32A-089 The Commonwealth of Massachusetts
Department of Industrial Accidents
Ji' Office of Investigations
i F —�' r f I g
- =i -i -, 600 Washington Street
Boston, M4 02111
r'=-. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): off: 'DIA-_
Address: AA s, .--
City/State/Zip: Matt, C&,, `:! 'hone#: rl - - - ►
Are you an employer? Check the appropriate box: Type of project(required):
1.[ I am a employer with 4. ❑ I am a general contractor and I
6. New constriction
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
s These sub-contractors have Q n n,lmolition
working for me in any capacity. employees and nave workers 9. Building addition
[No workers' comp. insurance . comp.insurance.t
required.] 5. ❑ We are a corporation and its l0.[ Electrical repairs or additions
3.❑ I 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.❑ Roof repairs
insurance required.] ' c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other__
comp. insurance required.]
#Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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: fk ill rillik.#1176 (LCD ---
Policy#or Self-ins.Lic.#: 59-r-7-3I L Expiration Date: r.. ! i 4
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'1 uran ; cover.,e verificatio
I do hereby certify u ,:. , 'a ,. and'ena!'es o :,r ry th a information provided ab've is true and correct.
Si. ature: _ ..ri r i , . .� Date: 4.... ...i'
Phone#: LIIS 1CS
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#:
NOTICE TO CUSTOM FR
Yon are entitled to a completely filled-in copy of this Contract.signed by both you and The Home Depot.at the time von
sign. Do not sign a Completion Certificate before the Installation is complete.
Acceptance and Authorization: Customer agrees and understands that this Contract is the entire a aIeement between Customer
and the Home Depot with regard to the products and installation services and supersedes all prior discussions and agreements.
either oral or sritten. relating to said products and installation. This Contract cannot he assigned or amended except hv a w-ruing
Signed by Customer and l'he I tome Depot.
Customer acknowledges and agrees that Customer has read. understands.voluntarily accepts the terms of and has received
a copy of this Contract. Customer acknowledges receipt of the Notice of Cancellation.and that The Home Depot has orally
informed Customer of Customer's right to cancel. Customer's signature below constitutes Customer's acceptance and
eyecution of each of the applicable Contract Documents. 1)O NOT SIGN THIS CONTRACT IF THERE ARE ANY
BLANK SPACES.
You are entitled to a paper copy of this Agreement if you choose. If you consent to an entailed copy,your consent applies
only to this Agreement. By contacting sales office t s 7)9n3-376s .you may update your email address.withdraw your
consent,or obtain a paper copy of the Agreement at no charge. By signing below.you confirm the following:
• You consent to receive only an entailed copy of this Agreement
• You have access to a computer that can receive and open entails and PDF(Adobe Reader Version 10.1.4 or
later)formatted documents.
• Your email address is correctly listed on the Home Improvement Contract
Submitted by:
Sales Consultant Donald\V -i;wall
License Name.
Telephone No. t.STT')`)t>`-'75
Sales Consultant
License No. t as applicable)
CANCELLATION: CUSTON1ER MAY (CANCEL THIS CONTRACT WITHOUT PENALTY OR OBLIGATION BY
DELIVERING Vs RITTEN NOTICE.1.0 THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY .AFTER
SIGNING THIS CONTRACT TO THE ADDRESS LISPED ABOVE. THE STATE St I'PLEMEN'T ATTACHED
HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S
STATE.
21.t Accepted by: dw41 (Sep 26, 2013, 1:51 PM)
11/30/12-SA Mrs. Anita Malachowski (Sep 26, 2013, 1:51 Fes)
H
Sold. I-urmshc(1 and Installed ht-
1 III):11-I fume Scr ices. Inc.
d ha the I[time Depot.At-I lone Seryiees
90N Boston I urnpike I.'nit I.Shrctrshur.At:A 1 545
foil I fee ti7790 5I aS U11)I)y(36111
Branch Name: Boston South Date: 2h 1013 \9l. I-ic L C 02410 RI Con1-t-ic- I64'7
(`I I_re 111C.US6S512 \I.\ !tome Iniprosement
Branch \o: ,I
Contractor Rcc. - I_'hsu3 l ederal 11)
-5-2.69S46o
Installation Address: 17 Graves Strut Northampton NIA 010611
-
Cite State Lip
Purchaser(s): N'tork Phone: Home Phone: Cell Phone:
Mrs.Anita Malachowski (-l1 3)5S6-2076
Home Address: I (iras es Street Northampton AI.A (1106)
(IIdillerent from Installation Address) Ciiv State Lip
E-mail Address (to receise protect communications and I tome I)epot updates):
\larketing entails will not be sent from The Home Depot.
Project Information: L ndersigned("Customer.). the oft hers of the property located at the abos e installation address. agrees to
buy. and HID :At-Home Ser ices. Inc. (-The Home Depot")agrees to furnish.deliver and arrange for the installation("Installati
on"I of all materials described on the below and on the referenced Spec Sheet(s). all ofwInch are incorporated into this Contract
by this reference. along ttith an applicable State Supplement and Pa mcnt Summary attached hereto and an) Change Orders
Icollecti■cly."Contract"):
.lob#: (Internal Reference) Products: Spec Sheet(s): Project Amount
_15217 Roo111111 7152175 56.665..11
:Minimum 25"'i, Deposit of Contract_ mount
due upon execution of this contract Total Contract Amount 56.665.-10
Customer agrees that. immediately upon completion of the work for each Product. Customer gill execute a Completion
Certificate(one for each Product as delined by an indis idual Spec Sheet)and pay any balance d tic. As applicable,each
Customer under this Contract agrees to be jointly and scyerally obligated and liable hereunder.
PaYntent Summary: The Payment Sununar\ 7 7152175 . included as Part of this Contract. sets firth the total Contract
amount and payments required for the deposits and final payments b) Product AS applicable)-
GENERAL TERMS.t ND("O NDITIO NS
Responsibilities:
The Home Depot: tt ill pros ide the Products identified ahoy e. make arrangements to has c the Authorized Sort ice Provider perform
the Installation serf ices in a professional and workmanlike manner. and arrange proper insurances. I.nless othery ise express[)
provided for herein. Authorized Service Pros ider trill obtain required permits and provide permit numbers.
Customer:will identils any properts lines. easements.cotenants. underground or otencead utility lines. pre-existing physical or
11/30/12-SA aay, 1
K,
. ..
City of Northampton
��`�-�' Massachusetts jrw�SX - Gr{•
�d , c
,r y .' '.; .ter � '�'�
t ` > DEPARTMENT OF BUILDING INSPECTIONS ` 4`}' ;
, �'..; 212 Main Street •• Municipal Building 0',l b'
, Northampton, MA 01060 s j�'s7 1
sY ,.r`,4
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends 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 home owner."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection
(before work is concealed), insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
�®„„; 600 Washington Street
p=
O. Boston, MA 02111 JAt
'° = ,1 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. 0 I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.El 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.$
required.] 5. 0 We are a corporation and its 10.0 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 12.0 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.
tHo meowners 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 under the pains and penalties of perjury that the information provided above is true and correct.
Signature: 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.EIectrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su�pee isso/r: /� ) Not Applicable £
Name of License Holder: V(/�' '•"7 ' 'i /� t/
29� (97/Di 0/4 �i`v�' License Number 44
Address Expiration Date
1'e/V3'149
Signature Telephone
9:Registered H me.lmprov merit Contractor., Not Applicable £
/ 493
Coma am yam, ,/ Registration Number
A. e• /N9 ' 62/15— Expiration Date
r
JL� Telephoner "�� ��
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 Ye £ 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 Windows Alteration(s) n Roofing rJ
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [D /Siding[0] Other[0]
Brief Description of Proposed FrA 1�. . j/f- .� gF �%r,.. //
Work: /" e/
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
saT.If,New house and-°or addition`io ezistinci housinq, complete the foilowinq:
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, 17n ,M J
/' ! >e,M A - 1- . ,as Owner of the subject
property / /�
hereby authorize — 'e" ' 3 e242 )43—
to act on my behalf, in all matters r tive to work authoriz-d b this building permit application.
Signature of Owner Date
I, .J� 777212)79-..
) as Owner/Authorized
Agent hereby declare that t e statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed and pain and penalties of e ' t
p 4:4-7,-/A) • if2-0m-
Print Name
it y S"� - / V >P --):
Signatu Hof 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
t Building Department
I Lot Size I I � l 1
FrontageI__.___-_.________...._-.-__.___._..._1 __ _____--`__ _.__... ._..._._.__»_.___--___.1
Setbacks Front j- I
Side L:I 1 R:= L:l ..�---
' R:= 1 I 1 }
Rear 1. _--1 = I
Building Height I--`
Bldg.Square Footage % L�- -
Open Space Footage E % rr--------'^ t
(Lot area minus bldg&paved l._-_,_.,1 L._�,_1 1.__,_..._ i L I
parking)
#of Parking Spaces =
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES 0
IF YES, date issued: u I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0 T_
IF YES: enter Book I T �I _..
Page .�. and/or Document#1...
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT 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 0 NO Q
IF YES, describe size, type and location: 1 !
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: ; 1
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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
•
,
r '�17epartent Use only L yl 11
r-- f bi c l r< ra LY f Y^' i ,.d f�. r�,r'' ,I k'T f+t v !Tt I'�1 r
1 � i VIL�:4 , „�' T r,r� ��1�iiya Y.��GI� ���'�1a i�p.�i6j,z �I'�IµC�+,�.�1 aM'ury�Fl S� i
City of Northampton tatuI Fernatt , i .� $ �, ��� 55�e�1 ,
�-�-'--�-------C ri .1 18g ltw c�',J m .R r }u� ,k.1°il vk L`.k'�1 rtor s u� F .
L„ , :uilding Department GCSrij GuiU[Tr1fvuewa9 Permtf t q:tom ,
f 51 �'!p3 kY is5! fLSh�lk4 1,�4h = Y CJ i 4 ?1 1 R �'
�
f'. 2.0i3 212 Main Street SeVVer/5eptic AWallabllity ) �7 �� ,k 1!u} ' h f t b 3
'i OCT v Room 100 WatJerftl�eii Avalla lllt i�i j�'" 1 t � i ''t 5
__J
N• hampton, MA 0110365087- Twa�etsRof'Strlrctural"PifinsaF�"' °� � " Y,, ''� ' `
ry' �j 1 Y �Y��+r. I 1��.nid -t 1 vi
Ct0 st 11vr ML1rsir�l"iii 1'- ''1 'f flt .):
Electric,PIumL nr k ,�-{'� 587-1240 Fax 4 - 1272 PIo�/Site plans' ,����I��°>t��,i' � ,s�,,rY �� t~,� ' Y �~.
Northrn :_,. ♦ n y w Isr ��'r JAI , ,
Oth0IMP.:cify y x 1"}' Nl r �4 t e, R IIF r ..x
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Thi i secti on Oto ebe l co mpt�l.e
e
d t y
office
1.1 Property Address: t UrnMap a Lt t
j 7 6,ê, V( / Zone . v ray D c I
i:� T 61 . J i i
El St istct : CB Disc : J m Dri
SECTION 2;PROPERTY OWNERSHIP/AUTHORIZED AGENT .
/7 Cj "/ i - .
2.1 Owner of Record:
s,TP- P/11 LAU rT I'
PI A9-- AvJ,
Name(Print) Current Mailing Address:
C LO TR-1' Telephone 9/3 ~3-"" e 0 76
Signature C�
2.2 7i { ent: /' A� `� l ' , x..94'
Names(P in Current Maili,. Address:
/� , LA'/— 0 3-=z6-3..3
'nature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 6 6652 0v (a) Building Permit Fee •
2. Electrical (b) Estimated Total Cost of
• Construction from(6)•
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection ,1 ‘ 1
6. Total=(1 +2+3+4+5) � �J ' 7 Check Number �� 77 9 'J
This Section For Official Use Only .
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
17 GRAVES AVE BP-2014-0434
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-089 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-2014-0434
Project# JS-2014-000757
Est.Cost: $6665.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 106837
Lot Size(sq. ft.): 5880.60 Owner: MALACHOWSKI ANITA TRUSTEE
Zoning:URC(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 17 GRAVES AVE
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVI DENCERI 02908 ISSUED ON:10/11/2013 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 10/11/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
4