32A-216 •IV••••-! . * W1, • UL UA.T&, 4 ,
PLEA S RE THIS : : .
Sold, Furnished and installed by,
' Btntttto • Dan .. . " Atrl!(oaye Services, Inc, • �l 1�� • . , . . , .. . •. &b.( *The dome Depot At -home Services
. .. • 345A Cireea:vogd Stmet. Unit 2. Win ester, MA 01607
' Prey ($QO} 657 - 5182; Fax, (5o8} 756$823
Breach Number: 3T ` F i d r ral : f D # 73 268840;1 # C 02439; RI Coat 1,X101642'1
.:catfi'C. I Ivomaa� Reg -a 126893
InstEaiationAddreas: 7`Z I QL CCL
�'rtQ. ,
. - d ose; ' 4 04 f,4 04 •
Ci •:. s cats :. Zi -
• is} . warg Plraee: l�a®e Pl,nse:' [Afl �...r
x-.14 1 1 C T .- ; [ . 1
. . • L - .. -' ]
Hone Address: .
(If different from Installation Address) Ststc 73p • nneB Address (to receive pjece communications and Home Depot:u daaegk' - •• Y . .
• D IDO N O T wish t o receive a n y m a r k e t i n g caimans f r o m T h e Homo Depot.:.:.' .. - z••• , : -- : ,.. •
Project Information: Undersigned ("Customer). the'o ness,of tfih•pro ir.kicaoed`at` abOYe ibst3Psoon aadre s,•agrees to buy,
and THD At -Hone Services, lac. ("The Home Depot ") agre�ea ao deliver and' arrsage•ftu the inatalladon'("Snatal►ation - ) of •
•
all materials described. on the below. and on the referenced Spen Sheei(4j all of•Avii cit'ax ' unto this Contract by this
reference, along With any apptcabte Star Suppler and Payment: Sgsnwary a44Fh5d : hereto. .an • any Wear ,ChanWear (coll'cetively, •
"ContrscC)e . •
Jab al nrr..raJ...d) [rc ms s) is . Amomtt
r a [�Yidin ] . "t
Fnoat vvr 1 ..
536 Zolot pouters r cow' Dll atiy 0 ' • - f 1•., • ' • . 5 f
C
6H CAI
7ttuofn DSidmg D Windows (0 •Insulatio • ' •
tio..#cta t Covers Day. Deers' f `i :• S
LiRonfing. l l�idiag Q.vrwaowe [ 1 lneularion : �. .
[Others I Covers DP.rmyDouts I1' , s'
❑Roofing ❑Sidin wmdo+rr.'Er ' i , .'. : $ , . •
❑ 47Q7ens, DE!p y eon. . [ ' . ..' - •
hen 2 55bDepaeltaf '. " -
: 3 d [AI' Cad
e a O AOant $ 2
. iaePmdrerasmay eot *parkmotedunooe-thida(theOss t sC , '' •. L �
Ms C
• agrees agrs then, innnodiaxly upon complotidn of the worklo' C�' ls Y+ ittdl?et ,'Cusitirriei';vi�`Il�exesstics a CertiptoRos Certificate j �
(one for each Product as dcfined by• an inthvidual'Spec Sheet)`and pd[g pny_balance dire, " - licable: each Customer under this .
Cowart agrees to be jointly and !severally obligated'annd ltable`hexei :, • • " •
The Home Depot reserves the right to issue.is Change Order Oreitiairette Cherract4ran igdiviriu t?mduct(s) included herein. at
its discretion. if The Home Depot or its authorized seavrce prov er!iletetininbs that It 'cat nOL orm its obligations due to a structural
. problem with the home, environmental hazards such as mold'esbestoa or iced paint, 'ottia afety.con a n's, pricing errors or because •
work required to complete the job was not included in:tre :Coutradt • • . .. :: , . •- -
Pavrnent wry: The Payment Summary # - ..4 : inetded. as'peirt'df this Contract sets forth the total e
Contract amount and
payrnrntfs required for the deposits arc liieall. . • e rttrt .. adnct (as apgtioeble) ' ' • •
NOTICE T) tJs'h:)s 1lIt. •
You are entitled to a completely fitted :m cupid' the C"os niar a tlde;igrt'y'cdti • Be bri[ sign a Cenipletioni CettiWs *te (note; • there is one Completion Certificate for earth listed Prednetats'delfitiEdby°fil i • l.;eCSbeetSytidore work on that Product
is complete.
In the event of termination of this Contract, Customer agrees, to pa The Mouse De the costs of matertaTa, labor, expenses.
and services provided by The Home Depot or Authorized Service Provider the date of termination, plus any other
amounts set forth in this A.greemnnt or allowed under applicable law. THE HO DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR.OTHER PAYMENTS MADE, •WITFIOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer .
and The Hoare Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements, either
oral or written, relating W said Products and Installation, This Agreement cannot be assignee or amended except by a writing signed
• by Customer and The 14orne Depot. Customer acknowledges and agrees that Customer has reed, understands, voluntarily accepts the
terms of and has received a copy of this Agreement.
• by. Sub T •
fe �' --Z --( { X: er�ra t t
s Sales Consultant's S gesture Owe
X Telephone No.
Customer's Signature Date Sales Consultant license No.
CANCELLATION; CUSTOMER MAY CANCEL THIS -r- . 61,54,106+6. 0)
AGREEMENT WITHOUT PENALTY OR OBLIGATION .
BY DEI,IVING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS .
DAY ArnER SIGNING THIS AGREEMENT, THE • •
STAGES SijrrLR;MENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
•
SPECIFICALLY PRESCRIBED BY LAW IN
• CUSTOMER'SSTATE.
NO'f ICs: A111WJIONAL TERLISS AND CONDITIONS ARE S TATiI ON THE StiMestSS ME AND Aid, tall OF THIS CONTRACT
• 12 -27-113 C-SC • While— Branch Fie Yellow — CuSton'tv
The Commonwealth of Massachusetts
_Department of Industrial Accidents
—" = g►� Office of Investigations
� . • 600 Washington Street -
` _'1a =g
Boston, MA 02111
INEP www.mass.gov /dia
Worker Compens ado ia Insurance Affidavit: B lders/ Contractors /Electricians/Pl mbers
Applicant Titfornation Please Print Legibly
Name ( Business /Organization/Individual): ir a, 1 0
• Address: a � . , -
City /State/Zip: Affr (3._ 633Phone. #: qWJ C
Are ?am tf'an employer? Check the appropriate box:
-- � Type of project (required):
T
1. 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
2. — 1 I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling
• ship and have no employees These sub- contractors have g'. 0 Demolition -
working for me in an. ca ac employees and have workers' •
g any P rty. $ •
9. ❑ ( Budding addition
. [No workers' comp. insurance comp. insurance.
required] • 5. [] We are a corporation and its 10.[I] Electrical repairs or additions
3. n 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.[] Ro
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' • 13. Other �C,
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 can an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
�
Insurance Company Name: 10 jr e 7\ 62
Policy# or Self -ins. Lic. #: 6 iL �; Expiration Date: 0/4 ),
.Job Sire Address: Yaw � City /State /Zip: 1).. t ��
Attach a copy of the workers' compensation poll declaration page a (showing the policy number and er rrati date).
n date
PY ' P P Y P g( g P Y F� )
Failure 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 certia sat he , , ins . /d pc. alties of perjury that the information provided ab, ye is rue and correct.
° fr , /
Si:. afore: MG 1 L �, i /t !- — Date:
•
____
Phone #: LDJ q E
Official use only. o not write in this area, to be completed by city or town official
City or Town: \ ` • Pertnit/License # •
Issuing Authority (circle` one):
1. Board of Health 2. Building Department 3. City/Towwn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervise. -- Not Applicable ❑
Name of License Holder : e Co(
St; -
License Number
\ $
1,-4g, t la tL l ! l .t 'V A
Addres � D ' Expiration Date /
ASZ
Sig . • Telephone
p. Registered Horne Im vemen Contractor « t Not Applicable ❑
Company Na Registratio Nu beer'
c 79M1 Di)
Address Q 1 gk, 3 Expiration Date
i / t) O ` 4 ' DI II Ol elephone
SECTION 10- WORKERS' COMPENSATION INSU NCE AFFIDAVIT;(M.G.L. c.152, § 25C(6))
Workers Compensation Insurance affidavit m t 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 ❑
It`, ,Hom FOwnerExempt on
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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Wi ws Alteration(s) ❑ Roofing El
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [ I] Decks [E] Siding [0] Other [0]
Brief Description of Proposed �" 1
Work: Low 6 . ..r..11111 ; ! %f, - j Ceyng
Alteration of existing bedroom Yes No Adding new bedroom Yes No Diha
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sad if view house at�c or. a dditi on " z >IStinq ' hou comtifete the fo i" i in :
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, , 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. n
Signature of Owner Date
, as Owner /Authorized
Agent hereby declare that t e tatements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed underth. and •-nalti of .erjury.
AMI A N
Print Name WV
Signature of Own r/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplgte Information -
Existing Proposed Required 133.i Zoning
This column to',be filled in liON Y r OM
Building Depar;finent
Lot Size _ „_, _ :.. _..,
Frontage_ ._ ., _...._....w,..._ ___.___ __ .„. ._.„._...,_.__.
Setbacks Front
Side L.._,.,__.._._= R :L — L: L.._ R:S_._.-.._.,. _.____ __.
Rear s I i
Building Height r -
Bldg. Square Footage 1 1 t% 1 I I
I. i
Open Space Footage
(Lot area minus bldg & paved �` t ' _ ? I f
parking)
# of Parking Spaces -
Fill: �.. _ .
(volume & Location) ' i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW Q YES 0
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book ! Page 1 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 Q NO 0
_.� l
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O 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.
RECEIVED City of Northampton
� � r 4 i7epar(tnent use oniy
5 f a {usaf 'er mi
: uil* ing Department Ctrl�tErlrVelNay hermit. b
MAY 2 2 Main Street Sevelfepticailsbiliti
Room 100 r - `II Av�i I � -, � { � �
DEPT OF BOLDING • rth : mpton, MA 01060 • • = u ate'{ " g
NcRTHAMpT�� 4 s4 ° f 3 -5: -1240 Fax 413- 587 -1272 ! o z e �'. � ' " z
, e ,, t f4 �
Otttier , P M'I - t
■
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
e---- Zone Overlay District
[ Eirn St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: <--------
L - � Viz • *• Ai..Iri Ir. ' �iIlil 4/111 • ;�
Name (Print) r Current Mailing Address:
r,rif1�i,�J Telephone
Signature
2.2 Authorized ,ii t:
►ik. 4 jai 4 i 1 r_ .r1, D(
Name (Print) / Current ailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building
6R'---7 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (5)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection /
6. Total = (1 + 2 + 3 + 4 + 5) �; 7 ^ Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
79 POMEROY TER BP- 2011 -0938
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 216 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit # BP- 2011 -0938
Project # JS- 2011- 001534
Est. Cost: $2257.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 56454
Lot Size(sq. ft.): Owner: CONZ LINDA A UNIT F
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT: 79 POMEROY TER
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 REPLACEMENT PATIO DOOR
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