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35-138 40 WESTWOOD TER BP-2013-1064 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 - 138 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-2013-1064 Project# JS-2013-001759 Est. Cost: $3476.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sq. ft.): 10454.40 Owner: FORRETT DONALD J&AGNES M Zoning: Applicant: HOME DEPOT AT HOME SERVICES AT: 40 WESTWOOD TER Applicant Address: Phone: Insurance: 908 BOSTON TPK Workers Compensation SHREWSBURYMA01545 ISSUED ON:5/8/2013 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 5/8/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner _._>....._y "��' ��� a '"�'Departmemt Use Only ra � � � �3 F' -.F @VED City of Northampton Status of Per��t} � ' �� �„ 5 ° Building Department CuthCutD ueway�Permitr� � �� v 2��3 212 Main Street Se�15epticAvaiiabrllty 4° � Room 100 Wa erJWe1I. 1atiab it,' Oro a�,.4�`"' U `ss� � � �� ?�—�. _� � Krs .mo �°T OF E, , (?IONS orthampton, MA 01060 Two'-' ts• .Structural Pansy * #� NNORTHAIvtPLOiN,rMA0II,:. r- 3-587-1240 Fax 413-587-1272 PJo I e r -ns � � � �� ` •. .. Other.Speo fy' r 4,.. P APPLICATION TO CONSTRUCT,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 x 'Lof' . Unit Map:_ "4 Ote)0 Zone Overlay Distnct L40 tA.1:, t Elm Si District ' " x CB District # SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Ow f Record: Pfir -. }-k Alut" ' C Current Mailing Address: Name(Print) 9 C-� `t Telephone Signature 2.2 , • hor-tr.'• •ent: • �� PWJPIb %9 Current ailing Address:. 44-01C1 ,--.--.. -,,,--3 dir .,,,,,..,„,,,__ . 4., „s' — ignatur: Telephone SECTI•,N 3-ESTIMATED CONSTRUCTION COSTS.` Item Estimated Cost(Dollars)to be Official Use.Only completed by permit applicant 1. Building Vq7� (a)Building Permit l=ee b Estimated Total Cost of 2. Electrical (b)) �=Construction from`(6). 9.41-7L10, -- 3. Plumbing Bwldmg Permit;Fee -' ' - - ' '‘ ',':.- — -''.' -, ' ''. ' "—c?6*- ' 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) (p' Gheck Number " This Section For Official Use Only - Building Permit Number Issued: Signature: Building Commissioner/lnspectorof Buildings Date; • t Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information n Existing Proposed Required by'Zoning This column to be filled in by Building Department Lot Size ' ? i l f f Frontage _ Y _ '• ' ,p Setbacks Front i t- . Side I.: R:. L: a R: , Rear Building Height Bldg.Square Footage t—'--,_ fl . • , Open Space Footage %o f (Lot area minus bldg&paved i , parking) #of Parking Spaces t Fill: .w (volume&Location) i 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 DONT KNOW 0 YES 0 IF YES: enter Book i Page; 1 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 , 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 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. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) r New House ❑ Addition ❑ Replacement Wi ows Alteration(s) ❑ Roofing n Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] ;Decks [El L Siding[D] Other[D] Brief Description of Proposed Work: _!w1 . a 11 arid Y, I . • 7 ;/ Alteration of existing bedroom Yes ho Adding new bedroom Yes No - Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -,Sheet sa If.New house.and or addition t" existing housing>complete-:t`he.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=T0 BE COMPLETED WHEN ; OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING P>ERMIT I, �o 6rileei'er , 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. V Signature of Owner Date 1, l� /� �1/f•�_ as Owner/Authorized Agent hereby declare that th tafement �r l nn formation on the foregoing application are true and accurate, to the best of my knowledge 9 Y and belief. Signed under the and p-•- •f perjury. ji 4 .Al 4 if / -' Print Name alit\waif Signat e of 0 /Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicabllee D Name of License Holder: A Y1 &-A941-4)/y ! � License umber , `51-AfFN-zec4 Hotet%4/14, Address / „ 4 ■ v Expiration Oat J r� e „,, 41 co) Signatu Telephone 9.Registe ed7Home Improvement Corit actor ,,,,__mil57 ., g !_,. Not Applicable ❑ . Company Name yes -t- Registration umber Address 4_01_1: 22,433. Expiration Date �� '`Ask / �.. JL�Telephon SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 p it. Signed Affidavit Attached Yes No ❑ 11 . a mn`fl.Wner,Exemption 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-bear 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 • 771,- (,6 N71,11 ,'J',..„iiiii .0 I 13/a',:;".';f!eil,t -'r i,•, 1).%'ptlt':flda Y,1 1,_'I Int ISirit i .4L7 t'i d✓71 .°, r rl —, 1, Office of Investigation P` - �„ i= '' i i I. I Congpess StPeei, Suite 100 r? ', Fic - Boston, MA 02114-2017 i' Workers' Compensation Insurance Affidavit: I uilriers/('onto-°act ors/Eieetric nis/Ph rnbers A hlpplicaty !r formatioY>t Please Print jA ibly Name (Business/Organization/individual): -_ Ball Address: 5 C.Xlmrhirletj tit-” — — City/St'to/Zip: '41 f il,t _4`°. -4 Phone #:_ t ( t.. Are y a an employer? Check the appropriate box: Type of project(required): 1. I am a employer with j 4. n I am a general contractor and I n employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.n 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.t required.] 5. 111 We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3.I I I am a homeowner doing all work n g p �' myself. [No workers' comp. right of exemption per MGL 12.n Ro repairs insurance required.] t c. 152, §1(4), and we have no �, _ nn''cL employees. [No workers' 13. Other �i' 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. !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. rr,___._ Insurance Company Name: \ I1_ _ V. I I_-I e __ !- Policy#or Self-ins.Lic.#: -3 557;J 14 Expiration Date: 0 ` f Job Site Address: LP LA (6-(2-- City/State/Zip: ,/i 4 , si,�� ,„ `� � Attach a copy of the workers' compensation policy declaration page(showing the policy number and ex ration 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/: o --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 .gainst e violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the 1 A for' surance coverage verification. I do hereby certi,7rr!der !e • s a 'p Ities of perjury that the information provided abo e is rue and correct. .Signature: I !� Date: I/11 f Phone#: 14D CO C-(25 t '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#: 7:°as,14-c,-r..st.-•:-::4 .1; • -".; 74,1;.; :" *: CtIfiqrtiction Su perl isur Speciait; CSSL-008785 IVAN KOSOBIlliXICY 411161111bi 72 STAFFORD ROAD MONSON KA 01457 04/27/2014 • • 0312812013 10:15 15088456076 HOME DEPOT PAGE 01110 HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,Furnished and m stalled by: r Roston Date: TAD At-Home Services,lee. d/b/a The Home Depot At-Home Services 908 9oston Turnpike,Unit I.Sbrewebury,MA 01545 Toll Free(800)657-5 182;Fax(5018)S4i-6017 Eraneh Number.31 Federal ID 0 7S-2698468 MS Lie I C 02439;RI Coot.Licit 16427 cr Lie a HIC.056554;MA Homo improvement Con p��o�t�fr Rog.0 126893 Installation Address' 'Ls 3 Lop S v Lt t�.,•C gaup A)!, .5� r" 1 r c i C a. City Stara Zip vnrahrser(s): Work Phone, Herne Pitons: Coll none: • LIVAN1Pr 3 c�YLRS2. 4-- [ ] [ ] [ I [ ]� C J 1 ] Home Address. (If different from lrytallation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates):,. El Pt?HOT wish to receive any marketing avails from The Horne Depot Protect Inferesatlear Undersigned Custawrer").the owners of the property located at the above installation address,agrees to buy. end THD At-Home Services.Inc.("The Horne Dep4,)egress to flumiSt,deliver sun at .r c the lrs-u?' ti C lentauatien")of all materials described on the below and oil the referenced Spec Sheet(s),all of which are iowrporated into this Contract b'this reference.along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(toltecnvelY. "Contract"): Job Mf p.m,d mr onto Pess $stmt)iM Project Amount --- -❑Roofing []Sidbag ndnwt❑tesulaice _ _Awe - I 4-�T ply ZO Mutters/Covert©Entry Doors ❑ b0,711µ00 $ ',5 74. l ❑Roofirg❑Siding❑windows mutation ❑Getters/Corm Qtm n ry Doom $ --J r+widitir. El e,._..t.L.7r,err!r !rev Dt�-rO�runs/Covers ['Entry Doors n �_ I,-rRnwfirre USIiodna 0 Window,❑tetniuiun $ ■ pGabcra/Covert DEntry Dacca nu __ Mldlinm.irt% *of Cm■Or•reAffnItling iKe MK.evocation adds%imotracc Totes Matee Purchasers May ire n,4:_than ank—i.,va arCatanrruat Araaast 3,f 7 Ica Customer agrees that,immediately upon completion of the work for each Product.Customer wilt execute a Completion Certificate tone for each Product as deSned by an individual Spec Sheet)and pay any balance doe. As applicable,each Customer under this .. Dram .. ___ ..'The Homo Depot reserves the right ro Wow.:a Cbang '3nier or tea.Tdr.a.o a k"Col : •:., n .._. -':-.-,..= - '`. its discretion,if"fhe Home Depot or its authorized service provider determines that g that it cannot perform its obligations the so a structural problem wit,-`a u.` ,.. -°.... k it _ _,_..- . .. _ -_. , -- - n .. r.c.,-1-2.---..... work required to ecanpla c N r of r.u....e.__- ...1,v ..F.. Pavrce-st Stir==s,,.- c ho uy S-.,._:airy;# --` L"5"I i;,0% ,,,..,io=our„ era par.;.:P this C erect,sets forth the total Conrad aritount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER Yon are a;yt:.,c^ ' _ ° • -4- , . )o net et f.7 A Completion Cart/lea a(note, there it°""C^••, b.s.,.;fi r.....,:-- . ,..13'3:.3`.._t....1,..3-: �... ::.....el Sfira f'i aiel huf re.went on that Product is complete. ` In the event of termination of this Contract.Customer agrees to pay The Home Depot the casts of materials,labor.expenses and services provided by The Home Depot er Authorized Service Provider through the date of termination,phis an other amott:.s__ ..s'!; n..... ,r -r.* ri wr.t ref-Dubois,DEPOT MAY WITHHOLD AMOUNTS ..r s lily WITHOUT 4 too,-x i) '�e ">s..,r,€... ..1 r ., - � - ' -^ma.4;.. �.s: ,_:4 thy. im eg-z.cYrtent between CualOMer Home Depot with regard to the Products and Installatitni services and superstdcs all prior diaeussions and agreements,either gal or written,relating to said Products and Installation.This Agreement cannot be assigned or amended exeopt by a writing argued m A^-casts lb y., led l g_ Sabre * -1111-cf + r _..ova, .. :?G--! X V'� ,'�-.us err c .,- ,-.. rye,.. ■ Sgl�, .,r ,u,, ;L'satare � ' Customer's Signature .Dam ��" Sales Consultant License Na_ CANCE]l,LJ17ON: CUSTOMER MAY GANCTUI<. THIS lac apps ieabtr) >f,REF'v __ 's t__a OR OEL1(ATION r. Ktft s.,.E, - -. '.- I EL IA• is tint a,.s , - ;,,yc3 __.....,,°.,3s ..9.. 71-im.,`,, ELIAa 'Ai Ii DAY AFTER SIGNING THIS ACkEEMENT_ THE STATE SUPPLEMENT ATTACHED HERETO I CONTAINS A FORM TO USE IP ONE IS . S PECic -m_ 'pia BV LAW IN CIA rV c'hSTArE. Nov &:rsl ` b.:: ..... .- - ...,. __.. -.+'�.. ..._ . ..,..wsn.Sy 315i0*TfACI 05.10.12 Mar-munch File Yellow-Cucbmor