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32C-125 (2) * . A, B • = egularons an• an•ar•s � One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 152379 Type: DBA Expiration: 8/23/2010 Tr# 0 I & ! REMODELING IVAN KOSOBUTSHYY - - --' - 72 SATFFORD ROAD -... .- . . -- MONSON, MA 01057 •. .. .... . ..-.. .. .- Update Address and return card.Mark reason for change. Address Renewal "' Employment Lost Card OPS:CA1 5OM.07ro7•FC8490 $ BOO.itaildiarffieliaddififitireffdla License or registration valid for individul use only --- HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: vrEfZ - .. Board of Building Regulations and Standards ;:=,_14 0,, Registration: 152379 One Ashburton Place Rot 1301 Expiration: 8/23f2010 Trf� 0 One As Ma.02108 Type: DBA 18,l REMODELING ) IVAN KOS08UTSITYY 7 (4( 2 SATFFORD ROAD MONSON,MA 01057 Administrator Not valid wi out signature • ACORD CERTIFICATE OF LIABILITY INSURANCE DATo I16I2oo8 TM. PRODUCER Dhono: (413)781.2410 Fox'13-731-7530 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE CENTER OF NEW ENGLAND ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P 0 BOX 1175 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR WEST SPRINGFIELD MA 01090-1175 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Peerless Insurance Company NAN KOSOBUTSKYY INSURER B: 72 STAFFORD RD INSURER C: MONSON MA 01057 INSURER D: INSURER E: COVERAGES T IC POLICCO OF INSURANCC LISTED DCLOW IIAVC DECN SEUCD TO TI IC INSURED NAMED AOOVC FOR 1110 FOUC'PERIOD NDICATED,NOTWITIISTAVCNG ANY REOUIREMEN-,TERM CR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT Wr-H RESPECT TO WHCH-F113 CERTIFICATE MAY BE ISSUEC CR MAY FFRTAN,THE INSIIRANCF AFFCRrFr)FY TI-F DCI ICIFS OFSCRRFr)HFRFIN IS SIIRIFCT-f)Al I TH=TFMS,FXCI ILSIDNS AM CONDITIONS OF SIICI- POLICES.AGGREGAT LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POUCY EXPIRATION LIMITS LTR NERD DATE1MMVDD/YYI DATE IMMIDOIYYI GENERAL LIABILI Y GL8439797 05/15/08 05/15/09 EACH OCCURRENCE $ 1,000,000 X COMMERZIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 n: PREMISES(Ea occuree) CLAIMS MADE © OCCUR MED.EXP(Anyone person) $ 5,000 A PERSONAL S AIN INJURY $ 1,000,000 G=NtHALA:iNhtiAIt $ 2,000,000 GENt AGGREGATE LMT APPL ES PER: PRODUCTS•COMD/OP AGG 3 2,000,000 n POLICY n JE 0. n LOC AUTOMOBILE LIABILITY COMRINFD SING!F AMT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BOCLY INLAY (Per pescn) $ SCHEDUED AUTOS HRED AUTOS BOCLY INJL*IY $ $ NON-OWNED AUTOS (Per OCCICOnq PROPERTY DAMAGE (Per accident) GARAGE LABILITY AUTO ONLY•CA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG 8 EXCESS/UMBRELLA LIABLITY FAC}I Dr.C.I IRRFNCF 8 n CCCUR in CLAMS MADE AGGREGATE $ $ CEDUCTULE $ RETENTION S $ WORKERS COMPENSATION AND I STATU- TORY WITS I I O-IlER EMPLOYERS'LIABILITY E L.EACH ACCIDENT ANY PROPRIETORIPARTIER/EXECW'IVE OFPICERMEMBER EXCLUDED? E L.DISEASE-EA EMPLOYEE $ Byes,describe under E L.DISEASE-POUCY LMT $ SPECIAL PROVISIONS below OTHER: DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS THD AT HOME SERVICES,INC.,AND THE HOME DEPOT ARE NAMED AS ADDITIONAL INSURED AS RESPECTS GENERAL UABILITY AS PER WRITTEN CONTRACT ONLY F#508.791-8047 CERTIFICATE HOLDER CANCELLATION SHOULD MY CF THE ABOVE DESCRIBED POLCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF THE ISSUING INSURER WLL ENDEAVCR TO MAIL 20 DAYS WR(-TEN NOTICE TO THE CERThICAJE HOLDER NAMED TO 1-IE LEFT,BAIT FAILURE TO DO SO SHALL IMPOSE NO THD AT HOME SERVICES,INC. OBLIGATION OR_/ABILITY OF ANY KIND UPON THE INSURER.IT'S AGENTS OR REPRESENTATIVES. 3200 COBB GALLERIA PARKWAY,STE 200 ATLANTA GA 30339 AUTHORIZED REDRESENTATIVE w Attention: tephen ..Gallagher ACORD 25(2001/08) Certificate# 36008 0 ACORD CORPORATION 1988 ,tilass• •tchusetts Board of Department of Public Co and ot►onilding Rez`uiations; d Safer. :: 1s0r S lty arpeciity Lice Restricteq CS SL 5 to: WS iVAN KOSOBUT 72 STAFF SKYY STAFFORD MONSp ROAD N� MA 01057 unumi.�iuner Expiration: 4/27/2012 Tr#: 98785 /ee ROME IMPROVEMENT CONTRACT t 0 6.3 6— S PLEASE READ Tale . Sold,Furnished and installed by: Branch Name: Boston Date: t 12+9 eh Tj]p At-Home Services,Inc. d/b/a The home Depot At-Home Services Branch Number: 345A Greenwood Street,Unit 2,Worcester,MA 01607 ❑North 33 ZSouth 31 Toll Free(800)657-5182; Pax(508)756-8823 ! Fedond ID#75-2698460;ME Lie#C 02439;RI Coat.Lie*16427 U r^ ` �) CT Life,#_565522.MA Homo Improvement Contractor Reg.#126893 Installation Address: 34 t'� mu i 6'T t∎01',T7`lei t'Vt . a, a ' aib b t City State 7ip Purchaser(s): Work Phone: • Home Phone; Cell Phone: 1-,, ,,,,S4Q..Qi ;. ;. liNEMEN [ 1 Mail. [ ] [ I [ I Home Address: (If dif erect front Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates); ❑I DO NOT wish to receive any mattering entails from The Home Depot P lect Information; Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and THD At-Home Services,Inc.("The Home Depot")agrees to furnish,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 any Change Orders(collectively, "Contract"): .rob#: e.w.y seeee.i Products: S.ec$b •a #: Project Amount a'"ling©Siding ■Windows ❑Insulation . ©5 63e ❑Gutters/Covers ❑Entry Doors ❑ 5I533 S 1355 ['Roofing []Siding ['Windows Insulation [Gutters/Covers ['Entry Doors [] T 0E00E14['Siding L)Windows U Insulation $ painters/Covers ['Entry Doors❑ ❑Roofing ❑Siding Windows Insulation $ ❑Gutters/Covers DEney Doors Ei Mbeimum 2g,t4[spoilt otComma Amount due upon oneeutton of*Fa contract. • Total Contract Amoent $ 1 3 s Maine Purchaser*rosy,not deposit more than one-third orate ContractAmotmt J Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate <4. (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(s)included herein,at [}� is discretion,if The Horne 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,ether safety concerns,pricing errors or because work required to complete the job was not included in the Contract. Payment Summarvj The Payment Summary# DP . , included as part of this Contract,sets forth the total Contract amount and payments requited for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-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 TrilE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTC REMEDIES FOR RECOVERY Oh'SUCH AMOUNTS. Aceentpnce and Authorization; Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot with regard to the Products and Installatinn services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed • by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a.copy of this Agreement. Accepted by; • Submi�tted-.ba:, . X •,� + X L t IICi `� ( `(v Customer's•gnaturc Date Sales Consultant's Signe Date X Telephone 14o. • Customer's Signature Date Sales Consultant License No. c„ANCELLA,FION: CUSTOMER MAY CANCEL THIS to.applicable) AGREEMENT'WITHOUT PENALTY OR OBLIGATION BY DELI'VERI'NG WR.TITEN NOTICE.TO TIM HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER 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.ADDMONAr,TERMS AND CONDITIONS ARE STATED ON THE REVERSE.SIDE AND ARE PART OF r tu8 CONTRACT The Commonwealth of Massachusetts Department of Industrial Accidents p= i__ t Office of Investigations 5 " • 600 Washington Street • 11=— $ Boston,MA. 02111 !.,,,,,,,,_—_,...70., www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers A s Dlicant Information j PIease Print Le°ibiv ..d. Name(Busines s/Organization/Individual): I Ile —tA Y r71 • •Address: (9455- C. 1 • • City/State/Zip: 4Tfr�dl �",3" Phone.#: cgnr3 f7 Are ygean employer?Check the appropriate box: Type of project(required): 1.Triton a employer with j too 4. 0 I am,a general contractor and I 6. ❑New construction . • employees(�'and/or part-time).* have hired the sub-contractors 2.0 I sin a sole pfaprietor or partner- . listed on the'attached sheet 7. 0 Remodeling ship and hive no employees These sub-contractors have ii. 0 Demolition • employees and have workers' working for me is any capacity. 9. ❑Building addition • [No workers'comp.insurance comp.insurance. 10.0 Electrical repairs or additions required.] S. [� We are a corporation and its ❑ np • 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 •airs • insurance required.]t c.152, 1(4),and we have no 13. _ ""�- employees.[No workers' �. .d • comp.insurance required.] • . •Any applicant that checks box ft must also tilt out the section belowshowing their workers'compensation policy infommtkir. ' t-Homeowners who submit this affidavit Indicating they are doing all lark and then hire outside contractors must submit a new affidavit radiating such. :Contractors that check this box must attached an additional sheet showing the name of the subcontractors and auto whether or not those entitles have • employees. if the Mors have employees,they must provide their workers'comp.policy number. Jam an employer that is providing workers'compensation insurance for my employee& Below Is the policy and Job site information. Insurance Company Name: k. �-- •- Mr? at It I &- Policy#or Self-ins.Lic.#: �� :5 Expiration Date: ( it •Job Site Address; '', 14 Ft.litt Cty/State/Zip ■ 1%M. a P 111 D)OLD I • 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 is civil penalties in the form of a STOP WORK ORDER and a fine of up to 3250.00 a day against they violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the a for insurance coverage verification. - _ I do hereby certi 0 4 p• /s••• •penalties ofperfury that the information provided ahoy- Is , and correct - .0! # L.' • a . .p Official use only. Do not write in this area,tai 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, • • _,Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: Not Applicable ❑ Name of License Holder: 4--#-r ''I 5 I er -- os ` License Num ;G Address Expiration Da n5 \14 Cpl ac-7 Signatur Telephone ��� 9.Reg'.tered Home.Improvement Contractor: Not Applicable ❑ rbt 3 Company Name Registration Numb r ? �g Tina g' )14) Address Expiration Date �,��C� C •- r K. l) (1067 Telephon)C'/T 2ID? 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 buildin ermit. 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 n Addition ❑ Replacement Wi ows Alteration(s) n Roofing El Or Doors Accessory Bldg. ❑ Demolition I i New Signs [O] Decks [C] Siding [1=1] Other[0] i Brief Description of Proposed G'' Work: Ci7 ,1.01'1 m Yes No Adding Alteration of existing bedroom 9 new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to istinq 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 stones? 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 2P c II C CI , 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. r de- Signature of Owner Date I,-------Eril , as Owner/Authorized Agent hereby declare that the statements and information information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed unclip- pains and p nalties of perjury. A .4 it Prin a W IPP; '' 7 - Signature of 0 ner/A e t 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 r------------ ----| r-'-------------� r--------------- ` Lot Size _--� Frontage � �--- Setbacks Front --- �--- ___ �--- F---� r---� F---� -- ----/ Side Rear „_ -�— r---- Building Height Bldg. Squar Footage _ _~ Open Space Footage (L»,mnum�m�mu�mpmou ----1 parking) #of Parking Spaces ----� ----^ ---- Fill: (volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? �� �� NO \~�� KNOW \~,/� DONTKNO YES m~� IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds NO �� KNOW DONT YES�_� r---- —�--> IF YES: enter Book [ Page and/or Document# ___-___-_____' B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW /-\ YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs tobeobtaned �~� Obtained Date |ssued' � obtained \�� �~� , Issued: C. Do any signs exist on the property? YES \�� NO \~~�� / �------------------ ----------'- ! IF YES describe. 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( ring, grading vation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YEG [ � NO { } �� �� IF YES,then a Northampton Storm Water Management Permit from the DPW is required. - 'N. Department use only. City of Northampton si tu4jof rn : Building Department CufBttt/Driveway Permit . 212 Main Street Sewei/SeptrcAvailability Room 100 0 1J T wwt63eN j.vaitab ty Northampton, MA 01060 Two Sets of Strucfural plans phone 413-587-1240 Fax 413-587-1272 Plot/ (te Mans '.) OtberSpe> �f'. :. ' 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 ,�� Map Lot Unit Zone Overlay District ✓ 1 i'rt�c ft`fir I ✓ Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �r eet( FGA;-1-51 ii - icam) Name(Print) c^ Current Mailing Address: 6-iir,C.1---- Telephone IIi� Signature 1111���v 2.2 Authori gent: t (G-1)( l ..,,r •1_k "[ , DI&D7 Name(Print) 4:71/ urrent Mailing Address: �� LID!C73 €21 9 3 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant _ 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 16) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) 13��� Check Number v y-3,7 This Section For Official Use Only Building Permit Number. Date `Issued: Signature: Building Commissioner/Inspector of Buildings Date BP-2009-0395 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2009-0395 Project# JS-2009-000533 Est. Cost: $1355.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sq.ft.): 5488.56 Owner: GIBBS BRUCE A&MARGARET L Zoning:URC(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 34 FRUIT ST Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935-2633 () Workers Compensation WORCESTERMA01607 ISSUED ON:10/9/2008 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT DOOR 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 10/9/2008 0:00:00 $35.0024339 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo