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17C-199 4. t HOME TVIOl2tD MS1 N'I i0'1`FPf2ACT' ' : PLE_ASERE4D 1111S ' . Sold. Fuen1S11ed. and Ytita11e;3 by B ranch Naint: Boston Bitten, / ,„ ; 0 THD .1-Home Sevi4cs;:lnc ,. d:hlh� Tfhp Homc:Depot At -T omc,ServiCtt . : 345•A.O eeixnxrotrd• Street; Unit 2, .WRrcester, ;vL: :01601 Branch Number; 31 , Tilll F>ate.(0.6) 6657 51$2 Rai (50$) 756-$323 ' , Lie# 16427 Lie r17, .0439 R1 CCoe , redcxaJ (b ii 75 26Y4641 i ME 1 j j t7T L.io if 3,6:6512; A4A.4.Pme .inpro�e it<.Emtractor ite t268 in seetterion A cidreea: .. z ei fLGl rVJ �.t :O,. F"' - -- -- - -.. C St Zip_ 1.'rirt-ha500): .: work kliouur Bi ivaPTtnne: '' Ceti Phone. ,.,4y _ � . _w Home Address: (if different from Installation Addresa) City State .Z.ip . E.itteii Address (.to receive project comantinie, (Tans attd HonieDepot updates) I 00 NOT wish 10 receive any marketing .miters •'ftiOxu .Ire: [ ai*pcpcir .. • Protect information: {lndcrsiE*ncd ( "Cvsattm t ); the rSsvriOs oft4te pnmppza?'ty 1t atie 1 atFhG e'6ove it-10311'40 adttire$s, aSti."' s'to buy. and THD Al -Heine Sei,ices Inc. t, `The Ho*e. Depot") agrees ib t 1tI t 1 1iOtlellyer a arras ga'feir..*lc•itss'ts'tlaftuti (`"installlt'iS'n") of • all yn> desr.ttbed,cs th, below AO n ttte -rc£cr steed $pee ce teens'): all i fwtkels InOiPoratc`d yo ttt tht9:CutatrrGi l.y tllis rctcr.ucv, aG with ith at applicable StateSupp1emeiit utd.Eay'i .' mzriary atraiihedhtr'efu and any Chat es Orders (egllcetiv l; Contract"): Job a. (mn,o +'it.r •a .prual t. S�p'ce 'l cet(s ' Pko }act motiat DRooftng L tding }'1>vanclowv- ❑ n : .c•�?'r? b% C }eider r ccwers ❑tetiy Doors Roofmg (_,.JSidtn; L;i 'tit inflows ET bSl t4ti >p $ ❑tautters i Covers- OEnay Doors ❑ ❑Reeling 1J Stdir4:0 \Vina615's- El bsiilYlati'do : . . ❑F� nttrn` I COVCC9' t1tY5 'ISD6[8 Q ❑Roofing 084h 1,4 U .i s . ❑ Tmsulat:}on J J ❑Cunar•' 1 coy. ❑Entry Dvt•re 0 a iniorotn,. %2 D sit of Contract.3nvn d uau n , " . ' "° ?iw po rctlQv no�TLGniwrtlaGt : t; _ T`�titl G'.b�& �� , : � � 1f.. ineF t, ichasera May fatdepostUmoleMOrine- tblirkiiie4v r�1 44rit ' : i Customer agree, that, iiiun uptiil''con>plcraoo t ± the' "Wptic I'ro't. €or eath'd , gIlatatl7er;tvrll exeriitt a Completion Ceeitifye4te ton for :ice Produci as definer by :t i irirli'ailnal Spec Sheet);and pa• any balance'431 c, d .s 4pplioa1. 1d. e ch; C'i toner under this Contract agree to he ointl y and scverelly >bligli1ed acid liable Hereunder . } 5 The Horne Depot Se.srir CS thitt ight to issue;a L'.liangc::Clyd.tr or tttrilmatp;llti, (,oturacr -dr any lndsvidtltrl,1r0&&Ct(s) inelodc3 herein, at its discretion, if the home Depot t r tt9 auth6r ax i S' ice pro tkder a.8tertn4no3 th:.t ate earaticM:PeeilytYkr s.9.1iligattrns dtu to a stYticfutttl problem o itt the home, env irolunwta1 Irani ,4 oc,h s t old, rtsbestoS or Tend (S,}y,1t,', uthef.,s fe' tV, c priding' errors of because ' c•:'6rk required to ompiet the job 'was not iv in e f4v Yiilutent Sunman; The Tav'il ent Stlnttniary # :; - Iirc.7u¢cd aF p� of this.Conttact, "sets forth. the total Contract amotun and payments required for the- dcpaeits oneIfival by! 'reruli (as; applicable); .NOTICE £O USTIGA ER ., you are cufitle.d to a cutlt'ptetel'y flaleti.An 'copy of the C O'rtfr wt'a(thr •thin > u'stRI I3o nut;:sigu a Cint[1'Pletioti Cett}lleate (note: there is one Completion certificate for etch TISted'Prodtiet as thiiiiiiithit 1>pdi'i tit1CalAlec Slueets) before.$ rk'un •that Product is comp tete. In the evert 01' teem; pat'ioo: of this Contract, Castdmtr tigi 16' ptly Tile F14m6 Depot the edttl o( tnsteelals, labor, expenses and services provided by The Route t)opot or Atithor.zed. f'rov3det.'thrutigh Sitsto' of termination,. pus any other amounts se forth in this Agretulenr or flowed under applicable law'. THE HOME DEPOT MAY WITHHOLD AMOUNTS OW11i) 10 T'ITE EOMME. DEPOT FROM T' 1'E 1)11.00S IT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LJyll'1'I 't ilk HOME DEe'O'T'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOCN T'S. .acceptance and Authorization: Customer agrees and understands that this A`rertuent is the Ca tire agreement between enstorncr and 1 he Home Depot with regard to the Products and Installation services and sttt?eraedes all prior discussions and agreements, either Hirai or written rehiring to sad Products and Installation. This Agreement Go not bt aaalgile4 or amended, except by a wanting ai ued by C isr , rnor and The Homo Depot. Customer acknowledges and agrees that Customer has read, understaiit1ss'vol'tvntarily accepts the terms of and has received a copy ol'this .Agreotn 0t, f Accepted b1; Subittitt • � - } . • x 0,1 '' . ,-- -- -' a — _..,..,._, X Yi �] • o " t om" ` Customers Si inure Datc Sales Col, rtitant's Si• ,tore Date Telephone No. • _, .. Customer' Sigiantte Date Sales COnaairtant License Nv. , ANCET J,ATION: CUSTOMER 1' R IsAA CANCEL THIS '. • (a:r c' ape:cable) AGREE11iEN'r WTTDOITT PENALTY" OR OBLIGATION BY DEL1VERLNG Lour N NO`f10E -TO THE HOME • ' DEPOT BY 1111DNTGHT ON THE THIRD) BUSINESS • DAY AFTER SIGNING THIS AGREEMENT. Tilt ` ' 5'iATI:, SUPPLEMLNI ATTACHED HERETO C'Ulv'TAINS A FORM '1'0 175E IF ONE IS SPEC.TFIC.aLU PRESCRIBED BY LAW IN CUSTOMER'S STATE. M)T7CE:.411k iT10NA. T EI018 AND CONDITIONS ARE, sTA E1) ON ITE, R1t,VMSE SIDE AN1 ,117E PART OFTT11S CONTRACT 7_1tno r_cr rpltIt, .Brandt Yellow = G.tstcrler'PI 3Blus - ' 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 • - • • • - • • - ' . • •r. - _ - . uires 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 pets- in-conjunction to _the - build' ermirissued, 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 Massathusetts Department of Industrial Accidents MI . — _ Office of Investigations • _4 ^ 600 Washington Street �7 Boston, MA 02111 '„� . ' www.mass.gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): f o Address: t OGA 4f -1 Av I It' - City /State /Zip: RI V? o t A G.,.,R).3-/- Phone. #: 7 f.i'I Are yo ' employer? .Check the appropriate box: •Type of project (required): / 1. I am a employer with ( c - 4. . 0 I am a general contractor and I have hired the sub - contractors employees (full and/or part- time). * 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have. no. Ployees These sub - contractors have. 8. 0 Demolition for me in any capacity. employees and have worker working Y P ty. 9. Q Building addition [No workers' comp. insurance - comp. insurance.$ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions m� 3. o.-eg a v . xereis heir 11-.-Q-Plumbing repairs or additions myself [No workers' comp. right of exempt per MGL 12.0 Roo repairs insurance required.] t • c. 152, §1(4), and we have no ,^ � employees. [No workers' 13. er`�( / �- t A5 - 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 affxdavit: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 street showing the name of the sub - contractors and state whether or not those entities have employees. Yale 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: ) ,�, P r 1/ti Policy # or Self -ins. Lic. #: 4`71.U6:1 5 Expiration Date: 0/ /0 Job Site Address: a ( l C /State/Zip: n vi k. 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 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 penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator; Ike advised that a copy of this statement may forwarded to the Office of Investinations of the DIA for insurance coverage verification I do hereby _certify u - der ' e , , pen ' s of perjury that the information provided above_is_true_and_correct -_ / (� 4: Signature: pate: M r L f • Phone #: Off'a`'3 - _ Oj idal use only. Do not write iii this completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): " - -f: Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector __ 6. Other Contact Person: Phone #: r � SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : �r I 11 Lr►. IA, hob (,7f21 License Number �� )al Dili It) Addre i ! Expiration Da J4d I� _ .1 _. ciD l��J�V'fr 33 Signatur Telephone 9. Improvement ° Contract rr^ .;,; .., .... ... .. .... • Not Applicable 0 Company Name Registration Numb Address Expiration Date / Wc 1 [. 4 . 0 I&Of lephone l 6 21 _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 0' 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 -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 oft ampton e r+ trances; a andL t' • • - tts General- Laws - Annotated. Homeowner Signature Sal SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [D] Other [0] Brief Description of Proposed Work: ---1446[41 (5)kJCej , � 1 ©CA> Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6elf,fte* hotlseinifOr adi ion to a "' ` m - housing, domplet f e.fotk nitric a. Use of budding : 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 G .2(, C511 , 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 , as Owner /Authorized Agent hereby declare that the tatement and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under t ins and penalties of perjury. r iPr l (1 �-- Print Naii L r► 4 - 1. - - -- Sig a !e ■owne / ge Date lob 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 1 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 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 0 Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D: ' are t ere`any proposed changes to or a itions o iigns nfen ed t e 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. .r ' AG. I 'V eattrtze Ait# t City of Northampton t o off' j Vx Building Department �� 7 , 212 Main Str e e ,sxtratia6 t = f:t,o F Room 100 , - ¢ : 7ab 4 F . i _ - ii4i E i Northampton, MA 01060 Tam ®t t c t t l °t are x - A - x phone 413 - 587 -1240 Fax 413 - 587 -1272 , �� �� ;, i ri � ,-. ���e 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: Map Lot Unit 6 Z Bglioh Zane Overlay District EImSt °District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address:,..., 6k-v- , MOD C1j i2,, Telephone Signature fff 2.2 Authori • • Agent: 16./(e /ale-- . 4/iff• '. .4/ . —402.1111 • 17 Name (Pri 4 Current Mailing Address: 11 41.. . d i a I-- 1011a5: 3 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) — � Ch Number This Section Fo Official Use Onl Date Building Permit Number. Issued: Signature: Budding Commissioner /Inspector of Buildings Date a r l&'I"h+€3N f BP- 2010 -0364 GIS #: COMMONWEALTH OF MASSACHUSETTS : 1 6 k: 1 7 C , , , - 1 9 9 ,f 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 -0364 Proiect # JS- 2010- 000485 Est. Cost: $5235.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 126893 Lot Size(sq. ft.): 4138.20 Owner: SINGH JAGDISH & BALBIR SINGH Zoning: GB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 2 BRATTON CT Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 () Workers Compensation WORCESTERMA01607 ISSUED ON:10/5/2009 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 10/5/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo