36-105 841 BURTS PIT RD BP- 2012 -0589
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 105 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2012 -0589
Project # JS- 2012 - 001005
Est. Cost: $1723.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 100689
Lot Size(sq. ft.): 52533.36 Owner: MAZUR EDWARD J & JOAN A MAZUR
Zoning: SR(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 841 BURTS PIT RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers
Compensation
WORCESTERMA01607 ISSUED ON:12/20/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION
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 12/20/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This cobinn to be filled in by
Building epartent
iTrA
Lot Size 1 1
Frontage 1 1 1 1
Setbacks Front 1 1
Side L: 1 R:1 L:1 1 R:= 1 1 1
Rear 1 1 1 1
Building Heig,ht 1 1 1
Bldg. Square Footage 1 1 1 1% 1 1 1 1 1
- 0fen - SPace Foomge
(Lot area minus bldg & paved 1 r 1 J
parking)
# of Parking Spaces 1 L 1
Fill:
(volume & Location)
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 0 YES
IF YES: enter Book Pagel 1 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 orneed to beobtained from the Conservation Commission?
Needs to be obtained 0 Obtained
, Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 1 acre'? YES NO
.
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
.. g
.SECTION S= D ESCRIATIQN " OFRROPOSED WORD ters ' afk - appiicabte), , ,,
t -t 434 a + 1 „s. i . 1 .. r,'�, r u`� , �r' '+'
v, �;,_,..�`�' - = A ?: < .. ..fir: �+r� .',� - ��:
New House ❑ Addition ❑ Replaceme • Alteration(s) n Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition Signs [ ] [0 Sid [p ] Other [Ct "
rY 9• ❑ New Si ns p Decks 4-
Brief Description of Proposed 1 Ati: .,___-, i �}; 61.a..4N-1 1 61a ,� •�, Work: I l C` , jLia ick 14 J ir41
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet � p y
.. : ?9ep (1. 4 i I f1 ^�6 . ,,,I , „:1-a.: - , 4ti `s;4� W Ij �. F:, ma:Z..: - 'i. 81 i , 8l: tl ' - h �w'�.17F �`. .Mali: ! ;.
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 ? es No .
I. Septic Tank City Sewer Private well City water Supply
- •wa;,` ti -• ' M - ,r p � -
�-
k- �.. . }fig
t 43. tw, -, i� 1 � 14 B *t - ® > t ^A
�OWNEfflid b s13 CQNFRA ® P al t n r ®TV EI ,
1, G.a_.. Cop* r,/ , 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.
4 t. 3n/
Signature of Owner Date
I . , as Owner /Authorized
Agent hereby declare tha 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 ' f perjury.
/' r
Print Name
ii
Signature of 1 er / Agent Date
a
H�-�
4SECTION 8 CONST1tUGTION :SER CES Vi '
k 'EnNk'wi s+.: R:Xts%,e?s xS.+1n .asr?`Rr_'2: r. .
-
8.1 Licensed Construction Supervisor: Not Applicable 1:1
of License Holder : �� � 1 OD (
License Number
Address Expiration Date e rt )4)
, —
"r',ari .a. /, l / .# r J i sue.
Signatu Telephone
ese overne4 t� ;`rra Not Applicable ❑ • 'rr 1,t7Wel5
Company Name Registration Number
rtIlA . lei,
- Address I ' Expiration Date
i
j tr . 4 1.1 [4... /I elephone (%mil i�C�j
,'
SECFTIO 1II4V FIfC ER ..u.COMPENSAMOMINSURANC l 1 1 ., $21,0••••
Workers o rkeis k denial Compensation
issuance ensation Insurance ce affidavit m be completed and submitted with this application. Failure to provide this affidavit will result
in ermit.
Signed Affidavit Attached Yes No ❑
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 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 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
.- ; � „,1 • 600 Washington Street
'; Boston, MA 02111
. 4. , ..- Q.0. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): .f ii 3j1E 0 61 \ --- '
Address: a a a t -r„ ,. y
City /State /Zip its . • A _ . / Phone #: DO &b
Are yo n employer? Check the appropriate box: Type of project (required):
1. I am a employer with R(. 4. 0 I am a general contractor and I
6
employees (full and/or part- time).* have the sub = contractors
0 New construction _
listed on the attached sheet. 7. 0 Remodeling
2. ❑ I am a sole proprietor or partner-
- contractors b- have
ship and have no employees These sub-contractors 8. 0 Demolition
working for me
in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.
$ 9. 0 Building addition
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised. their 11.0 Plumbing repairs or additions
m y s e l f . [No workers' comp. right of exemption per M G L 12 0 R repairs
insurance required.] t c. 152, § 1(4), and we have no � -- �
employees. [No workers' 13. . Other V I l 7 (,.;
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.
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. Tithe 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.
t'W7 0 Insurance Company Name: \7 ��
11 __ g
,,
Policy # or Self -ins. Lic. #: 113973 Expiration Date:
Job Site Address: ( 91 PQt't4X City/State /Zip: k '641,, ,, it J /�
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expi ation 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 u p to $250.00 a day - _ . • st the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the r insuranc l overage verification.
— I d hereby ce ' under t : O d pe # Ities of perjury Date: ' ury that the information provided above is true and correct.
Siu n =MIMIC Ai .. � /
Si. / i
4,.
_
Phone #: tZ.r
- -= = Official use only. Do-not write -in- this areas to -be completed by city or town 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 #:
0.0=1
City of Northampton
( Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS ou ,
212 Main Street • Municipal Building
Northampton, MA 01060 4N144,,7-
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 defines "Homeowner" as, " Person(s) who owns a parcel on which
- 1Telshe resides or Intends to be, ortwolarnily 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 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 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
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
- - -- •1, _ 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.
Date
Address of work location
!TOME IMPROVEMENT CONTRACT
PLEASE READ THIS
• Sold, Furnished and Installed by
Branch Name: Boston Date: THD Az-Home Services, Inc_
t J, La-- d/b/a The Home Depot At -Home Services
345A Greenwood Street. Unit 2, Worcester. MA 01607
Toll Free (800) 657-5182; Fax (508) 756 -8823
Branch Namber t 31 Federal ID # 7S-269040k ME Lie # C 02439: RI Cont. Liar 16427
CT lie # HIC.0565522; MA Have Improvement CoMhec r Reg. if 126893
lastalladon Addrean `-� 4 - C- V .�- 22 (per r -
city State zip
Purchaser(s): Work Phone; Home Phones Cell Phone:
� Noe N� rah [ J [ 13 J Ski t 3 [ J
[ J [ l [ J
Hoare Address
(If different from 1natafation Address) City State Zip
E -mail Address (to receive project communications and Home Depot updates):
❑ 100 NOT wish to receive any marketing emails from The Home Depot
Project Information: Undersigned ( "Customer'), the owners of the property located at the above installation address, agrees to buy,
and THD At -Home Services, Inc. ("The Home Depot ") agrees to furnish, deliver and an-ange for the installation (" Imstallation") of
all materials described on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contact by this
reference, along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively,
"Contract "):
Job #t nwrsnn,e..w Produotz _ !l:
Mila ■!Goofing ❑Siding • Windows !" anon
Mauro / Canto • a, , :,,.. • lib $
• Roofing • its le windows ■ Insulation
Mimed / Covers DEntry Doors fl $
• - • • , ■. • Wigdows ■ Insulation
❑tunes /Covent DErtry Doors n
■Roofing B *•'.:.._ • Windows [Jlnrolsean
/Covets DEntry Doors n $
Magee= 2596ntmeit&C Amami dm epee a iao et this unkint. Toad contract $
maim Femme= may net deposit mere tharronended &the C sctAmenar. (` 3 —
Customer agrees that, immediatdy upon completion of the work for each Product, Customer will execute a Completion Certificate
(one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable, each Customer under this
Contract agrees to be jointly and severaPy obligated and liable here under_
The Horne Depot reserves the right to issue a Change Order or terminate this Caetract Or any individual Prodtux(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 structural
problem with the horse, environmental hazards such as mold, asbestos or lead paint, ether safety concerns, pricing errors or because
work requited to complete the jobs as not included in r th . e � Con (c tr � a [ ct-
Payment Se, m ymeat ast : The P. Summary # t�►Sg efi. a . included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final payments by Product (as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filled -in copy erf the Contract at the thus you sign. Do cant sign a Completion Certificate (note:
t etc tit
Completion Cerg►se for esebi !ed Product as defined by individual Spec Streets) before wort on that Product
In the event of ter manatioa of this Contract, Customer agrees to pay The Hem Depot the costs of materials, labor, expenses
and services provided by The Home Depot or Authorised Service Provider through the date of termination, plus any Outer
amounts set forth in tll is Agreement or allowed tinder 2.p Ii law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME •EPOT FROM THE DFk%CISIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
AeeeoCWee sad Ate: 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 prior discussions and agreements, either
oral or written, rearing to said Ptudncu and Installat ion. This Agreement cannot be assigned or emended except by a writing signed
by Customer and The Horne Depot Customer acknowledges and agrees , has read. understands, voluntarily accepts the
terms of and has received a copy of this Agreement-
Accepted by — .:
t : signeNre sales « , sultan's s• Dace
X Telephone No. I t ( 3 436
Customer's 'Signature Date Sales Consultant Uccnae No.
CANCELLATION: LLATION: CI TOM ER MAY CANCEL THIS tw 2PPnicable0
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVEPI NG vW•IT"FEN NO'T'ICE TO THE HOME •
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING TUTS AGREEMENT. THE
STATE sOppLEMEzirr ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
term ADDITIONAL TERMS AND COr ro TIONS ARE STATED ON THE REVERSE SIDE AND ARE rAYT arms CONrRACC
12.2710 C-SC White - Branch Fie Yellow - Customer