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Board of Building Roeulations and Standards
1".•
Construction Supervisor License
License: CS 67121
Restricted to: 00
BRIAN C THOMPSON
38 WI LLOV-SEROOK LANE
2111
WESTFIELD, MA A5
Expiranon: .V30/2012
Tr: 21015 '
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• .Pardunar(s): . • • . •• Work ineeni : • - .r ,• ..' .. ,i' •,,- -: .• , fliaPhens: : • •
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Hone Address: • • . . . .. ..
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(If different frominstannion Address) Cdy
E-nasilAddr.80 (to =coin project communications and Hoirm•DqUittmdatet)c.; • - :;'•'',.: • : . • - • •: ,- • , . - , •", ::' • • • • •:•-. -
Protect-Information: Undersigned ("cnstainerl. diet:kenos Ofthe.ipMnitYitienethentiitiebbeeintitaltation.aikkein.ajgreta '
and TIM At.iforne Services. Inc_ Cite Home Depot"). Sgrt:es te funtish.-deliverkendinings fee UM IttethilattottrInitelbtheinn) of
all Materials described:on the .belOw and on the referenced Spsc5hiset(s).:1101: alliekuroincoMminerb_ thin, Oa: Crinism by,this •
reference. along with any applicable State 'Supplement and Paytnent Seimosary; attached hereto; end.eity• *MOO: (ce.n*tivr*
. . . .
Jobler tweinereasso Produdn
s c a 3 p t . i ( L a n t s = i C a u s e s C l a r a r i t t o r e s la . '• ? :•-•• .. ••,.• • • •-• :::: ....16i5.•71 .. .: rzft. 4 ,.. • ., .•
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..,co..Clantry.1)00 E1,—..--..4..- ...._, • :.•;,:.-...:.. , • , . . :;:• ,;• ".. •:,:. • ' . • •
0Roofing 0Siding. 0 Windows • Elltdrinettaf ' i;..., .; ..!....2„,.......:,:r7.i. ,..: • •• ::: ; . : . --1
. • Cletauev't Covert 0EntrV Di t.1 "' '' ': •= ''''- :Y. ..: - • .,; : .... .. ,... ,.: .. : , .. ; ..,_,. ,- .. .. . :"
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Mmkto 2f4 Depth of Calmat Amend clue erweseenain4dismtrct:!,?1:Ita 1 • ;,,,••
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Maine Paninsen my not deposit men tina eneetint Wan Oseintitimessea : . . • ,.,• ::_.: f . . : , `: ' .' ..: ':'.... 4 ".''.'".•!.
ettitOMer agrees that, • imenedistely upon, Co ndon Of the w&k Si tiach:PIndoCrtitintOPla" ,. •3 _ • _, ,... : •
(one for each Product' as defined by an individual- Spec Sheet) andOi kiiiir- *,* 0 . 103 0t th
Convect. agrees to be jointly and severally obli,gned . rod liabistareander.:: • f , .. ', . ' :''','• • . •i• " • • ' : ' • " • :" • • . • ' ' ' " .
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The Home Depot reserves the right to issaatmaaar 4 -ewmoriene.49k . , li 0*. 14 4 3 4 - **A c ti. 1 4:1 11 4. 4. 00 11.44 , 01.1 • .
its discretion, if The Home Depot or its authodred servicegroviderde that itOrautot:Perfrent:at 044100 .., *WO: la` U Mr00010011
problem with the home, environmental hazer& such As tooltk,?0M1tos.or lead paint; other is conmenripricion.encia or because •
wcet requited to complete the job was not included in the Coatract
bagngammin The Payment Summary # - : .: .• - , ...,.niandiikasipart, riff:thin-qt.lti solo forth the total •
• Contract amount and payments required for the dePoSitSand Bert/payments.by:Prodoci(M.applicable). • „.:-,-: . .f... f• ... . • .• • . • . .
NOTICE FO•CILISTOMEIL -• ' • .: •• 7 . , .. . .. ' . . " . •
You are entitkd toe filed-In copy lathe Contract at the thneyoit:.Stgai• El.. rist sigew Conitietheti:Cartitkate(ente:
there Is one Completion ernecatt for each Prod uct byindl*MinklAMEInstetil' beforeivork on that Product
,
is complete.
In the event of termination of this Contract, Customer agrees to pay The Baum 13opo,t tha Of 0 labor, Memo
and services provided by The Home Depot or Authoriand•Serviise Pt 4' Old I II *it. _.__—thtcrughliie OMB?
date Ottlee...IMLIMLANklgus.O4' other
amounts set forth in this Agreement or allowed ender applicable )aw. THE tIONEIDEPO'FREAV wrimOLD AMOUNTS
•
. OWED TO THE HOME DEPOT PROM. THE DEPOSIT . pAymEsr . OR OTHER PAYMENTS MADE WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS:
Acceptance awl Customer agrees and understands that this Agreemem is the entire agrecenentbetween Customer
and The Home with regard to the Products and Installation services and supenedes.all ptior discussions and•ameonanin. either •
oral or written. relating to said Products and Imtallation. This Agreement cannot be assigned or unooded.ercent by a writing signed
by Customer and The Home Depot. Customer acknowledges and. agrees that Customer haeread, understands:. voluntarily accepts the
terms of and has received a copy of this Agreement. :
•
•
Siebmitted'hy: •
"l 5) 4 . .).)- 4 41.11_,_1
Customer's - Date „ Sales Consultant'ss • '
: .
X Telephone•No.
Customer's Signature Date •
Saks Consultant•Licenae No.
' CsesppIcath)
• CANCELLATION: CUSTOMER MAY CANCEL THIS . .
AGIONIVOZPIT WITHOUT PENALTY OR OBLIGATION: . .
BY DELIVERING witrrrEN NOTICE TO TBE HOME' •
DEPOT PS NODNIGHT ON THE THIRD BUSINESS: •
/ DAY AFTER SIGNING THIS AGREEMENT. THE
/ STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE
\ SPECIFICALLY ritEscRutan BY LAW IN .. •
• .,
•
CUSTOMER'S STATE. •
Noma: ADDITIONADTPRIVIS AND commons All scratch ON THE REVERSE SMIE AM AlUtiAleraP MIS CONTRACT
11 0 White- Branch File Yellow- Creamer " Pink -Batas Consultant. .
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
• NI ' f - ••• . • - 4 - . t the buildin • de • artment 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
- - -- pernits- in- conjunction ,to_the b _issued,_ and_ that 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
. . . ,
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
• =iv= ,Q. Boston, MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): -- )1(1(2 1
Address: C.1w1194 (S WL,oy
City/State/Zip: l 4 Cc--1,-, '13hone#: T) 61;7 _
• ,
Are yo employer? Check the appropriate box: Type o project (required): I'
1. I am a employer with t (...1.9 4. 0 I am a general contractor and I
6D ° New construction
employees (hill and/or part-time).* have hired the sub-contractors
listed on the attached sheet 7. 0 Remodeling
2. 0 I am a sole proprietor or partner-
These sub-contractors have
ship and. have DA employees 8. 0 Demolition
employees and have workers'
working for me in any capacity. 9. D Building addition
[No workers' comp. insurance - con insuranceJ
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. 0 I am ahomeowner-doing-alPwo& _ Dfactrs_hay‘arsisesitieir— —1-Rluanhalaa : .epairs or additions
myself [No workers' comp. right Of exemption per MGL
12.0 • t a repaKs
insurance requited.] t c. 152, §1(4), and we have no
employees. [No workers' 13. ITI Other L.(
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 indica4ing they acre doing all work and then hire outside contractors must submit anew 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.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
irtformation. ,.. -\
Insurance Company Name: (../u ----- , ) tr' ---)
Policy # or Self-ins. Lic. #: Do (9_.6e,..-2____---- Expiration Date: - *
Job Site Address: q to ,,----.,1,411 5) City/State/Zip:Lt 4..
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 $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 a . . . - aa the violator. lie advised that a copy of this statement may be forwarded to the Office of
Investigations of a DIA or ins a , a ce coverage verification.
I d ii o hereby certi und, P e t p, i i/ "penalties of perjury that the information provided _above_ , e , , orrect.
..'
Si • • ture: AiiirrAlOrtitar. • , ..,=-
9 a - 401!
Phone #:
' '....
- 3r- -
-, -
- Official use only. Dii n Wi-Tte Ili this be by cityiir town official
City or Town: Permit/License #
Issuing Authority (circle one):
. L--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 S isor: Not Applicable ❑
Name of License Holder : (o •• 11 ` 6-1271t2 • (
. I License Number
,�► . . at _ Fin.3, A t r c/3
Address/ / Expiration Date
alk , . A I. � CT.. A►'1
Sig :In Telephone
9.; Registered' HomwhriDroveme n V n t racto s Not Applicable ❑
Company Name Registration Numb=
'g 5 ----- C ; 4 '' et / ) et r Y( )--- ( -- • "N
Address / Lk) / Expiration Date
1 �- iiii ileph one k %% ,
—
SECTION 10- WORKERS' COMPENSATION - RANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) J
Workers Compensation Insurance affidavi ust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the build' g permit.
Signed Affidavit Attached Yes la 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 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
Northampton Ur to a e _ • •,
. • ral-Laws- Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement W ows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [D] Other [D]
Brief Description of Proposed I
Work: I ai _ et _ ,,,A . .4,d.. 6)4(--.4,1"
T) - f4
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _ Yes No
Plans Attached Roil - Sheet
6a as ffi6Fa
• 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
-
1, .4: � t� 416C1-
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit applicatio .
5
)
Signature of Owner Date
I (e'1/ , 1 7_..___ , as Owner /Authorized
Agent hereby declare that the statements an n ormation on the foregoing application are true and accurate, to the best of my knowledge
and hPiief
Signed under the - and pen f perjury.
AP - `1h. / 11 IDS
Prin . - ..0111W/
/ / , ...
°,,
: gnat - . 0 ner /Agent Date
N .
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 1 i .._
Frontage I t _ �___., _.
Setbacks Frontm"i
Side L: =L. i R:i.._..__.__J L: . R: w ___ , i . _:
Rear L _ . i
s
Building Height r°°° ' '
l
Bldg. Square Footage ? % i I
Open Space Footage %
(Lot area minus bldg & paved ? J
parking)
l w
# of Parking Spaces L---- --
Fill: ; �. ...._r _ . .� ,
(volume & Location) ?___. II 11
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 Q DONT KNOW 0 YES 0
IF YES: enter Book i I Page; ? and /or Document # * my
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 l Obtained Q ,Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
— - r e here any proposed - changes o or a i ions of signs nt� ended" for t ie property ? YES 0 NO 0
IF YES, describe size, type and location: 1
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.
A
m
City of Northampton 7 -
Building Department
-
212 Main Street "" f3
,c,',(.:1 Room 100 a k `
,�� - L `' Northampton, MA 01060 ,„ _ �
phone 413-587-1240 Fax 413 - 587 -1272
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
Li `� ` Zone OverlaxDistrict
r (
Min St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner o e rd:
keil cadi_.g . - lg— / ....‹. 3 . ! kit/. 4/10 i t.--
-- -- --
Name (Print) Current Mailing Address: ,
a0 L.
� e CO OI . Telephone V—
Signature
2.2 Authorized A.:
Name (Prin ✓ 1 Current Maili g Ad qt) ,rte 0 �' / , ` t)ig77r,2c
Signature o Telephone
SECTION - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building `%r 421-)qt-1 (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 ■
�J
6. Total. (1 + 2 + 3 + 4 + 5) �� � Check Number � �-
This Section For Offcial 1f se O Fy
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
t:46NURSHALL ST . z:. a BP - 2010 - 1118
GIs #: COMMONWEALTH OF MASSACHUSETTS
k: 25A .O37. 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 -1118
Proiect # JS- 2010- 001640
Est. Cost: $2094.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 5270.76 Owner: KEVREKIDIS PANAYOTIS & MARIA E NIKOLAOU
Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 46 MARSHALL ST
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 0 Workers
Compensation
WORCESTERMA01607 ISSUED ON:6/9/2010 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 6/9/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo