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Board of Buildino Rom lations and StandartIN
Construction Supervisor License
License: CS 67121
Restricted to: 00
BRIAN C THOMPSON
38 WI LLOVVEROOK LANE
WESTFIELD, MA C111135
•
Expiration: A/30/2012
...... Tr: 21015 ...0060000014.
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Branch Name: Bataan ] :� J . J ( ) . iza t b � y
0 4 1 h t ' 7?te H e r n e 'i:iep* At -Home Services$
Biondi Number: 31 34,5A Greenwood Stteet:'Unit 2,,Wereastas; Mft Ql6O7
:mil F� (0) 657 518'2; Faa 008).7564023
• Paderat,UD S ` ***Soli: : MtE Tic: #.0 0P�t .. iU C i.ied i6S27
Lk t► 56SS2:1d4 hakes #
CP 126693'
IasbDahon Address: ) l A $ t '�1
Pascluserta): 'Watl:1Phaee • FJbraalPlsa� • • Centions:'
•
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i . 1 • • ''t'' . :.':.: • Home Address; as % � ,_ s{ >< jt: CS I : k u 0 • •
(If dif from hratakltt On Addtc s), •rSmle
E-mail A4tIre (to reC ve pro jeer lam aaunical3pris ana.t ntne.Depot k
CI I DO NOT Wish to•receive any marketing ettualls ftomTko Hestle : "
Vect Iffari : Undersigted 'C "7; tpt 3 ea ofihc' enpbtt ' : at the ive ii n 5 ddreas: awes to soy, ' • . V
Ac -Home Services, Inc- ("Ile Hbmie D.rpotl• an see' o, f rniati; deliier a zit a ininge:fuedie.' ' ('Teat I sof
all materials (lambed on the below and on the reereioced Spec',Sbeet(a %.all: al Shp:.. -. into this !' pnasct by Iris
reference, along with any applicable stare Su plement and P yment. S a nd do and c Dane's (cOilecnveiy. &)
•
Jebrf a Vie.: AiawrMat
0'f 3S Dtlonetatcovtts' 'hoots. 3 $" ' :� 1 •
�omta i / Corxrs �smry iioo.x, l" i Y
a []siding L�vYbtttoavr:C7Tmaletioa:. >:. ; •
i sIV E�aoryboaa, '. i' ;. •
7. % p*arc.aaesaeom=d me upon taego5onclt6i ale � a tr+ntiaiatA iottut:~� "w
i► se
Pan: asmaynetdmaeitmethanemehi at ttAelyrmsrat Amhgt. ¶ t
Customer agrees that, imanediately upon gostp arms, cif the "akrvk 1 Pr tomer 'waIi 0.r4,f b a Co/mphctiop Centtrease
Cone for each Product as defined by an iint$vidual`Sp )'and pa .any a. r " ;n's aliplicab& estfi Customer inder this
Contract agtea* to be jaint*y and rev crony Oh lt ated.iWiliablc, itmkr : '
The Home Depot reserves the right to issue a Change ..Otdtr:or scawinate'tH Cimtraca am tq?F ±rd u&al; so dn ct (s} tacluded hereia, at
its discretion, if The Home Depot or its aglhorlaad .Sea:Yiceppmvi1tn'deternMm.that ittcantnot na*ObligOo* to structural
problem with the home, environmental hatarda seek is mald,,asbeatpa or kead.pal1,;o �
ter safer,' pcecre,:.Pl &r
are r€oi because
work required to complete the job was not included 'a {bee`(piitr!itt`- :','"- •
Payment Summate; The Payment. Snmm. dt •_ included as pan of thia':Contract. sets forth the total
Contract amount and payments regUiced for the depreittr'aiut pfd p nts.by,Peadro ee (at app'6'caala)_ . . ..
NOTItU
Yen are entitled to a fliled -in aapyMr the mat the tin yatas m. Idanot•rge,% 'e
ii Certate (note:
there is one Completion Ceuta cate for tack Ili Pr+odnet as: deli ad by'�•See S ieetsf"bafore work on that Predict
is complete.
In the event of termination of this Contract, Customer agrees to pay The Hoirie Depot the abet* of otterials,'labor, expenses
and services provided by The dame Depot or Ai rtbodzed Service PresWo r. the d oE' intimation" pleat� other
amounts set forth in this Agreement or Mowed under. applicable law: THE H�DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR , m PAYMENTS , MADE, WITHOUT
LIMITING THE HOME DEPOTS OTHER =BIRDIES FOR RECOVERY OF SUCmAMOUNTS.
A_c lance t ore s Customer agrees and uadrrsteods that this Ag ecmnt is tbe.entire agreement between Customer
and The (tome Depot with regard to the Products and Iostaltatiion services and supersedes all ptior'diseussions and agreements, either
3r el or written. relating to said Products and Installation. This t cannot be assigned or amended ei apt by a writhing signed
by Customer and The Home Depot. Customer acknowledges and agrees that Customer has•mad, understands, voluntarily accepts the
struts of and has received a copy of this Ageement,
l 7 �. J,tej
Lasso • * y Date Sales Consultant's igstaror . Dare
IC _ • Telephone No.
Customer's Signature Date Sales Consultant License No-
c !j,LATION: CUSTOMER MAY CANCEL THIS • t t
AGREEMENT WITHOUT PENALTY OR OBLIGATION • •
BY DELIVERING WRITTEN NOTICE TO TR& HOME •
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS •
DAY AFTER SIGNING THIS AGREEMENT. THE '
STATE SUPPLEMENT ATTACHED HER rO •
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE. •
?emu : ADDITIONAL TEEMS AND cONDM01 ARE STATI>a ON i10R itglittaSI sm6 AND ARE PANT On THIS CONTRACT
i1.10.09 c-so wrote - Dramna to ' ' - Customer Pink 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
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
iermits 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
The Commonwealth ofilfassachusetts
,----...-7= Department ofIndustrial Accidents
t' • _ ' Office of Investigations .
600 Washington Street
•!.. — Inv — ,.., Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print L - • *blv
.--
Name pusineseorganizationadivicinao: e 0
r 1-5-,-Per -
Address: g 2i,.1 - 1 0 G y4,_ici Wuy ,. •
City/State/Zip: , _ 1 9 - Phone.#: .
t 6 0 qt tot;75.)0,---
Are yo .. employer? Check the appropriate box: •Type of project (required): i
1.1r I am a employer with I DO 4. 0 I am a general contractor and I
0
employees (full and/or part-time).* have hired the sub-contractors 6. New construction
listed on the attached sheet 7. 0 Remodeling
2.0 I am a sole proprietor or partner-
These sub-contractors have
ship and have no employees 8. 0 Demolition
employees and have workers' •
working for me in any capacity. 9. 0 Building addition
[No workers' comp. insurance.
10.0 Electrical repairs or additions 0 We are a corporation and its
required.] •
3. 0 I am a homeovvner doing all work officers have xercisal their 11.0 Phmib epairs or additions
t
myself [No workers' comp. right of exemption per MGL r--,
12. u KA rep () . •
insurance required.] t c. 152, §1(4), and we have no
, employees. [No workers' 13. Other I
- comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below shovring theirworkers compensation policy infonnation.
t Homeowners who submit this affidaVit inclicating they are doing all work and then hire outside contract= must subnrit a new affidavit indicating such.
lContractors 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.
Jam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. . . \ ,\ ‘ i i 4 .___• i „,
l ,
Insurance Company Name: NYtA) tkryi pl hire.,_1_1(6 C.:0 •
Policy # or Self-ins. Lic. #: P{Y3t-tg.- Expiration Date: - 7)// i 1
v ,
Job Site Address I LA)It I 1Ckm k E City/Statz/Zip:' • th i z:z,' .
. .
Attach a copy of the workers' compensation policy declaration page (showing the policy number and exp ation date).
Failure to secure coverage as required under Section ofMGL c. 152 can lead to the iMPoSition of criminal penalties of a
fine up to 51,500.01 d/or one-year imprisonment, as well as civil penalties in the form of a STOP WOPR-ORDER. and a fine
of up to $250.0 t - day = gainst the violator. Be advised that a copy of this statement may be forwarded to the Offfce of
Efeitikatioris T, f the D I .. for " ■ - ura coVer .- ire - ii.fiCatiiii - - - - - -..------- ----- ...--- — 7_7.. - - _.
_ I do __ebyc ,- . u , or I / ' an kaltzes of perjurythat the information provided above e_and_corTect.____
Sigria 4 . - - 7 / 1/.., ____.--- Date: 7 )1 ,
--
Phone #: LI ) 19c -
• Official use o y. 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. ElectricalInspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
SECTION 8 - CONSTRUCTION SERVICES • 8.1 Licensed Construction Su Not Applicable ❑
�1/
Name of License Holder : e' G ► 1 () ` r o ( y � ✓ p License Nu mber
ddress Expiration Date
Telephone
(-101<L T7 c20;"5
hone
gr tae P
=r i :4'«'"fii Not Applicable ❑
J \af � 7 1? 1.
Company Name Registration Nu ber
))) 2.)
Addre Expiration Da e
\,k v 0,6D7 ,---
T elephone r
-
SECTION 10- WORKERS' COMPENSATION INSURANCE 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 building rmit.
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 1083.5.1.
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
. t
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Wi ows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. El Demolition El New Signs [D] Decks ED Siding [D] Other [D]
Brief Description of Proposed --''---- I
Work: _•i"i ler ► ' v.
gel /l . I t' _ . . C- I
Alteration of existing bedroom Yes No • dding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa ` f 144):1io Bata • iii f itdditt& . iciifi ilr. of rrcEio ii .the;Yfiiit 1i :
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 y" t , 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.
( 0 (�
Signature of Owner Date INV
•• ., ` til _ , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed - •er �- pal s an. • • - - e- of perjury.
Pri XIV if ' // c-7/*
"-- . • • ature oT Own - r /Ag nt I Date
e
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 1 I �
Frontage
Setbacks Front 771 1
Side L: ' R:= f L:' I R: 1 .
Rear = = m t
Building Height 1 I I I F
Bldg. Square Footage € I I - 1 , % ' = r
Open Space Footage %
(Lot area minus bldg & paved 1 j ___ i 7
parking)
# of Parking Spaces I ;..„
Fill:
(volume & Location) 4 ` b —
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
t
IF YES, date issued:; I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Pa J 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 Obtained 0 , 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
r
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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
s
• City of Northampton
Building. Department
212 Main Street = -
__._�_.. -_. Room 100 � ..a
• rthampton, MA 01060 � e P � rtvAtV
U U L ph -587 -12 Fax 413- 587 -1272 a ' {
Ova X46.
J - _ ��
APPLICATION TO CONSTRI%aT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
i Map Lot Unit
{ 111icin
Zone Overlay District
Eta St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
- •
• r vo . ■I._ a, 41 1 0i 04i)
Name (Print) Current Mailing Ad rs:
'S(cl Telephone
Signature
2.2 Au . 'zed Agent:
. 11.. .- e IP
Name (Pn / / Current Mailing Address:
1 4i) ( 35
S ignat+ - Telephone
SECTION < ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ' (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) 15 -- Check Number , 35
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
I ` = BP- 2011 -0010
GIS #: COMMONWEALTH OF MASSACHUSETTS
R Y CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH 1YIREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0010
Project # JS- 2011- 000013
Est. Cost: $1917.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 1916.64 Owner: BERNSTEIN ELLEN & STEVEN TEMENBAUM
Zoning: URC(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 81 WILLIAMS ST
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401
Workers Compensation
WORCESTERMA01607 ISSUED ON: 7/2/2010 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 7/2/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo