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17A-097 (3) The Commonwealth oj'Massachusetts Department of Industrial Accidents - Office of Invesdgations 600 Washington Street Boston,MA 02111 www massgovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ApRlicant Information Please Print Le 'bl Name(Business/ftanization/individual): } Address: City/State/Zip C� ��Phon�e#--:_�4464�V Are y an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 2-0 4. [] I am a general contractor and I 6. El New construction employees(full and/or part-time). have hired the sub-contractors 2.[--11 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9 n Building addition [No workers' comp.insurance comp.insurance. required.] 5. [J 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 boa#1 must also fill out the sectionbelow 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'comp ation insurance f r my employees. Below is the Ucy and job site information. Insurance Company Name: �G f Policy#or Self-ins.Lic.#: Expiration Date: J Job Site Address: - `1/r1) �" l 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 u p en of perjury that the information provided above is true and correct. Sim ature: Date: .-r Phone#: Official use only- Do not write in this area,to be completed by city or town official. City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other HOME IMPROVEMENT CONTRACT PLEASE R)KAD THIS Sold,Furnished and Installed by' Branch Naorar Horton Nertb&South Date1Z/Ll 13_ ' THD At-Home Services,Inc, d,Va The home Depot At-Rome Services ,Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shiro"bury,MA 01545 Toll free 877-903-3768 Federal ID#7S 269$46(1;MB Lie N C 0'1439;Rl ConL Licit 16427 CI'Lis#HIC.0565522;MA Hama I n ovarnmat O mtracaw Reg.#126893 Installation Address,. �1�1 t l tJ � 111 10Q �A 6 14�, city State zip Purcharer(al: Warn Pbougn Home Phoam Cell hone: Home Address: (If different from Installation Address) City State zip E-mail Address(to receive lwc4 t communications and Home Depot updates):— ©I DO OT wish to receive any marketing emails from The Home Depot Protect Infarntaiietn: Undersigned Cnsiomer'�,the owners of the property located es the above inatalladon address,agrees to buy, and TI->p At-Iiaaare Services,Inc.("�he Home tTepot'�agnnxs to finraitsb,deliver and strange for the ipstallatiorl('[DataTiatlon")of all materials described oa the below snot ors the referenced Spec Slueet(s), sill of u+bich ar+r alcoryorared into this Conhact by this reference,along with any appEir:able State Stmpplement and 1'syrrraot Summary attached hereto and arty Change Orders(collr:ehvdy, °COatract"}. SW 9h s ProJectAmaust Roofing USIdivS LJ Winiadvws Ll Fm on 7a5 oGuttara/Covets❑F.no'Y ows 0 $ A c- Roofing QSi4fing indows U lusntadon 110maters/Covers ClEntry Doors i-7 $ Roofing Siding Ll Windows Lj Insulation ❑Gutters/Covers i]Bntry Dom Q $ Ra ma Llsiding UWFdm M Guist= QduteCS/Comm©Entry Doors C]—_ $ Mmimum 2VA Deposit:d(Aaaroet Awmmt due upon execution of this cosaarL Total Contract Amouut $ Illsirm Purchasers racy not dspadt marethan ene41kd of the CeotrsciAm"sht Customer agrees that,irrnnediately upon completion of the work for each Product,Customer wilt execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applitabla each Customer under this Contract agrees to be joiutly 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 authorised service provider determines that it cannot perform its obligations due to a structural problem with the home,environmental hazards susb as mold,asbestos or lead paifit,other safety concerns,pricing errors or because work required to complete the job was not included in the Comm Payment Summary_ The Payment Summary#. / "a included as part of this Contract,sets forth the total Contract amount and payments required for the deceits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled too eompleteiy fdkd-in copy of the Contract at the dine you sign. Do not sign a Completion Certificate(note; there is one Completion Certificate for each listed'Product as defined by ladividuel 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 ROME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING TITS HOME DEPOT'S OT VIER RFMEDWS FOR RECOVERY OF SUCH AMOUNTS, As$Wnee and At ritation: Customer agrees and understands that this Agreement is the entire agreement between Customer ancl The Clone Depot with regard to the Products and Installation services and supersedes all prior discussions and egresmeWs,either oral or written,relating to said Products and InsWletion.This Agreeauat cannot be assigned or amended except by a writing signed by Customer and The Home Depot.Custorer acknowledges and agrees that er has read,understands,voluntarily accepts the terms of and has received it copy of this Agreement. Aces d by Su j I j / >�� x C er's Siguatt Date Sales C204jut s Signature Date x 1 / [,�a � Telephone Nm -usto e s � Sales Constiltent License No. CAiNCELLATION; CUSTOMER MAY CANCEL 'I Ht$ (asapplieable) AGREEMENT WITHOUT PENALTY OR OBLIGATION q13 6-b.f- C 2 )Q BY DELIVERING WRITTEN NOTICE TO THE HOME L'7 J J of ) DEPOT BY MIDNIGHT ON THE TIiIRD 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. NOTiCM ADDITIONAL TERMS AND CONDITIONS ARE STATED ON Tut$Rtv)MSX SIDE AND ARE PART OF THIS CONTRACT 08,90-13 WNte-BranchFlle Yellow-Customer 6500 VantagePointe LxC Dcubie-liuig 1,;8"Cass Arqw- LwvE Nc Lan-0-1a d G- s Gd.ds Ven na de dobiz giftotne-Vnib 3.18 mm M.drio Arg6n Law-E-Sin ta Adfio laminado-Con reillas CPD.-S3P-A44-21042-00002 07-75 DH ENERGY PERFORMANCE RATINGS EVALUACM DE REwlmEwc aMr.EMCO U-Factc;r j Solar Heat Gain CwTderd 0.29 1 .65 0.24 ADDITIONAL PERFORMANCE RATINGS FVAUMCM MMILEWWARIA DE RENMMWO Visbic T mnsm#mce 0.45 Em t4,zm*z-4OIX&oft U*res=p-cor.In Pwt,165e�c tAZd Pk W-Rc 3w."eklminm PW&A lc lke o ka Lo 14.1drF.Ite a y px,�-es;o�-USIC romwlri,ftja :�rqA *4yrw gwarAza qL*V"mclsea ad-Usca Wa tA isr,espxle�;.0ia iw kmi - fib--ima.--a al.s- Unit qualiflei for ENERGY STARS regior<s):Northern. Norih Cenral,South Central, Southern. STC:M DP:+25/-25 11411 Rein OO/Gass ProSolarili-LC25 Tested Sim 48"x 80° Florida ProductAppiavii.FL6167 Applicable Test Standa-As): ANSVAAMAP4VWVDAIOIA.S.2-97,AAMANVDMAACSA 101A.S.2fA440-05.AAMANVDMAr.SA 101A.S.21A440-08. A44ML09 Canadian Suppi 885879=1 q0333 HS Haward 6400094A 06&m erm pcsbknmem�..os t-:%ERG"f STM*Pam cw4c--mts we=de esta,r a"W.m1RS!WTUV. r City of Northampton _ MassachusettsS�s WZ w- \y DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building ' Northampton, MA 01060 ssy •. Lh� 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 rouqh 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 1, understand the above. (Home owner/resident's signature requesting exemption) 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 Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLvibly Name (Business/OrganizatiorAndividual): Address: City/State/Zip: Phone M 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 g. F� Demolition working for me in any capacity. employees and have workers' 9. [] Building addition [No workers' comp. insurance comp. insurance.1 required.] 5. EJ We area corporation and its 10.E] 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 12T] 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 Off ce of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury 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 SuRmiso r: Not A plicable £ / Name of License Holder: 2` :/ License Number Address i._ Expiration Date Sign Telephone �^ 9:Re isteredl H' " m rovem , Contractor Not Applicable £ Com an me Regis ration Number ss Expiration Date Telephon (��/ �^ SECTION 10-WORKERS S'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 Egemptiori 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. De£nition 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) F7 Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [[]] Decks [❑ Siding[0] Other[p] Brief Description of Proposed W Lao ork: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet bar If.,New:house and:o addit"onto"exisfing aiouslng; cornp(ete tFie fo[iow[nc: 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, as Owner of the subject property hereby authorize to act on m behalf, in all m ters reI tiv o work authorized by this building permit application. Signature of Owner Date as Owner/Authorized Agent hereby dec are th the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. f Signed undnt��-pe rjury. Print Name Signature of r/Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Tbis column to be filled in by Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg.Square Footage 01"o Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Permit/Variance/Rnding ever been issued1or/on the site? NO 0 DONTKNOy 0 YES 0 |F YES, date ioued: IF YES: Was the permit recorded at the Registry ofDeeds? NO ~_'K ) DONTKNOYY 0 'ES IF YES: enter Book 1 Page and/or Document# B. Does the site contain abrook, body of water nrwetlands? NO 0 DONTKNOYY 0 YES »~� IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to beobtained �~� Obtained »,� Date Issued: �~� �~� ' �� C. Do any signs e�st on the property? YES ��/ NO �~�� � 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 0 IF YES, describe size, type and location: ' E. Will the construction activity disturb(clearing, grading. excavation,or filling)over 1 acre orioit part ofa common plan ' that will disturb over 1acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. j� b3; 7E7e atfinm't er J.use o ( s 1 y �j City o Northampton �, � Cy � .,'��'�� tY p Status a Perrntt hFk:A':�71N C , Bulldln Department Ct3t�Cut/D�A�rewa Perot �, 4 r t "yu r 'k§ Rk'C R,1'sk "�r � '°S ':�..'P s,�r'� r 212, ain Street ewe�/5ePTlca . °'"�7 .-+ �• RO m 100l+tater/relE-Auaila�lhty ' ' y s '' + 1 4 fi 1tx'i 1Y 5 11 1 North , MA 01060 TwulSets�i1 #r ctrir I P'dF}S a' f " k' JS u i _.pholie 413-58 - Fax 413-587-1272 PIofIS Plans'i �4 = s x� i+" t r !M e�i (]tl7er�5�}eClf fi h 1 sM � �1�, t g r APkJ6ATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE_INFORMATION This sectign fo be completed by�offic 1.1 Property Address: , -� e i r ��� k`Zone � � Overlay D�sfrict ' " = 5 Elm St rDistnct CB Distract SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT -. 2.1 Owner of Record: Name Current Mailing Address: Telephone Signature 2.2 Authorized sent: Name yl Current Mailing Address: �dl-`4i����� T S' nat a Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building j��7/) w/�- (a) Building Permit Feb' 2. Electrical 4— vhf (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official'Use'Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector`of Buildings Date 37 GRANDVIEW ST BP-2014-0752 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-097 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit# BP-2014-0752 Project# JS-2014-001294 Est. Cost: $2220.00 Fee:$35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 126893 Lot Size(sq.ft.): 9365.40 Owner: DREYER BARBARA J&SHIRLEY I SICURELLO Zoning:RI(100)[URA(100)/WSP(42)/ Applicant: HOME DEPOT AT HOME SERVICES AT. 37 GRANDVIEW ST Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCER102908 ISSUED ON:1212712013 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 6 REPLACEMENT 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 12/27/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner