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29-038 Z8 LS-LS9-008 aaa j Ilol•EZ88-99L-809 XLJ •9899-99L-809 L90[0 VA `aaIsaDaoM.Jaaa;g POOMUaaaO y gts Y •�u�`saainaaS 9WOH-id 4Hl •dlay uw a/yj •11 op ue3 noA Jan 08 09 09: 48a Michael Bedard 1-401-246-2868 P. 1 Thursday,January 08,2009 Lead I nq u i ry-4089243 9:13 AM Customer Information Job Information Homeowner............. Mrs.Tammis Lander Sale Amount................. $2,787.00 Balance Due: $1,858.00 Homeowner............. Product........................ Insulation(8%) Job Site Address...... 68 Pioneer Knolls Status.......................... Sale/Finished and Unpaid Florence,MA 01062 Entity........................... RSW Branch......................... Boston County.................... Hampshire ..... -- _. ..__...__ ...__.... Billing Address......... 68 Pioneer Knolls Sales Florence,MA 01062 Commission.................. $0.00 Rate....... Consultant Name Term Date Spilt Comp Plan Home Phone............ (413)5843249 Timothy Drost 100.00%Straight Commission Work Phone............. Ext. Cell Phone............... B-Back: No Cross Ref#.... 1-952002542 Siebel Ord... Pager...................... PIN - _. .._... .. Marketing Work Phone 2............. Referral Store.............. 2662-W SPRINGFIELD Cell Phone 2............. Base Store.................. 2610-CHICOPEE Cross Street............. Gfc Lead Source................ 0080 Store Associate Key Dates Sale Date.... 11125/2008 FUP Date........... 116/2009 Final Payment Information Credit Date.. 12/4/2008 FPD-Customer..... Source Approval Code RTP Date.... 12/112008 Post Install Date.. 1...Home Depot Credit Card 1... 2... 2... Start Date.... 115/2009 FPD-Home Depot. 3... 3... Inspection........... Close History Comments Commissions Costs Inquiry Order Detail Payments .lob Issues Services Resulting Print Touchpoints Order Entry PO LlpdateJob Accounting Custinfo Work Order Permits HOME OWNED EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CNlR 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 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 1, 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. Date Address of work location ' The Commonwealth of Massachusetts Department of Industrial Accidents Office bf Investigations a- 600 Washington Street 'mom r Boston, MA 02111 . Www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Le6ibly 7n_ , Name (Business/Organization/Individual): Address: ` �/' VY W CitylState/Zip: !M6 Alz Phone#: fl Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.El am a sole propri etor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g_ ❑ Demolition working for me in any capacity.h employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing have exercised their 11. Plumbing repairs or additions g all work self. ' per MGL m o workers comp. right of exemption p Y ['�' p l.. ❑Roof rep?!'As _ insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. ther comp.insurance required.] *Anv 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 information. Insurance Company Name: - _ Policy#or Self-ins.Lie. #: Expiration Date: Job Site Address: I 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify arnd r t1 p 'ns a pe aloes of perjury that the information provided a ve is tue and correct. Sianature: Date: der, Phone#: Official use only. Do not write in this area, to be completed by city or town offzciaL Citv 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#: 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,Im ravemerit Contractor Not Applicable ❑ Company Name Regis Num er Addressl Expiration Date + Telephonee� SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§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 a lemption 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-vear 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) Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [[:I] Decks [Q Siding[O] Other Brief Description of Proposed.,� � Work: 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-exist'iha hoUSinl , domplete the.fottowinu: 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 stones? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. INasscheck 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, 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 as Owner/Authorized Agent hereby declare t a e s atements anad-information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under th s and QeLaWes of perjury. 1 - Print N e Signatur of OwnedAge t Date _ 1 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.---. Rear Building Height M. ..,... _........ Bldg. Square Footage % __...._... Open Space Footage % _._... (Lot area minus bldg&paved a _ µ_ --••� -- parking) #of Parking Spaces --- "` Fill: € (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:'' IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book ' Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 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, 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. 3 � . City of Northampton stags of Perrmit. Building Department Curl Ct Dry i-vaT. rmi � 212 Main Street Sev er, pti"'A w6ill y $ Room 100 e lFabititr4S Northampton, MA 01060 Two sets o�fStructuraf Platts - - phone 413-587-1240 Fax 413-587-1272 Plats�te Plarts �. Oo F Speclf)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 V Map- Lot Unit (�j^� , t "`°� D � �©� Zone Overlay District Elm:St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner�of Record: i ©�-.�,A" Name(Print) Current Mailing Addr Dee plot Telephone Signature 2.2 Authori ent: Na (Pri Cjrrenf Mailing Address: L4©1 Hat. Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building p� (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. Totai=(1 +2+3+4+5) Check Number .� This Section For Official Use Only Date Building Permit Number: Issued: Signature: _ Building Commissioner/Inspector of Buildings Date F 'ifiOl L BP-2009-0648 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 c.142A) Category: BUILDING PERMIT Permit# BP-2009-0648 Project# JS-2009-000945 Est. Cost: $2787.00 Fee: $35.00 PERMISSIO.NIS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group HOME DEPOT AT HOME SERVICES 126893 Lot Size(sq. ft.): 11979.00 Owner: LANDER JONATHAN&TAMMIS Zoning: URA(100)//WSP Applicant: HOME DEPOT AT HOME SERVICES AT: 68 PIONEER KNOLLS Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935-26330 Workers Compensation WORCESTERMA01607 ISSUED 0N:112012009 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION 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 Si nature• FeeType• Date Paid: Amount: Building 1/20/2009 0:00:00 $35.0025334 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Corrvnissioner-Anthony Patillo