29-033 (3) 32 PIONEER KNLS BP-2017-1085
GIS4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-033 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-2017-1085
Project: JS-2017-001853
Est.Cost:$12803.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 106011
Lot Size(s9. ft.): 11979.00 Owner: SCHNEIDER DAVID& HPFOMI
zoning_ Applicant: HOME DEPOT AT HOME SERVICES
AT: 32 PIONEER KNLS
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 0 Workers Compensation
NORTH PROVIDENCERI02904 ISSUED ON:3/29/20170:00:00
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 3/29/2017 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
_ Department use only
1" _ _ City of Northampton Status of Permit:
Building Department Curb Cut/Dnveway Permit
II t�IRfv n0 7 9 '2'i ''I' 212 Main Street Sewer/Septic Availability
'I Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 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 6,- /7- I V 26
1.1 Property Address: This section to be completed by office
l /+ Map Lot Unit
9Z 1)wju i KJmt)/ f�.� Zone Overlay District
I` ✓H. LLfY� Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
12--
Dftv)P <'ri/,,lgi MLS 1z 7Ol)es kn oui&3
" Name(Print) Current MailfVtl:ress/2-rala +-^ifr 0 IVW2.
l 7: -r/ Telephone t) ) y/ - . 033k
sgnamra ? — .i
2.2 Authorized A, en
Name(Print ) Current Mailln Address'.
11y2 4- n as a 4 0-
agnature Telephone 4101— ,-23 /'9J5-'--
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building )2) vyn/� (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 JJ ..ed q 'o
6. Total=(1 +2+3+4 +5) 12 ..e i Check Number a 0 39' 440
This Section For Official Use Only
Building Permit Number Dale
Issuetl:
Sig nature:/ l f� -- — y- ,7- /(/�/-)
u 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 in he filled in to
Building Depanmcnt
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Hcight
Bldg. Square Footage 90
Open Space Foolage ru
Lm area inlnux tilde&timed
perkiest
g of Parking Spaces
Fill:
Mdume K LzuIium/
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document k
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and Location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
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 O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
•
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ri
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [ J Siding[C] Other[❑]
Work_
Brief Description of Pr �y�L4i� ��ed �/q
.�a'LIY�i'CV,C �
Alteration of existing bedroom Yes No Adding new bedroom Yes No �ie[Zni-
Attached Narrative Renovating unfinished basement Yes No C
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. 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 Ta-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR�IAPPLIES FOR BUILDING PERMIT
I, T7NT / as Owner of the subject
property
hereby authorize
C)1-' �11i� &rife? J 3
to act on my behalf, in all matters relat ve to work authorized by this building permit application.
(In) c7 — 7z 17
Signature of Owner Date
n�[� —7"e0 Date
I. Lc7, G 9/" 3 � ,as Owner/Authorized
Agent hereby de are that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
Signed under the r s an. penalties . perjury.
!� A ,f � / ' /'"
Print Nam-
Signature of owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supe is�or:) Not ApplicableEl
�
Name of License Holder: YV � t7Li- /j� /Qkff�j
ber
/�,. g
License N —1
sb
Address i Expiration
Signature / Telephone
9.Registered Home Improvement C ntractor: Not Applicable ❑
Tie i 2r 1 z g 3
Company it.201 /-- Registration Number
Address Expiration Date
• �(/r.41:1 P.i l Telephone9J
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit m st be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi permit.
Signed Affidavit Attached 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. .\ 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 Law's and State of Massachusetts General laws Annotated.
Homeowner Signature
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: @2�64,g >O l F2Ca1a //,i"�/ ` ow62—
The debris will be transported by: G09---P -7�f/' -
The debris will be received by: 14)g-etf //in-
Building
r/n
Building permit number: �y
Name of Permit Applicant I � !f / )!'/
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
—t. —7
97
Office ofInvestigations
M.--iv J= 1 Congress Street, Suite 100
;l/� Boston, MA 02114-2017
�� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Rusiness/OrganizatioaIndividual):
Address:
City/State/Zip: Phone#:
Are you an employer? Check the appropriate box: Type of project (required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
have hired the sub-contractors 6. 9 New construction
listed on the attached sheet. 7. 9 Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have S. 9 Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.'
required.] 5. ❑ We are a corporation and its 10.9 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.9 Plumbing repairs or additions
myself. [No workers' cora right of exemption per MGL
Y p. 12.9 Roof repairs
insurance required.]' c. 152. §1(4),and we have no
employees. [No workers' 13.9 Other_
comp. insurance required.]
*Any applicant that checks box PI must also l ill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
i 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
emplovccs. If the sub-contractors have employees, they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance fbr my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lie. it Expiration Date:
Job Site Address: 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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a tine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
City 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#:
A a CERTIFICATE OF LIABILITY INSURANCE DAAT MM/ODNIYYI
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CQNSII I UTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and condittans of the policy,certain policies may require an endorsement. A statement on this cartifIcate don not confer rights to the
certificate holder In Ileu of such endorsement(s).
PRODUCER CoNtACT
MARSH USW INC. NAME:
TWO ALLIANCE CENTER PRONEgg= tjvi Nnt:
]SN]LENOX ROAD.SUITE 2400 EMAIL
ATLANTA,GA 30325 ACDHEBS ,^
WBURBRISIAFVC ONO COVERAGE I NAM*
104E2-Home)U1'M97.IP INSURER A_OM RapubNC Inexance Co 124117
INSURED INSURflR e'Me General InWIance Company 142757
THE HOWE DE'OT.INC
HOME DEPOT U.S P..INC. INSURBac:New Hampshire ins Co 123941
2455 PACES FERRY ROAD
BUILDING C-20 INSURER Bi 1
ATLANTA,GA 10339 INSURER2:
INSURER F'
COVERAGES CERTIFICATE NUMBER: ATL-00374636514 REVISION NUMBER:2
THIS IS TO CERTIFY THAT 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.
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I LLeee roe OF INSURANCE INSOW1..O..' POLICYNUMBEp Mw�w� 1MMDINOM'SYCY1 LAT
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AA "I COMMERCIAL GENERAL LIABILITY MWZY 310022 10]1011201 103111112018 cACHCCCURRENC= S 9,0000W
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CERTIFICATE HOLDER CANCELLATION
HOWE DEPOT USA.INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
2455?ACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ATLANTA.6A 30339 ACCORDANCE WITH THE POLICY PROVISIONS.
Ammar:Fs REPRESENTATIVE
of MEM USA Inc.
Manathi Muklellee Stsumwi -}4-.0.0.En at4_
IC 198B-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
•
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Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration; 126893
Type: Supplement Card
Expiration: 8%3/2018
THD AT HOME SERVICES, INC.
RICHARD TROIA
2455 PACES FERRY ROAD, HSC C-11
ATLANTA, GA 30339
Update Address and return card. hark reason for change.
Address Renewal I Employment I Lost Card
Office of Consnmrr Affairs C Rosiness Regulation Liecasc or registration valid for individual use only
NOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and nosiness Regulation
Registration: 126893 Type: 10 Park Plaza -Suite 5170
Expiration: &a/2018 Supplement Card Boston, MA 112116
THD AT HOME SERVICES, INC
THE HOME DEPOT AT HOME SERVICES - I
RICHARD TROIA ^�
455 PACES FERRY ROAD, HSG
I
ATIANTA, DA 30339 t p +1--
thiekrdnietall j 01 191id Ivrthnnt signature
by �Y v�Yf't�e
e h
bYr� K. s .Y, L,t ••u , -N 3..T- i.iai#F. at"u.. _ ,A
, rty
• s1-4
#„mss¢ C5SSL 106006 a
1:4-, -ki▪ s-r
is .4..,I .efiiU
1ill u:
" ,it
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t .F i t .c.i 3�V'b�Lr 4:4 %, ' y�- �' i 4. 2.
Off+
Home Depot Contractor License Numbers:
MA Home Improvement Contractor Reg.#126893
Salesperson Name and Registration Number:
Timothy Drost : HIS 0553710, R-R-073-15-00005
Home Improvement Agreement
Home Depot U.S.A., Inc. ("Home Depot")or Service Provider named below will furnish, install and/or
service the equipment listed below at the price, terms and conditions as outlined on this form.
Customer Information:
David Schneider (Boston North 9857159
Test Name - last Name tt ch Name Leadk .
32 pioneer knowles FLORENCE „I MA 101062
Customer Address 'CIn _ State Zip
(413) 341-3834 ....... .......
Flame Phonet/ Work PhonUN tcellneN
schntomi@gmail.com
Customer EmaIAddress
NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR
OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT:
908 Boston Turnpike Unit 1 Shrewsbury MA 01545
Address ... ZiM State Zip
Or Email CustomerCancellationNorthEast@homedepot.com
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME
DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME
CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU.
OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT
HOME DEPOT'S EXPENSE.
THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL.
Acknowledged 6y:
X 02/19/2017
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Contract Price and Payment Schedule: Payment of the Contract Price is due upon completion unless
a different payment schedule is specified in the State Supplement.
12&03.00 Includes all applicable discounts, rebates, and , taxes.
Contract Price $ Excludes finance charges!
Minimum %deposit$ Due Immediately
Remaining balance $ Due upon completion
Finance Charges
*Any interest payments or other finance charges will be determined by Customer's separate cardholder
or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's
payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or
loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service
Provider may collect Customer's payment(s)made payable to The Home Depot.
Insurance proceeds will will not v be used to pay some or all of the total amount of sale.
Description of Work to be Performed:
Installation of Roofing
A more detailed description of the work to be performed is included in the section entitled Scope of Work
which appears on page 3 of this Agreement.
Anticipated DeliverLDate 1 Installation Schedule
Approximate Start Date: 04/16/2017 Approximate Finish Date: 05/14/2017
All dates are approximate and subject to change based on unforeseen events including inclement
weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if
applicable.
Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you
consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and
written communications related to this agreement. By contacting your Service Provider, you may update
your email address, withdraw your consent, or obtain a paper copy of the Agreement or related documents
at no charge. By providing your consent and verifying your email address above, you confirm that you
have access to a computer that can receive and open emails and PDF documents.
By initialing this paragraph, I consent to receive only electronic records related to this transaction.
t Initial
Acceptance and Authorization: By signing below, you authorize Home Depot to (a) arrange for Service
Provider to perform Installation and/or(b)order and arrange for the delivery of special order merchandise,
including special order merchandise that may be custom made,as specified in this Agreement. Do not sign
if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.)
By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety,
including the General Terms and Conditions and State Supplement, if any. You further acknowledge
receiving a complete copy of this Agreement. Keep it to protect your legal rights.
X� J 02/19/2017
Cualumnl8IgnaWn Dale
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Cosen:rlir applicable) Dale
XI - -- I 02/19/2017
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License number(s) held by or on behalf of the Home Depot:
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