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42-118 (2) BP-2010-0129 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 -0129 Project # JS- 2010 - 000152 Est. Cost: $14514.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 126893 Lot Size (sg. ft.): 18600.12 Owner: LEPAGE HECTOR J & CHRISTINE M Zoning: RR/SR(100 /) /WSP 11 Applicant: HOME DEPOT AT HOME SERVICES AT. 29 BRISSON DR Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 () Workers Compensation WORCESTERMA01607 ISSUED ON :81312009 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING & 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 8/3/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo f d of Northa `'� Pfat#�r�� � D Mn Bu g Departmen $ r 212Main Street ��1 3 Nortt4mpt6p, MA 01060 :. r phone 4,13 -687 -124 Fax 413 - 587 -1272 i s „ `..APPLIDATION Ti6 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 'El rti St District _ CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) /�^�, Current Mailing Addr s Vi e— —'�k*� 1l Telephone tot Signature 2.2 Authorized A ent: / � r Name (Print Current Mailing Address: Signature Telephone SECTION ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building _ (a )'Building Permit Fee c 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) Check Number /p�0 This Section For Uffrcrai Use Onr' Building Permit Number. Date _ Issued: Signature: Buiding .Commissioner /inspector of Buildings - Date , � ' r ' 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 Rear Building Height Bldg. Square Footage % ' Open Space Footage % (Lot area minits bldg & paved # of Parking Spaces A. Has a Special Permit/\ariance/ Finding ever been issued for/on the site? �� �� �� NO �,� DON7KNOYY �.� YES ,�� /F YES, date isue& IF YES: Was t permit recorded at the Registry of Deeds? ND � � DON7KNOYY YES ��~� - ' IF YES: enter Book P and/or Document# »~� B. Does the' �tecon��na brook, body nfwa� /~ �` water NO �_� DON7KNOYY k_� YES IF YES, has permit been or need to be obtained from the Conservation Commission? [ ---'--~--'- 1 Needs to bembtained ^�� Obta ned �-\ ' Date Issued: ! | _ C. Do any �gns�dst on the property? YES ��/ NO �~� |F YES, describe size, type and location: - p'"p='`x �~� 7 YES �� \_� NO �-* IF YES, describe size, type and locat E. Will the construction activity disturb (clearing, grading, excavation, nr filling) over 1 acre oris it part o,a common plan that will disturb over 1acre? YGG� 3 NO K ] �� �� IF YES, then a Northampton Storm Water Management Permit from the DPW is required. w SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition [] Replacement Wi ows Alterations) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs {a] Decks [Q Siding { Other [Dj Brief Description of Proposed �-- Work: i rI � ` o r Pp�4e Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet ca lf,stew.hvii e.arfd.or..acfdI# tart 04e '"sfln " °iiousin coin jf 4iji Mfi 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. L Septic Tank City Sewer Private well City water Supply SECTION 7a-0 WNER AUTHORI7ATION.- TO BE'COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I t Vfilr4 11 as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit applica 'on. Signature of Owner Date (7-4 �_Y) as Owner /Authorized Agent hereby declare thaf 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 penalties of perjury. i� Print Name Signature of Owner/A ent Date s SECTION 8 - CONSTRUCTION SERVICES , 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder : %-e lk License Number Addres Expiration Date Signatur` Telephone 9 Rectlstdret.l4oi ,, A- mbroyein- VeoitractoF: s ., i. ... ' .. -.. q r ...> Not Applicable ❑ Company Name r Registration Number Address Expiration Dat _ Telephone 1 DI jy � D J C �� � 3 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, §,25 C(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 emit. Signed Affidavit Attached Yes....... No...... ❑ ._The_ current _exemption,for "homeowv_ners" was extended to ji1q,1u4e 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. Aperson 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 fob 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 -Laws.-Annotated. o ampton r finances,` a e o Homeowner Signature The Commonwealth of Massachusetts Department of Industrial f1 ccidents Office of Investigations 600 Washington Street Boston, MA 02111 °'� • www.mass.gov/dia - Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print Lejibly Name ( Business /Organintionflndividual): Address: City /State /Zip: ? �4 #: Are you an employer? Check the appropriate box: Type of project (required): 1.2. am a employer with ' 4.. E] I am a general contractor and I employees (full and/or part time). * have hired the sub- contractors 6. ❑New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling ship and have no emp loyees These sub - contractors have .8. ❑ Demolition working' for me in any capacity. employees and have workers' 9. Buzz addition rs' [No worke comp. insuran comp..ins # required -1 5. ❑ We are a corporation and its 10. ❑Electrical repairs or additions s� cC�s�la_v.1:eL their 3. El I- am- a�omeo-wne�- doi$�- �vor-k- - - - - -- - - -�--- --- 14--❑- 1?.Iumbingrepairs 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 1 rl 0 comp. insurance required.] 'Any applicant that checks box #1 roust also fin out the section below showing their workers' compensation policy information. t Homeowners who submit this affidxvit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. zContractors 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- r am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site Insurance C ompany Name: fli I Policy # or Self-ias. ic. #: { QK Expiration Date: Job Site Addre ess City /State/Zip. Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure g fine up to $1 and/or one ear requir under Section 25A of 1vIGL c. 152 can lead to the imposition of crimfiW. penalties of a -y imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. -15e advised that a copy of this statement may be forwarded to the Office of Investigations of the DlA for insurance coverage verification.' I do hereby certify under th pa s . d '1 : s ofperjury.&& the information provided above. is true_andcorrect_— Signature: Date:(� 01 —7 Phone #: Official use only. Do not write in this area, - 10 be comp ed by city yr iown offcW City or Town: Permit/License # Issuing Authority (circle one): 1;:- Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrica1 Inspector 5. Plumbing Ins ecto __ . - 6. Other r ' Contact Person: Phone #: 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 insection ur o ��se quires that the building department be calle 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- coniunction,.to-the-b _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. Address of work location RtsbrjCb&d lo: WS IA MalDbry uoly RF - )moo r c o.-c ritsg WS - Windows sod Siding SF - Solui Fucl Bwuiag Dev{tci DM- D- 011dom oaly Faa7urY to 9osscsr a rurrent editkm or the DTasxchuaetts State Building Code is ctuse for revoeatioa of this Geenx. Rzfcr rL: WWW.11Saas CQ ID PS achusol's - Dcliawtmcnt ui Public �afcn Rnut•tl n1' RvilJiny Rc1 ulltiun; and 5t44ndnrd• Construction Supervisor Specialty License Lice-se. CS SL 99209 Restrined to: WS VLADIMIR SHEVCHUK 5 OGDEN STREET i CHICOPEE. MA 01013 Ezoiration: 10/12T2oll i r • n..ui, }j..y r Tr9: 992M OV J f ^n ! vn. �n xr vnern 1n hOGCnCCC Tn /fi:fiT RGQ7 /1C /CQ HOMI 1MPRQV EMENT co.N 4T I sold. rurnished and dnstalled by ": Branch Name:, Bo ®ton Date: TkID At rime Services Inc dlbfa I ttc Noma I7! p4t Ablotne Sar�ICes 345A CextsKg4do cat Unit Worcester l4TA 4T607 '.. . Branch Number: 3i Toll'F (SOOj:b5151ti2, rare (5Q1#) 756 -8'823 Fedeaal'IJ?' 0 75= 2fi98rt4t7; NO k $ C ViOY: RI Cont. Lj CTtia k AlliSsiirTmrroviancntf�an 'tti<xorfttg.tKt2y893 ''Installation Address:' y S*� :zip Work Phone: House Phone: Cell Plwn6. Home Address: If different 1Tom'Tngtallation Address ( ) a ypy "S,taic Zip E -mail Address '(to receive project communications and.HoLne Depot.updatcs): Q I DO 340T wish to receive any marketing emaila froni'tno Borne, ftot. lrro formation lJndersiEned [ "Customer );.the mvper4oY rive ;pcppaety: geaxad:atrhe•etique.inpt lie don addross. agrees wo buy, and THD At Services. Inc. ( "The Tlome Xlepoi "). agrees to. firrnish, dclxYeisgr(d.arrHpga i`or,the iastAllation• "Iifstallatipn") o all ►materials described on the below and an the referenced Spec Sheet(s),.all of which 'are incorporated into tfiic Contract by this reference, aloaig with any applicable State Supplcrtte4t and Payment Sutttirtaryattuctied herein 9tid:;any CU)119b ;lhrclers'(collec�ive3y; " Contract"): .Job#. (i. SA ltv.) prodWtq k ow..q6ee t s It: Pro act Aaa.onat � ❑ltopting ng Lj Windows JJ16WIation 1 ❑Ouitera / Covary []Entry Dgor9 ❑ J ? r nor Roofing ©Siding mdovk' U Insulation 7 �L7 dGuttcrc l Cor ct'S ❑Entry boors ❑� j, '' ..+ , - 6 .. 12ncfl Sidin 'Windows 0 An " U A R.wtint Siding U lnSolation': E]Gutter lCnvers .❑EntryLto= ❑ $ — I 1N111i0wal 2s% Depaeit of Contract Aniotud doe.npbtt taeaittan oox tbii .. lVta .7areil,,r✓Rjn „ h l� u t M POIEVItasorc �v not depnot mo pth re than gnfid of the Couii` dAm4ynt.. ; , Customer ngrecs that, immediately upon complction,of fhe4ork'foi each Prodnc� ...6't Y .,e�Gpte'a:iCcsmtilotioti CcrtiftGate (one for earth Product as dcimed by an individual Spee 5hpei.) and ',i an ,.ai2jaAge:° p y `y dtxe. �% :rptrltcalxle each Cugtoataer under this Contract agrets to be jointly and severally obligated and liable hereunder: ' The Home Depot reserves the righr to,isauc a Change Order or terrtitnare..rhts ConptiiriLir zt}ty tvadµal l ino)uded at its discretion, if The Home Depot or its authorized sdiVict pro.yider de�n4l's this' Ga(uto�,p rfoyrn acs oblrgxEiiatis dae to q srrti turp] problem with the home, cnvironmcntal hazards such as mold; astiectus or lead gaunt pibAi 'safety cohcetns pricing errors 'or because work required to complete the jab waA nor iuchided in the Contract. Payment Summary: The payment Summary (f 1'Z 1 the }irdrrr, as part qt, rtlisonrxaet, Secs forth the .total Contract amount and paym requite d for the .deposits. and .iinal.ppymaitg'bY a5 RpP,ii€ t )•: NOTICE TO: CLISTOIWkR'.. You are entitled to a completely i4 ied-in copy ;bf the, Contract at the'tieie yolk I}o not'*04 Coiupletion'.Certifiicate (note: there is .one Completion Certificate for each•ltgted'Pr >dehoed �y i:0d 61)ee. before work on: titan Product B complete. in the event of termination of this Contract, Customer agrees to pay The acme De ut the costs. of "teria* tabor, expenses and'services provided by The Horne Depot or Authorized Sdrvke ProvWr t1►iervo :thi'date 60 termination, plus Any other amounts set forth In this Agreement or lowed under ap p licable law. THE II(Jhil ' brLPOT'MAY' WITHR()I.D..AMt)VNTS OWED TO TIIE HOME DEPOT FROM TITF DEPOSIT PAYMENT OR' OT!ffElt PAYMENTS M A: DR, 'WIT -ROUT LIMITING THE HOM E DEPOT'S OTIIBR REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Customca' agrees and unrjerstaii& that this Agreetnent'is mg, entire agreement beLween Customer and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements, either oral or written, relating to said Produce and Installation. This Agreenuut Cannot be assigund or amended except by a writing, signed by Customer and The lions Depot. Customer acknowledges and agrees that Customer has read, dudersiands, voluntarily accepts the terms of and haA received a copy ol'this Agreement. �ccepte Sul) tm r' ig Sales Congultant'a Signature Date Telephone No. us . mar's Signature to Sales Consultanta.icenseNo. CANCELLATION GUSTO R MAY CANC THIS (0s Apptic mle) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO TUC HOME DEPOT BY MIDNIGHT ON THE THIRD IIUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE 15 iPFCMCALLY PR1'+.SCRIBED BY LAW IN MSTOMER's STATE. NOTICE: ADE)MONAT. TF,k%Z AND CONDMOM ARE Sl'ATRD ON THE 'REVlrM .SWII AND AttF, PART Or TIRS CONTR.4.CT 5 -10.08 0-9C White- BrWhFoo. Yellow- Customer Pink - Sales,CnmtjitAnr