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STATE OF CONNECTICUT
DEPARTMENT OF CONSUAIER PROTECTION
HOME. IMPROVEMENT CONTRACTOR
GLET.I•
,114.'.4DRIAlY AVE
• ... . ..,
• I WEST SPittNGFJ;81?4,2q1c. 01089-2904
.. ..
SILVER CONSTRUCTION
j
LIC. / REG NO. - ..-......._:; s'EFFEOTIVE.;y. EXPIRES .
HIC.0622049' ,::-.■,;,: 1 120.08:o 1 /30/2009
SIGFIED_
..__ _ _ _ .___ ___... _._. _._ _ ....• • .
— , . .......
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' -'•-•,'• Nitt■sitChUCCIN - Department of Public .. '-, •;.
o-u of Builtlin Revlations anil . ;
\_,onstruction Si.ipei S:)%:"Ci 2117 L,c
License: CS SL 1006139
Restricted to
4 ..8.,-..,:....,
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GLEB LEIDERMAN -•.i ;?'"."--. '.,::i :-.-.:
114 ADRIAN AVE •-k- .. ,": : :
WEST SPRINGFIELD, MA 0108 . ,.,. ,-," ' • .441.7:,. - (
..,,
' ... ,
Expiration: 4/18/2012
( umini,,i,.111r Trg, 100689
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Branch Name: Basest .. Date: '.... Sold, Pa abed end'2ritaalle4 by: ( t U. • . .' 1-Kt3 tome'Scrvioe lac. •
. dib/ar T1te Iiarne Depot Aa.Idon,e ti . •
. 345A Greenwood $Meet, Unit 2; Vi urmetttvr, MA. OI6117
Branch Number. 31 • . . . . . Toll pine (AM) - 3 id 2 :. Pax (S8$)' 75# s23 '
.. . • Parent iP g'7s-24ga46ft 4 c ti2439;, ltii'Uaoi, LAO id4z7
. ] CT Lie 05, . 522 MA,HnineT.;,p:oven 'ConcaemrReg #)1 15.295 •
Inttul4Won Addoean: °� 1 • . , t t .. P , t e i it t e . e ' '• • : 6
Cit State ip
fY Ph Home Phone C s� •
At! UVA [ .1 . E , 1' [ ? .1 ....
Heine Address: • . *differ.* from lnstalllation Address) . . City ,. State yip .
E -mail Addamos (to receive project commonications and•Home Ihrpotupdadates):' . .
El It DO NOT wish to receive any marketing snails from The Horn De .
Prided 1nfmtmOon: Undersigned ( os:tamer), tie owners the property tweed at the abiree.instridimMaddiess. to buy.
and THD At -Home Servicxs, inc. ( Horne Depot "). sus to, fiirmah, deliver -6A' surge for hie' iustailide i ^): of I ^ t 1
all materials described on the below and on' the reformsped'Spec .Sheet(s),'eliicithf which 'ate stcorpesaoed• irttcrthis Contract by this' ( } / ) u - )
reference, along with any. applicable State Supplement and Payment Summary attached bereto and any change Orders (collectively,
Contract "): .. .
IoI pea.e,amewd . . .'Spec ' '1Prgleet'Amo®t'
II Roofing ■ Siding a , •. ws • Insulation •
-?' L 1 ❑Cn>nana /Covers l nrrs nas l l • . A. y t,t , q , ' $ ' .34,46'.- .
C3Raosns 0 0 Wice n II 1ntatt. ion
[]Outten 1 C overs Onn ty Dora /;1.1._ .. .
Roofing ■ Sidiat Yl writ iwa'. � .
•
•
flanttasi C�PatryDoon{7 4- ;. ,, . .
mooting DStong ti.pink u '
QGunc a 1Covas p13ra+ Doors ` f
Mkthm 2s% ftediat.COMIWIA • ,
iatnerta�dme:aamay not depear mareth naoa- ttrreorthaCamelotAmiens . Total i nisei •itinor,�t ' . $ ' :• yP ,
Cuslomer agrees that, immediately upon completion[ of the wpm fee. each Prodllt t,' Cast° met' •Wi['.eieet tc a Conidetirin Certificate •
(one for each Product as defined by an individual Spec Sheet) and pay any bafance due: "As apr1OCafiic stomrier. this
• Contract agrees to be jointly and severally obligated and liable hereunder. '
The Home Depot rcacrvca the tight't0 issue a Change Order or, urC,minaire this C17nitsrtt br any indivfAuai'Ptodtigt(s) iaciuded herein. at
its discretion, if Too Home Depot or ite authorized service provider determints.tl» it. cr�tnotpst't'orm ii8 obAgation due toe structural •
problem with the home, enWrunmetntal hazards such as mold or lead,
•
work required w comp etc the job was t included et the CneiYC[. ' , ' ' raG may' error* or because
Payment Seminary: The Payment Summary # • �i.i , —,I . , iooluded `a$ . pelt of this Contract; sets forth the total •
Contract amount and payments required for die deposits.• and'fural pgyeaents by Product Ucepplieeble), • .
NO110E TO CUSTOMER ' •
.
You are emitted to a completely lilled -in copy of theCoritract at the tiate.yw $an:: D$'aot i tepee Cartt6cate(pote:' .
Mere is one Completion Certificate for e .h listed Prod ict as Mined hy'fretividuial Sllect ' that Product
is complete.
In the event of termination of this Contract, Customer agrees• to pay The Home the' ot mlateniale;:lahor, expenses: I
and services pra te A The Home Depot greement or AutLOristed Provider. OM DEe tits; of Gcr9milaaticta. plus an other
amounts set
forth In this t or wed under law. THE HO DorE2't' MAY 'N" TOLD AMOUNTS S
OWED TO THE 'K AU DEPOT FROM TIM DEPOSIT PAYIMIENT ok OTF R Pi►'iMENTS MADE, WITHOUT
LIMITING THE ROME DEPOT'S OTHER I MHDI€S mit RECOVERY OFSSUCH AMOUNTS.
Acce ice n' 'ration: Customer agrees and understanda that this Agreement is the entire agreement between Customer
and The Home pot with regard to the Products and Instal stinn servir es and supersedes ail pri discussions and agteeIneats, either .
oral or written, relating to said Products and Installation. This Agreement cannot be fined' Cr amended except by a writing signed
by Customer and The Home Depot, Customer acknowledges and agrees that Customer has read, understands. voluntarily acocpts•the
terms of and has received a copy of this Agreement.
x la ✓� wl Su _ c, {1 ct
m
•
Custoers Signature Date Sales • • : uitsnt'a • - statures • • _
X Telephone No. '
Customei s Signature T1ate •
5ale4 Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS . t"' )
AGREEMENT WITHOUT PENALTY OR OBLIGATION ' •
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY Arrot SIGNING TOGS AGREEMENT: THE • •
•
STATE, SUPPLEMENT ATTACHFA . HERE W •
CONTAINS A FORM TO USE IF ONE IS
SPECI'PICALLY PRESCRIBED • BY LAW IN
cUSTOMERPS STATE. • ' •
Norms: ADDITIONAL TERMS AND CONDITIONS ARE STATED ON TEE ItEVUSIL SIDE AND ARE FART or UDR CONr'nacr
11 CAC what•- Branchlle Year* ow OuStomer Pink - Saaea Cerement • • .
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 (beforepour), 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
jiermits 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
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
.... .
4r --. ' '
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office ofinvestigations '
t a irli m $
600 Washington Street
1::1/4 IMMIMA el= ,
: Boston, MA 02111 .
,. 7 _A"
. -3nr - -sev 1 www.tnass vvldia o .
- - ww w.mass.gov/dia
Compensation Insurance Aflida Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name pusinessiorganizationfindividmo: :
Address: .- -
City/State/Zip: . Phone.#:
Are you an employer? Check the appropriate box: Type of pi-oject (required): I'
1. 0 I am. a employer with 4. ED I am a • -0. eras contractor and I
.-
employees (full and/or part ' • , -time).* •
' hired .. sub-contractors 6. 0 New construction
2.0 I am a sole proprietor or partner- - ,... on the • .. ched sheet 7. 0 Remodeling
• ship and bave no employees I • ctors have 8. 0 DeMolition
working for me m any capacity. ems;loyees ,. r have workers' .
9. 0 Body** ad.ditian
[No- workers' coi p. insurance
required] 5. U We are a , •iporation and its 10.0 Electrical repairs or adations
. ,
3. 0 I am a homeowner doing all work offic-, . - vexer their 11.0 Phmibmg repairs or additions
1 . l .
myself. [No workers' comp. n 1 . of exemptio . i , MGL 0
12. Roof repairs . •
insurance required] t ' c. 152, § 1(4), an. f• .., ve .o
eMployees. [No o • • ' 13.0 Other
• co]x p. insurance' ..,. n
*Any applicant Mat checks box #1 must also fill out the section belcrwshowing theirworkets compassation policy information.
t Elomeownas who submit this affidivit indicating they are doing all work and them hirc outside contractors must submit a new affidavit indicating such.
:Contractors that chick this box mint attached an atkUtional sheet showing the name of the sub-contractors and state whether °root those entities have
emisloyeas. If Me sub-contractors bave employeeS, they mustprovide their workers' comp poRcy number.
oI am an employer that &providing workers' compensation Insurance/or my einploye the p licy andjob site
information.
/
. .
Insurance Company Name: • - •
Policy # or Self Lic. #: Expiratio
Job Site Address: City/State/Zip: - 1
Attach a copy of the workers' compensation policy declaration page (showing the policy numb' er and expiration date).
Failure to secure coverage as required Under Sectidif25A ofMGL c 152 Can lead to the inipOsitiOn °fain:dual Penalties of a
fine up to 51,500.00 an.d/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ____,
Eifeitiatiolis Of the DIA fox insurance coverane VerifiCifiCi. ..
- - - . - - . - - - -. .
Ido heraby_ceriffr under the pains and penalties ofperjurythat the informationprovided:aboveisinse_andiorrect,____
_ ___ •
Signature: . ' Date: . ,
, .
. , . •
Phone ik .
- Offic_itzl use only. 1)0 not write in this. area, tb be completed by city or town officiaL
• •
City or Town: Pormit/lAcense #'
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 SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder : 2 Le t4irvim (} `1 j9
License Number
L_
Address, / Expiration Date
Li- 0 tci5
` .! re Telephone
1 2' Not Applicable ❑
, t j i )ec4 ( tr7
Company Name Registration Numb
Address Expiration Date i L) r
' ._) 42` ( 1 0)6/97 Telephone h=f
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.15Z, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin 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 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all aa
New House ❑ Addition ❑ Replacement Wi ows Alteration(s) ❑ Roofing (❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [El Siding [D] Other [CI)
Brief Description of Proposed --- {-
Work: _ 1S'� 0, i11 A1 • C � Ir�+( 11 "
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
"rte ��?. ��� � �.*l x �PV
sa f 114. se. iialtWaftr Sidi is + s t r i+ f r p:
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 stones?
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. floodpiain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
1 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
[ rte r
L O P 1;1% , 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.
T `
17 1-
Signature of Owner Date
I, 1f ( , as Owner /Authorized
Agent hereby declare that the statements a nd nfotmio on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains :penalties
a
Print Name 9
Signature o er/ g: nt Date
f
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 I L _ £ 1
Frontage
Setbacks Front 1 1 r "
Side L:i ` R:U p —J Li i R:! ! r .
L
Rear ' r 1
Building Height t 1 1 1
i
Bldg. Square Footage 1 1 ET % En 1
Open Space Footage %
i
(Lot area minus bldg & paved ; __,,,, j
parking)
,..-:
# of Parking Spaces F_
Fill: ---- ,...,.,,.. _. , r n., .. ._ , 1
(volume & Location) 1
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
, I
IF YES, date issued: 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
1 IF YES: enter Book Page and /or Document # .
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , Date Issued: ,
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: f
D. Are there any proposed changes to or additions of signs intended for the property ? YES (J NO 0
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton ,,
•
,„ - � 75
Building Department n = 0 t-
212 Main Street - r V & ' ' s i 11 4%
Room 100 , e ' k . 41
N MA 01060 �� •ZP �Z -
PT' 4 phone 413 -587 -1240 Fax 413 -587 -1272 V
, * f
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
9 4 11 t.o (,1,0 It 1 Zone Overlay District
Eim St District CB. District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner Record: r ---
Name (Print) Current Mailing Address: 1\)/11—
6 4 ,2--- ..„( j Telephone
Signature
2.2 Autho 3!j .. ent:
WV .. — y .glitt. 2
Name (Pri g l , 11)
/ Current Mailing Address:
Signature Telephone
SECTION ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
1 v
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)� 5� - Check N umber qcr Y
This Section For Official Use Only
Date
Building' Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP- 2011 -0022
GIs #: COMMONWEALTH OF MASSACHUSETTS
MapSkiok42 Z:4 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 -0022
Protect # JS- 2011- 000044
Est. Cost: $3526.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES
Lot Size(sq. ft.): 32582.88 Owner: DUVAL PAUL H
Zoning: URC(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 94 HAWLEY ST - UNIT 1
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 () 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