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29-531 HUMVME 11V11 V L+'1VMLIN 1 UU]vt 11AAt 'l PLEASE READ THIS Sold, P'tlrnisbed and Installed by: Branch Name: Boston Date: 9 1' °Q TAD At -Home Services; Inc. dlb /a The Home Depot x'At- Homc:•Services • 345A Oreonwovd.Street; Quit'Z, Wuri.iester, MA 01607 Branch Number: 31 T'o11,free (800),657- 5182; Pax (508) 756 -8823 Federal :tb # 73- 2098'46C; M t-tc # C ()Z439; 1tt Cunr. i:ic# 16427 / ; �� Lie # 565522; MA Fioinc Improveriiant Contractor Reg. # 126893 Installation Address: 2_ (p 4 I° i P1 �4C4 M flflr 1 'A . 4'0 0 ( City State -Zip 1'urchascr(s): Work Phone: Hbme Phone: Cell Phone: tit i r , r e 1 . ; . � [ ] [ ' f [ 1. [ t J5 4423.[ • } Hoare Add.. :If different, from Installation Address) City State Zip E - mail Address (to receive project communications and Home Depot updates): 1 DO NOT with to receive any marketing entails from The Home Depot ?toted Information; 'Undersigned ( "Customer "), the owners of the jjropert located at the above. installation address; agrees to buy, tad THD At-Home Services, Ino. ( "The Rome Depot") agrees to furnish, deliver and arcarigo feir'tkte iristallytion ( "Iottatlat800 ") of 111 materials described on the below and on. the referenced Spec Sheet(s). all of which are incorporated into this Contract by .this efercnco, along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders. ( collectively, `Contrast" ): fob #: pneneeneterowi P rai d ne t s: Spec Sheets) #: Project Ainnunt ❑goefiirg U$idiag t'Wiedowx Insulation ' ❑Gutters I Covers ©E.ntry Doors ❑ - ..... 71 t ,,» .0. $ ( $ ct r DR.00fing dSidin 0 Windows ❑ Insulation. ❑Gutters / Covers C Eutty'Doors ❑ ---- . • g • [Mooting ['Siding 0 Windows 0 Insulation , painters I Corers DEntry Doors ❑. ...___ - ❑ oo fi ng Sidin g Wincloew8 Inselsti0a []Gutters !Coven Entry Doors ❑ — $ • Minimum 25% Deposit of Contract Amount due upon execution of this contract: Total Contract A $ �( Marne. Purchasers may not deposit more than ono of the Contract Amount, :;.ustotncr agrccs that, immediately upon .00mpletion of the' work for oach Produot, Ctistorper 4x11 execute e Cot Certificate One for each Product as defined by an individual Spec Sheet) and pay any balance dire As fip each Customer under this Iontraet agrccs to be jointly and severally obligated and liable hereunder. • fhe .Home Depot reserves the right to issue a Change Order or terminate this Contract or any indivittue1 ■Prodnci(9) inCliyded heroin, at is discretion, if The 1 Depot or its 3uthonzcd provider determines: that it cannot perform its obligations' due to a structural ?robicm with cho home, erauOrunental hasards woks as mold, asbestos or toad paint, other safety 0o11,cern3, pricing errors or 'because vork required to complete the job was not included in the Contract. ?avment Summary: The Payment Summary # 2 J ' , included as pars of this Coiiryact, sets tort the total 'ontruct amount and payments required for the deposits and final payments by Product (as applicable), _NOTICE' TO CIISTOMEti t'ou are entitled to 6 completely tilled -in copy of the Contract at the time you sign.' Do 'not sigsl a Contpletdon Certificate (note: here is one Completion Certificate for each listed Product as defined by lndividitat Spec $hects)'before work on that Product s complete. n the event of tertninatiou of this Contract, C:usromer agrees to pay The fIomt pqact the co$tx of materials, labor, expenses end services provided by The Home Depot or Authorised Service Provider through the date of termination, plus any other (mounts set forth in this At!rectnent or allowed under applicable law. T.fL HOME DEI?O' a AV WIT'tilIOLI) AMOUNTS )WED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OT•I'AEIR ?ANTS MADE,. WITHOUT MITI C TIIE ITOME DEPOT'S OTHER R.F.MEDIES FOR RECOVERY OF SUCH AMOUNTS. Icceptance and Authorization: Customer agrees and understands that this Agrreetnent is the entirc agreement between Customer ,nd The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements, either iral or written, relating to said Products and Installation. This Agreement cannot be assigned or smendcd except by a writing. signed 15, Customer and Thn Home Depot. Customer acknowledges and agrees that Customer has read, understands, voluntarily accepts the arms 'and has received a copy of this Agreement, �;'� �q, .' Submitted by : x 411 Ill) 4 �y 9 ( /0. ,comer's Signature Dare Sales Consultant's ignaturc Date Telephone No :ustomer's Signature Date Sales Consultant License No . ;. A;VCELLATION: CUSTOMER MAY CANCEL THIS ias airplicable> kGI2EEMENT WITHOUT rENALTY OR OBLIGATION • 3 DELIVERING WRITTEN NOTICE TO THE HOME )EPO1 E) MfDNMGk11 Oti '1'BJ 'VI BUSINESS )AY AFTER SIGNING THIS AGREEMENT, THE STATE SUPPLEMENT ATTACHED HERETO :7ONT,AINS A FORM TO IJSE IF ONE IS 3PECW1CALLV PftESCR 13'Y LAW IN "CUSTOMER'S STATE. NOTICE: ADDITIONAL TERMS AND CONDITIONS Ara STATED ON THE NI.VERSB SIDE AND ARE 1'AIIT Or rills CONT'RAC ' -45 -09 C -SC white– BranchFlle Yellow – Customer Pink - Selea Consultant e ff o' t otoneia et c * Bo i of Building 1�egtiiation and Standards Construction Supervisor License k i License: CS 67121 It Expiration: 4/30/2010 Tr# 20346 Restriction: 00 BRIAI:; C THOMPSON 6 CAMPUS VIEW RD �'/-'- -� MONTGOMERY, MA 01085 Commissioner ✓fe 65,?toZfineisecdd o ,'17frrJJadiadeLa `. Board of Building Regulations and Standards P-- HOME IMPROVEMENT CONTRACTOR Registration: 150438 Y Expiration: 3/30/2010 Tr# 262894 Type: Ltd Liability Corpor AMERICAN WINDOW SYSTEMS LLC BRIAN THOMPSON 6 CAMPUS VIEW ROAD MONTGOMERY, MA 01085 Administrator < 7te Co ttmo.zwealsn YI ofMassa'.uss'ts ` 'Per :731m en` of / t dustrial A CCide .,ItS 1 aine (B usincss /Organization/lndividuai): i r t. Address: ( -- City /State /Zip: O e ` % � D ,',a Phone 0 ( � 5/ Are yo an employer? Check the appropriate box: • . Type of project (required):, 1. kzJI am a employer with 100 4 . [ T am a general contractor and I employees (full and /or part- time)_* have hired the sub- contractors 6. 0 New construction 2.1 1 I am a 'sole proprietor or partner- listed on the' attached sheet. 7. [] Remodeling . .ship and have no employees These sub - contractors have 8. 0 Demolition for me in any capacity. employees and have workers' working Y F ty. 9. 0 Building addition (No.workers' comp. insurance comp. insurance.$ required.] • • 5_ [ • We area corporation and its 10.0 Electrical repairs or additions 3.1.1 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.E Ro airs insurance required.] t _ c. 152, § 1(4), and we have no employees. [No workers' 13. Other 'fig comp. insurance required.] `Any applicant that checks box #1 must also fill out the section below showing thcir workers' compensation policy information. Homeowners who submit this affidavit indicating they arc doing all work and than hire outside contractors must submit a new affidavit indicating such. tContractors 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 subcontractors have employees, they must provide their workers' comp. policy number. • . • 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. ,.._—___^ Insurance Company Name: 1..• ' !I aI Gig ' _ U Policy # or Self-ins. Lic. # : Li-, ! j Expiration Date: h? Job Site Address: .0� C;c L-1_.-- City /State /Zip: :p ..� _ a Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration 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 $:1,50.0.00 and/or one -year imprisonment —a :. :. - , • : . _ e • • e • •_•-!: : o f up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. . • • I do hereby certi un..•r e p• S an. penalties ofperjury that the information provided above is true and correct. Signature: Site r :. /A 1 • Date: ) 1 '1 _ f Phone #: •Official use only_ Do not write in this area, to be completed by city or to 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 n PILO ne #: . 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 ' • 1 lit- ' • • - 'ow - -- • -s that the.buildin. de • artment 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- in -conj unction- 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. Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Wig ? Office of Investigations _ r - � l = 600 Washington Street ii. =� Boston, MA 02111 www.mass gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /ElectriciansfPIumbers Applicant Information Please Print Legibly Name ( Business /Orgniration/Individual): Address: . City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): / 1. ❑ I am a employer er with - 4.. fl I am a general contractor and I 6. ❑ New construction employees (full and/or part- time).* have hired the sub- contractors listed on the attached sheet. 7. ❑ 2. ❑ I am a sole proprietor or partner- Remodelin g ship a nd have no em These sub - contractors have. S. 0 Deiaolon for me in any aci employees and have workers' working > y ty. 9. D Building addition [No workers' comp. insurance cow. nlstzrance_$ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. I am a homeowner -deieg all-work- - cers have xercised their — 1-1.0 Plumbing repairs or additions myself. [No workers' CO mp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other 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' comp. policy number. . I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site formation Insurance Company Name: Policy # or Self-ins. Lic. #: Expiration Date: Job Site Address: City /State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration 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 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 again ttie:violatoor. Fie advised that a copy of this statement may be forwarded to the OfRon of Investigations of the DIA for insurance coverage verification. I do herei_y certify under the pains and penal: ps of perjury that the informa#ion provided _above -is_true_arzacorrect.___ _ - Signature: Date; Phone #: Official use only. Do not write in this area, to be complefad by city town official City or Town: Permit/License #__ Issuing Authority (circle one): -1. Boa -rd of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 1 I/1 l - V 1 4'n f 6(DY1 10 1 License Number • r, to Address rergimmase E xpiration Date Signatu — Telephone 9. Registered Home Improvement Co tractor ..f '; Not Applicable 0 Company Name Registration Num �� Address c Expiration Date CeZ)1L-,1 in — C�trC 1 (C�U2 Telephone L k ) ) / '5 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 it. Signed Affidavit Attached Yes No ❑ I Rea The_current_exemption for "homeowners " w 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, ui is intended to lie, a one or two family dwelling, attached or detached structures accessory to such iise 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 Ur to ces; to a • + _ • w , - , • -rai= Taws- Annotated. Homeowner Signature 9 R ire J 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 [0] Decks [C] Siding [0] Other [0] Brief Description of Proposed . --" Work: _ y_ ` "i j,J1 , k L.` c Alteration of existing bedroom Yes No Adding new bedroom Yes No i Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a; If.Neiii and40i,additibn to sting 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 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? W 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 C- �'� c I, E ' ( )r'l e- , 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 % ` q L ?�,,, as Owner /Authorized Agent hereby declare that th statem8n s and i on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains, =u. penalt'-s of erj ry. Alf `t .i ce AN 4 Print Nam- /� Ira . � A Signatur_ of 0 er"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:—_. R:m_ _ 2 L: R . _ ._. _.. _. Rear Building Height Bldg. Square Footage % Open Space Footage (Lot area minus bldg & paved �, __ parking) # of Parking Spaces • ........... Fill: ��. �e�..__..�� S (volume & Location) ..-._ A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES IF YES, date issued:, i IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book 1 Pagel i and /or Document # L. B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW a YES 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: -------- - - 11 v` - Fe "`t ie e any propose• c anges o or a • • itions o signs mte naed for the property ? YES 0 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. ' f 4 � A D'et rtr ,114i�se�x5nly 1 City of Northampton � s'`Partxtt l ~ Building Department Ci d im way * i t U 12 Main Street Se r e. toArOglltty P w 'T 411 ' z k Room 100 „ �5 r i r � (Northampton, MA 01060 . � ltd �?ian e )phone 413- 587 -1240 Fax 413- 587 -1272 Pt a :>z� s k fl 4 y /r f ,F, 3- �4 1 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 Unit '"7 `'' � �. 1 7 11 Z on e Overlay District �< Elm St District GB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record:,,,, ="[ f Name (Print) Current Mailing Addre �- Dee r iZ Telephone �C Signature 2.2 Authorized Age • , " _ MA L? 11 -/ t 1 :O(C faf Name (Print) r s Current Mailing Address: 1_, Ci f 1 40 1 C-7 ,3-- Signature Telephone SECTION 3 STIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Onty completed by permit applicant 1. Building i (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) i a q---` Check Number c l �y ?9 / , 'C This Section ici Far Offl Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date • UAW' ,<LI BP- 2010 -0502 Gls : COMMONWEALTH OF MASSACHUSETTS 29 53i" ` CITY OF NORTHAMPTON Lot: -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 -0502 Proiect € JS- 2010 - 000691 Est. Cost: $1384.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: use Group: HOME DEPOT AT HOME SERVICES 67121 Lot Size(sq. ft.): 10105.92 Owner: ASHTON THOMAS L & ELEANOR C/O DRYADS GREEN GALLERY Zoning: URA(100) / /WSP Applicant: HOME DEPOT AT HOME SERVICES AT: 26 GREGORY LN Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 0 Workers Compensation WORCESTERMA01607 ISSUED ON:11/4/2009 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 11/4/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo ��a" t., iv • u4 . .. X0 84201637 FREDERICKS INSURANCE ta002/002 CCPRif CERTIFICATE OF LIABILITY INSURANCE 1 , HIM CElRTWICATE IS ISSUED AS A MATTER OF iNFORMAATiON ONLY AND COVERS NO RIGHTS UPON THE .CERTERCATE HOLDER. THiS ERTIFtCATE DOES NOT AFFIRMATIVELY OR NEGATIVELY MONO, WATERS OR ALTER THE COVERAGE AFFORDED BY THE POLICIES low THIS CCRTWICATE OP INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE 1$$UINO INGLIRER(S), AUTHORIZED L DENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. MPORTANT; If the cartlacat. MStfor'ls an ADDmONAL INSURED, the poSny(ies) taunt ha endorsed. W SUBROGATION IS WAND, eu*ct to he Patin and conllUans 4E0 pWky, ceit yin policies may require en endarsement. A stMselerre on this cediticste does not aaMer rights to the .eiNfente holder in der of seal _ . , DDUC6R '' ' !'REDERICKS INSURANCE AGENCY I C ,,,. it. x (5O�)42B-899 n or (5Oa) 420 -1637 ?co Box 427 �; i .J k )sterville, MA 02655 R - --- - ---... _______ INIKIIIIERtin Anr=oeorue ccroenAce _ _ _ ►wacay - SwftED Ronald J. Dick 1 _ easuftgn A: MES'1'ERN WORLD INS. CO. ___ P0 Box 4002" ` ' ' " " _ INSURER ns :_ — --, i shfield, NA 01330 INSURER 0 - _ I INSURER 0 INSIt%R E c ;.RF: *VERAGES CERTIFICATE NUMBER' REVISION NUMBER THiS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LUSTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POIJ Y INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT Olt OTHER OOCUPAENT WITH RESPECT TO WINCH THiS CERTIFICATE MAY BE OWED OR MAY PERTAW4, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN iS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND COMMONS OF SUCH POUCIE8_ LMIMTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- . TYPE of i3121111APiI;E P' NUMBER ,i.4, ate, ' l GENERAL uAnLrrr EACH 0G0I1RRENCE s 1, #00100. WI COMMERCIAL GiSNERAL LIABILITY pRs t_E, o o.I 50,000 cAnismAnE LIE] OCCUR M ED EXP (Any antst ) s . � 5 000 A 1111 NPP1265572 $ /12 /2010 4/12 / ADVINJURY 1 l AMU , — ` GENERAL AGGREGATE s -71 ; 000 , 000 GEM. AGGREGATE 'p LI3IIIT APPLIES PER: mowers • coIwio Am : 1 f 0-6 07 -6615— FoucY 4 ■ : WAILi7Y COMBNEA 6MHLOX LIMIT s (Es eccieeml} ANYAUT0 ALL OWNED AUTO$ BODILY INJURY (Per person) $ II _ ___, DULED AUTOS scaly wow (Per - " PROPERTY Daunt* $ r HIRED AUTOS (Per accident) 1 _ . —� MMOWO>NMED AUTOS _ —._._ — _ _ $ �_ 4 IN UMBRpLLA use OccuR EACH OCCURRENCE 3 im c$9 11A • CI.AA1$WM ADE AGGREGATE a _ _ DEDUCTIBLE $ a N ,-a r: ,._ �t` ors al s ea—_ AND EARPLOYfiRS LAWN 'u MY NE Y -j 141A 6.L. EACH ACCIDENT $ OPFICERIMEMBER r is elsia a+ar► t { _ EL. DISEA6E - EAVISPLOTEf $ Q C° ' OPERATION$ bolo' _ , El.. DiseAS Y UM$T S —_ , - J 1 OE$0RPRO$ OF OPERATIONS / LOCATIONS f VF.HiCL S (A$aoh ACORD 101, Matte** Remarks Dolockde. M marl w. e= va raq+i var Carpentry - residential - not exceeding three stories. CERTIFICATE HOLQER CANCELLATO____ „....., —,,, City Of Northampton SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Bi-!ONE Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN 212 Main Street Room 100 ACCORDANCE WITH THE POLICY PROVISIONS Northampton, MA 01060 AlTHORIZEO KEPRF$E$TATJE O FAx 8 1-413-587-1272 4:::t.'"*P1.(1.1.5t,-Cli.g.Cia-loi'CiCii 0 19138 -2OO9 ACORD.GDRPORATION_ RN rights reserved. ACORD25(7009/0B) The ACORD name and logo are registered marks of ACORD Massachusetts - Department of Pubiic Safety Bo {.trd of Construction Building Super Regulations visor License and Standards License: CS 10 2688 Restricted to; 00 RONALD DECK 562 SUBURBAN DRIVE PO BOX ASHFIELD, MA 01330 C _ �� - c Expiration: 3/25 /2013 ('umrnissiuner Tr#: 102688 Bo ard of Building Regulatio a d Standards c a 1 _* .f■ HOME IMPROVEMENT CONTRACTOR rfH Registration; 154344 ExpiratiiOn 212812011 TO 280635 `�` Type tntividual RONALD J. DECK ■ RONALD DECK 562 SUBURBAN DR ' ~' ASHFIELD, MA 01330 ` • Administrator A • 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 iermits 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 Date Address of work location . . • , The Commonwealth of Massachusetts =,,.,— Department of Indusz'rial Accidents . T=.::,...;— 0, Office of Investigations • #0=... T=.- ..t.. =rzlitL:= '41 600 Washington Street Boston, ilL4 02111 www.mass.gov/dia . -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A. i licant Information Please Print Le. *blv Name (BusinesS/Orgazdiation/Indivichino: , _.,-, ( 2 \. .- • - , Address: '5Z07-- I D Q \,0 ,..1., -- 7?,0" - , A.-, ‘...s.I___ .- • t.). 1. i City/State/Zip: Al, & tei, -- 31V Phone.#: 6 2 - - - 3 3 4 r - 4` - t I . Are you an employer? Checkthe appropriate'box: • Type of project (required): 7 1.0 I am a employer with • 0 I am a general contractor and I 6. 0 New construction have hired the sub-contractors employees (full and/or part-time).* 2 I am a sole proprietor or partner- listed on the atta.ched sheet. 7. 0 R.emodeling nd have no. ,aiii These sub-contractors have -8. El Deinolinon . . •a eroplo_yees_and have workers' working for me m any capacity. 9 -Er Build*k Aildition comp.in _ [No workers' 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 havelxercised their . t 11.0 Phimbing repairs or additions • myself [No workers' comp. right of exemption per MGL 120 Roof repairs . • insurance required.] t ' c. 152, § 1(4), and we have no 0 13.er employees. [No workers' Oth comp. insurance recitiiredd • ' • *Any applicant -that checks box #1 must also fill out the section below showing their woricers' compensation policy information. ... • • t Homeowners who submit this affidaVit imficating they are doing all work and then hire outside txstractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contactors and stale whether or not those amities have employees. If the sub-contractors have employees, they must provide their workers comp policy number. /am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. - . • . • - Insurance Company Name: Policy # or Self Lic. #: Expiration Date: • . , Job Site Address: City/State/Zip: • • - . Attach a copy of the workers' compensation policy declaration page"(showing the policy nuinber and expiration date). Failure to secure coverage. as required Mid& Section 25A 'Of MGL c. 152 can lead to the iMPOsitibri 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 against the violator. Be advised that a copy of this statement may be forwarded to the Office of Eiiiitions &the DIA for initti Mice CoVeraieVeCa I do _ ...4, _ce • ;A -,.. - - • , and p nalties ofperjury that the information providedaboveitinte_tuid_Correa _ _ .. Sismature: ■ '• , — Date: / . 45'- i C- • - • , . . Phone #: C........ - - . - - Official use only. Do not write in this area, 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 5. Plumbing Inspector 6. Other , f• . • Contact Person: Phone #: t SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone to N . . `.i_H i ' Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GL. 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 ❑ 1.- Weer 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 ❑ Addition ❑ Replacement Windows Alteration(s) n1 Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [I= Siding [O] Other [0] Brie`, Des i ption of Proposed Work: '' tt i y_ r , Ste; `C.^+Z -- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 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 Ta'- OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT E ie4_4 -)v," 5h-6 Jz— , as Owner of the subject property hereby authorize t' to act A my behalf, in all matters relative to work authorized by this building permit application. 1 C ,_1..,� ✓fo-� �^ (� c /!Sf rG� Signature of Owner Date I deu h e , 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. -°e Ash ha Print Name OE./c5/1 Signature of Owner /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 1 Frontage Setbacks Front n7 = ? 1 Side L:I 1 R:1 ( L:i ? R:! 9 ■ Rear ' Building Height [ t ___, Bldg. Square Footage % Open Space Footage % r (Lot area minus bldg & paved 1 i u �..,. �.. 1 . parking) # of Parking Spaces - ._, Fill: _ (volume & Location) i A. Has a Special Permit /Variance /Finding ever been 1 sue for /on the site? NO 0 DONT KNOW 0 Y'`, Q IF YES, date issued:; IF YES: Was the permit recorded at the Registry of 0 : eds? NO 0 DONT KNOW 0 YES ID IF YES: enter Book E 1 ' =ge? and /or Document # B. Does the site contain a brook, body of water or w: lands? NO fib DONT KNOW Q YES Q IF YES, has a permit been or need to be obtai -d from the Cons: atiori Commission? Needs to be obtained 0 Obtai I ed Q ate Issued C. Do any signs exist on the property? YES 0 NO • IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q IF YES, describe size, type and location: t 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 Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton 1-3-S , • rng • - • - ent - �x 212 Main Street Q 31.,IN 1 5 2010 Room 100 'a Northampton, MA 01060 " a s phone 413 -587 -1240 ;'Fax 413 - 587- 1272 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 Unit �shewr icane_ F/ Ye vice, Zone Overlay District Etm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ;10.4l.1CIP Ash ash' /U✓l WSJ 61ego; L(t/i2 Flee ewe_ ,./ C5.'G Name (Print) Current Mailing Arldressj 1 -4/3 iJ9 77 Telephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building - , (a) Building Permit Fee )i 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 3 d fcc 6. Total = (1 + 2 + 3 + 4 + 5) Check Number J This Section For Offic Use On Date Building Permit Number: Issued: 4 Signature: e7 /C/ /e) Building Commissioner /Inspector of Buildings Date 26 GRBGOR:Y LN ; BP-2010-1138 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 531 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2010 -1138 Project # JS- 2010- 001671 Est. Cost: $1500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RONALD DECK 102688 Lot Size(sq. ft.): 10105.92 Owner: ASHTON THOMAS L & ELEANOR CIO DRYADS GREEN GALLERY Zoning: URA(100) //WSP Applicant: RONALD DECK AT: 26 GREGORY LN Applicant Address: Phone: Insurance: P 0 BOX 4002 (413) 628 -3384 AS H F I E L D MA01330 ISSUED ON: 6/16/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REPAIR TERMITE DAMAGE & INSULATE 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 6/16/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo 26 GREGORY LN BP-2010-1138 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 531 CITY OF NORTHAMPTON Lot -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2010 -1138 Project # JS- 2010- 001671 Est. Cost: $1500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RONALD DECK 102688 Lot Size(sq. ft.): 10105.92 Owner: ASHTON THOMAS L & ELEANOR C/O DRYADS GREEN GALLERY Zoninu: URA(100) //WSP Applicant: RONALD DECK AT: Cis GREGORY a Le Applicant Address: Phone: Insurance: P 0 BOX 4002 (413) 628 -3384 ASHFIELDMA01330 ISSUED ON:6/16/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR TERMITE DAMAGE & INSULATE 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: 01 < 6 ( Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: OK- Final: Smoke: Final: C3 jc 6 (zz. i o ( m ( S THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. AZ* dgaro.110 Certificate of Occupancy E"/7�to i,�^ " :;nature: FeeType: Date Paid: Amount: Building 6/16/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo