24C-078 (2) Ms. Laura Fallon(Sep 2,2013, 1:52 PM)
Mr.Jonathan Fallon (Sep 2,2013, 1:54 PM)
11/30/12-SA Page 7 of 7
Sold.Furnished and Installed bv:
ItIll At-I Ionic Services.Inc.
d b a I he I tome Depot At-I lontc Scr ices
908 Boston Turnpike F'nit I,Shrewsbur .Ai:A 1545
Toll Free 8779032768:Fax 8009863610
Branch Name: Boston South Date:9' 1013 \IL Lie -C 02-339 RI Cont. Lic>- 1642'
Cl'Lie IIIC.0565522 NIA I tome Improsement
Branch No: 31 Contractor R ._ 126893 Federal ID u
75_2698460
Installation Address: 12 Massasoit St. Northampton MA 01060
City State Lip
Purchaser(s): ‘%ork Phone: Home Phone: Cell Phone:
Ms. Laura Fallon (413)586-5265 (732)673-3325
Dr.Jonathan Fallon 1.-11')586-52265
Home Address: 12 Massasoit St. Northampton M.A 01060
(If different from Installation Address) City State Lip
E-mail Address (to receive project communications and (tome Depot updates):laura ann Fallon a hotmail.com --- ---
Marketing entails will not he sent front The Home Depot.
Project Information: Undersigned("Customer").the owners of the property located at the above installation address,agrees to
buy,and THL)At-Home Services. Inc. I''Che Home Depot")agrees to furnish.deliver and arrange for the installation("Installati
on")of all materials described on the below and on the referenced Spec Sheet(s).all of which are incorporated into this Contract C 'f
by this reference, along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders
(collect ix ely. "Contract"):
Job#:(Internal Reference) Products: Spec Sheet(s): Project Amount
7058910 Rooting 7058910 SI7.070.07
Minimum 25% Deposit of Contract Amount 2 ��
due upon execution of this contract Total Contract Amount S l ).)117
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.
Payment Summary: The Payment Summary 7058910 . included as pan of this Contract.sets forth the total Contract
amount and payments required for the deposits and final payments by Product(as applicable).
GENERAL TERMS AND CONDITIONS
Responsibilities:
The Home Depot: gill provide the Products identified above. make arrangements to have the Authorized Service Provider perform
the Installation services in a professional and workmanlike manner.and arrange proper insurances. 1.nless otherwise expressly
provided for herein,Authorized Service Provider will obtain required permits and provide permit numbers.
Customer:will identify any property lines.easements.covenants. underground or overhead utility lines. pre-existing physical or
11/30/12-SA Page 1 of 7
.Y ` The Commonwealth of. assachusetts
Department oflndlastrialAccidents
==,,,*_ ! Office of Investigations
� }� � y • 600 Washington Street • •
',. M Boston,frtA 02111
'. �4� www muss gov/diia
Workers' Compensation Insurance Affidavit:Builders/Co ntractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business!Organization/Individual): 'C
' •Address: of VC(ji) ` it . 'u `I'nC. Pi •' .
City/State/Zip: ANt At 4 .,. 1 ., Phone_#: o�g
As!t1 ws : r
• Are you an employer?Check the appropriate b, : Type of project(required):
1.❑ i am a employer with • 4. f I am a general contractor and i ❑New construction
6.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. ❑Remodeling •
ship and have no employees These sub-contractors have 8. ❑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 100 Electrical repairs or additions f
officers have exercised their
'3.❑ 1 am a homeowner doing all work 11.❑Plumbing repairs or additions
myself[Na workers'corp. right Of exemption per MGL ti
• 12.0 Roof repairs
insurance required]t �c. 152,§1(4),and we have no
employees.[No workers' , Uthe;r 1
comp.insurance required.]
*Any applicant that checks box tI must also fill out the section below showing the,:workers'compensation policy information.
I.Homeowners who submit this affidavit indicating they are doing all west and then hire outside contractors must submit anew affidavit indicating such
contractors that check this box most attached an additional sheet showing the name of the sob-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
z
• I am an employer that is providing workers'compensation insurance,for my ernploye�es. Below is the policy and job site. i
information. ,...- 5•Insurance Company Name: L.'I_:1 1 i Lila at r 1
Policy#or Self-ins.Lie.#: •-3 7 Expiration Date: a i e.4
! k
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 1
Failure_to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a t
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 r
of up to$250.00 a day against the violator. Be advised , t a copy-of this statement may be forwarded to the Office of
Investigations of the Dom; r•• ,41„,,,,a,,overage v cstio,.
:I do hereby certify / I - . - -and : � ,erjury that the information provided abo:•.is true and correct.
,� 2
Signature l _ Date: _/ P
Pr
Phone#: L I l
Official use only. Do not write in this area,0 be completed by city or town official
i
• i
City or Town: Permit/License# i
t.
• Issuing Authority(circle one): }
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
S.Other • _ - - - I
•
Contact Person: Phone#: ;
%
I
i
"4/ �-
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supe or: / Not Applicable £
Name of License Holder: ��/■1
// 0 &
License Number
c3 I9//y
Address Expiration Date
Signature Telephone
9.Registered Home.l 's rovemen 'Contractor:: :,::,:-:: :]..:; ,:,,,�_. . � Not Applicable £ ^�
� - i- `. . ._. (2 9
Com n Name Registration Number
S // )3, f ) 0_� �/2ZExpiration Date elephone
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.. r No £
11. -Home Owner Etemption
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,amend Local Zoning a nd State of Massachusetts General Laws Annotated.
Homeowner Signature. ii,-/ 67,71 )) - e/T---
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [0 Siding[❑ •ther[❑]
1
Brief Description of P ij • 4- if, ,1 . J , - d� / ef
Work: /J
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
4;If:Nev -house"and.or addiition toTexistinq,h`ousmq;'complete the follow lia:
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 f /,, 4
, as Owner of the subject
property /
hereby authorize I
to act on my be c1 , in tatters re- " e to work a}� on -•,•this building permit application. /
G , — _ 3
40 p• A 071
Signature of Owner Date
I, t/ 7 ? ' I , as Owner/Authorized
Agent hereby eclare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
yI
Signed under -- p- ns and �enalties of•erjury. ba`J
L ' _�iPrint Name// �� ' }��,..../3
Signature if Owner/Agent 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 I i f _1 I .
FrontageI_____.___..______J T___ti_._____._.__ L_..__.___._..-_.___ ___J
Setbacks Front L___I I ? !_l
Side L:1-1 R:= L:1 , f R:1 I L 1 1
Rear
1 1 L '
Building Height k---1 i t_.. =
( `
Bldg.Square Footage ---1----1 r L____ 1- i % = r 1
Open Space Footage %
(Lot area minus bldg&paved L___ __i L____„.I L_____I l I
parking)
#of Parking Spaces 1
Fill: _._.......__.�._,�..w..�_..._..w...�..._..�...i i._,,..,....�.._._.__.....�...M..._......_...,..�..�f_...._.._..._._._...._......w..._.__..._._..�....}
(volume&Location) I [ s'
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:{ I
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book I __.___— ----_--7 Pagef� and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q 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
0 , 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 Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Dg e fm" enttu se o
Ir Z ; ir
b
3
'''\
/ . Ciof Northampton C I . . t
, l `�f 2G1 3 Building Departmen
�i 212 Main Street Room 100 I, s � 1 x i� 1 ,' r N 4IkN i ' r� 3q0� tiw Q K 1 s i tas=:R f rm r ,, IaE . MM Si tilc rjCt eivy ?e # t a 5 u " 71vt" A ti4 9,r 0Y:14,s Rva,r "a t ty a 5 i' ' .e5 iLau t -e , i iv ;i Wtr e tAua,lability ° '' „`. arrV '# # a l i k t ' !1wo Sesof S pul Pan1 s t N rthampton, MA 01060 PfSi las r t t it wi r rNm &Va '', e � 587-1240 Fax 413-587-EsCtNorthamtg n,MAK� 1272 � eSpcygR a gt gi 'T;R
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:
01 Map Lot Unit
12- P r Zone ' Overlay District 7 ......,...„ ,..:. •••
04).. /1-, p/7--T --. ,' EIm St District CB Distr ct . .:
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Liw i- hM " l2 �Na me(Print) Current Mailing Address: N fi
` ✓Z. COV ' `-�� '/' '" Telephone r/ D�C d
Signature
2.2 Auth.,:,t•d A•a t: of LI
P �1 f'1- ��` I
Name Grimm� Current Mailing Address: _7733
Si.1 lure Telephone
.SECTION 3-ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Cost(Dollars)to be • . Official Use Only
completed by permit applicant .
1. Building /7 q�7 "7 (a)Building Permit Fee
2. Electrical r "/ /"7 . (b)Estimated Total Cost of • .
Construction from(6)•'
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection /� 7
6. Total=(1 +2+3+4+5)
/71. / /9� Check Number 1'� / eo. f
. This Section For Official Use Only /. .•C7
Date .
Building Permit Number: . Issued:
Signature:
Building Commissioner/Inspector of Buildings • : Date
•
12 MASSASOIT ST BP-2014-0273
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C-078 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2014-0273
Project# JS-2014-000468
Est. Cost: $17979.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 88261
Lot Size(sq. ft.): 15942.96 Owner: FALLON JONATHAN M&LAURA A
Zoning:URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 12 MASSASOIT ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCERI02908 ISSUED ON:9/6/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 9/6/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner