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29-582 131 WOODS RD BP-2016-1290 GIs#: COMMOWEALTH OF MASSACHUSETTS Map•Block:29-582 ITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2016-1290 Project# JS-2016-002222 Est.Cost: $12178.00 Fee: $40.00 PERMISSION IS,HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 106011 Lot Size(sq. ft.): 22738.32 Owner: PULSIFER STIlPHEN E&LIZA M PIERRO-PULSIFER Zoning: Applicant: HOME DEPOT AT HOME SERVICES AT. 131 WOODS RD Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCER102908 ISSUED 0N.-5151201&0:00:00 TO PERFORM THE FOLLOWING WORK.•STRIP & SHINGLE ROOF 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#'i 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 Sigpature: FeeType: Date Paid: Amount: Building 5/5/2016 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Status of Permit ` Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Q` Room 100 Water/well Availability " ©rthamp ton, MA 01060 Two Sets of Structural Plans \��N�',NMP��O� of Noae�psoN one 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 I �V Zone Overlay District Elm Sf.District: CIS,District' SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Polz,) "I 3� �� '� l�• ��Z Name Print Current ailgo Add s: ✓�� > l � Telephone Signature 2.2 Authefized ent: + Name( rint { Current Mailing Address: 2,49 Signa Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building ^-� /7/� (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) Check Number a - This Section For Official Use Only Building Permit Number: IIsssued: Signature: Building Commissioner/Inspector of Buildings 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 0DONT KNOW 0 YES 0 ._...._... ._..._.._._..__..._._... IF YES, date issued:, ........................ _ IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT 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 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued C. Do any signs exist on the property? YES NO 0 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: !..._.....w 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. i SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors C] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[71 Siding [O] Other[O] Brief Description of Proposed ,, Work: aC�jnit�✓� N10 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. Ma$scheck 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 wo rized by this building permit application. _ Signature of Owner Date 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 unr pai and penalties of p r ur . J Jj2w le Print Name Signature 0(/caner/Agent Date i SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervi r: Not Applicable £ Name of License Holder: `.<.ov 1 a/I ^ License Number TA 3i _/ —f Addresd Expiration Date Signature Telephone I9. Re istered Home Imrovement C ntractor: _ . Not Applicable £ Companv Name Registration Number Add Eviration Date ' ® Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 162,§26C(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 th permit. Signed Affidavit Attac 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 I e a 77,ke Cot-�Imonweulth of1�.;assachurse& Depaz ;wen'oafps ��:.fst-LtFIAcdde;ifs y o l�°ds'24`$LcY'e�j 1.)c&—e 100 4 - 7tC."r 'Uj '�'Go?��^ 4a �s'e u�s� ai _ �air3aR��sa "'Es" : u'fl� s� �izr� 9 PL-Rease 1\I aiLP'.( IISL=-s!Orggan Tz t!?oa/IIIdividual): 1- ddxa5 s i• /� }')r� n 3/F✓...r-+ ,. �V J t f phcut:ri: r 1 -- 7'1= s 3-aae of project(requi edl): a emclo;rer vtL 4. a genetzi couiractor and I «e 11.:ed tie sty,-coot-raceors a. n New construction cmp?oy ees (it�zJo pa:� ?e�. 2.❑ 1 am a sole nra-,deYor or pZiner- listed on tho aUched sheet. i 7. []11emodelmg i ship and h--:ve no e play ees These sul-goutractors Lave o. 0 Domolitioa :voL i for nae in any dapa 't,�. employees azd have workers i B\To-ror�.e�s' coma.insurance comp. stake 9. ❑Bin addition r.,ceui,-ey•r 5. ❑ Wa are a car,,, and its 10.❑Electrical re-pairsor addi<dons , 3.-E—J _ a Lomeovmer do orf,all-work oLr,-s hay e,:ercised their 11_Q Plimmbing repairs or additions LyseL. ,10`:ton ers' comp. nslt of ehulgdonper it-lGls 12. "ooi repairs } ins.tn ance req iced.i t c. 152,§1(4),and<2e have no employees.1 a workers' 1 _ Other comp.ins,ronce required.] i =kny appflcznt that ch—-z bc. i#1 must also fill out the section below Sliming their v(oric-am'compensatica policy Mrormation. r�lorceoencrs crho sul ur tfhis affidavit adice b ih�ara doing allsro:k and*ca Ilse ouzidc eontractvcs must submit a now ar'idavit iadicafmg srra $Ccntmcto;s th, chccL,this bo;:must attwhcd m additional s§ere shown g the rm'me ofthe sno-cant aacturs and state vrheiher or not those entities have employacs. L the sub-contractors have employees,they mns'i pravidetneir-meter'comp.policy n=bar. i C i3 CP e,w1p10"t?r 64C,:'`-is-17ij-0.11 .;yq z IP0i,1re;- s C0T'I �JZuC�9D72 t?Sr�im G ZC2 i(1^aa-iy Lr 37IlDyees. Below s the policy rundiob&.9 I Insurance Company'iame:,;/6, X1-1 ;1'11`6 -4 P 7 Eviration Date: ' F , Job Site Address: l Ciiy(State/Zip: vj .—tach a copy of the cepa i?efi s' cejmpensafion pulley sie^iva_a'iqu Gage(siaob7iu 'the p2a)st y na bt r and ezparaeon elate}. Fat lure to secure coverage as required under Section 25F+oflv±M c. 152 caa lead to the imposition of carnal penaltim of a fine.up to 14,500.00 and/or one-year rnprisonmen;,as well as civil penalties in the fora of a STOP WORK ORDER and a ftne oz up to 14i�250.00 a dwI agaiist the violatur. Be advised dint a co0y of t'Qis statement may be forwarded to the Office of InvestigCtions ode DIAfor tstyaq R coverage verii-aeatioa. GTD ZeE�Jy f E' c �cy22 tZ.B C Fes. :GGFJy'D� r a a l vhzat'th ft, o7mmla'.pr owl ed L3�3��2�a:c3e fT: co. act Si e: G� — Date: Phone 9P�{, � i i 17CaCt ease 0-dy. DO not trrl8e€s>diis cr e",to he co_Vielev,�y ci�J or 90t713 00leFr�l C4,17 or`='o:•fz' : f s$talt`s g Autho—IRaj/ 11 I.Board of Health I Building and c ent 3.Ci-tyrL own Clerk 4.Me2tr icai Inspector 5.Numbing Lspecior f 6.C"Eer - 4 tan ac ?erson: P hone;#: i City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit 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: 1 ?�,/ �vP2� ' The debris will be transported by: )-)-)Tz:— The debris will be received by: � f� 'r Building permit number: Name of Permit Applicant Date Signature of Permit Applicant HOW,,IMPROVEMENT CONTRACT PLEASE PLEAD THiS y 2,4 .sw("L Sold,Furnished and Installed by: Branch Name:Roston North&South Date:_/�J. THD At-Home Services,Inc. d/b/a The Hame Depot At-Home Services Branch Number: d 33 909 Boston Turnpike,Unit 1,Shrewsbury.MA 01545 Toll Free 877-903-3768 Federal ID#75-2698460;ME Lic#C 02439:RI CMt-tie#16A27 CT lie N1HIC..0565522;MA Home improvement Contractor Reg-#126893 Installation Address: i 3 "W+ '�JL �" �e�d U l0J , —� City State Zip Purchaser(s): War Phone: Home Phone: Cell Phone: Nome Address, (If different from installation Address) City State Zip E-mail Address(to receive project communications and Home Deport updates): LJ I DO NOT wish to receive any marketing emails from The Horne Depot Project information: Undersigned("Customer"),the owners of the property located at the above installation addreas,agrees to buy, and THD At-Home Services,inc.("The Home Depot")agreas trnfumish,deliver and arrange for the installation("Installation")of all materials described on rhe below and on the referenced Specs,Sheet(s), all of wbieh 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"): Loh Rdirn,o Products: Spec Sheet tt k: Project Amount txrfing OSiding LJ WindowF U Tnsulatidn +� q M rY ❑Gunem 1 Covers MEntryTkxxs ❑ J2- ( $ \�L t Roofing ElSiding Ll Windnws LJ Imulatioin [I Gutters I Cover% EJ Entry Doors Cl_ Roofing Siding El Windcnas EJ inwlation $ ❑Canters I Covers ❑Entry Doors❑ _ Roofing Siding Windows insulation ❑Gutters!Covcrs ❑Fntry T)om d Minimum 25%Deposit of Contract Amtou ll:due upon execution of this conn act. Total Contract Amount $ 1 Maine Purchasers may not deposit roore than one-third 4 the Contract Aim unt Customer agrees that. immediately upon completion of the work for each Product,Customer will execute a Completion Certificate (one for each Pr(xlucl as defined by an individual Spec Shcct)and pay any balance due. As applicable,each Customer under this Con tract agrees to be jointly and severally obligated and liable her¢=der. (� Tlic Frame Depot:reserves,the right to issue a Change Order or ter'mlinate this Contract or any individual Product(R)included herein,at its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home,environmental hazards such as mold,asbt`stos 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# �,3t , 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 of the Contract at the time you sigh. Do not sign a Completion Certificate(note; there is one Completion CcrtifFcatc 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 crus of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination,puts any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WI'T'HHOLD AMOUNTS OWED TO THE ROME DEPOT FROM THE DEPOSITPAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES Folk RECOVERY OF SUCH AMOUNTS. Acceotance and Authorization: Customer agrees and understn ds that this Agrccmcrot is the entire agreement between Customer and The Home 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 Agrccmcnt cannot be assigned or amended except by a writing signed by Customer and The Home Depot_Customer acknowledges and agrees that Customer has ream,understands,voluntarily accepts the terms of and has received a copy of this Agreement. Accepted by: c Submitte 4- C �tAat j i"2tt-Z r] X ustore Date Sales Consultant's Signature Date X Telephone No. Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS as apprcabteT AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THF HOME DEPOT BY MIDNIGHT ON THE THiRD BUSINESS DAY AFTER SIG.NiNG THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONF. iS SPECIFICALLY PRESCRIBED BY LAW TTY C:USTOMEW&STATE. NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATFID ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT 03-17-15 Whfte-Branch File Yellow-Customer I