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29-387 • • Pre- Renovation Form Date: This form is used to document compliance with the requirements of the Federal Lead -Based Paint Renovation, Repair, and Painting Program after April 2010. OCCUPANT CONFIRMATION . Pamphlet Receipt • 1 hake. received a copy of the lead hazard information pamphlet informing me of • the potential risk of the lead hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet before work began. i Y j ear' of Property Construction f l 7) Enter the year my home was built. 7 Owner - occupant Opt -out Acknowledgement (A) No child under age 6 or pregnant woman I confirm that 1 oH and live in this. .property, that no child under the age of 6 resides here, m re, that no pregnant woman resides here, and that this property is not a child-occupied facility. Note: A child resides in the primary residence of his or her custodial parents, legal guardians, foster parents, or Informal caretaker If the • child rives and sleeps most of the time at the caretaker's residences. • Note; A chilli - occupied facility.is•a pre-1978 building visited regularly by the same child. under 6 years of age; on at least two diffetent days within any Week, Tor at Ieasl:3 hours each day, provided that the visits total at leap 60 hours annualry, If Box A is checked, Check either Box B or Box C, but not both: (B) Opt -in • request that the renovation firm use the lead -safe work practices required by EPA's Lead -Based Paint Renovation,' Repair; and Painting Rule; or (C) Opt out 1 understand that'the,ffim:performing the renovation will not be required to use the • lead- safework practices required by EPA's Lead -Based Paint Renovation, Repair. and Painting Rule: • .'. C tt � rita of. • • - nted Na ' ereocupant - 5 n .a'' nt • J . rt... y • • • t _ _ , . „ '' g • �4esd PsmpFi - llcNileiy = " ' •--- • • . . • . • . •• - liuMR•IMPIWIMWAP4.1.--ADY4 lit • • • . ' ek ' . .... , . . . Branch Name:. aoseeni Deter+ ALI/ .' (.2 .. . . . • • • Sold, FumiskedoodInstalled by: l'Itt) At-Horne, 'services, Inc.. . . . • Wit The gore Depot At-Home Services . . . • ... • . . . . ' • ' • 34M Greet:lived Street, 'Unit 2.,..Worcister, MA 01607 . . Draidieh Number: 31 . . Tell Free 00) 657-5181: Fax OM 756-8823 • • • ' • Pedini D547542698460; Melte * C 0249; RI Qat- Lie* 16Sr ' . . cr Lic.# 565524 hik Rome linprovendot Contractor Reg. ti 1249993 'State. . Zip , . . . .. . . . . .. . . .. Pinebarte): Week MOM .. Hood Pivot*: • Cell Phone: - .( o. '.-/ t2A-: i [i(.; 1, 6' 2G - [ • 1 [ . J I ) J. 1 . ltiruniAddreas: ' . . .. - (If different from Installation Address) ' " , City . , ---, . ' Statc ZiP . • E.-msa Address (to receive project communications and Home Dept Updates): ' . EI I DO NOT wish to receive any marketing ernaile fmm The Thnne Depot , . tiffektongdgo: Undersigned ("Cuatemer")..the lemma otelixvperi y located. at Ole atioNe instailaii0 a address, Went to biy, At-Home Services, Inc. ('The Home DePar) names fttnnobonotnfot lied toolndolo.rna; in.slaunttne ('listrutOnlinn of all materials described on the below and on the 'referenced Sg6c:;Shiseiks all Of whick ate incorporated.into this Contract by dds reference. along with any applicable State Supplement tinOeyddieSpearearAj:Muiclied tidbit, ea any Cliringe Orders (collectively. "Conbraer): • • • • " Job*: odious itatosuu 4 0Roofing OSiding 0 Winnows Erf!so. ' tun'. ... • , : . ; . ! ., : - ., • .. . . • 6y/t-f / daft l 'iq I 3A GCS D tpfintlY Dem' cf '• : ,..-..;:'•: ' • .•2-4134,3t) ( . - $ 807 • . ___. ., • L') Oltoofing DSiding LI windows 0 inside • • • • :•-:.•,'. ' •. • ' : • ...... .. • ... .. ' TY - 7-- $ Ile 8s OGorters r covers °Emmy Doors p e :.... :,,-, ..'.: , . • • EiRoofing usoiug LiVindows E' . • . ..: :..... • .:, • ''' • ; . . - s -- . • OGutters / Covers ORntry Doors Q 1 — 1 (j 12k Yd. . 0R.fir,,, Lwi 0 1.,..iatio. , .. • ,• :- ,••.. .• • . : . . • • / . . . ...—. 944- OCiutters / Covers paltry Doers fl .. . . . . .. • • mini..., 2Ssa Deposit stemmed Aiming due upon execution Ordiattitdridt: . i ciw • . eputract . - • Amount s t f Nu. Partimata a uut ro deposit mice gm ampthirdottbeCAtirsttAmiromt.: _ • ' CUSUaria agrees that, immediately upon completion of the work for each'Prodoct. Customer 0,111 exestue n Completion Certificate • (one for each Product as defined by an individiial Spec She. andpity. any hUlalscelliii.' Aa appbcatile,.eadi Customer under this Ctmtract agrees to be jointly and severally obligated raid rlehle.h?. • • •Y : ' '''.. ' , ' • ', 1 . • ' ' . ,. . . . . Tho Homo Depot reserves the right to issue a ammo Order . 00etnainat1a this' COarrnet or arty indivitivitiliorechict(s) included herein, at its discretion, if The Home Depot or its authorized service provisler•detertninesthat it cannot patio= its obligations due to a sou:tuna problem with the home, enviromnental hazards such as mold, aSimitiis or lead paint. 'other safety' orsincerris. pricing errors or because . work required to complete tbe job was not included in tbe•Contraci: : ' " . ' .. • . - ",,...,. . • . , ; .. Payment Sunanzarr. The Payment Summary # • , - (=3.)-... - 1' . , ineluded as.PtOr of this Contract, sets forth the total COiltritin amount and payments required for the deposits and final payments:by preciuct• 60 400abio. . . . NOTICE TO CUSTOMER • • • • ' • ::• • • • . • ' • . You are entitled to a coluOeteld 4 the. contract' itt. &Can* yo net nri At Completion Ce.rdikale (nonn there is one Completion Leeli te for listed Prods:10 As.defhwed isd t . ' . . Spec Sheets) before "V* cm that Product is complete. • .• In the event ot termination of thls Contract, Customer agrees to pay The Home Depot the costs of materiels, labor, txpeuaee and services provided by The Horne Depot or Authorized Service Provider through the date otterraborion, plus aby other amounts set forth di Did Agreement or snowed under appli law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT PROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITLNG THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. e and Authorization: Customer agrees and understands that ilia Agreement is the entire agreement between Customer tifd Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements. either ore! or written, relating to said Products and Installation. This Agreement cannot be assigned or amended except by a writing signed , by Customer and The Home Depot. Customer acknowledges and agrees that Customer has read. understands, voluntarily accepts the terms of and has rtxtivrAl a copy of this Agreement , A zzci__ S ■ to„!_,I....' 1-7-.‘ . ....i te) ,_ MR% V QS% .. 4. le (0 .. Customer's Signature Date . . Sales Consultant's - ignantre • , t • X Telephone No. Customer's Signature Date Sales Consultant License No. • CANCELLATION: CUSTOMER MAY CANCEL THIS ' Ots applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION . • BY DELIVERING WRITTEN NOTICE TO THE HOME • . DEPOT IIY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACKED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN • , . • CUSTOMER'S STATE. SOTICE: ADDITIONAL TROTS AND CONDITIONS ARE STATE.D ON THE REVE&SE SIDE AND ARE FART OP THIS CONTIttiCT . . 6-10-09 0-SC wh r non file. yeacoe -Customer ..pin's 9mea pommel " • . . . . • . . . • Pre- Renovation Form Date: Thle form is used to document compliance with the requirements of the Federal Lead -Based Paint Renovation, Repair, and Painting Program suer April 2010. OCCUPANT CONFIRMATION Pamphlet Receipt V I have received a copy of the Lead fleapit information • pamphlet •informing• rife of . the potential risk of the lead hazard exposure from renovation acti'�ity, to be • performed in my dwelling unit. I received this pamphlet before•work began_.; Year of Property Construction 14- Enter the year my home was built. Owner•occupant Opt-out Acknowledgement (A) No child.under age 6' or pregnant woman , 1 • confirm that I own and Live in this property, that no chid under the age of 6 • resides •here, that no pregnant woman resides here, and that this property Is not a child- occupied facility. • • Note';A.'child resided in ttle'primery rei his or her custodial perfrrte legal guardians, foster parerfts, or ,informal• caretaker If the child lives and sleeps moat of the time at the caretaker's residencies., Note: A diNd- riciu • iati facility is a pra•1978"bUiiding visited• egulerly by h e:egma diiiki,•uridere of age, on at•least two different days wlthin•any week, for at least 3 hours each provided that the visits total at leant So hours annua y. . If Box A is-checked, check either Box B or Box C, but not both: _ (B) Opt -In • I request that the renovation firm use the lead-safe work practices required by EPA's Lead - Based Paint Renovation, Repair, and Painting Rule; or • X (C) Opt 1 understand that the flint performing the renovation will not be required to use the lead -safe work practkes required by EPA's Lead -Based Paint Renovation, Repair, - and Painting Rule. Printed a of Owner - occupant . I /.t . .. ...... ign= ' = of Owner-occupant • • O. fir- ::�.�t; 3' tore of Deed Pamphlet Delivery • • • • • • HOME.1MPROV MEN1' CONTRACT ' PLEASE READ THIS Sold, Furnished and Installed by Branch Name: Boston Date: 4 /LL / 26 MD At -tome Services, Inc. • . . d/bla The Home Depot At -Home Services . 345A Greenwood Street, Unit 2, Worcester, MA 01607 Branch Number: 31 Toll Free (800) 657 - 5182; Fax (508) 756 - 8823 Federal ID # 75- 2698 460; ME Lic tt C 02439; RI Cont, Lica 16427 • . CT Lie # 565522; MA Hone hiiprovement Contractor Reg. # 126893 Installation Address: 43 B ooKW ocv she: FLA-Az &ice tW% ca tc06 Z. City . State Zip Purchaser(s): • Work Phone: llosae Phone: • Cell Phone: 1( 4'A 1 Elul cNI [ ] • [413]5$6 lZ4' [ • ] • . . 1 (o( . Home Address: - (If different from installation Address) City • State Z ap • • ID Address (to receive project communications. and Home Depot updates): Pram GM LZQ. T DO NOT wish to receive any marketing emails from The Home Depot • I project Inforgietioq: Undersigned ("Customer"), the owners of the property located at the above installation address, agrees to buy, • and THD At-Horne Services, lac. ("The Home Depot") agrees to furnish, deliver and arrange for the installation ( "Installation ") of all materials described on the below and on the referenced Slice Sheet(s), all of which are incorporated into this Contract, by this . reference, along with any applicable State Supplerirent sad Payment Snenmary Attached hereto �yChange Orders (collectively, "Contract "): . Job it: oft...1 as.e.•,'> .. Products: • S . , - - s #: Pie - Amount L i q 13�0�3 Roofing Ill Siding III Windows .W Insulation C � ^� CO DGutters / Covers natty-Doors C] Q 6)7 r_ J $ 9 .1 m ' Weal Y _ _ _ _ `` Windows • Insulation • ■ Roofing t/ Siding • Windows • Insulation . I:Gutters / Covets DEinry Doors 0 • 1 • Roofing • Siding • Windows • Insulation . DGutters / Covers DEntry Doan 1 $ 1 • Minhouta2S% Deposit of Conine AMOR* due upon vacation art Total Con' ra c t Asriiount — �,� =t.• Maine Purebasers may not deposit make than one46ird our Contract Arno . Customer agrees that, immediately; upon completion of the work for each Product, 'Customer will- execute as Completion Certificate (one for each Product as defined by an individual Spec Sheet) and' pay any balance due. As applicable, •each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. - ' The Horne Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s) included herein, at , its discretion, if The Home Depot or its - authorized service provider detee mines that it cannot perform its obligations due to a structural problem with the. home, envirotmnental hazards such ea mold, asbestos or lead paint, other safety concerns, pricing errors or because work required to complete the job was not included in the Contract. . Payment Sam i - . The Payment Summary • 20 , inelndc as part of this Contract, sets forth the total Contract amount' and payments required for the deposits and final payments by Product (as applicable). • . NOTICE TO CUSTOMER You are entitled to a co p etely filled-ba copy of the Contract at the time you sign. Do not •sign a Contpletioa Certificate (note: • there is one Completion C for each fisted Product as defined by individual Spec Sheets) before worse on that Product is complete. In the event of terminadon of this Contract, Customer agrees to pay The Home Depot the costs of materials, labor, expenses and services provided by The Home Depot or Authorized Service Provider through he date of termination, plus any other amounts set forth in this Agreement or allowed under applicable law. TIIE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT' LIMITING THE HOME DEPOT'S OTHER REl4MEDIES FOR RECOVERY OF SUCH AMOUNTS. ' Acceptance and Authur'wtlun; . Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot with regard to the Products and Installation services 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 and The Home Depot. Customer acknowledges and agrees that Customer has read, understands, voluntarily accepts the terms of and has received a copy of this Agreement. . . Accepted by: S, , , ; tted , : . 0 Customer's Signature Date es C . ■ 's Signature Date X , e ephone No. . t i 1. -37 4 --732tt . Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (as applicable) - . 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. • NOTICE ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SAGE AND AXE ?ART•OF THIS CONTRACT 11 -30-00 C-SC White — Branch File Yellow - Customer .. Pink —Salon Consultant ' . Uupunmmnr public ,x[,/ t���� Board ,fBoi|dincQrxu/"b,m, and �/u"dx,U, � �� Con License CS SL 9e785 Restncteuuz WS IVAN 72 STAFFORD ROAD MONSON.MAO1O57 � - sxp/mtmn: 4/27/202 n=: 98785 ` . r/ �� �� / 1 /( i �/ . 1, Cc t. iS S9 02. DEp 'Hichael 13adartl 1-41-24-2B p. I OC7-11-01 02 ::-U N fali-RIA None for/ 1:31 30373323H 1°1617 P.:DIAD2 7-215 . Nr VFn 6 1 : 3 ' � � ^ tt. rr f Y a Mr q T ROOFING INC. ER ' r ::i.,,,./..t . ` � m VYACHESLAV O . � r- • v., • 444A NORTH MAIN ST. `•f -: '--'" y E. LONGMEADOW, MA 01028 ; q ffi . fa _ : : • , '�'•t f: '� �' Ammo Address MO felon aoi.Olukvai n du nom a eoKe�Ar.dru� [] Mena 0 Imo Ind 0 Atploystattt [I Lon Card 4 - f E OONMAa1CR t'i beforetdptrea.I . Shwa Wont*: Rend 0- _ 1 S1 Rend ofR sod 9�4rrdrrdi • TOO 272e14 Oran Aditiorno Ma Ram - /U . ......1 . SPIRT ROOMS �r,rnr� ►v � • :,G f', © mil e •t 444 A MGM E. LOWt MEADOMi,I&01t128 handsbastar Not INN sellasst i tie - NIanoc nrtt• - Drp4td'trdt O! Public NJ, ■ • , Board a MIMIC Rawl ration". moil Swink l. Copakuctlon 3upervieor Specialty Ltci.tlse Lamour CS SL 10012 ,- sett toe Rfwe - Atd./ tae . I4 Sionon7 _ VYJICIf AV I tEiIPU 41 ' SY - Rod Ce.rsi8 14 SOW /AfEtOJE EAST W5 - 7Vb6.i d Man EAST LION GMEADOW. MA 0102 . . Mt - HtNAllttiBOttitSf & DM- Ihrondas oar • i I • • . . ° - -e --ceiling! F,cplr non: 11130+201 • Facie m rodeo s sum* Mu"I eilllb t •wJMI•+bre 4. TIC towns litioontwootto Man OMAN Coin 11 taro for nrar000dor of rr Osaas. ®rArr• to M'WW. OMS \ k • Y ../ 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 constructrpn 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 •ermits 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 • , ,......, , . . The Commonwealth of Massachusetts Department of Industria I Acidents . Office of Investigations • 600 Washington Street i Silif=,- zi Boston, MA 02111 t.,.. •-z.-=- 4 : ' . -• , vw.mass.gov/dia ... -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly : . Name (Businesi/Organizzion/Indiviring1): , • Address: ,. . City/State/Zip: - Phone.#: Are you an employer? Check the appropriate box: • •Type of project (required): l 1. El I am a employer with 4. 0 I am a general contractor and I 6. 0 New construction have hired the sub-contractors employees (full and/or part-time).* listed on theattached sheet 7. 0 R,emodelin ship and have np g 2. El I ani a sole proprietor or partner- These sub-contractors have .8. 0 Derablition r3loyees employees_and have workers' . , .:_, _ . • working for me in any capacity. 9 - - 0 Building aaditiOn [No workers' wrap. insurance r ___, requirecLj - 5. 0 We are a corporation and its 10.[DElectrical repairs or additions 3. f_J I am a homeowner doing all work officers haVe‘ercised their 11.0 Plumbing repairs or additions myself [No workers' comp. Hen of exemption per MGL 1--1., .. 12.Li /cool repairs insurance required.] t ' . 152, § 1(4), and we have no employees. [No workers' • 13.0 Other comp. insurance required.) . . *Any applicant -that checks box #.1 must also fill out the section below showing their workers' cornpensation policy &formai:km. t Horneowneri who submit this affidaVit intficating they are doing an work and then hire outside ecmtraetors must submit a new affidavit indicating such. - Contractcas that check this box must attached an additional sleet showing the name of the subcontractors aid state whether or notthose entities have employees. lithe sub-contractorshaVe employees they must provide their workers comp. poliCy number. . . . - • : lam an employer that is providing workers' compensation insurance for iny einplOyees. Below is the policy rind job site information. .. . • . Insurance Company Name: . Policy # or Self-in.S. Lic. # Expiration Date: Job Site Address: City/State/Zip:' Attach a copy of the workers' compensation policy declaration page (showing the policy number andexpiration date). Failure to secure coverage as required tea Seetitin'25A c 152 can lead to the imposition Of Caning' - penalties of a fine up to S1,500.00 and/or one impaisonment, as well as civil penalties in the form of a STOP WOBX ORDER and a fine of up to S250.00 a day against the violator Be advised that a copy of this statement may be forwarded to the Office of iiiiiiiiiii thbIA for iiiiiiiii6i 66iiiiiiii . - 7.7 ----- 1.77:1 - 7:77:7-7, - .7. 7"..._ ... _Ida herebycertifil under te pains.and penalties ofperjwythat the infarmationprovittedi b ove_iiiiii;_and_Coriect, __ • Signature: - Dali: • , , , Phone it: . . • Official use only. Do not write in this area, to be completed by thy Or town official , City or Town Permit/License # : Issuing Authority (circle one): '• - . • :1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector 6. Other , Contact Person: Phone #: f, SECTION 8 - CONSTRUCTION SERVICES J- ,`.- ,/ 't or: 10( a� ' . Not A livable ❑ W 1' 8.1 Licensed Construction Supervisor: Name of License Holder h 4-1394114/./ (351t5-- 'ti 94114/.y L,,...314. 11 f` 5 I F)! P. Lilaila i 1 br / ti -1 iItaTizi4 4)1 He; D 1 C.i3 CJ 1 .+nse Number y i A y/ y Expiration Date lr r / 11_ /�' 1f) S r Telephone 11 Rettiste dkHot p to W6iV i r ... fsi Not Applicable ❑ ar i 1.€ �i l l � - fi e t d 52 37 Company Name Registration Number O Address Expiration Date W 017 5 D j(if elephone t---k 1' ? 3 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit st be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi permit. Signed Affidavit Attached Yes No ❑ The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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 buildine 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 t SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Wi ows Alteration(s) ❑ Roofing [1.-- -- ' .----- Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [L7 Siding [dOther [D] Brief Description of Proposed • Work: _ t i l yzi 'ti !� i .., v � ► c .� s h Its !n J Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes ■ o Plans Attached Roll Sheet `N 1 .. . r 1 , j 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, ■! �0 �r Cj� 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 44 I 1, Re 1 int , as Owner /Authorized Agent hereby declare that the statements nd information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under th ins and otalties of perjury. Ak r It Print Name , / at i. 4 ri 4 AL 1 Al — 6 Signature of • ne /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 1 1 1 1 Setbacks Front I 1 7-1 Side L: R: L: R:` 1 I e Rear i Building Height I I 1 Bldg. Square Footage 1---1 11 % 1 i Open Space Footage % (Lot area minus bldg & paved € _ ' i i parking) r° -_ # of Parking Spaces Fill: j t (volume & Location) 1 r, 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 € l Paged # and /or Document B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q 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 i ! 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. 4 City of Northampton ' ff Bu Department s _ 212 Main Street ,_ ' : " ` +o a N a y ' 1 Room 100 ` :• 1. r �� - N North n pton, MA 01060 � _ ; \�' phone 41 3- 57 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 Lot Unit Map s. fi+ -E (� Zo OvertayAistrict ' t=int S . District' ; DB District vt SECTION 2,- PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of rd: 47) t i ) )(W14 Jiej ,..er Frbicz12.47 i-if Name (Print) Current Plaiting Addre e r l - ve, Telephone v Signature 2.2 Authoriz - •_.,1,! : nt: l — --- .. �- ,gr 1. .1.7 Name (Print) JO I , Current Mailing Address: �/ 1` t- Signature Telephone SECTION 3 - STIMATED CONSTRUCTION`: COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant a 1. Building e -, (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 6. Total = (1 + 2 + 3 + 4 + 5) c Check Number 3 3 $ 7e This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date t � trOPKWPOPPR:: BP- 2010 -0988 GIS #: COMMONWEALTH OF MASSACHUSETTS Mitp.Bl k :20 387 t 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 -0988 Proiect # JS- 2010- 001454 Est. Cost: $25058.00 Fee: $70.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sq. ft.): 18817.92 Owner: ROWLEY WILLIAM R & PATRICIA C EMERSON Zoning: URA(100) //WSP Applicant: HOME DEPOT AT HOME SERVICES AT: 43 BROOKWOOD DR Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers Compensation WORCESTERMA01607 ISSUED ON:5 /5/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF & INSTALL SIDING 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 5/5/2010 0:00:00 $70.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo