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02-028 The Commonwealth of Massachusetts i� *�._ Department of Industrial Accidents _,-5411=�� Office of Investigations �_ 600 Washington Street • . � =. Boston,MA 02111' • '` ,.:t," - wwx.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legf'bIy Name(BusiaessJOrganizstioa/Individual}: I '_ M�� •- I . . Address: 'l ` it 1'Y1r1 --' • City/State/Zip: iii/i 4 . ' 1.i1% Phone.#: r--� 7 a l 3 Are yen an employer?Check the appropriate , • • -Type of project(required): 1.0 I am a enxpktyer with - 4. ft, I am a general contractor and I 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-condors have 8. ❑Demolition • working for me in any capacity employees and have workers' . 9 z:' addition [No workers'comp.insurance comp. .t ❑Bi iM. E required.] • • 5. 0 We ac-a-corporation and its 10.0 Electrical repairs or additions offictrs have exercised their'3_❑ I ama homeowner doing all work 11.0 Plumbing repairs or additions ' myself[No workers'comp. right of exemption per MGL . 12.[]Roof repairs insurance required.]t - c. 152,§1(4),and we have no 13.©Oilier employees.[Na workers' _ ' comp.insurance required.] . *Any applicant that checks box#1 asst also fill out the section below slowing theme workers'compensation policy information. . t Homeowners who Submit this affidavit brelcating they arc doing all work and then hiss outside contactors must submit a new affidavit indicating such. :Contactors that check this box must attached an additional sheet showing the roue of the sub-contractors and sate whether or not those entities have employers if the a tb-ermeactors have ea>ploycev,they mast provide their workers'comp•policy numbs • tam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. • , -- "P Insurance Company Name: 1.'�! 11 r 11,t it -,.e.... • Policy#or Self-ins.Lie.#: _ _ Expiration Date: l 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 a....%.- .-violator. Be a• '--./4. a copy of this statement may be forwarded to the Office of I n v e s t i g a t i o n s of the a il f o r%•2, . , • i,: •e v-,,:. •i, I de hereby certifFIJJZI4Cd' ,erjury that the friformadorn provided is true and correct. signature: pate: I 1 - P hone#: LiDi e M +'5? 00,J' 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 Inspector S.Plumbing Inspector 6.Other . • Contact Person: Phone#: 2013-09-11 20:51 PRODESK 4137755612 >> Home Depot AHS P 1/6 PLEASE READ THIS.�.�.. . Sold.Furnished and installed by: Branch Name: Roston 11)ate: Ti 11)At Home Services,Inc_ 1-41 , 3 dlb/a The Ilome Depot At-Home Services 908 Boston Turnpike,Unit 1.Shrewsbury,MA 01545 'Poll Free(800)657-5182;Fax(508)845-0017 Branch Number:31 federal 11)4 75-2698460;Ml:I.ic a C 02439;RI Cron.1.4:4 16427 CT l,ic J1 HIC.O 522;MA flu e Improvement Caooractor keg.it 1261193 Installation Address: le q Z P'CQTg fertee ( 09/41a City State Zip Purchascris): Work Phone: Hoene Phone: Cell Phone: 1-0+2 3 t-l t I t l r`bj z3a -1l0 g t I / it ; r i r Home Address: (If different from Installation Address) City r State Zip E-mail Address(to receive project communications and llome Depot updates): Y ![ Ci>` ,Keen ❑I DO NOT wish to receive any marketing emltiis from The Hoax:Depot Project Inforalatior(: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and'1110 At Home Services, Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installation")of all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, 'Contract"): Job#: ttorrro.I aceerexc, Products: S Sheets)5i: Project Amount ❑Roofing ❑Siding Q Windows ❑In. tun 17, ��} ❑C;uuers!Covers ❑hrtest)utxs O, 8 7a' I jrLt .- I ❑Roofmg ❑Siding ❑Windows 0 Insulation v • ['Cutter,:/Covers ❑1•:ntry Doors ❑ I . I Roofing USiding ❑Windows 0 Insulation f ❑Gutters I f'overa [Maury Doors l I I $ (Roofing ❑Siding 0 Windows 0 Insulation i I ❑Ciuttetx I Covers ❑Entry 1)oor% ❑_ Minimum 25%Deport of Contract Amount dew upon execution of this avntrvet Total Contract Amount ' $ /0 Maine Purchasers may not deposit more IIWn tatedhbd of the Centred Amount ( `i 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 he jointly and severally obligated and liable hereunder. The Monte Depot reserves the right to issue a Change Order or terminate this Contract or any individual Pro ducts)included herein,at its discretion,if The Howie Depot t or its authorized service provider dctcrmincs that it cannot perform its obligations due to a structural problem with the bores:,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 Summary: the Payment Summary S ?Be ei 7 , included as part of this Contract, sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-in copy(tithe Contract at the time you sign. Do nut sign a Completion Certificate(note: there is one Completion Certificate for each listed 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 s of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the coals date of termination,pins any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY W 17'H HOLD AMOUNTS OWED TO TILE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE H()ME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Horne 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 writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terns of and has received a copy of this Agreement. Ac opted by: Sur • , by: Cu. .r's Signature Date Sales Consultant's igna re pat• Telephone No. _ -b5 3r 9.5 3 Customer's Signature Date Sales Consultant License No, CANCELLATION: CUSTOMER MAY CANCEL THIS tasnpprrai,tet AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO I CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE, I NOTICE:ADDITIONAL.TI:RMS AND C.ONDiTIONS ARE STA'L'ED ON THE REVERSE.511W Ants ARE PART OF MIS CONTRACT 10-11-12 White-Branch File Yellow-Customer SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: l Not Applicable)£ Name of License Holder: [I T L.�— e e (/ I2y 2 ��� )� ` i- License Number)/ I Address (,�i )) , sq. 1 �/ s Expiration Date/ 1/ / / Afr' P1 f' Signature Telephone 9,Registered Home Imps v meet-Contractor Not Applicable £ 7-- 1- %� / Co•1.an Na •- Registration Number Pr / -5 -3----/ e Ad r•ss G ./*--1 / Z Telephone / 0 Expiration Date 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 permit. Signed Affidavit Attached Y No £ it = 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 Wi.dows Alteration(s) n Roofing ❑ Or Doors �f Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [D Siding[D] Other ID] BrioerfkDescriptios. • Prop.: i CC. Fr o� ' A J1 � T ': ���lG / �'1 vv 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 end or to'ezisfing:housing;'complete.thelollow>Ind: 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 L Eizeer-77)- .1� ,as Owner of the subject property / yam } hereby authorize ( /91Z__ � W to act on my behalf,idg s e to w ized 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 t ns an,/ p penaltie er' —7-4 g4) )A- Print Name "40, ����/ r/7‘ / / Is S' at e of Owner/Agent Date • Section 4. ZONING Alt 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 I I Frontage1__.___.______._-..._.__.:_. 1_..-_____.__.._-____-_. ___i L_......_._.___._._.___ ._ _____1 Setbacks Front ( —I ( ii [ 1 Side L« R:= L:L___._.; R:= = 1 - Rear 1.--- --1 € I I Building Height I 1 Bldg.Square Footage 1—`--1 = % I--` � 1_____._i Open Space Footage { # % rr------''-,� (Lot area minus bldg&paved (_____._i ET L__w...,.: i L.._..1 parking) I't__ #of Parking Spaces Fill: (volume&Location) 1 I l t A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW 0 YES 0 IF YES, date issued:; I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES Q F---------, IF YES: enter Book i Pagel and/or Document## 1 i B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO 0 IF YES, describe size, type and location: ! -' T 1 D. Are there any proposed changes to or additions of signs intended for the property? YES O NO Q IF YES, describe size, type and location: i 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 O NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. • I c/� r //J V ; 5 aepartrrjent�use only ;1 i_ rI \,, I Mts.V ,i'" +., G j� 'C' sr�rn 1 5�1+��� "cfi( a § , v J _� w City of Northampton �'tatus of Permtt f" � �3 '� � �F t g�i 5 t,. ,. u �} ,r f ru.+fr x'h3 }xiPn l i �,� r;.;'` s n., �h5�1+ �9r*g2�fF;�Y r-�r s� 1 ' I, Building Department CEr:.Ia CUtIDt�ueuvayPermt# ", A 1 /��( r/11^1 �1S �;I 212 Main Street Seyuer/SepticAvaiCab)Icty KT1� ", , ,} F "1 i d R 'F E ,yi Y i 4 5�" Room 100 Water/W )Wailability t �L ra ,€' 4 Northampton, MA 01060 Two Sets ofStruo� aIi'1att �` AP ` " 'M >., t I ctric Plifmt' Gt s Insp�CtcGUiry z MA o10 lone 13-587-1240 Fax 413-587-1272 PIof/Site Plans '�, ur�J x ai ` , r a Northampton, kF. 3�� al .d >Jx Otfler0Sp ..5. n, :: 3 "g�, ' i. Mi t 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 el/2_ Mer#-14p13 W, e Zone ommi;:wit_mifill:::gata Overlay D!strtct , Elm:St District - CB District �a }, . SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner el Record: � i IV b/Z iva4 p,,t -6troteklA44--.4,9 Name(Print) Curren Add 49/42 c-e-. 6,7i-Igi4e-• T. / Telephone Signature 2.2 Aut.• ' ed Agent: ‘ 2 e/ /11/005 ,2)/e' —R2,1' 012-1 1 1 Name(*tint) Current Mailing Address: yv/ 93c- 433 Signat ,! Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS. Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant • . 1. Building .�;�f VD a s-�' (a)Building Permit Fee 2. Electrical , / 7 (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection rJ'� , 6. Total=(1 +2+3+4+5) y�� (.�'" '- Check Number �9/� 3 l5 This Section For Official Use Only • Date Building Permit Number: Issued: Signature: Building Commissioner/lnspector`of Buildings . . Date • 642 NORTH FARMS RD BP-2014-0473 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 02-028 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPLACEMENT DOOR BUILDING PERMIT Permit# BP-2014-0473 Project# JS-2014-000814 Est. Cost: $5440.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 062476 Lot Size(sq. ft.): 81805.68 Owner: POKELA JULIANNE&ELIZABETH DENNY TRUSTEES Zoning:RR(100)/WSP(100)/WP(84)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 642 NORTH FARMS RD Applicant Address: Phone: Insurance: 24 SUNRISE DR (401) 935-2633 O Workers Compensation PROVIDENCERI02908 ISSUED ON:10/18/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT PATIO DOOR 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 10/18/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner