34-005 4. r
•
Sold, Purnished and Inatalkd by:
Irands Name: Ronan , Data t . . . . TKO At-Horse: Servipes.'
. dlbias 'Tint ioste Depot Al Home:Service . '
345A Cugaatvood Streak Unit2Aftlercester, MA. 01607'
Brands Number. 31 . ...Ttdl � (8A) � ttb7 -5182; : F.ag (508) 75.04823 , •
• . , P4p l ar a tI I ) C'7s- 269B46e. hE Z;.ic it C 024» Ri Cons Yuia'16R27'
' . ' 'Cr d 565522; Ro1n
MA e Impmveaene'Ctioniy [r Rn. C 126893 •
•
installation Address: — . e . • , ■ t. • RD' 06 c o .. ' i t 1.. C t•Crz;›
•
Parthmer(s): W anti Phsoe: Pldrahe Phawaa rte, : '
NI ft - i . -, • 11.111111111111t 1 j .
[..�. [ . 1.. :[.:':1.. •
13nrne•Addras : .
(If. diffeinnt foes lmteilationAddress) City'..:. Stater Zig •
• E-mail Address (to receive project communications and Rowe Depei updates): • ' • .. • .' •
0 l DO NOT wish to receive any marketing emaila fiom.The •]•loos Depot • .... .. . .
Proliect littotmatioa: Uaderatgued ( "C aseinieY'), the owner x of.the prr jfe ty located at dre above histallation mss, agrees to buy.
and TID) At-Horne ter-vices, Inc. ("T'he Home Depot -) agreca•w futriieh.' deliver and-arrange:for tbeins atiac'(` ou") of
all materials described on the below and on the referenced Spec.Sheet(s), all of which are incorporated`jige this Connect by this
%
reference, along with any applicable State Supplement and Paymcnt.Summsry'ched hereto and any Change Clydgrs'(collectively: )L__dL /�
"Contract "):
Jane: rt..".rn:ram .ant
ed • 'e ' Sisaa S Sbatitfg)'# i.. • P oieeiAy mom .
tJSooflnt USidine 4
Ja U
502 a'''116 D r a w e r s / Coven C y Doors Q . S C ` a,,., ' • . • • � � Ji
■ .. „ _ .cA waerrowp D 1pxrrtr�n �•� �/
. Dowers /coves Fe won rnwon n .�.•.S•e> 1,a, $ . .�a` �" ri
•
Dig USidie U.GVm4otvs. ❑' IaASltxinn
Dt a, Cova.s c r y t l ..
°Wien 8 DSidI s' Q a tido 0 I> ;a' `;` ,: , . ; . , , .
•
Dcluttern Oaa,e:a OE~ Door .n ` :. .
t> 2S% Daperst et Canaan fuming ere upon meniften elirlr esnuad. Total Contra • . • . rat ;
.- Total $
MainsPnex�a wee then me. t utor 1p+�in tAmeas. . 1 • •
•
Customer agrees that, immediately hoer completion Of the work for each Prodecx. Customer` will eueoute a Corrghletion tertiReate
(one for each Product as defined by an individual Spec Sheet) and pay any balance dec. • As applicable, each Customer under this . • '
Contract agrees to be jointly and severally obliga red a nd liable hereunder_ ' . .
The Home Depot reserves the right to issue a Change Order or. terminate this Cotutact. or tiny individual pbudnct(s) included beteiut at
its discretion, if The Home Depot or its authorized service provider saes tlrsl it cannot Perform its • otdigstsana due to a structural
problem with the home. environmental hazards web as•mold, asbestos or lead WM. other safety' concerns, pricing.er ors or because
work required to complete the job was not included in the Contra pt.
Pavement Summary: The Payment Summary..a .13 : $. 1 ' 43 . tacluded; as part of this .Contract, sets forth the total
Contract amount and payer =Mired for the'dcooeits and•tlns1paymlents by Product (as 'applicable). • • . •
3I'OTICE TOCUSTOii .R • . . • . . . .
You are entitled to a y Idled -in copy of the Cantina at the time you sips. 'De not sign a Completion Certifies* rake:
there Is one Completion tate for each l lie d l"rbmtct• Its defined by individual:Ss* Sheets) before Weak eta that• Product
Is complete. .
In the event of termination eat this Contract, Costa :ter toots to pap The Home Depot the coats of materl$a, labor, expenses
and services provided by The Home Depot or Authorized' Service Provider the date of termtnadon,. plus any other • .
amounts set forth in this Agreement or allowed guider law. THE HOME h DEPOT MAY WITHHOLD AMOUNTS
OWED TO TIM HOME DEPOT FROM THE /) PAYMENT 'OR OTHER PAYMENTS MADE,. WITHOUT
LIMITING THE HOME DEPOT'S O'T'HER REMEDIES FOR RECOVERY OF SUCH AMOUNTS:
• A and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Cuitemer
and The Home Depot with regard to the Products and Installation services and suptrscdcs all prior. discussions and agreements, either i
oral or written, relating to said Products and Installation_ This Agracux.t cannot be assigned. or amended except by a writing signed
by Customer and The Home Depot. Customer acknowledges and agrees that Customer has read. underamnda, voluntarily accepts the
terms of and has received a copy of this Agreement.
Accepted y:
G ( ./ sSxabilau ( (t t, C) . -
Custonirs's Si ties Sales Consultant's 'granite • Dun • .
r .
X Telephone No
•
Customer's Signature Date Sales Consultant License No.
CANCELLATIONt CUSTOMER MAY CANCEL THIS (as applicable)
AGENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRrrrEN NOTICE TO THE HOME . .
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS •
DAY AMR SIGNING THIS AGEEEMINT. THE • i
STATE SUPPLEMENT ATTACHED HERETO..
CONTAINS A FORM TO USE IF ONE IS •
SPECIFICALLY PRESCRIBED BY LAW IN .
CUSTOMER'S STATE, ..
•
NOTICE: ADDITIONAL TE*MS AND COMMONS ARE STATED ON TM REVERSE SIDE AND ARE PART OF'TRS CONTRACT. . .
It•ao-OS C.= White - Branch File Yell :- hal
ow - Customer Pink es ■
Consultrrt i
.0. •
, .................w
-. NI asNachusctts - Dcpartment of Public Sitret:s
Board of Buildin2 Reu,ulationN and StandartIN
\---0 C Supervisor Specialty License
License: CS SL 98785
Restricted to: WS ,
IVAN KOSOBUTSKYY MR
72 STAFFORD ROAD
MONSON, MA 01057
...) ---- ----€ Expiration: 4/27/2012
Tr: 98785
I
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 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
Date
Address of work
location
4
r
.�
The Commonwealth of Massachusetts
Department of Industrial Accidents
1� Office of Investigations •
9 -f®1- y
600 Washington Street
== Boston, MA 02111
; ` , www.mass.gov/dia • _
-Workers' Compensation Insurance Affidavit Builders /Contrac tors /Electrician /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Indiviii
Address: -
City /State/Zip: - Phone. #:
Are you an employer? . Check the appro • . • • Type of project (required) /
1.0 I am a employer with 4. I am • _ eneral contractor and I
6. 0 New construction
employees (full and/or part-time). have e d the sub- contractors
2. I am a sole proprietor or partner- listed o. e attached. sheet 7. 0 Remodeling
ship and have no loyees These •- contractors have. .8 ❑ Demolition
enpi•, and have wo
working for me in any capacity 9. Buil addition
- - • .aq a ve: e .- - - — [No workers comp: insurance
required:] .0 ' e are a co • • ' on and . 6 10.0 Electrical repairs or additions
officers hay!' x- cised it 11. - Plumbing repairs
3.0 I am a homeowner doing all work ! ,14.: ❑ ?ng eP or a dditions
myself [No workers' comp. rightofa •e'. GL 12: 0. Roof repairs
insurance required] t c. 152, § (4), .. • have no
employees. [No workers' 13.0 Other
camp- Inst once required.]. •
*Any applicant -that checks box #1- must .also fill out the section below showing theirworkers'- compensation policy information: .
t Homeowners who submit this affidavit indicating they are 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 ar not those entities have
employees. If the sub-contractors have employees, they must provide their workers' comp. policy numkr.
I am an employer that is providing workers' compensation insurance for my - ' -, , • . w is the policy and job site
information.
Insurance Company Name: •
Policy # or Self-ins. Lic. #: Expira on Date:
• Job Site Address: City /State/Zip: r -
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage; as required under Section25A ofMGL c. 152 can lead to the iiipOsition ' 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 and a file
of up to $250.00 a day against the violator Be advised That a copy of this statement may be forwarded to the Of'ce; . ,
I"xives`tiQations' the DIA for insurance coveraze ve
Ido Hereby certify under the pains and penalties ofperjury that the information provided :ahove:is_true_and orrect±_____ _ _ - . - .
Suture: Date: - . ,
Phone #
Official use only. Do not write in this area, to be enmplP!pd by city or town official
City or Town: # _. _ .
Issuing Authority (circle one):
.'1. Board of Health 2. Building Department 3. City/Town Clerk . 4. Electrical In.spector 5. PIumbing Inspector
6.Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervi� sor;_ Not Applicable ❑
Name of License Holder : yr h LJ43 - 1 �"` License N 997v.5._
er " _
0656 t` I W 1.1.)/t
A. ss Expiration Date
11D)/ 3
• ur Telephone
9: t i ®a± a, = ue a e tai ar a4� s , *ligaZ Not Applicable ❑
� E193H c �
Company Name I Registrati Number
4.5 9/110
Address - Expiration Date
(....e4 of b i) TTlephone 1 �
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 ❑
E l!)lll V,� . wui
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
•
• y
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 [D] Decks ED Siding [D] Other [0]
Brief Description of Proposed �� ) ,}
Work: t:r'i . • _ - ii IAA 1 s Ki i
Alteration of existing bedroom Yes No Adding ne •edroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
; a�ls�iha;�crrirleet+vrs:
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
ri , 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.
1D
Signature of Owner Date
I,
F;) /011-1 ' 1 /0 . , as Owner /Authorized
Agent hereby declare that the statemen s and information oh the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the - - ins and • - • - (ties of
all
Print Name zwej ,
•
P
Signature • ner /A: ent 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:l ` R :l 1 L:' ? R:` 1 , E
.� ""1
Rear = I
Building Height
Bldg. Square Footage i _ _ = % [ 4 1
Open Space Footage %
(Lot area minus bldg & paved t i ...J ..___A...
parking)
# of Parking Spaces i '-
Fill: € I � . �. ........,.�s�.,.�..�.......n.� .,.� .�. _.�...�, _�._
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
E t
IF YES, date issued: 4
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES
IF YES: enter Book I I Pagel I and /or Document #1 i
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: I '
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q
IF YES, describe size, type and location: i {
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 C.) NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Building Department _
" ,�.
c ;112 Main Street W T'
Room 100 •
Northampton, MA 01060
phone 413 -587 -1240 Fax 413-587-1272 ti
4
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
: : ct: e Overlay Distric
Li 1 e-
� � CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
•
I■VcriL IL .04 Fficovv
Name (Print) Current Mailing Address: //
/ ( I Telephone
Signature
2.2 Authorized . - - nt: I , ,,) -ter
Name ( Current Mailing Address:
Signatu - Telephone
SECTI • N 3 - ' ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building C-6 y POD (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) t 7 Check Nu 3
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
6 TU1L Ic BP- 2011 -0021
GIS #: COMMONWEALTH OF MASSACHUSETTS
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- 2011 -0021
Project # JS- 2011- 000043
Est. Cost: $8120.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 98785
Lot Size(sq. ft.): 80019.72 Owner: NAKASHIAN NICOLE
Zoning: RR(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 296 TURKEY HILL RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401
Workers Compensation
WORCESTERMA01607 ISSUED ON:7/12/2010 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 7/12/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo