16B-032 BP- 2010 -0911
GIs #: COMMONWEALTH OF MASSACHUSETTS
ty. J 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- 2010 -0911
Project # JS- 2010- 001348
Est. Cost: $192.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 19602.00 Owner: AMATO CHRISTOPHER
Zoning: URB(100) Applicant: HOME DEPOT AT HOME SERVICES
AT: 58 FERN ST
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401
Workers Compensation
WORCESTERMA01607 ISSUED ON :411512010 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 4/15/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
City of Northampton
Building Department
212 Main Street
Room 100
F X010 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
Map Lot . Unit
5 T Zone 4verlayDrstrict
Efrii St Distinct CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
L�04CCL�
Name (Print) 14 Current Mailing Address: ,
n_- Telephone Fir
Signature
2.2 Authoriz ent:
Name J(Pnt) Current Mailing Address:
Signature Telephone
SECTION 3 - ES71MATEDI CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building i ®� (a) Building Permit Fee
2. Electrical 1 (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
Date
Building Permit Number: 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 Fron
Side L: I.._. ' R: L. R:
Rear...___ --
Building Height__
Bldg. Square Footage % � t--m-•--7
Open Space Footage _ %
(Lot area minus bldg & paved j
par
# of Parking Spaces -- -
Fill: ( I
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW I0 YES 0
IF YES: enter Book_______ Pag ! and /or Document #'_
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
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 I
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 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Win ws Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [0] Other [C�j
Brief Description of Proposed
Work:( C
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
S [ . �e nr.: Aft" M a MW r l n �. obi r Fix
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHI=M'
OWNERS AGENT OR CONTRACTOR APPLIES' FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit applicati n.
- 6 'n
1. Signature of Owner Date
1, as Owner /Authorized
Agent hereby declare the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under th pa s and enal ies of perjury.
-- l
Print Na e
Signatu a of er /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction S t rviso - . Not Applicable ❑
Name of License Holder :
i License Number
t �
Add s
Expiration Date
Ljo
S n ture Telephone
'. tt.R Not Applicable ❑
Comoanv Name
Registration Number
r--
Addres Expiration Da
— Telephone
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 buildin ermit.
Signed Affidavit Attached Yes....... No...... ❑
NT Ti
E 1 V
+ni
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 buildine 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
7'he Commonwealth of Massachusetts
Department of Industrial Accidents .
Office of Investigations
600 Washington Street
Boston, MA 02111
:• www massgovldia
-Workers' Compensation Insurance Affidavit:.Builders/ Contractors /Electricians/Plumb.ers
A licant Information Please Print L �'blv
Name (Business/organization/individual):,
Address:
City /State;0p: Phone. #:
s re y an employer? Check the appropriate box: Type of project (required): _ 1I am a employer with 4., [] I am a general contractor and I
employees (full andlor part-time).
: have hired the sub- contractors 6. ❑New construction
liste
2.. [D I am a sole proprietor or partner- d on 1h6-attached sheet 7. [].Remodeling
sub - contactors have.
ship and have no: e�loyees 8 D DeIIOhtzon
for Me m an employecs_andhave workers'
working y capacity- # ' qv o pmildiag audition
U40 workers' comp. ;T surance - comp.
required ) 5. We are a corporation and its 10.❑ Electrical repairs or additions
officers havexercised their 11. Plumb r
3. I am a homeowner doing all work r : ❑ � epai s or additions
myself [No workers' comp. right of exemption per MGL 12:[]. ofrepairs
c: 152 1 4 ' and we have no
employees- [No wo
insuran required:] t ' § ()' 13. Other .
rkers'
- comp, insurance re m l
"Any applicant that checla box #1 nxw.also fill out the section beloWshowing t6eirwmi=s'.cmwcnsaticn policy information:
t Homeowners who submit this affdasit.mi icating they are doing all work and then. hire ouwde cont r=t= must submit a new affidavit indicating such.
ICo=actors that check this box must.=whed an additional sheet showing the nanr of the sub- contrrcmrs and state whed= not those- entities have
employees. If ft sub•mntract have employees, they zstp mde their wow.' comp- .policynunibm
I zm an employer that is providing workers' compensation insurance for xy employees Belo_ w is the policy and job site
information. \ �-
Insurance Company Name: ZL�
Policy # or Self-ins. Lic, #: ��i �� Expiration Date:
Job Site Address: - � io o f City /Sta&Zip:`
Attach a copy of the workers'* compensation policy declaration pa ge"(showing the policy number and ex&:!tiou date).
Failure. to- secure coverage: as requited uncTer Section 25A of 1vIGL'c: 152 can lead to inti impodtion of'cnmm4I penalties of a
fine up to $1,500.00 and/or one- year as well as civil. penalties in the form of a STOP WC1ZK-- ORDER and-a Erne
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the 005 ce of _
_.
Investisations_of th for insurance` coverage vedficadon
Ido.hereby,cetti under airs dp. .allies that - the fnfo rmatfonprovided..ab pE rrer
Si tore ate-
Phone
#��
Offieial use only. Do not write in this area, to be comp y ctty f w al
feted b or town o
City or Town: PermitUcense #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. CitylTown 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, - to 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
�ermits 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
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 tome.
Date
Address of work
location
.......,..... .s.....,.,......,....,.,....�.. 1!�vti I I -r
TLI&A.SE READ TM9
Sold, Kwaiabod. and toctattad by
Brsncb Name: Boston Date: j r 3 . l ._ THD At -Horne Sa vices.•Iac.
dlbla The Home Depot pt -Home Services
345A Chemwooil Street, ilndt 2, Woer v, MA 01 607
Brawl Neahar: 31 Toll Fctt (800) 657 -5182; Fax (508) 756 -8823
F. .W lb it 7$= 1� W Y.io # C 02194, Rt Cow. Curl 16
r ' CT lee * 565522; MA 96ma IrrVm"0e111 Cont[aeier # 126893
Mien Adam%, � �� 1� - SQ &2& Q ' W A t3 (r �
State zip
Perdmsertak Week i"lare time 3'hsoec Ceti Phand:
Home Adder
of different Dam Installation Address) city Scare zip.
E.ma►� Address (to tacoive project Wrnar4roiCati9t48 anadt 1;3fpaleDopot,ttpdatoa):
❑ I DO NW 'wish to ngrive my marbawg eataiia fTorn The Home
act'Nsuation- Urrdardped ( "�oroer"), the of the ptupe ty located' at the'AKWd inatrsil M 9d6tss. egrets to leery.
and T r- Inc. ("The Home Dep Yn agreta'ta tfamisk deliver and a62W for the iivgait Gon ('°10staffndon'7 of
RU matvia)s desCaw on the below and on the refisrenced• Spec Sbe %0), an of ,winch am � �D this Conum by tins
referenac, along witb any applictible Sbft SWpkmeat aud'Pstyu ttw
�et.Sm» att8abltd E=M and any .t haV Orders'(POReeUV61Y-
ProjectAnseent
q o4fmE idiot Indosss Qom. t
U b l uu I coverer by Doors ❑ i. ��
EI Else O Wlndowa p rnmi*tion
pvnmers 1 co+vera [psotry, Doors Tl
psaaiag wi 0 dnaubdon
pcb►teers /Covers clel*yUbors rl
25% ne pe rtdCaels adAi~dn.WM..ffM=lio.'aeiLp.40° Tgtpl Cq®t *aAima®t
'Name lratiioeera men art dt4srd �mse Linn ae�tad at the Corrz� Aaao�t .
Customer agrees that, immediately upon caurpiefm of the Wo*. - for t Product, Cusmmcr wit racecatt a•Completion Certificate
(one for each Product as defined by an individual Spec. Shae6 sued Pat SAY Uwiat= dire. As applicable; each. Customer under this
C4nmaet agrees ro bo joiA* sad severally obligated and liable heri;under..'
The Home Depot reserves the right to issne a Change Order or terminate this Conmat.'t of MY individual• Piuduct(s) included herein, at
nd
its discretion. if The home Depot or its aai ed service Provides' demos that it'CEUUnOtpyzforta its obligat —o duo to a structural
pmblom with the hnmt3, environmental hazards such sa molct asbestos or lead pain[, grilse Safety concerns.. priciltE e[surs or because
wank required to compete We job was mt i in the COMA t
9 .t,
I9vmeat S imma ; The Pay"Ot Suinrnrry # �-L' L tocumm W part of dis' Contract, sets fonh the total
Coattaa amount and payments required for the degosits and Seal payments by Product (as applirstsle).
NOTICE TO C> $T4)M M
You art endded to s completely Iflled -ta cepT of the Contract'st tbe-ft* y ou* , Do not ap a Completion Cetrarste (mote:
there is one Comple6m Ctrdfko& for each Bawd Product as . defined by brh'vidaal Spee Sheets) before work on that Product
is complgw
la the event of tarminitfion of this Cautraat, Customer agro4s to ply Tbt l W00 imp a the coats of muclals, labor, expenses
and services WoVided by The HW- Depot or AUOWIZW Service Pr"ider through the date of terwh atlon, plus• "y other
amounts set forth in thts AEraeereat. or a7towe un der a Inide. lim. THE HOWIE DEPOT MAY WIMMD AMOY -*tN TS
O I.IMT ED T OTHYt HOME DEPO S OTHER it p�
FOB )IE�Y OF AMOUNTS 1►tADE, WITHOUT
AM01 mad Authorfi�tlgq C ustomm agrees and understands that thin; Agreement is the entire agreement between Customer
anF pot with regard to the Products and Installation savicA* And supersedes all prior disouidonu and agreements, either
oral or written, sedating to said Products and Installation. This Ag7eet etit MAO be asstgaod or amended except by a wtiting signed
by Customer and The Iiomc Depot. C M& acknowtodges and apses that Customer her read, undts%Ands, voluntarily aeeepm the
terms of and has received a copy of this A.greement-
A /f 1 i j� Selbmfdtedb UL t I to,
ig"ture 01" f / Sales Consultant's 9160mure
X Telephone No
Customer's Signature v Bate Salts Consultant License No.
CANCELLATION CUSTObIER MAY CANCER. TMS
AGXEEM%NT WIT' OUT KNALTY OR OBLIGATION
BY DELTV921NG ` MITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE TEa" U09](NM
DAYS AFT= SIGNING TMS AGREEMENT. TIM
STATE SIOTLEMEN'T ATI'ACMED Warm
CONTAINS A FORM TO USE IF ONE 19
S>'T?CH'ICAUY PRSCRMED BY LAW IN
CUSTOMER'S STATE.
NOnCE: APPTTIOmi. T6QM$ AND CO26MONS ARE STATED ON Talk ll;EYUR SIDE AND ARE PART OF TJ= t,' MTRALT
11-304M G-G Whits- BranehFlle Yew-Customer Pink ,Stilim^Lior6su"M