36-056 r
- r q
HOME IMPROVEMENT
ASE THIS (16.O
� Sold,Finished and Installed by
*"*a MISame:,$os North&South Dater V' ,t 3 THp At-Home Services,Inc.
e d/bfa The Home Depot At-Home Services
t Branch Nwabet':31 ind 33 908 Beaton Turnpike,Unit 1,Shrewsbury,MA 01545
Llecti Toll Free 877-903-3768
e .; )Q Federal ID#i 75.2698460;ME lee#C 02439;RI Cont.Lie 16427
_.. CT Lie#HIC.0565522;MA Home Improvement Contractor Reg.*126893
Installation Address:
City State Zip
Purehasertak Work Phone; Home Phone: Cell Phone:
� ;pi A lo ciAJ [ ] { ] [ ]
[ ] C ] [
Home Address:
(If different from Installation Address) City State Zip
•
E-mail Address(to receive project communications and Home Depot updates):
❑1 DO NOT wish to receive any marketing entails from The Home Depot
Proiect Iefornselipg: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
and TND At-[Dame Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installation")of
all materials described an the below and on the referenced Spec Sheet(s),all of which are mcnrporated into this Contract by this
reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively,
"Contract"):
Job#: fivirrad P •test: Spec Sheet(s)N. ProiectAmouot
U-(Roofing 1]Sidng :1 WindanvsU Msuladon
_09 fiat..ad" ❑t;nrttets,Corers❑Entry Doan ❑ g $ 3411
�' r
•Roofing •Siding •windows • insulation $ c/ I.
OGlrtters/Covers❑fitury Doors ❑
•Roofing ■Sung at Windows • insulation
❑Gtrtters/Covets flfint<y Doors❑
LU•oofing ❑Siding❑Windows ❑Insulation
❑Gutters!Covers❑finery Worn ❑
Itl iafmam2eneDipentofCostaet Anima due upon e:reainoneftbssoetraee. Total Contract Amount $ 3 t j
Maine Purchasers may not deposit mare than a/wo rd of the CattrsdAmoutta
Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate 0
(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 Products)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. j
Payment Summery: The Payment Summary# CJ '1 7-t ,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 filed-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there is one Completion Certificate for each listed 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 OF SUCH AMOUNTS.
Acceu attare and Anthorization: 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 ar written,relating to said Products and Installation.This Agreement cannot be assie■ . or amended except by a wasting signed
by Customer and The Home Depot.Customer acknowledges and agrees that ee d,understands,voluntarily accepts the
terms of and Its;received a copy of this Agreement,
Accepted Submitted
y!/ x ;j T't( 4 71)/04
C .,f a ignature Date Sales Con Signature Date
Telephone No,
Customer's Signature Date Sales Consultant License No_
CANCELLATION: CUSTOMER MAY CANCEL This {asaQpHo.W,e)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME ( ,] 3 f 5 3(�'!
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS `(t (�
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
•USTOMER'S STATE.
NOTICE ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF TOM CONTRACT
5407.13 White-Branco PH Yaw-Customer'
( r ) ptI:1 isor
-•
IVO KOSORTASIOCI
12 STAFFORD ROAD
MONSON its4,.. 01057
04J27/2014
),
'Y•$
City of Northampton
s S
?"' Massachusetts J t�`"+sue ; �of{` ` .
,� _' � ix,- ' Y f DEPARTMENT OF BUILDING INSPECTIONS ter• ! .' ,'
\` 212 Main Street • Municipal Building rJt:'', `' O
Northampton, MA 01060 :
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
==fits
= 600 Washington Street
A 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: 9'i �
City/State/Zi s� '' �)10 , ,}-. Phone #:
Are you an employer? Check the app I priate 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 N 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. n Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. n We are a corporation and its 10.❑ 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.❑ 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.
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.
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 un,'r th/pain •nd pen, •es of perjury that the information provided above is true and correct
Si•iature: / i j.4(12it: _A/ � 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#:
J -
SECTION,8-CONSTRUCTION SERVICES -
b
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �'" � C/f r-� (r/9 %��t/f%��%/
License Number
_______V2- -si---TP-Ffiof2_1) .-W .
Address Expiration Date
/ 21 6 J )7) 9j/27
Signature Telephone
9 Registers Home Im rovement Contractor,. _ Not Applicable❑). .61(i.
--7-7-
Company Name (/ Registration Number
BT r /V
- A.. ess_� �j) Expiration Date
.4 /4�,y 427 ,o,. Telephone
I
:SECTION 10-WORKERS'�COMPENSATION INSURANCE AFFIDAVIT(M G L c;-152,-:§-25C(6))_ .--.L- ,.: -
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 =Hoine 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 Wirlyi5ws Alteration(s) n Roofing n
Or Doors L
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding [O] Other[0]
Brief Description of Propo �� /�j➢.�i1 /`� �f���jl"'j �,�
Work: a��
Alteration of existing bedroo / Yes No .ding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.if New house and or add tion tOemstinq •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
_
,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, ) =- - )._ O)t , as Owner/Authorized
Agent hereby declare tha the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed_under .ains and penalties of perju
/ Ai A 040 40 6 (2)19
Print Name / ,
, i �.�
Signatu'of Owner/Agent Date
J .
, w
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
e
Existing Proposed Required by'Loning
This column to be filled in by
Building Department
Lot Size i
Frontage
Setbacks Front I i '
Side L:'' R:! L:i •, R:i 1
Rear I
Building Height I a 7-1 1
Bldg. Square Footage I I I _ % I i 1 1 i
Open Space Footage % --
(Lot area minus bldg&paved i I I I 1 ! i t
parking)
#of Parking Spaces E i I I
Fill: ;1
(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:I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book Pagel I and/or Document#1
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 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
IF YES, describe size, type and location: I
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.
Department ueonly -
f City of Northampton Status of Permit
Building Department Curb Cut/Dnveway P_ermlttw
wer/SepticAvailabiIit
212 Main Street Se y
Room 100 1Ntaer/Well Availability
Northampton, MA 01060 Two±Sets of'Structural•Plans _ -
phone 413-587-1240 Fax 413-587-1272 PlotSite Plans . t
Other Specify_
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:
i-i) ,' (1,)q?tQ. ,,Q , Map Lot Unit
..i•-..-:..-71'.--,..:••••,::7,,,,,:':-:::,:c?;..T.-:-::'.---•--..-•_-_:..-•,---=-,..:,:r•-•'!•.:•-•.-'''--.:-.. :::- '....':::',31..k::Ft'il'[..-'-•-*';-:4•:'--'-!:',. g:,•;.- ----'-,,:i':?-..Lf'-;•::::',.=.;-•;!::--r,',.i--.!i::..::----',-.
e 010 eAd/6C. //Y) )41) V/9
Zone Overlay Distnct T
Elm St..District CB District
SECTION 2='_PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
'. 11F,$) P Al Al>4)-6 )A/ -/,
Name(Print) r--- Current Mailing Address:
',,,,.2: ei7-7ie--3---i-0,),-‘,J Telephone
Signature
2.2 Authorize en . r ,vT P
Name(Print) Current Mailing Address: 9 f
Signat ,! Telephone
SECTION 3-'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only _ -
completed by permit applicant
1. Building j� ''�- (a);Building Permit Fee -
..94 2. Electrical (b);Estimated Total Cost of
,< Construction from(6)
3. Plumbing Building Permit Fee =
4. Mechanical(HVAC) =
5. Fire Protection
6. Total= �� l Check•Number
1 +2+3+4+5
_ . _: This Section For-Official Use Only
Date
Building Permit Number. Issued: _ _
Signature - -
Building Commissioner/Inspector of Buildings__ _ _ - Date
File# BP-2014-0002
APPLICANT/CONTACT PERSON HOME DEPOT AT HOME SERVICES
ADDRESS/PHONE 24 SUNRISE DR PROVIDENCE (401)935-2633 0
PROPERTY LOCATION 41 REDFORD DR
MAP 36 PARCEL 056 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
fr're-e Paid r°�c:aJ 4 F( 9 (
wilding Permit Filled out
Fee Paid
Typeof Construction: 5 WINDOWS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION PRESENTED:
(/Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street,Commission
7/9(l-1)
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
41 REDFORD DR BP-2014-0002
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-056 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: windows replaced BUILDING PERMIT
Permit# BP-2014-0002
Project# JS-2014-000031
Est. Cost:
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: ':cc,:sc:
Use Group: HOME DEPOT AT HOME SERVICES
Lot Size(sq. ft.): 12501.72 Owner: ALHASSAN SOFIYA
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT: 41 REDFORD DR
Applicant Address: Phone: Insurance:
24 SUNRISE DR (401) 935-2633 ()
PROVI DENCERI02908 ISSUED ON:7/9/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:5 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 7/9/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner