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18D-053 (4) • . ..� ∎� ,,,a.V • ui,awl V.I. ,Ur, 1M,141'U1 V f�' 4 ' (3�3� . PLEASE REAHTHIS . • Y r t , 4 Sold, Furnished and Installed by - ,r Branch Name; Boston Date: • :J•Q • 05 : • , fi'ETD i ttfiorne Services. Inc.." I't . • d/bhfa The Horne Depot At -Home Services 345 •reanw.ond Street,'Unit 2s Worcester, MA 01607 Branch Number: 3I Toil Free (800) 6$7 -5182; Fax (508) 755.8823 edoral ,75 769844 ; Mp Lty,ti C Q2439; �I Cont. i t 18427 • - - CT Ltc %3 IdCi $anic v ant C trp Reg # 12489 Instal;Iatipo Addross_ D f -G� • A tV . . ,, t.t t vl ity. •State Zip. : . . Pumltiaser(a)- ''W�ki Phonei Home tyhone: Cell Phone: _ [ i , L J ( i 1 ]• [.. 1.• , �. 1 , • Houle Address: (if different from Installation Address),'. • • , . ' City .. • State Zip • E -mail Address (to receive project co mmuxiioatiotis'and'F3bmc Depot updates) 0 T I)O NOT wish to receive any marketing ernails from The I$ome Depot, Protect Info�i ation: Undersigned ( "Customer ") tire} oy�nxers df thepro;erty Iocate'd at tore above i ntitallart0n address, agrees to'buy, and TI-ID At Services, Inc. ('The Hoare agrees Yo thtniah;'ae:iver d aritinge:f6r Nt'instal a:tiou ( "Installation ") of all materials described on the below and 'on the're£erented Spey $hiset(s-e.11:Of.'..,Whilth srejimorpotaierl inter Kids Contract by this reference alms with any applic State. Supplement and Payment S utl tnary.attaehe and •any Changd Orders'(col1cotively, ".Contract "): rob #: taaA.: -.. teweiAV Pi ■ au , S Ac Nheet e .i #: Pro act Aivaunt p QRoafing NISiding" : indOWai U Tnitiiation -�y L k` ' et E /C [Entr boots t( ... - ` +ri, • ' S : 22 3 3 . ' • ❑Rooting DS =ding ❑ WipVows' 11141StXFation ❑Gutters / Covers flEntry Doors [= - •• ❑Kooftng g^ W ;Gtit* ' saal4 +a,.r i - M. , []t'Nmn / C6Y"Lrii IMurx � ! • • 0Roo fins, (Siding fl Windovys Tnau ' °Cannes / Coyote ❑ •ntty boors 0 • hrotinnun 25"3 deposit or Contract Amount duC upon. execut4m of this. ; 'L ':. • 'oirtra�t Aitieunt $ . Maine purcbaaers may not deposit more than one or the Contract A mounts . ....e 73 - Customer agrees that immediately trpon completion of the Per i earn Product': gto m ar r zll e;recute a C onapleoit Cor • x tifiaisto (one for. each Product as defined 1›y an individual Spec Sheet) and pay: any ba anCe - A s applic each Cunwnier uncle' this Contract agrees to be jointly and severally obiigatcd,and liable ,hereunder, ' The liom'c Depofresctves•the right to issue. C ra#ge,•Order Or texmjnat Contidctor, any indiVidual:;Produoot(s) included herein, at its discretion; if The Home Depot at-its authoi7Zed service provider detennbies the( it'oara9ot;perf ; iaa obligations due to 8 structural problem with the home,, environmental hazards such as mold„ asbestos or lead p nther concerns, ,pricing errors or because work required to complete the job was not included in the Contact `, • ' Payment Summary. The Payment • Summary W_V t ti included ss: part of this Contract, sets forth the total Contract amount and payments required for'thc deposittaitc'±ien by Pa'iadoo (aa.appiieable), ' tgOT TO 4(1T.C1I)ILR ; You are entitled to completely filled -In ropy of t he'Cantraet a k Iict� a yoir i 13p too ai a Certlple CeiaifiCa (note: there is one Completion' Certificate for each listed I'rodnct''aS dellue Ise ifditiduti Sire Sheets)'befare wOrk on Hutt 'Product is complete. In the event of termination of this Contract, Customer agree% to.pay Home Depot the coats of materials, labor, expeasea and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any other aanounts.set forth in this Agreement or allowed under applicable .law. THE HOME .DEPOT MAY WITITIIOLD AMOUNTS OWED TO .THE HOKE DEPOT FROM THE DEPOSIT PAYMENT Ott''OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF 8Ut 1 AMOUNTS,. Acceptance atttd AuthoOzatian: Customer agrees and understands than this Agreement' is the attire agreement between Customer - and The Some Depot with regard to the Products and Installation services arid supersedes alt prior discussions and agreements, either., oral or written. relating to said Products and Installation. This ment canoit be assigned or amended except by a writing signed by Gusto r r and The Home Depot. Customer acknowledges u�ces'.that Cnetanoet has read, understands, .voluntarily accepts the terms of/. has received a copy o - ' is Agreement. Acre ",•a by : / S C stomer's Sigyoa r Date S oneultenf s• SUaturc Si Date Telephone No. ..._, Customer's Signature Date Sales Consultant License No. -,, CANCELLASION :' CUSTOMER MAY CANCEL THIS ' (as applicable) ' AGREEMENT WITHOUT PEINALTY OR OBLIGATION . BY DELIVERING WRITTEN NOTICE TO THEE HOME DEPOT BY MIDNIGHT ON THE THIRD. BUSINESS • . DAY AFTER SIGNING THIS AGREEMENT. Tin , . STATE SUPPLEMENT ATTACHED HERETO • CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE, NOTYC1t: ADDYTIONAL AND tON3ITIONS Alai STATED ON THE REVERSE SIDE AND API: PART OP THIS. CONTRACT 7.1e -00 C -S• • White - erancn File 'Yellow - Customer Pink - ^ sales.Cs u l uitetnt 4/1111101P 4f, f 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 • • I I• - • • • - '. • • • r-. _' es that the buildin • de • artment 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_bui1dingpermit 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 me. _ -- --Date Address of work location . The Commonwealth of Massachusetts ' — Department of Industrial Accidents =: 1- - Office of Investig,ations ,h y 600 Washington Street a Boston, MA 02111 „� . www.massgov /dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): / ' r - Lr1 liP Address: A i1 .. r:1 /.11 .1 " - City /State/Zip: r l - , , i u Phone. #: 6 , 5 7 ' ] 2 , Are you employer? Check the appropriate box: Type of project (required): i' 1. am a employer with r O 4.. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub- contractors ti 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have a. loyees These sub-contractors have. 8. ❑ Demolition for me in any capacity. employees and have workers' working Y P ty 9. ❑ Building addition (No workers' comp. insurance cOII7p..hnStTraneP -$ required:] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ am asmeawaer dsingl � -- �ce?vecisedear _ -1 1,,❑_gluaabing repairs or additions myself. No workers' comp. right of exemption per MGL 12.0 Roof airs insurance required.] t - c. 152, § 1(4), and we have no employees. [No workers' 13. er comp. insurance required_] *Any applicant that checks box #1 must also fin out the section below showing their workers' compensation policy mfommation. t Homeowners who submit this affidavit indicating they are doing an work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must art'rhed 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' com nation insurance for my employees. Below is the policy and job site formation. Insurance Company Name: 1:1) 6 v i-- "Pl ' J ) ( "), - r-- Policy # or Self -ins. Lic. #: 0 . Expiration Date: // 0 . , Job Site Address: ...04, l / Ant � if e , q tete/Zip ■ _ "1 1 . Ad %. II Attach a copy of the workers' compensation policy declaration pa ,e (showing the policy number and expira I • n 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 up to 5250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA : , .. ce cov . • e verification I do hereby certifythe p d / 1 n , %s of perjury that the information provided abov_e_ist-rue_andcvrrect S i • . • ture: r _ % s . !J► Phone #: /135--1--43 O Do not write in this area, to be completed by city or town o iciaL City or Town: Permit/License # Issuing Authority (circle one): I; 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 Su 'or: Not Applica n ]1 Name of License Holder : 1 l4 to v LJ r � , License Number la L4 tfit rk 1 / e Address Expiration Date Signature Telephone 9. Registered Home lmprovementContracto , .,. :, .,..._. ` Not Applicable ❑ rD poj j am Company Name Registration Number 3q106-740/ *OD Address Date � Telephone `-'` — 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 buildin rmit. Signed Affidavit Attached Yes No ❑ 1.1. — HQTiie Owl a xemati®nl 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 Northampton Ordinances; e .n. : " . . , s-Gener-al- Laws-Annotated. Homeowner Signature , SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House E] Addition ❑ Replacement Win s Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other [0] Brief Description of Proposed e"' Work: A-"I . -■1111111r - I . 1l/.J/ . // / } 0 - ii , d f------- _ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6 If, , llr- hOUe'arxdz©raddition to irk; ho US' nil oinplete tfie.'1•o1io1Afi lq: 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, e= CC) h 4e' , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit applicatio . l( I Signature of Owner Date I, +� , as Owner /Authorized declare the statements an in ormation on the foregoing application are true and accurate, to the best of my knowledge Agent hereby dec that t sta a 9 9 PP Y e 9 and belief. Signed un. - • - •ai ? d pen - erjury. AMP - f [ �--- Print WalrAr7 1 Signature of iifwner/ gent 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: Rear Building Height __— Bldg. Square Footage 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 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 Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO 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 0 IF YES, describe size, type and location: -- AidiFere - a - n - Y - TDTop - 5S - FrcFa - igFsdiffoiTcif e property ? YES 0 NO 0 IF YES, describe size, type and location: E. VViII 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. t City of Northampton Sas of Percni# Building Department Pub, pre+iyerr� 212 Main Street Seer efiAva abi� y Room 100 It y Mg 4 Northampton, MA 01060 TQe ►f z r * 424 pv A' phone 413- 587 -1240 Fax 413- 587 -1272 ° p ,tan ; iP r 3ther e i , F.,. ..w vr,1. e, .; ,.a ...�s s., n.w. �. APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORMATION 1.1 Property Address: (Q ( O is section to be completed by office 3,(( Map " ./ 1 Lot Unit+ �� l O✓/ �a Zone /� a/ i st r ict Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Q.w -C— n o r vim 012 4y)ivi4 ' ut o- Name (Print) Current Mailing Address: 1 J7 C o& t [f Telephone Signature 2.2 Authorized �;,- nt: .121 l h A 0 1 1 .17 Name (Print)' Current Mailing Address: o * / , I - L - 4 0 1 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (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 Use Only Date Building Permit Number Issued: Signature: Building Commissioner /Inspector of Buitdings! Date 1. 80 DAMON RD #6304 BP- 2010 -0440 GIs #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18D - 053 CITY OF NORTHAMPTON Lot: -158 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0440 Project # JS- 2010- 000596 Est. Cost: $2733.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sq. ft.): Owner: ROBINSON GORDON Zoning: GB /GI /SC /WP Applicant: HOME DEPOT AT HOME SERVICES AT: 80 DAMON RD #6304 Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 0 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 o i (w ` BP- 2010 -0440 GIS #: COMMONWEALTH OF MASSACHUSETTS ... 8t 953 ' CITY OF NORTHAMPTON Lot: -158 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP-2010-0440 Project # JS- 2010 - 000596 Est. Cost: $2733.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 I of Si?e(sq. ft.): Owner: ROBINSON GORDON Zoning: GB /GI /SC /WP Applicant: HOME DEPOT AT HOME SERVICES AT: 80 DAMON RD #6304 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