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32C-082 (2) . Sold, Aurnisiied and Installed, by; •.' , Ozmicb Name; . Boman Dete: - ' e' i' `.141 Milo*. Services, Inc.. •" dlfi a The Home'DCpat. Ait'IIOtee Services , 3454 Greeawoi Street; Unit 2; NV9r.ceaier, MA 01607 • Branch *saber: 31 . • • Toll Free (SOO) 657 -5182; Fax (508) 756 -882'3 • Yedcrat 113 a 734.49an6U; SIR Lie #.C`OY24.g9; RI-Cent lads 16427. C l l test ante lmpwvereAarGaurattar Reg. 0 3268N$ Installation Address: ;: k.-4..- ?a' I ' • Patcbaer(�r � . Work Phone: Home Plane: - Cell Phone: 1 1E - ■cam% (AwTUp2 . .. [• ] :. I ] [ J Home Addreae. • .. . of dilferent from histaitaiinn Address) Ci State Zip • 8 •ssail 'Address (to receive project cemmun_ioarions and Home Depot u da ):): . gl(rc/ J I DO NOT with to reccivc any marketing entails from The Home Depot .. Prof linformatlout Undersigned, ("Customer!), tltc'owiwrs,'o tale ltM l at;4�►enbove iinstallat#ahadddrass,agrees to buy, and TIED At- Home . Strvicea. Mc. (“The Hama Depe ") sgrpos to:p� vcr 3n�atteugi .fQr..ihe instidtation (4 htstel tetesi) of all materials described on the below and on the referenced. Spec St ec t(8): ail. Of Which . eC fated' into 'this Contract by this 'no reference. along with any applicable State Supplement d Payment Svtrrmary aagched hereto' aid eey Chimp Oedors (coltcativciy. "Contract "): , .lob tl: c.n.rata,a,a.w . Site: Shut(:) tit .: _ Praise Amount ORoodng °Siding a El elation • �. (+(',00 tier; . poQuers /Covers DEuayDoors•O ..; ... • '.11. - 7 -- 0. L ( • • (]RnO6ng 'OSlding .)� Wutdows [ LasetaGto 1 coven 17oors t`1 • r2Roofn LISiding U Windo ❑ fnsulation IDOutsers /Cows DhatiyIiotsas.f1 • , • • . ..• $. , DRoofing ❑Siding 7]. TiadeWs Li ingwatiou . . • $ - • ©tAetrers /Covers retry I)aors f a2 % lap e* �pn tdoeetacatiun ottMs •taproot : Alt na . Again l ehasars way not deposit mare man aroe cane eetteet i me. ' Total Contract •Amwtnt Customer agrees that, immediately upon completion of the•.wtnk fd:t eaeh•Proihiet, Customer wilt eaemite s 'Completion Cettifteate (one for each Product as defined by 'an individual Spec Sheet) and pay any bilk due. As appiidabie;h Customer under this Contract agrees to be jointly and severally obligated and liable hereUtider. : . The Home Depot reserves the right to issue a Change Order or terminate Or this Contract or any individual Prpduct(s) includad•herein, at its discretion, if The Home Depot or its avthOriieed service,providdr determines that it cannot perform hi obligations due to a sttucnual problem with the home, environmental hazards gush as rnOld, asbestos or lead paint; oilier safer condos, inking errors or because . work required'to complete the* Was not isccuded in the Contract. • . • • Pa yttsea t Sunmt The Payment Summary # L t 5S 1 • . included as part of this Contract,. sets fort the total • C amount and payments required for the deposi amount ts and final payments by Product,(as applicable). • ' • NOTICE TOC.UI3TOME.R • • • . tort You are Entitled to co filled ID copy of th Contract* the time you Do not a ion Certificate (note: there is One Comaletion for etch lusted Product as defined try #n Spec Sheets) bee work on that Product is complete. In the event of terminurlon of this Contract, Customer agrees to pay The Home Depot the coats of materials, labor, expenses and services provided by The Home Depot or Authorited Service Provider thriiugh the date of termination, plus any other amounts set forth in this Agreement or allowed. wrler,a 'law: THE HOME D18PmT. MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT PROM THE DEPO 55 PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acc+tn an A,nt lwslzxtlam: Customer agrees and understands That this Agreement is the eotlre agreement between Customer aid-TM-Home Depot with regard to the Products and Installation servi and supersedes all poor discussions and agreements, tither, oral or written, relating to said Products and Installation. This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and agrees that Customer has read, understands. voluntarily accepts the terms of and has received - copy of this Agreement. . Atee ); e•C„ I. Submitted bye. Customer's Signature I. . / Sales Consultants Sigishintre Date • - X Telephone No. . Customer's Signature Date Sales Consultant License No. CANCELLATION; CUSTOMER MAY CANCEL THIS (as Applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS 1 DAY AFTER SIGNING THIS AGREEMENT. THE . STATE SUPPLEMENT ATTACHED HERETO • CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN . CUSTOMER'S STATR. NOTICE; ADDITIONAL TERMS AND CONDITIONS ARE STATED ON TEE REVERSE SIDE AND ABPART Of Ti11S C$NIIACT 61408 C.-3C White,- Breech File Yellow - Customer .,, Fink - Sales Consultent it . • , . __---..— •-■, — . Ress:, to: WS IA - Iiiikiv.ry RP - Rini Corti '04; WS - Viineores sod SiclinK , ' SY - Solid Yisal liuraip, (1, 12-eviczi ' DM -Ific_inoilrior, on l y , Faure to posiesi 7. rurrent edition of the Mansatzlwititts State liuilditig Code li Cliuve ror rrsoc*to of this Liu-,t. - Refer to: WWW.Maas.GoyMeS . . . . • . . . -,- :■1.issuehusetrs - Department of Public S:11cP IP Snarl! 413 Rilildin2 Rcl and Standard, Construction Supervisor Specialty License Licknse: CS SL 9132r19 . Restricted to: wS _ VLACIMIR SHEVCHUK • 5 OGDEN S i REET NI ; CHICOPEE, MA 01013 ...<7.i- _.,:".........---„, Expiration: 1012/2011 t -, ,, i••tit , Tr: 07200 x i • lic ' ft f • i f \t 1 1‘ 1 41) 1 1 • 1; ik ttP , • (, 4 , • IDN\rNt . • . . . . . • . . . . . • • . • . , , . ... ..._ ........_, ... . . • .. • • • The Commonwealth of Massachusetts Department of Industrial A ccidents la �t� r7� of i ,� , Of tce of If 1'esRi. ation.> V� t'U �.t_ Bisaoh, MA 02111 ma - H , ww,niass.gov/dia Workers' Compensation pensatiori 4rT.si rortee Affidavit: Builders/Contractorshilectricians/Pluraliers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): • fl�' j 01 DIA _____________ • Address: gicf i , l 4V1, . City /State /Zip: - � - r ?� 3' Phone. #: 'I A ,r i Are yoy 1• tk —�71/ an employer? Check the appropriate box: Type of project (required):. I am a employer with l 4 . ❑ I am a general contractor and I �. �) 6. ❑ New construction employees (full and/or part-time).* have hired the sub- contractors 2. i 1 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub- contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' g y ca p ac �' 9. [11 Building addition [No workers' comp. insurance comp. insurance.$ required.] . 5. ❑ We area corporation and its 10.11 Electrical repairs or additions 3.1, i I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ of repairs insurance required.] t _ c. 152, §1(4), and we have no r,n employees. [No workers' 13. Other W 1`7 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_ tContractors 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: , ,/ - .c. la 4 .. I - _ L Policy # or Self -ins. Lic. #: 35 ,Lj<' (5- Expiration Date: 3 1 / 0 Job Site Address: ( I A)11S©n Bk._ ` City /State /Zip: tali >, , tAxa /_ V /0 I/ Attach a copy of the workers' compensation policy declaration page (showing the policy number and exp ration 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 $1,5.00.00 and/or one -year imprisonment a - ... - • s - .. , •.e _ - . - of a STe ' • 9.'_ ! 0 - 9 - ' -: - .. 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. Signature: J Date: *Iilfr _____ Phone #: i a'9. II 3 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 #: . SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Superv' or: Not Applicable ❑ Name of License Holder : ! eel I ( Gte j , c19 thJ License Number '' l �Al ,.0" >,/. >I 1 ) ly Address Expiration Date Signature r Telephone 9. Registered Home Improv- ent Contractor. " Not Applicable ❑ 1 . .i d Si Company Name Registration Number Addre Expiration Date r / Telephone toq;_ Phi 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 No ❑ 11.: Home Ow ner. Eetic>l 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 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 Eiji pet sun(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 i a,. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House n Addition n Replacement Win s Alteration(s) [ Roofing I I Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [CO Decks [El Siding [O] Other [❑] Brief Description of Proposed /^ ��p 'v ji 5fre ii4"1 vtJ �1� �� /v Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa. If New house and or, addition toe sting housinq, 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 I, .e Cni4144 , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit applic Lion. Signature of Owner Date I, eV 14 -{ , 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 penal of per! Print Na Signatu _ efIre ner /Agent 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 Rear Building Height Bldg. Square Footage 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 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 , 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 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. I c Department use only, City of Northampton status of Permit Building Department Curb Cut/Drivewa.y,Permlt 212 Main Street Sewer /SepficAvailability Room 100 Water/Well Availability `' /_thampton, MA 01060 Two ;Sets of Structural Plans k∎ Cph 413 - 587 - - 1240\ Fax 413 -587 -1272 Plot/Site Plans S Other S,pecify ■ APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1 1.1 Property Address: 9 p ) \: (.J,� -� This section to be completed by office Map Lot Unit iI1 11/111)-- � ' � �, J� r} - ,11 �. Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner o Record: 1 w / 07,1a if,/ I'.4 ',,-..;fr .111!• it .. , i I iiI,EJ a,. a Name (Print) Curren Mailing • d +ress: C ` __ i I , Telephone Signature 2.2 Authorized •_.!4gt: 4 Name Current Ma Add - / v Lh Sig atur= ' �� Telephone SECTION 3 - ESTIMATED CONSTRUCTION COST 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 ,4 6. Total= (1 +2 +3 +4 +5) 6(A)t- Check Number tj � � It35- This Section For Official Use Only Date Building Permit Number: Issued.' Signature: Building Commissioner /Inspector of Buildings Date • BP- 2010 -0237 GIS #: COMMONWEALTH OF MASSACHUSETTS 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 -0237 Project # JS- 2010- 000300 Est. Cost: $2094.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 126893 Lot Size(sq. ft.): 5096.52 Owner: MONTUORI TONI Zoning: URC(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 26 WILSON AVE Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 () Workers Compensation W ORCESTERMA01607 ISSUED ON: 9/1/2009 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 9/1/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo