17A-091 ,7D ` 1 li irJ All ..�.,-LT:t.� ..S __ffl , �_i2f11'!. /ii._.1r,r rr _e_� '�, 1 f ,i- 1 i, ) P;I c.Iibrelr:
•V 55Y iV l!H1���.y ✓1/9 :.�J'�i� .. �
A Ciefi nn In for mahi ill PIE-a.,-,e ff runt L ibl_k
�. ii
Name (Businss%Organization!Individualj: --- iJ 10--. 1i..5 ----
T
City/St to/Zip: (�' ; `3 )` Phone#: ' }
Are y t an employer? Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1._ I am a employer with 'l U 6. ) !New construction
employees(full and/or part-time).* have hired the sub-contractors
2. _ I am a sole proprietor or partner listed on the attached sheet. 7. 11:1 Remodeling
ship and have no employees These sub-contractors have 8. — Demolition •
working for me in any capacity. employees and have workers' ❑ Building addition
[No workers' comp. insurance coup• insrirance.I
required.] 5. f— We are a corporation and its 10.E Electrical repairs or additions
3.P 1 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.n Ro re airs
insurance required.] t c. 152, §1(4), and we have no r
q ] 13. . Other
employees. [No workers'
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.
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: q,34-4.14,,,,,i_05 ,.,
Policy it or Self--ins.Lie.# S: -5557 314 Expiration Date: 3 / 1f
A /
Job Site Address: PD � t31Q ex �� City/State/Zip: ,. a _. 1 e
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D . or insurance-coverage verification.
I do hereby certify a der to p,ins nd penalties of perjury that the information provided abo a is rue and correct.•A • ,, , f,A . j. /
Phone#:
LID Foc.gg-:
,
'Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Pernik/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ,Y
Phone#: J
S-vAa‘
tl
\ 01 11 )
A 0
Cr 0 tft
0 \
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
C on%-ruction Supen iaor
License:CS-067121
BRIAN C TII0141PSO‘'- N
3B WILLOW421ACXMC LANE
WESTFir 14,11M.A ellt135
iratlion
Commissioner-
04/30/2014
PLEASE READ THIS
Sold,Furnished and Installed by:
Name: Beaton Date: THD At-Horne Service$,Inc.
4.L1/12_ dtb/a The Home Depot At-Home Services
908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free(800)657-5182;Fax(508)845-6017
Branch Number:31 Federal ID#75-2698460:ME Lie#C 02439;RI Cont.Lice 16421
�' ACT Lie#HIC.0566555122:MA Home Improvement Contractor Reg.#126895
Inatallatlpu Address: (S �2AIV O�(r:G-� V�•S` fi` 4t i?d j t t o1
City State Zip
Panhater(t):
Work Planes Boras Phone. Carl Phone:
extyvv, Lz - [ I [ [ I
[ . I [. I • [ I
Home Address:
(If different from Installation Address) — City State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑I DO NOT wish to receive any marketing entails from The Home Depot
Prof eat feconstivnr Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
and THIS At-Home Services.Inc.("The Home Depot")agrees to flattish,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
"Contract"): army Change Orders(collectively,
Job#r trewsnr.w,rj Plum: Sgeta s) eT PralactA®ouat
�j
Roofing Siding Windows Insulation
6^7�)�o esP Mutters I Comas Denny noors ❑ ���` � $ '�--
Itoolrag ng Windows Insulation
Douttera7Coven OlrnnyDoors 11
•
■Roofing ■Siding E Windows ■Insulation
[]Gutters 1 Covers MEnry Doors C1 S
❑Roofins • u mdowa tnautation
°;Gutters t Covers DEntry Doors
Minimum 2S%Deposit of Contract Antea*t rue apart eceaWm of t$5 osetract Tetal Ctmtrnct Amount $
Maine Purd rasers may rot depose more ffimone-third gum Contract Amount
(� fr"
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 Summary. The Payment Summary# 7.7CD c- ,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
Yen are entitled to a completely filled-in copy Mae Contract at the time you sign. Do not sign a Completion Certificate(note:
there is one Completion Certificate for each Product as defined by Individual Spec Sheets)before work on that Product
Is complete.
In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other
amounts set forth 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 OP SUCH AMOUNTS.
Acaentaace and Autho tIo : 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 A ment cannot be assigned or amended accept by a writing signed
by Customer and The Home Depot.Customer acknowledges andagrees that f,. a has read.understands,voluntarily accepts the
terms of and has received a copy of this Agreement.
A bye Sub. 'tted j
X - — X �;1 Tin'
Customer's Signature Date Sales Con is Signature Date
• Telephone No.
Customer's Signature Date Sates Consultant License No
CANCE ,ATION; CUSTOMER MAY CANCEL THIS (nsWwlicai+k)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGIfT ON THE THIRD BUSINESS:
• DAY AFTER SIGNING TINS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS •
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICE:ADDrisoNAL TERMS AND CONDITIONS ARE STATED ON TM REVERSE SIDE AND ARE PART OR THIS CONTRACT
1042 Norse.-Branch into Yellow-Customer
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su or: Not Applicable ❑
Name of License Holder: Uj(h t O t.--,
License Number
Addra, Expiration Date
►
4‘,/ �1 ------- 40 I ��4,?
Sig : ur: Telephone
9.Registered Home Im rovement Contractor: Not Applicable ❑
Company Name �C Registration
a 1: /. er /
Address
1Lrle.‘ Expiration Date
L J �''�� �-i 06
Telephone l l 55—c24::
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 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Win ws Alteration(s) ❑ Roofing n
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [lJ Siding[D] Other[D]
Brief Description of Proposed .r-
Work: _A _A iL AiAIb /,4 "i1.f111 t. , w(C]
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 t existing 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, '' / 9 . ,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
I, to, . i 1 ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under tho cp s and pe•- s if perjury.
Print Name 4Fdrel' /
Signature of Owne ,'.e 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
ILot 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.
J Department use only
City o�No hampton Status of Permit:
j " lildi ! D partment CurbCut/DrivewayPermit_::: 1 . a n Street Sewer/Septic Availability'.orh 100 Water/WellAvailability
,_D ior.444F.Ati_AY_
O N. Lenv !ONF, I
• ' I o P )n; a itoh, 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
/ p W_ Map Lot Unit
C90 4i4V l '5j1:—
6 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Recor�
°72)* 60404k)Sr frr\reme- V.-
Name(Print) Current Mailing Address:
ga, Ytr-z, Telephone
Signature
2.2 Authorized A At:
4. I,1C6e (94 5--mrt5;-P- Pr6 J _..--_-1_ o-g *),S'
Name(Print) f Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building t2 (a)Building Permit Fee
5.57—
2. Electrical (b)Estimated Total Cost of
Construction from (6) 0447
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) telhz„, ,._ Check Number 41/9/(6 635
This Section For Official Use Only
Building Permit Number: I sssuu
ed:
Signature:
Building Commissioner/Inspector of Buildings Date
20 GRANDVIEW ST BP-2013-1065
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-091 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2013-1065
Project# JS-2013-001760
Est.Cost: $1966.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 11630.52 Owner: BARILLARO MELISSA A&BRYAN K LEHR
Zoning: RI(100)/URA(100)/WSP(0)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 20 GRANDVIEW ST
Applicant Address: Phone: Insurance:
908 BOSTON TPK Workers Compensation
SHREWS BURYMA01545 ISSUED ON:5/8/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ENTRY DOOR REPLACEMENT
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