32C-163 (26) City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
k 12 P/
ss of the work: n 3
Address 7_
s will be transported by:
The debris p _
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The
debris will be received by:
Building permit number:
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Woe, 112,01,1-
Name o� Permit Applicant
Date Sign-ature of Permit Applicant
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Dec 0214 06:13a P.
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
` ` Sold,Furnished and Installed by:
Branch Name:Boston North&South Date:0 1 I C`f THD At-Home Services,Inc.
&bla The Home Depot At-Home Services
Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free 877-903-3768
Federal III 4 75-2698460:ME Lc a C 02439;RI Cont.Li,* 6427
CT Lie e##ilIC.0565522;MA Horne Improvement Contractor Reg.#1226893
Installation Address: �zi°F�� rka.., LIMA ll t� 2-3 ���� iaim
City Stale Zip
Purchaserf s): 'York Phone: Hoare Phone: Cott Phone:
Home Address:
(if different from Installation Address) City State Zip
E-mail Address(to receive project corn municauans and Home Depot updates):
L1 I DO NOT wish to receive any marketing emails from The Home Depot
Project Information: Und:rsignod("Customer"),the owners of the property located at the above installation address,agrees to buy,
and THD At-Home Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for die installation("Installation")of
all materials described on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contract by this
reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively,
"Contract"):
Job M: a..—i t<nrc ni Products: Spec Sheeds)k: Project Amount II,,11
t ' Roofing Siding Wind�wn Insola600 -r W p� 6
OGUtrerS I Covers ❑E try Doors ❑ e,3 1 a $ l V ,4 111
Rcoftrtc OSiding El Windows U Insulation
[]Gutters I Covers ❑Entry Doors ❑ S
Roofing Siding 0 Windows El Insulation
❑Gutters!Covers ❑Entry Doors[]
Roofing ElSiding, LJ Windows Ll insulation
❑GuuerN!Covers ❑Entry Doors ❑ $
Minimum 259E Deposit of Contract Amount due upon execution of this ctmtract Total Contract Amount $ -2
}tame Pumhasers may trot deposit rrtnre than med9rd other Ctmtract Amount.
Customer agrees that,immediately upon completion of the work for each Product.Customer will execute a Completion Certificate
(one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable, each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,it The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with due home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because
work required to complete the job was not included in the Contract
Payment Summary: The Payrnent Summary# `Q(.Z-l'S`--t , included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely(illed4n copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product
is complete.
In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOIA AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMEr rS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Ac�ce-Once and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Producs and Installation services and supersedes all prior discussions and agreements.either
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 receit�d a copy of this Agreement.
Acce ted b d Submitted by: !
Cust ner's Signature ,f/y'DaL-t'e ! Sales Consultant's Signature Date s�-1
X Telephone No.
Customer's Signature Data
Sales Consultant license No.
CANCELLATION: CUSTOMER MAY CANCEL THIS ("s a{plies b eJ
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS - 3
DAY AFTER SIGNING THIS AGREFAMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW 11
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-Workers' Compensation'ID=trrancQ A.-Tiidavit: Build ers/Contractors/EIectricians/ Iumbers
,D'Dlicantrnfbrmatiori' Pfe'ase P/utLe?ib`l�y/
Nan°t, ssl0rgzn:zarionllndivid z1): /t/�' t -�� /Y"„ �� //y' ' L' ✓Y /C�S
City/St�tefa: ) ��' fin ' ' Phone u• �jf �-7�
A.re you an'employcr? Chcck the appropriates_bo
Type of arojea(required}:
1.❑ i c l a cmploycr with �• I a,n a general conuactor and I
have mired th�' 6.� N:w constuctioa
employees (lull and/or part-ti,,.c).` sub-conuactors
2.❑ I am a sol:'proprieior or pay W:r_ listed on the attached sheet. 7. (7 tZcmod:iing
snJp and have no e:nplo s These sub-conuactors have'
Y-c- � i � 8. �D-:nolition
v_ �lpioytcs and have workers'
wo7}irg for 1:�� a�ly capa iy. g 3uilding addition '
V 1°'Or};:7 ' O:a 1%�L1raT1:� COTiD. 1 SLliarlCC.i
We ale a co-'ooraticn arld is . 10.��l ecui:sl repairs or, additions
3.❑ 1 a n a-homeowner ooin; zll'wor':: o=fficers have :x:rcised their ?lu nbb' r:paL-s or addition s
e11. ?vo or}:e7S'.C:.—n-) , , '. °_lt OI:xOMMIOn per MOL } 1 I
)' �ODI 7�oa1"5'
ias�lcc i:cu r:d.] t i 53, and,wc
tnaloytes. (No wor}:trs' 130'^.er r/�
'��y z?piieznt c:_; {h:e5's box-! r::ust air. ihll out ti+'c.: ca below shoo ig L:u wo:}--rs'ccmp-rsa•ion poii:y info=z3 on.
t'So^coxr.: who sub-i::a z`adavit indiez�ng hey L:Join;zll wo:}:and L en hi; ouuido eontz-to:s must sub it a new zrtldavit indi a^eg such,
:Coa,ze:es Wzt:..x}:this box must znach:d an ad3iticnal sh::t showing the azr-of tih:sub aayzcLCiz
and s to wh:rcr o:no;' ,os hz4 c
hployr_s. If the svb-:crczctors hxv::mpioy:s;:1::y most provid:th:ir wo:i c,—,'oonhp,policy narnb::.
I aria;, trat is pravidiro Ivor:ers' Conipe:lsafion �#surarse jor my�nlDlayees. Below is the policy and job site'
• ~ii3jorn3a.ior.: . I/. � ' '• .
Cotnpany rit:
Policy= or Sei -ils. Lie. '-" =xai:anon Data:• •''--�
Job Si!c.4dc es= l Ci y/Stat J�ip
Attach a copy of the worl:trs' =ptrsation policy dtclarntion page(showing the poli^y, nutnbtr and expi atioa. crate).
t ally:t0 S^C'= CJV: 2�G 25 rGOL'iS:7 LL*1Ctr SeCtioa 25.4 of 1vIGL C. 13 Can 1^ad to L�--ImDosltlon OI C;Hm-dal D_r?l!leS Oi 2
II :'up to 51,500.00 and/or one-year imp.^'sO=fnt, as _ll as civil p-aalri:s is the io of a STOP WOR.k OP-D=R and a me
ofuo to 5250.00 a day agai=st tl:e ti�olatc7. 3:advised L�at a ^opy of th=s sty!c^cnt may b:io warded to th:Omce of
�v--sn.�tio:S of th=DL4 for iYsw'aDCC.COVCraQ:,vC^:aCdtiDII r
t
I d0%t a,_b ._:.C�rr1aj,� CIIt°� �y' •:f °G13d LOrT:LL •
y ..-�^ark rev That the :rjor^lawn z), -led above s rru.
sia;,ar�c
PROS
Off_ial s sc onlV. Do nor lv :!e ir nhis area, to be car.3ple1ed 5y ciy or town ojJ:_iz-r.
Ciy o.Tow _ L e,:•1t�T ietIlse
' Issulr.;Autrlority (=�:It one): .
r
I.Board of lth 3 But dWg Dtpar-eat 3. Ci:yitt owm Citr; ;. �L°_...c'1 I�sDector S.?lumbL^_p T^snt:tor
6.0 _
COrta:t Person: h 0 n t r=:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applic ble £
Name of License Holder:
Licensef�Number
/
Address Expiration Date
Signature Telephone
.
9.Re istered Home Im rovement Contractor Not Ap licable £
Comnanv Name Registration Number
r s xpiration Date
' Telephone 19. w
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil ' permit.
Signed Affidavit Attached Yes... . £ No...... £
11. - Hame Owner Exemption
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 buildint 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 ❑ Replacement W' ows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding[0] Other[O]
Brief Descri tion of r se
Work: _'�� _ -
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a,If°New house and or addition to existin'
q housing complete the no'w-inq'
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
1, D �'V � - as Owner of the subject
ti
property {�/9
hereby authorize , ,z b 72,o,0—
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
MOE
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.
Signe er the ins and penalties of per'ur .
Print Name
Sig ure of Owner/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
Setbacks Front
Rear
Building Height
Bldg. Square Footage 010
Open Space Footage %
#of Parking Spaces
(volume&Location)
A. Has a Special Pennit/Vahance/FincUng ever been issued for/on the site?
x�� YES �—��'\
NO �_�~� DONTKNO/ �/ ���
|F YES, date ioued:1 �
IF YES: Was the permit recorded at the Registry of Deeds?
NO �_/
�~�
UUN7Knuvv 0 YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water orwetlands? NO 0 DONT KNOW 0 YES
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained v~� Obtained y~� Date Issued:
�~� '
C. Do any signs exist on the pm ��property? YES �~� NO «=�
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, gradingexcavation,or filling)over 1 acre orioit part ofa common plan
' that will disturb over 1acre? YES NO )
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
^ —
F )Jepartmehi use only
I
k
` City of Northampton Status ofPermtt fi �''n '` r 4
Building Department Gur6 Cur/Drlveway Perrrslt x
.ors 212 Main Street Sewer/Sept�cAvaiCabiltty
r•c1 Room 100 1Nater/WeiiAvailablhty
JU j RU
�e�t";o. �� c�.� t� Northampton, MA 01060 TwolS is o>'Stru turai Plans
f
e ` '`� phone 413-587-1240 Fax 413-587-1272 P[of7Slte Plans h"° �' j " E
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: his'section to be completed by office
Map Lot Unit
Overlay District
iF
V
Eim St D�stnct CB D1stnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�1/j T,;
Name(Print) Current Mailing A ess:
'f�a��C., Teleph ne �
Signature j;?_ G G-
2.2 A rize A ent: �7q.. 3
LAI
47
Name P' Cu'rrreent Mailing Address: Q D
ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building /7/7 (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 I i 4e 41
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: _
Building Commissioner/In..spector'of Buildings Date
23 RANDOLPH PL-UNIT 23 BP-2015-0678
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 163 CITY OF NORTHAMPTON
Lot:-034 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit# BP-2015-0678
Project# JS-2015-001301
Est.Cost: $2418.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 106953
Lot Size(sq. ft.): Owner: WEBSTER DAVID
Zoning: CB/URC/WP Applicant. HOME DEPOT AT HOME SERVICES
AT. 23 RANDOLPH PL - UNIT 23
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.1211812014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 3 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 Sisnature:
FeeType: Date Paid: Amount:
Building 12/18/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner