42-047 BP- 2010 -0129
GIs #: COMMONWEALTH OF MASSACHUSETTS
A " Wit., CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate BUILDING PERMIT
Permit # BP- 2010 -0129
Proiect # JS- 2010 - 000152
Est. Cost: $14514.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 126893
Lot Size(sq. ft.): 33105.60 Owner: CHEVERETTE DANA V & LINDA A
Zoning: SR(100) //WSP II Applicant: HOME DEPOT AT HOME SERVICES
AT. 637 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 0 Workers
Compensation
WORCESTERMA01607 ISSUED ON :81312009 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 8/3/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
Department use onty
pity of Northampton Status of Permit: ,.
Building Department
Curb,' utt. nveway Permit
212 Main Street Sewer /SepttcAvailability
Room 100 WaterNltell Availability
21 Northampton, MA 01060 Two Setss'of Structural 'Plans
5Wne 413 - 587 <1240 ,Fax 413- 587 -1272 Plot/Site Plans
Other-','Specify
APPLICATIOkfO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - S FTE'INFORMATION
1.1 Property Address This section to be completed by office
Map Lot Unit
3 —7 Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Du� :7
Name (Print) Current Mailing Addre /j /yam
:�� Telephone
Signature
2.2 Authorized Agent:
: &c I & j 6.L -._ j�n� 7
Name ( " Current Mailing Address:
e21o31
Signature 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
Constriction 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 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
SideL. ...,,._ R :- , ---- , — L. ,__.._ R: _......_,
Rear
Building Height"
Bldg. Square Footage % ;
Open Space Footage ° "` ..
(Lot area minus bldg & paved
Arkin
# of Parking Spaces.
Fill:
(volume & Location) -•• -•-
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES
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
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
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 Q NO Q
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 W dows Alteratibn(s) i Roofing
Or Doors (�
Accessory Bldg. ❑ Demolition ❑ New Sign. [0] Decks [Q ' •• Siding [C1] Other [O]
Brief Description of Proposed
Work: �J•r• .
N
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. 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
I, `7J� , ��h ►� L ! . as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit appli atio .
Signature of Owner Date
I, as Owner /Authorized
Agent hereby declare that the statemen s and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the ains and penal ies of perjury.
n�
Print Name
Signature o r /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Constructi on Su ervisor: Not Applicable ❑
Name of License Holder
MIC
License Number
fl 1 DAP A/
Address Expiration Date
Signature :' Telephone
9. Registered Home, l nprovement Contractor: Not Applicable ❑
Company Name .� ^ Registration Number
Address '� Expiration Date
hone
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 Attached Yes....... L� 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 ho meowner.
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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 fEashington Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /PIumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): �jy 4r ���
Address: CARD CW M In P(�I�—
City State /Zip:
j �j 1." oie" r Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. []'I am a employer with 4. ❑ I am a general contractor and I
6. New construction
employees (full and/or part- time).* have hired the sub - contractors
❑
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have S. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
comp. insurance.T
[No workers' comp. insurance
required-] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
re
3. ❑ I qu a homeowner doing all work officers have exercised their 11. El PlumbinQ repairs or additions
myself. [N c. 152, o workers' comp. right , exemption per MGL 12.7 Roof repairs
insurance required.] t §i(4), and we have no 13.�er
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
, 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
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site
information. t.
Insurance Company Name:
Policy # or Self -ins. Lic. #: b ���n�' ]� Expiration Date: A ,
Job Site Address: City /State /Zip: ��o�
Attach a copy of the workers' compensation policy eclaration 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 $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 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 v
I do hereby certify n r t e p )2ndpenalties of perjury that the information provided above is true and correct.
Sianature: J y� Date: e 3k ) l /r
Phone #: l V
Official use only. Do not write in this area, to be completed by city or town officiaL
Citv 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 #:
i
HOW
Q Sold, Furnished and Iristxlled, by
Breach Nam : %aton Data• �? / 1 Fill: s1t SeivicE§. Iac.:' i
d16/a T]+e' irrbe F?Tot ADlioilu ;
� crocuw�Vd Stxeea, C.lnit z; w«ecsoor,.nKa.o15�'r"
Brancb k�wmbex: 31 o11 )?ree (800).657,5182;' ftk(508) 756 -8823
Fedi ral•1D # 75- 2698460;,1�1Ri tti #.0 tYZ499;1C( Coat .l~iu# 16427
� ' CT L" 565'522; M ikapzvYi t•Coniractor Reg, #
Installatiorwh,Atldtesa �J� _+ -Arm. t .A}'
• C;ity State zp ..
i
pw�uear(s): 'lV ,Iiaone tbpne: Cpl Phoae:
Home Addre":
(if diffeieat from Installation ,A.ddteas) City Sate ZaF I
H -rgia� A44rere (m izcelve Project communications and'Iiome,Depot updates).
13 170 NOT wish to receive any aaarkatiug emalis,tle>m rte (lame t?elx�t•. i �� Y
Froiect.l>� Undersigned ( "C>mbotoaRr"), dre.ownets Gf the at the aboye'inatallatioa ,addrnss, agrees tv'brry,
and `t'tW At -Home Services lEnc. (•"I'he Hotae Depot") agrem.-to fttwibtr; tialivyr-vAd,*i ,,mgt, for the i4stalladon (" Iastallardw) of
all materials described on ra
, the below and on the reter ced Spec 86wt(s), all of which are incorporated into this Contract by this
reference, along with $oy applicable State Supplement atal Payment Sumutaory altanhed hereto and ahy Chem 0rd6m (co1ka6;Mly,
°Contract
Job #r No-xw a.W, products: t; Project Amo®t
Rasl"tag 051" rn 0 b00 00 $
�t3rrttars /covers DEatry 1loexs Q
3 E-5 2,i:1
Roofing Sidin [jWiadows'LJluWiW
Modw% r Covers pay n $ .
Itoaflrdt; Siding
— %-do" badation
pcutters 1 Covers DEntry Dovrs.Gl $
ORm fing ElSifts u,doas lasrrlatdou $
[]Gutters 1 Covers '[]Entry.Doors f 1
NGidatmraz5°61DepatfROf Asao�te.�paa+mone�m: ' `:(.. ?.
bLifaef'tudasarsesaYtwt maietb�rdut4.e{o�erontraL�AdiM
Customer agrees-that, dtumediately upon cwTirtion of.lhe work for e:at:h PM&Jl ,t Customer will 4caecute tz .Completion Coatificatc .
,(ow for each PmdtW as defined by an individual Spec' Sheet) •and .pay slay bo-ce due: 'As applMCRb .each• Customer .undrr Otis
Contrast agrees to be jointly and severaily obligadcd and liable hattradtC
The Home Depot reserves the right to is*ue a change Order or.terAOiibaro rbis Contract of any.Fudividitpl•Prod s)'iaciuded herein, u
its discmdon. if The home Depot or its audwized sch*6 provider detertoes that it cannot perform its obligations due.to a sttnetural
problem with the home, eiavirownuntal hazy nls stwlr as knuld, asbestos or khd paint,' odWt safety cvacersas > 'priciag ethers or ba ease
work required to complete the job was not mclpded•i4 to Conifact
Egr mo! Summ= The Payrorm Summary # . g .•� included as.;i it of this Conowt, sets fisrth the total
Contract amount and payments acquired fur trq JcpWts.Ynd final paymatrts by Psoduot (se amloublO.
`NO'T'ICE TO CUSTOMER' '
You sire a atltled to a completely tUled -lia copy yof the C:mntract.at the tb= yea' Do tent; sign, p Q=pletioq,Cetrdlk % (note
there is om C:ompietwo C.ertWeate for each bated product as defined by ISSp�t llheeta) bdore-wor�t ort'tatf Nrnditet
18 complete.
In the event of termUmtion of this C:ont=t,.CaaftWr agrees to pay The -HoM •De the costa of materials, labor, elm
and Services by The home Ihtpol or Authori�eed Service 1!ravider the:dabr of termbtation, plus arty other
amennts set forth in this Agreemeat or adrowW under ap finable 1 &w. ! 1Ft8'ftO vi MAX WiTHIt()I,D AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER. PA,YMaEN" MADE, WITHOUT
L1Mt'1'tNC THE HO'MM DEPOT'S QTE ER REMEDISS FOR "XOVERY OF SUCH AMOU_N'M:
ranee tall n •r : C;uet:clRw agrees and understands that this Agreement i5 the entire agntxment between Customer
and'fhe ome Depot with regard to the Products and•lnstallation services and supersedes all . prior discussions and agreewnts, either -
oral or written.. relating to §aid Products and Installatiom This at canna be assigned or atnended except.by A writing signed
by Customer and The Home Depot. CWtorner acknowledges a�ecs that Customer bas read, undersiands, voluatuily accepts the
terms of and hw received a copy or this Agreement.
Accepted
X
Cuslotn " S ia m i ate Saw Cons tern's Sig � Ewan
� Telephone No,
astoiner's Signature Date
Sales Consultant License )30.
CiANS`�r' L+f-& I -1 0M CUSTOMER MAX CANCk•Y- THIS (aa a�tieebk)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELDTMEIG WRTITEN NOTICE TO THE -ROM
AWYOT BY MIDNIGHT ON THE THIRD BUS M. SS
DAY ArfER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A, FORM TO USE W OM IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMERIS STATE.
ly0'i•IC E! ,WDTR'lO7%L TIV4 A1VD,ICONDMOM ARE STATED ON T= R£VEM Slog AID AR@ PART OF TW CONTRACT
RtstrKtAC 10: WS
IA - r4astmry unly
RF - Roof Ctrvering
WS - windows and Siding
SF- Solid Fuel Butaiag Dcvkci
DM - Demolidom only
Faaurr to PO17C17 a rurmat edit3m of the
Nbmm Umtts Statc Building Code
it Ca jve for rrvo".tom or this Ucc c.
Retcrto: WWW.1lSaacGov/DPS
Ocll:utmcnt ul' Public Salco
B-nartl nt' Ruildinl Rcgulatiurr, and 5tandaro,
Construction Supervisor Specialty License
LicFnsec CS SL 88:7119
Rescriclea to: WS
VIAMMIR SHEVCHUK
5 OGDEN STREET i
CHICCPEE, MA 01013
i
Expiration: IOM2IM11
(• .pin i>fi •ups Tr:: 992M
hO rho - anti - Vnu"1n7t.lC vri�rnn fiOCCnc CC Th /h:nT ggL17 /TC /CA