29-592 120 WOODS RD BP-2016-1291
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-Block:29-592 CITY 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-2016-1291
Pro iect# JS-2016-002224
Est. Cost: $13365.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 106011
Lot Size(sq.ft.): 21300.84 Owner: KAMEL MOHAMED S&PAULA D
Zonine: Applicant: HOME DEPOT AT HOME SERVICES
AT. 120 WOODS RD
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.51512 01 6 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# 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 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 StatusofPerrrirt.
Building Department Curb Cut/Driveway Permit
C 212 Main Street Sewer/Septic Availability
MAY f Room 100 WaterNVell Availability
TioNs N rthampton, MA 01060 Two Sets of Structural Plans
pEPT.
C"TVA Ap p ON,r�A 13-587-1240 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
Zone Overlay District
Elm St.:District CB,District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
6M!�Wf 11,9L2-
Name(Print) Current M iling A r s
Telephone
Signature
2.2 Authorized A nt:
l� i � Tial - Or-fLV��.� -
Name(Pri Current Mailing Address:
Signat a Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by permit applicant
1. Building ,,,�t (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=0 +2+3+4+5) ,Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
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 i
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 0 DONT KNOW Q YES Q
.........................._...._.......
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 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 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 Obtained Date Issued:
C. Do any signs exist on the property? YES 0 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.
..... ........ _ .
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.
SECTION b-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors I]
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [Q Siding [0] Other[O]
Brief De ption of Pr
Wor .
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 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. 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
0 I. pa as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters r ative to work authorized by this building permit application.
Signature of Owner Date
I. 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 undierfil'e)painsphd penalties of pe .0
Tr
Print Na
Signature Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder: 9V`� 6 a 4—
v
License Number
7WIT-� 6v,>en 1Z Z
Address Expiration Date
Ile
Signature r� Telephone
i9.Registered Home Im rovem nt Contractor: i Not Applicable £
Company Name Registration Number
7 �---3-/d
Address f� �' Expiration Date
•!/ ���'/� Telephone
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 Attac Ye ... UE_ No...... £
11. -Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied DwellinEs 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
ne Camunonweahh oflllassachmseit3
of
a ,iof
1 C0f22:-M 01kie 100
Corzar
,CnS,arka lmqT Maa- jn
20-! -
Address:
U01-4 r /!VAL J/t YPhone 4:
:,L? acti e :)7'o9m-' b
Tpe of projeat(roc paired):
i.D i am a emiralmer wird-1 4. 7,,
aia z gerzzral coatractor, and I
6. New contraction
e m-Dlo (fad, au&M—nact-tim, h^";'ted te wb-con:Lractors
- yees(nom,.
- e). 7. ❑Remodeling
2.F-I I am.a sole p-oprietor or pa- ter- listed on t—he atiached shieeL
ship and no.C.M-ployeas These sLib-contractor-shave Of'. 0 DomoUtion
emplTyees -and have viorkers'
1,70LIdng rOZMe 171 any 02?, aalty- 9. M B-m-lding addition
C,.\To-,7.rofke.—�' comp.insurance ccs p.ms=i Moa-•
rec-m-red-I 5. ❑ we sip,a carp oration.anal its I 01�Electrical-main or additions
3.❑ 1 aim a Homeowner doing all woflc- offi=s ha-e exe-Ecis ed their ILEIPIumbiag repairs or additions
T
MYSCEL [No--iforkers, camp. rightt of exdmaion per it,3OT 12,N�rzco-Lrepairs-
im--mce reqairad-] 1 c. 152,§1(4),Md have no
am—playees, [oto workers' 13-El Other
comp.insurance required.]
.,Any applicant that chec!=buiz 91 must also fill'out the section Wor.,shor-Ang their workers,compensation policy in-lormation.
T Homeowtiers who submitthis a0d-aiit ladiczJngti�a =doing an wm-,and ttm hire antside coatrncturs must submit,anew,Mdw.,k indicz9ngstyli
tContmcions thft checLr this bw>must attmchcd an additional sheet shoving the name of too mb-cou=rors and state whether or not ftsr entities have
emplayecs. Lf the sub-contmetats have employees,they mart provide their vmrterz'comp.policy number-
rkers J CL's,2g72itSG"fon kswl -emcef
hismance Company Name,-" Al ci,- I S f', v,
PCHCY 0 or Self-has.Lic.4: �',fv '—Expiradon.Date:
Jot)She Address: City/State/Zip:
Atta2 C0137 0arae workers,comparasn"Hon,-30LICY declamtwz page(shag the policy number and expiration date).
ch �
Faffiva to sec m. coverage as required mder Section 2,5A-oEYIGL C. 152 can lead to the imposition of al penalties of a
flue up to$1,500.00 and/or one-year finprisonrnent,as well as civil penalties in the f-bm of a STOP WOU...ORDER and a fma
of up to$250.00 a day agahvri the-violator. Be advised that a copy of emis statement maybe fbivarded to the Office Of
2!ivesdgadoni oJIF dio DIA for insuraace coverago veri-fication.
'do{dee 6olwb�s' andeQ Eel
Si Date:
ft
Mone A �5-0
�fj7cidl nse mziy. D-10 Rol"Prite ftz this arec;to he rm-,,pMaged by cL� -wz o WA j or toi
Czi"Y a T T 07r-n ft
�SSU Lg Antako.-IILT(circle OR6):
D-o a mil a'I He-alta 2.Bu Edina D-1)a rlmant 3.City /Town Clerk 4.Menctemal Insp zetor 5.Pol-amNng lm�moor
ether
,CC?ntse'?erson; -Phone ff:
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:
The debris will be transported by:The debris will be received by:
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
ROME IMPROVENIENT CONTRACT
PLEASE READ MS
2,1< W Sold,Furnished and Installed by;,
Branch Name:Boston North&Sonth Dater-J-j— TMD At-Horne Services,Inc,
d/b/a The Horne Depot At-Home Services
Branch Number&33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Ree-877-903-3768
Federal JE)ff7l-269W;MELic#CO2439-.RlCont.T,ic*16427
CT Lic#141C,0565522;MA.Home Irnprovernott Corittactor Reg, 126893
Installation Address: 7!1
City State Zip
Work Phone: Home Phone- Con Phone,
Home Address:
(If different from Installation Address) City state Zip
E-mail Address(to receive project communications and Rome Depot updates):
[j I DO NOT wish to receive any marketing cinalls from The Home Depot
P�W!V Lor Undersigned("Cirtomer"),the owners of the property located at the above-installation address,-agrees to buy.
,�hon: Undersi
and THD:At-Home Services,Inc.("The Rome Depot")agrees to furnish.deliver and arrange for the installation("Imtellation")of
all materials described on the Wow and un 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 f: (T—.d Itfo—) Products: _1199ee Sbews) rroled Amount
Roofing LJSiding[I Windows 0 hvq—Ulation
171G.ttv,/Covers LJEntry Door; 0 13 3C
MRoofing ElSiding 0 Windows Ll insulation
EjGuttcrs[Covers ElEntryDoors 0__ $
Roofing0Siding El Windows 0 IDsUladOn
0clutters I Covers []Entry Doors 0— 2,
URoofing Siding Windows fnsudadc+n
Ljoutters/Covers ElEorry boars n_-_ $
Mininumn 29+%Wpoxit of Contract Amonot Sue upon cWcution of ft tontract. Total Contract AmountLL$
Nbine purchasers MRY not deposit more than AffiWIthird of the Unut=t Aounnit,
Customer agrees that iminediitely 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 Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Prod uct(s)included herein,at
its discretion,if The Home Depot tv its authorized service provider determiner that it cannot perform its obligations due to,,istructural
problem with the home,environmental hazards such as mold,asbestos or lead point,other safety concerns,pricing errors or because
work required to complete the_0 was not included in the Contract,
Payment Su The Payment Summary
included as part of this Contract, set' 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 corrttely filled-in copy of the Contract at the time yousa Do not sign a Completion Certificate(note:
there is one Completion Certificate for each listed Product aq defined by individual Spec Sheets); before work on that pr
is complete. oduct
In the event of termination of this Contract,Customer agrees to pay The Horne Depot the costs of material-
,labor,expenses
and services provided by The Home Depot or AuthoriTed Service Provider through the date of termination,plus any other
amounts set forth in thi%Agreement or allowed under applicable law. THE ROME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THF,HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
A5;cc�tance and Authqp
:ration: Customer agrees and understands that this Agreement is the entire agreement between Customer
and'Khe Home Depot with regard to the Products and Installation servicer and supersedes all prior discussions and agreements.either
oral or written,reladn to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed
by Customer and gellonne Depot.Customer acknowledge.,and agrees that Customer has read,understands,voluntarily accepts the
terms of and has received a copy of this Agreement.
Accepel Submitt
11fal-.K LA-2,4- ZA X
,Vs Signature Date Salus Consultant's Signature Date
Telephone Nu. 41> -6 3
Customer's Signature Date Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS
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 it
D 4FE-11IS0
CONTAINS A FORM TO USE V
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE,
NOTICE'ADDITIONAL rrRm.s ANI)coNDYTIONS ARF%T8TFD ON TNF PVVFRSR SIDE ANT)ARE PART OF 114TS CONTRACT
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