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17B-016 QUOTE - Continued Last Name: SINGH Page 2 of 2 No. 8452 -11730 HOME DEPOT DELIVERY #1 (Continued) REF #V06 STATE: MA ZIP: 01062 COUNTY: HAMPSHIRE SALES TAX RATE: 6.250 PHONE: (413) 586 -0700 ALTERNATE PHONE: (413) 585 -8727 -71 4 ° E .. $2,290.80 DRIVER SPECIAL INSTRUCTIONS: 1 • END OF HOME DEPOT DELIVERY - REF #V06 TOTAL CHARGES OF ALL MERCHANDISE & SERVICES ORDER TOTAL $2,290.80 SALES TAX $138.49 TOTAL $2,429.29 BALANCE DUE $2,429.29 END OF ORDER No. 8452 -11730 Page 2 of 2 No. 8452 -11730 Customer Copy . . -' ' QUOTE Page 1 of 2 No. 8452 -11730 Store 8452 HADLEY Phone: (413) 587 -2790 r t 350 RUSSELL STREET Salesperson,Jl P�29 HADLEY, MA 01035 Reviewe J Name Home Phone QUOTE O SINGH BALBIR/JAGDASH (413) 586 -0700 I— Address 419 BRIDGE RD work Phone (413) 585 -8727 0 J O Company Name U) City FLORENCE Job Description ROOF 2009 -10 -13 19:56 State MA Zip 01062 County HAMPSHIRE Prices Valid Thru: 10/14/2009 HOME DEPOT DELIVERY #1 MERCHANDISE AND SERVICE We reserve the right to limit the quantities of merchandise sold to customers SUMMARY REF # V06 �� STOCK MERCHANDISE TO BE DELIVERED: �O REF # SKU QTY UM DESCRIPTION TAX � ACH EXTENSION R01 166 -103 18.00 EA 23/32 4X8 RTD SHEATHING -SYP / c��Jv $17.65 $317.70 R02 304 -830 3.00 EA STORMGUARD UNDERLAYMENT 2.0 SQ / > $112.50 $337.50 R03 793 -752 54.00 BD LIFETIME PRESTIQUE HD FOX HOLLOW SG / Y $25.79 $1,392.66 R04 797 -391 2.00 BD TTEX HIP & RIDGE FOX HOLLOW (NEW) / V'S''° Y $49.00 $98.00 R05 368 -843 2.00 BX 1 -1/2 E.G. ROOFING 30LB BUCKET / Y $34.97 $69.94 PI MERCHANDISE TOTAL: $2,215.80 DELIVERY INFORMATION: SCHEDULED DELIVERY DATE: 10/19/200 V06 515 -663 1.00 EA CURBSIDE DELIVERY SERVICE N $75.00 $75.00 �� DELIVERY SERVICE SUBTOTAL: $75.00 THE HOME DEPOT WILL DELIVER SINGH, BALBIR /JAGD SII� MDSE TO: ADDRESS: 419 BRIDGE RD 0 CITY: FLORENCE � �.) * ** CONTINUED ON NEXT PAGE * ** O � Page 1 of 2 No. 8452 -11730 Customer Copy 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 ----- . - - - -_ per -mit-s- in- conjun. ction_to the building ..permitissued,_ 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, •y \ understand the above. (Home own • A /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. ----Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ; 600 Washington Street 7=1: = Boston, MA 02111 „� www.massgov /dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Address: City /State/Zip: Phone. #: Are you an employer? Check the appropriate box: Type of project (required) 1. I am a employer with 4.. 0 I am a general contractor and I have hired the sub- contractors 6. ❑New construction employees (full and/or part-time).* 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodelin Z ship and have no e loyees These sub - contractors have. 8. 0 Demolition working for me in any capacity. employees and have workers' Y P t9• 9. Q Building addition [No workers' comp. insurance comp._msurance_. ed ] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3 am a honieo-wdoing doglerk o cers have'xercised t --1-1.1=1 Plumbing repairs or additions myself [No workers' comp. right of exemption p er MGL 12.0 Roof repairs insurance required] t c. 152, § 1(4), and we have no . employees. [No workers' 13.0 Other comp. insurance regained } . "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. Iam 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 /Stafe/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 51,500.00 and/or one :year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator: 15e advised that a copy of this statement may be forwarded to the Of'ce of Investigations of the DIA for insurance coverage verification I o hereby* certify under the pains andpenahiPs of perjury that the information provided _above_i true_andcarrect Si • . -cure: v II ate: a Phone #: Official use only. Do not write in flits. area toto be completed by city or town ociaL City or Town: Permit/License # Issuing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector _ .__ 6. Other Contact Person: Phone #: e- - SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9: "Registered,Ho ►e Improverrienttontractor° , ...... .: ..... .... a ,,... Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG.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 ❑ No ❑ t '� :+Y %wh 3 �.,��.°�§ - ,t P� atas�l ul 11t . -F$d �a1 T_he_current_exemption for "homeowners" was extended to include Owner 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 Ur inane s, a e •- `_. • - 0 . . • - eral -Laws- Annotated. Homeowner Signature ,, SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑ Or Doors E _ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks , N Siding [D] Other [D] /Brief Descripticyf P o i � �� ( lz M . p ; 7.1/ _ ;/ Work: A (,J kk C \'rV , �ic- RA-01H- -- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 4' i .itevir house a%t for dditioix #o=existtni fhousinq, =,complete the fi ilowiit : 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 , 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 the pains and penalties of perjury. Print Name r__ 4); LisA ___.............,_._ C/Signature of Owner /Agent' 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 Side L R: L:, Rear Building Height Bldg. Square Footage 1 ; % Open Space Footage (Lot area minus bldg & paved # 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 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 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES (3 NO i IF YES, describe size, type and location: '' -Aree tthere any propose• c anges to or a..itions o signs iriten ed for property ? YES (3 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. .li e City of Northampton Stouts a ii,t K � € Fes,„ cp+q wad ': "` ii : .,. r< - Building Department s , � � v 212 Main Street 5 ept£c Ar� k �� � , — Room 100 ��� ** Northampton, MA 01060 T4 1 fi phone 413- 587 -1240 Fax 413- 587 -1272 P �' 'l st� s i � 4 i� ° bab a 4 " xl t y . v „,,,,,,,,*,,,,,,„-14-34t,'„, +'z y C . °cam, "'lkl ,,i p i 4` F`k *eiii.t a _ .e._.., .,No- T ^ v +2 . * ,,,..„ .e .. .. APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION .1 Property Address: 4 k \ (1 This section to be completed office �- Map Lot Unit _ 4 Zone Overlay District La t C '© -; . •Elm =St District CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: �°' � VS ` \ G Telephone Signature 4 .1” ‘ .Zf Cf 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3- ESTIMA 1E'ED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant /(. Building C � (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 ( �� \ j � 5 Fi " This .Section .Fo Official Use Only Date Building Permit Number Issued: Signature: Building Commissioner /Inspectorof Buildings Date • a Nit 1 BP- 2010 -0429 pis #: COMMONWEALTH OF MASSACHUSETTS 016 ' 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 -0429 Project # JS- 2010- 000583 Est. Cost: $3200.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 43560.00 Owner: SINGH JAGDISH & BALBIR SINGH Zoning: URB(100)/ Applicant: SINGH JAGDISH & BALBIR SINGH AT: 419 BRIDGE RD Applicant Address: Phone: Insurance: 419 BRIDGE RD FLORENCEMA01062 ISSUED ON:10/20/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE PORCH ROOF & SHINGLE GARAGE ROOF OVER 1 LAYER 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 10/20/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo