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,'\ The Commonwealth of Massachusetts
l - Department of Industrial Accidents
�, Office of Investigations
M.,.,,
a ,= :
600 Washington Street
Boston,MA 02111
%. ...0. wwwmassgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): +4 p i' �
Address: :::„...t. ,,-;. i jl Of j1 �rt', i/ R.�
Ciy/State/Zip: f(2it / ; /4 f, -71' one#: 1711. 7.7 . 1 _
Ares you an employer?Check the appropriate bo '` Type of project(required):
1.0 I am a employer with 4. I am a general contractor and I
1 employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
g Y P h'• 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 Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13. Other Li)f routj
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 bn employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: \)\,)='LC �1- �� llF°2 CCU
Polic #or Self-ins.Lic.#: ` /15—?/L-/- Expiration Date:
Job Site Address: 1 City/State/Zip: ik A /H/, di I
Attah a copy of the workers'compensation policy declaration page(showing the policy number and expir.tion 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 tip 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 upIto$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D ' er insurance coverage verification.
I do i hereby certify u , he p s a penalties of perjury that the information provided abo e is ue and correct.
Signature: -CI' A,v c1:35 , 1-
Date: f
�
r
Phone#: . �,
Q#ficial use only. Do not write in this area,to be completed by city or town official
Cilty 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#:
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Furnished and Installed by'
Branch Name- Boston I Date: TIU)At Home Services,Inc-
-.1� ---- f dlb/a The Home DepotAt4Hosne Scrvioes
908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free(800)657-5182;Fax(508)845-6017
Branch Number.31 Federal ID a 7526%460;ME Lice C 02439-,RI Cont.Lin#164,27
CT Lie it HlC.o565 MA Home Improvement Contractor Reg.#126893
Installation Address: .33y k..1 IQ N/ A.) W t Tht`-
City P4C3jtate Zip
Purchaser(.): Work Phones Home Phone: Cell Phone:
u Pam [ ] [ ] [ ]
[ I [ 3 . I ]
Home Address:
(If different from Installation Address) City State Zip
8-mall Address(to receive project communications and Home Depot updates): •
01 DO NOT wish to receive any marketing emails from The Home Depot
Project Information• Undersigned("Customer"),the owners of the located at the above installation address.agrees to buy.
and THD A�Services,Inc.("The Home Depot")agrees to furnish, and arrange for the installation(installation")of
all materials described on the below and on the referenced Spec Sheet(s),all of which are in into this Contract by this
reference,along with any applicable State Supplement and Payment Summary attached hereto andyCChange Orders(collectively,
'Contract"):
Job#: (mama u'a.'s Products: _ spec needs)* Project Amount l
(DRoofing❑Siding 0 Windows 0 Insulation 4) )J/�
b85(D 1®" 1 I: DOutt�r covers Day Doors❑ `7! "13.7 $ 405 t.
URoofhng Usiding(_„f Windows U Insulation 1it�1 ,�7
kern e.4 Oche.,/Cowers DF.rwy Doors a -7 16( $ (Q b )3 ( U t vim°,
URootleg QSiding U Windows 7 Insulation S /"—
0C/utters r Covers p5ntry Doom f-7 ... x--"
---- — DRoofing 0siding 0 Windows 0 Insulation 1 ( j ,)
[]Gutters/Covers f]Pnuy DOOM❑ t/t/
. Minimum 25%Deposit of Coated Anoint di e.aeon execencm of min covered. Total Contract Amount S i ti j)2 4;:i Maine Purchasers may not deposit more than me-third ofthe Contract Amount ` II CO
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 Sheet)and pay any balance due. As applicable.each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Rome Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because
work required to complete the job was not included in the Contract.
Payment Suminarv: The Payment Summary# 62 C , included as part of this Contract,sets forth the total
Contract amount and payments required for the deposits and final payments by Product(es applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy oldie Contract at the time you sign. Do not sign a Completion Certificate(note:
there is one Completion Certificate for each fisted Product as defined by individual Spec Sheets)before work on that Product
is complete.
In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination,phis any other
amounts set forth in this Agreement or allowed under applicable taw. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE,DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
4ecentenee and Authorisation: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements.either
oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a wasting signed
by Customer and The Home Depot.Customer acknowledges and agrees that C ,., has read,understands,voluntarily accepts the
terms of and has received a copy of this Agreement.
Aecep by: r Sub ,fitted N. ±`
tit§amer's Signature Date Sal— 2 Signature Date
X Telephone (o.
Customer's Signature Date Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS tasrsmticablei
AGREEMENT WITHOUT OR OBLIGATION
1W DELIVERING WRITTEN NOTICE TO THE HOME ( 6 3 6-5 4
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS F
DAY AFTER SIGNING THIS AGREEMENT. THE
. STATE SUPPLEMENT ATTACHED HERETO _--
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN .
CUSTOMER'S STATE.
NOTICE:ADDITIONAL TERMS AND CONDITIONS ORE STATED ON THE REVERSE SIDE AND ARE PART OP TINS CONTRACT
6510 42 White—Brandi File Yellow—Customer
J
SECTION 8 CONSTRUCTION SERVICES
1/8.1 Licensed Construction Su ervis : Not Applicable ❑
Name of License Holder: /) ) /
^ alyeri '/ ice-77,, License Nurpbpr�']� / /?
Address /f�! /,//l „ Expiration Date
(((%///Cs/�
E6 in te—r- 0/013
S
/0 ignature Telephone Z /
`Registered
some Improvement ontractor Not Applicable ❑
WI' IIL.L„wolf
Com•an Name/ /- '° A' o Registration Number_..irtho oJ657v
Addr //� / , xpiration Date r-
�i ,� _/III Telephonee� �� � 4
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MSG 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 ❑
11 ., Home Owner Exemption
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
•
SECTION 5--DESCRIPTION OF PROPOSED WORK(check'all-applicable) -
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding[D] Other[D]
Brief Description f ro o Work: / / �> �7_ —.
/ 'a �
V I
Alteration of existing bedroom Ye No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing 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? 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
I, , 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.
Print Nam�
Sign'u o iwner/Age Date
t
J
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
r ,,L
Existing Proposed Required by'Zoning 6* -
This column to be filled in by
Building Department
Lot Size L.., 1
Frontage — �
Setbacks Front i ; 1
----, I
Side L:'' R ' L:L_.._ R:' i ,
Rear
Building Height 1 8 1
Bldg. Square Footage 1 I i % 1 r
--- Open Space Footage %
(Lot area minus bldg&paved ; I 1 I I n I
parking)
E i
#of Parking Spaces
Fill: _-__
--
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES 0
IF YES: enter Book I Page; I and/or Document#I
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T 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:
C. Do any signs exist on the property? YES Q 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 Q NO Q
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 Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
1
RECEI\- ..-1 Department use only
R City of Northampton Status of Permit
Building Department Curti Cut/Driveway Permit:
MAY 2.3 2013 212 Main Street Sewer/Septic Availability .
Room 100 Water/Well Availability
per of sur oN Q°;ON$�
■orthampton, MA 01060 Two Sets of Structural Plans
"oR + phone 413-587-1240 Fax 413-587-1272 Plot Plan
/S�te s
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION.1.-.SITE INFORMATION -_-
This section to be completed by office
�Y.'I Property Address:
/./.....1-.1
� d R,1/ 6r Map Lot Unit
b Zone' Overla =District. : _
y
I C� EIm St_District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED_AGENT
2.1 Owner o Record: 0// /V )4/'-ii ` L 1 8-A , .
Name(Print) i Current Mailing Address:
talir 6-ir Telephone
Signature
2.2 Authorized Agent: d� � 1204 ,
Name(Print) Current Mng Address: /� (� g
P/l#D170 '2? ! &
ignature Telephone G
SECTION 3-'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant __ _
uilding /zi 03/ ,----- (a)i 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) Check Number
i
'1;'-'-;,...--.::"--'.... - This Section-Foe Official Use Only =
Date _ -
Building Permit Number: Issued - ] .± _
Signature.__
Building!Commissioner/Inspector of Buildings Date
504 NORTH KING ST BP-2013-1128
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 13-015 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-2013-1128
Project# JS-2013-001854
Est. Cost: $14839.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 99209
Lot Size(sq. ft.): 101059.20 Owner: PATEL VINU V&SUSHILA V
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT: 504 NORTH KING ST
Applicant Address: Phone: Insurance:
908 BOSTON TPK Workers Compensation
SHREWSBURYMA01545 ISSUED ON:5/22/2013 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 5/22/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner