31A-117 (6) I `IG I-rr t i i_i.. _r Ld ii r 1 / 2 f ;.y,�l r_, 0Ij
1 1i Bp,;f n 't__4 r?.y.1 j" ! i,
.oltei-s e'impe4a.> dti.,:a ii',3u1., r.;:tlra.ti� :, l'Vilf1.�_y!:- ;r 1 1 :1 Fli Y..'(°.'I't t'j 4 i fill,K
'-pplk.41- -rifo °ma iop. Plans.e F r nt L effii i};
Mime (Business/Organization/Individual): Tri„ t-ir..
Address: 1 q 60iyi' 4`` ' `elf; a�T -
City/St to/Zip: ' / - . Phone#: ;,ft•- ' Y5 7 5-1-''
# '
Are y t an employer? Check the appropriate box: Type of project(required):
I. I am a employer with ( 4. ❑ I am a general contractor and I
have hired the sub-contractors 6. C New construction
employees(full and/or part-time).*
2.r 1 am a sole proprietor or partner- listed on the attached sheet. 7. [1 Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition •
working for me in any capacity. employees and have workers' Li Building addition
No workers' comp. insurance comp. instirance.t
required.] 5. We are a corporation and its 10.11 Electrical repairs or additions
❑
3.^ I am a homeowner doing all work officers have exercised their 1 I.E Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.E Roo- pairs
insurance required.] t c. 152, §1(4), and we have no 13. Other (,�[
employees. [No workers' j
• 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.
.,-----r--Insurance Company Name: t
E
Policy#orSelf--ins.Lic.#: -3 5576? 14 Expiration Date: f /if
■
Job Site Address: L C 6 , 1 City/State/Zip: ■_i/!. . ...Ae.
Attach a copy of the workers' compensation policy declaration page(showing the policy number and exp 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/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 e DIA for insurance-coverage verification.
I do hereby ce ify a d; the gains d penalties of perjury that the information provided abo e is rue and correct.
Signature:�► a1 — i Dater .._-_` // ./.3..........._..._ ........,_. .;
Phone#: D IC05-4;?0:35
,
Official 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 c:, "_
Phone#: ---" .
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Furnished and Installed by:
�N B Date: TeDD At-Home Services,Inc.
-1 d b/a T e Rome Depot At-Home Services
908 Boston Turnpike.Unit I,Shrewsbury,MA 01545
Toll Free(800)657-5182;Fax(508)845-6017
Branch Number;31 Federal ID It 75-2648460;ME Lie*C 02439;Ill Cont.Lira 16427
CT 'e# C.0565522:MA Home Improvement Contractor Reg.#126893
InstaflationAddt ; 3`�UQnNi]� S-�- �1 �(9-6.1 4- OLOb0
City State Zip
PitreMaerts): Work Phone: Home Phone: Cell Phony
1� $ 'tom ►. • [ l [ l [ l
[ l [ J [
Home Addrers: __
(If different from Installation Address) City Statc Zip
E-mail Address(to receive project communications and Home Depot updates):
D I DO NOT with to receive any marketing emails from The Home Depot
Project Undersigned("Customer).the owners of the property located at the above installation address,agrees to buy.
and T)-ID At me Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installation")
all materials described on the below and on the referenced Spec Sheet(s),all of which see incorporated into this Contract by this
referents along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively,
Contract"):
Job#: tl.r,.nn.p,.prrr Produclw S ,: # Amount
❑Roofing DSidin Windows IN Insulation
be7 34}"1D eta /Cow ['Entry Doors p, Litsl lea
•Roofing ■ iding H Windows [f lnsadanon -
❑Guttas/Covers DEntry Doors D_
L.{Rootna USiding ❑Windows ❑Insulation
❑Ouucis/Covers (=Envy Doors f i $
❑Roofing ■ idiug U Windows El Insulation
❑Gutrera/Covets Danny Doors n
Minim=25%D40010 dred Amount due upon eueardeoo f this contras Total Contract Amount $ /(J h4,e
Mike P smarn otdepositmoretheeene4MrdottheContractMnnunr. t t.3
-
Customer agrees that.immediately upon completion of the work for each 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 Product(s)included herein.at
its discretion.if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because
work required to complete the job was not included in the Contract.
Payment Swnoipry: The Payment Summary C 7 " 3 . included as part of this Contract,sets forth the total
Contract amouni and payments required for the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filled-in ccoqpp of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there�ne Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product
is
In the event of ter mination of this Contract,Customer agrees to pay The Home Depot the costs of matensis,labor,expenses
and services prrovided by The Home Depot or Anthorieed Service Provider through the date of termination,plus any other
amounts set ih in this Agreement or allowed under applicable 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 FOR RECOVERY OF SUCH AMOUNTS.
Acaotaace and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements.either
oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed
by Customer and The Home Depot.Customer acknowledges and agrees that Cuss. read,underistands,voluntarily accepts the
terms of and has received a copy of this Agreement.
Iy , 11( X Submitted by:
X ( , -Th d.x —ir C\.„men's Signature P 2
Dad Sales Consult: nature Date
X Telephone No.
Customer's Sigteutae Date Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS tae applicable)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE ROME € / 5
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 PRESCRIBED BY LAW IN
CUSTOMER'S STATE. •
NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON TM REVERSE SIDE AND ARE PART OP THIS CONTRACT
10611.1$ White.-Branch Fie Yellow-Customer
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder: t P Q�C�I(� --( 1 �v/5,
J
License Number
/l . 1/li. t C�f /�
A-dress / � Expiration DatE�!"`
0���5 �
��gnats re T Telephone
9.Registered Home Imerov ent Contractor: Not Applicable ❑
cici
e_140 kir----- ---Company Na Registration Numb-'c r
e
..9'0Z` lirrAt-
Address 4./011.3 --- Expiration Da
Air r
=� / • J r Telephone
111111/ 711u77/ ,.
SEC 00 10-WORKERS'COMPENSATION INSU; CE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers 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 buil'. g permit.
Signed Affidavit Attached Yes • No ❑
11. - Home Owner 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-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 W' doves Alteration(s) n Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [Q Siding[El] Other[El]
Brief Description of Proposed r /lOk 10 11.
Work: 1 "3 ._ ‘1,
Alteration s_ r
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to '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? f/ 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, 5-- --&---- , `-' L ,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.
3D
Signature of Owner Date
I, 1 C.f,�E tI f ikl-ems ,as Owner/Authorized
Agent hereby declare that the stat ments and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the p- .-.and :flies of-- . .1,, 0
-. __A Print Name Air / /
Signature. • •er/Age t r 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
Lod
area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW Q YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
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 Q
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 Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
RECEIV -.
1 Department use only
y�� City of Northampton Status of Permit:
i 11 i B�lilding Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
v
DEPT.OF BUILDING i v� LG1'0N= y Room 100 Water/Well Availability
NORTHAMPTON,Ma 01060 _Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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
•.. L . `r yOrl ` Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: i )1 KID rtLyibh /1
Name(Print) Current Mailing Address:
-e c217 Telephone
Signature
2.2 Authorized • .ent• VP` ii
giLlk /► � . AA 1ism i r, ls- ,2A,
Name(Print) WI, , Current Mailing Address:
Signature Telephone
SECTION 3-ES (MATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building I ff_j v (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of ��?
Construction from(6) (28 '_
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection / J'
6. Total=(1 +2+3+4+5) I "_ Check Number L// 1-ig '3s
This Section For Official Use Only
Building Permit Number: I sssuu
ed:
Signature:
Building Commissioner/Inspector of Buildings Date
34 VERNON ST BP-2013-1067
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A- 117 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-2013-1067
Project# JS-2013-001762
Est. Cost: $1088.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 98785
Lot Size(sq. ft.): 7274.52 Owner: DOHERTY MARC
Zoning:URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 34 VERNON ST
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 WINDOW
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