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You are enfillyd to a c ntpRicte -ly filled -1n copy of the Cmat at the alms yoti sigm..U0 nett n ate C:amptetion.Cext4flc to txeote. lbw t it am Completia'cn C:rrti'katr fcm' rch hated Produ t at'a e$t ib t •i y 4a t Spat 5laretsj Iscfcsre vrork on that t'roduct - -- _ � Th _ � T tr 4it u�' Hama ; T'�nt 41zt` r�rxt.� of trxnrte.'t'al+�; tfzl4�rs �'fptm6e6 ° e tarps. Chi I3t �� rt mlv tall er tartl , r czc� rcarrttePt e tarn lie t mf , � AtittTt +nrnrr� itrt3CC t rcer �r F�t1F�ct *sn� r }t t�'IY22f�t�4ii23Ia P_ .s r a: s�saa'«iozr tEtis +�## � tat t� .._vhs. sat tisrt;t w +:ttFS �.„reBR + +sarrY ten.: TA:s s ' tr..�.m€ PrYl6 Elk:'#?E 'T U'kv vet It ftLlT A 1R'g lUT� tS m c..wA *er tit trs' t.t 1S- ,�taTpl Zy#+CI€TT_,__ U5i'2:r11 W THE 11014€13 LtEI'Ct'i l'Is�Olt9 t a'a"axaaa ar'axar". .« LJNIfPL^vG THE HOAIU IEPOT'S O HER REMED S FOR t C VIuI k, E ?F filet I; &N TS. S. Ac:cep %44nc ar: A:nt9rogi xattfin- Cuss >mer nTm; and uu& xFtund,: That this Agrekti is the entire ugte nreut bzt veeut Ct touter -- and Tbr- f- ic,rE: Dtpul wit > rd u> the f ru3ucts and a ticllaEacrn scsx%ccs luau ..s i c 4t xlc r da _ ain v and agreaniestts, e:thcr Grail t krzuexs, rclxtir>g to mid prod ota awJ trzstaliath rr Taus Apn �natt auacnt C'tt be as%i 'et tied. or amtzt ercep . e liy Cw tFar'+cr used The Home Detv, Customer acku wledggS And agre€s tlh Cu torncr hhr'r d, undrrttands voluut�Yily ae eDts fhe tcrnt: of and bss, receiv a copvof (his A,grcttl nt {{ Acct cdtti•a i j f e„�, 4� ^-� 4` ti ,Atoll fs Z — / ; - J,„ "+`( ,.- tsstcr's Ssg re rste bstIecE tzaultsrtt'S ,naC.ure i :Yte Tclepx crrn N. _.. Cu &.uttKr' S S Demure 1)aG sale's E _onsultarnt. Liz a e N. C,Vlt ELLAT1ON CUSTOM 1R MAY CANCEL THIS ra +PFticab4e5 A GRb_.?YT '.Zd I WTrHOUJ P AL'Y OR Q.JLIc ATIO R \' ItELwERrNG Si R3':CPjtF NOTICE TO 'F HE HOW, DEPOT RY MIDN {GI F ON THE TI D US IS DAY Arf1R SfraiN 4( Imo AG C N - T., IIE SPATE S11PPL 11 NT ATTM$ FD 'tf CONTAINS A I TO USE W ONE IS SP1ECiFICA1 t,5 1* $[:1(€11tl II RY LA'W C4ihfOMERSS':tA'TE ! t,3Tt.f_.g AXIDiTt€ NL AL e GS,RtS AND t1t }`au €n'Qr/5 !1ttE, te'[t'F t+:➢' 'I IaF rki ;'t I S5 SBZP_ , NfY &E t A5rT iW Th 5 C4)Nrr 4 t C_ 22 » Wh to — aralc `t RK vt-,tou' - °f`- mr r t- !t!if - I:i:tY •^ :F.lh:;ulL°.:it 7 e t- • � -. �'r Commonwealth ofl'�I�ssachtz�'__j., "--' Department Ofl.Jdrtsft'ialAccident ''1, :, '''''71):-----,' =-. t (2/Wee of In v estigations - 1, -; _ . . 600 s th- o r Sr; ez . C L =-, ;l os L,. 111.'4 0 . 7 1 1 • Workers' CGMI3F,TISa i i s111 ± 1J -. _ 2i1 ct rS: 1.c':y -_' c7_f . -etici r.s: 1 :. Applicant Information. Please Print Ler 1; • N me (Easiness /Organization/ individual): t t _ , . Address: 4 ` A , ' . City/State/Zip: OC - i Pbone #: 1 � Are you as 'r- ployer? Check the appropriate box: Type of project (required): er with 1. L1 ;gym a em to t Do . 4. 1 1 am a general contractor and 1 employer 6. E. New construction employees (full and/or part- time).* have hired the sub contz actors 2. ❑ I am a sole proprietor or partner- . listed on the attached sheet. 7. [] Remodeling ship and have no employees These sub contractors have g, n Demolition working for me in any capacity. employees and have workers' 9. n Building addition [No workers' comp. insurance comp. insurance. required.] 5. [] We are a corporation and its 10.n Electrical repairs or additions 3. E I am •a homeowner doing all work. officers have exercised their 11. ❑ Plumbing repairs or additions • . myself. [No workers' comp_ right of exemption per MGL 12.0 Ro repairs insurance required.] t c. 152, § 1(4), and we have no • employees. [No workers' ' 13. Other u� flf 3 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 arc 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 employees, they rqust 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 ilnforrrtgtion- Insurance Company Name; 1"..„„V tr2 j .. a_ . r- _ . ' Policy # or Self -ins. Lic. #: '5 9 /5 e' Expiration Date: Job Site Address: inn , s 1 ijl. �--"'- City /State /Zip: 0 ^ Attach a copy of the workers' comp policy declaration page (showing the policy number and expiration date) Failure to secure coverage as required under Section 25A of MGT, 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 DIA for insurance coverage verification. - I do hereby certify u der h= in .nd • enalties of perjury that the information provided above is true and correct. Signature OA / . D ate: • Phone #: ` .. . • Official use only. .Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Depai latent 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector „ 6. Other Contact Person: - Phone #: . 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 occupancv 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 itissued,_ 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 41 _1 t. — � Office of Investigations • k EE - = y 600 Washington Street �== Boston, MA 02111 www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/rndivicl Address: • City /State/Zip: Phone. #: Are you an employer? Check the appropriate box: Type of project (required): /' 1.0 I am a employer with 4.. 0 I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub - contractors 2.0 I ani a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have no. employees These sub - contractors have. 8. ❑ Demolition working for me in any capacity. aci tY employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance- required.] - 5. 0 We are a corporation and its 10.0 Electrical repairs or additions o cers. ave ,exercised their -1-1.0-Plumbing r 3.[� I- ama�on�eo-wnerde }ng�ll�vc�lc------ __.__ -- • repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance requited ] . *Any applicant that checks box #1- east 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 subcontractors have employees, they must provide their workers' comp. policy number. Iam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: - Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /State/Zip - Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration 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. }le advised that a copy of this statement may be forwarded to the Office of Investisations of the DIA for insurance coverage verification. _ I do hereby certify under the pains ; and penalties ofperjury that the information provided _above_isirue- and-correct Signature: Date; Phone #: • Official use only. D� not w in this area,, to be cornpfeted by city - Jr to 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 Su isor: � Not Applicable _ ❑ e Name of License Holder : \ / ► �7 iC License Number A j hill .■ ; '� J13 L f/ / 1 Addre - ,w/ ' S Expiration Date Aar 7 "agile ig r: Telephone 9: 12eQisterettH omelnili'OVemirii`6O1 e":""Ctiiii i ; ., .,.. HI &„Li q' g, .,.. Not Applica 0 Company Name 1) Registration Numb qr. lie ., :A P% / �� Address VI Expiration Date � j' elephon — c' '' _ SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affiday ust be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buil g permit. 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 NorthamptonDdtnances; a e : r i Y . -- , s- General Laws- Annotated. • Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Win ws Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [0] Other [0] Brief Description of Proposed —_ _ t , ��� ��� if Work: r l re s 0t• 00 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa et° tiiifi tiVrit ` ci ° q iietisirf , millet ific ob - Mng: 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? .e-- No . 1 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 1, _ - • 1 , 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. r - ) Signature of Owner Date Aiamimmimmumamaau 1 J , as Owner /Authorized 9 Y A ent hereb dec hat he s at © nd information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed u ' e pai . • • - nalties of perjury. il. ..r A Did —Q -- /f .,074/6: Signature of Owner • g ent Date J 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 -- W i.._ _ _, ", __. ._ ._._. Frontage L ` I ` 1 Setbacks Front 1 1 1 1 _ Side L: . ... ' R L:€ J R: L .. Rear t __ ._ ... Building Height , i `" Bldg. Square Footage i % t Open Space Footage % (Lot area minus bldg 8c paved _,,,_, —4 ' ' __ _� parking) # of Parking Spaces ----- - , -°-~ Fill: I -I, -,. (volume & Location) , A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 i 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 Q DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO 0 IF YES, describe size, type and location: v D dre thieve any y proposed changes to ore rtions o signs inter ed Mr - the property ? YES Q 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 Q NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton - � A � b � Building Department 212 Main Street , . . Room 100 Y 2010Northampton, MA 01060 k i- phone 413- 587 -1240 Fax 413- 587 -1272 ° -t - rf APPLICATION TO CONSTRUGT, 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 ,2 r I,tC -(_f t I nj done Overlay District Ettn_St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of R d: • r Name (Print) Current Mailing Addr -s: 'b Telephone Signature 2.2 Auth..,r, -d A. e Alli I, r ,/ ,�° �C �t� �� 4 t . " t)(60 Nam: - Current Mailing Address: � ow _ � 1. -tu Telephone SEC F ON 3 - .ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building rfj (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) 1 i Check Number This Section For Official Use Only Permit Number. Date Building Issued: Signature: Building Commissioner /Inspector of Buildings Date . . SP AVt BP- 2010 -0758 GIS #: COMMONWEALTH OF MASSACHUSETTS 1; +Tap:Block: - 017 f 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 -0758 Project # JS- 2010 - 001132 Est. Cost: $1791.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 126893 Lot Size(sq. ft.): 24393.60 Owner: FOURHAWKS AMALIA Zoning: URA(100) / /WSP Applicant: HOME DEPOT AT HOME SERVICES AT: 35 SPRUCE HILL AVE Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers Compensation WORCESTERMA01607 ISSUED ON:3/2/2010 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 3/2/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo