29-171 (4) The Con-,man of Hassachusehhts
Department of ndustriaiAccidents
Z Cols•ess.street,.quite 100
oston,MA 02L74-2017
}VYJI V.iYZ lISS.go v1d is
-" Norkers' Compensation Insurance Af�:davit:Builders/Contractors/'Jlectricians/Plumbers,
T O BE?ILED W-I T Ii THE PERlrLrTTL4G AUTHORITY.
_DDUCEIIIt?nformation Please Print Legibly
!tia,Tt�(Bt�i_ness6r•�aniratioarindividuat): � `T�.1 !/J '� 5�-- 2L; �_1•j'
Phone-:
P :
re ue an eranloyee?Check the no box. ';ype of project(required):
am a_ ;lo_^:.,i h _li.ployees(full aad'orpa.—.-t`Mc?_
" 7. ❑New construction
2. }I=_y a sai_prop actor or pa rtn —,•Diti and have no c Lnio_t•c•__wMa' a fc-r me in
: - S. Remodeling
cao cir:.vivo worker'camp.?=isarauicc rcaL mc'.j
,.—.. _ p• ❑Demolition
•y011::;Sa (?\a V. - °_r•co _in i-tnc.rc aLired l i
1 IG❑Building addition
-cowa r and will be ilsg cone c[o_s,o conduct aI!t.ork oa i-i p on Try. I will
-P_L•'`?[a i i Conn- cto.y ei;hcr!,--re woi?:er'comp••, at;ol;sttrancc or are so It I LE]£-.lectrical repairs or additions
"r:^^'o,writ a emplo!:ees.
_ 12. Plumbing repairs or additions
5.,li i=n a gcn aial eoauactorand i haeehimd the sub—contractors listed on the attached sheet.
ti I3. o:repairs
Lase sub-con actors have=Dih-vees ana h�v_•aC76'Cr'c0 L^SLt'�RCOT
� 1� Other ka
o.i ;ii'e.re a coo atiaa and it o=tce l are cxcr�ed heirs of csemotion per\iGi c.
i 5', :!(4):aad we have as ern0oyees-[\o�.er >_ com1.it h..mce rouired.]
s_pLcamm tiitnt ch?ai boil=!Taint atsa flit out the seadca c Iol.s^owiag their wori-a;'compensation nolic}•information.
' ib c ,. _.,:,i,o st:'arit r`is a-CSrii acicating[`ec a c do n ,it;, Ld men h r outside contrac[os must submit a new hind c•it;neicating such.
Con: acior-i tat clte:zk is box West attached an add;r;caal sheet sho;:-i.=:h_ .—c of the sub-coat actors and state wbether or not those e=3ecs have
C"C'it�iQY_s. li'_TtiU-C.ut 1Cta�5 ha,c eta=la •_��.-�Ic melt orotza_ c:r -vat cis come.policy nt tibcr.
1 aia ah ei:?plCtel-tiiai t:(7T0Tltlifi�){'oTn'L'i•s COiltpellSai?D:I iiISllTaliCE f0I'717�'e7flpl0i•BES. Beloit,iS thepollcl'and job site
t7 forule3on. ,'y
Insurzlce Company Name: vv % :J �/7 f
Policy_or Self ins.?ic.-:j�� ✓ U C7 Expiration Date:
.lob Sae Address: D �� Dx, City/State/Gip � .
_Uach a copy of the:S•orker! compensation policy dectaradon pact=(showing the polic; iifn r and ctipiratlon datC).
Failure to secure coverage as required under 1�-IGL c. 152,§25A is a crirninal violation punishable by a fine up to S1,500.00
and/or one-year l;u.rsonrrerc ;;`.:°li as_i.. l n�nal._ _i__the form ai cs iUP WOTui ORDER and a fine o?up io—S?50.00 a
i.Clay against Che violator._•1 copy of this staiernent tray be forwarded to the Omce of Investigations of the DLk for insurance
coverage verification.
(do hereby ce,-t* d p�ral!iec� erju,7 that the i;Iforination provided above is true and correct
r � J 1 ��
Si4natu�e� `'' � / /
� � Datc:
Phone
Official use only. Do not write in this area,to be corr_pieted by city or town official
City or Toyrm: P ermitlLicense
Issuing Authority(circle cue):
1.Board of Health 2.Building Department 3.^ii?;r`?own Clerl_ 4.?lectrical inspector 5.Plumbing±nspector
5.Other
Contact Person: Phone r:
Nov 01 1506:59a p.1
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Furnished and Installed by:
Branch Name:Buston North&South Date:L0_2 �_7_ THD At-Home Services,Inc.
dtb/a The Home Depot At-Hume Services
Branch Number:31 and 33 90813ml irn Turnpike,Unit 1.Shrewsbury,MA 01545
Toll Free 877-90-3768
Federal 11)#75-M698460;NIE Lic#C 02439;RI Caul.Lc#16437
C� ,, (��CT Lic#141C.0565,522:tMA Horrc hnprovemen�tt Contractor Reg.9 126893
Installation Address: 1 QQ _ tSCSC.�t n
City State Zip
Purchaser(s): Wi orir Phone: Home Phone: Cell Phone:
C l [ ] C I
Home Address:
(If different from Installation Address) City State Zip
E-mail Address(to receive project communication-,and Home Depot updates)_
❑I DO RIOT wish to receive any marketing emails from The Horne Depot
Proiect Information: Undersigned("Customer"),die owners of the property located at the above installation address,agrees to buy-
and THD At-Home Services.Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installation")of
all materals 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 Ordera(collectively.
"Contract"):
Job 4: 'r""""Rte"'°" Products: Spec Sheet(s)r1: Pn)ect Amount
L1b` Roofing Sithn- windows Irriula[icn cQ $
5{ ❑Gutters 7 Covers mry L?�xias ❑ / 1 {
Roofing Siding windows 0 Luulation
❑Gutters a Cowers ❑Entry Doo[s ❑ $
Rooting Siding Lj Windows Lj Imulation
❑Gultets/Covers ❑Entry tk)ors F1 $
Rcotiog Siding El Windows 0 Insulation $
❑Gun:n/Cowers ❑EntrvDrxws ❑
Ntlnimum 25%Deposit of Contract Amount due upon execution of this contract.
Total Contract Amount $
t41sinc Ihtrctmgcrs may nut deposit morr Haan one-third of dw Contract Amatntl,
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 pity any balance due. As applicable, each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individua!Product(s)included herein,at
its discretion,if The Hume Depot or its authorized service provider determines thtd it cannot perform its obligations due to a bi uctural
problem with the home,environmental hazards.such as mold, :asbestos or lead paint,other safety concerns,pricing errors or because
work required to complete thejob was not included in the Contract. i
Payment Summary: The Payment Summary # {�- J�-�lJ included as part of this Contract. sets forth the total
Contract amount and payments required fir the depo%its and rowan payments by Product(as applicable)-
NOTICE TO CIJSTOTNIER
You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Compktion 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 casts of materials,labor,expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any other
amounts set forth in this Agreement or allowed under applicable Law. THE HOME DEPOT MAY IiTTHHOIA AMOUNT'S
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOb/E DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
_A_cc_ceptance and Authorization: Customer ajmces and understands that this Agreement is the entire agreermw M".vccn Customer
and The Home Depot with regard to the Products and Installation servictb es all prior discussions and agreements,either
oral or written,relating lo said Products and Installation.This Agreemeigned or amaided except by a writing signed
by Customer and The Home Depot.Customer acknowledges wid abmxs has read,understands.voluntaril y accept;the
terms of and has received a copy of this Agreement.
Acc�pled bvi��� Subm j t
.�, 5 f" Z'�f zv1 s' x cILJI
usKOn7cr's Sinnattac Dare Saks su 's Siimature Date
X Tel e N
Customer"s Signatetre Date
Saks Canvultanl License No.
CANCELLATION: CUSTOMER MAY CANCEL, THIS a.aprlicahki
AGREEMENT WITHOUT PENALTY OR OBLICAiTION `� r
BY DELIVERING WRITTEN NOTICE TO THE HOME 3�9
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS .J LLLJJJ
DAY ALTER SIGNING THIS AGREENICNT. THE l
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIrICALLY PRESCRIBED BY LAW IN
4
City of Northampton 212 Main Street, Northampton, Na 01 060
Solid Waste Disposal Afndavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: � � Y
The debris will be transported by: � ��
Th P _
The debris will be received by: �zG' �I � r
Building permit number:
f
Name of Permit Applicam
T'(P or
- y t
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable E
Name of License Holder:
License Number
hr/G� � o
Address Expiration Date
Signature Telephone
9.;Re`isteredHome lm rovement Contractor = Not Applicable £
Company Name Regis ration Number
Add r � Expiration Date
j
(� /�;Telephon 4 �Z
SECTION 10-WORKERS.'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c:152,§25C(6))
Workers Compensation Insurance affidavit must be completed aad 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 Qwner.Egemp ion
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,
i
i
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement W' ws Alteration(s) F7 Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [[] Siding [17-1] Other[M]
Brief Description of Proposed IAW 69^4"" > > NO
Work: 1787
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa, If New house and or..a8d141.0 to existlnq:ftousinq:corn fete#lie followlnci:
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
Lr y✓ !� as Owner of the subject
property
hereby authorize l):;vo e—Tl"' Jt;l
to act on my behalf, in all matters relative to woo-�kk authorized by this building permit application.
Signature of Owner Date
I,
as Owner/Authorized
Agent hereby declare t t the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
t
Signed under the p ' s and lonalties of perjury.
Print Name �-
Signatu f Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
T hiis column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:' 1 R:E 1 L:I i R:= I a
' j I
Rear
Building Height
r
BIdg. Square Footage j I % —1
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 Q DONT KNOW 0 YES 0
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book I Page and/or Document# 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 0 , Date Issued: ;.
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location: 1
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: j
E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan
that wilt disturb over 1 acre? YES O NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
I
i iais
J
f
xv
r )3epartment use only.. � i
City of Northampton atPerm,t
Building Department h Curb CuCFDri+teway Permit
212 Main Street Sewer-Septle 4varla6�Irty
Room 100 later e'C� "va�iability
�!
sf
_._c..—_,_.._:=:L.::�c;-.._: :f.E_-.:y[I,iY. -:.__—-e3ii:-i:i:--a=:.�s�15a r•'_'..__+:: : :RIM.Northampton, MA 01060 TwolSefsof5#> ct&5l Plans
phone 413-587-1240 Fax 413-587-1272 1P[of/Site Plans ��
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE,INFORMATION
--= This secfiorr to be completed 6y office
__—
1.1 Property Address:
Elm St DiSt[ict. r -:--
SECTION 2.:-PROPERTY OWNERSHIP/AUTHORIZED:AGENT::'.
2.1 Owner of Record:
Name(Print) Current Mailing Address:
C���Tr3� T Telephone
Signature
2.2 Authorized Agent:
I `a Al✓ ✓1'
Name(P ' Current Mailing Address:
AD 1 ��
Sig ure Telephone
SECTION 3 -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'
�/� l
Construction from (8):'
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number 1,3 yq
This Section For Official Use Onl
Date
Building Permit Number. Issued:
Signature:
Building Commissioner n.spector o Buildings: Date
90 DEERFIELD DR BP-2016-0732
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mar-):Block: 29- 171 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2016-0732
Project# JS-2016-001229
I st. Cost: 54704.00
Fee: 540.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq.ft.): 18382.32 Owner: EMERSON EDWIN B III &JENNETTE
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT. 90 DEERFIELD DR
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON:121112015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 2 REPLACEMENT DOORS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.N.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 12/1/2015 0:00:00 $40.00
212 Main Street, Phone(413) 587-1240, Fax: (4 13))587-1272
Louis Hasbrouck—Building Commissioner