19-007 301 DAMON RD BP- 2012 -0590
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 19 - 007 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 -0590
Project # JS- 2012- 001007
Est. Cost: $1938.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 99209
Lot Size(sq. ft.): 8319.96 Owner: LUCIA MICHAEL
Zoning: URA(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 301 DAMON RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers
Compensation
WORCESTERMA01607 ISSUED ON:12/20/2011 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 12/20/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
RECEIVED city of N rtnamptoi� ? i wR ��PPe n
Building Department - �i �L �� ... T '
" O f '' ', ' 9" t.
212 Main Street M,t ,� ` j
DEC 1 9 2011 Room 100 ,����, $ ' L ,�
�r orthampton, MA 0 1060 I k : , u E -„, j '.-1.'•-'- -1I �r t
nromHAMp ' ,t. e 3- 587 -1240 Fax 413 - 587 -1272 ° � ' a
tirn oroso' _ .
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APPLICATION TO CONSTRUCT, ALTER, REPAIR, REN OVATE OR D ONE OR TWO FAMILY DWELLING
man
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1.1 Property Address: _ (,
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2.1 Owner of Record: 9 �
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Name (Print) Current Mailing Addres
e.e_ CcoteEt— d �/
Telep hone �1
Signature
2.2 Authorized ;,• t:
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Name (Prin �/ / Current Aai!!ng A— :Idress:
Telephone
Signature
ECf tN � STIIGIA�E1� ?CONSTftt7_ ` ��
Item _ Estimated Cost (Dollars to be r � 1 � cra I ,P` `
completed
by ermit a licant '' Iryr r� t ,' ; ,F,y;'
P Y P PP s _ ,
1. Buildin m �� dAf0., - " i „ � Rh, � -- . .�. � ' :
2. Electrical ` . stla e. ',.t° "° , 4" q av `
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4. Mechanical (HVAC) _ a -, `, x ' ^lx P " '' -,',4_. •
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5. Fire Protection 7 r,TM'i �> k 12y r 'r � f ' , - �.� � af
6' Total (1 + 2 + 3 + 4 + 5) l U ` Q � x ", a ' t s
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•
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Section 4. ZONING. Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by'Loning
This column to be filled in by
Building Department
Lot Size I 1 I I
Frontage
1 1i, 1 . I
Setbacks Front 1 I { _
Side L:1 1 R: 1 L:= R:1 1 1111
Rear 1 1 1 1 1 1
:: Buildin Hei r ,1:..,:.. I _ : - ------- . ( 1 1 1
Bldg. Square Footage
- .. _ Oiien SpaceFootage — /o
(Lot area minus bldg & paved l 1 1 1 1 I 1 1
parkin
# of Parking Spaces 1 1 I. _ 1 1
Fill: , I
(volume & Location) 1
•
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 Q YES
IF YES: enter Book • Pagel i 1 ' and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
- - IF_YES,_has a: permit been ,. or_need to;be_obtained. from the Conservation Commission?
Needs to be obtained ~' Q Obtained Q , Date Issued:
Y
C Do an signs exist on the property? YES 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 a 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 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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.SEtw'FtOT �ESCRIPTIDNtQ P ROPQSED WQRI checlgalt i ofica a le l _ ,4 £
.mot , - f 0" ..,. c
New House ❑ Addition ❑ Replacement Wi • • ows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [0]
Brief Description of Proposed 1��
Work: "t' J 1 i t QPki 1 1 0 � 1 � 1 1 V A l ^ D C 0 � 1 \ .4
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
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.� � I,Q � F�' EX1 "a 6?#s Q f t �. am bC - a s a � �"o`.';� .' '
-. � V ® . c _. 7 ®. ;GAO a oa �. "' •i I
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
h-E 1 4 'I ¢51A 'N "e MHO ^ _ JE"a7 9 °) 1-4'1 ' : w � ' ° a l •
Z E Pi . k®� J'�- .y®r ' Y 1111 am
I, rT , 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.
Signature of Owner Date
______
I E as Owner /Authorized
Agent hereby declare tha the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief. • _ _ and pe • perjury. -
'OA T!./
Print Name / SY J
ea t Signature of! er / Agent Date - I
M �+ •
x�aae., G ,.
8.1 Licensed Construction Su • ervisor: Not Applicable ❑
Name of License Holder : , . IA II J 9e /
License Number
dab. 1 f
/�.... l C r,• /. '0 11)11/1_,,„
Addre . / Expiration Date
'
�,
Sign- Telephone
Gs, • *IsteSeclitionMr. Warne, .n._ e r '�w ���.± '.� , 'kr r Not Applicable ❑
n
Company Name Registration Number
Z�'a . a�. .ri )�-
_ - Address i - Expiration Date
g1 / +) i 1 I elephone 1 .2k
•
j Cr JO a .'OR ER � MP NS ONdNSU13AN , FF1DA Nf ; 52,
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Workers Compensation Insurance affidavit m be completed and submitted' with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buidin ermit.
• "`Signed Affidavit Attached Yes No ❑
•
The current exemption for "homeowners" was extended to include 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 108.33.1.
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 faun
structures. A person who constructs more than one home in `a two -year period shall not be considered a homeowner.
Such "homeowner" Building Official; un 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 reference t i C6apter=l'S2- (Woiiikers' 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 tl is permit:
The undersigned "homeowner" certifies and assumes responsibility for cornkliance with. the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and - State of 1V Massachusetts Laws Annotated
Homeowner Signature
&ik The Commonwealth of Massachusetts
Department of Industrial Accidents
11 , ,....= .. . r .,- ,...,„.....„ 0
Office of Investigations
- '-7:-.Sit___=- -- --, • - ,
- IS..."47.1.- - • 600 Washington Street 4.
Boston; MA 02111
-t ---- :
ww
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): c lVI . - t \ f3 i /1 t-T ' ______
Address: atOqo r
City/State/Zip: i
Mill _. • • A ... /OP /Phone #: q DO
Are yo . n employer? Check the appropriate box: . • Type of project (required):
1. ro I am a employer with 6,2,,...) 4. 0 I am a general contractor and I
6. ID New onstruction
employees (fullan part-time).* ------ h
_
2. I am a soleproprietor or partner- - listed on the attached sheet.- 7. 0 Remodeling
— — - ship and haire - - - - These - 8. 0 Demolition
working for me in any capacity. employees and have workers'
9. 0 Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
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
12.0 Ro epairs
insurance required.] t c. 152, § 1(4), and we have ne 13 oth 1
employees4No workers' • er LA i v VLJ.Y
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' C011:i3. policy number.
lain an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
.information.
Insurance Company Name: - - V) C.------
tiAVIrl0/ ) re—(X16 6)
Policy # or Self-ins. Lic. #: (C 0 71 Expiration Date:. .......
--Job Site Address: -r ?" 3 3nk - D 4 v)4 r)t.,V CitylStatelzip: i, ) „ i Si rk 4
Attach a copy of the workers' compensation policy declaration page (showing the policy number and up' . tion date).
Failure to secure coverage as require(' 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 fine
of up to $250.00 a day -. : • , st the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of ji tAr insuranc - overage verification. • . .
,
1-d _
hereby ce - ii. under :. i ' d P e ‘ !ties ofperjury that the information provided above is true and correct
Date:
Phone #: n 4
— —0.1 ciatuse only. Do-notwrite-in -fit is-area,-to-be completed by ciOtortown-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 #:
„,,,,.......
City of Northampton
...,,,,
4gt,4-A massachu '
setts
. Ow aari' 1
f.t '
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 "Hon”, " F'erson(s) who owns a parcel on which
hest residewor intends 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 want any 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
process 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 ins • ection if re • uired ' and a final buildin • ins • ection.
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
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 conjunction to the building
permit issued, 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 .
—___ understand the above.
(Horne owner /resident's signature requesting exemption)
1 will call to schedule all required building inspections necessary for the building permit issued to me.
— - _
, - Address of work location
HOME' IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold, Furnished and Luualtai by:
�Npri m Bottom Date: TIC Pct- Itortae Set oio�, Inc.
t1 �l
Obit The Home Depot At -Horne Services
345A Greenwood Street, Unit 2, Worcester, MA 01607
Toll Pao (800) 657 -5182; Fax (508) 756 - 8823
Branch Number: 31 Federal ID 4175 ME Lac # C 02439; RI Cont. Licit 14427
Installation
CT Lc # NMC. 522; *(one Improvement Contractor Reg. # 126893
InstallationAddresm .,e b
City t . .tt Zip
Pnrchaser(sh _ Want P1w_ae: Hume Phone! Ceti Phone:
I l e hae.� Lae L4 [ 1 C ] [
[ 1 [ 156t -'( .i1 C 1
House Address:
Of different from Installation Address) City State Zip
. E - mail Address (to receive project communications and Home Depot updates):
01 DO NOT wish to receive any marketing entails from The Home Depot
Project Inforrnatton• Undersigned ( "Customer "), the owners of the property located at the shove installation address, agrees to buy.
and THD At -Home ervices, Inc. Mb, home Depot ") agrees to furnish, deliver and arrange for the installation ( "Installation ") of
all materials described on the below and on the referenced Spec Shect(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 "):
Jab#: t+..w a+..st Stem Sheet(s) #: Project Amount
•
DRoofiag Midi ,�•■•: ` indoors 0insulation
5rtt770410 Mutters / Coven []Entry Deem Q 4 1 tACA2 (qa 1-2.0
QRoofug [lading 0 Windows Cl insulation
Llcrutass I corers °llaoy Dogs ❑
❑Roofigg )_(siding 0 Windows 0 inndation _
DGmters I' Covers afiatry Doom f7 �y �
■a:. • • ti Windows ■ insulation $ -/► ht.
Ooimers / Covers Quarry Doom n
- ` Mfaim aa2 oDem* reCeoaact
Total Contract Amount $ � Q
Maim Parduae= may nut deposit MiroWr l theCaoasdAmuse.
Customer agrees that, immediately upon completion of the work for each Product, Customer will execute a Completion Certificate
(one for each Product as defined by an individual Spec Suet) and pay any balance dui As applicable. each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depot reserves dhe right to issue a Change Order or terminate this Contract or any individual Product(a) included herein. nu
its discretion, if The Horne Depot or its alithor'sned service provider determines that it cannot perform its obligations dne to a structural
problem with the home, envi oImiental hazards such as mold. asbestos or lead paint. otter safety concerns. pricing errors or because
work required to complete the job was not included in the Contract.
Ratan t Sua weave.! The Payment Summary & 4 i ✓ G J . included as part of this Contract, sus forth the total
Contact arnoalnt arad payments required for the deposits and final payments by Product (as applicable).
You are entitled to a completely filled-in copy at the Contract et the time you sign. Do not size a Completing' Certificate (nate:
that is are Catnpledom Certificate for each listed Product as defined by individual Spec Sheers) before work on that Product
is complete.
In the event of termination of this Contract, Custouter agrees to pay 'Ilse ]Marne Depot the costs or stater fats, labor, expanses
and services provided by The Home Depot or Authorized Service Provider through the date of terminations, phis any other
amounts net forth in tido Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM TTIE D1O,SIr PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIlNft4NG THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OP SUCH AMOUNTS.
Accentance and Aotheeimatan: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Products and loatailation services and supersedes all prior discussions and wee-menu, either
oral or written, relating to said Products and Iauallatioa. This Agreement cannot be assigned or amended except by a writing signed
by Customer and The Home Depot Cnsaamar acknowledges and agrees that Customer has read, undelxtnnds, voluntarily accepts the
terms of and has received a copy of this Agreement,
A ( Subtadtted by:
's Sigaehnre Date l°1161" Sales Consultant's Sigoathue Date
X Telephone No.
Customer's Signature Date Seim CorsWtam License No_
CANCELLATION: CUSTOMER MAY CANCEL THIS (err applicable)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON TTIE THIRD BUSINESS
DAY ARTIER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE Ill ONE IS
SPECIFIC.AILY PRESCRIRED BY LAW ' IN
CUSTOMER'S STATE.
NOTICE: ADDMONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE Stun AND ARE PART OF THIS CONTRACT
—
07.13-11 C-SC White — (Ranch Rio Mow — Customer