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29 HOME I1 WROvniertr CONTRACT PLEASE READ THIS • Sold. Furnished and Installed by: mNat pr: hasten Date: At-Home Services, Inc. 1 d✓Wa The Home Depot At -Home Services 345A Greenwood Street, Unit 2, Worcester, MA 01607 Toll Free (800) 657 -5182; Fax (508) 756 -8823 Branch Number: 31 Federal 11) # 75.2698460; MEIic it C 02439: RI Cont. lic# 16427 . CT Ile # HIC.0565322; MA Hoare In:prment Con — �ce yes. q 126893 Installation Address: .eg— clO'd.N (la_ MA. C.aVC ---+ City State Zip Purchaser(s): a- Work Phone:: home Phone: Ce11 Phone: u , d, r k •._. . 1 ) [ I13l 5 Xa t 1 ] 1 ] [ l [ ] E,iue Address. - -- . (If different from Installation Address) City State Zip E -mail Address (to receive project communications and Home Depot updates): 01 DO NOT wish to receive any marketing erases from The Home Depot eat Information: i)ndersigned ( "Customer"). the owners of the property located at the above installation address. agrees to buy, an At- a ne vies, Inc. ("The Home Depot") agrees to furnish, deliver and arrange for the installation (`Installation ") of all materials described on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contract by this reference, along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively. "Contrnet "): Joh it: (tom aeerese) um, - SP= Sheet(a) #: Project Amount +l Roofing $ []N g Sidi Windows Insulation �} b t D A - AI f ❑Critters / Covers 0Entry Doors 0 - c-.) o 1 LJRoofi; ❑ windows L1 Insulation $ , 4 t 6') OGutters I Covers Daley Doors n -- 1_1 USiditg U Windows U Insulation $ Dowsers r Covers ❑rte boon ❑ - ❑Roofiag USirfing Windows 0 Insulation $ Delmeer's / Covets ❑Entry Doors ❑ mites rum25%'% Doom &COMM& Amount due upon eacention reads matte& Total Contract Amount $ al ti Iv py any oat deposit mare than enethad dens Canned Amount Customer agrees that, immediately upon completion of the work for cacti Product, Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable, each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Preduct(s) included herein, at its diseestion, if The Horne Pepot or its authorized service provider determines that it atone perform its obligations due to a structural problem with the home, environ mei*al hazards such IS mold. asbestos or lead paint. other safety concerns. pricing errors or because work required to complete the job was not included in the Contract Past S.®n 'y: The Payment Summary # b0t63 - . included as part of this Contract, sets forth the total Contract amount and payments required for the deposits and final payments by Product (as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time you sign Do not sign a Cotyledon Cerdll cale (note: there is one Completion Certificate for each doted Product as deWmed by individual Spec Sheets) before work on that Product is complete. In the event of termination of this Contract, Customer agrees to pay The Ijnnte Depot the costs of materials, labor, expenses and services provided by The Rome Depot or Authorized Service Provider through the date of termination, plus any oar amounts set forth in this Agreement or allowed under apOimble law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOB RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agtecment between Customer and The Horne Depot with regard to the Products and Installation services and supersedes ail prior discustrons and agreements, either oral or written. relating to said Products and Installation. This Agreement canna be assigned or amended except by a writing signed by Customer and The Hone Depot, Customer acknowledges and agrees tha t - . ,tier has read. understands, voluntarily accepts the tetras of and has - wed a copy of this Agreement. 1 �[ O al �� , ��/ Sub 7 * c 1 •a,.4.t,, x 1. r r's Sign Date Sal a' 1` pant's Signature Date -- Telephone No. Customer's Signets a Date Sales Consultant License No. CANCELLATION(: CUSTOMER MAY CANCEL THIS tad applicable) AGREEMENT wrruotrr PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME . DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRDI D BY LAW IN CUSTOMER'S STATE. NOTICE; ADDITIONAL TERMS AND CQNDITIONS ARE STATED ON THE REVERSE SIDE AND ARE TART OF THIS CONT1tJCCT 01.1844 OW White - Branch Fite 'fallow - Customer - - _ , - . 10 Park Plaza - Suite 170 Boston. :\lassachusetts 02116 Home II ement Contractor Registration RE-p;str-an. 150517 Tvo individual Expirattort.. t6;2D Tn 2228rl--" VLADIMIR SHEVC VLADIMIR SHEVCHUK 5 OGDEN ST CHICOPEE, MA 01013 - Update Address and return card. Mark reason for chanze. dtiress Renewal Frnplo!.nlent Lost Car License or rcuistration valid for individul use only HEtH0ME Office of Consumer Affairs & Business Regulation IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Rogistrat 5O517 Type Office of Consumer Affairs and Business Reflulation • : 10 Park Plaza - Suite 5170 Expiration: 4'6/2014 Ind Boston. MA 02.116 /.__AtDR SHEVCHUK SHEVCHUK Et OGDEN ST CHCOPEE.. 0',C13 Undersecretar Not valid without shmature !,■• ,or,!f -•.- t Lill I ,tn,: -0:, Supe L.tce Si_ 99209 - • Restricted tG: VVS VLADIMIR SHEVCHUK 44 5 OGDEN STREET CHICOPEE, MA 01013 E 101122013 7572 ..,af� _ rhti • to n ( CERTIFICATE a- U B U / SUR A E ��_. - -z 12 NW +rP ryr 1' S J' t THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS 1WOt<I TI- E CE ?TI!Fr HO! D=R. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT C NSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), A JTHORIZEDa REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must )tie endorsed, If SUBROGATION IS °f?f'",i'•.9Et3 subject to i the terms and conditions of the policy, certain Policies may require an endorsement. A statement on this certificate 'does not confer ,i hts r`,eo the. i PRODUCER roi3IZP u Ira Iie�a not such eaoe acselaoertu s a �coNTa ^c ___v_._ _��__�._ � g i 1- 866 - 966- .,66.. -.. NAME: —_- Marsh USA Inc. ■ PHONE FAA (AIC. No. Ettt)_ --_ —.- — _ -__ -. (A /C. Not: homedepot.certrequest®marsh.com E DSS: Two Alliance Center, 3560 Lenox Road, Suite 2400 INSURER(S) AFFORDING COVERAGE NAIC# Atlanta, GA 30326 Fax (212) 948 -0902 INSURER A : Steadfast Ins Co 26387 INSURED INSURERS: Zurich American Ins Co 16535 The Home Depot, Inc. New Hampshire I ns Co 23841 T.J. Home Depot .S.A., Inc. INSURER C: P 2455 Paces Ferry Road NW INSURER 0: Illinois Natl Ins Co 23817 Building C -20 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURERF: Illinois Union Ins Co 27960 'COVERAGES CERTIFICATE NUMBER: 30289573 • REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE ADDL SUBR I POLICY EFF POLICY EXP LIMITS LTR (NSF( wvn POLICY NUMBER (MM /DDIYYYYI (MMIDD/YYYYI A GENERAL LIABILITY GL04887714 -02 03/01/12 03/01/13 EACH OCCURRENCE $ 9,000,000 X DAMAGE TO RENTED $ 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) _ CLAIMS -MADE X OCCUR MED EXP (Any one person) $ EXCLUDED X LIMITS OF POLICY XS PERSONAL &ADVINJURY $ 9.000,000 X OF SIR: $1M PER OCC GENERAL AGGREGATE $ 99 ,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 9,000,000 i X POLICY PRO- , LOC $ .IFOT B AUTOMOBILE LIABILITY BAP 2938863 -09 03/01/12 03/01/13 CO SINGLE LIMIT $ 1,000,000 (Ea X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS NO OWNED _ PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) X SELF INSUR D PHY DMG $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION WC019736915 (AOS) 03 /01 /12 03/01/13 X T(WIRYLMITS OTH- ER C AND EMPLOYERS LIABILITY D ANY PROPRIETOR/PARTNER /EXECUTIVE Y/N NIA E (Mandaatory in NH) WC019736917 (FL) 03/01/122 03/01/13 E.L. EACH ACCIDENT $ 1,000,000 OFFIdt ory in NH) CLUDED9 IN I WC019736916 (CA) 03/01/12 03/01/13 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 ' If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 E Workers Compensation WC1192494 (QSI) 03 /01 /12 03/01/13 SIR (AOS) /SIR (GA) 1M /750,000 C Workers Compensation WC019736918 (WI) 03/01/12 03/01/13 F TX Employers XS Indemnity TNSC46566397 (TX) 03/01/12 03/01/13 Occurrence /SIR 30M /1M DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Addltlonal Remarks Schedule, If more space Is required) RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, I INC . HOME DEPOT U. S . A. , INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C -20 .�.,( ATLANTA, GA 30339 , , q•v,A�) s.V.A-lk h.t,�l {t USA 0U I © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ' <r Jthornton_hd ,nnonc'V 4 • sa . • • • • • • • . . s. DD • • • • o • • • •• - a - .. • .Ctj r4 t ® o 'U t 3 >, -° 6 • • - .� - • • c n u �` • • no e- t v . Q a ❑. A Aa • , ' m m +-4 ° P c'a v • i i 1' • \ F- CI U O � � a . . A , • . o \ , w . CO. N CA • ( t ( JJ� I n o ® Pa • • Ez o� . �1 3>. �JC • I : il1 • . �t f 0 .i U P /-• . _ • • 0 s U` 75 0 . • �. _ 0 g - . 0_ v � ! L + am .-._ C t � � °' ? r on _ v r' C� �., , 4]' o 1, � s U p T 1. 0 Vin. Ir ' i°i - .. t it .a 'h _ r 1 l��ars a a /�i } '� 1 ;�I'l Dr) i i t .o .n -i- -3 j )-/ 1..,! 1' K t 9. ' Ott /�:. yip :_ 'r- 3 ( me #: Are yo .:: employer? Check the appropriate box: Type (required): 1. I am a employer with 4. general eneral contractor and I P e e of project ( q uired ) ❑ am a employees (full and/or part- time). * have hired the sub - contractors b. 0 N construction 2.0 1 am a sole proprietorpr partner- listed on the attached sheet. 7. 0 Remodeling ship and have do employees These sub - contractors have ' 8. 0 Demolition working for me in any capacity. employees and have workers' g y $ 9. 0 Building addition [No workers' comp. insurance comp. insurance. required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Ryf repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. Other u 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. tContractors 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: f Policy # or Self -ins. Lic. #: 1,41-0 J 5 Expiration Date: /`•` Job Site Address: ( {/ City/State /Zip: ,r•�(I!��r, th • U �— 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 $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 DIA for i s • nce coverage verification. I do hereby certify under the pain • and nalti of per ury that the information provided abo e is tr and correct. Signature: 1 /1.■ ,t ` Date: / 6 t3. / Phone #: D a6? Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit /License # Issuing Authorjty (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone #: K � City of Northampton . ,, ""` ''' 1 . Massachusetts P " t \� '� '"'`r R ¢ � p DEP OF BUILDING INSPECTIONS w _ .4 . "t,. " 212 Main Street • Municipal Building r t3a,, , w Northampton, MA 01060 ss.',h 4 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner w Assistant Commissioner 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 any 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 Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): Address: City /State /Zip: Phone #: Are you an 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. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance. required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ 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 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 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 $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 DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder : V 14 . I n ) { ( Al a fr o/ �,- License Number Address Ora Expiration Date I r Signature Telephone 4'�"" �?""- '�^x3*�'r z r,.. , pia• 9:`Recjistered Home:lmprovemeot.Contractoi :' „ �, C ,Z _ n> ; � �, ` , Not Applicable ❑ 1F4 Company Name Registration Number Address Expiration Date 44//i,. faC�"°1 a4 R fi 0 (9» Telephone_ ��35 ,SECT.ION 10- WORKERS' COMPENSATION INSURANCE iAFFIDAVIT (M.G L .c.'152, § 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 building permit. Signed Affidavit Attached Yes ❑ No ❑ 7417+7,414 ," , , 4'730 1 .. �. - C © caner Ex mptio 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 SECTION 5- DESCRIPTION OF. PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Wi ows Alteration(s) n Roofing n Or Doors Accessory Bldg. n Demolition . ❑ New Signs [O] Decks [171 Siding [D] Other [E] + a Brief Description of Proposed I ' j Work: O ' A. i 11.11. 1i 14 0 a. L s/ � Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa If New' =houae.andeo o, o exisfnq hoi is nq, 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. SA- 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, i r / r 4 , 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. ■ Signature of Owner Date Mfr INFIff / as Owner /Authorized Agent hereby declare that the s ate -its n. inf. '':tion .n the foregoing application are true and accurate, to the best of my knowledge and belief. Signed_ under the pains a zi p cities o ,: . • , . Print Name 4 YJ r —" Signature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information e Existing Proposed Required by'ioning This column to be filled in by Building Department Lot Size 1 L . . �_._ Frontage --- . — Setbacks Front Side L: R:— L: _ R: Rear r ' E Building Height 1 Bldg. Square Footage % ' i Open Space Footage % ----- . (Lot area minus bldg & paved _,_ __„ i I parking) k 1 ; ; i # of Parking Spaces - Fill:£f (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW Q YES 0 IF YES: enter Book i I . Page; i and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES l 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 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 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. a >��u DG' artm t u t o . r .. �: _ * ;:- ''arcs , y ,..., y , r ^n. , City of Northampton $ tatus,o Permli, ,4 , � 1. Building Department : e " :4 6"' et r : 1 ; ', ..;: t r ; v :7 1 7 1.4 :; - : 1;,,,, -- , ,,,T. : .,, 441 k eirnif . r , � .: ;„ , " 212 Main Street ; „ z �' ' k.„e§ x. p f” 1 . , e ms a`m' a . Room 100 Water/Well,. irailabihty 4 € w . E . 1'' 2 2O2 orthampton, MA 01060 a ; u Ida v phone 4 3- 587 -1240 Fax 413 - 587 -1272 P lo S I Pl DE FE of ��� �o o nsorvs Other Specify--: + 1 ROH i nA Mr . r ' oN, D 9 l APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION Thrs s c 1.1 Property Address: et ion to be completed b office Map :� L ot ' Unit 13q G "' -' n,. n , 0 ' ,W � Zonie Ov D,sfrtc . ,E1m St Distric CB Distrac SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner o Record Name (Pent) Current Mailing Addres /I. _.� it •`.� 0„,-17-4(t Telephone N. Signature 2.2 Authorized A • en D r 110' 4 AU, _ A 'OA . .°‘1:: ° 991 O Name (Prin Current Mai ing Address: o % !_ ._ r Signatur: - Telephone ��C� 4. SECTION 3 CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only , ' completed by permit applicant 1. Building .31q2'*- (a) Building Permit Fee 2. Electrical (b) Estimated TotalCost of.' Construction from (6) 3. Plumbing ; Building- Permit Fe 4. Mechanical (HVAC) = 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) ��` Check Number ' '37141c5'(:)'' ''' - This Section For Official U se Only - - Building Permit Number Date , Is sued . :° -. Signature. Building Commissioner /Inspector of Buildings Date • 39 GOLDEN DR BP- 2013 -0653 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 422 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit # BP- 2013 -0653 Project # JS- 2013- 001075 Est. Cost: $3192.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 99209 Lot Size(sq. ft.): 36633.96 Owner: STEFANIK ANNMARIE C/O ANN MARIE OSOWSKI Zoning: Applicant: HOME DEPOT AT HOME SERVICES AT: 39 GOLDEN DR Applicant Address: Phone: Insurance: 24 SUNRISE DR (401) 935 -2633 () Workers Compensation PROVIDENCERIO2908 ISSUED ON:12/12/2012 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 12/12/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner