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17D-039 a , llassac } ursctts - Department of Public tiafct, � n Board of Building Re!,ulations'antl Standard, Construction Super isor License License: CS 56454 Restricted to 00 JEAN G GIRARD. 131 N WASHINGTON ST BELCHERTOWN, MA 01007 Expiration: 6/6/2011 ('onunisioner Tr#: 17108 4 A JAN -13 -2011 17:18 HOME DEPOT 8452 4135877813 P.001 HOME IMPROVEMENT CONTRACT .0.1-E88,, R.EAD TH1S j q Sold, Furnished aact.lnsttillc d,by_. Brat.c6 Name Roston. D a t es f 1 / j f THD Ai Home Scrviea:4 Inc. . . , . d/b/a The Horne Depot At -1lome Services " 345A Greenwood 3treet, Unit 2, Wo rcester, MA" 01607' • • Branch Number: 31 Toll Free ;800) 657- 5182; Fax (508) "756 -8823 Federal 113 it75- 2698460; ME lie # C439- •RI Cunt: Lac# 16427 • •CLLac # 565522; MA Bom: Improvement Contractor Reg. # 126893 . Installation Address: _../ /h.4 s ^ .. r2C.l Y/c .- ,41.4 . �`4 :2:4 City., . . State - . ,Zip )= Work Phone: � Home c.. Pboa Cdt Phone: • A S $ R usaft,' f 1 . • L 1 ; .1w3.149-(4.45.,.1 11n 'A;ad(:rss:" . _.s,4,} -426. . :. _ • - _.. . . (If from In iailation Address) ' ' _Ci State Zip E-mail Address (to receive project c municationsaud Home.Depot update.)_. . 0 I p0 NOT wish,to reccive,any marktxing entails from The, Home Depot . . Project Information: Undersigned (" Customer"), the ownersvf the property located at tic above installation address, agrees to buy, !„ • and THD At-Home Services, inc_ ( "The Home Depot") agrees to furnisk.dcliver and arrange for the installation- .(`Luchellatianr) of L�QI/f all materials described on the below and on the referenced Spec Sheet(s), all of which are ncorporatcd into this Contract by this reference, along with any appli mblc State Supplement and Payment Suminary attached hereto and any Change Orders (colleetiv 2y; � °tract "): Job*: (t.a..a vasww,o Pr • Spce Sheet(r:) # Project Amount • DRoofing ©Siding. lAWindows. D Insulation .. .1 . . • 6 154, gl aGuttars / Covens EEnm Doors a ... _ . - _ . / q . t'v.. -$: , • /y!4.?" -: lei' • ' a l iding - • windows ■ Insulation , - - -- • . - $ [��G covers' QEntti 3c ors n . • ' • _ Ni • outing R Siding:_ ■ Windows. • t vu ati�in • . $ O(jwters r Cori• Der l C .. _ .. • ' .. LlRoot [-Siding .L0w+n< � In cutaticm . • .. _ • . - , • . • pc r l'ovees nr y; _ $. Maim= 25 %Depee.t or smw'rct An okctae open a(ptationat'...fl . fir- ,:.• alContract.lmouuR .... f /Q MakePYn o- ssmymidtptaitmo vimiam- MintgirlieointraitAMmit: / ‘q- .. !-+: Customer agrees that, immediately Upon completion :of the w+ ork .fer•ea c.hrProduct::Custou►et '!will:execute aComptction Certificate (one for each Product as defined by •an individual Sheet):. and - qty any. balance; due.:..Ai; applicable, . eac - Customer under this Contract agrees to be jointly and seitliailj•obligated"and liable here .. .. •... ,, . ... . The Home Depot reserves 'the light. to issue a Change' Order of terminafe.ttas.Con'rractor any individuatProduct(sj 'included he -rein, at its dc'scmtion. if The home Depot cif irs authorized service' provider:detetmines:that.1t cannot perform at., obligations.duc to n, structural problem with the home, environmental haarrds'urch'as mold, astieitos or load paint, other gaiety concerns; pricing errors' or because work iegwmd io comp the job was not inc./titled in - the Contract ' r Payment Summary: The- Payment.. # 4,9 1 " . " Suuuna Y.. - included . as pat of this Contract, sets forth the total Contract amouotand:payment. required furthe dcposits-andfmaLpayamcata by Product.(as app: icable).. . 'NOTICE TO CUSTOMER . ' . . YatiamentitiedAntreamplately fretl- autopy.a the ContEactattlac: time. yoasiim,Damo:siga:a.Corndetionc etaTSTea. ante; there is one Completion Certificate for tact listed Product as:ddinedby. individual Spec Sheets).beforc w ik,'oa t eat ct is complete. ... _ . . _ . In the event of termination of this Contract, Customer agrees to pay The Home Depot the casts of materials, labor, expenses and services provided by The Hone Depot or Authorized Service Provider through the date of 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 OTHEi•: PAYMENTS MADE, WITHOUT i IMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH .AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer and The home Depot with regard to the Products and Installation services and supersedes all I rior discussions and agreement., either oral or written, relating to said Products and Installation. This Agreement cannot be assigned :tr amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and agrees that Customer has recd, understands, voluntarily accepts the. terms of and ha - . • v e f this Agreement. X p ub 'tied . , : )../ g...1.( x c (1 / Cu. - - I41 : - Date 41 . sultunt's Signature Date X - Telephone No. Customer's Signature Date Saks Consultant License N<. CANCELLATION: CUSTOMER MAY CANCEL THiS (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THLS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NO TIM, ADIDMONAL TERMS AND CONDITIONS ARE S t ON THE REVERSE SIDE AN CI ARE PART OF THIS CONE RAC! 6- 10-09 C-SC while --.B ao : 7 Custome , PaI<_- Sales Consultat ., .. • 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 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 Date Address of work location . The Commonwealth of Massachusetts Department of Industrial Accidents • :r * = - z 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/Individnal): - The_ i Address: � (, it 'rl Z /, City /State/Zip: Aa (?A - (}' Phone#: if 1 Ar . . Are yo employer ? .Check the appropriate box: Type (required): e of - 4. I am a general contractor and I am a employer? er w ith �-�- - g employees (fl and/or part-time).* he sub- contractors 6. ❑New constriction have hired t 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no eioyees These sub - contractors have 8. 0 Demolition working for me in any capacity. employees and have worI e rs ' 9 0 Building addition - comP. insurance #:.. -- [No workers' eomp insurance 10. Electrical r required:] 5. Ei We are a corporation and its ❑ epaas or additions officers havexercised their . 11. Plinth" r 3. ❑ I am a homeowner doing all work ❑ repairs or additions myself No workers' comp. right of exemption per MGL 12.0 repairs c. 152, §1(4), and we have no insurance required:] t � � 13. Other 1 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 affdavit.indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. IContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whetter or notthose entities have employees. If the sub- contractors have employees, they must provide their workers' comp. policy number. Tarn an employer that isproviding workers' compensation insurance for my employees Below is the policy and job site information. " 4'� / l i , i b W / ,� Insurance Company Name: Kk( T" ) r J . • Policy # or Self-ins. Lie. #: P03 `� Expiration Date: -. 'Ai; )1 Job Site Address: I a 4 I City/State/Zip : - Attach a copy of the workers' compensation olicy declaration page"(showing the policy number and expiration date). Failure to secure coverage. as required under. Secttoif25AofMGL c. 152' _cafi 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; 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 1nvestieatrons of the DLk for 4: .. ce coy . • e •veri f cation. ..; T... . I do hereb y certi under th , , , ..1 , altie • , . — y fy fperJury thaf the information provided aba is3 rtie and e a r rert - - __ Si. .. tore: . . . . Pate• _ r - - , Phone #: `y :- tx Official use only. Do not write in this area, to be completed by city or towi officiaL City 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 #: • • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervis r: Not Applicable / ❑ Name of License Holder : ^ n Cie/4 � 5 ' V - n itag License Number f `VAS►" 3k / n ` 1 f 6,eVi4 x,11 4l' >I Address Expiration Date S at L 0 � IeTe hone ( q 5- P 9.: Regist r d dome <leribro" trieiii crr r;aic bt ", „g i a i ¢ g # , , Not Applicable ❑ - - 1 - 61)1ci -- Company Name 6P Registration Numbe Address Expiration Date - SECTION 10- WORKERS' COMPENSATION INS NCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit 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 ❑ -1 om ner Exe > pti The current exemption for "homeowners" was extended to include Owner - occupied DwellinEs 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Win s Alteration(s) ❑ Roofing J Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [E Siding [D] Other [0] Brief Description of Proposed �-- jJ �} i kb Work: - 1 ����;r� ic�C1'9��1�c Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet ea r(f rnr rol se tl riiiidchi r : c>i sib€ iias gs aliipiiei hro f 1 aWt : 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, _ (t t I, 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. i qi? Signature of Owner Date I, l � c�/1'e. , as Owner /Authorized Agent 9 hereby foregoing A hereb declare that the statemehi and information on the fore oin application are true and accurate, to the best of my knowledge and belief. Signed underh pains ansWenalties of perjury. 4 r)L.,-tit-vv_._______ Print Nam i , i ..L -- l hl 1 f dllglrAPA. tre o • ner /Agent' Date • • f 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 I ` _ .. ._..,` _ Frontage Setbacks Front i 4 i Side Li I R:! !w. J L:I _I R i i _.._.._ Rear E Building Height Bldg. Square Footage " ' % i i Open Space Footage , % (Lot area minus bldg & paved s 1 i �.- parking) # of Parking Spaces Fill: •_ __ _... � _.ro ....... ,. — A. . �m. _ (volume & Location) i i 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:1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW O YES 0 IF YES: enter Book Page 1 1 and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: ; C. Do any signs exist on the property? YES 0 NO Q IF YES, describe size, type and location: s , D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q a. IF YES, describe size, type and location:__ E. Will the construction activity disturb (dearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton r � r Building Department 212 Main Street - $ Room 100 r � �r),i Northampton MA 01060 . .� �� � A � 1 y V 4 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 This section to be completed by office 1.1 Property Address: Map Lot Unit ( Zone" Overlay District 1 H ..J 1 Ern St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: BruYol,Ct Name (Print) Current Mailing Adi ress: , , �� Telephone (� Signature 2.2 Authorized Age I . Allk • 4g„ Name (P) Flip / / Current Mailing Address: Signature Telephone SECTION 3 - ES MATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 1401 (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) ILIL1 Check Number 003 '— This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 1 BP- 2011 -0661 GIS #: COMMONWEALTH OF MASSACHUSETTS m +` - CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit # BP- 2011 -0661 Project # JS- 2011- 001074 Est. Cost: $1469.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 56454 Lot Size(sq. ft.): 8755.56 Owner: BRUNSKI CHRIS Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 12 HIGH ST Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341 -9401 W ORCESTERMA01607 ISSUED ON:1/31/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOW 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 1/31/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner