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•
11assachusctts - Department of Public Safet.
e Board of Buifding Re2ulations and Standards
Construction Supervisor Specialty License
License: CS SL 98785
Restricted to WS 1
IVAN KOSOBUTSKYY
Itfr
72 STAFFORD ROAD
MONSON, MA 01057
c --�- Expiration: 4/27/2012
('miunis.ii,ner Tr=: 98785
,k y-LO -e-(1 VL9
��.
• HOME IMPROVEMENT CONTRACT
PLEASE READ 1THS
Sold, Furnished and Installed by:
nrsharr Saviors Doe: THD At-Ilorne Services, Inc,
Mile The Home Depot At-Rome Services
345A Dreenwood Street, Unit 2, Womester, MA 01607
Toll Free (0O) 657-5182; Fax (508)156-88n
Brand, F yrs el* v‘r - T
CT Lie * ITE.0.56:622.
Installation Address: oic)(2_
City State Zip
" ) [ 91 7X7-&[
[ [ `69 ( .7'1 i
"
(If different from Installation Address) City State Zip
E-mail Address (to receive project communications and Home Depot updates):
El I DO N011 wish to receive any Tlm- I
and THID At-Home Services. Inc. ( Rome Depot) trees to furnish. deliver :aid &linage for tc fibub4,4L4V1 k 1"...,,..:;,L.;.ikrie) Of
all materials described on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contract by this
F.,,finr.fEte., *mg with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collecuvely.
'Contract"):
at Pr
" ijitoofing LiSiding tawiodows lasidation
t riG /covers pinny pools $ t
Roatir.i5
ti iiing v tl insulation
— 0 - 1 — toofing - n&a,t,44
_
hgaintam 25% Daps& decennial Adam,* Arve 4am arta% ctmwaet. Tod t Amoun
NMI= Parchment raw nat &porn mum than onoshini of dm CentrariAmmat. 5177
— , , • .„ •
(one for earl PrUkiod. tiernar41 .71;avc..tto
Contract agrees to be jointly and severally obligated and liable hereunder.
The flwi,t, .1=7 prnelf iftrill4ed herein, at
problem aid) the home, essiii,usati6,:idi
work required to complete the job was not included in the Contract
pirfficunf " 0 517 57e, incimud as part of this Contract. sets forth the total
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of the Contract at the time yon 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
and services provided by inc home Depot or Authorize:0 'ervie;e
amounts set forth in this Agreement or allowed under applicable law. THE ROME DEPOT MAY iVITIPEOL AM
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITINC: TIM IF D.77 tYT " r.'" P FFPOVF.Pv (W VCS; AMOUNTS-
, _
oral or written, relating to said Products and Installation. This Agreement cannot be assigned or amended except by a writing signed
by Cestorner and The Mot= Depot- Dastomer acknowledges and agrees that Customer has read. understands. voluntarily accepts the
.., zzc.-f. of tis Agreement
'.4 1i;.:( " 1 1 ,4ta u r- 0 40; 3 4-'
!Inspire Date Sales Consultant's ig re Date
..„
Customer's Signature Date Salo Consultant License No.
2 CUSTOMER MAY CANCEL THIS (as apptleahro
AGRFEMEN s 731,1
DEPOT BY MIDNIGITT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUr"!.. ATTA.r1'FED HERETO
IT 77.7, 777.! TS ?,
SFEC�LALL wal D L.W IN
CUS'POMER'S STATE.
NOTICE:AntwriONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE mbE AND ARE FAIT OF TH1S CONTRACT
es: 3C "
&s The Commonwealth of Massachusetts
•- -- ,._, * Department of Industrial Accidents ' EGEIVED
� " ! L = ' Office of Investigations
y =at'
- � 600 Washington Street -
ACT $ �� I
;�
Boston, MA 02111
www mass gov /dia
4- DERT.OF BUILDING IN • ECTIa S
Workers' Compensation Insurance Affidavit: Builders /Contracto . A. • tA"ar� AL <:+A' t ,I_.
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): 11 • i de /j
Address: � � OA Ae .• i _
y .
City /State /Zip: �� ( `j Phone #: .•w _ '� •
Are y an employer? Check the appropriate box: Type of project (required):
1. I am 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. Ell I am a sole proprietor or partner - trts have on the attached sheet. 7. ❑ Remodeling
These sub-contractors 8. ship and have no employees ❑ Demolition
- --
working for me in any andhave workers' -
in any capacity. 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. [] We are a corporation and its 10.0 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 12.0 f repairs
insurance required.] t c. 152, §1(4), and we have no S - n _
employees. [No workers' 13. Other J
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: .,t) _ Qi
/ - Expiration Date: I•
Policy # or Self -ins. Lic. #: �(��0 p
- - Job Site Address: ijr' r City /State /Zip: r 1W 4iya ,r a qr.__
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 2-5A-of of-criminal penalties ofa
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.
-- I - do hereby certify un r the p ' ins / dpenalties ofperjury that the information provided above is true and correct.
—
Si. afore: i' A i / • , /. Date: '
Phone #: Li 41.1--.9..
- -'` — Official use only. Do not write -in- this - area; to be completed by city 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 #:
•
SECTION 8 CONSTRUCTION 'SERVICES
8.1 Licensed Construction Supervisor: / Not Applicable ❑
Name of License Holder : --A "1
!! �/ License Number
PP
Addre / / Expiration Date
_ ,
.. /
AIM 7/ L ,. ._
T- Telephone
.. qr tere • ' o%imes m a couemein `. ontea „ .,. �° = Not Applicable ❑
Company Name Registration Number
: l
Address Expiration Date
- : �. S / r , . f elephone
t SECTION110 .WORKERS,COMPENSATION.INSURANCE AFFy1? SXIT�jM � c - 152 -4 25C(6)Y 1 ,
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit wilt result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes ❑ No ❑
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2 fam ilies
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 Whi 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. Akerson 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_wilLbe- 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
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, Cit of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
•
c - ECTION 5 DESCRIPTION Oh PROPOSED W ORK ( alt a
. r a* u n _,., Maas , Y s i S t' - ' f U `.
1-Jew House ❑ Addition ❑] Replacement ' ows Alteration(s) ❑ Roofing ❑
Or Doors
p►ccessory Bldg. ❑ Demolition ❑ New Signs ED] Decks [Q Siding [p] Other [0]
Brief Description of Proposed l
work: �1 Amer—All rl
L - gr Cam'
Alteration of existing bedroom Yes No Adding new bedroom Yes No r� 3 - 1 A-fq
Attached Narrative Renovating unfinished basement Yes No
plans Attached Roll - Sheet
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
SECTI.ON 4 9JWNER:AIITHORIWION TQ ?t_E ED 1ltlEN ' ,
OWN1 RSAOEN GQNTFZ ICTOkApPLIESrzt- UItiDIWCIPERIVirt
I, % a. ` : , 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.
or
Signature of Owner Date
1
C1f 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 • .Ities of p '
rupj
Print Name /
, /
Signature of • erlAgent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
e
Existing Proposed Required by'Loning
This column to be filled in by
Building Department ,z
Lot Size 1 1 ! H
Frontage I 1
Setbacks Front = 1 __—
Side L: R:1 I L:1 1 R:1 1 1 1
Rear
1 1 1
Building Height
Bldg. Square Footage 1 1 1 1 /u 1 I = LJ
-- ____ -- Open Space Footage
(Lot area minus bldg & paved 1 I I I 1 ► t
parking)
# of Parking Spaces 1 1 1 1
Fill: 1 1 s. 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 :! I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book i Page I and /or Document #t 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 0 Obtained , Date Issued:
l
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 0
IF YES, describe size, type and location: t
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 ('°; NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
520 FLORENCE RD BP- 2012 -0403
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30C - 050 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 -0403
Project # JS- 2012- 000645
Est. Cost: $1827.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 98785
Lot Size(sq. ft.): 59982.12 Owner: SERRANI LETITIA
Zoning: SR(100)/ Applicant: SERRANI LETITIA
AT: 520 FLORENCE RD
Applicant Address: Phone: Insurance:
520 FLORENCE RD 013) 727 -8250 0 Workers Compensation
FLOREN CEMA01062 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