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Z1 401"91 S)tNrTfc35 614004 3 c-s M 41 a,v oarct M � gnVr . 4 0214 • Dr13d15 114 0 - `�' Mfr mac+ rn I. ®;; �. - to w i ! �` ,rig ' --- '' -1111111 Mg r%I."1- aillilliallill" 111111111111111111111111111111111"-- 41•1040V .jI K $ 3 1 'Si 'b" $ y 1 `st `4t es. a - d XUA 13r213SH1 dH WdOO =S 6AO2 OI AQW • ROME 1MKrk(t irssav't':Cb1+I'TgACT' PLEASE R 3I3 Sold, Banished andTnstsned byr, .+ grouch Name: Boater Date: u3t • C:15 . - ...I. .. . T'EIi3- AtHome Services, lnt . - : dlb/a dente Depot . At- Home.•Services • . 345A Greenwood Sir set, Unit 2, Wrncastcr•, MA 01607 . Branch Number: 31 . TODFtae.($(IEI)457 -8823 , • .. •Fcdcrsl,ID ,# 75 638460:1 E,1-ic # 02 Lice 16427 . CT I is # 3ti5yZL:•iytq f Ho + me impr000ment Coptraetor Iteg # papa. 'nstailation Address! t '�' k f-lQ ! 'J f 1 as -. • State . Zip Pnra... 0 : • • •• Work Pt(atae: . . re,,, pe #6...ir' • • CellPhorte • • . . [•..1 ' - . .� ,.. • Home AddtYSe; • . 1-- /F If different from Installation Address) • City State Zfp Femail Address (to receive project t:ommtmjcations end Herne :Depoktaidatea):: . I DO NOT wish to receive t ty marketing entails from•The eme bepex' •: •:.;• • • . !roiled Information: Underaigned (*Cuitamer"), the owners of drat' ' liktnt d'ai curs olio a installation address, agrees to buy. sad TEED At me Services, Inc. ("The Hmac Depot") aSi enci• '.d'dlYkei'tatrl ax*atlge for theinstallutionCbtasEurtonl of al materials described on the below and on the referenced Sloe: shoet(4), ell:Ol Which ate ineOxporated *Millis Contract bY, this efetence, along with any applicable State Supplement and Payment Sw rmaraty, pit?tOe L hereta. any Change (ideis (eolleetxvely, 'Contract "): . . lob # tw..w re,ce.tono instincts: ee, ., iir Ierolett Amount .. Ong siding Windows lnsuhuat, .yam 1 r- -} uKeia, COva s burr � : T 1 ( / /� n ❑S . q:Ins, gien' 4. -1 t� 4 !04 DGutk:ts /Covers DEntry DoOtt•.Q._,... ,.210.i. _ t.+� ► O2 []Roofing [ T S i d i n g © Wiatiowe•ClInstdtsion .. . . CICautets / Covets Oar Door* 0 _. . DRtoofmg OSiding u Windows 0Insu Denture / Covets QRony Doora�[�_„___ Mialsaam25% Deposit, alCoai )netAmuwtdltettase.ea4mtltatofO Minna ... ' Melee hacksaws may not deposit mots than one.nand niche CeesreetAiaomtt , . • • iE a t dtHt.''unt $ ':::astomer agrees that, immediately, Upon coanpletioe Of the. ivotit'l* eaeh. Product,.: Customer'wwill' egeentc a pletian Certificate one for each Product as defined by an individual Spec Sheet) and,pay'any' due -•. As a each C under this ontract agrees to be jointly and severally Obligated and liable heretm4er.. .'. • the dome }:repot reserves the right to issue a Change Order or terminate. this Contest o y� imcl t idual products) included herein, at to discretion, if The Home Depot or its authorized service pro%scter deteeani.*s.thkt it:cannot perPorm its obligation 'idue to a structural . nobles with the home, environmental ha2atxls such as mold, asbestos or lead paInt,.othat safety concerns, pricing, errors or cork requited complete the job was not inoluded.lntho Contract. • ... ....:. • .• .. . Payment Srtmmaty, The Payment Summery # , ' , , . . 2. Included as•,part. of this. Contract,'. acts fish the total ootraef amount and payments required for the tieparits and.t'itin : peyniet is •by'Proihft t'(as tcppha able).' . • NOTICE. TO CVSTOM R. You are entitled to a cos tely filled -in cop of the ConRttd'.st .'t a yensie . bone; s s Car"apletivai• Certificate ('note: *ere is one Completion Ce rtificate for each IWted Product. wi.deTiaed• by ins vkvt,Ieit Spec• Sheets) before work on that Product s complete. • .a the event of termination of this Contract, Customer agrees to pay The dome of the costs of materials, labor, expenses 'lid services provided by The Rome Depot or Authorized Service Provider through he date of terMIu dtosi, plies any other onounts set forth is this Agreement or allowed under applicable law. THE 11!O DEPOT MAY WITHHOLD' AMOUNTS ?WED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT DR OTHER' PAYMENTS MADE. WITHOUT LIIVIITESTG TEE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. . cJotance en Authorization; Customer agrees and understands that this Agreement is the entire agreement between Customer - m d The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements, either Tad or written, relating to said Products and Installation. This A.t'eet rent cannot be assigned or amended except by a writing signed )y Customer and The Home Depot. Customer acknowledges anti agrees that Customer has read, understands, voluntarily accepts the . arms of and has received a copy of this Agreement. tccodr - .y: Snbm Wadrby-� / _ � l As di , 1YVV �• :'0 • ..., 's Signature Date • Sales Consultant's Signature Date • f w _ — Telephone No. . :ustotuer's Signature Date Sales Consultant License No. :/NCELLATION: CUSTOMER MAY CANCEL THIS (sa settleable) AGREEMENT WITHOUT PENALTY OR. OBLIGATION 3Y DELIVERING IO BITTEN NOTICE TO THE HOME . )SPOT BY MIDNIGHT ON THE THIRD BUSINESS )AY AFTER SIGNING THIS AGREEMENT. THE i;TATE SUPPLEMENT ATTACHED HERETO .7ONTMNS A FORM TO USE IF ONE IS . ,PECIFICALLY PRESCRIBED BY LAW . IN ' .IPSTOMER'S STATE. . . • NOTICE: ADO1TioNAL TERNS AND CONOITYONS ARV, STATED ON Thep, REVERSE $WE AND ARE PART OF TRIS CO-t1AACT , ..le.m r• Ai' 1Am:,.. D.......,. 6,... .,..1.,..., r......:,.—._ n .,1. e. iw,, n...- ...__.: r ° \ The Comm ant.' of Massachusetts Pevarti77 en` of7 ?iriiustrrol42Crdell s (j,, C 'r - c - :: : r � , r / (i I 1 ; ;%, r, ifl1t c: \ j ' i '?:, ... E i • Name ( Bu sincss /Organiz,ation/Indi'/idual): __ Y 1 j `1! iVr1 _ � • Address: _', •• ,. , qt c',4,0y _ • City /State /Zip: n11=l 1 ' - Phone. #: 'D (4)51 5 Are an employer? Check the appropriate box: • . - Type of project (required):, 1. I am a employer with ) 4. C J am a general contractor and I ,�� 6. 0 New construction employees (full and /or part - time).* have hired the sub- contractors . 2. (1 I am a sole proprietor or partner- listed on the'attached sheet. 7. 0 Remodeling .ship and have no employees These sub- contractors have 8. Q Demolition working for me in any capacity. employees and have workers' g Y ca ac P tY 9. 0 Building addition [No.workers' comp. insurance comp. insurance.x • required.] _ 5. n • We are corrorah and its 10.0 Electrical repairs or additions 3. n I am a homeowner doing all work officers have exercised their . 11.0 Plumbing repairs or additions myself [No workers' comp. righ of exemption per MGL 12.0 Roo repairs insurance required.] t _ c. 152, § 1(4), and we have no • employees. [No workers' 13. ther idol f1 4 �_ comp. insurance required.] • . Any applicant that checks'box #1 must also fill out the section below showing their workers' compensation policy information. ' 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 : - 1\/ ' 6° rT-Y1—___ _C } — Policy # or Self -ins. Lic. #: 3(� J (5 Expiration Date: 3//11.3 • Job Site Address. I 041V City /State /Zip: TIOR), y H , 0 , 6 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 tip to 5:1,5 and/or one -year imprisonment,-a- , ... _.. a' :. = i. .e . : . _ OP WORD ORDER and a fine of up to .1250.00 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 una -r e p/s an• penalties of perjury that the information provided above is true and correct. Sig nature: • „ :. / e / Date: I _ Phone #: l f 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 d. Electrical Inspector 5. Plumbing Inspector 6. Other Phon # Rcs nctet IC: WS LA - Mnsotsry only AF - RooT Cort:cing WS. Windows sod Siding • SF- Solid Fuel Hurting Devices " DM - Demoli d oat only Fai ure to possess a current edition of the Mstunchusetts State Building Code is cs wit for revocation of this liccntt. . - Qrf to: W WW.Mw Ciov/DPS 1 �Iis< aihusettr - Dcltat1mcnt of Public S:tict■ IP &lat•d Id Ruildin2 Rcguut+ur» and Standard Construction Supervisor Specialty License Licnsr. CS SE 9t3209 Restricted to: WS VLADIMIR SHEVCHUK 5 OGDEN STREET CHICOPEE, MA 01013 �L - --' - .c Expiration: 10/12/2011 (. , :i.. Tr: 9C209 N oir e • a g ir i 1 \t‘ 6 1 0 )1>N. 4( , A \D-. , , Lp\r\Q- . • • , • • . . , • . . . .• • • . • • .. - »PCC nc CC Tn /h:hT pPG7 /ir /Ct �� R no Jhr? ']C1HJ .Anul/.'7Lc yT�d Tl7YI1n �t_r"' HOME OWNER EXEMPTION ACKNOWLEDGEMEN'1 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 xegniatinns The inspection proc_eas.re es 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 - - - , - - - -- - - -perm its -in- conjunction_ to- th.e_buil,ding etmit 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 The Commonwealth of Massachusetts ,;, Department of Industrial Accidents TV Office of Investigations • —:.a__ g 600 Washington Street e = AS Boston, MA 02111 � 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 m: Are you an employer? Check the appropriate box: Type of project (required) :' 1. El 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. CI I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no. loyees These sub - contractors have. g. El Demolition working employees and have workers' g for me in any capacity. 9 D Buflahi addition [No workers' comp. insurance _comp. ; nsurance... 10 required.] 5. 0 We are a corporation and its ❑ Electrical repairs or additions 3. E J am -a h o m e o w n e r - d o i n - w o r k -2 ee lave :E ze c esl-their_ — I- 1.Q- Plumbiug repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 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 aftdagit: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 sleet 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 tire 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 and/or one :year imprisonment, as well as civil pent ?ties in the form of a STOP WORK ORDER and a lime of up to $250.00 a day against the violator. tle 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 and penalties of perjury that the information provided _ above_istrue- and.correct Signature: Date: . Phone #: Official use only. Do not write in this area, to be by city or town off ciaL City or Town: Permit/License #_� - - - -. Issuing Authority (circle one): .L -Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Ins. ector 5. Plumbing Inspector 6. Other - Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable tr ❑ Name of License Holder : ( �� 1M �{ CLX0/ License Number 40 ' \ r i D 5 1.p 07 i aficir Addre Expiration Date Signa tire Telephone 8.'Registered.-Ftometlm toveinent":Gct th ctbr:4 F ... Not Applicable ❑ Company Name Registration Number ( 43 Address Expiration Date OA 01 4 Telephone �v i Sacs 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 rmit. Signed Affidavit Attached Yes e No ❑ The_current_exemption for "homeowners "was extended to include Owner 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 hi 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 referenceto 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 Nortt mptoii Ordinances Sfatee aratdca rtjl7g lv)assaehusetts6eneral- -Laws- Annotated. Homeowner Signature JP. k SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House 0 I Addition [l Replacement Wi ws Alteration(s) ❑ Roofing El Or Doors Accessory Bldg. ❑ 1 Demolition ❑ New Signs [l ] Decks ID Siding [0] Other [0] Brief Description of Proposed Work: g am : el al *1 l /s • C ' . ' i.d. Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a Iftte 3 iouie2andeiir diti: id � , • "fi rg: hotti ki,, eotraeti t e fat - 6 *k : 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. y45 Masscheck Energy Compliance form attached? h. Type of construction 50 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, ' O ` , 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 WtLV Lb® , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and p ties of p IV ,. :c J6 i- -- Print Na - f i -■Waii07, .1- 4 i )==_Aa3i Signature of wed. gent Date Amovenummok 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 Rear Building Height Bldg. Square Footage % r 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 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 IF YES: enter Book Page and/or Document if 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 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. - Ace there any -- ctidnieS — tiiiii = 7 - ailabiiiiiiiisijniinterided foie 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. AP City. -of Northampton 410 -- � � �� '� ` ' -�� r _ ..__ __ ` 'Building Department u � tr flpor e� a t ... v ¢ � ��� 212 Main Street sx e re = tail U � i NOV 1 Q 200 9 North Room 100 , a g �'' i am pton, MA 01060 e � US � � sr '� �� � �" � � w 3 ry, 1 � 0 Fax 413-537-1272 « 4 Y r `c�,.� " '' �� ' t �` � 0 1 p NI I1711r .� L�]- -:� r - 1 �+v Fax ra•� wit a � a �-��� `s,� ` a� ��^ L-- - APPLI CATION 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: Map Lot Unit l.L V� -� t Zo Overlay District Eltrr.St District CS District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .] 3 [ Fi c►'7 v D I rid Name (Print) Current Mailing Address ; t4 I . J ' p 6, 1 Telephone Signature 2.2 Authorized A. e. • . y al /1 . E� al � . r. � . ; t‘.....4.',..., r _ ..,,ii 7 Name (Print) / r t Current Mailing Address: / M / � ice . Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION. COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit ap.licant 1. Building *�( (a) Building Permit Fee t " } 4 / �/"l"" 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) -, Check Number b� This Section For Official Use Only Date Building Permit Number: issued' Signature: Building Commissioner/Inspector of Buildings Date • Of' f BP- 2010 -0522 GIS #: COMMONWEALTH OF MASSACHUSETTS $ .106:owl 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 -0522 Project # JS -2010- 000736 Est. Cost: $3876.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES Lot Size(sq ft.): 16378.56 Owner: HEYMAN JON B & KAREN S ROWE Zoning: URB(l00)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 13 OAK ST Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 0 Workers Compensation WORCESTERMA01607 ISSUED ON:11/13/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACMENT 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 11/13/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo