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34-005 4. r • Sold, Purnished and Inatalkd by: Irands Name: Ronan , Data t . . . . TKO At-Horse: Servipes.' . dlbias 'Tint ioste Depot Al Home:Service . ' 345A Cugaatvood Streak Unit2Aftlercester, MA. 01607' Brands Number. 31 . ...Ttdl � (8A) � ttb7 -5182; : F.ag (508) 75.04823 , • • . , P4p l ar a tI I ) C'7s- 269B46e. hE Z;.ic it C 024» Ri Cons Yuia'16R27' ' . ' 'Cr d 565522; Ro1n MA e Impmveaene'Ctioniy [r Rn. C 126893 • • installation Address: — . e . • , ■ t. • RD' 06 c o .. ' i t 1.. C t•Crz;› • Parthmer(s): W anti Phsoe: Pldrahe Phawaa rte, : ' NI ft - i . -, • 11.111111111111t 1 j . [..�. [ . 1.. :[.:':1.. • 13nrne•Addras : . (If. diffeinnt foes lmteilationAddress) City'..:. Stater Zig • • E-mail Address (to receive project communications and Rowe Depei updates): • ' • .. • .' • 0 l DO NOT wish to receive any marketing emaila fiom.The •]•loos Depot • .... .. . . Proliect littotmatioa: Uaderatgued ( "C aseinieY'), the owner x of.the prr jfe ty located at dre above histallation mss, agrees to buy. and TID) At-Horne ter-vices, Inc. ("T'he Home Depot -) agreca•w futriieh.' deliver and-arrange:for tbeins atiac'(` ou") of all materials described on the below and on the referenced Spec.Sheet(s), all of which are incorporated`jige this Connect by this % reference, along with any applicable State Supplement and Paymcnt.Summsry'ched hereto and any Change Clydgrs'(collectively: )L__dL /� "Contract "): Jane: rt..".rn:ram .ant ed • 'e ' Sisaa S Sbatitfg)'# i.. • P oieeiAy mom . tJSooflnt USidine 4 Ja U 502 a'''116 D r a w e r s / Coven C y Doors Q . S C ` a,,., ' • . • • � � Ji ■ .. „ _ .cA waerrowp D 1pxrrtr�n �•� �/ . Dowers /coves Fe won rnwon n .�.•.S•e> 1,a, $ . .�a` �" ri • Dig USidie U.GVm4otvs. ❑' IaASltxinn Dt a, Cova.s c r y t l .. °Wien 8 DSidI s' Q a tido 0 I> ;a' `;` ,: , . ; . , , . • Dcluttern Oaa,e:a OE~ Door .n ` :. . t> 2S% Daperst et Canaan fuming ere upon meniften elirlr esnuad. Total Contra • . • . rat ; .- Total $ MainsPnex�a wee then me. t utor 1p+�in tAmeas. . 1 • • • Customer agrees that, immediately hoer completion Of the work for each Prodecx. Customer` will eueoute a Corrghletion tertiReate (one for each Product as defined by an individual Spec Sheet) and pay any balance dec. • As applicable, each Customer under this . • ' Contract agrees to be jointly and severally obliga red a nd liable hereunder_ ' . . The Home Depot reserves the right to issue a Change Order or. terminate this Cotutact. or tiny individual pbudnct(s) included beteiut at its discretion, if The Home Depot or its authorized service provider saes tlrsl it cannot Perform its • otdigstsana due to a structural problem with the home. environmental hazards web as•mold, asbestos or lead WM. other safety' concerns, pricing.er ors or because work required to complete the job was not included in the Contra pt. Pavement Summary: The Payment Summary..a .13 : $. 1 ' 43 . tacluded; as part of this .Contract, sets forth the total Contract amount and payer =Mired for the'dcooeits and•tlns1paymlents by Product (as 'applicable). • • . • 3I'OTICE TOCUSTOii .R • . . • . . . . You are entitled to a y Idled -in copy of the Cantina at the time you sips. 'De not sign a Completion Certifies* rake: there Is one Completion tate for each l lie d l"rbmtct• Its defined by individual:Ss* Sheets) before Weak eta that• Product Is complete. . In the event of termination eat this Contract, Costa :ter toots to pap The Home Depot the coats of materl$a, labor, expenses and services provided by The Home Depot or Authorized' Service Provider the date of termtnadon,. plus any other • . amounts set forth in this Agreement or allowed guider law. THE HOME h DEPOT MAY WITHHOLD AMOUNTS OWED TO TIM HOME DEPOT FROM THE /) PAYMENT 'OR OTHER PAYMENTS MADE,. WITHOUT LIMITING THE HOME DEPOT'S O'T'HER REMEDIES FOR RECOVERY OF SUCH AMOUNTS: • A and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Cuitemer and The Home Depot with regard to the Products and Installation services and suptrscdcs all prior. discussions and agreements, either i oral or written, relating to said Products and Installation_ This Agracux.t cannot be assigned. or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and agrees that Customer has read. underamnda, voluntarily accepts the terms of and has received a copy of this Agreement. Accepted y: G ( ./ sSxabilau ( (t t, C) . - Custonirs's Si ties Sales Consultant's 'granite • Dun • . r . X Telephone No • Customer's Signature Date Sales Consultant License No. CANCELLATIONt CUSTOMER MAY CANCEL THIS (as applicable) AGENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRrrrEN NOTICE TO THE HOME . . DEPOT BY MIDNIGHT ON THE THIRD BUSINESS • DAY AMR SIGNING THIS AGEEEMINT. THE • i STATE SUPPLEMENT ATTACHED HERETO.. CONTAINS A FORM TO USE IF ONE IS • SPECIFICALLY PRESCRIBED BY LAW IN . CUSTOMER'S STATE, .. • NOTICE: ADDITIONAL TE*MS AND COMMONS ARE STATED ON TM REVERSE SIDE AND ARE PART OF'TRS CONTRACT. . . It•ao-OS C.= White - Branch File Yell :- hal ow - Customer Pink es ■ Consultrrt i .0. • , .................w -. NI asNachusctts - Dcpartment of Public Sitret:s Board of Buildin2 Reu,ulationN and StandartIN \---0 C Supervisor Specialty License License: CS SL 98785 Restricted to: WS , IVAN KOSOBUTSKYY MR 72 STAFFORD ROAD MONSON, MA 01057 ...) ---- ----€ Expiration: 4/27/2012 Tr: 98785 I 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 Permits 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 4 r .� The Commonwealth of Massachusetts Department of Industrial Accidents 1� Office of Investigations • 9 -f®1- y 600 Washington Street == Boston, MA 02111 ; ` , www.mass.gov/dia • _ -Workers' Compensation Insurance Affidavit Builders /Contrac tors /Electrician /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Indiviii Address: - City /State/Zip: - Phone. #: Are you an employer? . Check the appro • . • • Type of project (required) / 1.0 I am a employer with 4. I am • _ eneral contractor and I 6. 0 New construction employees (full and/or part-time). have e d the sub- contractors 2. I am a sole proprietor or partner- listed o. e attached. sheet 7. 0 Remodeling ship and have no loyees These •- contractors have. .8 ❑ Demolition enpi•, and have wo working for me in any capacity 9. Buil addition - - • .aq a ve: e .- - - — [No workers comp: insurance required:] .0 ' e are a co • • ' on and . 6 10.0 Electrical repairs or additions officers hay!' x- cised it 11. - Plumbing repairs 3.0 I am a homeowner doing all work ! ,14.: ❑ ?ng eP or a dditions myself [No workers' comp. rightofa •e'. GL 12: 0. Roof repairs insurance required] t c. 152, § (4), .. • have no employees. [No workers' 13.0 Other camp- Inst once required.]. • *Any applicant -that checks box #1- must .also fill out the section below showing theirworkers'- compensation policy information: . t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. . :Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether ar not those entities have employees. If the sub-contractors have employees, they must provide their workers' comp. policy numkr. I am an employer that is providing workers' compensation insurance for my - ' -, , • . w is the policy and job site information. Insurance Company Name: • Policy # or Self-ins. Lic. #: Expira on Date: • Job Site Address: City /State/Zip: r - Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage; as required under Section25A ofMGL c. 152 can lead to the iiipOsition ' 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 and a file of up to $250.00 a day against the violator Be advised That a copy of this statement may be forwarded to the Of'ce; . , I"xives`tiQations' the DIA for insurance coveraze ve Ido Hereby certify under the pains and penalties ofperjury that the information provided :ahove:is_true_and orrect±_____ _ _ - . - . Suture: Date: - . , Phone # Official use only. Do not write in this area, to be enmplP!pd by city or town official City or Town: # _. _ . Issuing Authority (circle one): .'1. Board of Health 2. Building Department 3. City/Town Clerk . 4. Electrical In.spector 5. PIumbing Inspector 6.Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervi� sor;_ Not Applicable ❑ Name of License Holder : yr h LJ43 - 1 �"` License N 997v.5._ er " _ 0656 t` I W 1.1.)/t A. ss Expiration Date 11D)/ 3 • ur Telephone 9: t i ®a± a, = ue a e tai ar a4� s , *ligaZ Not Applicable ❑ � E193H c � Company Name I Registrati Number 4.5 9/110 Address - Expiration Date (....e4 of b i) TTlephone 1 � SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L, c. 152, § 25C(6)) Workers Compensation Insurance affidavit st be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi permit. Signed Affidavit Attached Yes No ❑ E l!)lll V,� . wui 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 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 • • y SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition [] Replacement Wi ws Alteration(s) [] Roofing El Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks ED Siding [D] Other [0] Brief Description of Proposed �� ) ,} Work: t:r'i . • _ - ii IAA 1 s Ki i Alteration of existing bedroom Yes No Adding ne •edroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet ; a�ls�iha;�crrirleet+vrs: 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 ri , 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. 1D Signature of Owner Date I, F;) /011-1 ' 1 /0 . , as Owner /Authorized Agent hereby declare that the statemen s and information oh the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the - - ins and • - • - (ties of all Print Name zwej , • P Signature • ner /A: ent 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:l ` R :l 1 L:' ? R:` 1 , E .� ""1 Rear = I Building Height Bldg. Square Footage i _ _ = % [ 4 1 Open Space Footage % (Lot area minus bldg & paved t i ...J ..___A... parking) # of Parking Spaces i '- Fill: € I � . �. ........,.�s�.,.�..�.......n.� .,.� .�. _.�...�, _�._ (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW 0 YES 0 E t IF YES, date issued: 4 IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES IF YES: enter Book I I Pagel I and /or Document #1 i 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 Obtained 0 , Date Issued C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: I ' 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: i { 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 C.) NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton Building Department _ " ,�. c ;112 Main Street W T' Room 100 • Northampton, MA 01060 phone 413 -587 -1240 Fax 413-587-1272 ti 4 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 : : ct: e Overlay Distric Li 1 e- � � CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: • I■VcriL IL .04 Fficovv Name (Print) Current Mailing Address: // / ( I Telephone Signature 2.2 Authorized . - - nt: I , ,,) -ter Name ( Current Mailing Address: Signatu - Telephone SECTI • N 3 - ' ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building C-6 y POD (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) t 7 Check Nu 3 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 6 TU1L Ic BP- 2011 -0021 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- 2011 -0021 Project # JS- 2011- 000043 Est. Cost: $8120.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sq. ft.): 80019.72 Owner: NAKASHIAN NICOLE Zoning: RR(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 296 TURKEY HILL RD Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers Compensation WORCESTERMA01607 ISSUED ON:7/12/2010 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 7/12/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo