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25C-075 , Ze • At )44 - Public ' Board i B ui I di n Rogututions lid 51:intlarciN ConstrzIcticr. Suoervisor License License: CS 67121 • Restricted t4: CO rob\ BRIAN C THOMPSON • 38 WI LL.C.:gROOK LANE WESTFIELD, MA c s ' Expiratio6; .4/3Cr ( Tr-,-4: 21015 —01041iif#444 • • Cr-C you c:AQ (Dc.Yzlau (. eimo.o,6 u.MU estate Sold, Fished end Installed by: . Br ;Sestet Dew THD At-Home Services, Inc. eta dlbla The Remo Depot Ac -Home Services 345A Greenwood Street. Unit 2, Worcester. MA 01607 Toll Free (800) 657 -5182; Fax (508) 736.8823 Arm& Number. 31 Federal 1D # 75- 2698460: IC Lis #C 02439; RY Coot Lice 16427 CT Lie : s • • • 522: HA Bane Imp eme tCoMmetorReg.8126893 Installation Address: , Z•9 � _ [2 _ L (48 'at �- -b ty64 City . , State Purebeaa(s): i .s,� .Z • [ I Mow [ zo3 4u71 I Celt t ] [ ] [ J Hem Mawr (If different from Installation Address) City State IT &oasa0 Address (to receive project commuicadons and Home Depot npdates): ❑ I DO NOT wish to receive any marketing emelt from The Homo Depot At-Heme p Uncle Depot the owners of the property located a the above insalstion address, agrees to buy, add "THD all arterials described on the below and on the t+ Spec Shoet(s � of into the_ due. along with any applicable State Supplement and Payment Summary anached hereto and any Change Orders (eollecpvely, lib#! a.,r:.su Amotmt '�''"'/] // b0 • Roofing • - • ■ Windows A Iumistion / 0 Molten rcoge>s plea" Dom ❑ 3w 00.0 Simn Meadows vewLtion Daubers I Covers p8my Doors 11 _ C7Roufats °Studer CI Windows G1Imitation CIO's / Covets DEa ry Doors l . DR*** osbang Dow. 1J blow= Donnas l carers []Ferry Doors ❑ . Mi mon25% DemonriCentrartAromedaeImoavmtboatib6aneeraet. T c ootract Amount $ , mime Poieba h a yuntli adtmae CIACl'1 • Customer agrees that, immediately upon completion of the work for each Product. Customer will execute a Completion Certificate (ore for each Produce as defined by an individual Spec Sheet) and pay any balance due. As applicable. each Customer under this • Contract agrees to be jointly and severalty obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or tern ate this Connect or any individual Product(:) included herein, at its discretion, if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home, environmental hazards such as mold. asbestos or lead paint, other safety concerns. pricing errors or because wont required to complete the job was not included in the Contract. Payment Sunman: The Payment Summary # . included as part of this Contract, sets forth the total Connect amount and payments required for the deposits and final payments by Product (as ap NOTICE TO custom= You are entitled to a completed filled-in copy 011ie Contract at the time you sign. Do not sign a Completion Certificate (note; ttbere is one Completion Certificate for ouch listed Product as defined by individual Spec ) berme work on that Product b complete. le the avant of ter:aation of this Con tract, Customer agrees to pay The Home Depot the costs of materials, labor, expenses MAY WITHHOLD AMOUNTS and mounts set OWED TO �OMEDEPOT FROM THE PAYMENT OTHER PA'Y'MENTS MADE, WITHOUT IThiIITC THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. A Eaed AW : Customer agrees and understands that this Agreement is the entire agreement between Customer and�o Depot with regard to the Products and Installation services and supersedes all finer 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 Customer s hasr H a omn of this tom Agreement. acknowledges and agrees that Customer hes read, understands, voluntarily accepts the X ..asp t / � 'L — �,. . Customer's S' : • Date Sales Consultant's igtwmre Date X Telephone No. Cm's Signature Comae Sales Consultant Breese No. NCEI.LUIOTir CUSTOMER MAT CANCEL TI li ) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME • DEPOT BY MIDNIGHT ON THE TAD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE le ONE L'sji SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. eras cz_ Anotnd[UL TERMS AND CONID31O14 ARE STAYED Ott TIM =VERSE SIDE AND ARE PAS' OF MS antrum 541 -10 O-s . White — Dan* Fae Yams - Customer • Teo City of Northampton , G HAAR >A\ --'. u s Massachusetts , 11;, utt DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building M o b Northampton, MA 01060 r . X 45. INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 - - die /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 any 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 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 permits in conjunction to the building permit 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. Date Address of work location • AK es' ,: , The Commonwealth of Massachusetts .4.4":444a Department of Industrial Accidents P .. = " ' Office of Investigations . }k 600 Washington Street . `.r IBC :ill, Boston, MA 02111 l.i It www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): CLAte)11,6pij ii C _. - Ai) Address: ,V (f�'10 N City /State /Zip: NI hA ('3o3i Phone #: g I'- . Are yo an employer? Check the appropriate box: Type of project (required): 1. I am a employer with au 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner - listed on the attached sheet. 7. ❑ Remodeling — ship and have no employees These sub- contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. [DI am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL - 12.❑ R. • 'repairs insurance required.] t c. 152, §1(4), and we have no , ` employees. [No workers' 13. IS Other [, I/1` -, ' 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. ��� � t Insurance Company Name: (ji I PC ,^ - ` 6 Policy # or Self -ins. Lic. #: (101� I g, Expiration Date: _ . - Job Site Address: 0c/o 61, City /State /Zip: .' AIR 4, 4i , 01 . I Attach a copy of the workers' compensation policy eclaration page (showing the policy number and expi ation 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 day - :. inst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of th 11 IA '1r insurance/ overage verification. Id hereby ce 'y under t ©� , ins , d pe - ■ lties of perjury that the information provided above is true and correct. *117L---- Siu a :: � i, AMU Date: Phone #: L (' f 'C :: lo � = 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 Department 3. City/Town, Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other • Contact Person: Phone #: SECTION 8 CONSTRUCTION;SERUICES t _: . „^'* ..,n.w ,a k, x .,• � �..,. -� ..a' �:d_ .*;zs .? r�•a� ; " ?'c • ti- 8.1 Licensed Construction Superv' Not Applicable Name of License Holder : ,�! V 0 r ! r _Z)- - L!� 7 c7` 1 License Number • ,tea 0 . �. f� c i ",44/ W *) Addre Expiration Date C' 411111b. .• Air c r- - Telephone l� ti ere= `o" a m. .ovenie , • woritra a . "' °r ` Not Applicable ❑ DefiC;br if)?L,C13 Company Name Registration Number 3-6 g ?/1 Address Expiration Date 6)01?" .4 * , . p p �6 el e hone 0 ECTION 10- WORKERS COMPENSATIO INSURANCE / PFIDA1/IT .(M G L [ 52,k -2sC(5)KW, T -x . �` Workers Compensation Insurance affidavit m be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buiidin ermit. 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 Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature • • i"'� t a. ` °k. m'Z,n7r.F,. .." '' . , ar l si 5 F�4 J.* ' �'� ,r� ` k ' ��G... NI'., e ,N4* .. - - z - SECTION 5 DESCRIPTION.OF PROPOSED WORK (check` all F a .7 10. y ,�.�'� -�..... -`-� ,, fi.Y.' . "':.. .,', §" ,�tr��� a �� iF �;� �".,e� .�- �.ck.aNw.,'},�.'ibrrw� �y �� ; d"s fi d�� New House ❑ Addition ❑ Replacement Wi ows Alteration(s) ❑ Roofing n Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [ID] Decks [D Siding [ ] Other [0] Brief Description of Proposed [ 4 — f Work: _!i . .4.. ill " f\ Ail If- 1Q05 l Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet '`3e ® • c 0 0 1, 7 ddittQR e*1s L o mcr , ®nv e , b ® tz tnq: 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" a, �OWNERIA THRRiZA?10j1 P E OOMPL'a'EPSNHEK diArNEPtgAtEiti OR Ct3 TO 4PPLtfS' E RR BCtt#x�iNC �PER1411 (b 7 , 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. 7 � 7 Signature of Owner Date , as Owner /Authorized �� information s on the fore foregoing application are true and accurate, to the best of m Agent hereby declare tha the statements a g g pp my knowledge and belief. Signed under th and pe • • perjury. �.� • t jj Print Name / Z 0 Signature oft er/A!ent Date Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by 'Zoning This column to be filled in by ' ) g 1 Building artment 4 Lot Size 1 I r "�, to Frontage f I I Setbacks Front I I I I - C Side L: I R :' 1 L:17 I R:' I I 1 I. ? \I ' Rear 1. I Building Height 1 Bldg. Square Footage f I 1 I% I I ! I I I Open Space Footage - % — — — — (Lot area minus bldg & paved € i 1 { I I I I = parking) - # of Parking Spaces = - I � Fill: IJ (volume 8c 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 1 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 0 Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: ! D. Are there any proposed changes to or additions -of -signs intended for the 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 ® NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 290 BRIDGE ST BP- 2012 -0149 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C - 075 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-2012-0149 Project # JS- 2012- 000215 Est. Cost: $2093.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 67121 Lot Size(sq. ft.): 8319.96 Owner: ROCHE CARRIE Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 290 BRIDGE ST Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers Compensation WORCESTERMA01607 ISSUED ON:8 /5/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 7 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 8/5/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner