42-118 29 BTM BP- 2010 -0079
51S #: COMMONWEALTH OF MASSACHUSETTS
1sI31o t CITY OF NORTHAMPTON
Lot: -001
Permit: Buildinq
Category BUILDING PERMIT
Permit # BP- 2010 -0079
Project # JS- 2010- 000085
Est. Cost: $14514.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES
Lot Size(sq. ft.): 18600.12 Owner: LEPAGE HECTOR J & CHRISTINE M
zoning: RR/SR(100) / /WSP II Applicant. HOME DEPOT AT HOME SERVICES
AT. 29 BRISSON DR
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 Q
WORCESTERMA01607 ISSUED ON. 712212009 0:00:00
TO PERFORM THE FOLLOWING WORK.-Siding and 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 7/22/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
Department use only
City of Northampton Status -of.Pefrnit:
Building Department Curb Cut/Dnveway Permit
212 Main Street Sewer /Septic - Availability
ROOM 100 Water/Well- Availability
Northampton, MA 01060 Two 'Sets of Structural Plans
phone 413 - 587 - 1240 Fax 413 - 587 - 1272 Plot(Site Plans
Other Specify
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
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of ecor
ot l� Telephone C�r ! 1 f31
Name (Print) Current ailing Address:
Signature — 1
2.2 Authorized Agent:
Name rint Current Mailing Ad ress:
t
°1D ( q3�Zg ;;�
Signal a Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
com feted by ermit applicant
1. Building (a) Building Permit Fee
2 Flertrir_.al (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) 3yf o
5. Fire Protection
6. Total= 0 + 2 + 3 + 4 + 5) ..= Check Number a.-
This Section For Official Use Onl
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
1
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: R: L. R:
Rear _..
Building Height
Bldg. Square Footage
Open Space Footage °
(Lot area minus bldg & paved
arkin )
# 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 0 , Date Issued:
C. Do any signs exist on the 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 Q 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.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable
New House [ Addition ❑ Replacement Wi ws Alterations) Roofing D
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [Ulf
Other [O]
Brief Description of Prop ed _
Work: , 00�
Alteration of existing bedroom Yes No Addinj new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to W isting housing, 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
1, 3 w I L 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.
a lnq of Owner Date
1, V . as Owner /Authorized
Agent hereby declare that t4 s a ements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under th ins and lti s of perjury.
E ,"V I "!d
Print Na e
v lal
Signa1wrel5f Owner /Agent Date
a
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor.1 Not Applicable ❑
Name of License Holder A 2JI- L-V votl
License Number 11JJ
r
Addre Expiration Date
Sig tur Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name V IQ cz
Registration Number
Address Expiration Da
��- z. -1-z -7 Telephone
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 permit.
Signed Affidavit Attached Yes....... No...... ❑
1 L = Horne Owner Exemution
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
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 Lnws Annotated, you may be liable fui ptisuu(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
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 me.
Tate
Address of work
location
The Comntonwealth of Massachusetts
Department oflndustrial Accidents
+
zz
Clffice of Investigations
600 Kashington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual):
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. El am a employer with 4. F I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship nd have no employees These sub - contractors have
P 8. ❑Demolition
working for me in any capacity. ernployccs and have wutkers'
[No workers' comp. insurance comp. insurance.
$ 9. E] Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. 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. ❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. ❑ Other
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.
, 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 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:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City /State /Zip:
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 25A of MGL c. 152 can lead to the imposition 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 a fine
of l ih to $750 00 a day against the violator. Be advised that a copy of this statement may be fonvarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
Of use only. Do not write in this area, to be completed by cio 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 #:
The Commonwealth of Massachusetts
_ Department of Industrial Accidents
Of
fce of Investigations
60 lC'asX in fon ,''tree
Roston, MA 02111
wwm /dta
Workers' Compensation Insurance Affidavit- Build ers / Col< atractors /Electricians /Plumbers
Applic ant Information Please Print Legib
r
Name ( Business /Organization/Individual):
Address: '1Llf� o i dyylt �'l�t ell/
City /State /Zip: fk4 aT �:, � 3� Phone. #: �[ _7 j I
AYam g an employer? Check the appropriate bog: Type of project (required):,
1. a employer with _ 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part - time).* have hired the sub- contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have g, ❑ Demolition
working employees and have workers'
g for me in any capacity. P tY• 9. E] Building addition
[No workers' comp. insurance comp. insurance.#
.required.] 5. E] We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 1 I. El Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. ther
comp. insurance required.] V61 Vol <3
*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 isproviding workers' compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name: CJ
Policy # or Self -ins. Lic. #: ��+�, Expiration Date: 2?/,
Job S ite Address: CIti( --.` City/State /Zip:K1E
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 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine tip to $1,500.00 and/or one -year imprisonment, as well a& Giui
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 cert=re s an penalties of perjury that the information provided above is true and correct.
Si mature: Date: _
Phone #:
Official use only. Do not write in this area, to be completed by city or town offcciaL
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 #:
Sold, Awnidwd ana,ias i2a UY `
rtmdr IVilmo: 1Baston Dptu:
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L- dn!icoe: Tub•:.'
-,s, - .dti�a `;iris °�3AmnesAcpot,At�gni4 �evipeY
3r+��Gtr�e4 $p+eet. lixut�.,;WotcpsteF.
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Stanch Nan ber: 32 'Toli Fre(t'($t30-51$2; Fa i 756.8823
hod(rsl:m`75b984d0; 1CAUitC0743 *y;'I�YCt�at.Uo10'1'847f I
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knstatllilfion Addressr �•� ti J VZ t �a S (�� • 4 �2�wrh tit � �-� . t� i.8 (d ">�„�
• .. City. ... , 7 aP
workpheur. uriso3Pheu� C CU FhogJJL_
Purchaeesfs):
Home Address:
(It different fioin tnstr l lfltion Address) LYcy. Siam Zap
E•nmil Address (to receive project ntmtmunicationa and-Home IJepot, updates) :'. -
❑ 1 00 NOT wish to rr�,cive Any trmrKeWTig etnails from't'he Horoe.Depot .
torum 6n Uoddr signed ( the aati '0 Qie•pt Z�dt ttta a4Yprre i+raxdlktlan a9dtrss: agneas to bay, r
A AL orrm 5srvicca, Inc. 07he Rom k>epo4 7 agte�s to =diUW.raTt3:Ant tv far t?w insupation: ("Xnstalkdou`l of /
eli materiaU descllbed on the below and -an the refetenoea Sprc Sheev(s,), alb, of wwh •are,inoor� orated .u(to this conteaci by this
rerenmce, along writh any ippiicabic State Supplcmant and Peytnent.$utnmary alto" wew And any Chauge`0rdeis �boDe(yiveiy,
"C.oatract "):
Job*
�T oofing ' iding' 1WutdM+vn' [naulat9om . ' `:.: > �' . ; !•-� + ,
`7 Do~ tCnvas OPaury .Do. C]
0Sinj Q
x#53 tg7 o� di
rt, �vra
«>tnLi : siding arm- lass i d- i
Roofing Sidicig 110 ws laeuistion
k7tiutters r covex.c, play noo;s. LI .
L.IiW�Y. Yw.1Aitf�YNiW �F.4iRii.�Olc�YO ';h.: �'. •::.:•':• ,
1VlehtDPtttthatusrmynMdepp (ttmtr+ethaneoalbadOf�eC �Otal•.t,:t�t.'..'.'$
Customer agrees that, ii iPon c6mpletioa 4 the Work pfbi'each, Profit?ctl.AGXxsi.".: dd���
(one for each Product as definod by an individual Spec % Sbr 0;)' and pat'y ffiiy -WJOF &. die:: 3!i .s apBeiable prieli. l +t, nwr under tlii.
Contract agrees to he jointly and severally obligated and liable hereunder. ' - :.: ; , °: .;?,.z:..:;t'.' : , : r'
The Home t turves tYte right re iasttc Chan 6rdor of xot7minata.this.Copt 8c%.9 : " z [v d" 'P►Pdu B incl udad.herein -at
b gh 4 Be . S•' ..,.1
its discretion, i The Hottte Depot OT UA aitthorined ACt Y1C0 (7TQVlder 4021 Y, thavit. P�'r 7Y6:4 1t$8t1fiTM d17B to k S UCLIIIa1
problem with the honto, environsrietital lmtanU 'such as mold. asbestos or read paidi,^o� Satet Cdttracrns gracing etrnYs br because
work required to otimiibete the job was not iii0h led it the;Contnct
l'a(vnarttC :Summary: The Payment Sumawrq' # 1 if►Clrlc3 as )iaKf Cf. drip Ciantract cars fotYh fire total
: .
Contraq amount and payments reiltiired fior the dtpasits and tnaCpa•5'mcWU by Pmduat':(a$
NOME TO' C'USTOftV 1t
ou are enti completely tltlCd••blt eaW df the Conuv t 8t tkwtime 0ft Do g4t•91 •!" UtoplR q)U' ( 1 C (nice:
tb= is auto i10n cemoca te.tor , each .ilio 1 11OtflrlCt i9.rl�inE(l
b convleta. .. " .... .
In the event of tarminatio'a of this CA fleet, Castamer agrees ;to pay T'he .$Ohre Depet'.the ,SQBts ot,toitcriaig, LVW erpftlaeg
and acrvices provided by The Horne Depot or Aotboldzed go-Am Provider #l0mgi 6 tlic iiti of termba *don, p lus any odler
a mounts set Forth In this Agreement or allowed under a pplicoMe low. TOE HOMEDEPOT MAY WITIMOLD.. AEMfOUNTS
O"ATD TO TIU HOME DEPOT FROM THE 11PPOSIT P,►XATENT - OR OTIWX PAY141>EM 1MlAVE, WrMOUT
UM1TiNG THE HOME DEPOTS•OTIIER REMEDIES FOR UCOVERY OF $(" A- 7 4OUNTS.
Aeeentapr a u tU: Customer agrees and uiWmNuinds that tis h Agreement i6 the entire Avmment between Customer
and The Wome spo C ry gard to rho Pr dum and Installation services and supersedes all prior' diacuasibns'aad agreements, either
oral or written, relatrrr to I said Prod LcEs and Tnstail This Agtix:rtrent cannot be assigned or exo" by a wri nng signed
by Customer and The Ffome i IPOL Customer acknowledges and agree,, that Cu s tomer has Tead, understands, voWntudy aci:epts the
termS of and has ftubived a copy of this Agreetnont.
Sales consultant Signature Date
Telephone No.
u s Signature Sales C:onsuitant License No,
CATVCELLATION CUSTO R MAY CANCEL THIS (21 Who")
AGREEMENT WITHOUT P&NALTY• OIL OBLIGATION
BY DELPVTJ G WRI'T'TEN riT(Y7lCE TO TM HOME
DEPOT BY MWMGHT ON TIM THIRD DUSIhM
DAs'' AFTER 810TViNG TINS AGREEMENT. THE
3PATE SUPPLEMENT ATTACHED Mg TO
CONTAINS A FORM TO USE EF ONE IS
MCMCALLY PRFSCRU" BY LAW IN
CUSTOMER'S STATIr
NOTICE.- ADDE'Y MAL TEAbts AND C)NnYl *NS ARE 9'PATRt) ON THE REV PAa WE A R PART OF TMS COMUACT
5-1" frSC White - @raicrf R1@ YaAow - Customw . PIN(- Sdep.Goniwftr0
A
RtstrKt&d to: w S
IA - Mlsomty uoly ;
JZY - Rmr Corcring
WS - Windows sod Siding
SF- Solid Fucl Burvi>ig DCVRL,
DM - B- molidou only
1 Lo p__" a rurreet edition of.lhe
MR—Clausrtts State $uilding Code
is cru,c for trvocasioa of this Gcccjc.
Rzfer to: WWW 1Ka. Gov/DES .
Dcliaitmcnt of Public Balch
Bnrri! of Ru;lJiny Rc�ul .nun< and StNndurd.
Construction Supervisor Specialty License
License CS St, BS209
Resiricled to: WS
I
VLADIMIR SHEVCHUK
5 OGDEN STREET i
CHICOPEE, MA 01013
Expiration: 10/'1212011 j
C . ,,..,,i- i..0 r Tr:: 99200
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..nv ... -' ! vnr�n�,r vTi.irn«, nOCCnCCCTn /fi:eT Atag7 /Ir /CA