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' O£:£4 92-4L-1.1,02
1ass.achuscttk - Department of Pnhiic S4fct■
(Board of Building Regulations and Standards
Construction Supervisor License-
LIcense: CS 102403
- estricted to: 00
ILSON VALDEZ =
61 MAIN STREET
ILFORD, MA 01757
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%. - �' �►� Expiration: 1112012012
('omm isbi.>ucr Tr#: 102403
4
Restrlet d to: 00 •
+ 1 - Unrestricted
1 + -1 2 Family'( comes
F, 'lure to possess a current edition of the
ssachusetts State Building Code
is arise for revocation of this license.
• Cr to: Vt►WW.M s.Gov!DPS
Ols
()face et Csnszimar Altai/a & nnsines� Regul2tiori
Ji HOME IMPR0vEttiCtitOoNTPA
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MAZTERROOF •
WILSON VALDE
151 MAIM S'T �—
MA 017$7 Undersecretary
1ViliFORD,
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I LO W E • S I ' ' CONTRACT # 0001765 017 6 5
MASSACHUSETTS EXTERIOR. SOLUTIONS INSTALLED SALES ROOFING/SIDING. CONTRACT
I INSTALLED �S SPECIALIST ' NUMBER CUSTOMER
STORE NO. STREET ADDRESS STREET ADDRESS
��l 6 l
dt, / 1.� Y`� r fGl � i ti i 51
CITY STATE ZIP CITY / ( STATE ZIP
/( _� !/Ar C 3 /Urt bl�w�)1 ln Y Chico
TELEPHONE - TELEPHONE
y( .3— Cr?-6a176 , 113_ y j 6
DATE LOWE'S HOME CENTERS, INC.'S MA HIC NO.: 148688 CASH BANK LGC REG
4 / / / _ FEIN. 56 - 0748358 CARD CHARGE
This is only a quote for the merchandise and services printed below. This becomes an agreement upon payment. Upon payment, the entire agreement, induding thespedfically completnd'pages of this'
document, the Terms and Conditions included with this document and any otheraddenda and attachments hereto, shallbe referred to herein as this 'Contract.' "' i
PLEASE READ ALL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING. l
NSTALLATION STREET ADDRESS CITY STATE ZIP
lor: 1 r; -r? 4ji, �-i
de: (-/t': C'c(t ' Li `s
II v J ` �
f t --
cessories: / 71: fry Up -, 5 /�. /—/ �/ J
/I ,,,,:. saAw. V a n I.- — , — I — A - /_—.
'_2 Cl/ j /a'_k l i/'r �cg ct /ma�w
(. F
* Show drawing where shingles or siding
will be installed.
, 0 6) Contract Total 5 5-r-) � '
•e permits required for this installation ?: [I/] Yes [ ] No *applicable tax included �¢ `
OTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right. By signing this Contract, Customer
cknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure
•om renovation activity to be performed in Customer's dwelling unit.
HOTO RELEASE: Customer grants to Lowe's and Lowe's employees the right to take photographs of all work performed at the Premises related to this
ontract, and irrevocably grants to Lowe's all right, title and interest in and to the photographs for use in all markets and media, worldwide, in perpetuity.
ustomer authorizes Lowe's to copyright, use and publish the photographs in print and /or electronically, and agrees that Lowe's may use such •
iotographs for any lawful purpose, includ' g but not limited to, marketing, advertising, publicity, illustration, training and Web content. By initialing
are, Customer agrees to the foregoing. [Customer to initial.to the left].
Nork is cojnmence upon reasonable ava lability of Contractor and/or any special order o,r customer made Good(s) which is anticipated to be
ir /;77/i
[fille in date]. Estimated completion date is / / /g' // ' [fill in date].
Said es imated substantial completion date is not of the essence A statement of cont)ngencies that yvould aterially change said estimated substantial
:ompletion date is as follows: cI/?H i C .. 0...,J r d 5 rt° 7n^/ 0--/ ,-(...v /% ✓r^',1 F,/ A
!! / (if appl le, insert a statment of such contingencies).
THE CONTRACT TOTAL IS $1,000.00 OR LESS Customer must pay in full.
DMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS $1,000.00:
] Customer to Pay in Full; OR [ ] Customer to use the following payment schedule:
Deposit $ to be paid upon siging contract. Deposit should be 1/3 the total contract price; and
Payment of $ to be paid anytime after this Contract is signed and before commencement of installation, Nile authorize Lowe's
do one of the following (check appropriate box below):
] Charge my /our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; •
or
] Deposit my /our check for the amount of the payment indicated above anytime after the date this Contract is signed; and
Final payment of $100.00 to be paid upon completion of the installation and both parties' satisfaction.
OTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L. c.142A
DWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT, THAT
OWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT-
E OFFICE OF CO - • - AFFAIRS AND BUISNESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION
SP• lift EDIN .G ci
y: _,x,,,01 _ . Date: /f �0 / /
Lo e's Rom Ce'?
y: . ` _[ gft,. Date:
iwner Signature
HE SIGNATURES OF ' E PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED
Y LOWE'S PURS L A ' TO M.G.L. c.142A. THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE
ECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES.
10 NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND
:ONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT.
IY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THE
'ERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS
: ONTRACT. YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE.
NITNESS OUR HAND(S) AND SEAL(S) BELOW THIS , DAY OF ../...4:1 U D Pl of , 6
_owe's Home e,' •ers, Inc. 1 O i
r -ciahst or ' , eve Owne / Co -owner or Witness
ustomer acknowledges receipt of a true copy of this contract which was completely filled in prior to Customer's execution hereof. You, the buyer, may
ancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See the attached notice of cancellation
Irm for an explanation of this right.
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121E512011 10:51 508634E780 MASTERROOF UNIENVIOS PAGE 02/02
• 2011.12 -08 15:13 loges 1916 ISO 413 588 0278 » 5086346780 P 2/2
_
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor; Not Applicable 0
tuamq of Licenses o1Por ; % r
Lie nse Nu her
At .. - Ae a -- 9 c) NA 01 J / /2 •
Address Expired Date
.4 . i . _ _ 7 _ _ _ _ 2 2 Y _ _ 2 1 7 . . '. 0 ____
5 gnat ,:.. - Telephone
9_ Repistered Home Imorovempnt Contractor: Not Applicable 0
,-e'i j /! 7
a 'psny. amp —� �h rs
Registration Number
'cJ -:i ` i .r "�i../ ,-- ''i rt // 2/
Address r ,c, Ekpiroti rtrDate
Telephone ` �r' n 2 4' 02_
t.
SECTION 10- WORKERS' C O 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 wilt result
in the denial of the Issuance of the building permit,
Signed Affidavit Attached YES No,,,,,, 0 .
H. Home Owner Exem t ,>n
The current exemption for "homeowners" was extended 16 isyctudo Owner - occupied Dwellings done (I) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided ru jJte owner nets
as Nop 78 k ervikor. CMR Sixth Edition Section IttB 3.S.1.
Definition rrr Boll uvner; Person (s) who own a parcel of land on which he/she resides or intends to r❑sidc, on which that
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
struelints, A c . s∎! _tixhn cnnstruet!c more dm nn home in a tw n- ventperind shalt not be cnttaidercrl a hotnenwner,
Such "homeowner" shall submit to the ['wilding Official, on a form acceptable to the Building Official, that helstte sham be
responsible for all such work perforated under the huitdinupermit.
As acting Cnnsrtructign Supervisor your pr❑seace on the job site will be required from time to time, during and upon
completion of the work for which this permit in issued,
Also be advised that with reference to Chapter 152 (Worker:' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resetting in Death) of the Massachusetts General Laws Annotated, you m. +v he liAle 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
Northampton Ordinances, State and Local Zoning laws and State of Massachusetts Gencril Laws Annotated,
Homeowner Signature,. __ _
,or,-
SECTION 8 - CONSTRUCTION SERVICES •
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9, Re4is "teroi Ham triiprovetiient= CorittiaaiiCarMEW iiIrtgaZdall:Z;;„;:, Not A licable ❑
Company Name Registration Number
Address Expiration Date
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 ❑
tlivr,lionittuvillerintlmon
The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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 buildine 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 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
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House D Addition ❑ Replacement Windows Alteration(s) E Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks 1C 1 Siding [D] Other [D]
Brief Deb ption of Proposed
Work: vi QNO 79ptACL, QC CwFIl\ih. MC) s- Tx?L}rTt)'( t ,C°;a- !A \'K\F_
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa If. ' ae: a ftt lr ' sffifr i aiiiiie e he clitaiith
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, �(1! -kN) E.)-k , as Owner of the subject
property
hereby authorize LOWE.'S k~1Cfn€ CENTEa INC.
to act on my behalf, in all matters relative to work authorized by this building permit application.
>f Cc m -r 1 2. (`X/ .
Signature of Owner Date
I, 1INOSF 7iE11v1f3('r , 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 penalties of perjury.
NI 0111.....i 4 j
Print Nam/ /
Aid , .,/.! A 1 / 2 . 11/
tur of Owner!' gent 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: R: L: R:
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
( volume & Location)
A. Hasa Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW 0 YES Q
IF YES enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for 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.
Department use only
City of Northampton Status of Perm
Building Department Curb Cut /Drive ay P- e G88 \'ED
212 Main Street Sewer /Septic A ails( ility
Room 100 Water/Well Av.0 labil y t, " 1 III
Northampton, MA 01060 Two Sets of Str ctur.1 Plans III
phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans ;. , , INSPECTIONS
Other Specify 14°R" Et0N.IYMAO1oso
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
'y N N LL``'%' jT Map Lot Unit
+ O 1-4MPIWTC1 fJ 0 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
SC CUTC).fn\e-k R= i N S NO_ , a2r_C v,MR c
Name (Print) Current Mailing Address:
,C1(r,
�7F CO - t - r - .ci:° Telephone
Signature
2.2 Authorized Agent:
IrSE`( ZiEMe R 2 L jZ YS ,`5T. 4 not F4 , Iti1 19 CI G �>
Name %' nt) Current Mailing Address:
.nature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Buildings (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) ` J, 2_F Check Number j
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date