24B-061 (un\tructiun Super+k■r Specialty . .
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IVAN AN KOSOBUTSRL3 i
72 STAFFORD ROAD
MONSON MA 01057
554—
04/27/2014
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ACGRD CERTIFICATE OF LIABILITY INSURANCE ; aka.( rrr,
�
..�'� 0212712013 t
iI THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
I CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AJTTriORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the poiicyfles)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to th
certificate holder in lieu of such endorsement(s).
PRODUCER NAME:
T
MARSH USA.INC.
PHONE FAX ALLIANCE CENTER N . .Exq: .
3560 LENOX ROAD,SUITE 2400 E-MAIL
ATLANTA,GA 30326 ADpRE55S:
INSURER(SLAFFORDING COVERAGE I NAIC B
100492 I tomeD GA4,r 13 id INSURER A:Steadfast Insurance Company 126387
INSURED INSURER s:Zurich American Insurance Co 116535
THE HOME DEPOT,INC.
—
HOME DEPOT USA,INC. INSURER C:New Hampshire Ins Co 23841
2455 PACES FERRY ROAD,NW INSURER D:11Gno,s National Ins Co 23817
BUILDING C-20
ATLANTA,GA 30339 INSURER E: _
INSURER F• _
COVERAGES CERTIFICATE NUMBER: ATL-00315954504 REVISION NUMBER:7
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
�m TYPE OF INSURANCE 1NBR POUCY NUMBER I(MM1ODIYYY U POUCY IIWYYYY)t UNITS
A GENERAL LIABILITY GLO4..7714-03 IO'n01/2013 03(012014 I EACH OCCURRENCE S 9,000,0601
X {COMMERCIALGENERAL LIABILITY PPRE
REMISES tea ccurr nceJ 1,000,000
S
ICLAIMS-MADE ( X 'OCCUR LIMITS OF POLICY XS MED EXP(Any one(erson) !S EXCLUDED
I OF SIR:$1M PER OCC .PERSONAL&ADV INJURY S 9,000,000
I, GENERAL AGGREGATE S 9.003.000
GENt AGGREGATE�UNIT APPUES PER: PRODUCTS-COMP/OP AGO S 9+�,�
X f POLICY[I JECT n LOC S
B AUTOMOBILE LIABILITY BAP 29938863.10 03/01/2013 0312014 carBweliNGLE uMrr s 1,000,000
X ANY AUTO BODILY INJURY(Per person) S
___.. AALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) S
HIRED AUTOS AUTO S PROPERTY DAMAGE g
_ S
UMBRELLA L AB I OCCUR EACH OCCURRENCE ,S
EXCESS LIAR CLAIMS-MADE AGGREGATE S
I OED I I RETENTIONS S
C 1 WORKERS COMPENSATION W 314(AOS) 0310112013 0310112014' X WC$TATU-AND EMPLOYERS'LIABILITY 'TOR IMjTS 10113H-
,..,
ANY PROPRIt-:TORIPARTNER/EXECUTIVE YIN �WCO3;i575315(AK,AZ) 031012013 103(0112014 1,000,000
II EL.EACH ACCIDENT S
I OFFICER/MEMBER EXCLUDED? N N f A EL.DISEASE-EA EMPLOYEE S
D (Mandatory In NH) WC033575316(FL) 03/0112013 �031011201d 10 006
d yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S
C WORKERS COMPENSATION WC033S75317(KY,NC,NH,VI) 03101/2013 0310/12014 (EL)LIMIT 1,000.000
C WC033575318(NJ) 03/012013 01,012014
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required)
EVIDENCE OF COVERAGE
CERTIFICATE HOLDER CANCELLATION
THE HOME DEPOT INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
HOME DEPOT USA,INC. THE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN
2455 PACES FERRY ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS.
BUILDING C-20
ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE
of Mush USA Inc.
I Manashl Mukherjee ,.Mar+ot.:
rtI utRR.9n1n ACORD CORPORATION. All rights reserved.
•
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84/24(2811 83:50 FROM 4546822 TO • A.01
,� •fiicgof Consumer Affairs&Btisiness Regulation '..I scene or registratloo valid for indivldut use cob/ ..
^,= before the expirstiori date. If:found return to:
x OAA IMPROVB�ENT COI�t'rFiACFdR Consumer Affairs and Business,Regulation
-ie ; . .;, Office of Coas
ti -. . TYYPe; .10 Park Plaza-Su+te'5170
'Expirati n.::: t' Su Plemerii :ard' Batton,MA 02116 �a' `` ,
The Home Depot ^``?¢�� E / . . ..
• ,.,:,1 i 0,4:d Wi' / `••
RICHARD TROIA ' v 4 �' /` �1�•
• 2690 CUMBERLAND�''A1 ' S • , i A• ---
Igirl5kFin,.GA 30339 Undersecretary Not valid without signature
•
•
•
•
•
1
\\
lamps IMPROVTMENTCONTRACT
PLEASE READ THIS
Sold,Furnished and Installed by:
Hooch Name: Hodes Date: TFIU At-Hame Setviaea,Inc.
f (/ d/bla The Horne Depot At-Home Services
. 908 Boston Turnpike,.Unit 1,Shrewabaay,MA,01 545
Toll Free(800)657-5182;Fax(508)8456017
Branch Number:3f Federal ID#75-2698460;ME Lie 4 C 02439;RI Cont.Lic4 16427
CT Llc a t1JG.565522; A Home impro_v`ament/ConuacextReg.y 126893
Installation Address: (fj(. ep ex 011es .'l '� 1 V��J4 j7.1-c�.v (l...- °.c
City • 1 Stagy Zip
Purchaser(s): Work Phone; Home Phpue: Cell Ptwaa . •
. lr2-1i� t'J JMA [ I ' • I ] • • [ ]
f . 1 . ' . [ . . 1. . . [ l ••Hume Address:
(If different from Installation Address) • City '. • grate Zip
E-mall Address(to receive project communications and Home Depot updates):
. ❑i DO NOT wish to receive any marketing mails from The Home Depot . .
PrelnInentatient .Undersigned("Customer"),the.owners of the located at die'above..instaiktionaddress,•agrees to buy
endAt-Home Services,Inc.("The Home Depot")agrees to final deliver and arrange for the installation.("Tnstatlatton")o:
art materials described on the below and on the referenced.Speo Sheet®,all of which are incorporated into this Contract by this
reference,along with any applicable State Suppteniepr and Payment Summary atmehcd.hereto and any Change Order's(collectively
Job# p.,s.d a,w�e,.y Products: 8h--,s 4 . Pro t Amount
■Eoofinn •Siding iR Windom.■itmalation
71%6 ( t. D /c DenttyDoors 0 x.;73-'447L $ • 5910.- .
D frog D$tding❑Windows 0 Insulation .
' Crmeers t Covers Denny Doors 0
ltewfttrg 1181,hug II Windows ■Insulation '�`
$
Docezea/Covers❑EntrY:Doosa❑ `
DRoofing❑siding 0 Windows D Issutatlon . /X
❑cheers 1 Covers IJentry Doors 0 $
l+fm®am 2S%Deposit orCeatrnet Amine due upon exeaition of this contract Potal Contract Amount S L'
Maine Purchasers may ea deposit moo than one-third of the Contract Amount l J 1.----7.\/
stomer agrees that,immediately upon completion of the work for each Product,Customer witi ieecente a Conpletioe Certificate V!1 All
(one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer order tbu
Contract agrees'tote jointly and severally obligated and liable hereunder,
The Home Depot reserves the right to issue a Change Order or terminate ibis Contract prim.individuial Produot(s)included herein,a
its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structure
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 •
javment SWeaptan'u The Payment Summary 4 6 i � _ / included as part of this Contract,sets forth.the tors
Contract amount and payments required for the deposits and final payments by Product(as applicable). .
NOTICE TO CUSTOMER •
You are•enttled to a completely tilled-In copy.of the Contract at the time Ion 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 Produc
is complete. .
In the event of termination of this Contract,Customer agrees to pay The Horne Depot the costs of materials,labor,expense
sad servieea provided by The Home Depot or Authorized Service Provider through the date of termrnatIon,plus any other
amounts set forth io this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD,AMOUNT:
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.
,Aeceetange NO Authorization: Customer agrees and understands that this Agreement is the entire agreement between Custome
and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,tithe
oral or written,relating to said Products and installation.Ilia Agreement cannot be assigned or amended except by a writing signet
• by Customer and The Home Depot Customer acknowledges and agrees that C .y• -. ,,understands,voluntarily accepts tb,
terms of and has received a copy of this Agreement.
A p by: &Mtn e.4 4
1 .
pier's Si e Date • Sal= '" s Signature Date
Customer's Signature Date T
Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS (as eppticabk)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME .
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AF 1 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 THE REVERSE SIDE AND ARE PART OF THIS CONTRACT
M
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Canada Zones
€FURS
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ENERti`f STAR energystar.nrcan—rncan.gc.ca •
ENERGY STAR Qualified in Highlighted Regions
•
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4 `'•'o^r<• 'fir7,�"! .x �':r
ENERGY STAR ''.:t
uz&Witted
Remove label after final'inspection;SAVE for future reference
•0 Weather Shield
V•► CPD#050—A-172 •
- `!NERC Model 8108 Double Hung Operating
• 're' Alum clad Thermal Frame
/'tats 4s7tFe nestrsti-n 3/4 inch Glazing .
MIN camsie 10—E .022 Low—E
cEnTlFIEU Argon Fill Grille in Air Space
ENERGY PERFORMANCE RATINGS
Q 30 U—Facto 70 So1a1H l oin Coefficient
N.S./1—P] RktriclSal
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance Condensation Resistance
0.40 0
. : Manutacforer snputstes that these ratings cmlbnn to appacable NFRC procedures for
determining whole product snergy performance.NFI1C ratings are delemdned for a
axed set of environmental conditions and epedac product sizes.NFRC does not recommend
sty product and-does not savant the suitability of any product for any speciIc use.
Consult manufacturer's literature for other product performance intonation.
www.nfro.org
Meets or exceeds M.E.C.,C.E.C.,end I.E.C.C.Air Infiltration Requirements
(DP) (psf) Testae to ANSVAAMNNWWOA 1011.8.2-9?
11–l.035 44X90
Tested to AAMNWOYNCSA
45 35 .�_– 101118.2t*a40-05
14-1C 3511102266(44X90)
ill.= 35
Una Mate Sraelerd Perlemaeea Pu ASTM E33a
010201
550534745-1—1 $160CO2A11NSTO
• Wave: 01/17/11.3 AS W11I88480t2CAGN
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Office rz,'esz g S
- P 600Washington Street
Boston,ML 02111
.-=_ ltwll•.mass.g of idz
Workers' Compensation Insurance Affidavit: Builders/Contactors/Electricians/Plumbers
Applicant Information _ Please Print Legibly •
Name(Btr- nixatiuylncfividuatl: t ��'� jn -
Add;
Address: • �4 7� } I
1 ,4..#s■ ' /m �. L.
City/State/lip: ,ii ,% .Si'A .r Phone t __6 l
Are y, e an employer'Cheek thilappropriate box: Type of project(
1.lit I am a employer with 7j 4-n I am a general contractor and I Re R i (required): f
employees(full and/or pat .)z have hired the sub-contractors 6 ..New cars xxirn
tfim !
2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have.no employees These sub-contractors have g. 0 Demolition - I
working for me in any capacity employe,... and have workers' ! Building additiint`
NO workers'comp.insurance CO mp insurance
•
required_] 3.° We are a corporation and its 10_([Electrical repairs or additions
3.0 1 am a homeowner doing all work. officers have exercised their 11.0 Plumbinc repairs or additions
myself:Rio workers'comp. right of exemption per MGL 1^ Roof repairs
insurance required.]t ,.152,a 114).and we have no s'.
i 13.0 Other 4
t `mploy . [No workers' -
camp.insurance required i] 1 i
-Any apphcnntthat citectshoe Of mead=fill out die setataa belowshowens their workers'comirtnatiae poky iaiartteaame_ - s
t Horne/mum who submit tha a idtre utdieatin:they ate daing all wort and then hie outside colorations s taw sobtait a air affidavit todica!ng sari. I
'Cant!aaota that check this box must ant lied an additional sheet shooing the name of tic and state whether w not those etiini%have
employees. lithe s oh.caataecots have enploym,they must amride their waiters'tip.policy number.
. I ate an emplaper that is proof/fag workers'compensation insurance for leer employees. Below is the policy and job she
information. _
Insurance-Company Name: . .• ■_ a t Cr el. _ 4.►_ NW
- 14 . Expiration _ I 1
- Policy N or Self-ins.Lie.#: � ration Date:
lob Site Address: "/ 1 — City,StateMP' N /.%(V',s' >1 IVY' i
Attach a copy of the workers'compensation policy declaration page(showing,the policy number and cep�tioa duet. adb/
Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of alpine./pataltin of a
i
fine up to$1.300.00 and/or out-year imprisonment-as well as civil penalties in the bun of a STOP WORK ORDER and a fine
of up to.S250.00 a day against the violator. Be advised that a copy of this statement may be fttewarded to the Office of
)nvestieatinns of the 014 fur ilhurance coverage verification. -
I do hereby certif.". erjier - ', ;„ , ,p " 'that the information provided above is true and correct.
_tiara:* t .;ei P.te: 3 .k► _
Phone R I) 'O) 'or -
. i- Q ffit igl use ante_ i3o not wile in this area,to be corn el ci{p or sown officiaL-
City or Town: Permit/License# .
Issuing Anthony t t circle°nee - .
1.Board of Health ?Bulling Department 3.GtvrTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
.
6.Other
l Contact Person: - - -- Phone 1r •
City of Northampton i
SH
i
o 4o �5 Sj
� � r4ry Massachusetts wtSy _.. �fl�
,' '' l ' G
,,--,,,,k+
t, m DEPARTMENT OF BUILDING INSPECTIONS '41 4`I' =,
°� �' 212 Main Street • Municipal Building yJ'• b'
`� h,,,.mss' Northampton, MA 01060 �sPA; ryjt��
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
s =` Office of Investigations
: L1= €�.
;f,� �� 600 Washington Street
srk
"ep®4 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:
City/State/Zip: Phone #:
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
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New 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. Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are:a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 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' 13.0 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.
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:
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.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
•
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor� •J,T✓�L/�'�L� Not Applica le £
Name of License Holder: /C J `y/'
jLicense Number
27
Add ress 0 71,& --1 pi )0,—, p/17 Expiration Date
Air
Sign. Ar Telephone 33
9:Registered Home"m `Move nt Contras • Not Applicable £
Company Nam- per o! , � `�— Registration Number
,i = 111? v If
Address _ Expiration Date
Telephon6/l/�/ _.
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 Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [D] Other[D]
Brief Description o op4s9d ) wi'' ) /1 �-/w
Work: r 1�1/� ,-[-ls 'sue/
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. If:New h-Cidse ifid::brad"dition tc;ezistinq..liausiiiii complete therfoilownq:
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
10 47" J hY , as Owner of the subject
property t
hereby authorize CA ,,_
to act on my behalf, in all tters rela ive to work authorized bbby this building permit application.
Signature of Owner Date
121( 72j7 JOi/r ,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,t#ir s an penaltiesi aerjT�
I ,I ._-
Print Name .' - )
/�/ dui`./I1lAi
Sig Lure of 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 H 1 l 1
Frontage 1____ J I_ . I_
_..1
Setbacks Front -____A 1 J i I I
Side L:= R:I L:I I R:= _... I
Rear Ell 1 {
Building Height 71
Bldg.Square Footage I-1 F---1 % 1-__.1 1 1 -
Open Space Footage % }} ;
(Lot area minus bldg&paved L____, t_,__,-,__1 L__,__„_� L__._...i I I
parking) --�
i 1 E
#of Parking Spaces
Fill: __-�;.�......_._..:.�._...,.._.:.,......... � s
(volume&Location) .i 1 I `1
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:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES _ `___
IF YES: enter Book I Page ] and/or Document#1 1
B. Does the site contain a brook, body of water or wetlands? NO Q 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: i
■
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location: I I
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO 0
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 Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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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 compfetetl by office
4 P #// / • 1-Map Lots 1 } .I ,1 Uit
J Y. i ,, i
m is rr I ,:
Zone Overlay District '
• Elm St District :a .: r 'CB District :r r;.:
. SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
l3TL
2.1 Owner of
'1')/V ecord: ✓Vy i'1 ,9141 AR4iDlitY4P !.' 0�
Name(Print) � �� Current Mailing Address:
Telephone
Signature
t'”,
2.2 Author' ed A• nt: f / p
Name(Pr ' ,rte Current Mailing Address:
/`� �. WI-�1= �- 3
Sig.-ture Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Cost(Dollars)to be •• • • : Official Use Only
completed by permit applicant • .
1. Building ),._... ..1 (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 e"----
_t/� gq I 436-
6. Total=(1 +2+3+4+5) ,"'/ Check Number vn((/`/
ThisSection For Official Use Only .
• Date
Building Permit Number: . Issued:
Signature: .
Building Commissioner/Inspector of Buildings .. . .Date
66 BRADFORD ST BP-2014-0645
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24B-061 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# B P-2014-0645
Project# JS-2014-001097
Est. Cost: $5915.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 98785
Lot Size(sq. ft.): 18774.36 Owner: NYMAN JOHN A&GUYLAINE BLAIS
Zoning: GI(108)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 66 BRADFORD ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR (401) 935-2633 () Workers Compensation
PROVI DENCERI02908 ISSUED ON:11/21/2013 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 11/21/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner