35-208 Rug 09 10 08:00p Michael Bedard 1-401-246-2868 p.4
.‘ 4 ,
v. .
• . T - ,isc Truly r • .
. .
'
- • • Sold; Runi3hed and Ingalled by:
Drench Nalklel Boston " • • Date: lh-7 . - ..-- : .. :4'. •••. . ': - -.., • :,.• --: 4 PHEIAt-Homs Services; ine. 4
, . . . . -- : ' ' • . .::. f .. : - i ' .. :--: • • ''• d1.-The 110meDepotAl-Home Services
' • • - ' - • ; -.• ..- ::i-. • ' .345Alarectinnod SUnit1; Worcester, MA 01607. . •
Branch Number: 31 .: ..... , ::.: .. • • - . ; ::
. .. • -- ..- .. :T911 Prcc 000) 657 'J Fax (508) 7S64.92.3 i lliaiLir-
.
. • ..... .. . , .. ....eder-4117a 754249060; ME tie 'ti c ii Cont. X.,i0/ 16427
• .- ... . •
. . • .. . ; .7 Contrnsier,R4*1261191
. - i. ti,,)431. • AfA i k? 47-. 'MA.- .. .
I nstatiadon Address: '• ' t VIC:)kr:1\ )432 -4_ 1 6 .
• • City State ' Zip - t• -44 i 7
• (0 ' • " . .
Paretic:et:0d: - • :weitertione: - name name:
_ Cell Pb.
o -. 1 - 1 .[ [ ...' ..E". 1 1 • ] ------
, . • . [.-•, )u,•.... .. i• :[,..:. 3 • .. ... ..: i . ._ .) _ ..
Rome Addicts: . • • •. .. • • .. ..• •. ••‘... . .
(If different ow installati hon Address) • . - . ' - ' . ' : • .,•City.: - -• !.. • ... • -•...... .- : . . : Slate • . - 2ip
Yl snail &direst! (to eticeivb pleject otteruntiniostitin end.Houtc:15cpcii tipdatea):. • :- •• ' ,: - : ': '' •
0 ID° NOT wish' to receive any markming crintils'fronsTlteHoineDepor •••• , . • • • - - . .
• .: , - : - : .. , .. .
Protect In(ormaiiont Undeviigned (Custonier"). the owners of Che proPert abovoinsadlution'addrtszi, agrees to buy.
and THD At-Horne gervioes. Me. - ("1:he Rome Depot") evicts tri furnish; deliver aud aria** for .the installation ("boinallaGoo") of
all matctials desolbrA'authe below andrin Me telereneett Spec of..whiehmre ince thia• Contain by-this
inferpre, along with any applicable State Supplement and PayitioR SunTrintry marled Oejeto and any .Changd Orders (collectively
'Comore): . . . - . • • .. - ,, . .... .
Job insit.i.iset.......e enamel - • ' • • - • SiseekineYiti ir . . ". • Ptialiet Amount
fatood 0
ng Siding 1 • — Insubtibh "" ': ' - . - 3, ' ' • - •.'i --'
SID 11; --7 painters t Covwc 1718iii Cl :. , - ., ''''''':- • • '.. : . ',. S • . ...' , 5t - . . • - •. - '. : 410 de" . • . •
. . .
Ditou . • Sithog. II iitenett :MI Ina...Winn : ' ' ' . •,. ,- ...' ,.. •'. ' : . . . .
Odunors 1 Coven Elgritty Doors Q. : • . , . . . • . - . ,, , . .
. • ..... , . .
- Ultooftag USidinci U Windows t3.htiatation. .:. ••• ; -.: '.. -:: • - - . • -
" - .- - • • . .
- - i .. ' • '
4.,
.
' Ottneteg °Stains, C:1 Winclekvs • 0 heatIstion • ' • .. '
• • . •
0Orteet / COVert Ofintey Dqt5ta. D $ • • - • . • '.. • • •,.. - - . .
• • . -.., • • ..• . . -.. • • •
.. . . . . . . . . .
tantalum 25% Daps& nil cZnyttnteenen.nnti dee satonesersitsityribil.ttintesin. .... . iiiiiii - .. *.it -: -1, • • .
Maim Ruthann may oot deposit mere than nets-third of metixtrisitAnsainiti - - • • r... -, • .• . . - .. . • - ._-_,( ..i •
.... . .
— - • •
2ustomer agrees that, immediately *upon 'coronlerion of the:Vimeklin•Cault •Ptoilact,-- Custossier,uill-excome, a :completion Certificate . .
:Om
tat c3CD elf0(1.1t ai defined by au individual. Spec:Sheet) •anrp•ak tist•31, 'Abe.. Aii.airptrosibtei leader thit
Zontract itgrees to be.jeiody and acverellY obligated aini...tiophes6uset.:: - . ..-. • i • • .;!. .. ..
. . . .
Me Home t3epo t toserves the right to ;sane Et Chnittzeit)rtine;tliar4tfikiAte•:** Ccritir4n*-Art•ji :traJjOilailt i b er e n. at
ts dismcdon. lf Tne Home Depot or its rouhoritrAt sermiee.jaroider dikeiritiiiitilaa' uit.t*TisinAts'obligarions pi* toltittructural
iroblem with the home, aivironmental hazard: -stitch* itioltkaaliestiSsotlead -.pant, otiati-safetit'coriciedis. pricing.ertors:or because
aunt required to complete shejob was not included in-tttecon1lait. , ,.. . ' . '. :" ' -: ';:, . .-_• .• , • - .. ' ' • '
.. , . . . .
- •
Piz:priest Sun:inner The Payment Summary .
* - 7'. ; :ie - i'c'• • . • ; inebuic&iiii r out of This CestitCti te rth le fO the. tete) '
„. .. . ..... .. .
2onnact amount and payments requited for the'depOithis and'final•*meive ey'PlodUeft•flinpidivable). ., • • • -
. • . NOTICE .TOGI ' • • • • " . . .
. ,
•. .. •.• .• •• •. - :
Van are entitled to a conisidetely filhelAn Copy of die.Otintract ekthelhne vu sign. 'Do not sign a Completibn Ccrtineate maim
:here Cs one Completion Cern/hide fur each listed Prinnet ni denne0 bY•indiridtabiStier Sheets) before Work on that Product
s template.
!n the event of termination or this Cootntet. Customer it topay The Hoene fMpo i the costs of matsriab, bber, expenses
MO Set provided by 'rho Home Depot or Authorised SeiviceiProvidei thr • i.t e date of termination, pins any other
. tumults set forth in this Agreement or allowed under apOlcubts tau. IRE ITO ' DEPOT MAY WITTOIOLD AMOUNTS
)WED TO TUE HC/NIP DEI I: 614.0Ni 'THE Okill'Ill• PAYNIliNT OR .U'llIER PA l'IMENTS MADE, WTITIOUT
. ../MMNG THE ROMP nEPO'f '$ OTHER REMEDIESTORRECOVERY.oF sutm Aidousrs,
t.ceentatipt ant Authorimtion: Customer agrees and understands that this Agreement is the entire agreement between Costumer
Ind The Home Depot with regard to the Produce: and Imdall ation services AVIrt inpargatift all riot dice:040m and figretroentc, 0i:th
nal or written, relating to said Products and installation. 'this Agreement catuna bc assigned or amended except by a writing signed
iy Customer and The Horne Dopot. Customer acknowledges and a tatmci that Cuttomer has read. understand voluntarily =Dept; thc
:inns of and h. receive , y oi this Agreement.
tecepte4 by: , • i ___....----.. Su ■. ,
.-----....
, •
( ' _ •DA. nrs) -- 7///0 . 7, • . .•
...,,, v„.
:..u..,„„....T.ssign „ Date Saks Consultant's Si ature Da
4 -.---,-- •
K Telephone No.
ustOzner' 5; S is nazism Date Sales Consult:au License No. • •
2ANCELLATION: CUSTOMER MAY CANCEL THIS . , . ta, epplovablej •
. ,
1GREEMENT 'WTITIOUT PENALTY OR OBLIGATION • .
3Y DELIVER1140 W'RTTTPN NOTICE TO 4 1111? HOME 1 • '
)EPOT BY traDNIGHT ON TKO,' nintt) BUSINESS . •
)AY Ariv.R SIGNINO THIS AORP'EMENT. THE
;TATE SUPPLEMENT ATTACHED HERETO
:ONTAINS A FORM TO USE W ONE IS
;PECIPTCALL'i PRESCRIBED BY LAW TN
.:USTO1VIER'S STATE.
warms.: ADDMONA1. TERMS AND 00=4 ARE sTieriRta ON Van KUVE;ASE Sift Aro AuR rAirrov.rtos covil:Aci
-7.10 CSC What - Euench Fee ',fellow - Ctn tanier
erk
lact) Li 7 . -
.0
r ,
_ .
Deparuniiit tuhIu c Nale t■ •
Board of Buildino Reoulations and Standards
Construction Supervisor License
License: CS 67121
Restricted to: 00
Ag a
BRIA19 C THOMPSON
•
38 WILLOWTROOK LANE
• WESTFIELD, MA 01065 s
Expiration: .4/30/2012
lllll Tr: 2015 -141,11 00Mte4
- _ • CC
v.
0 .1(
yo-u b,wJ
•
• (d(-t
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 me.
Date
Address of work
location
"' The Commonwealth of Massachusetts
"-- ` Department of Industrial Accidents
[ 3
1 ; , , a.---- Office bf Investigations
600 Washington Street
Boston, MA 02111
_,x_ - " www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /EIectricians /Plumbers
Applicant Information Please Print Legibly •
Name ( Business /Organization/Individual): 1 ► 1C. (40 14E ii _
('�
Address: atA"() 6,I+t,1.r� f- w, Y 1 //
City /State /Zip: h max► 9 (7 Phone #: (p' --
Are yo employer? Check the appropriate box: Type of project (required):
1. I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. El New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. f 1 Remodeling
ship and have no employees These sub - contractors have g. ❑ Demolition
working for me in aci employees and have workers'
g any capacity. tY 9. 0 Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11. Plumbing re
3. ❑ I am a homeowner doing all work g airs or additions P
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ Other WI ►'1Pp r.
- 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 contactors 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
employee's. If the sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. .
Insurance Company Name: 14 �,� - )r� L U
Policy # or Self -ins. Lic. #: c7 0'54,9 3 5 - 5 --- Expiration Date:
Job Site Address: 5 — ` j9 U6c r kyl P '-PS City /State /Zip: ,
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL 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 8250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for • ranee coverage verification.
I do hereby certify under t e pa is - d p' altie of perjury that the information provided above is true a id correct.
S ignature: ., a' / , 1,— Date:
Phone #: L W( 913C 2
Official use only. 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. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
• 4
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ i /� (r
Name of License Holder : f34 y \ Y) t)vT ("- ('i 1 C?( 1
License Number
ll
r • .. • 1.1 .. i 413D/ia
Address // Expiration Date !`
s
Sig . t - Telephone
9. Registered" Home Con€racfor s � Not Applicable ❑
N - C.)' 01
Company Name , Registrati N er ip„
Address � 1� Expiration Dat
1./Uoce4 ( 0 ? Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
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 build permit.
Signed Affidavit Attached Yes No ❑
11. - Home Owlaergep>iori'
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
w i'
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Win s Alteration(s) ❑ Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other [0]
Brief Description of Proposed
Work: �"' , � �� 1 � f
n r`
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
fa. If New house and or addition toe sting housing; complete the following:
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, G'.g CI)1 , as Owner of the subject
ro ert
P P Y
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit applicatio
- /i 0
Signature of Owner Date
I, L A4 7; ( tO1____ , as Owner /Authorized
Agent hereby declare t at the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under t -110 s and pe . ie . f perjury.
all ._ _ �/ E ( one
Print Nr���ff
Signature o Owner /• g -nt 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: .. __. "., R. _... _.. L ..,._._ ., _ R...,. .... _....
Rear
Building Height " .
Bldg. Square Footage
Open Space Footage „ .._ %
(Lot area minus bldg & paved 3W
parking)
# of Parking Spaces
Fill:
(volume & Location) _
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 Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
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
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 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavatiorr, 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.
A ! '
i
Department use only
City of Northampton Status of Permit
Building Department Curb CutfDryewayr Permit 1
212 Main Street SewrerfSep#rcAvaiIabiitty
Room 100 WaterfWeD Avarlabrltty
Northampton, MA 01060 Tuuo Sets ofStr - ucturalFlaps ..
phone 413 - 587 -1240 Fax 413 - 587 -1272 P1ot/Srte Plans
f
Otther Speafy
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
1 5;31) ��
r „ • / � j � Zone Overlay District
EIm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Re rd:
V SZ` ^ n A - ec iv) . ' »1 ,R °iota)
Name (Print) Current Mailing Address:
V\ k Telephone
Signature 111
2.2 Authorized - • ent:
VP
Name gpritif Current Mailing Address:
/1111PAA A de 1 4 Di ci ,g
• Telephone
SECTIO '3 - 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) �-` Check, Number
This Section For Official Use Only
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
RD BP- 2011 -0184
wlss�rx,�MPTOrr ,��
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 - 208 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 -0184
Project # JS- 2011- 000313
Est. Cost: $2094.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sci. ft.): 70567.20 Owner: TSERING PEMA & PEMA TSEYANG
Zoning: SR(100) / /WSP II Applicant: HOME DEPOT AT HOME SERVICES
AT: 539 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401
Workers Compensation
WORCESTERMA01607 ISSUED ON:8/31/2010 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 8/31/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner