43-041 (2) The Commonwealth of Massachusetts
,,,,..,= Department of Industrial Accidents ECEIVED
-.. - � Office of Investigations
t � 600 Washington Street =ACT '� $ 2011
4 • Boston, MA 02111
www.mass.gov/dia DEPT. of BUILDING IN PEC71 s
Workers' Compensation Insurance Affidavit: Builders /Contracto . A. • =r�, ,it LA' 1 ,
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): - 1 - Y r ia- -- HDHE
Address: ,r,-, < <� r
City /State /Zip: A L_ , r _ _= _ii �i Phone #: 7 '
Are y , an employer? Check the appropriate box: Type of project (required):
1. S I am a employer with ,^� 4. 0 I am a general contractor and I
v * have hired the sub - contractors 6. 0 New construction
employees (full and/or part- time).
2. El I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
These sub- contractors have
ship and have no employees 8. ❑Demolition
employees and have workers'
working for me in any capacity. $ 9. 0 Building addition
[No workers' comp. insurance comp. insurance. 10.0 Electrical repairs or additions
required.] 5. 0 We are a corporation and its
3.0 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. ❑ f repairs I r �/'�
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. Other (/W
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. p
Insurance Company Name: Lt 1 j 1("0___- 10 L,C.
Policy # or Self -ins. Lic. #: ,� �` ,i �, Expiration Date: 1 . l
Job Site Address: . le.55.9 City /State /Zi ♦ �� qc---
p a �� i�'►s v
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expir . tion date).
Failure to secure- coverage -as- required under -Section of-MGL c7--1-52 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 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 D ' ` . insurance coverage verification.
Zdo hereby certify un , er the p , ins / d penalties of perjury that the information provided above is true and correct.
Si afore: / - Date:
Phone #: 461.11 �
-- -- — Official use only. Do not write in --this area, to be completed by city or town official
City o r Town: Ci or Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical _Inspector G. Plumbing Inspector
6. Other •
Contact Person: Phone #:
F
Richard Fall 401 453136? P ,1
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PLEASE READ THIS •
1 '
Sold, Furnished and Installed by:
• Bostola Date: THD At -Horne Services, Inc-
` \ d/bla The Home Depot At -Home Services
345A Greenwood Street, Unit 2, 'Worcester, MA 01607
Toll Free (800) 657-5182; FOX (508) 756 -8823
Branch Numbers 31 Federal ID 0 75- 2698460: ME Lk A C 02439; R1 Con . Liar 16421
.n l CT Lie 0 HIC.0565522; MA Home improvement Contramor Reg. • 126$93
Installation Address: E ALA.T f t, {M D T' (cl4SLl� c , 4'V l N3 0
City State Zip
Parcbaset(s): Work Phone: Home Phone: Cdr Ptrons:
NCO . N4A VAA [ ] [ ] t ]
[ ] { l E J
Home Address:
(If different from Installation Address) City State Zip
E -mail Address (to receive project communications and Horne Depot updates):
Q I DO NOT with to receive any marketing entails from The Home Depot
Project : Undersigned ( "Customer"), the owners of the property located at the above installation address, agrtct to buy.
an Y arm ' nD At -Home Services, Inc. ( "The Home Depov') agrees to furnish, deliver and arrange for the 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 it: atb: __Dees Sheet(a) # Project Amount
URooh•t; Gaining VNedows O Insulation
r oti • POuttemrCovers army d► � e,4
QRoofiag _ ■ Windows ■ Insulation
❑Goners / Coves OEmy Doors f $
DRoofing EISirrmg U Vila:k ss U to ration
°Gusts /Covers Many Doors ri $
C]Roafir►g 1:ISiding ❑Windows ❑ Insulation $
s / Covers DEnoryDoors ❑ Il
ithelmezH41,ThemadCenta% Ammo doe urea mama IneF taisoratrad.
Mao Perehaaeessoay net dtped than anonrdintofdeCooaaetAeaornr. I�1 Goekraetwtnamt $ 50 eq
Customer agree that, immediaaety upon completions of the work for each Product, Customer will execute a Completion Certificate
(one for each PTroduct as refund by an individual Spec Sheet) and pay any balance doe. 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. if The Home Depot or iu authorized service provider determines that it cannot perform its obligations due to a smrcniral
problem with the 110 = 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 Snurrna Y: The Payment Summary # ', 1 - - , included as part of this Contract. sets fotth 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 ro filled-in copy of Use Contract at the lime yon sign. Do not sign a Completion Certificate (notes
there is age Completion C '. a for each listed Product as defined by Indtrl¢pt Spec Sheets) before work an 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 Servke Provider through the date of terminatmn, plus any other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING I NG THi2 HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OP SUCH AMOUNTS.
idaece and Authorisation: Customer agrees and understands thae this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Products and. Installation services and supersedes all prior discussions and agreements. either
oral or written. retatiet 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 ago= that Customer has read, understands, voluntarily accepts the
rem of and has received a copy of this Agreement.
Accepted by: . Submitted by : j
X • 1 X 1111 1 th i
Customer's Signature Date Sales Conawhant's Sig
X - Telephone No. 1
Customer's Signature Date Sales Consultant License No. -
CANCELLATION: CUSTOMER MAY CANCEL THIS (as :macaw
AGREEMENT WITHOUT PENALTY .OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME •
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE W ONE IS
• SPECIFICALLY P SSCItIBED BY LAW IN
CUSTOMER'S STATE.
NO11CF:: ApperwaVAL TERMS AND Comorn)NS ARE STATED ON THII RKYItItSR SMO E AND ARE PART OF THIS CONTRACT
me - - C.SC write - BranettFile Yellow - Customer
•
1
SECTtONl B CONSTRUCTioN SERVICES
8.1 Licensed Construction Supervisor: Not Applicable D
Name of License Holder : . AMP 1 _
License Number
I / A d % a Expiration Date
.i.n. u Telephone
9 "f re,k1 if ''m °coviertett ` .pitta a .. , , Not Applicable ❑
% Company Name " \, ( Registration Number
- Address Expiration Date
s � felephone
fSt CFION Q WORKERS" COMPENSATIONJN1SURANCE AEF DAVL (M
Workers Compensation insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will r�
in the denial of the issuance of the building permit. suit
Signed Affidavit Attached Yes ❑ No ❑
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) fes
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 fan.
structures. A person who constructs more than one home in a two -year period shall not be considered a homeown
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she sh lla be
responsible for all such work performed under the building permit.
- - -- - - -- -- As acting Construction - Supervisoryouur_ 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 t
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be Liable for pern
ons
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
c ECTION 5 — DESCRIPTI • N OF PROPOSED WORD c heck aIFa • : ticable) s ,
m 1 5 u5 :ig ' .:. w .. a r !
mew House ❑ Addition El Replacement Win s Alteration(s) ❑ Roofing ri
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [ID] Decks [Cr Siding [0] Other [0]
Brief Descri of Proposed t
Work: fe - t 0) l�fC '
Alteration of existing bedroom Yes No Adding new bedroom Yes No "mot
Attached Narrative Renovating unfinished basement Yes No
plans Attached Roll - Sheet
0
ra ' _ : +: + ® f tdditjOri tore^ Stitt o . L oU It . " of;1il D MIA , ested ! H av is + 'a._
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?
Square footage of new construction. Dimensions
d. Proposed
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
4 � '.i - "``°•fi r K4•• n : 5 r A . { t4*A1 * i4 `k t'V, 0
SEcrrloN 7a, OWN At J THOR I4ATION ,.TO BE,COMPLET A!HEN,, ,
Cl kgitz , AGENNrOWCONTRA4CTOR .A- PLIE
G 7-'_ Ca44;--1 , as Owner of the subject
property
hereby authorize
to act on my
1
behalf, in all matters relative to work authorized by this building permit application.
.
Signature of Owner Date
--- 1, -- FA 1 , 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 00-Ities of p.
Alk ,J/1 11 �V i
Print Name
/ /
Signatur, of ', er /Agent Date
•
,
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information r
Existing Proposed Required Lotting
This column ". be 441.1.41Y ,,.,, .4
Building D . .,, a',� 4 .4 ,„,,,
Lot Size 1 1 1 1 1
Frontage 1 i H I
Setbacks Front 1 1 1 ( j
Side L: / R: 1 L:= R:1 1
Rear { 1 1 1 I
Building Height _ , I
Bldg. Square Footage / 1 / / ° C I 1 --( 1 1
Open Space Footage ,
(Lot area minus bldg & paved 1 1 1 1 i f 1 1 i
parking)
# of Parking Spaces = 1 1 1 � 1
Fill: 1 1 1
(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 I Pa and /or Document #! I
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: i 4
C. Do any signs exist on the property? YES 0 NO I
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 0
IF YES, describe size, type and location: 1 1
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 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
k
58 AUTUMN DR BP- 2012 -0404
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 43 - 041 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2012 -0404
Project # JS- 2012 - 000646
Est. Cost: $5089.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 99209
Lot Size(sq. ft.): 18382.32 Owner: MARTIN BRUCE S & SOPIE H
Zoning: SR(100) //WSP II Applicant: HOME DEPOT AT HOME SERVICES
AT: 58 AUTUMN DR
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers
Compensation
WORCESTERMA01607 ISSUED ON:10/19/2011 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 10/19/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner