23D-032 (2) - Ovvartincrf 1 Pu
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Construction Supervisor Specialty Lice
Licsnssr. CS SL 9S2C9
Res!Ticted to. WS
VLADIMIR SHEVCHUK
• . 5 OGDEN STREET
CHICOPEE, MA 01013
F.xcirat■on: 1011-212011
99209
•
rL•L`Aze,•st:6!lri, ' •
•
Sold, Furnished and installed by:
ancT) game: Boston Date: TI(l� At Z omc Services, Inc,
d b!a. The I-I,..mc Depot At -Home Services
.. . :345A Greenwood Street. Ueit 2, Worcester, MA 01607
Toll Free (800) 657 -5182: Pax (508) 756 -8823
. graneh Nun e r:. 31 . . ' ; oilerxi I # 75- 2698460; lt& lie C RI Corr. (.io* 16427
CT I.t c'#'tl1C.Q5632 ; mA kb* nmpxnvcmi enLCIS:inte rer R #f 12689
Installation Address: L L td .N: '., lP P ,- • . . d i j •
Cr# , f State Zi
u(s)e WritrlrPtroeae l3soePJtotre Cell Phener
•
y
[ 1.... .. .. .,[.:;::.:1.: ..[ • .1
' Home Address:
•
(If dlf&tenr Acorn Installation A4cress) .: i sty Scare Zip
E -mail Address (to receive project amomvuica' ma and Home trepeatolatesr ,_ . •
mails DO NOT with receive any marketing ails from The Horn..;fepee, ., •• :'..., •: ` •
Project Inform d:mu Undersigned ( "tlas2omeY"}; tt)i;':o.of; the ` " Ynbai�, ,s iljie',pboye installation address, agrees to .buy,
and THD•At -dome Services. Inc. (`The Home Depot") agtees.tq ivee:mhd n forthe installationd"Iastallation") of
all materials• described on the below and.em the referenced. Spec:,Sh ,(t.): „alI :of°t cli ore, icome ed into this Connect by ibis
reference, along with any applicable State. Supplement and P?yiuent,Ni!m aitach4Q.heneire.and. any Change Orders (collectively..
” Contract"
•
lob it: **mamma
ma Prddo,ts: 5�t°` G Atha °°R
•
I ❑ltoofmg ❑5idutg Windows D Iusylxtiuu'
❑CYUt*s /Covers ntYy.Dooct J,T $
• • . ❑ci i Co is ❑troy iwp.... Ly ''ti ` `, $ . . ' 1 ' •
❑mss C:dng. Ci .whado,�s Q lul r
°Guters I Covert REnav Doors 17 • s " ' . . •
Likoofing• LJSiding U intense U latadati at ::'. .
•
❑Guere ❑ Enrt y l7o«s. h
MG�uuun125% t aECaah .Aa�al»da4W aa4diic. ' ,- , ) (x...../ /
iainePtnch+ smu nettlepadtmauethmeci • e4 id'ntlie't` ice - � • ' ° '� - . ..It r
Customer the iromedi. . i ..:_ < ..i w,,..., • c l ,. » e.: -. ,
agrees 4 3' trpott. ? oieitk;�tu' Produa;G,us)c1!xiRF : x.eici c li‘.,a:C;esrnpleion Eerti
(one for each: I'roduci, as, defined by an individual .Spec S`beet?'sgit.pny ern ':lialiuKSo:'i3i e�':'. appIicahlr, each Customer under this
Contract awes ro be jointly and Scvtsally • obligated' and lishle.'h
The Home Depot reserves. the right to issue a Change o ' . ttenntigijto spit:Cooeiact: nr. indivudnsl:Produet(s) included herein, ei
its disaYetion if The Home Depot or its authorized sezviee° pravi that earmo ' en•lts'obligations doe to a aunt:Weil
problem with the home, etivirontnental hazards 'such', as mold,:sther.M )r lead',paits4 Other safety concerns, pricing errors or because
worts rr4uited to compute the job was not included in the Con ••••••••• : ' '..,:... • •
Payment S anme The Payment Summary: if . u i . d as:'pext of t his C ontract, sets forth the total
Contract amormt and payments required for the deposits and final payment., by P,ii:4 i tt?s:'3p ,. .
NOTICH TO CU$TOMt' l: , '
You art entitled to a completely flied - in copy of the centracf at the time you <Do situ a.Com,2ettrarCertiBeate (note:
there is one Completion Certificate for each listed Product as '.dellindd-hy lisCRVid4'af: ;S ) before work on that Product
. 1 is complete.
In the event of termination of this Contract, Customer agrees to pay The Homie•Depot: tbt, c n, of materials, labor, expenses
and services provided by The Home Depot or Authorized Service Provider. Ibis dam of tormlantlon, plus any other
amounts set forth in this Agreement or allowed under applicable law_ TU((' HOM, DEPOT MAY WITIMOLD AMOUNTS
' OWED TO THE HOME DEPOT FROM THE. DEPOSIT PAYMENT OR OTHER' PAYMENTS MADE, WITHOUT
LINHI NG THE HOME DEPO'f'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
AceePtance an�tliorization: Customer agrees and understands that this A Comilla
gihement is the entire agreement between Co
and The Home with regard to the Products and Installation service., and supersedes all prior discussions and agreements, either
oral or written. relating to said Products and Installation. This Agreement cannot be. assigned or amended except by a writing signed
by Customer soil The Home Deport. Customer acknowledges and agrees that Customer has read, understands, voluntarily accepts the
terms afoul has received a copy of this agreement.
. • t
A.��, ., by Su.c✓,
C t ' er f Date ��" I' Solos Consult - Date
•
X Telephone No.
Customer's Signature • Dare
Sales Consultant License No-
CANCELI,ATION_ CUSTOMER MAY CANCEL THIS . • (as appli: able)
• AGREEMENT WITHOUT PENALTY OR OBLIGATION '
BY DELIVERING WRITTEN 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.
NOTICK! ammTIONAL'11it1MS AND i_(NDhi IONS ARE STATED ON THE REVERSE SUE AND ARE PART OF THIS CONfnACr
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12 -27 -10 C-SC White — Brunch Fie . Yelow Gnettaner
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The Commonwealth of Massachusetts
, --- = Department of Industrial Accidents
e:.' I�
- till=
Office of Investigations
• 600 Washington Street
E i i f Boston, MA 02111 -
-' www.mass.gov/dia
Workers' Compensatri0n Tn si.rance Affidavit: B Hiders /Canto actors/Electricians/PIunabers
Applicant hformation Please Print Legibly
Name ( Business /Organization/Individual): or 1 ETI' Cr
• Address: J V . r� - _—
City/State/Zip: Ajf .- �r } hone. #: ` ' � ; i
Are y t an employer? Check the appropriate bog: Type of project (required):
1. s I am a employer with ,,' 4. [] I am a general contractor and I 6. n New construction
employees (frill and/or part- time).* have hired the sub- contractors
2. Li I am a sole proprietor or partner- listed on. the attached sheet 7. ❑ Remodeling
ship and have no employees These sub- contractors have g, ❑ Demolition .
• working for me in employees and have workers' •
g any Y ca P ac rtY $ . 9. [j addition
. [No workers' comp. insurance comp. insurance.
required ] • 5. [ 10. ] We are a corporation and its ❑ Electrical repairs or additions
•
officers have exercised their 11.[] Plumbing repairs or additions
3- n I am a homeowner doing all work
myself [No workers' comp. , right of exemption per MGL 12.[] Roo • s
insurance required.] t c. 152, §1(4), and we have no � A
employees. [No workers' G C 13. thrr 5
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.
1- 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 mustprovide 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. � ,�
Insurance Company Name: ' -mod (re \ j ` t _
Policy # or Self -ins. Lic. #: 63 i 96 � —' . Expiration Date: •
Job cite Address: L K H t l f og 591 City /State /Zip: k 11 61 /_VA i F14---
Attach a copy of the workers' compensation policy declaration page (showing the policy number and ezpira: on date).
Failure t 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 $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 un , e the ins d pe aloes of perjury that the information provided ab ye is, rue and correct.
Signature: f. dlgt r/ Date: , r .
Phone #: ( e r k- c --- .
Official use only. o not write in this area, to be completed by city or town official
City or Town: \ °.` Periuit/License # .
Issuing Authority (cirde'one):
1. Board of Health 2. Btzildin'g Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervis : Not Applicable ❑
Name of License Holder : jm Ir --‘ 5We "1
License Number
11 6r Ch& Dli '
Address . / r Expiration Date
Signature Telephone
9:" Registered .liomefmprcivetneintContractor , ,_ fix.,...... Not Applicable ❑
fpx_F,ct-3
Company Name Registration Numb r
V 5/0-
Address Expiration Date
'e:i
I ` D Telephone 1 1-0 )535
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L,c.152, § 25C(6 ))
Workers Compensation Insurance affidavit be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the build' permit.
Signed Affidavit Attached Yes No ❑
11:FAIOnitthtitetEkeiliiitleii
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 ows Alteration(s) i Roofing El
Or Doors
Accessory Bldg. ❑ Demolition El New Signs [O] Decks [E:::] Siding [0] Other [0]
Brief Description of Proposed *
Work: ti A, ".e.. lit re. �'' i1L f OD 51
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
ea: `If New °house andor.:addition existinci holism u. complete "the `foliowinq:
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
l
9 -6 9 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
I ' , r me_ as Owner /Authorized
Agent hereby declare that the stateme is and informati • n on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pain penalties of perjury.
.. A it
Print Name I
41
r i
11∎
.II
Signature of •w er /Ag: nt Date
Section 4. ZONING Atl 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 , .__... ..__M .v. ___ _,._._ _ . ___ _ ._
Frontage _ _ _ ___ ,_ .
Setbacks Front 3 i j i , ,
Side L:, R:— _. ! L: R: ___
Rear i -- -- : ,
Building Height?
Bldg. Square Footage i i I% I ri s
Open Space Footage i l
(Lot area minus bldg &paved ..,,,.. L_____, 1. ! ,„-
parking)
# of Parking Spaces `.,
Fill: wr. .�. ,- -,, 3
(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 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 , Date Issued: f _ _a a. rvN
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location: .__ __
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
-
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
RECEIVE
ts , Department use only
Y 3 20 Cit)� of Northampton Status of R 4 E .6
Bui ding Department c urb C Pe rmit t,.
212 Main Street S Av tit
DEPT.OFBUi .:, ;TiIO S Room 100
NORTPA �� �wt�+ut 4 as
F IP -On "r L 060 '; 5 '4A ,L ' " a' ,,, 1, ?�'S ' y
NortKampton, MA 01060 TTV
phone 413 -587 -1240 Fax 413 -587 -1272 Pi# 4 - lac y A � ,- � A
Beer�e ,c 1
r : " r „ , " "
t `
'ST
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
l Zo ne Overlay District
Elri St District ' " CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: ,
- (
• _ - h 1 i r. /la
Name (Print) Current Mailing Add ess: i
1 1 4 '. (204 - ft Telephone
Signature
2.2 Authoriz:.•L . ent:
/I3
Name (Pnn / l Current Mailing Address:
/ / r
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
1 �
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection x ����
6. Total = (1 + 2 + 3 + 4 + 5) P-1/432----- Check Number k..
This Section For Offic Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
49 MILTON ST BP- 2011 -0937
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D - 032 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit # BP- 2011 -0937
Project # JS- 2011- 001533
Est. Cost: $2182.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 99209
Lot Size(sq. ft.): 6403.32 Owner: WILSON JOANNA
Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 49 MILTON ST
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 REPLACEMENT DOOR
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