r • insurance required.] t c. 152, § 1(4), and we have no 1 employees. [No workers' 13. flier 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. 1 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: [ >(i Policy # or Self-ins. Lic. #: q2) (�Ci /�`7 - / Expiration Date: - 7 r 1 Job Site Address: 1,25 ii i +P � City /State /Zip II ►..r/ '' W , 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. le advised that a copy of this statement maybe forwarded to the Office of Investigations of the 1 • for insurance coverage verification I do hereby certify er p • ; an, penalties ofperjury that the information provided_abo a is- true_aruLcorr-ect - Si•..ture: f�/ l c� %I� %� i /_7 _ : sate — Phone #: 1935 O ff i c i a l use only. 1)o ffo write iii bits area, to_be completed by city or town o fficial 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Su rvi l r Not Applicable ❑ Name of License Holder : 14 ` '�' T �n I o '-2 ) ^ 1 '� n v� License Number 411 L )/ 9 1P/i. Address a � Expiration Date Signatur- Telephone Registered Home_im rovement:Contmctor. Not Applicable ❑ ( 1. )1DPIVO Company Name Registration Number Address Expiration Date 'VA V/(' hone •70 SECTION, 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit must completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building p it. Signed Affidavit Attached Yes No ❑ T_he_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 - vear 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 o ampton et, mances,° a e .n. - i _ - + - tts- General- Laws- Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition [] Replacement Win s Alteration(s) Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding [0] Other [o] Brief Description of Proposed y Work: Ii7 .� . •i 1, /ti MI Alteration of existing bedroom Yes No : new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa lfl te.h use a n d o r : addition t o axis #'r; bous nci, complete the following: a. Use of building : One Family wo 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? % es No . 9 Y_ 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 L , 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 Ie__" + l 1 1 ' r -e , as Owner /Authorized Agent hereby declare that the statements ah information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and i es of • - i • Print Name W r Aar .41 , _ _ Signature of Own- Ag: t 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 % a Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) _ ._ ._.i ! .. _ _ _ 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 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: " D. iXre thieve any proposea changes to or a - pions o signs intended fort 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. tits City of Northampton Satis�of�erin f rir Building Department 212 Main Street Sew Room 100 Northampton, MA 01060 413 - 587 -1240 Fax 413 - 587 -1272 *thiisitg, .*Avuttfoitz 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 ■5 H 1 I Lr'sJ l , Zorie , Overlay District - Ein%St Distrlctr CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Rec rd: L{ 16'e Stoiden_ tc? HJIIC,'?'"..it4JE161?1, D)14)1 Name (Print) Current Mailing Add . 'x"Q i 1 /� Telephone Signature 2.2 Authorized Agent: '.� F 117 4e s _ - o :. .4 , vim Name (PrintO4 / Current Mailing Address: Signature Telephone SECTION 3.- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit 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 = (1 + 2 + 3 + 4 + 5) �P✓ Check Number This Section .For Official se Only Date Building Permit! Number. Issued: Signature: Building Commissioner /Inspector of Buildings Date . . IULLCREST DR BP- 2010 -0439 G1S # COMMONWEALTH OF MASSACHUSETTS gip:810a: _ 17A 3 ,. 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- 2010 -0439 Project # JS- 2010 - 000595 Est. Cost: $2285.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 67121 Lot Size(sq. ft.): 21867.12 Owner: SWIDER ALAN C & LOUISE P Zoning: URA(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 125 HILLCREST DR Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 O Workers Compensation WORCESTERMA01607 ISSUED ON:10/20/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT SLIDER 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 10/20/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo