38C-052 (3) . ,
• 1 t33Mt. tf i rirc4 tl , • .
PiM THIS,
.. ' Sold; burnished and Inaesl&td.by.: ; .
Branch Name. BOa Bate: •,I. '.r ''1 ).M4 attie- SerVie Inc. • d/b/s rse.Ft4atie.IktrAt -Noma woes
. 3454 'art cuwada:'STreetr'. Link 2, or.'ester,'MA' •
Branch Numbert, 31 • • •• .Toll 800) ¢57.5362; •Fa; (508) 755 -R823 •
. .•Psde?arra.#.7S-2 , 'tto.tA C 0'd3� >, U C nit.1 i6427
. 'C'T Lie # ; 3 63, 522 Mt .framer ,iuu.,�ga cn r at ce Rag. •# 1 268 93. . •
Installation A Address! 3 1 0%-h...
-h. Pe •>7 7fL , I]:%.t G$ � .
City 9ta <' • - � u � • APliose • HbmaAYapec C, -
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br
q (4)
Elam 'Addreaa:
(lfdtfferent f om Inatailatron Addreea) '. Ctty Staap., Zip
E-ynhal Address <to'reccive project c otinoti iParions'and:Home.Depot' ): ' • :. • , . " .
p I DO NOT w'i- h to receive any knariteting, oaiaila'frcm �'L' `1-tome Depot • .
ant le
THD e , : 'die ( Carnal
• ,a H i vvr r the . the oa cif p;; ErC'1oe .'att+e•nb re,ipetallano ..addreea. egr to briy, ,
Hone ervices Inc, (. oafp lepofl agree6'.tii'i iisb.:de71' ds. aiid Iran e'• Dr the`iastatldtion ( *Ilcu" of •
all .materials described dm the below and on eSpec. S&tas) ''+ E: h 'ruC:,caoip ` intq• teis Contract by this . ' • .
reference.' along With any applicable, State Supplement'toid;,P,ayi ..*4ri1 •befoto and any Change • i F .('ealJoc'Eivdby,
"Contract")
lob fit '
p 1 •
it ''.. j !7 ' .. to l at �y +-.
LI S 5, Jf 09.wrr. / Cavers m .5 . T1,46rs Cl. � . 3 Vii - ::: :S......•
l':. -: 1 • . t' .
`t , y� Mr r g s :
i=' ' ° " iridii�vg• Id.. 'lation ;`:" •. a
+ •'r; ;'..';: ; :' ..
L 5 0 .. pa ,rs;.Cover, QEn 0 ` .. :S':
C Lis .0 R' oyva.0 inn Iaaion''':
EI Gnto s., Covers: penny Diver -.
• ` oaring • siding:[] QiFeado . i 13taulatitiai •
. .p('nruers'i Oov.ers • [ it - Soots. E3' i;_ ` : ...,. • ; ..; • •
Minimum 25%DepaeittiO lOetAtoneirteteet prq ugpp ' {a
Maine Pandwaetx any sot deposit newt than ore thtird°K Hk mek. -. a Q ct iK • . 9 • + .�,
(•e
Cuitomer for ea Product as d�a lyb Upon 4:04100 midi , it . $ pf ..Shtc) end pa an c, "0 e.' .. 1 cdbit, e ton ".n i ei rhos
Contract a to. be of and soverall obli' and h abit ' Y r: .
The Home Depot immense right to issued Change Order or ti tbitte;i]ais Contract orvitiy`Wivi4 :Produet(s i included herein,
its discretion, if The Home Depot or its authorized, soxv'iuc pa0V 'deteriniiles•$t 4•eiaiiti+)e ;i34.4 fit' abl tione due;to 2 s tural .
Problem with the home, envirq�mesttai.hazards •such as co
mwixl,. a, estdg: t,'Ic paint, fa theetisfeiv: consent ;..pd g eitota'ar.because .
work required to. comploto,the job was not iochhded in tt1 utraot, . F t; ..:. • i e_ •i ' . :' ; ' ' .... • • •• Pav'ment Summary: The Payinent .Simintaey' 0 • '1 .. tfi - mantled "a putt t] s Continci;'4sets forth• the total .
Contract amnia and payments tegriired for'the•depgsite pivy lcnts'$Y;I I.(1e4Mplie#e" '.''
•
You are entitled to a : conipietely felled -fa copy orthie Coott ,ti44'i 'yti�,i I rouot ' * CuaaYi e r 6 • ' •
there B one Completion Certificate Tar each listed' Prater a& `'4e Bill by # 'Spec Sletefs "bie #ore wark,on t'kiatPi- ndiuct • • .
Es complete.
la the event of termination of this Contract, Custorirer agrees to pay The Rome Depot t e costs 'Of. materials, labor; expenses •
and servleea provided by The Home Depot or Au2har-ise8, Service Pro Oder through the dote et ter ehtat io . plus any other .
amounts set forth in this Agreeme ,tor allowed andop ''ppli able la*. THE HOME I EP,OT MAY WITIMOLDWIdOUNTS
OWED TO THE HOME DEPOT FROM THE DE00S T. PAYMENT .01C OTHER 'PAYMENTS MARE, W1TIlOVr
LIMITING THE HOME R7[POT's OTHER REMEDIES FOR llECOV;f3 N GE SUCH' AItIOLN S;
Acecotanre and A uthorization: Customer agrees and understands that Ibis Agrcgnent is the entire agreement between. Customer .
and I Home Depot with regard to the Products and Installation serrriees andauperSedes all prior discussions anti agreements, tithes -
oral or written, relating to said Products and Installation, This Agreement tantioi•be assigned or amended except by a wrativg, signed
by Customer and The Hoare Depot Customer acknowledges and agrees that Customer has read, understands, volunwtly accepts the
terms of and has received a copy of' this Agreement .
• Ace . sod .e • Snb�1It ,�jy; • tlet
Custom • lure Date Sales Consultant,. Si Date
Y, ' Telephone No. _ .
Customer's Signature Tare Sales Consultant License No. ' • • CANCELLATION: CUSTOMER MAY CANCEL, THIS • (asapp8abaa)
AGREEMENT WITHOUT PENALTY OR OBLIGATION • '
BY DELIVERING WRITTEN NOTICE TO THE HOME •
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTE.'Lt SIGNING THIS: AGREEMENT.• THE . • .
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS • r A FORM TO USE IF ONE IS • ' • . •
SPECLflCALLY , PRESCRIBED BY LAW IN • • •
CUS'1'UNIER°LSTATE. .
NOTICE: Anntuots L TERMS ANb CONDITIONS Ant :STA1TD ON THE iteirEltsz SIDE A-Nl Ant PART OP TM CONTRACT'
7.15-09 C -SC • VYhite = Branch Fie -Yonne = 't'�.m rar ��R p
►ne yank daa 6;i ..04; , :
At. '+
•
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
---- ,-- - - - - -- permits-in-conjunction _ -to the_buildang.permitissued, 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 me.
ate
Address of work
location
A r . _ .
The Commonwealth of Massachusetts
Department of Industrial Accidents
T Nye: Office ce of Investigations
/� J✓
1= 600 Washington Street
• == d
T- Boston, MA 02111
s� . www.mass.gov /dia
Workers' Compensation Insurance davit: Builders/ Contractors /Electricians/PIumbers
Applicant Information f Please Print Legibly
Name (Business/Organization/Individual): l /, `HD 1 t f 7 f
,t
Address: c=9/4 G {k vls1 wt,o .
City /State/Zip: I vit, OJA ' Phone. #: ) 1 ,1 7
Are you an employer? Check the appropriate box: Type of project (required): i
1. El-rim a employer with i ) 4 0 I am a general contractor and I
6. 0 New construction
employees (full and/or part-time).* have hired the sub- contractors
listed on the attached sheet. 7. 9 Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have. no P' =' loyees These sub - contractors have. 8. 9 DertoiiLLon
for me in any capacity. employees and have workers
working
Y P tY• 9. 0 Building addition
[No workers' comp. insurance _ comp - insur' nce-
re aired 5. We are a corporation and its 10.0 Electrical repairs or additions
q j o cer have °zixercse ter_ - 11z in
.3. 9 I -am a- hemeewner- deina- all�vorlc d hi
�- g1�b� g epairs or additions
myself [No workers' comp. right of exemption per MGL 12.9 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no ' .
employees. [No workers' 13. er I S
comp. insurance required.} (A I ) )l l" j
'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.
I_
Insurance Company Name: 1 E vvi 6tll ---Vt Q J L(
Policy # or Self-ins. Lic. #: J e - ' ] Expiration Date: - */) Job Site Address: 1 7) , V .IyC t�( City /State/Zip: , i �df, r /A► ✓, -` 1G�
Attach a copy of the workers' compensation policy declaration page (showing the policy number and exp' 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 fi ,1P
of up to $250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA ..mein urance coverage verification.
I do hereby_ certify and N i ' . , , . n. 7 s of perjury that the information provided :ahoy is true_andcorrec ___- _ ai L ..
_. y
,5 •. tore: - - - i /' s. - j• r
Phone: 2 .9 7 I 3
O dal use Drily: Do riot rvrzi`e ire lieu area, to be completed b city or town officiat
- City or Town:
-
Issuing Authority (circle one
6_ $card of Health 2. Building Department 3. City/Town Pe Clerk rmit/License 4. Elec: __ _ _
6.Other
Contact Person: Phone Inspector 5. Plumbing Inspector
i .
w
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su oAs'or: Not Applicable ❑ Name of License Holder : j J 1,4 0 L ZJ t 9V r1J
g
�` License Number
I PO
/ Expiration Date /
Address P 4r# k i L. ,01176 3
Signature Te eTne
9....Registered.Home ImProvement::Cantractor s, H-, ... ' ..,.' k .. Not Applicable ❑
1Tie WIernT
Company Name / ^' (/�� 9
Registration Numbe
• _—\
� l f l 10C
Address � Expiration Date ✓ / GJ
� 4 I)/ (r)b7elephone
_ SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) J
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 ❑
: 4loiiit.O n e E ° Dtit n
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
o a liton r rances, State ' • i _ • - • • • General-Laws-Annotated.
Homeowner Signature
' I
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [D Addition [] Replacement doves Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [CI Siding [ Other [0]
Brief Description of Proposed'
Work: a
/r"j i _ /I-,�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a ` f I! ew,Thouse'anc# r adi# ao x ° xis if rq :fioust>aq omp[ete, i> ..foI[a rin :
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
(0 , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit appfcation.
In a/ Signature of Owner Date
C:11 �^� { �j 1100-42--- , 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 p -�:nd penaltie of'erjury.
Ar Vl-
Print Name VAT,'
/
A dr Ap
Signature of Own -r /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:.__._.._ R:.__ ..__4
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
(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 F 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 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
"" mm m D: -- Are there an ro osed Chan es to or a itions i o s ns inter ed the property ? YES 0 NO 0
YP P g g P P Y•
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.
City of Northampton S st P mart � f
Building Department )599% r*z . 5 ` N
A
212 Main Street � _ � '
Room 100
Northampton, MA 01060 � T�v �f a ffk
• phone 413 - 587 -1240 Fax 413 - 587 -1272 P I � i � J n�`
O r Spec
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
, 4.-1- Overlay District
-Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owne ord:
Name (Print) Current
� Current Mailing Address: �,!/'., ` ��
L7 y Tele hone '-)f
Signature
2.2 Authorized A •
Name (Print) ? � Current Mailing Address: c-
Signature Telephone
SECTION 3 -- ESTIMATED CONSTRUCTION; COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building
19/f d0 17 (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) c d roa� c i Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings ............ . Date
31 SOUTH PARK,TER..RP BP- 2010 -0435
GIS #: COMMONWEALTH OF MASSACHUSETTS
ntsarott, , 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 -0435
Protect # JS- 2010- 000591
Est. Cost: $20228.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
t!seGroup: HOME DEPOT AT HOME SERVICES 98785
Lot Size(sq. ft.): 7187.40 Owner: NARKEWICZ DAVID J & YELENA MIKICH
Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 31 SOUTH PARK TERR
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 () Workers
Compensation
WORCESTERMA01607 ISSUED ON:10/20/2009 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 10/20/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
.rte