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29-443 (4) i ,` AOORD, CERTIFICATE OF LIABILITY INSURANCE DATE(MMI 6i08 YY, a21z PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequest@marsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 Fa:c (212) 94s-o9D2 _ INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Steadfast Ins Co 26387 Home Depot U.S.A., Inc. The Home Depot, Inc. INSURERB Zurich American Ins Co 16535 2455 Paces Ferry Road INSURERC:Illinois Natl Ins Co 23817 Building C-8 Atlanta, GA 30339 NSURER D:American Home Assur Co 19380 INSURERE:New Hampshire Ins Co 123841 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSIR= POLICYEFFECTIVE POLICY EXPIRATION LIMITS TR POLICY NUMBER D IDD/YY A / A GENERAL LIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE $4,000,000 X LIMITS OF POLICY ARE EXC SS PREMISES NTED 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES Eaoccurence $ CLAIMS MADE �OCCUR "OF SIR: $1,000,000 PER CC" ME D EXP(Any one person) $EXCLUDED PERSONALS ADV INJURY $4,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $4,000,000 IF X POLICY PROT LOC B AUTOMOBILE LIABILITY BAP 2938863-05 03/01/08 03/01/09 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X ANYAUTO ALLOWNEDAUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIREDAUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) X SELF INSURED AUTO PROPERTY DAMAGE PHYSICAL DAMAGE (Per accident) $ GAR AGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHERTHAN EAACC $ AUTOONLY: AGG $ A EXCESSIUMBRELLALIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACHOCCURRENCE $5,000,000 X OCCUR EI CLAIMS MADE AGGREGATE $5,000,000- DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATION AND 1928757 (FL) 03/01/08 03/01/09 X WCYTATU- OTH- D EMPLOYERS'LIABILITY 1928756 (CA) 03/01/08 03/01/09 E.L.EACH ACCIDENT $1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE g OFFICERIMEMBEREXCLUDED? 1928755(AOS) 03/01/08 03/01/09 E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $1,000,000 SPECIAL PROVISIONS below OTHER F TX Employers Excess TNS-C45197967 (TX) 03/01/08 03/01/09 ccurrence/SIR 25M/2M D Workers Compensation 1928759 (QSI) 03/01/08 03/01/09 E Workers Compensation 1928758 (KY, MO, NY, WI) 03/01/08 03/01/09 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS *FOR EVIDENCE ONLY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 30 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 2455 PACES FERRY RD., N.W. BUILDING C-8 REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2001108)datkinson ©ACORD CORPORATION 1988 8213215 HOMEIIMPROVEdIM CONTRACT Sold t-ud and Installed by. Broach Name: Date: THD A At-Home 5enices,Inc. d1h/a The Rome Depot At-Home Services 345A Greenwood Street,Worvwter,MA 01607 Branch Number: ► '- Job* G3'.3� Toll Frey(800)657-5182; Fax:508-756-2659 `. FedeW W•75.2698W ME Lie N C 02439 RI COW.Lich 16427 Cf{'L'iiei1 5651222;(MA Hama knMvemmrt Cantramw net.k1M893 Installation Address: '. 1�� > Sr l�s�+�t lam+ It`► ��`�-�, /fit( 1✓l�r� city state Zip Porchaser(a): Last 4 Diane of Driver's J Lie.tI&Exis.Moryn !Work Pillow; Home Phone: 7A C. Home Address: (If dill<ctertt from installation Address) City State Zip E-mail Address(to receive updates and promotions from The Holm Depot).__ Project Infarmagent I/WedYau("Purl axr")l,the ownem of the pr located at the above installation address,offer to contract with THD At-Homo Services,Inc.( klo?e.Deuc�t"'}to fumisho�fiver alit arrange for the installation of all materials as described on the attached Spec Sheet# t �-{ i incorporated herein by reference and trade a part hereof. Hone Depot reserves the rigbt to eawd this contract R;upon tit-antspettion of the job,Rome.Depot deterrnina that it cannot perform fib obllptlons due to a sh adural problem evlth'the home,pricing errors or because work required to complete the jab was out Included in the Spec Sheet or Contract. DEPOSIT PAYMENT OPTIONS _ 0.*-a m now verWiimloe anNor ettdtt apPr�al•) CONTRACT'AMOUNT S_—3650 1. may.,Cyyicrs Chat or US Posts'.Servkr Mmrey Order DeW)$(Made payable to The Homo tLESS,DEPOSIT S •~ 2. Credit Cad—willm odar pay-amt opdam•Cimle Owe lldow BALANCE DUE 03 visa MastaCard Disomer Amerian Hxpma ON COMPLETION $_ IU dome t]"Hate Improvarpee t Loan Thu Hans t)epot Credit cut J'Minlmum 25%of Contract Amoont due upon 0 New Acceaat U BsbnnaArmtmt MIL&RDOC ONLY) execution of this contract Available Cmdn:S CM A HO CC ONLY) Indicate Psyn ant Method For Acwlt. Exp,Date:.,._._,_._-•_._ BALANCE RITE ON COMPLETION: - A+ - Nuns as It eppeera m.sad: -By my/our signature below,VWe agree to allow Home Depot to f> charge the above rafenloped credit card for the deposit indicated. *When you provide s ebedc a orrntmt,you authorize ut cutter w use itd'amaion from your check to make a onvAimc clectronic Ciniaoldees Siga n re_ DeM find awda flan your soeaum onto praoess rho wymest as a duet o+rnew ics,when we use whamatlaa from yore obek to H:II,or HDCC Autborbsation Coda male an dcmum had tralafa,trade may be whbdnwa floe - - you account n won as the pays m0a icceived,sad you will not V otttt J. Final Payment rowiveyourchsckback. ""1 ;(t nn.Purchaser agrees that,immediately upon c o lotion of the work.Purobaset will execute a Completion Certificate and lay any balance due. Purchaser also agrees Do be jointly y and severally obligated and liable hereunder. Entire Aareanent:This agreement and its attachments,inoluding oily financing agreement,contain die cmiplete agreernent between the parties and can not be arnonded or modified tudess in wridag in a separate agreement signed by both parties. NOTICE TO PURCHASER Do not slgn this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time you sign. Keep U.to protect yopr rlphts. Do not sign a Completion Certificate before this project is complete. Law prohibits home repair eontructora from requesting or aceepdng a Compledoa Certt$eate signed by the owner prior to the actaai completion of the work to be performed ender the contract, " You may cancel this transaction any time prior to midnight of the third business day sillier the date of this contract. See Notice of Cancellation for an explanation of this right There will be a service charge equal to 10'%of the contract amount If Job Is cancelled by Purchaser AFTER the tbird business day,but BEFORE materials are ordered.There will; be a service charge equal to 25%of the contract amount if job is ancelled by Purchaser AFTER materials are ordered. BY MYJOUR SIGNATURE BILLOW,VWG i1NDFAtSTAND THAT THE AGREEMENT MAY BE SUBJF.G'T TO REVIEW OF MYJOUR CREDIT WSTORY AND UWE AUT i0RtZE HOUL DEPOT TO VERIFY AND REVIEW MYJOUR CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL LIABILITY INCURRED FROM IN ADVERTENT OMISSIONS OR ERRORS, BY MYJOUR SIGNATURE BELOW,IIWE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. VWF.. ACKNOWLEDGE RECEIPT OF A COPY OF TTW,,CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATION. SUBMMED BY: Date: also ACCEPTED BY: Date: Psteinset Date: Purebmw NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIM AND ARE PART OF THIS CONTRACT 9-21-07 rov 4-2-07 GSC Yt4ifto—Baron Eke Yel w—Cuaf vnor Pink—Sales Comusaot 9 -d XUJ 13rd3SUI dH WU00 c 6 9002 €0 jeW HOME IMPROVEMENT CONTRACT Sold,Furnished and installed by: Brandt Nsmr. � Date: Oz>,Cs THD At-Home Services,Inc. dthts. 'the Herne Depot At-Rome Services 345A Greenwood StroOt,Worcester,MA 01607 Br•rmth Number: �7•�: Job#' 3& Toll Free C$00)657-3 3 82; Fsa;50$-?56-2859 padaal M#75-26984b0 ME I is#C 02439 Rt Cons,Lie#16427 L f t-ic#%5{5222;+MA Hans Iropmoisaent Cann"eouurr Reg.#[26893 Installation Address: Kt+ �0 E �1 .] + -- C {S,1L�. ��f+Z`—' i`'--�1 '•� City State zip Last d Digits olDrlvees lrtrehaser(s): Lic.# Mo/Vv Wodt lboov, #2p--PIIO-12 ,VJkL r r l ) Home A on: --- (If ditlhrent Prom lnetatlation Address) City State zip 9-mal)Address(to receive updates and promotions from The Home Depot): Yrejttstt Information.. VWelYou("Purchawe,) the owners of the property located at the above installation addreas,offer to contract with THD At-Hama Services,Inc.("H of"}to furnish,deliver and arrange for the installation of all materials as described on the attached Spec Sheet#_i1�c-1 r aI S!'�C incorporated herein by reference and made a part hereof. Home Depot reserves the right to eaaeel this contead ir,open rl-luapection of the job,Home Depot doterVAnes that It cannot perform Its obligations due to a structural problem witb the home,pricing errors or because work required to eompistethe Job was act included in the Spec Sheet or Contract DEPOSIT PAYMENT OPTIONS q�-y (3ubjxt to fwd vaincadon andrar or"r approval.) CONTRACT AMOUNT S f L 1. ©,rek<.Cahims Chair or US Posnt Saone Money Order (Made:payaNe to The Home Depot). tLESSDEPOSTI S_ 2. CraditCa rd"anNorotrerpeymemoPdm•ClrckOaeEsbw ' BALANCE Dl7Fj (it„ Via MoswcCord Discover Aamrkaa EW I" ON COMPI:ETIOI S_ M.How Depot Nome Imaovena of Loan 'Me Home Depot Crodit Cxd tAl)nhouro"%ofContraat Amount due upon 0 New Acconat 13 Existing AMOW (fill.a HOCC ONLY) aeration of thin twotrnd. Avaliahis Crdit:i (IM A KDCC 044LY) Indicate Payment-Med led For A=*: yam.Dow BALANCE DUE ON COMPLETION: NwM as it appom on cud: t r. -*By my/our signature live, agifec on alldw ROM Depot to ch o the above referenced credit card for the deposit indicated. -Whe*you provide a deft as paymeat.You autbetm as eiottr to use hibut tio:t bwa your shock m maim a matimo elocamic dholder s Sfgnaauo —S�a fund erapdr(Fora year om amt or k,pruoea the pay,twtt as a check transaction:Wad wo ass infamstbG sae yaw otxak n HIL or HDCC Authorization Codes snake anekehmie God transfer,..ruses owy be widtdrown Gott.. D t Final Payment yaw scour..a torn as the psymmt Is ae ceivok and yuu Will not mceive year check bank. purchaser agrees that,immediately upon completion of the worn,Purchaser will execute a Completion Certificate and pay any balance duc. Purchaser a1w. agrees to be jointly and severally obligated and liable hereunder. Entire AgregttO This agreemast and its attachments,irldudmg any financing agremmad,contain the comptete agreement between the parties and can not be amended or modified unless in writing in a separate agreement signed by both patties. NOTICE TO PURCHASER Do not sign this contract beforalyom read IL You are entitled to a completely filled-in ao ff of the contract it the time you sign. Keep it to protest yogr rights. Do not sign a Completion Coiftate before this project Is Complete. Low prohibits home repair contractors fmra requesting or accepting a Completion Certificate signed by the owner prior to the actual completion of the work to be performed under the eoatracL You may cased this transaction any time prior to midnight of the third business day after the date of this cmtrract. See Notice of Cancellation for an explanation of this right. There will be a serrlee charge equal to 10%of the contract amount tf job is canctelled by Purchaser AFTER the third business day,but BEFORE materials are ordered.There will be a service charge equal to 2S%of the contraet amount ff job is cancelled by Purchaser AFTER anateris)a are ordered. BY MY/OUR SIGNATURE BELOW,ifvi'L'UNDERSTAND THAT THE AGREEMENT MAY 8b SUB&C-l'TO REVIEW OF MYIOUR CREDIT HISTORY AND IIWE AUTHORIZE H.ObAE DEPOT TO VERIFY AND REVIEW MYlOUR (MEDrf RFtDORD WITH AN INDEPENDENT CREDIT REPORTINQ AGENCY AND RELEASE-THEM FROM ALL. LIABILITY INCURRED FROM INADVERTENT OMISSIONS OR ERRORS, SY MY/OUR SIGNATURE BELOW,1/WE AGRPE TO BE BOUND 13Y THE TERMS OF THIS CONTRACT. LrWE ACKNOWLEDGE RECEIPT OF A Y OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATIOr,,�...__ . t SUBMITD BY: T Dow. , 0 TE - C� ACCEPTED BY:l� Date: urttweer ra Dare: 3 t NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT 9.21-07 rev 4-2.07 C-SC White—BranchFle Yellow—Customor F41*-8a1e8C*ftWtoN g •d XU3 13rd3SU1 dH WUd•b :8 8000 60 Jew <-1 N ° t DEPF•aTMENT GF BUILDING LiiSPECI"IONS - INSP-ECTCP 212 Main Sweet 0 Municipal Building Nortbwnpton, MA 01060 HOME O",VNER EXENUITION ACKONOW E'Dr'EMENT The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to act as ris1her construction sup . , :sor. 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 dwe.Uing, attached or detached structures accessory to such use and/ 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 any per sons)who seek to use the hom'e'owner exemption, to act as thew`own construction super viso, 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 backfIl). sonotube holes (before sour) a rough buiildine inspection (before work is concealed). insulation ins-oectiun (if required.)and afiitai_lzuzld na 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 occupanev until-the-work ran--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 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 L 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. y Date Address of work location \ The Commonwealth of!Ylassachusetts —�-- Department of Industrial accidents .ji e of Investigations 600 Washington Street Boston, %1M4 02111 www.mass.gov/dia Workers" Compensation Insurance Aida-vit: Builders/Contractors/Electricians/PIumbers A>7 licant Information Please Print Ledbly Name(Business/Organiaation/Individual :2207--v Address: City/State/Zip: ��+ �I �' �� Phone.rr: Are vo employer?Check the appropriate box: Type of project(required): 1- am a employer with i W ❑ I am a general contractor and I Y 6. -New construction employees(full and/or part-time)-* have hired the sub-contractors 2.❑ 1 atn a Sol le proprietor or partner- listed on the arched shee 7. ❑Remodeling slip a--d have no employees These sub-contractors have 8. (�DemoliLLon workEng for me in any ca P act t3' employees and have workers' 11 9. Bu❑ ilainv o addition [No workers'cow: s�a:lce comp.insurance.+` required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions ❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp- right of exemption per MGL 12.❑Reofrepazs insurance reed]t c. 152,§1(4),and we have no employees. [No workers' I3. Other comp.insurance required.] -----"ttriy app Iran cner ooz�. an�s2 atso out a se�von ouow saowm= workers'cotttpeasatioa policy mformmaaa ------- _ t Homeowners who submit this affidavit indicatin they are doing aB work and then hire outside contactors must subffit a new affidavit indicating such. :Contractors that check:this box must.atached an additional sheet showia=the name of the suo-contractors and state whether or not those entities have ernployees. Y the sub-contractors have empiovecs,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance fo r my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. r#: p2�1 j(e-5) Expiration Date: ,0 Job Sire Address: � City/State/zip n6a Q(�a Attach a copv of the workers' compe tion policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 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 cf`phis statement may be forwarded to the Office of Investigations of the DL iss.irance coverage verification I do hereby cerdfy u er a ins d p aloes of perjury that the information provided above is true and correct Date: Phone r- vfficuu use oniy. loo not write ui this area,to tie completed by city or town officiaL _City or Town: ___-- �.---------------- _.----- .—Rer-mitlLicense n Issuing Authority(circle one): 1.Board of Health 2.Building Department 2. City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6. Other Contact Person: Phone.-: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9. Registered Home'Improvement Contractor: Not Applicable ❑ 7Dk Company Name Registration (umb r , ltL Address Expiration Date N&aNlephone 3 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M:GIL.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...... ❑ I L Home Qwner 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 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 responsible for all such work performed under the buildin2permit. 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 % Y a SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacemendows Alteration(s) Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [C]] Other[CQ Brief Description of Proposed Work: l 1 A, Alteration � CC�/Y1ri.,1 Alteration of existing bedroom Yes No Adding new bedroom Yes o Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa. If New house and or addition toe existing owing: 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 applicator. Signature of Owner Date as Owner/Authorized Aqent hereby that the s atements and information on—the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under pains and penalfes of perjury. Prin Nam Sign tur of Owner gent Date Section 4. ZONING Ali 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 Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? �� �� NO v_/�� DONT KNOW \~� YES \^� IF YES, date issued: IF YES: Was the permit recorded at the Registry cfDeeds? NO � j DONT KNOW YES �� IF YES: enter Book i Page and/or Ducument# � �� B. Does the site contain a brook, body ofvvaterorwetlands? NO \_��� DONT KNOW \_� YES \~�� � IF YES, has permit been or need to be obtained from the Conservation Commission? ' Needs to be obtained »�\ Obtained /�� Date Issued: !----------- � *�� «�� ' ' / C. Do any�gnsexist on the property? /~�y� YES \�� NO *~~/-� � .-------- -----'-- -----, IF YES, describe size, type and location: / D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 IF YES, describe size' type and location: . E. Will the construction activity disturb(clearing,gradingexcavation, orfiUing)over 1 acre orisK part oro common plan that will disturb over 1acre? YESC��) NO ( ) �� |F YES, fien-a--Northampton Shorn-WaderNanag—effent Permit from the DPW iorequired. • Department use only City of Northampton Status of Permit: \n`�-- Building bepartment Curb Cut/Driveway Perm+# - C�12 Main Street Sewer/Septic Availability ,. 'r L Room 100 Water/Well Availability' Northam ton, NSA 01060 Two Sets of S`tructural"Plans'> 0 phone 4,1�-5 �, 40_F�x 413-587-1272 Plot(Site Plans OtherSpecrfy..'. API�LIC ► TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: Map Lot Unit Zone Overlay District 0►�� Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: P' IaJ Iv Name(Print) /^� Y Current Mailing Address �et VVAaz-�. s t ` Telephone Signature 2.2 AuthoAzed A ent: t.)CM& U)Q Name(Pr. t) Current Mailing Address: Signature Telephone SECTION -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit 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 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: -- - -- —------- Building Commissioner/InspectorofBw ing—Td s Date 58 ELLINGTON RD BP-2008-0758 GIs 1�: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-443 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 Pere„it # BP-2008-0758 Project# JS-2008-001176 Est. Cost: $3947.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 126893 Lot Size(sq. ft.): 13111.56 Owner: KOCHIS ANN M&MARILYN KUSEK Gonin<�: URA Applicant: HOME DEPOT AT HOME SERVICES AT: 58 ELLINGTON RD Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935-2633 O Workers Compensation WORCESTERMA01607 ISSUED ON:311012008 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL NEW ENTRY DOOR & 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: T111S 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: 13uiiding 3/10/2008 0:00:00 $25.0021939 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo BP-2008-0758 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: BUILDING PERMIT Permit# BP-2008-0758 Project# JS-2008-001176 Est. Cost: $3947.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: CComt. Class: Contractor: License: Use Groin HOME DEPOT AT HOME SERVICES 126893 Lot Size(sd ft.): 13111.56 Owner: KOCHIS ANN M&MARILYN KUSEK Zoning: URA Applicant: HOME DEPOT AT HOME SERVICES AT. 58 ELLINGTON RD Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935-2633 O Workers Compensation WORCESTERMA01607 ISSUED ON:311012008 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL NEW ENTRY DOOR & 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 3/10/2008 0:00:00 $25.0021939 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo