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37-005 Sold: Furnished and Installed by_ . • Beslv� Date 3'( . Ye � f1 .us 3oroc:Scsfi ..1nc. , /A .'Lg c 1 Ogie.fpt:At Hfome.Smvieea : ; e' 43 Greenwood Unit 2. WoroenMA ar, M 01607 :. }.A ' ..., Toll,p (880) 657 -5l 2; Fax (508) 75{ -8823 Branch Ntnmber 31 . F {al E f!:7 -2t pi M Lie 0 El Con*: Vic* 11642 7 . . • :,: L am. #TifC t MA Iitim Cautrgcror Rcg. # 126843 • 7nstallatfrou Address: 5 F t i {i,' .< �• . 0,8; a e * r00: r ' :. lire CellP �fFu 1�4lltYil • I [ ] . • Home Address: (lf diffr'ra nt from lnstallation.Address} , : - . S tate - Tap E-mail ;Address (to receive proje t co canons andd Depdtnpdslea):. ' ' ` " . ❑ 1 DO NOT wish to receive any t eiiegermils'fmnt The Home °C of "": , Protect Information: Undeisigncd ('Custoe'9. the 'ow nera of :t e load St 'Sbeit insiailaiite address, agrees to boy, and 1'111C? As.1 oaia tarvieas, Tn4- (fie Home Dot") :agrees lik livne and : i ; fie iiiestailsrion ( "lneraIIetloe ") of all materials described on the and ou:'the nced .. ):.a ;Vf,R�bicl(; ;lox tied' to this Contract by this : reference, along with any applicable• State �t and Paymnt=Summar'y :y,atlC.�hed bemo. end any•Chadige Orders (collectively, "Contract"): . . • Job 0! to to ui keanwo x'5. p noptnnt' ill000ra.g !Siding i•;;v�t .: ' i .. :,' ; : :, :, ••' ` �� i fide ots l Covers p1 uw is '.p ' .: : ' .f: '. ( ' WY'1 • pRoir ng :•Osiding' [3 nw!t' Q i?; eu-. , -"_ 3 . • • . Tomas tc ' C1 ie T M'-` • $ • . ElhoormaiUSiding ❑ Wi : •shat'... _, ;,:. .. . QOaeere.r coinrs E�ry D,,czs ©: .. . [l erg DSidibg .0 W tndowii Cf inn io :. - • Dtentiers :Covers Eli > 1j' ;: = : r• :. ? -.,- :. , ° . .. ; • rnm 25% ofCalr®rsia4ennrteire ' .:.:=' ii. c t ` i ' " - 1.y-�7 - lilei Owen °g .. 7C,bts�f ? Ga�ii�a� i- �lig oaotn t '� `''l -1 1 j , iatscot more that a c-4 nl etude Cdatrac iinorset: : :' , ... :... ;...., t :. M,ePbsens may not dep /t Customer agrees that, immediately akin of the w,nti[.'fo :'tent Product, . `.tC niter- 'avi11 eXe.44te'a:'ComPle¢on Certificate ` l \ (one for each Product. as defined by in individual Spec Shea) s pay. ar balance due.: - M .appbcabic... it .Customer under this Commer ageea to be je$ntly and severally obligated and liable hrxwidce.. : - :" .: ' . :.; ' ..' ' • The Home Depot reserves the right to.issise a:Change Oratie t.or:tecminste; this•Contract or. n_y,:lpdi.Midual,P'tc+duct(s) included herein, at its discretion, if The Home Depot or icts althanzed sari - ice proMidee:.deti stiistir : asi i morn i ebb galioiw d re to a auucturai problem, with the borne, environmental hazards such as n414,. sralwrrOe fir, Land #10y• at emsIlceres, ,pricing errors or because work required to complete the job was.net includedisthe•Coiurecxt :: * . :.' :: . • PavmeStrmntarv: 'Mc Payment Summary: # . - -� f`.:. . :' due ed as .peter of 'Contract. sets forth the total - . ' Contract amount and payments required for the deposits 'fetial paymenta'by P and roducc.(atappli'cable) :' • - • rL � NoTICETO CUSTOMi iE " : : .: : : You are entitled to a completely �-if ropy :oft$re Contract at ;the tits pdta :trais ot'sigii a Co 1+ mpletion'Certdicate (note: ' there is out Completion Certificate for each listed. Piudirti is 4146814V vidd afSpec be ) before worth on that Product is complete. Li the event of terrttirration of this Cant act. Cestolncr agrees to pop The flame Depot, the mots 'of materials, labor, *Vow" . and services provided- by The Home Depot Cue ' Authorized'Seevim Provider through the date of termination, plus any other amounts art forth in this Agreement or allowed under applieshle law:. THE HOME D> MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PA' MC,NT.1OR OT's; PAYMENTS MADE, WITHOUT' LIMITING THE HOME DEPOT'S OTHER REMEDIES TOR RECOVERY OF•SUCH AMOUNTS_ Acceptance and Authorization: Customer agrees and understands that this Agreems tct 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. tither feral or written, relating to said Products and Instafllatson. This Agreement gannet be assigned Or amended except by at writing signed by Customer and The Home Depot. Customer acknowledges and agrees that Customer has read, understands, voluntarily accepts the • terms of and has met •i .,: of this AgmcmenL • A by: i . X�^� err : x TO .d..... -........ 3 - y . p - a ..?Tr 's Signature a .,,. Consultant's g Sales Consultanature Data • X Telephone No. customer's Signature Date Saies Consultant License No. CANCELLATION, CUSTOMER MAY CANCEL THIS (es applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING W*1TTRN NOTICE TO THE HOME • DEPOT BY MIDNIGHT ON THE .THIRD BUSINESS • DAY AFTER SIGNING THIS AGREEMENT. THE . • STATE SUPPLEMENT ATTACHED HERETO . CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. . NOT tCR: ADDITIONAL TEIMSIAND CONDITIONS ARE STATED ON THE 1tFvantSR S DE AND ARB PART Of THIS CONTRACT 12.27.10 CSC White - Branch Fat veaaw - tlistern er t . The Commonwealth of Massachusetts _., -�_ Department of Industrial Accidents 1 • t �� Office of Investigations �.: = 600 Washington Street t. s Boston, MA 02111 r. s. www.mass.gov /dia Workers' Compensastion Jns r nce Affidavit: Br4lders/ Conk . - actors/E'ectrici /1'iurbers Applicant TT fornatzon Please Print LeiblI Name siness /Organization/individn I): -1–Cle _ +Ht '.CJ or • Address: '� y' t /' , - • _, City/State/Zip: : . t ' + �'3 ?hone #: q ( r '1` ; Are 'r(an employer? Check the appropriate box: . /' Type of project (required): 1- it I am a employer with RCI 4. [] I am a general contractor and I 6. [1] New construction employees (full and/or part- time). have hired the sub- contractors 2. [] I am a sole proprietor or partner- listed on theattached sheet. 7. ❑ Remodeling • • ship and have no employees These sub- contractors have 8. ❑ Demolition - • working for me in employees and have workers' • g any Y ca P ac rtY $ • 9. [] addition . [No workers' comp, insurance comp. insurance. required] 5. [] We are a corporation and its 10. ❑ Electrical repairs or additions - • 3. n I am a homeowner doing all work officers have exercised their 11.[ Plumbing repairs or additions myself [No workers co • right Of exemption per MGL . Y [I`I ' mp • 12.0 Roo repairs insurance required-] t c. 152, §1(4), and we have no • employees. [No workers' • 13. Other 1,0 ` (� � ( �, 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. If the sub - contractors have employers, 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. _ Tn surance Comp any Name: 1 . - 11: 44 ,L •.f. A (t - 7 — Policy # or Self-ins. Lic. #: (x, c 16, - ) — ?` �- Expiration Date: 3 .1,-.1-, Site Address: II 'fir' J I City /State /Zip: y,■ 1,011( . Attach a copy of the workers' compensation policy declaration page (showing the policy number and ezp ation date). Failure to secure coverage as required tinder 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 against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D • , or insurance covera_ e verification - I do hereby certiA an he 2 &ins /d pe , cities of perjury that the information provided ab , ye is rue and correct. i 1 Si:a ature: Mi d . /1 ,e: 4// _ __ Date: • '; — Phone #: Lf'Tj i 935 °(35 -- j Official use only. ) o not write in this area, tb 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 #: • • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : �^'/ cri9 License Number -.�� _ AdA /4 facti. (44 Address Wir © D Expiration Date e Telephone 'h _.,. Not Applicable ❑ ' �� Company Name ��� Registration Numbe - 7-)L15 -- eiPerh)n 41 Address : Expiration Date v \ Lob 7 Teleph1(0I -(3��`17 j SECTION 10- WORKERS' COMPENSATION INS CE 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 buildi permit. Signed Affidavit Attached Yes No ❑ -.om r4' E I p>1Q 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 SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable) New House [] Addition ❑ Replacement Wi ws Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [D] Other [D] Brief Description of Proposed � ' n � {�j r/1 Work: � 1' &1 t k e i 4 e ► ( 10 ( ' o i.o Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet W Neal' 5i "if " titl iDt O? Sift I GI +O Shit ttS�l't;111i Est he l]o' nna: 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 const fiction 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, / Witt. , 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. q c99 I I' Signature of Owner Date I, 1/' -h 1 I. l� , as Owner /Authorized Agent h ereby declare that t e statements an info ion on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains an. - • - (t of pe 'ury. ■ op ,_A + Print Name 411 ue. -.1 ;._ At , 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 filed in by ; Building Department _ 4 74' i 4 ,, Lot Size __.. t i Frontage _.._.._ _ _ ...__..__ Setbacks Front i 1 Side L:1 —_-__j R :i__...__ L._ R:.__._.....__ ._..___ _ gI ---- -1 I Rear i -- Building Height , I I Bldg. Square Footage _I [ 1 % [ I 3 1 i Open Space Footage ; ` % e (Lot area minus bldg &paved .,1 f [ � I �� parking) # of Parking Spaces ! i — - Fill: ,,_,. .._ .. is (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:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book [ I Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: _ w C. Do any signs exist on the property? YES 0 NO Q IF YES, describe size, type and location: ! o D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: i 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 Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. k 4 iOe ag use only b ,,s , �c�,� D City of Northampton St a f4rs f Pe rrrt uilding Department Curia CuttDrtvre Permit s i . x 1 212 Main Street 0�� S , l t f� Se`s er��`pt�c ��tatfabi 4, � � ?' 0 \ (� L ,�p , , as 't,' Tc y s (� R oom 100 a r;u No ampton, MA 01060 1` W� A' i �c u i1 a nt '' .of—. ' . , - . ;7 -1240 Fax 413 -587 -1272 e � . " n � � �a�� ' 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 5 -Wq Zone Overlay District Ficrelly_e Elm St' District CB 'District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: . is _ 1 .. . • i ■ • •.I ►11Ii 4- ..44.. Name (Print) Current Mailing Address: i ll 5et___COVII Telephone Signature 2.2 Authorized , .,171 Mor Aseht .. 1111 IA...) Li ,915' it) iim7 Name (Print) Current ailing Address: �... / 40 � c135 ' Signature w Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Oniy completed by permit applicant 1. Building 1l_L4 � (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) � AP `� - -- Check Number ® o This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 589 FLORENCE RD BP-2011-0939 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 37 - 005 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 -0939 Project # JS- 2011- 001535 Est. Cost: $1497.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 100962 Lot Size(sq. ft.): 35719.20 Owner: SULLIVAN SEAN T & LAURIE A Zoning: SR(l00)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 589 FLORENCE RD Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers Compensation WORCESTERMA01607 ISSUED ON:5/16/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 3 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 5/16/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner