24A-114 78 PROSPECT AVE BP- 2011 -0323
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map :Bloc 24A -114 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-2011-0323
Project # JS- 2011- 000528
Est. Cost: $4606.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 20995.92 Owner: GUSAN STEPHEN
Zoning: URA(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT. 78 PROSPECT AVE
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 () Workers
Compensation
WORCESTERMA01607 ISSUED ON. 10 /7/2010 0:00:00
TO PERFORM THE FOLLOWING WORK.- INSTALL REPLACEMENT WINDOWS
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 10/7/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
M
c
City of Northampton
Building Department
212 Main Street .
Room 100
Northampton, MA 01060
phone 413 - 587 -1240 Fax 413 - 587 -1272
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
ap . Lot Unit
Zotre Overla�r Distract `
El"'14 'Dlstrict ` `` CB District
SECTION '2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
f54 I'a
Name (Print) Current Mailing Address:
r�� �t }— Telephone
Signature
2.2 Authorize ent: r n
Name (Pri ) Current Mail g Ad �l�1
3
Signature Telephon
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
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Onl
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date '
�
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomptete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front F
Re
Building Height
Bldg. Square Footage F
Open Space Footage %
(Lot area minus bldg & paved
# of Parking Spaces
A. Has a Special Permit/Vahance/ Finding ever been issued for/on the site?
�� �� ��
NO x�� DONTKNOVY ��' YES v+�
/F YES, date issued:
IF YES: Was the permit recorded at the Registry ofDeeds?
NO �� D
v_� ~.,. .`.,~,, 0 .^~
IF YES: enter Book PageF and/or Dncument#
��
B. Does the �tecontain a brook, body ofwmter.orwetb �� wetlands? NO ^�� DONT KNOW «�� YES �~ ��
� .
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tnbembtained »�� Obtained »-� Qate|ssued'| 1
�~� «�� ' .
C. Do any signs exist on the propert �� �� y7 YES »�� 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, gradingexcavation, or filling) over 1 acre orisit part nfo common plan
that will disturb over 1acre? YEGK l NO K �
�� ��
|F YES, then o Northampton Gtnnm Water Management Permit from the DPW isrequired.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement
ppd ows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [0] Other [EA
Brief Description of Proposed ( -�i„�
Work: /�i
Alteration of existing bedroom Yes No dding new bedroom Yes No �el6 -
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a C1TISkllyCd�1 �O St rf' 4�I1]1C7E�l�i :r. `,
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 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 applic tion.
Signature of Owner Date
I, as Owner /Authorized
Agent hereby declare that thd s t e is and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under th pai and pe erjury.
Print Nam
- / PA Z2 'd
Signatur o r Date
f+
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor �- Not Applicable ❑
Name of License Holder i
License Number
1
Addr s Expiration Date
Liv
ig tur Telephone
Not Applicable ❑
Company Name F- gistratiorf Num er
Address T � Expiration Date
WAQ1 AW 1 ephone -_.
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (KG.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 buildingpermit.
Signed Affidavit Attached Yes....... No...... ❑
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
T
?7te Commonwealth of Massachusetts
Department of Industrial AOcidents -
Office of Investig, ations
} 600 Washington Street
Boston, MA 02111
www.massgov/dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print L � 'blv
Name ( Business /Orgmization/Individual): t
Address: ►Y
City /StatelZip: n � er� 26 "3 bne a employer c 6-
Are Za employer? -Cheek the appropriate'box: Type of project (required):. ��
1. m Io. er with 4-- ❑ I am a general contractor and I
. y 6. ❑ New construction
employees (full and/or part time).* have hued the sub- contractors
2.. ❑ I am a sole proprietor or partner- listed on the sheet 7. [] Remodeling
ship �d have no. loyees These sub - contractors have. .8. ❑ Demolition
working for me in gay capacity. employees and have workers'
• mctminrP #.: 9 [j Building addition
No Workers' comp: insurance _ Comp. • _ -- -_
re ed 5. [] We are a corporation and its 10 ❑ Electrical repairs or additions
officers bavexercise their d 11. Plumbin r
3. El am a homeowner doing all work ❑ g epairs or additions
myself [No workers' comp. riit of exemption per MGL 12. ❑. repairs
insur -Ante required.] t c: 152, § 1(4), and we have no
to ees: 13 �j
. �P y [N o workers' - .
comp. insurance required j
'Any applicant 3bat checks box #Xl a =..also fill alt the section below "showing 6- e irworka3' compensation policy information
t Homeowners who submit this affcdavit,indicating they are doing all work and then, bire outside contractors most sub=t a aew affidavit indicanmg such.
ZConuactors that check this box mnst.attached zi additional sheet showing the namc of the sub=contractors and statewhether ornot:those- catities have
employees. : If the sub-contractors have employees, they mast provide their workers' comp. policy mmnber.
tam 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. Lic. Expiration Date:
Job Site Address: City /StawZip:
.�
Attach a copy of the workers" compensation licy declaration page'(showing the p9licy number and eagira on date).
_ --
Failure to secure coverage: as required under- Sedd - , 25F: - ofIvfGL c: 152 ca i lead - 6 the n iposition of crinima.I penaltres of a
fine up to S1,500.00 and/or one.- year as well as civil penalties in the form of a STOP WORK ORDER and! a fmc
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
Investisatrons of the "DIA f uraucc overage verification
I do_hereby certify un 'p-aft p .. s ofperji" thatthe reformation- provi&d.Abov rr.
07h e)
Si lure _ ate
Phony
Official use only. Do not write in this area, to be completed by city or town 'off ciaL
City or To
vsn: 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 #:
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 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, 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
I, 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
Date
Address of work
location
Sold, Furnished and Installed by:
Branch Nuo Boston Date: T W At -H0me Setvices,Uje,
d!b/a The Home Depot Avliome Services
345 A Greenwood Street Unit 2, Worcester, MA 01607
Branch Number: 31 Toll Free (840) 657 -5182: Fax.(508) 756 -8823
cderal ID # 75-2698464; W...i is O C 02434; Rl Cont. L.ic# 16427
'l
CT• c # 565522 MA Imptovemx C mWitetoir Reg. # 126893
installatlonAddrew: it to �(G
City zi .
r u r ceeeer(s 1: work Phone Flanks Phone; Cetl Phone:
11ame ,Address:
(If different from lmrtalladon Address) City 1 State zip .
E -mail Address (to receive project communications and boots Depot updates):
0 I DO NOT'vrigh to receive any ruMtMing email= from The Home Depot.. � V
Pretext Iatermatiou Undersigned ( "CuAotnWl, the ewiters'of kite property located at ihe'above •iniWIstion address. agrees to bu },
and TIPS -Home Services. inc. ("Th# Omaha Depot ") &FQm•tb 'fbt is4, deliver �aud at6+$e :fhr "tire installatrdfl'( "ilosRt►Batiaa ") of
all materials described on the below xrxl cm the referenced Spic: S t(a), all of, which are incorporated into this Contract by this
reference, a long with aA.y applicab State Supplement and Payn*zw Summary attached herew and any Change Orders (collectively,
"Contract"):
Job #: amnor{to~i Products s # Pro Amuuot
15 Sim L3 Windpm 0 r nsu latioe
`A Om" / Covets [3tntry Doors p
O 0Si4iag windows M insulation �
Lo rn� / CAv�. ❑Rntry D.&% .
Roofing Siding Windows fnsuhitidri '
oGuners / Covers L]I rtry Dears p
)]Roofing 0sidins LJWiftdows L i Insulation.
L]Gutuers / Covers 012ndy boors. rl
fvnilmmluun 25% Depao<t d Conoratt Aruannt clot uNna.erraitja4 efthie slni T Ctiatracc A,ttati pt $ r
Maine Pueehaar" unty oat avian more than orra-tbird or the Cwhsd Anrnant �p
Customer agrees that, irnmiadixtely upon completion of tbe' work for each Product,. CusWarer will -cxwae a Completion Certificate
(one for each Product as defined by an individual Spec Sheet) and pay, any badanx* due.' As apOcibde, each Cu'swmer wider this
COADI Gt agrees to be jointly and Severally obligated and liable heraiwder:.. .
The Home Depot reserves the ri& to t$Cne a Change Order or terulinate this Contract: or my irtdividoal'Prod=(s) included berein. at
its discretion, i f The Ronne Depot or its authorized service provider determines that it cannot' perfe m its cbligatioes due to a structural.
problem with the home, environmentod bttxrrdl; such As mold, asbestm. or lead paipt,. &hr-T safety concertos. pricing errors or because
work required to.cPmplete the job was not included in.tho,Contracc
hrmett Summary: The Payment Summary # ': l4t�' - included as part of this'Conttact,'iets forth the total
Courraet sarount and payments rcquirod for the depositi and final payments by Product (as applicable).
NOTICE TO' CUSTOMIER,
You are entitled to a completely filled -in copy of the Contractsit the time poll sfgix. Oo alit stn's Completion CertMcate (note:
there is one Completion Certificate for each listed Pro&wt as &&a by al Spec Sheets) before work on that Product
ei complete.
In Ott, event of termination of this Contract, Customer agrees to pay The Lome Ds tha costs of matortalst, labor, expenses
and services prpvj! by The Home Depot or Authorited Service Prodder throtigh the date of termination, plus any other
Amounts set forth is this Agreement or al lowed un4cr law, THE'HOME DEPOT MAY WITHHOLD AMOUNTS
Ot WF0 TO TtiE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTF ER PAYMENTS MADE, WITHOUT
LIMTCL'+iC THE HOME DEPOT'S OT IM REMEDIES FOR RECOVERY OIL' SIICH A- MOUNTS
Ame lance an A uthorization, Customer a and Undemtandk that this Agwine u is the entire agreement betw GGn CUStortler
at+ a me pat w wiL r regard w Ute k'taducts and Installation .ervtoes and supmedes all prior d6cussions and agreemenra, either
oral or written, relating to said Pnxlucts and Installation. This Agreetent cannot be assigned or amended except by a writing signed
by Customer and The H ome Depot. Custom= acknowledges and agrees That C1 sronier has read, undentan4s, voluntarily accepts the
terms of and has received a copy of this Agreement,
Accepted by: Sub -
z, x � l
Customer's Signalu Date Sales Conauitenr's Sign roes Dare
Telephonic No.
Customer's Siganture Date
Sales Consultant Lia;nso No, _
CANCELLATION CUSTOMER MAY CANCEL TIM (as appticablal
AGRFMMENf WFWOUT PENALTY OR OBLIGA'T'ION
BY D]cLfVERING WRITTEN NOTICE TO TFFE ROME
DEPOT BY MIDNIGHT ON THE THIRD 'BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SL- PPT,F,MFNT ATTACHED KERETO
CON'T'AINS A FORM TO USE Ile ONE IS
SPECIFICALLY PRFSCItWED BY LAW IN
Vl!gT N1IFR'S STA
NOTICE: ADDIITONAL TERMS AND CONINCIONS ARE STATED ON T1 M REVERSE SIDE AND ARE PAwr OF THIS CONTRACI
5 -7 -10 GfiC Whfte - Bratroh File Yellow- Customer