18-002 - rBYII'1 tI L'lyYlLlNt k.dt.;KyYY It k'. A'
PLEASE' ]AD Tom•:
Sold, Furnished and: Inifalled',by: •
• Rra,nch Name:, Rnston hate T'i T At- flantiwS erviaea; Its.
• dTh a T :E spo At- I Services'
345A C+reenwood •Sift; t. 'Unit 2'; Urm . ter, MA 01607
P1 14/(
Branch Number: 31,, q11 Free (1 QQ ) 657' Farr (508) 75% -8$23
FaQezA111) # 7 ?,6'98464,'tb1E Lie C 02439t RI Conti Lisa 16427
� C i Lic #'565522 !ytA }1c ConuapteriPeg n 1843
e 6 h 2
Installation Address; [ C 3 d' 11�' —?X ; ' F-601 t i `l i Q i� . E , &
Sta - -- Zip
Parchascr(s): 'WtirkPhone. 04me Phone: "•Cell Phone:
_• 11111111111111111
tloune tddr.r _
If different from InstalIation•.Address) (its State Zip
E•maU Addresis. (fo ieceivc proje camisuirlicat Its &id H '4ni l fdt trpd�CO ):
�: TDON( 1Twishaoresetveanytreaticetttrg t ile•fioa:a1heI ' , '
Pcgiee�t� orma�tib "' Undersigned (' Guar mee) the ov i2er8 e f' l+ tt:3 islet ret , agree* to buy,
and Tfll) At-home Services. Inc. ( "T"hc Home Itepnt') ago th f . d Kv f ail at rohge fer' 2 Tnstaltatica (o taotallatioti")'
tlI materials described on the below =let `on'.the: reteeenced, Sje. Contact by this
'eference, a1(nr3 •riih any applicable Srate.Sjppiam 'an ; Pa ent t y, :,4, 1 4 h x to a Chs fie Orde'rs,.(yollectively, • 'Contract');
fob #: mama iteoreu,o 'Sate , to S'ii t # Pxo ecf Anw
r of`uil5 �S +:' 7induw& 13 0 xion '.
b .� C]flt2erg! CuverS' Entry Doors `" S'
DRoo g. U5idrtp � ■ � W txkoiws lI..1nautanam' ".. �..
DC3ungrs.l Cov r i- irttliy D44LS , '1
: C Roofing • Siding 0 Wiarlowts C 'Tnsulatla ,;;;
flGutters i Covers, (' ]l'rrtry' 1?onr, M
(']Roofing (]Siding i Windows
.00otters!CoVeri (Entry Doors -
Nrttnimum 23% i)tpoaitof 4 - onteset Amnmf dui, upon etetittion o this poptrl L
Totat Cuttfrtrt i e* nitr, tit , S
Maine Purchases a may not dapadt mace Rm. one -bird wt the Cou rat to epgh ,
.ustonrcr agrees that, intmedie.tely. upon completion of the work to7 sash Fro:(1tt(j, 91.1 ot lret t 01::*C a' r.d‘ripletieeer Certificate
'one far each product as defined'by an individual Spcc• Sheet) and',pay any.balance' &e. this
::onbact asrcos be jnintlyahci sevcra.11y abligarad sad li'41t1'a hereunder
Ile (Tome Depot .reservea•the right to issue a Cltswge.Qrder or t rs this Coioac tEor .,01 included herein, ,at
is discretion, if The Home Depot or its authorized setvlce preivider'deterrrrines tbt yt:cfnmot perfvrhl its obligations due:to a Strtr tutaf.
problem with the horde, citvironiaentai hnasrds stic t :me sab •o lePd p my q b 8r Ct t triztie tas;eg emote u= because.
Yvork required to co'mpletc the job was not incl in the Contract
Payment Summary; The Payment Sunrnary # ;inotuded of tins C.optract, sets forth the totht
_ otitract amount and payrneuts required fnr- thcidepoaita: and + finitl'tpi4 byPr`pdoci ( at applicWle) , •
soneE TO:t USTORMETt
You are entitled to a completely filled -in copy of the ContraCf dt;.}lts tim kot e aR Do^ sign a Corm)ietiorr'Certitieats ( note.
them le one Completion Certificate for each listed Prttdtict aa'aef uee+#f5 c tt#f`Sk.c •S}teefs)'• before'ev n on t'hut Product
s complete.
to the event of tormination of this Contract, Customer agrees to pay The Ilome,Dcpot'• tire costs of rtrateriais, labor expenses
and services provided by Tbt Rome Depot or Anthortzed'Service Provider: thTOtthll the dale o£ ternt?rzation;. plus any other
amounts set forth in this Agreement or allowed tinder ap licable'isw'. i'}TE HOME DFt'0T MAY \11 FfHOLD AMOI NTS•
OWED TO Tat ROME DEPOT FROM TIIE•.DEPOSLT PAYMENT OR 'OTITER'Pt#:VM.ENTS hiAD'E, 'WITHOUT
LIMITING THE HOME DEPO'T'S OTHER REMEDIES R'E:(`,c3 l?(Cs (Iv.' 'Sten AMOUNTS.
Accentan and Authorizaf<loll: Customer agrees and understands that. this Agreement i5 the entire agreeeinent between Customer .
and The Horne Depot with regard 10 the Products and lnstattation services and supersedes all priO. d'iseu•5iorns and agreements, either
oral or written, relating to said Products and Installation. This A eeenent cannot b'e assigned or amended except by a writing sighed
?y Customer and The Home Depot, Customer acknowledges and agrees that Custe.nei basreef, understands,: voluntarily accepts the
;ens of and has received a copy of this Agreement.
Acte • ed by: Sabtti
i
Cto
us ms - S !eidt titre a'.: c Sales Cons iqna bate.
X - _ Telephone No. .
C'ustomer's Signature Date
Sales Consultant License No.
CANCELLATION: CUSTOMER MAY C4NCEL TOTS - (as xpplicat+te)
AC.R EIrIENT WITHOUT PENALTY OR OBLIGATION .
BY DELIVERING WRITTEN NOTICE TO Ti, HOME
DEPOT' BY MIDNIGHT ON Tilt THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. • IRE , •
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
Nana: At)nr1IOlY.4l, TERMS AND CGND!TSONS ARE STATED ON THE REVERSE SIM AND Ant FAlti Ot 1H S C=ONTRACT
1 -15.00 C-SC, white- Ord -.4' File Yellow- Customer Pink - geY s .Crntsuear,1
or
•
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 'xocess 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-imconjunctionto- the- building..pe mitissued, 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.
Date
Address of work
location
- -
• ' 4 "
The Commonwealth of Massachusetts
- Department of Industrial Accidents
....c.—
Office of Investigations •
• —,:e. -1 .s.
600 Washington Street
15_,..-)
.=.- Boston, MA 02111
. — .
ar '
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrician.s/Plumbers
Applicant Information Please Print Legibly
a -L.__
Name (Business/Organization/Individual): . I. • 1.611111, a •
ovalar _ .
Address: it"-ifli . • Al .0 ''' , ..0. 4 _
IIII
City/State/Zip: 1111114 0 r CA 0,3 # : 7 ,cZaD45 _ 7_ ,... 13:2,,...__
Are you employer? Check the appropriate box: Type of project (required): l
4. 0 I am a general contractor and I
1. arn a employer with icrY.._...) 6. D New construction.
have hired the sub-contractors
employees (full and/or part-time).*
listed on the attached sheet 7. 0 Remodelinz
2. 0 I am a sole proprietor or partner-
These sub-contractors have
shit) and have no. e..loyees 8. 0 Demolition
k
loyees and have workers '
working for me in any capacity. emp 9. D Builnfr addition
[No workers' coi32p. insurance comp. insurance.:
required.] • D We are a corporation and its 10.D Electrical repairs or additions
3. Ej I ama-hemeowner-doimg-all-werk .0-efic_erslaze_ rixer_cised_their__ 1-4:1-Phimbing -re or additions
• right �f exemption per MGL
myself. [No workers' corop. 12.[3 Ryfrepairs
insurance required.] t C. 152, §1(4), and we have no
employees. [No workers' 13.aOther
comp. insurance required.j
*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 employee; 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. .. c ------ 1
Insurance Company Name: ''' t A EL Ai Alb 1 bAil
Policy # or Self-ins. Lic. #: (L/ ------- Expiration Date:-
Job Site Address: '1 oe5
7 City/State/Zip: I fa diA, , 4 1 #
Attach a copy of the workers' compensation policy decl ation page (showing the policy number and expir don 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 frne;
of up to $250.00 a day against the violator. e advised that a copy of this statement may be forwarded to the Offlee of
Investigations of the DIA for ..., ., . . ce coveraze verification.
I do hereby certify under , e p , ' a1 1 per , ' I s , f ped that at the information provided:alio _e_is_true and_correct
Gi l rt) rtm at IIII :
- 17)1 C re i-C-
Phone :0 u.se otily. D - I w tlii:7rEa, to co Inp d by city or town o;fl cia L 1! I.-
Issuing Authority (circle Permit/License # -
Board of Health 2. Buildi g : De: City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
- 6 i
Contact Person:
1 I:
Phone #:
,
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su ry Not Applicablle
Name of License Holder : 114 Y \ 1 ovn In) / d<
VIODRQ
License Number ( /911,4 5
Address Expiration Date
Lb) 1 5 -7 )
Signature Telephone
9..RegisteredHome_hn rowement ..,�._. �., ��` Not Applicable ❑
014
Company Name f— Registration Numb
Address Expiration Date
e5 n) c -T-7 Telephone /Pi
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) J
Workers Compensation Insurance affidavit be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the build' permit.
Signed Affidavit Attached Yes No ❑
14 _Homeruzsemu"
T_he_current_exemption for "homeowners" was extended to include Owner 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 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 referenceto 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" c ertifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ur mantes, a -- • n
.: - * _ • • - tts=Gener- al- La -ws- Annotated.
Homeowner Signature
r - „ . M
s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement wi ows Alteration(s) ❑ Roofing 0
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [p Siding [❑] Other [❑]
Brief Description of Proposed C"' -
Work: 1 1. � I r '� j . : ,
k t• ��e_l
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a lf. N e w s ouse and :or a ddition to sti a fiouslnci .,complete thhe. fot(owinia:
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
I, ee--`v 44, / , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit appli 'on.
q c
Signature of Owner Date
_ _
I, I L{�
� f __ 1 i 00-e____ as Owner /Authorized
Agent hereby declare that the statement nd information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the , and pe - - of oerjury.
•i . .∎ •V
Print Name / wo r �,/ f/
Signa ur- • O-r /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
Frontage
Setbacks Front
Side L.__µ R:M.. .." L:_.._ _. R
Rear
Building Height
Bldg. Square Footage f %
Open Space Footage _.,.,,
(Lot area minus bldg & paved
parking)
# of Parking Spaces — - -
Fill:
(volume & Location) a -- ,
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
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 Obtained 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
" 6:" dre tyre any propo`sedc ranges to or a itions o signsintenced or the property ? YES 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.
. r .
City of Northampton S. a 'of�� i
Building Department Cu : k Pe . � .
212 Main Street Se wer ep cif fl i alto `
Room 100 Wa ,01 RAvaila a ' i# l h
No MA 01060 Two Se - . f S t a c ti n art
phone 413- 587 -1240 Fax 413- 587 -1272 t n � t �� Z £ ,
otl g
le ,w. ,....r� iiri 3, xi, r 3
a..n �,¢ 1. ^' a „ .- �. F- :
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
Q
P This section to be completed by office
1.1 Property Address:
Map �U Lot (5e (5e C U(�/�
/
`70 Poie5' 0 ' i2t Z one S Fla strict
/ Elm St: District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Re ord- / I
Name (Print) Current Mailing Addreas:,
6 Pe ✓/t( `fl Telephone ,134--, d
Signature
2.2 Authorized • ,E.. . t:
Name (P ' / f Current Mailing Address:
LID/
Signature Telephone
SECTIO 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building VtV7 — (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
6. Total (1 + 2 + 3 + 4 + 5 ) � Check Number
This Section F O Use Only
Date
Building Permit Number: Issued:
Signature:
Building •Commissionedinspector of Date
•
70 PINES EDGE. DR 4 " BP- 2010 -0438
GIS #: COMMONWEALTH OF MASSACHUSETTS
'.4/ CITY OF NORTHAMPTON
Lot: -012 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit # BP- 2010 -0438
Project # JS- 2010 - 000594
Est. Cost: $2437.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): Owner: LENKOWSKI STEPHEN J
Zoning: RR/URC /RI Applicant: HOME DEPOT AT HOME SERVICES
AT: 70 PINES EDGE DR
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401
Workers Compensation
WORCESTERMA01607 ISSUED ON:10/20/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT SLIDER
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 10/20/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo