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35-120 (2) • • Massachusetts-Department of Public Safety Board of Building Regulations and Standards, Construction Supervisor License:CS-049918 t-4,6 MARKS JOOOIN 1,4;2 '', 137 PORTER LAICE D�1 L LONGMV ADOW M.A,Oiil; i •j ';j ; , 1 .. „[may. 't Si'N. Expiration ICommissioner 12/29/2014 • - ,. The Commonwealth of Massachusetts Department of Industrial Accidents ,?, '� �',, Office of Investigations ti r 600 Washington Street '1 '= Boston, MA 02111 '" ''t www.mass.gov/dia •Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):-. t'( , c 11 JY6---$246- ti7 ,---//GU C_ Address: /27 /q/z7-, , v2 ( ,- - Cityl State/Zip/mle6�t?t?', 46)WO- eV/06 Phone#: V/ — ,(Yr-- 730/ Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I yrtployees(full and/or part-time).* have hired the sub-contractors 6. New constriction 2.]._ I am a sole proprietor or partner listed on the attached sheet. 7. Remodeling ship and have no employees These sub contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' (No workers' comp. insurance cutup. insurance.# 9. ❑ Building addition required.) 5. ❑ We are a corporation and its 10.11 Electrical repairs or additions 3.❑ 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 insurance required.] t c. 152, §1(4),and we have no 12•0 Roof repairs employees. (No workers' I3.0 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. k'onaactors 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. 1 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-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$1,500.00 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 Investigations of the DIA for i surance coverage verification. I do hereby certify 4 ' to pains an, penalties qfiperjury that the information provided abo e is true and correct. Si.nature: Date: 7 / /3 Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority: Contact Person: Phone#: LOWE'S CONTRACT#0000245 MASSACiitist .TS E CT•RR1 R SOLUTIONS INSTALLEDrSALE&COI)ITRA*1' • j INSTALLED SALE SPE .LIST NUMBER . CUSS MER v+\ .I(1� 1 •1'O4t 5 /163t9d ^ C x r ee. S6-1i cc lyc ! , STORE NO. I STREET ADDRESS STRE RE t5 Ol9IG ()Sc . CITY STATE ZIP .•`- CI - STATE ZIP rA w�r Mc� ata33 rtrxevic� 1^-4 ©/¢!5' TELEPHONE ." TELEP ONE y13-5-Ft8 0a-7)11 ad DATE LOWE'S HOME CENTERS,INC:S MA HIC NO.:148688 CASH K LCC REo FEIN:58-0748358 r,Aao a: CHARGE This is only a quote for the merdiendme end$4;,,cas pined Wow.The beeon ee an agreement uroit Payment Upon payment,lhe enure agreemsnL,inodding ghe nperaificaly oorn]lemdpegee M ihis document the Tonne-and Conditions Induded With,ihia `document and airy NOW addenda and attachments hereto,shell be referred to herein as ills-convect PLEASE READ ALL TERMS/yND rONOrpOt4 owri f 1 ,,,q;eE SIOE[1f THI4 PAGE AND FOLLOWING PAGES-BEFORESIONING INSTALLATION STREET ADDRESS CITY STATE ZIP 5,,,ors u P� f- relic._ _ j Til v.c �4;S-��r by in cj _ QG S; It)U /pi f A.510, rjix} e,)t tits J tot e-IY Ida '114"' ar- T S,—CI°_/mac Contract Total a i "` Are permits required for this installation?:[ Yes [ ]No *applicable tax included (-0a0"1 r NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right.By signing this Contract,Customer acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit. PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees the right to take photographs of all work performed at the Premises related to this Contract,and irrevocably grants to Lowe's all right,title and interest in and to the photographs for use in all markets and media,worldwide,in perpetuity. Customer authorizes Lowe's to copyright, use and publish the photographs in print and/or electronically, and agrees thatLowe's may use such photographs for any lawful purpose, including ut not limited to,marketing, advertising, publicity, illustration, training and Web content. By initialing here,Customer agrees to the foregoing. [Customer to initial to the left]. Work istcorytmence upon reasonable availability of Contractor and/or any special order o cus mer made Good(s)which Is anticipated to be /_9> Ville in date].Estimated completion date is '//3/,� [fill in date]. Said es(mated substantial completion date is not lithe essence.A state ant of an,y-contingencies(that woul materially change said estimated substantial completion date is as follows: O pyl /tc t r/n rr4 �°�: t e.r�°r� (l(Ni i ,C 1 ( applicable,inserta statment such contingencies). IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full. . COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00: [ ]Customer to Pay in Full; OR [ ]Customer to use the following payment schedule:. (1)Deposit $ to be paid upon siging contract.Deposit should be 1/3 the total contract price;and (2)Payment of$ to be paid anytime after this Contract is signed and before commencement of installation,I/We authorize Lowe's to do one of the following(check appropriate box below): [ ]Charge niy/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or [ ]Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed;and (3)Final payment of$100.00 to be paid upon completion of the installation and both parties'satisfaction. NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L.c.142A LOWE'S AND,OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT LOWE'S MAY SUBMIT SUCH P ISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT- IVE OFFICE OF CONSUMEEFFAIR$AND BUISNESS iEGULATIONS AND THE OWNER SHAL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROV DED IN M.G. A.{ d $ _ ' ey:/ 1I_'� Z Date s L. -Z 3 B ' Date: C— /3 - / L ner Ig :ture THI`SIGNA RES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWE'S PURSUANT TO M.G.L.c.142A.THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT. BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ,UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATU E. WITNESS OUR HANDS)AND EAL(S)BELOW THIS 13 DAY OF 3."-(Jul 4 �/' Low ome Ce If' SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: /1& JOL O // e 5 - 0L(? ( �f License Num er , / ? 7 (0e /��� S ,U oeL) )('i //0;C 7,1 ,?-P . 1' Address Expiration Date Kl3 -- geY3---- 73 ( Signature Telephone 9. Registered Home I provement Contractor: Not Applicable ❑ Company Name Registration Num r /3 6 .F',e1� , - - ied �. � ,cy29 /0 /F --)-c1/3 Ad ress ,��f1f r7 Expirati n Dat SU 0UC// /� 0/? -7 �- Telephone C71.3-J�1� -°?-7D 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 buildin ermit. 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 Wiipdows Alteration(s) Roofing ED Or Doors L! Accessory Bldg. ❑ Demolition El New Signs [0] Decks [E] Siding [0] Other[0] Brief Description of Pp, ed �� Work: 7 ,er( C.�'I,�ic/'7 Gl�- 7t)Qd(A} NO 37 C1c cO g4-6- (L)O 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 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 I, G A e,/ (J2 , as Owner of the subject property hereby authorize (� S to act on my behalf, in all matters relative to work authorized by this building permit ap lication. 5e-e, v - - 7/ /3 Signature of Owner Date I, (/C1r2,r.G1A- ■ , as Owner/Authorized Agen 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 enalties of perjury. Print Name £) / _.- 7//3 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 Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW 0 YES Q IF YES, date issued: IF YES Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW Q YES 0 IF YES enter Book Page and/or Document # 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. COI q(225 ti 35 Department use only City of Northampton Status of Permit: _ 20I3 Building Department Curb Cut/Driveway Permit L 4 ' —` ' 212 Main Street Sewer/Septic Availability t Room 100 Water/Well Availability Electric, F iu,-molon, Gus inspections Northampton, MA 01060 Two Sets of Structural Plans Nut,-r,nion,t�LA C10�;0 p phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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 Zone Overlay District Elm St.District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Addresl: Jgo WA/772- qC Telephone Signature 2.2 Authorized Accent: / /�,� /d w S 2t om sS -l6. %�f!y�4 G` 4%03J`-- Name(Pant) !1 -'" Current Mailing Address: 70 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 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) p7 � $: . 6� / Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 37 DREWSEN DR BP-2014-0042 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 - 120 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-2014-0042 Project# JS-2014-000111 Est.Cost: $2415.00 Fee:$35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.ft.): 15507.36 Owner: SCHEURER GEORGE B&CAROL A Zoning: Applicant: SCHEURER GEORGE B & CAROL A AT: 37 DREWSEN DR Applicant Address: Phone: Insurance: 37 DREWSEN DR (413) 584-6227 () FLORENCEMA01062 ISSUED ON:7/17/2013 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 7/17/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner