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22-013 (2) The Commonwealth of Massachusetts ___ Department of Industrial Accidents 1 � — �=�M1.— f Office of Investigations • t - =� . ;14r,--. 600 Washington Street 9 • _" = ,y, Boston, MA 02111 w w.mass gov /dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Orgnnization/Indivienat):. 71V 1 '19 Address: r O l d144 ni ray City /State/Zip: - s h Cis 3,3 Phone. #: Are yo employer? Check the appropriate box: Type of project (required):. 1. I am a employer w i t h 4. ❑ I am a general contractor and I mp y 6. ❑ New construction employees (full and/or part-time).* have hired the sub- contractors listed on the attached sheet 7. ❑ Remodeling 2. 1:1 I am a sole proprietor 'orpartner- These sub-contractors h x shits and have no °TMTloyees Th b 8. ❑ D.eao,�.on working for me in any ac employees and have workers' - capacity. 3. 0 Buildin addition [No workers' comp. ;insurance cep.s��rancP. required] 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions 3. ❑ I am- a- homeewi3 - -- -- officers ■ • ve : , ' , - - - glib' --r repairs or additions ' exemption per MGL myself [No workers comp. mP tion P 12.❑ repairs inexxrance required ] t ri t of c. 152, §1(4), and we have no employees. [No workers' . 13. Other. comp. insurance required. }. *Any applicant that checks box #1 must also fill out the section beiowshowing their workers' compensation policy information t Eoxneownets who submit this affidaivit mdica1ing they are doing all work and then hire outside contractors must submit a new affidavit indicating suck IConn actors 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,a {m an employer that is providing worker' compensation insurance for my employees Below is the policy and job site _information. ormation. f r y_ _ Insurance Company Nance f j p t ) - Policy # or Self -ins. Lic. #: �t �� � c j Expiration Date: - " j Job Site Address:; 6_7 (J 141! / OCity /State/Zip : d 'lr--‹. Attach a copy of the workers' compels . tion policy declaration page (showing the policy number and expiration date). Failure to secure coverage, as required der Section of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 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- Ige advised that a copy of this statement may be forwarded to the Office of Invostizations of the nu for insurance coverage verification d aloes o . e that the in ormation rovtded.above true tdcorr _ecr: -_ __ I do hereby certify ri • the p ,• f-P t1�Y f � - . ur n Si � .tore: - � , � � . 10.1/ A. " . Phone #: '7'x� ���j j f zcial use only. Do not W te_ n tlhii.ar to a co wed b or town � Y e� mP Y ctt1' wn aff�>it _ - -- City or Town: Permit/License # Issuing Authority (circle on e): .boa -rd of Health 2. Building De ,artment 3. City/Town C1erk 4. Electric inspector 5. Plumbbi er=ror _ _ s. 6.O ther Contact Person: Phone #: s � 4 , ..' c ��n 6o tnA.ratonealf/ of, :fzp9�r�`1fi Boar of Building iiegulationS and Standars 6 Construction Supervisor License License• CS 67121 ' , Expiration: ' „4/30/2010 Tr# 20346 R estr i ct i on: 00 • BRIAN C THOMPSON 6 CAMPUS VIEW RD S MONTGOMERY, MA 01085 Commissioner • 1 e - ^omzmomeoea/a. o /,..iffacuac%uve 4 1 Board of Building Regulations and Standards r F qt l HOME IMPROVEMENT CONTRACTOR � Registration: 150438 1 Expiration: 3/30/2010 Tr# 262894 Type: Ltd Liability Corpor AMERICAN WINDOW SYSTEMS LLC BRIAN THOMPSON • I 6 CAMPUS VIEW ROAD �4r+- MONTGOMERY, MA 01085 Administrator , k .. ROME'Idat> ttpva ill av�; . € • • • • '' • Sold, Fished andlrtst_stle:d by.: ,r BrancbNams :..1100gn, ..Pate.. ,L , ,. .... , , '. ?, Hot Secvic.s .*- • . .dlbla . Thn .4 O me ; qt- Fr47naSSrviEes 4S ls tires ►Wood S urat,' rat. • woreeater, .01607" . BraDdt Nts 31 • . , • Toll Erb 4100) 657- 3182• Firm. (50 755 S$23. . ,.; • .' i ettr :i tr�'d.9'* t642? 'Feaaeall;Sici: � c.lrc' a r ' .. .. ... CTLie # 56s52.2:'bit::r see orovemotit l A rt. 4° • ' • inettil .,=•-• • ' , r. , 4; .° •� ►: wk c> _mils: 4 �., , 4. ., • • I PlOrCba844.0: . . • ;r W0Kk .:. •�. H0.1aleYheatt; '. ' . Pbiotte: .... : : I pcLm1 'KR_ _ : i 44:51.. ' . �:...,. :,': .[.' ' , .}.•,. :•:, •:, t ...... 12 —a ne) • H Addtrasii: (IC di.fti t, from Inc i4ii p*,.. d0,so • City , State 4 if.Add.r ('to r eceiveproject #itatiatts.and i#ottic.filepot.npdrste ?); :_ _;, - ' • , . p t DO NOT *vista to zeteive any. marketing entails ftgin Te Hen i Dep tt,;. .. - . ` :.: 4... .... .. . Proi{q b rntina c Undersigned•('Cbsp e. ); the Y'ttheep periy'IOtt00: *'th 504 of . 04retw;>ign° to boy, � and TkID .AsMron Scythes, Inc. ("The Rome Depot") agrees f ush. deriver asftk n bx ta t illstallatios (. "installation') •of . Ir/ all materials : described on the l below, and on.:the n0% 'Sptxt ;Si> k' alt; of.'Xrrhieb. arc:; enc d !►9to Cmtatac by this referenc e , along with any .apptidebre Stair Supplement afia'P$ywettt .S'tlittniaiy : saWc ltd : her o �d a1►Y' .44e. 1cOunct ively; • , . Job is ammo' t*Bereaco' • Spec'Siii t).i..... 'Protect Amount ,' • ❑R 'ooftitg ❑Siding:. 1Yiadows :[Q' Ittsettttit6a '' .• 30 - •13Gntt s'icosecs p rte . 'C .... ., . '.. x.,( °. 3o • rel i;Wi!indowt' _ C1Gutr i Covens ❑E ay Daota l`t :; $ , Siding Di(ftttivws j,Lt?tettnwu. ` f, + T ❑Gutter# /COW" []Sntc boors ❑. ❑Roofin ©S :❑ Winii0 & ❑ Insulation r Ofiut[eis /Covers LAY. i?oois , h MMnePntdteetrs not > ored n o .hftddtlee'Cp+trres+l eRwrc�c�CEICiHOQldott!►ta�i�q may !1 ...• • . ' •• :YAm FiiG• • :$ • ,r • Ctt totner ag that, itntnediately upon comp of:he, letion : work .fie i 'f'ry duct Cost wtlt: exe1te' Ctio cate One for each Product as defined by an individual'SpaC" Sheet) iad'pay. balance : daa2:• As Spill otible :'P : ' el4teisoer'e u i d er tht's . Conuact agrees to'be jo and severalty oblige bii�ted'andliable hereandema' .:. •.• ' ' • , ' • The ]"lone Depot teserves.tltaright;to issue a Change Order or trnt nnate this Con1 metal any ndividetal Prod s) :'inclnded•hereitt, pt its discretion, if The Horne Depot ot or its authorized service lwovid'ex. aetrrminta iba ut:cat i oi peift ti its',pb i +loons due to ; a ' u?tctural , problem with the home, environmental hazards. such as mold, asl estos.tir lead ,aiat, orhei.sa'f, congciris,, ' " errors of b ecause. work required to t ampfrw ttln' job *as shot nastier in'ttta c tea ,; Psivnieat Summery: The' Payment. Summery. # 1 5 5,B :O .. ....acted ., . a? :part Df, Core . limb,. the. total Contract. amount and payments requited.fot.the•depoaita Mid: final pa nts by #aroducc.(as..•appltcable ). - . :' ' <•:" . . You art entitled tots completely tilted -rites y'b1 the Ceotl'ttwet.*t tlia•titaie. s tn, p Dope aim: btfore rate (tints there is one Co pletiou •Certificate for eerie b listed Product: as:3etitied: . .. . S Ware wont on. ttaat: Prodncx • . E complete. . • In the event of tertmnation of this Can di-act, Customer agrees to pay The.Home Depot the costs at natterbdii labor, expenses and ttervte provided by The Horne Depot or Authorized Service ProvIder thr the date of termination, plus tiny other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO 'ITIE HOME DEPOT FROM TILE DEPOSIT PAYMENT Olt .OTHER PAYMENTS MADE, WITHOUT • LIMITING THE HOME DEPOT'S OTHER REMEDIES I OR REC'OV'ERY OF SOC'II AMOUNTS. • . Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer'. and The l#ome Depot with resaid to the Products and Installation services. and supersedes all prior discussions and agreements. either oral or writ ten, relating to said Products and installation. This Agreement cannot be as igaed or amended excerpt by .a writing signed by Customer and The Home Depot. Customer acknowledges and agreesahat. Custorner has read, understands, voluntarily accepts the terms of and has received a copy of thus AgrOanent X 91 • irrl l t +6.11.: 7, i 9 x •i' { .. .r. • '-� � � mer's Signature Date Sales Consultant's. •gnatwe .. Date . Telephone No. Customer's Signature Date Sales Consultant License No . CANCELLATION' CUSTOMER MAY CANCKI. THIS (es t seen) AGE[ WITHOUT PENALTY OR OBLIGATION BY DELIVERING WitI'I'iCkN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS . DAY AFTER SIGNING TIUS AGREEMENT. THE • STATE SUPPLEMENT ATTACHED BXR1ETO • CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE: ADDITIONAL TWOS AND CCsNDITIONS ARE STATE) ON THE REVERSE SWE AND ARE PART OP TRH CO.NTRA.C1 6444111. t~SC w1na. •grAneh•Rla Willow — ri,Mnnwr.. • Pink...Snlrac.rtnne. . . . . . . s t SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction S rvisor: Not Applicable ❑ Name of License Holder : fl / V 1 1 Yk(1 " r p2 1 License Number / Wit& vl iod Rbf o►6ii•oyneoi slog' r v P Address Expiration Dat e / Signatu Telephone 3.. Registered Ho `rnelrOjaroweirr"entGonttaet - °< d , „;... , w_ , ._ia., i. .4 , ,,i , .. "4 Not Applicable ❑ lb() V1f 1for 1 Company Name Registration Number 3/0 Address I Expiration Date lfv rz ' o . k 4 Telephone 4w/ .)z33 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 building rmit. 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 ampton inances ; a MI _ • ,' s-General-Laws- Annotated. Homeowner Signature a , • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Win s Alteration(s) n Roofing I I Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [L] Siding [D] ^^ Other [O) Brief Description of Proposed 4 r 4e., Work: T 1 / _ 005 fl4C) Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa , if NeW :houe itid"O `acldltiontto - 'sting "hous>inc ,- complet6 the?fiollornring: 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, C . 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. Signature of Owner Date ` eV 1 <-. 'Dv) ., , as Owner /Authorized Agent hereby declare that t e statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signe• l-r the pains and penalties of perjury. Print N w--� Signature of • er /Agent Date • a t NI 4 A 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 i 7 € Side L.' �_ mm' R::.--....2 L:w _ R _. .. __. Rear Building Height _. Bldg. Square Footage I 1 % i Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces ____ ., _ Fill: y,m.._...._._..,_N.,� I (volume & Location) 1.___ — b 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 g Page ' and /or Document # : B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ,Date Issued C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: — D Ale t ere y proposed changes to or a rtions oisigns inten ed the property ? YES 0 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. t ( �2i 113ent,ti Ofi y , L j ,y,',, City of Northampton v ( '''''''''.-C,-,.., r . � P Statu�af�e � x,, ��� � k � �, � �� c, \� ' Bt lding Department Caa� t3l -fi)re 4P t � eitf ; \ \- -� �'' 10- 212 Main Street s e r e4t, *r1iiabtla t 1 fr 7 3 r) Rom 100 `. � I' a�t / ��w4 \ ND a n, MA 01060 al_ glat ans m � ,I e � z �i y . ' .phor 41,0-681 Fax 413- 587 -1272 0s, ii i : 4 44 . p 4 4 \-� P' e. pe �:14.0i 9 rt, (Ii.i ' �� g ' , , its ti ` ` _ t C,) .$' _�de644 ,•'t._ _ ---moo *�Y . x.-1.04' *A.. ., 4, _ \ APPATION 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 /��. � i �, } Zon O �erlayDistrlct �V EtmSt District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: i' Y , -A -i t-1 (2 _ :._ %' -- i -- Ode- FlQ(n«' f- Name (Print) Current Mailing ddress: k i/ ‘ / �� er ( 0111 Telephone Signature 2.2 Authorized Aaent: P -- Name P' Current Mailing Address: (:, � i . _ � J i --.� -- g �DI� 5 2t 3 � 1 X0 7, Signatu Telephone SECTiO 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) 5 . .3h Check Number d 17/° d /t� <'�-- This Section ;Far Official Use Oril "' Date Building Permit Number. Issued: Signature: :............ Building Commissioner /Inspector of Buildings Date BP- 2010 -0127 GIS #: COMMONWEALTH OF MASSACHUSETTS 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 -0127 Project # JS- 2010 - 000150 Est. Cost: $5736.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 126893 Lot Size(sq. ft.): 27007 Owner: MULLANE JEREMIAH J Zoning: URA(100) //WSP Applicant: HOME DEPOT AT HOME SERVICES AT: 67 SPRUCE HILL AVE Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 () Workers Compensation WORCESTERMA01607 ISSUED ON:8/3/2009 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 8/3/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo