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24A-114 (2) ri$A$6 •*EA�rTf '. . • • Sold. Fundahed and Installed by: • N Botatua . Date: T'PtD.At liotae Srrvk s.'lnc.. . . • •. • . . ,; 4/br Thetleme Depot At-Homo Services . . • • •... t; .4 345A•tilmeli routtSttexl , :[lait•Z•Won:eatesr, MA ..01607 L Branch Number: 31 Ta11 Ps�e Ems) 65T 5182; Fax {598) T4l► BS2}. J dri t D # ? ME Lid #..,•024339: RI Coat S 16421 . . CI' Lit: '1 a ' g5S '•.' i ' tOde ni er Couf a hoc Reg. # /26$93 Imo , . hh Ion Address: ' --- /e, ? Lilt- . r . - • �. , s. ` i ` ilt ! ' • ,y • :Ji At Oay; crate; ... Tip IPtamc6aaar(s1: Vfiar?IcZ!isbelG Midst C�#1]P6otie Rome Address: — , (If different from laatal letion Addireae) , • ' -. .. : ., , , - . Zosiiii Addi'eas (to t vc project c nieaticeisa d HHme I 9epOs t!FdtRee ' :: • • rn I DO NOT wi sh-to receive soy marketing m oods born The (~/careDivot. - • • . . . fen U ( "Customer"), the owns of the po ' "loett die abov a uristi union address. agrees to bay: and AE Services, Services, lw- ("'The Borne Depot"). agreee to furl islB eHwn'at 3be Matson' "YnsptIlath t of all nmatcri.ds detcaifed on the below and OIL l i d+ 1 k 4'0O1c 7 1t{t : •4,4,0 this Contract by this reference. along with any applicable Stare. SnpplcmAnt sad .Payn > :ate and a0 Chatrge Gliders (coltecnveaY, Jab #: a.a...a See e Slhde i, i) tii Trilled Annum • • • • ,, ' i ",,r @" indows< ,11wn1+clon . 59'09)5'. Dc.iteCs/c � o � v - u � r. ORany'ileorsta'. !_,'.' , tc'. :. .. .$ 2q2 . • QR L_ts+g ■ Windows U ldayln. ' papaws / Covets CJEutry ❑Dots __. .-'t ; ', : :'.•: ` 1 . ��' (, ^ • t! I II l rtndows B - . . ... .. J t' V' ) ❑ouieis / covitrs .[]Eetry i**(ta na ' . ; , i'; •',' -a .., - `: c t h ' ' .,. *' 11- lesahg• . - [javtters / Covers y»o sa •[-1, } ' Mitatemi Detach& Costa& Ammo ant open i teatlonat$a�a rt . ? . ! S •M�ePti' tlasasmeyarea :postumethanamodirdeldesC Amein . + aEt*rii c4'At --... •' 2 � 2...-, . customer agrees that, immediately upon conviction Of Me 'y tr'.f ' eacti t, C»a Er, . .'t7ompletion Certificate . (one for each Product as defined by an individual. `.tai i ` SSec 5 gt�t :,belauxe' diva:;t�bl�, a , � - d each customer under this Contract ages to be jointly and severally obhptcd and sitahie he retredm.': :: '• `.. , . : '`'it � ,i 7 : ::.: ... ,. 7 ': .. . • • The Home a; a:; :• IIePOt reserves the �gM to issue e'�!� - . �*Vma?G ft�8trontrarx .cx' :a�?�Qi incIi+0e4 haFe4n, at its discretio . if The Horne Depot or its authortized service: p ?Oi>idersdeteemmes.'ther itcainop, Cfo trill ib ona.thte.to a structural problem with the home, environmental hazards such.aa wok/: or.lead•paste. ottie : : coi l ins. king mars our because work requited incomplete the job was not /minded in the Contract, : . ` - : '. • • . • . ' :. .' ... • Ptomain =. The Payment as tlf;th Summary:, ta t A /tract, sots forth the tot if -s� = :113 � ,. ini � ;; Contract amount and payments required for the deposits and Bled Payments. by Product (as appliMsble). Nf7TxCETOCUSl EH You are entitled to a completely filed-In copy of the ContrAtt'at theilme piss � uut al �•(notiit there is one Completion Certifteate for each listed ct'as-de6ue y ,� p ? •b .e'w n srk on that ?'rodeo is complete - in the event of to rn inatioa of this Contract. Customer agrees is pay The O oi '-ihe• codas air Materials, labor, expense& sad services provided by The Rome Depot or Authorised Service Provider th rough the date of us any other amounts set forth in this Agreement or allowed under a law. THE HO T EPOT MAY WITHHOLD AMOUNTS OWED TO Tie HOME DEPOT FROM THE DEP SIT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. 4� a ecgitsuce Agthp : Customer spots and understands that this Agtecmcm, is the entire agreement between Customer Ind The Horne Depot with regard to the Products and installation services and supersedes all prier discussions and agreements, either xai or written, relating to said Pioducti and Installation. This Age cannot be assigned.or amended except by a writing signed )y Customer and The Home Depot. Customer aclmowledges and agrees t Maat Customer has read, understands, voluntarily accept& the .tams of and has received a copy of this Agreement 4. r ;,,,,s. ,J "O . f �, { " :ustomer'a 5' a • Date Select Causuitanr's "gamuts Date K Telephone No. 11 lretomer's Sigma= Date Sales Consul amt License No. — . ^.ANCIP Lr1 1ON: CUSTOMER MAT CANCEL THIS . v • tat avolicabl6 . IMMINENT MENT WITHOUT PENALTY OR OBLIGATION . IT DELIVERIING'WRITTEN NOTICE TO THE HOME ?IPOT BY MIDNIGDT ON THE THIRD BUSINESS )AY AFTER . SIGNING T llS AGREEMENT. THE . . . TATS SUPIUMENT ATTACHED HILR1eTO :OIhTAINS A POEM TO USE IP ONE IS • - iPECIFTCALI..Y PRESCRIBES) BY LAW IN • • • XISTOMF.I['S STATE. NO77CL AptornoNAL TERMS AND Cis NDITIO?rS ARR S1'A*) ON TOE RE VE1 E SIng AND ARE PART OP THIS CONTRACT 2-27.10 C Weis - Branch Fee Yellow - Customer The Commonwealth of Massachusetts Department of Industrial Accidents = s ::1� Office of �xvestigatiInvestigations . _;; ; 600 Washington Street - Boston, MA 02111 . • _+ www.mass.gov/dia Workers' Compensa ton Insurance Affidavit: Bailders/ Cone - a.ctors/Electricia s/Piumbers Applicant Information Please Prtut Letsiblx Name iness /org ni7ation/Individual): T. nHE, .L • Address: a .D '. $ - • _ City /State/Zip: ail■ .' A :. ja =3 ('hone.#: '?U ( 97 ;` :a _ Are yy tf'an employer? Check the appropriate box: Type of project (required): 1. ► •- .L am a employer with ' ( 4. [ I am a general contractor and I employees (full and/or part- time).* have hired the sub- contractors 6. ❑ New construction ti 2. [] I am a soleproprietor or partner listed on the sheet 7. ❑ Remodeling • • ship and have no employees These sub- contractors have g 0 Demolition . • working for me in any capacity. employees and have workers' • 9. C] But7rt;ng addition . [No workers' comp. insurance comp. insurance. required] • 5. [] We are a corporation and its 10.0 Electrical repairs or additions • 3. ❑ 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 Roo pairs n) - insurance required.] t c. 152, § 1(4), and we have no 13. er � employees. [No workers' • 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 roust 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 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. Tnsurance Comp any Name: i. ■ 14 Cm. . _ A. • Policy # or Self -ins. Lic. #: ,;y t 6i 73 ` j Expiration Date: Job Site Address: • gI :%1%1.4 % City /State /Zip: ,.11,44„..g.._ Attach a copy of the workers' compensation . oIicy declaration page (showing the policy number and dpi ation date). Futu t secure coverage as required under Section 25A ofMGL 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 certis un , e the , ins I d pe . cities of perjury that the information provided ab ye is rue and correct. Si: ature: Mi 14 4 /4 !.__ Date: _ Phone #:�5 Official use only. � > o not write in this area, Lb be completed by city or town 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 ❑ Name of License Holder : vi � qjfi) ��� / License Number 461// A (A'N 111441 C_ Add - ss Expiration Date g n -t re Telephone • 9. Registered Home Int rovem rd. Contractor: :w - � _._,. � .�, � � ��uu� .. . __ • - ..,.: Not Applicable ❑ Company Name Registration Num r Address c\ �( / ,� 'f Expiration Date ' �'r� �(��j�( 0 / 4 / Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M. G. L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit mu a completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin ermit. Signed Affidavit Attached Yes No ❑ 1 = H 1 oene O er o 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 1083.5.1. 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 [J Addition [] Replacement Bows Alteration(s) ❑ Roofing El Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [I:=1 Siding [0] Other [©J Brief Description of Proposed Work: __>hr / ' � r � , '4 A - Ilia l 0).- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet si If: Nevlr house and or addition t©� ,strop housing. c o m p l e t e foliowin 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, 7 6� ; T: t; 4/- 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. I 00 t Signature of Owner Date I, • '� �/� , as Owner /Authorized Agent hereby declare that t - 'St- e ents and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pai d penalties of perjury. Print Name \ 1 — ,g/5/0-- .. Signature of Owner /Agent �/� Date t Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incompl= e In •.rmation 1 Existing Proposed Required b Zon g ✓I This column t be fi - din by Building Dep, u en Lot Size i g Frontage 4 _ i ... _, Setbacks Front Li j 7:_„...r.7.7...",,,,....9.„:„., ..... i —1 Side L:! I R: L:= R. P Rear 4 Building Height r Bldg. Square Footage = i % = = i i a Open Space Footage % (Lot area minus bldg & paved i i `. 1 „ parking) # of Parking Spaces - ~ --- Fill: _,______— , __mil _ 1 _ _ ,� T (volume & Location) l A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW 0 YES Q IF YES, date issued:I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book I i Pagel and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q 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 i . IF YES, describe size, type and location: i ; D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q IF YES, describe size, type and location: € i 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. k City of Northampton � NO 16� ulldmg Department - : ` ', - ; 212 Main Street g a 3 ` Room 100 = _ r . • .�. • , hampton, MA 01060 �� t phone 413- 587 -1240 Fax 413- 587 -1272 i APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE O TWO FA DWEL W SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: C fi A v�1 p a Map Lot Unit 1h Zone =' Overlay District '� ,,,)))'‘ ii, ��`'""`"`___ Elm St. 'District` CB District ., SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: '-}- 0 c) _0_, i _ ______.k Atli. c■■ a1 #1 Current Mailing Ad.: i Name (Print) C-je. Cn n r rl Telephone Signature 2.2 Authoriz •._ !. ent: . . a g,.� .k el; 1 _ its II, I►I1�?( Name (Prin Current _ a A. dress: c 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) E C of Constru ction Total from ost (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection l 1"(p f 1 6. Total = (1 + 2 + 3 + 4 + 5) f Q Check Number This Section For Official Use Only Date Building Permit Number: Issued Signature: Building Commissioner /Inspector of Buildings Date 78 PROSPECT AVE BP-2011-0941 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24A - 114 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit # BP- 2011 -0941 Project # JS- 2011- 001537 Est. Cost: $2292.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 67121 Lot Size(sq. ft.): 20995.92 Owner: GUSAN STEPHEN Zoning: URA(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 78 PROSPECT AVE 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 3 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 5/16/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner