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32A-058 (3) t i PLEASE READY THIS Branch Name_ Boston Date: LJ. 1 6 Sold, Ptardshedaid Installed by. THD' At�loeue Services. Inc::' . ditda. Theihnne. Depot AUHome Services • 345A Greenwood Street, l3»it2.QVpypa.lviA O1607 Branch Number: 31 . . Toll, ?tee (800).657 -5182; Pax (50a) 7568$23 , . Fedargl II? #• :75 atE 1 C 0.2459; ET Coat Lice 16427 CT Iic # 565522 : MA � le pi'o ' -..; Contactor Reg. #126893 • Installation Address: ► 1 e►.. " in iL._,.►rLIC:. hi f } City $rata - Purehmee(si): Work/Morn: hams P6eac , '. OA Phase: • _1)( —( pit 4s 4 ( fix. f [' ] [ I E. l .1 —11. • : . • [ • l Home I ckddress:. _. • Of different from nsiatlatioa Address) City state Zip 7 /F E-mail Address (to receive �• project communications and home LteF>�ulidau� >i �. ., 1 ❑ I DO NOT wish to receive any markedng details front Ho» le Depot • . . . Pi jeintormatfon: Undersigned ("Customer"), the owacrs of* p rtipetty located at the above installation addles. agres to buy, and 't EW At -Home Services. Inc. ("The Horne Depot") agrees till tarnish. deltvec.and throngs .for : 'tae ivarexistian { TnemBulon') of all materiels described on the below and tm the referenced Spec Sbect(i); all of which ate MeeMoraled tuna' this Contract by this C / II) '1 reference. along with any applicable State Supplement and yment' Summary hereto end any Cage Carders (eolletvely, • . Contract "): . . iWs #: ammoaear,.eer Peodtaaa Ste ik 1!trtil ! Atgo4aat ■1Roofing 111 Siding 0 Windows. IS +'oft . • • . • ' (]@enters f covers ClEn+ ny Doors ❑ , .. ' , ff :: ' . URoonag status ■ Wndows • Insolation' ' ]Gutters DEntryDoors 0 • L1Roofing ©Braids 0 W ndow. abhsuhtion • :• S 0Gutters i Covers OEntry DOOM n _ . • ' II Roan* • Siding • windows ■ Insatation ' • . . . . ©Gutless 1 Covers [Whin Doors n • . M9ebaaoaa 25% Deuosit of Contract Aaanat deer avow:stewtop of this emutact fatal Contract Amount $ Maibel'tn rosy lheCentraitAlmos , . • ,�• 6 Customer agrees that, immediately upon completion of the work foe each I Customer 4vil1`'dxec►ur? s C'AinpLdioa Cerufioate . (one for each Product as defined by an individual Spec Sheet) and Pay any •balance one.' Ai applioable;'each'Customer under this Contract agrees to he jointly and severally obligated and liable hereunder. . • The Nome Depot reserves the right to issue a Change Order or terminate this Contract or any badividual Prodoct(s) included herein, at • . its discretion. if The Home Depot or its authorized service provider determines that'll cannot perform its obligations due to a samurai problem with the home, environnxatal hazards such as mold. asbestos or lead paint. other safety corn, price. e is errors or because . . work inquired to complete the job was not included in the Contract. • 1Pa ►�t ett Sutnmatr: The Payment Summary 0 2,..k ,( i 4 4 • : ' : , included as part of this .Contract aces forth the total ' Contract amount and payments required for the deposits and fmai naytnenta by Predact (as applicable): . NOTICE it CUSTOMER. Yon are entitled to a fUe d-ta copy of the Contract Mtn dine ' on Po riot efts CoimPietiori C (eater theca is one Cwnpletioe� Ce to roc each listed Pr oduct rm •desired by tidiri 'Spa t SlieetspTfrgtire rwoYh an that' Prodder is complete. In the event of termination of this Contract, Costumer agrees to psq The Home Depot the costs of mterlrk; labor, etpemsea and services provided by The Home Depot or Authorized Service Provider through the dale of tetmmrtioo; Om my. other amounts set forth In this Agreement or allowed under apptirahle law. THE HLThIE DEPOT MAY WITMEILD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER RE'MEDi.ES FOR RECOVERY OF SUCH AMOUNTS, udlpr'itation: Customer a and understands that this Agreement is the entire agreement between Customer and The home epbt with regard to the Products and Installation sources and supersedes -all prior discussions •add agreements, either oral or written, relating to said Products and Ineshllation_ Thus cannot b assigned or amedde t-exoept by a %writing sig by Cuttwmer and The Home Depot. Customer aclmowledgeS and agrees cannot Customer has read, understands, volnntaa ly accepts the terms of urn! has waived a copy of this Agreement • Accepted b Customer's Signalises- Dare Sales Cansrrltane's Signat,rre • Dace , '; X _ , ��� JJJJ Telcpholre No. • t ... Customer's Signature Date Sales Consultant License No. r CUSTOMER MAY CANCEL THIS is WP) AGREEMENT WITHOUT PENALTY OR OBLIGATION • BY DELIVERING WRITTEN NefricE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS • DAY AFTER SIGNING' THLS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO . CONTAINS 4 FORM TO USE IF ONE IS ' • . SPECIFICALLY PRESCRIBED BY LAW iN CUSTOMER'S STATIL ' • NOTICE: ADDrrtorv%L TI*MS AND COMMONS ARE STATED NS MR REVERSE szat AND An PA= Or TgliS CONTRACT s 11 -30-09 C-SC Mite - Branch File Y9aow - Customer . Pink - 8atea.Consulrom 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 jermits 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 Date Address of work location „,,... ......, - The Commonwealth of Massachusetts Department of IndustHal Accidents Office of Investigations . 600 Washington Street t e . Boston, MA 02111 . . ' www.mass.gov/dia , .... Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly -' Name pusiness/OrganizationAndivirinnO: 1 i I. — PE e id • , . _ • Address: p6-Rn k if vnbal ,,,,,,Q w,D r • City/State/Zip: a 6 ()3 Phone.#: q Op (625 Are y pAr• employer? Check the appropriate box: • Type of project (required): //' • 1. I am a employer with 0 t 0 4.. ) 4. 0 I am a general contractor and I 6. 0 New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. 0 Remodeling 2.0 I am a sole proprietor or partner- ship and have no. e.wloyees These sub-contractors have. 8. 0 Demolition • enxdoyees and have workers' working for me in any capacity. 9. - ET Building additiOn [No workers' comp. insurance - comp---ipsulauceA- required.] - . 5. 0 We are a corporation and its 10.0 Electrical repairs or additions officers havAxercised their 11 Plumb . .0 ing repairs or additions 3. 0 I am a homeowner doing all work -:, myselt [No workers' con :tp. right of exemption per MGL 1 r-1 2,.0 r repairs A insurance required.] t • c. 152, §1(4), and we have no emq3loyees. [No workers' 13. Other %,0) leiNne • comp. insurance required.] ” *Any applicant that checks box #1 must also fill out the section below showing their workers' coropen.sation 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 sfir.b :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 worlors' comp policy number. . I azn an employer that is providing workers' compensation insurance for my anployees. Below is the policy and job site information. . • . • Insurance Company Name: • )■■.. 4 a , PAP Al siN■ _7 . Policy # or Self-ins Lic. #: QA 3 4 ... ) C - 7 Expiration Date: - , / jE) , ,_.._.1 1 A Job Site Address: 5(_0 L4 IA a ii -) I 1 4 0 i I City/Stafr../Zip: • en- - Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Failure to secure coverage as required under Sectiiiir 25A Of MGL c. 152 can lead to the iiiipesitian of criminal Penalties of a fine up to $1,500.00 and/or one-year imprisonme4 as well as civil penalties in the form of a STOP WORK ORDER. and a fire of up to $250 00 a day against the violator. Be a.dviseci 'that a copy of this statement may be forwarded to the Office of Iiiv of the D ' ittinee coVeraie verification _ - - . , ... .. fild liere.by certify 7u n pat - d ' p ;rimy that the infM-ntationprovidedib;ve_ / rr 4-0 jj Signature: ?.-4- % a , Phone 0: l'e--*-- Date: • " 4596:7 • • Official use only. Do not write in this area, to be completed by city or town officiaL • City or Town: Issuing Authority (circle one): .- Permit/License # 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbin.g Inspector 6. Other Contact Person: Phone #: f— • . . 0 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Superviso Not Applicable ❑ Name of License Holder : 1(51 Aa 1 AV License Number 111 )1 Addres All TI Expiration Da Signature r Telephone e - i ".� Not A licable ❑ �:Registeredk#rtime_ #mpmve .�,�� „x.. �.= ��,,,�u_E�,;..._.:� PP Company Name Registration Nu er AIM 73 it 3 Address Expiration Date C - 0 30(0 -e i Q ` Telephone — SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GL. 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 ❑ No ❑ :01 ei ein on 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 buildine 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 ❑ ReplacemenWtpdows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [0] Other [0] Brief Description of Proposed -----' j � Work: , Cl 1 6 ()kr.►,et i►-,�11:,�s DiRef Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 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 ' C a 7 t , 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 R v , G. ( , 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 * and penalties of perjury. Print Nai 7 .46. i 1 . 1 _ Signet • re • • ner Agent Date M • t• 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 ? ?s Frontage ! 1 ( •--- -- 1 _ _ w .__.. . Setbacks Front i 1 =Li j 1 , Side L:G 1 R:1 L:' _ R:` _I i--- ? 1 i I Rear ET 1= 1 Building Height s { I Bldg. Square Footage ( I °A' 1 1 ] ( j Open Space Footage % # ; (Lot area minus bldg &paved i L. . t parking) # of Parking Spaces - • - -- — ~ ~ ~-- Fill: � # ..d.o it (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:1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book I I i ? and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q 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 there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q 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 Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton t Building Department _ a - ` 212 Main Street 4 ~ < Room 100 �` ��� � Northampton, MA 01060 :l •. 3\o` \- 3 h 413-587-1240 Fax 413- 587 -1272 "' APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -. SITE INFORMATION 1.1 Property Address. /(32- This section to be completed by office Map "" Lot Unit 0 LI v (OVI .D( Zone } Overlay District Elm St District' CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner o� &' LAV 1e- Ct 1 t141 5 ( 6 VA — E -- pk . 9j ) all /lit F L-- Name (Print) Current Mailing Address: 5 1 42, e roi4--aiel Telephone Signature 2.2 Authorized fur, t: r /1� _ . C - �.r� C � A . , - ! 0 1� r_ • +fir . : rdi V 1{OC -�7 Name (Print) Current ailing 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 e" 6. Total= (1 +2 +3 +4 +5) V f r � / Check Number ° OQ5 C� ®I (JS This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date s i y BP- 2011 -0080 GIS #: COMMONWEALTH OF MASSACHUSETTS Map Bleck: 32A rt 058 w CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2011 -0080 Project # JS- 2011- 000136 Est. Cost: $2187.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 99209 Lot Size(sq. ft.): Owner: MALONEY DIANA J Zoning: Applicant: HOME DEPOT AT HOME SERVICES AT: 50 UNION ST - UNIT 20 Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 0 Workers Compensation WORCESTERMA01607 ISSUED ON: 7/30/2010 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 7/30/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner