24C-080 Restricts lo: WS
IA - Masonry only
RF - Roof Coreting
WS - Windows sod Siding
SF.- Solid Fuel Burring Device-I .
DM -Demolition poly
Pasture w Pet 1.4t3.1 a rurreat edition of.1i.
M State Building Code .
is cause for revocation of this ticensc. • .
Kazan r to: W W W . $aa:s. Go r /D PS
�-= Sl4 t.hu'eIr - Dt:lla riment of Public S :ilvt7 pi' Btt:ar ■of RuilJinl Rrgulnrnan.' and Standard-
Constru Supervisor Specialty License
License: CS SL Ett i2Ca
Res triced to: WS
j
_ I
VLADIMIR SHEVCHUK
5 OGDEN STREET
CHICOPEE. MA 01013
' -d/3,.. Expiration: t0/12f2011
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Coital= areas that. nnm upon aelh0:4 Olaitt*?•a*4 •
(ene each ribaua -as 4A4bit• by an individual SPee •q#0..,' 'ii0 eSkeeh,e;"01 under this
Contra& a0ea*helOttilYinattev0e.treti*!? :.'-•• ::;,..• I. :.•...•:, ••' `.: • .:.•,•,..-•,• 'I :.: ' - : : • • . • • •
The Mee Depot rtSerVes thetiehtt0,404teitafttdgeOtdekAiliO40 ..,...4*..440 1 .4er .. , . , ..,.#0:#1i,F440,efh*O./Tiehele4 •
its discretion, if 'The flome•Depot or iii authotimalacmiCki*V1*4...****,“ • .thiatRoeIRReaSPOtaraa-„ „ IV*** .
Pre,Wero viith the htel?e, eavitoreneOtal:h,*4. 104* *641**494444.04•#*;00:iif,'PoPorPs pricing ',IT .P. , r!`''` •
*fork retio*,to complete the Joh was not Maintain iliCtolitisce.' .•••.• •• •"• '• ••• ,1,.. ....;•[•:••••• ..., ,•'••••• '. ••, '•••••:•• • '. - • ....:• ; 7 '.." ' ' '
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pirvineat Surnmery't•:' The 'Payinent Sunintary; W•■• . '*:,Z7 , ..j: • *elidet illCr te'reOhe .A0 •
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ItKliCR TO.0.44b0:1„ ......' . ,'', .,'•• , .1. ',..;....;„....'. • '....... , •.• • .„ ,,, .
YOU lie 'entitled its a OOSOISISSOO ruled copy the :Cpntriiet 1011e.tihne you ... _;kipg'illilOA tiIK:td**dbiliiht (note '
there is Otte Completion Certincate for eischilistaPrmlait,'411cfleiali/ bYlndiennliVIROMF •
• • . . . , . .. .„ . . . .. ,... .
In the event of termination of this Contract, Custom, agrees to pay. The Hoist . ' • '. ..iise Oita of tonteiriali, iabor..exiiemos '
and services provided by The feint Depot •t. AuthOritted• Service Prosidet twit; : .• tiOtn•Orecamfmagoti, Ph any D oa Other
amounts set forth in this Agreement or 'sv._ ed matte *AR* Ittli`.. •litE IA ." WRY mkt :100*Toloug' AMOUNTS
0
OWED TO THE HOME DEPOT FROM THE DEPORIT:RAVMENT.• wrfrioxr •
LIMITING THE HOME nErors OTHER REMEDIES MR rflOYERY OIR 0 • ' •
. . . . . . . .. .
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Acceptance and Authorization: Customer agrees and Undercuts*. that thitierer Hi0.• the .Pori,reritftreeinent hetWe ttateater
and The HolOC Depot with 'regard to the Prcvlucts'and Inetalietioo services end atiPege Weenxers either
ond or written, relating to said Products and histallatiori, 'Ns Agreement rennin * , , or amended• elicerrt by a writ?* Ognect '
by Customer and The Horne Depot Customer aelcoowledgm'andcMces:Pit Cnienner:hakt*,•tiedetitatlets voltneettlY tweet* the
tot-tag of and has received a copy of this Ageem . • ent.
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Accepted by: . so -
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1...„,".. .,. 4 11 ..-..., AL (rire .dr . .....-‘ Telephone No. ' . .
. . . . . • .
Jgptature Date • '
Sake Consultant ,...ieente No '. _
CANCELLATION: CUSTOMER MAY CANCEL TIM , ' . . • • • . (etanflitalit)
,, .
AGREEMENT WITHOUT PENALTY OR OHLIGATION , ..
,
BY DELIVERING WRITTEN NOTICE.TO THE :HOME • ' -. ,: : . • • . • . . .
, . . .
DEPOT IIIY MIDNIGHT ON THE' MIRA •TIT. • .• ' , • .
DAY AMR SIGNING l'ItIS AGREEMENT. THE '• • . . .. .
. •
• . . . • .
STATE SUPPLEIVIENT ATTACHED .TITRETO • . • • • , . . • . . :
. CONTAINS A FORM TO USE IF • ONE • IS : . • . • • • • . . . • • . •
• SPECIFICALLY PRESCRIBED BY • 'JAW • . TN.' • • : • •' • • • '.
CUSTOMER'S STATE. . . . •
NOTICE! ABISMONAL TERMS AND CONDITIONS ARE STAVED ONTRE szvEns,mintartoonit raAT tiv:Tms cONVitA,Cr •
•
1-15-09 G-SC • •
. Wtato.- go:mu paw' . !Veiny/ '- Uptown : : 'Ilk* 4 D;alee COnaultent .' • ' • ' " • • '
. . .
. , .
s 1
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 nrocessxr quires 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 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
— p€ rmits- in -conjunction:to_the_buildingper it.issued,_and. 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.
Address of work
location
t i The Commonwealth of Massachusetts
_ ' Department of Industrial Accidents
: —4— ( Office of Investigations •
_° a
t .
if
600 kYashi z: , Street
r Boston, MA 02111
S . www.mass gov /dia
•
Workers' Compensation Insurance Affidavit Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): 41 F7ht
1
Address: gtM 0 ri 4 f pO
City /State /Zip: f)\i 7 ) t A( :) ) ,- ,‘ 303', Phone. #: E51 5 I _
Are you,,an employer? Check the appropriate box: •Type of project (required): /�
1. i I a employer with (0 Q 4.. 0 I am a general contractor and I
have hired the sub- contracto 6. ❑New construction
employees (full and/or part- time). *
2.0 I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have. no e loyees These sub - contractors have. g. 0 Demolition
for me in any capacity. employees and have workers'
working
Y P ty 9. 0 Building addition
[No workers' comp. insurance
comg..insurance_ #.
required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3- (l / am-a-_iorneowner -daing_ all _work — — o —fdc s _have g xercLed_ _I 1.0 Plumbing repairs or additions
myself. [ N o workers' comp. r i g h t of exemption per MGL 12.0 R f
insurance required.] t 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 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 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. .
Insurance Company Name: IlA C ' _Ana to .
Policy # or Self-ins. Lic. #: (9 / ��. Expiration Date: -
Job Site Address: i__, ' ( rt City /State /Zip:` • ! 111 A . ... Ai. fly.
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expira :on 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 51,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. to advised that a copy of this statement may be forwarded to the Office of
Investigations of the D •- or . .• ce coverage verification
I do , y _ c'' der the , j d 4 alt es , f perjury that the information provided above iztrue_aruLcorrect _ -_
Si- :... - / O � Date Ic� ) ` _
r-- 6 -
Phone #:
q35
0cial use onl Do not write in this be completed by city or town official City or Town: Permit/License #
Issuing Authority (circle one):
•
• - - -1 Board of Health 2. Building Department 3. City/Town Clerk 4. Electricai Ins. ector 5. Plumbing Ins. ector __
6. Other
Contact Person: Phone #:
j • r.. •V4 .
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supery or: Not Applicable ❑
Name of License Holder : ` �`r t 1 VII ) /' li V CRPCiCi
License Number
Addre� Expiration Date
Sig , -t• - Telephone
9: Registered. Home ImprovementTContractor ,,,.. Not Applicable ❑
1-11
Company Name ( ► fi Registration Number
L- 45 --- G 7 'reei)irt)0(4 4 31 — D
Address Expiration Date �(
wo r C t ; ? - - - ` fr # 01(1)7 Telephone L L 4 9 - 36 - 2k33 - 5
_ SECTION, 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G:L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit mu be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin ermit.
Signed Affidavit Attached Yes No ❑
1 44A11iieU . y$ do
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 Supervisur your presence on the job site will be required from time to time, during and npnn
completion of the work for which this permit is issued. -
Also be advised that with referenceto 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
o ampton I r. mances, T i • °' . . tts General-Laws-Annotated. -
Homeowner Signature
1
s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement doves Alteration(s) ❑ Roofing ❑
Or boors
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [[:] Siding [O] Other [D]
Brief Description of Proposed . , \ . —4
4 1
Work: '_!r� _ , e,. . _' 44 U c
w
Alteration of existing bedroom Yes No • dding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. 11,Ne house ar addition to existing licuisinq,= acomptetethe #ollciuvinci:
a. Use of building : One Family �wo 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 vfir • , 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, t r 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.
Signed un glik pains - I • •ena ies of perjury.
r `- Pi 1i
Ai - ..eqpirr
IIIIVA , ,, .,„, „ , 0... YIN " --
Sig ature re wner %Agent 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
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 Pagel and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained , Date Issued:
C. Du arty signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
_ P t�PrP n " mnsPd c es tn Or a s =inns n Signs intPri Pr Tnr tl e'prnl Arty 7 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.
4 D p2rtmet5t �13e 4i1Fy
City of Northampton StS of e n
Building Department Cu e " tn�ewayt
212 Main Street S Ecr I�
Room 100 iv
Northampton, MA 01060 a
phone 413 -587 -1240 Fax 413 - 587 -1272 PI ns 7 r
• rJ
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
s 90rt
Zone Overlay District
EIm`St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Tr;ff t
Name (Print) Current Mailing Address -
w Telephon
SPP
o i1(Z
Signature
2.2 Authorize • -.' ent: �1_ _ ,_1,
104 _ . .i. cr :' . r�95" r 907
Name (P� / Current Mailing Address:
, 40 1
ign- Telephone
SECTIO 4 - : 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 Fcc
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) ( C heck Number awe - 3 S
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissionerilnspector of °Buildings Date
q
6 MASSASOIT ST sir BP- 2010 -0603
GIS #: COMMONWEALTH OF MASSACHUSETTS
gk: 24C Q$O 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 -0603
Proiect # JS- 2010- 000880
Est. Cost: $3168.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES
Lot Size(sq. ft.): 7884.36 Owner: FORD MICHAEL D & MARY L
Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 6 MASSASOIT ST
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 () Workers
Compensation
WORCESTERMA01607 ISSUED ON:12/15/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT SLIDER
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 12/15/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo