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22D-044 �i.u�,lCilu�Ctt� - Dcl?artrncnt of Public •af7;t■ Bnar l nt Bui Retnulatinn. and >tantlar(1 Construction Supervisor Specialty License License: CS SL 99209 Restricted to: WS VLADIMIR SHEVCHUK • 5 OGDEN STREET CHICOPEE, MA 01013 Expiration: 10/12/2011 99 ■,711■li�-i nt`i' - : 99209 • p,,,.,��, ,y�,y : Boaters pater y �. y y{, 1 .: soi Art ;md@?Ynnat_e4 �0.4 . :: Branch NqM/{• $etrtr/a Ilra 1 ':1C3 f.. ... a�/�W Inc •,. .. :. • :`''', V .'. l rviC` t�a 'T1�.'E�ppgid - ? * War 17 Psx (5,81.756 -852 Branch Number 31 : r tS $6. b i ' -1+ `'#" $4:c:0u 16427 . . C Goo t °a' !Y'125$91 . • j oie Address, � ,: +.rt 1 • .?F t ' , { . 0 t ! 1�, �. p Cit �' { ` i Pa rehaeertul; Woeit P6w�e; tilenie C� . [ . (If different Installation Address) . : qty h E4'* Address (to receive pr+o}etr co mnunicati e t'updet4�fi' D I DO. NOT'wish to receive any marketing email s from llte Been. Depot , ' ' Fero boat: Undersigned ( "Cnstamrr" , •the ownota of '►off et ttic.abov tnstelltit ri ad ress; *nester tiny. andome Services. Inc- ("'Au home )pat") aim t t aad tb`i ; l its f r C ltlnn") of • �aa all materiels described on the below and on the erenecd. Apse S 1(,$)'. elk of ,Wine h' ¢ ; , reference, along with any .applicable Stare Snpp]e onr.and • ,$uinrnary atf#4*.4 1) ° Q :QtdC'fk( 11ecii e1y, 'Contract "): Job* 'tatenernereme • :" - Amaaart °Roofing ['Siding ( r"dnvit.:,111 'ntifenan ` 9 .", e ' E1 l 7 . L7t�sttere /envoi ' Doors d ' ' "' - err ..tin ■siding ■ .ewe fD tena:oriar Otiinaeix / covers ( Bnuy Doors n ' - ' ' cilto QSirgr,8 a.v.rmdows. U•ioenia ' , 1. , ,.: . . aeMntm / CCvcre OEmry DL oer.n' .. i "'`. ,:'...:; r•::::r, G71ag UStding O.wenaaus Qlfnsrilaffiom � y ❑Gutters ! Coverr 013n Dome .n N uutax596Depo tdcpwrotrlAraouat8ae.opbr•em anuC prrr sk' i T40 r t; .*game;' : � bMNnePi salafp'notdeposkruoetdrag ird''ef.dn Custorieer agrees that, imttlsdiat open c tmpletion of t •.: of : :, ' �. ;; ire Ceitifioate' m et l* h s ( one' for each ProdttCt,as det an ��2Rta1 dP" S�r� Pa'Y, a �' x 1`�Ft Cam' S•, tindcr 'this 'Contract agrees; to be j(intly and severally 8liligated atdl tidble '' ' The Iloale Depot reserves, tree right to issue a Change Order or terminate this (ontreet Ay z dwidngl iltgdttat(e included herein, at its discretion, if The Home Depot or its amber: ed se vi . o a ei ms ?I f :. a xe'iirs c{ 5 cur t9 a problem, with the home environmental hazards mo1d P�'}?? tr.+.a .. work renuired to complete the job was not iitoluded in the Coeti'4et -' . ,, , . , ;', ,:. ' ; ' .' . . : Payment' Somnser'v: The Paymeru Summary # • . • : 2,fU aA _ rnckldcd as gart':o£ this CPna sets forth the total Contract amount and payments required for the deposits and fitraVpa7sisents by Prodvei:( 'appl'irable . NOTIC$'tt4;01X TO .. r ,( 11n:i ist+t" C.a�pr You are entitled to a completely tRled. 'op7 M ilte�antrast lit l td tis�ynt Iona' e�°" �YY1>atik�ret there is one Completion rtificate for each listed'?rodncl d ? fmdiiz�Witi1 ,;3 ec�ShlctBi,b u e't ` is cartlplete. .. .. • 1n the ev'eta of termination of this Contract, Customer ag�reeees. to alto per. Ttie.:1000c,D of tlw ' of'n tati�, labor; expenses and services provided by The Home Depot or AathodrAd'S&ice irawiacr" 4t .'d f` af>e'..', ma other Aamounts ad forth iii this AgAgreement ac. wed, fara::• I'�':D+D rAF.T'QT'� 1ViAY WRT �AMOUNTS. OWED 7Q THE HOW DDEPOT FROM THE D � s A'YMEN'T Ott' O R. PA lidENTS M DE, WITTHOUT LIMITING THE HOME DEPOT'S O.Ttruit REMEDI•Es t PIt EECOVERT O! SI*H AMOUNTS: Acceotance Authorization: Customer agrees and understands that thit agreerlrept°is. the' entire , agre meat between Custo� and The Home Depot with regard to the Prodi cts and Installation aetvicet and super s'ali;prier. sctsaaioas, t nd•agrece enta. oral or written, relating to said Products acrd Installation. This' Agreement eanrurt.be'essi er aatcaded"etteept'by a writrug,signed by Customer and The Homo Depot. Customer acknowledges and agrees that Custbmethas read, andttstanda,.vohzntarill' accepts the terms of and bas received a copy of this Sulunitgediri ( - it j i . ' - toner's Si _ , enre Date Sales Consultant's Signature . Telephone No. Custotmer's Signature Date Sales Consultant l icense No: • (ae apptiat:ac) CANCELLATION: CUSTOMER MAY CANCE.LL THIS AGRF"EMF,NT WrnHOI)T PENALTY OR OBUGATIOI4 BY DELIVERING WIRITTEN NOTICE TO THE HOWIE ' • DEPOT BY MIDNIGHT ON THE THIRD BUSINESS . DAY A.'BTER SIGNING THIS AGE. 'THE . STATE SCTPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS ' • SPECIFICALLY PRESCRIBED $Y LAW IN CUSTOMER'S S t'ATE. ' TERMS icrnCB: ADDITIONAL TERM AND CONDITIONS ARts 6T ATITI ON Tax V@RSE ODE AND Au g FAC O7P Mr S CUNTR.4C"t • 11~30 -09 C•SC White — Branch Re Vetaw — Customer .Pleb - t e .t wsultara . 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 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 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 •ermits 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 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 , • , -,. .0. ' . The Commonwealth of Massachusetts ==.= Department of Industrial Accidents Office of Investigations • v , 600 Washington Street -... — •• • =:1: =7 Z Boston, MA 02111 www.mass.gov/dia - Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print L . • *blv Name (Business/Organization/Individual): PIIIIHNIM, Address: , .. b i . 4 A A Alf' 11 111 r2 • City/State/Zip: gaga g A i ' Cur hone.#: - ' ) - , 0 L.6 5 --- r, -- Are yo an employer? Check the appropriate box: Type of project (required): l' 1. a' am a employer with \ no 4. 0 I am a general contractor and I N 6. 0 ew co - 'on employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet 7. 0 Remodeling 2. 0 I am a sole proprietor or partner- ship and have no ;tioyees These sub-contractors have. 8. 0 Demolition ernployees and have workers' . working for me many capacity. 9 013mIclink addition [No workers' co mp. 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 have4xercised their t 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 ":f ' . rep if p insurance required.) t c. 152, §1(4), and we have no employees. [No workers' 13.1Mther comp insurance reclthred-1 *Any applicant-that checks box ttl roust also fill out the section below showing their workers' compensatim policy information. t Homeownera who submit this affidavit inolcating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1 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 camp. policy flambee J an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. ■& \ r . Insurance Company Name : IA (-- —1- Ins (--/-- I\IQL-01 _ 1 - ' ' • Policy # or Self-ins. Lic. #: .., , _ _ Expiration Date: - Job Site Address: ' 7 - y4 0 c- fi Cit Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ... Failure to secure coverage as required Under Sectioii'25A'ofMGL c 152 can lead to the imposition of diming Penalties of a fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WOFIC-ORDE:R. and a fine of up to $25000 a day against .. . violator. Be advised that a copy of this statement may be forwarded to the Office of Ififeitions &the DIA 5 ins ..:; e cov : "i VeqilieitiOn. [do hereby certify under e ,ai.:' Ls 4 , , , ,, 4 ,. - ohm:jury that the information provuletabove . ._, , , .ref . . _ St-i. -tire: Ila N. / 4 .. bate , , (- .. Phone #: ' to 035 - - - ..3r • • Official use only. Do not write In this area, to be completed by city or town official City or Town: Issuing Authority (circle one): ". Permit/License # 1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector 6. Other Contact Person: ' Phone #: I- SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervis r: Not Applicable ❑ r Name of License Holder : V I41 t vyi) � y k' , k Q License Number Address of ` Expiration Da . /" a 1. I ���� Signa ure Telephone &'Resists° 3 ,1io ' _ r . - m _ C p iaac -g fi: li g , at Not Applicable ❑ e ovt t tP Company Name J Registration Numbe c eVl ut)f-it- //L) Address �� Expiration Date o cc A T ' �l �lS E�-' SECTION 10- WORKERS' COMPENSATION IN URANCE AFFIDAVIT (M.G!L. c. 152, § 25C(6)) Workers Compensation Insurance affida ' must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buil g permit. 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 108.3.5.1. 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 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 r • J SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [] Addition ❑ Replacement Win ws Alteration(s) Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [D] Other [D] Brief Description of Proposed - l �/ ` , `tA) t _ a Work: ' � ( `G ` C{ h. YY� th Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet ta IfN� a` and.or diflon tact h a t f # C :folti 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 SECTION la 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 applicatiof Signature of Owner Date 1, i t,4 1 1M11 . , as Owner /Authorized Agent hereby declare th- e statements and information onTi'ei foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pain -Cp•enalties • • &A ' L ,i ( prf? Print Name Signature 7 'g= t Date . , 1 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 1 ! , . Frontage Setbacks Front 1 = s w_ Side L:! - I R:l ! L: ` R: Rear I Building Height i Bldg. Square Footage 1 i Open Space Footage % (Lot area minus bldg &paved I 1 1 I 1 i 1 1 1 i parking) # of Parking Spaces -.._ Fill: ii i $ (volume & Location) I 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:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book 1 i 1 Page 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 Obtained ® , Date Issued: , 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 Q NO Q i IF YES, describe size, type and location: 3 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. e. - p City of Northampton s , ; �i� � E T Building Department � .;' ¢ �` , 212 Main Street s = < e. Room 100 A E t7 : Northampton, MA 01060 _ �} � ' Phone 413 - 587 -1240 Fax 413- 587 -1272 ° > a , - - � .. 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 Map ° Lot . Un 7 R 0 Zone Overlay Distcict E - tm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record- A r 1 Lt� t0 Vl 111 IIii /_ _ 1 ��� ( 4 i, ...4_ ' i ,At Name (Print) (7- Current Mailing Ad ess: A , 4 r7!� Telephone " Signature 2.2 Authorize. • • ent: ----- ' / 1 ...r ` '.�// .1 /.�� Cpl i Name (Pnn, / Current Mailing Address: © f _f�.7 �,A. (- ��J ICJ Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant (a) Building Permit Fee 1. Building �•-1O 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) 560 " Check Number . p This Section For Official Use Only / ,J Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector o Bu Date RYA' i3 BP- 2010 -1117 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON tot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -1117 Project # JS- 2010- 001639 Est. Cost: $5503.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 99209 Lot Size(sq. ft.): 112820.40 Owner: MCLAUGHLIN LIA Zoning: URA(100) //WSP Applicant: HOME DEPOT AT HOME SERVICES AT: 78 RYAN RD Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers Compensation W ORCESTERMA01607 ISSUED ON: 6/9/2010 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 6/9/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo