42-063 (2) 998 WESTHAMPTON RD BP- 2012 -0234
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 42 - 063 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofin BUILDING PERMIT
Permit # BP-2012-0234
Project # JS- 2012 - 000362
Est. Cost: $10000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES
Lot Size(sg. ft.): 7579.44 Owner: SCHMITH MARY L
Zoning: SR(100, //WSP II Applicant: HOME DEPOT AT HOME SERVICES
AT. 998 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401
WORCESTERMA01607 ISSUED ON. 919120110:00:00
TO PERFORM THE FOLLOWING WORK: Strip and roof 1800 SQFT
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 9/9/20110:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
g
City - Northampton
Building Department
1QI1 212 Main Street r
Room 100
Northampton, MA 01060 r
413- 587 -1240 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
�S TIQN 1 SIT KI (3RMia[�FI t
o
1.1 Property Address
IMe w
EITYO,.WI�[ESHIPfRkJlTkfOR1ZE
f 1 Owner of Record
ame f Pdnt) Current Mailing Address:
'��e Telephone
Signature
2.2 Authorized t:
Name (Prin Cur e. ^.t Vialli ng Address:
Signature Telephone
ECT ON43�ESTl MA�ED,:CONSTRUCTION F
LL_. -- • _ . -._ __. Tm_. -,. _
Item Estimated Cost (Dollars) to be ' Qftclallse_Onl
completed by ermit applicant 0 -
1. Building
c
2. Electrical W asm x-
3. Plumbing
4. Mechanical (HVAC)
5. Fire Protection -
6 Total 0 +2+3+4+
� � a .. - ... ,+ x s - ,t^`t x�' �f�: �t'L � ' 3es �'u "`� k"ti `�1 �a �
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Aw
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arBu�IdinComIssio er/1rTScto�aBmldin ry e .` * .� y °� > . s* "r
!?:a .G, ..s.`W.u..�.�°!,i4+r,+ t .^ ttnw•aan ,nrM -.Kr .:,WT;.,L' x_,:..�£,:?'.+'l°� ,..:{»??F.1k - :: ..= �Aw•t•F1t,�':r, ate 1+ tikve .k..- sY'svz p,?.' ..
Section 4. ZONING. Ali Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Requiredby•Zoning y
This column to be filled in by,
Building Department '
Lot Size
Frontage
Setbacks Front [�
Side L: R: L: R: 0 0
Rear
$uildin$ Height .. .
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
adds )
# of Parking S paces C7
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW U YES Q
IF YES, date issued
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 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 Q YES Q
- -- -
IFYES,- has -a permit- been- or- need..to be- obtained.from the Conservation Commission?
Needs to be obtained' ® Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, - describe size, type and location:
D. Are there any proposed changes to or. additions- of.=signs intended for the property? YES ® 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 4 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
J
ti. Rt' "2 t .s v. 1, u`„q„, • . 'y,3 �^ .
rSECTtG 5" QESCRIPATION`ORPROPOSED WORK fche'c al pnh cab
ler
. �.i4 a'ww+h. {K ^ns. ,..lti!'fa'k*�
�' rk�s� °4ri7.»'.'�' ::.�fi.. ...: T,. �'.
New House ❑ Addition ❑ Replacer Alterations) ❑ Roofing
Or Doors W I
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks Siding [❑] Other [ ❑]
Brief Description of Proposed 5 Y ` r
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
al Use , & building : O ---- - - -
ne Family Two Family Other
-- -- - -
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
€ rte► a
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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_under_th and pe perjury.-
Print Name
Signature of er! ent Date
�SE�1rlON�B ,�CaNS7'�UC �1QN5SERYICES r
8.1 Licensed Constructi Supervisor:
Not Applicable ❑ C/
Name of License Holder �1
License Number
�- `
j res Expiration Date
t re Telephone
Ts. ere' m oMerue • p c c� Not Applicable ❑
� �6q
Company Name Registration Number
_ *:Address - Expiration Date
- elephone
�1 k CL6)
EGIi]! . li1tiCX I�DA'��' u
`'Workers Compensation Insurance affidavit m becompleted and submitted with this application. Failure to provide this affidavit will result
in I the denial of the issuance ofthe buildin ermit.
`' Signed Affidavit Attached Yes....... No...... ❑
w
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. CMR780 Sixth Editiou Section 108.3.5.1.
Defimh
• • on 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 andl or farm
structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner.
Such " homeowner ' Building Officials an 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 referenceto Chapter = -l52 (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 ilus permit.
The undersigned "homeowner" certified 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 Washington Street
;
Boston MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): .�
Address:
City /State /Zip: ®/ Phone #: 1 9DO
Are yo n employer? Check the appropriate box: Type of project (required):
1. I am a employer with 4. I am a general contractor and I
employees (full and/or part- time).* havered- the "soli = contactors
6 -.0 New construction - - --
_ 2.0 I am a sole proprietor or partner- listed on the attached sheet.- 7. 0 Remodeling
- These sub -- contrator Have
-- — ship and have no employees -` - cs 8. O Demolition
working or me in an capacity. employees and have workers' .
g y p �'• 9. ❑Building addition
[No workers' comp. insurance comp. insuran
d.
re q � uire 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. El officers have exercised. their I am a homeowner doing all work 11. ❑Plum ' g repairs or additions
right of exemption per. myself. [No workers' comp. 12. of repairs
insurance required.] t c. 152, § 1(4), and we have no
employees.' [No workers' 13.0 Other
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.
lContractors 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 - co ntractors have'employees, they m ust provide their workers' comp. policy number.
I am 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: Y, -ka
— Job Site Address: _ -_. -_ _._ ;; City/State/Zip:
.Attach a copy of the workers compensation policy declaration page (showing the policynumber and expi tion 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 inst the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of th IA r msuranc ..... overage verification.
end `hereby ce under t p ins d pe lties ofperjury that the information provided above is true and correct
Si a Date:
Phone #:
0ffccaf use only. Do-notwrite -in -this area; to be completed by city town
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health. 2. Building Department 3. Clty/To- n Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
_- Contact Person: Phone #:
City of Northampton
Massachusetts �
3 .
DEPARTMENT OF BUXLDING INSPECTIONS r �
212 Main Street • Municipal Building �b
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 define s "Homeowner" as, " Person(s) who owns a parcel on which
_-
- I fshe resides - or lntertds to be; - a one ortwcFfrm11y dr elling, 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 any 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 occucangy 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 _
understand the above. -
(Home owner /resident's signature requesting exemption)
IL will call' to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
.w
. ,�.. «....«..,... ..,.•. " 'Vll�Sal'`lllt;It� - {)e`I1aYC.ItitTtj ` ttt
11t I' {1t)Ill tl
Sward of Suilditt %tz�,utatiu +lc ;iit(t 4tundartl
�_..a C,OI15i1'UG11tJ {1 ,[IPK`Y'��
n:SEl
License: CS 96194
Y
MARK FREEMAN
11 DAYLILY DRIVE `
NASHUA, NH 03062
Expiration: 7/14/2012
T r =: 28530 Y
( „mntisi
C onsumer.
t �w " ^^ HOA4E ►MPROV 4ffairs &Business (
Registration: , EME�� CpMTRACTORutauon
,.. ; Expiration; _ 1013()1
2012 P ES D 2012 Type:
ROPERTI R d Li
Ltd Corpot
MARK FREEMAN.'
11 DAYLILY DR
NASHUA, NH 0 3062 _1
( Jndersec r
etary
2011 -08 -24 10:52 8923- EXPDTR /PHN SLS 4135643514 >> Home Depot AHS P 1/6
HOME IMPROVEMENT CONTRACT
PLEASE R EAD THIS
Sold, I urtiished and Installed by:
Branch Name: Boston (late: 7/1;1 � AD TIM Al -Home Services, Inc.
d /b/a The Horne Depot At -Home Services
345A Oircenwood Streit, Unit 2, Worcester, MA 01607
Toll Free (800) 657 -5182; Fax (508) 756 -8823
Branch Number: 31 Federal In # 75- 2698460; ME Isis # C 02839; Ill Cont. Lie# 16427
CT Lie # 111CA565522; MA I tome improvement Contractor Rq.- # 126893
Installation Address: 9'q� : $ ' kn - � MAD -0-�"-
City State Zip
Purr haser(s): Work Plntn Hom Phone: Geld P hone:
Home Address:
(If different from lrtstallation Address) City State Zip
E -utail Address (to receive project communications and home Depot updates):
❑ 1 DO NOT wish to receive any marketing entails from The Horne Depot
Project Information Undersigned ( Customer the owners of the prope=rty located at the above installation address, agrees to buy,
and THD At Honie Services, Inc (' The Home Depot agrees to furnish, deliver and arrange for the installation (" Installation ") of
all materials described on the below and on the referenced Spec ShceL(s), all of which are incorporated into this Contract by this
reterence, along with any applic=able State Supplement and Payment Summary attached hereto and any Change Orders (collectively,
"Contract ").
,lob *: ,r.ma.Mnd—) Products Sp - Sheet(b) Prnj eMAmount
0fing ❑Siding Windows El insulation
❑Guters /covers ❑ I t►t;} C�
[]Renrting ❑Siding ❑ windows Insulation $
❑Clutters / Cuve-n ❑ltntry thrors ❑_ , —
I
0R.,Vm8 ❑Siding ❑ windows ❑ Insulation - ---ii
I i
❑(;utters /covers ❑ 1 retry doors ❑
❑Roofing Siding ❑ windows ❑ imulauon
❑Guue / rovers ❑Emry TAaKS Q,
Miuirrmuru :596 Deptrit of C'.nntract Amount dtn upon exec or this contr.rct Total Contract Arnotint
Maine Pirrchagets [nay nut dgxo it are (torn oonrwird of the Cutd act Anton. � .0 e
Customer agree=s that, immediately upon completion of the work. for each Product. C'.usioruer will execute a Completion Certificate
(one for each Product as definers by an individual Spcc Sheet) and pay any balance (Inc. As applicable, each Customer under this
Contract agrees to be 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 Produci(s.) included herein, at
its discretion, if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a stntctural
problem with the home, environmental hazards such as mold, asbestos or lead paint, other safety c=oncerns, pricing errors or bec=ause
work requircxd to complete the jcth was not included in Lite Contract
Payment Summary: The Payment Summary #�� included as part of this Conu•act, sets forth the total
Contract amount and payments required for the deposits and Beal payments by Product (as applic=able).
NO'T'ICE TO CUS - fOMFR
You are entitled to a completely tilled - copy of the Contract at the tune you sign. Do not sign a Completion Certificate (note:
there is time Completion C=ertificate for each listed Product as defined by individual Spec Sheets) before work on that Product
is complete.
In the event of termination of this C=ontract, Customer agrees to pay The Home Depot the costs of materials. labor, expenses
and services provided by The Home Depot or Authorized Service Provider through the date or termination, plus any other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME. DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
11MIT•ING THE HOME DEPOT'S OTHER REMEDTF4 FOR RECOVERY OF SUCH AMOUNTS,
Acceptance and Authorization Customer agrees and understands that this Agreement is the entire agreement between Customer
and'l'hc Home Depot with regard to the products and Installation services and xupersedes all prior discussions atxl agreements, either
oral or written, [elating up said Products and Installation. This Agreement cannot. be assigned or arnended except by a writing signed
by Customer and The Home Depot. Customer acknowledges and agrees that Customer has react, undersaands, voluntarily accepts the
terms of and has received a copy of this Agreement_
Accepted by: Submitted y
X. ofi_SGPCvI��l�lAU . o � X
C ustori ignatnrrC Date! Sa C culta t' . i tore D
X _ , 'L' ne No.�
Customer's Signature Date I Sales Consultant License No.
CANCFLLATION CUS'T'OMER MAY CANCEL THIS (asapplicsmc/
AGR",MENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTF.N NCYTTCE: TO THF. HOME
DEPOT BY MIDNIGHT ON THIS TEmw BUSINESS '
DAY AFTER SIGNING THiS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO 1 i
CONTAINS A FO RM TO USE IF ON I.S
SPECIFICALLY PRESCRIBED BY LAW IN
CUST'OMER'S STATE.
N(Y11CF: ADDITIONAL. TRMS AND CONDITIONS ARK STATED ON THF. REVERSE. 511H6 AND ARE PART OF THIS CONTRACT'