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24C-187
HOME IMPROVEMENT CONTRACT • PLEASE READ THU Sold, Furnished and Installed by /rjr Nam : Boston Dote: THD At-nome Services, Lie- -V j d/b/a The Home Depot At-Home Services 34-5A Greenwood Street, Unit 2, Worcester, MA 01607 Toll Free (800) 657-5182; Fax (508) 756-8823 Branch Number: 31 Federal W*75,269846% ME Lire C 02439; RI Com. Licit 16427 # HIT:a:no Impnivement con orn.eg. # 126893 butaliation Address: C 1 6 elk ,16t City State Zip Purehaser(s): Work Phone: Home Phont: Celt Phone: 1111,WWWM110. ( 3 Wit '65 I [ 1 { ft D. AddreS3) City State ZIP tr: I DO NOT wifih t=.3 teethe any Marketing eznjl &dm The Home Depot . • , „ form•rrt, InnA 41. stbovit, inStiaRtitlfl, address. arrees to buy. r-ts 1rielo and on The merits:cm pec amsutst. au or W111. ": cant-rites ): _ = M Ifl Li rn,i 1 — 1 6 ) . ; I, 2 ,1 , 1..7;1, Roofmn •Siding 11 windows CI hootadon _14 th}iloCi ; i 10-40160 *Roofing Siding NI Windows 0 Insulation 1 1 Or:ha:eta: Coven 0 1 thstfy Doors 1 1 1 fl CI Insulation — I 1 Maine Purl may not deposit more Unto one.dilrd af tltc Ctrqr2..4-t Au - Th. 1-Zr Test-rstettS the dent to iNsue, Cngs (. Xeli 111 Condact Of any indi'ilclua1 ProdaL it`sloded hertin- thn honie envisionmentel hazards such as - nand. asn O ;04o Povment Sununatot The Pmenteut Sulfunary # C1d an Fan of this Comma sets torth the ;ono there ix one Cnnettietien tnriiiiente for twit listed Product as defined by individual Spec Sheets) before ..ork on that Peocitici. rtrk 4" rostormer ovrees to tot* Lilt Kuoute to.13c.x cr,,r , • -- arrk-rdnis i tfll o to cilia Agr.re_on.,a, e.strvins ter, -role aiii ovotyr ;room 1 rfirfi; 151EP081fT PAYMENT OR crest PAYMENTS MADE. WITHOUT • . - ties, rist ereenetot ts MC- enure ne,reefuniu uctsidicit - " ' ' • rf.o.atinz P121 and ins-hillation. "tins Agre.orkeni. t tlittg-ttuctti ttt:t TrVrps thnt Ctismtmett v;:4 Zt • f ta ' "1-71'1,' aat,n ato CUSIO1Da 1.,44St Sales Consultant License No 64; upplicabitl tvi wart t LC, 'Ult. DEPOT BY MIDNItiki UN firiE e.A A. treqlo 1v.W 'nits ACAF.F.MENT. THE „ a ATP- i 1 07;NTA INS A FOR7-4 TO 1J' 1 •t- T114 CUSTOMER'S STATE. , 0 TIff VF.PS.F. 51m 4Nrs ARE r Parr OF THIS C'ONTIFACT O7-13-11 C-SC White — eranc Fie Y SHOW — tjtAtOrnert , The Co Tirtnonwealth of Mas sa ch Lrse s' 2 ;- Department of Industrial Accidents .� Office of Investigations w= f - , 600 Washington S'teeet . ` = Boston, MA 02111 www. mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leoib! Name ( Business /Organization/Individual): '' i i " A. t Address: cV0 r NA City /State /Zip: jai, , or ® 1 Phone #: . `' DO e - Are yo an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 673 4. 11 I am a general contractor and I _. -- -- _ __.--- . - -._. 6 0 New construction employees (full and/or part-time).* have the sub contractors 2. E I am a sole proprietor or partner - • listed on the attached sheet . .7. ❑ Remodeling _____ - ship and have no employees These sub - contractors h 8. ( Demolition working for me in any capacity. employees and have workers' . 9. n Building addition [No workers' comp. insurance, comp. insurance.x required.] 5. Q 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. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.V er f repairs insurance required.] t c. 152, §1(4), and we have no n � , 13. v i j employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fit 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 outs ;d:. contractors must submit a new affidavit indicating such. IContractors 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 w orkers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ITV) 'w7 :i'% ) Pe g Policy # or Self -ins. Lic. #: C)1q(5-09- Expiration Date: Job Site Address: - -- - 1 11 Ci ty/State /Zip: i aau1, il /I s i I—L_A Attach a copy of the workers' compensation policy declaration page (sho the policy number and expi ation 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 fine of up to $250.00 a day - :. inst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of th r msuranc - overage verification. 1 d hereby c k under t . 'd Pe . , hies of perjury that the information provided above is true and correct.. Sig a . / . Date: Phone #: q 5 -- - Official -use only.- Do not write-in-this 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 #: _SEC -TION 8 C NSTROCT1 ©N SERVICES s • 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 5t tint) 90kii-At ,e4/.c.fi License Number r) 43) K 4 (2 5 1 pari Addres Expiration Date A /Q it Signatu Telephone ;g. e•as dY oiz�etlm.coverne 'COrtractcir; VeMi lifer "'. k ' ; ,WEF WI .1= Not Applicable ❑ Company Name Registration Number Address h _ - , Expiration Date � l : . a� .�. 1 1I elephone _E T3QN1fl WOF31<ps COMPENSATIOKlA1SURANCE ,AFFIDAS:(MGL a'5_2,§R sT 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 buildin ermit. Signed Affidavit Attached Yes No 0 1 .om :one: e1io 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 108.3.5.1. 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 two -year period shall not be considered a homeowner. Such " homeowner" shall submittorthe 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 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 onsibihty for with the State Building Code, City of • � P 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 ❑ Addition ❑ Replacement Wi ows Alteration(s) ❑ Roofing n Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E ] Siding [0] Other [0] Brief Description of etopesckf - Work: ( ( 60,2-par t��tc' l ` )D Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition toe ting housing, complete the following: 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 stones? 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 , 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 [ , as Owner /Authorized Agent hereby declare that t e statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and �. es of : - • • v. - Print Name IP I - Signature of Owner /Agent Date 213 CRESCENT ST BP- 2012 -0678 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24C - 187 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-2012-0678 Project # JS- 2012 - 001169 Est. Cost: $4959.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 048697 Lot Size(sq. ft.): 13460.04 Owner: SINGH INDERJIT Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 213 CRESCENT ST Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers Compensation WORCESTERMA01607 ISSUED ON:1/26/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 10 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 1/26/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck— Building Commissioner