17B-016 (2) rilllvixf.a1VIYA:W1' MALL tr t AJ'! t-Ai &-a° . , •
_
'i:L:'16`k'Et tYD TliIF• . .
/ Sold, Futr and Installed bv: •
• 3r dnetl Nsrne- Boston " Bade: 9 1i3! - TED t r> S rnc,9cxvtar , lac:
dthla' The Horn Depot At=llomc Ser4ices
345A:Drcesowrtind: &rent airt'2> W L?.
oro:Ater, \'.p1S67..
3raach Nnmher :31 . •T e.(80Q) 51 , 1$2•,. Faac (508) 756r$a2
FaSel'e1 t7J z ]52r98466' Pelf I:ic C 024N }U. nut: r, 1642
CT Lied 5 655 4A Hoare lmprovcment Contrachar5 r• 12 93
u sfallation Address: 1 4 t b_ � craG 1 -- E ', - ' '1�__ 4 . 62--
C ty State dip ,
Purcha Work',Phmncs li io.'Phoil t Cifl' e- '
��► • 1 [ J . ,. (4(3],0 [ ]
Monte Adttress:
1f different from )fast„ llatitts Address) .. it „, $tide ' Zip
E -mail Address. (ti, receiw°G project
I DO NOT wish to receive any marketing emiiiLs ittn T"Ite•i3isne Depot •
Proieet infrirmation: 'Undersigned ('"Customer ") • • the ea to ated attic above instdTh tion ttdd? , i5.; agrees tb, b'uy,
and T l.1) At Titanic Set, icc$, L«. ( "The - loin Depot') agrco't0 tiltltilh, delitQT.ond arritnge for (ly inStslla tiopr.(°°frlst;,lliituni• of
aii materials described on the below and jr l the referenced Spco Sheens} .all , ' tf•.tw°ltich are incorporated ,flitt is C by : thi °,;
re n-rerii:c . along svitt .arty applicable State Supplement and I . Spmiital-y attaeihed hetea :,and arty Change Ordexsl (c■ik.`tii
Job k: onmr...i h.n:e.ra pp ro aces: a ec s #: Pr eM r (gnat
.� ... l ❑T�oofntg QS'idiug +indork 1 D• lissulatton • s 27 ! ❑(ir(((on 1 Ci ❑ :Eli y boors '0 • `6 $ - ....
❑T{uo13n} ' ❑siOisi . 0 windows: Li iusbl.tipo .
. DC34ttara r'Cnvors DF.nrry. toe I]- -h. _....., . . •
01toofug.C,�Stidiu� [ • outdo is :..i(aiWldti.C!{•;..
❑Cluttets ' Coven rrliktit .,Dr ❑
w �.,.• - m Roofate, ❑ S't An,g • 111' Wiodcwva • • nUiets xt.
DCGutters l Cov -s 3E [] •
Aliuimuro 25°A. Deposit td Contra4; Antptnit due-upon eteettdotpu1'tbis lOntr'att. . C �,drn f t c '. rini , t
Maine Purcbnxur9 may nut po w
it urt'thaA Ono-tblyd of the
Cuiti.lner agrees that, .. irranaiditcly u•Cw Lunlltict1On cif the N.irli'for eaelt Product, CLStotp r will '' 6,1,tii...1 COrtlpletioli ("ertltt ate
(One for each Product as defined by no individual spec ',heer) atld pay any balance dt1e. ' As. applicable, each Cnstoinbr tntdcr „this
Contract 3P,rres h iotritl }' and severally obligated rtd liable hereunder. :
i lee flume Depot reserves the light to issue 4 Change ,Order AT tq iitate this C_,c rtttatit or. airy individoiiPtcrduct(s) included herein, at
T
its discretion, if e Home Depot or its ant glu service se p r dctennin'es> tha '1iin t tt c t,perror r'tts'c doe to 5.5trucmr5l
problem with me home, e1lcifu40 erisai baxalyd's as mold, as or tenet pautt; othe adtfetypotw ns, pricing errors or becaote
murk required to complete: the job was'ntt 1rrt u&:ed m ttrc 4ritKiet.. .
Payment St5mmxry: The Pattrienr Surntne r# . • T +:t , , iwtLkkdl ks •part Of this' C0utta0t, sets forth the total
C ontra; t alTIOunt and p yausintn required' for the dcpo ttts ttin8ttcnta1 pavtiletlts by Pr at ?� gp
(iusbie).
� i
11)ftfleF T( CtSTO1WSE i
•1 oil are entitled to a eo alp lettly' t'lll6d-In ulpy of the Ciillt'1•aex at #.tie tune yu` its1g Tit Haft xtgu a Compretiott Certiticate jnute .
there . is o Compleriou Cerrltirate fair rat.h hated Irudlte As,' a tea bN •milli” dtrsi$, Spat Sheets)' lidere work on. that P
k co(ffplett. - ' ,.
la tile. event of termination of ttlis C■iutttCt, Customer agrees to pity°'Tli r 7ilotoe
vi
la costs d materials, labor, expenses
and services provided by The Home Deptit or Authoi-ized • Sertriee Yrdeider throe Li the date of tertmination, plus any•other
amounts set Portte to this Agreement or allossetl r�rder a law Tilt Wilivi1: MAY WIT' OLD AMOUNTS
OWED} TO THE HOiM11 DEPOT FROM: THE. DEPOSIT PAYMENT OR: OTf E'R IPAN1VIENTS MADE, 'WITHOUT
L15111 1'- G TI1E HOME DEPOT "S OTHER R MEDIE, ' 6frt FcECOVEEYi° Of S0C'TT AMOUNTS.
Acceptance and A oYi atlnn• Cuttomcr agrees and uiiderstands that this Aga is the entire agreement between Customer •
and The florae Depot with regard to the Products and' installation. services and sttperseiici" 511 prior diseuasion5 and agreements, either, •
oral or written, relating to said Products and Installation,.This Agreement cannotbc.assigred: or amended except by a writing signed
by Customer and The Home Depot. Customer acknowledges a th Custorrler leas' zeal t understAnds, atuntatliy accepts the
•
has of and h received a cdpv of this Agreetrlent.
Accepted Fiy; n ) hmilt
Sutett x•
t
�fr
CtistitlC13 Sigma c - ,--- Sales Consultant's 5 nature Date
X _ w„ -- Telephone No. ...:, —
CustOme 's SigfuttLtre Date
Sales Consultant License Nr±.
C.YNC .? I,,• TI()N: CUSTOMER. MAY CANCEL THIS I • (asapplIokbie)
AGREEMENT W liff0t.T PENALTY OR.001 t;ACION
BY DELIVERING WRITTEN NOTICE TO TIC HOME
DEPOT BY NI111MMG111 ON THE THIRD` BIJSt_NESS
DAY AFTER SIGNING THIS AGREEMENT, THE ,
STATE SUPPLEMENT ATT'ACi3Eb TIERETO
CONTAINS A FORM TO USE IF ONE TS .
SPECIFIC:LLLY' PRESCRIBED BY LAW IN '
CuSi i oMEU'S.STATE.
Nosica MID TERMS AND CONI)ITLCJNS AFE STATED ON. T fit 1iv EASE SIDE Ab76 ARE PART OF THIS CONTRACT
7 -15 -09 C -SC Whitt ge3neli File Yellow - Customer Pirik- Sales Consultant
, •
HOME OWNER EXEMPTION ACKNOWLEDGEMEN'1
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
permits- in - conjunction_ to_ the_ building ..peunitissued,_ 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 me.
Address of work
location
•
• " The Commonwealth of Massachusetts
Department of Industrial Accidents
a
=ZIh P Office of Investigations •
t " ° / ,1 ' j 600 Washin atop Street
t Boston, MA 02111
„ . www.massgov /dia •
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers
Applicant Information Please Print Legibly
Name ( Business /Organization/Indiviinai): 14/ (-
�
Address: 4! 1 1 - 111 I L : '/ I .
City /State/Zip: I i yh ( 0 ,nPhone. #: cnD /,-5 5
Are yo employer?.Check-the -a ropriate box: - ofprojecf required):
1. am a employer with 4.. 0 I am a general contractor and I
employees (full and/or part-time).*
have hired the sub - contractors 6. ❑New construction.
2. I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship '. and have no sloyees These sub - contractors have. g. 0 Demolition
for me in any capacity. employees and have workers'
working •
Y P ty. 9. 0 Building addition
[No workers' comp. insurance c�P ice. #;
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a tameo-u eF deing weak _ _ ---- Qfficers ve xercis�d. zr _- _ -1. - ❑ Rlmnbsrg repairs or additions
myself- [No workers' comp- right of exemption per MGL 12 .0 Roo repairs
, C .
4 .
insurance required c. 152, t ' § 1 O' and we have no
13. er �,( j nn om'
employees. [No workers' ! U
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.
TContractors 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 is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: ) t\e CO
Policy # or Self -ins. Lie. #: ` J V/ Expiration Date: 3 / /D
b
Job Site Address: L 4 I City/Stare /Zip: - (Vey 14, r Attach a copy of the workers' compensatio 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 $1 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 . _ ainst the violator. 15e advised that a copy of this statement may be forwarded to the Office of
Investigations of the A for insuran, coverage verification.
I do here,, certi ' - 4r, , ' • rr 0 1 alties of perjury that the information provided _above zzt, e , uLcorrect_ _
If id
Signature: i / / . / / ._ - -- _ - Date: ( �.i r s _
Phone ##: z D! . / r'c�l, 3
Official use only. Do not write in this urea, — fo be completed by city or town officaL
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Ins. ector 5. Plumbing Inssector _
6. Other
Contact Person: Phone #:
p
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ /
Name of License Holder : 1 Cam(
License Number I
C .Z7 nle.15 01-04) *Y) Address Expiration Date Br3L/ /1e
Signatu - Telephone
9.,,12ea istered Etame lin.. r = v=mertt art star �., r � , „ Not Applicable ❑
FIZATinitver
Company Name Registration umber
Address (J O(Coi5f r� / Expiration Date
) Gt U// /Telephone I/O! 7 (Y /�
_ 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 by permit.
Signed Affidavit Attached Yes No ❑
11. -J :;Owner Exemption
The 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
NortFampton Ordinances, Staf anfd° o al and State tifiMassachttsetts General Laws - Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ 1 Addition ❑ Replacement W' B ows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ I Demolitio ❑ I New Signs [o] Decks ID Siding [lam] Other [DJ
Brief Description of Proposed �- -
Work: _,A K_ - 7 : .' _ U, 1 I . . y
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
ea, Tf Ile libiiS d of dditie to itc hoiis iiq.a compiste the foirdiiitinaH
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 WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, �'a l, as O wner of the subject
propert
Y
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
ti
.-/ / g .
Signature of Owner Date
A
I, PA . l • 1 , as Owner /Authorized
Agent hereby declare that e atements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under t � s and,ppnaities .f perjury.
I
, I)L ` t 0
Print Nam$ 1 ,
Signatur of 0 ner/Agent Date
.1.A.- • A
A
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 .
t ,
. 1 -,
.
Side L:-----: R:L._ __1 L:!_____.i R::_____,
i
Rear
Building Height
Bldg. Square Footage % !--- r___,
I :„____;
Open Space Footage %
(Lot area minus bldg & paved
parking)
# 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 0
_. _.
1 ,
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
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 dia oriaailitTricars Igiii 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.
a sera "If a '�
City of Northampton i , _ 4
Building Department O IE
212 Main Street e �valias fi . . , te
Room 100 '
Northampton MA 01060 " �n
I.J �_ _ _ .. 413-537-1240 Fax 413-587-1272 x '� ,.. �. r . ,
I I V I IC 1 c7Jl o a - � r� � � �� wa �-� � ,
g § Pl �"
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
y 1 '' �r R Y
J Zone Overly District
Elm. St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
•
- - - \ — L_ � s ! I ��, e IA 0 At,
Name (Print) J Current M -ir . Add -ss:
(o Telephone
Signature
2.2 Authorized Age r,
PI fe--- f3q5 k)crz.34)e-A 0/407
Name (Print) fp Curren Mailing Address:
'�. � .' ��. _ l
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ; ^7c (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 U Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
r
•
BP- 2010 -0363
GIS #: COMMONWEALTH OF MASSACHUSETTS
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 -0363
Project # JS- 2010- 000484
Est. Cost: $3182.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 126893
Lot Size(sq. ft.): 43560.00 Owner: SINGH JAGDISH & BALBIR SINGH
Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 419 BRIDGE RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 O Workers
Compensation
WORCESTERMA01607 ISSUED ON:10/5/2009 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 10/5/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo