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nuaswamratuvtt:nuuyr Lux rmtwt.:r PLEASE ItEAif Twits � Sold,Putabed tad Ix%u edhy: � a:Cli l ya$mth Name: Dar on THD At-Home Servicaa,Ines dlblo The Rom Depot At-Home Services lirpoeb Number: 345A Grewvrood Stmt,Unit 2,Wareeaaer,MA 01607 QNorti 33 th 31 Toll Free($"657-51$2:Fax(509)756-8823 rodent iD M 7s-269ad6o;mR Lie#C 02439;JU Coa Chat'16121 CT tan#RM22;MA Ko m TmF[nven�R�Ccuawam Rrg.a 126143 Yg wlatlenAddreta: C? i.c S� CO- I t 10, �l�; 4"ity Suft TP PmxLmstr(sk WeNe plronc I7sA Pioaee Hama Adam..: �- (1f dilYer Am hu;W don Address) (hr Stan' ��o Mat Aadrem(to zeceive omieee cummmicatiow and Home Dgwt Wdases): U I DO NOT-wiab to mxire any n arkcang enaitits fo The Haase Depot Ed f 'U�("Costume'l the cwnere 0160 property located at t'he above imtallafon addam, to buy t- LW-CM Hatam 04W')�a to 8uaimh.deliver&ad mrr&og&'Nr the WW'Mdm(ti.shdlatton'�a all ttioasertals described on the below and on halo re6renced Spec 5hec1(sl ads of which are IM dtlm C0411 t 111b e� refatam,along what ady applieable State 5ulgrtemont mod Poraxat Sam=7 attached bertmn�GbMW Ctrd—(-UftCdVQIY. "CoaR'mttet"). Job prwrrawew! a' tatiae ]Cnn t Cvc OB8Vy1)m 7 Cs^y ok.affit ON.Ig wk&-In $ C30HU s/tests OEatry Daats rI Wdoin E3 s paua&rs I t:nvau CrIa"DOOM 0 01ftfing 0926suVioilowl 0 mmulatlott 3 C7GMt-t/Cavto EUnuyDeoa C!. 1 m18%9apwttatcorlrattAa►aMrtaneepaaemaealisiaFtliaoel6aet Takal CatathaetAuoWd S 1, Maleaxzioxlsaarat��p,letd�awatm.naretkacrb.Caaaaat,MaoMat: Customer agrees*rot,hune&vjy Mott eamplebon of the We&for tmtsh Product,Cluurtoer%FM exoaeoe:Cmr0009 C4ni80016 (amt for each pmdaer ma dsgnecl by m*&v4W Spat Sheet)hand M any'a*=cow. As eppticabie,each 411eIMW under this Couvaot sgraem to be joiudy&na sevaally obligated mad Roble haezmdw Tht:Roane Depot reserva the right to inane a C bmp Ordas or tMm2M to dtim Contract or any iodivickW Prod WWS)Waded braid+at is dUMOOX if Tke Rom Dtpat or i*uubW=d towhee pmri t dpsttob a tW it cauaot pontes iia ablisadous Ate to a structural puoblom Whh the home,tnvinotttDea W ha w&such as mold.aabutes or lead p"other safety eongeans,pricing MO 0 ar became WCrk wphtd to template thgjob W93 M Waded to the Cwtlatt ftPmmart blatnaaaav: The PayMCM SttMMMY ti t"?l40 .'.6 htelttded m put of this CMu"cats fatdt the MW Cantmet amwat and t>oyn"ts rogrtited fot the depoelts mad fingraymients by Pruehut(u1 oppliatbbm NOT'3CE'PO CUSTObtM You are#Rotted to a CONVIddy 611ad-br em of the CearU%d at W Una ydu Do a#spa a Cam*dm Cert11leaft(Row. t sera bate Compledauo C CW for aacb-tistod predoet to dyad by�oai Spat g6aeto before work an that Pradtet is"bo" In tie event of tsrmb Aden of tide Contract,Crsmhnar as pr Ths Rome the eostm of auterctaiP,labor.esp&Nea and marvleae=b5 The 3lext D a Awehmri> Slrvta R't�vWar�ie dse0 let tCtusiahaYNa y other tuaor4t*net la thin AAeaetetnt Or utaderr )anrr_ Tliiv I1tit+DTA i[tiVt fi1i1dOCTI1l S OWZD TO THE HOML Deem mom Tls D� 1if pAYMENT OR OTHBR PAVNIENTS [T� LIl13I"CMG TEM&ME OhdPM OMR MtXIMS FOR RRCOVIRY OF SUCH AMOUN'1'!i. Cw"W arm and u ndealamdm dub dds Agreacaat is tare eat—be aged went between Customer &au 3m rao,oc.eopvi vino:- :�to the Products and howintion mehvicros and m pwaft all 9 dboat 4UM&nd agr*aweek oidaer oral o r WriMIL to stud lhoducm mad botaRation This Agrlaemtdnt cannot be asaiaaod at r> eztczept by a!fit dVAd by Cumwmrr sad M* Depot,t aaeeoeer aolmoariedgoa and agrees that Oustom,Ina read.wrdetsahnda,volamarily&caegts the teams ofand bas received a copy oaf tbis Agreement. Camp ncr's Signature Dote Sates 's S s D&% X TdapboneNo. Cu 'm Signabae YOM Sakes Consultant t.acanme Leto. - T16 z CUSTOMZR MAY CANCZL TEM c'°e 0e°tw AGREC111)r T WPIHOUT PI N'ALTY OR OUJIGATTON RY OELf<VEMG WALIT IMN NOT IM TO TSL NOW DEPOT ev MMNWW ON Tim TUMO Wifimm DAY AMR SIGMGr TRW AG RIEMffiLVT TM STATic SUpDx.EmItN'T ATTACBkA 019Rg,'Y'O CONTAINS A FORM TO USE IF OM 13 $ltq¢C IhCSLLY "MOC'R3Rmd 8Y )LA'Cit' IN CUSTObSWS STATE. lifntt:6;AnOn Wt1w L'rAftr3AM M4tdKTatM mw aTAm an TM 1tt6v7 M MM AND A1tE XART OP TM CtPrTRACT a Om of C-SC tAmiite-8nrricn t 1a Yaat&v-4uatarn&r Pints-Sahs tea • 1 . t, 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 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 a, Department of Industrial Accidents i Office bflnvestiga ations - ,� 600 Washing aton Street Y s; ie+P Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): _ Address: City/State/Zip: Phone Are yo n 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 construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. F-1 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.F-1 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. R of repa' s insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. the comp. insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners 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 thepolicy and job site information. �--� Insurance Company Name: r-- Policy#or Self-ins. Lic.#: Expiration Date: / Job Site Address: City/State/Zip: tYZ2;21 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$250.0 against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investiolatio of the for ins ance coverage verification. I do here certify u d t e ns d penalties of perjury that the information provided above is rue d correct. Date: Phone#: 07fc•ial 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: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Registered Home lm''rove t l ohtra cfor y, ',�. .., Not Applicable 11 Company Name Registration Numt er V Addre,% Expiration Date MA�lv I I 6n� Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§35C(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. -Rome Qwii 'r ExeAipfion 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) ❑ Roofin ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [[:l Siding IV Other(0] Brief Description of Proposed "ter n Work: (/ %, YL4A ' Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition/ ' exiStind housin '.com 'letL-,'the fbttowin `: 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' sw_ G IQ/fi as Owner of the s::b1°Ct property 'y hereby authorize Ri eV to act on my behalf, in all matters r lative to work authorized by this building permit applica ion. Signature of Owner Date I Fe, loo4et— as Owner/Authorized Agent hereby declare that the s atements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pai s a d pen so erjury. Print Nam Signature o dAgent Date ` 1 Section 4. ZONING Alt 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 LotSize _ .,,.__,.,.. ._.._... .. _.. ._,_.. . _. _......... .......... Frontage Setbacks Front SideL:' _._.,,.. R.T. ._._.. L ....m .__. R .... .,._.: _.... Rear Building Height ry Bldg. Square Footage % Open Space Footage ° -" (Lot area minus bldg&paved 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 0 YES 0 IF YES, date issued:` IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book ; Page- and/or Document#' B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: 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: 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 0 NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. k h 1 Qepaent use©nly City of Northampton Stags of Perth' ; Building Department Fe, tt �� ` 212 Main Street SewefiSeptl arlalstltty3`� \�a� �ti i Room 100 WafeclYllfett�t�rarlatlttp ? n Ndfrtham ton, MA01060 €wobetso€StructurafMans 0 _ u - p _ phone 41'3-587-1240 Fax 413-587-1272 Plo Claris 200$ Other ec�>.. P. � y A PLICATION TO,F,ON�TRUC ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING t nt S'ECTIOW a,-SPT�I�OR'MATION t� This section to be completed by office .'T 1 Property Address: Map Lot Unit C �ZY_51DYr2 6�Yi-e- Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) � Curre t ailing Ad��S�,,,,_,,.,� di Telephone /�C► Signature 2.2 Authorized Agent: - Uh .1'J ljv4t Name nn t) Current Mailing Address: Si ature s I �� 9 Telephone SECTI 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com leted by ermit applicant 1. Building (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 6. Total=0 +2+3+4+5) Check Number a�d S— This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date t r a BP-2009-0339 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) Categor. BUILDING PERMIT Permit# BP-2009-0339 Project# JS-2009-00046_2 Est. Cost: $21679.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 126893 Lot Size(sq. ft.): 32844.24 Owner: SLOVIK NINA Zoning: SR Applicant. HOME DEPOT AT HOME SERVICES AT. 62 WEST PARSONS LANE Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935-2633 () Workers Compensation WORCESTERMA01607 ISSUED ON.912512008 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 9/25/2008 0:00:00 $35.0024210 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo