36-027 (2) The Commonwed1th ofMassachusetts
flepdriMent of Indushial Accidents
Office of Investigadons
660 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit:.Builders/Contractors/Elecfiricjaus/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): („ _.
Address:
Qty/state/Zip: . f �f :.} Phone.#: .1.A.27-519
Are you employer?Check the appropriate box: Type of p'roiect(required):
1. am a employer with 4• ❑ I am a general contractor and I
employees(full and/or part time).* have hired the sut-contractors 6. Now construction
2.[] I an a'sole proprietor or partner listed on the'attached sheet. 7. 0 Remodeling.
ship and have rto employees These sub-contractors have g, ❑Demolitions
worldn for me hr an capacity. employees and have workers':
g Y P tY• 9. ❑Building addition
[No workgs'comp.insurance comp.insurance.
required.)• 5. ❑ We are a corporations and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers hage*exercised their 11.❑Plumbing repairs or additions
myself [No workers'comp. right of exemption per MOL 12.❑Ro repairs
insurance required.]t c.112,§1(4),,and we have no -
employees.[No workers' 13. that
coin.insurance required.]
•My 6pplieant.,,1 ho checks box#1 must also fill out the section belowshowing their workers'compensation policy information.
t Hon waen who submit this affidavit indicating thoy an doing ill work and then him outsider contractors trust submit a new affidavit indicating such.
t6ntractors shit check this box must attached an additional sheet showing the.mne of the sub•conttutors and state whether or not those ci6tFes have
employees:if*o sub-conaw n have employees.dM must provide their workers'oomp.policy number.
Ian an employer tlftd isprovumg work=,vmpensaden lasumnce for my employeez,Betow is thepoiicy andJob site
Insurance Company Name: , ndv6h A T6,t(020,ce_ 1p,
Policy#or Self-ins:Lic.#: Expiation Date:
Job site Address: 3(0 Cityis taterzi : t � b�j ,
Attach n copy of the workers'compensation policy declaration page(showing the policy-number.and ezpirxdon date).
Failure.to secure coverage as rcquired under Section 25A of MGL c.152 caa lead to the imposition of crimbW penal es of a•
fine up to$1,500.00 and/or one-year imprisonment;as*411 as civil penalties in the form of a STOP WORK ORDER and a fine
of up io S250A0-n ay against vioRE $e advised That a copy of this statement may be forwarded to the Office of
Invests lions of slit:bIA or kam e=amasg verification.
I do hereby ce e p d penalties of perjwy that the inforrnadori provided abov4 is true and correct
S' a Date: Q
kL3 t
71ftagrd se on Do not wr area,tb a comp e y or town ofjlcial
own: PermitUcense#
uthority(circle one): '
f Health 2.Building Dep artment 3.Cityrrown Clerk 4.llectrical Inspector 5.Plun bing.Inspector
Branch Name:yi Dpte: J�17' TFiD At-Homeeivices,Inc.
dWa The Home Depot At Bane Services
345A Greenwood Street,Worcester,MA 01607
&much Namberf Rj% Jab p: Toll Free(800)657-5182; Fos:508-756-2859
Podmal ID 9 752698460 M11 Lic 0 C 02439 Rf CoW.Lief 16427
Cr LAc#563322; MA I-row i n fmctc nt Comnenr Rex.#176993 9 �
rustailatlor Adthws: � •K-FigL.V Die ��uj�?tr l] A �Oio6--1
zip
I
City state
L"4#Flip of e/Y"s `
Parcnasetis?, Lie.#& Me/Y" Vk'ork Itaawc Paoee:
Home Address:
(ff different from installation Address) City state Zip
E-mail Address(to receive updates and promotions fie*The Home Depot):
Project information: 1/WeNcyu C"Purchaser•') the owners of-the Atop"located at the above installation address,offer to
contract with THD At-Boma Serviccs,•I1r. p��to furnish,deliver and arrsogo for the installation of all mataWs
as described on the attached Spoc Sheet#_fG?fo�_ ',incorporated herein by reference and made a part hereof.
Hone Depot reserves the rW to cancel tbls coWraeb lfr stpao re-Eoapection of the;obf lfome`Tkpot determines that it
cannot perform its obiigadom due to a structural problem.with the hoses,prlchrg errors-or because work required to
complete the job was not ineiuded in the Spec Sheet ar Contract
DEPOSIT PAYMENT OPTIONS
(SYbieei to fund verif mdcs and/or credit approval.)
CONTRACT AMOUNT S 1. Cbe:k•,Cgahicn Ckeek or ttS Pas W Service Mm+cy Order
e3 (Mate poyable to 11ro Home DePntl.
f LESS DEP0Srf 3 'z�' t 2. Cteatt Cane arms ad"p+arweet epflew-Chvie Out Gnaw
BALANCE DUE � I j�/ v;.. stastuC"d p:'°°"er
ON COMPLETION 5 �[ 7 �stoma Depart Game Iffptwctant: can, Home Depot Orem Cad
('Minimato 25%of Contract Amount due upon t7 New Acco at ❑XV11tlnt'Aeodanr (Hfl 4,
esecrdan of this CO6 Araliails CreIIC S t 4 , (NIL A IMCC ONLY)
tN<t¢
y indicate Payment MetindFor
AeetiA°,
BALANCE DUE ON COMPLETi N:
Name as it appear an card:
--By my/bur signature below,UWe agree to allow Home rlolmt to
3�Oa 3 •� 'e7gb charge the shwa credit card fartbe ti
•Who you provide a cbwk as paymeat,you atthorine w either ]
to use iaramatim fig your cheek to asks a on*-doe eketrosie t.
rood Mm*w 4mm year aeeawt or to proems We Mn-Ant as e
cbeek tmasaetoe.When use an int'ora0000 ram year drA to till.or 1_=C Authorization Codes
make asatecwWoforddrawler.Amh a"be mithdtaws*= -
yove acmrm as soon are the pwr wet is raoeiv#A end you will not Flnai Pa lent
reoei"your:hmk be*, #
Pumbaser agrees that,immediately upon completion of the work,Purchaw will execute a Completion Certificate and pay say
balenoe due. Purehasa also agrees to be jointly and severally obligated and liable hereunder.
Entire Astreeteat:This agreement and its edtachmer1%including any futancing agreement,contain the complete agrccrnelt
between the parties and can oat be amended or muddled milers in writing in a separate agreement signed by both patties.
NOTICE TO PURCHASER
Do not sigh this contract before you read IL You are attitied to a completely tYied-in copy of the contract at the tube
you skip. Ksep It to pm►txet your rtgkta Uo net stir a Cumpittion Certlfleate before this project is complete. Law
prohibits home repair contracton from requesting or accepthtg A Completion Certificate signed by the ON ner prior to
the actual completion of the work to be performed udder the contract
You may cancel this transaction any time prior to midnight of the third business d%after the date of this contract• See
Notice of Cancellation for an explanation of ibis right. There will be a Service charge equal to 10%of the contract
amount if,job is cancelled by Purchaser AFTER the third huslness day,but BEFORE materials are ordered.There will
be a service charge equal to 2501a of the contract amount if job is cancelled by Purchaser AFTER materials are ordered.
BY MY/OUR SIGNATURE BELOW,IIW£UNDERSTAND THAT THE AGREEMENT MAY BE SUB3ECT TO REVIEW
OF MY/OUR CREDIT HISTORY AND VWE AUTHORIZE IfONM DEPOT TO VERIFY AND REVIEW MY/OUR
CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL
LIABILITY INCURRED FROM fNADVERTENT OMISSIONS OR FRRORS.
BY MY/OUR SIGNATURE BELOW. 1/WE AGREE TO BE BOUND AY THE TERMS OF THIS CONTRACT. UWE
ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF NOTICE
OF CANCELLA
SUBMrrTED BY: r Dote
ACCEPTED BY: Date: C3
or
Date: _
Pnrclatsa
NOTICE:ADDTrf0NAL TERMS AND CONDITIONS ARE STATM ON THE REV ERSE SIDE
AND ARE PART OF THIS CONTRACT
e•f•D7 mv4-2.07 C-SC White—Stanchftle Yellow—Cualomer Pink-SalmConsuttont
s .d xd3 13r83SUI dH wdse:c coos t'o AOW
DEPF??T1v±_NT OF EUILD_EJ I-,SPE=ONS
212 yfain Strteet * Municipal Bu1IdItIg
INSPECTCP ���
NorthatnPtnn, MA 01060
L1 LL 11 it NN ACKNOWLEDGEMENT
Fas f Massachusetts allows the homeowner the right under 780CNa 108.3.4 to
er construction sups: ' cr. Tlie state defines "Homeowner' as, "i ersoa(s)
a parcel on which he/she resides or intends to be, a one or two family
tached 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 I
home owner."
The building=depaftment for the City of Northampton wants any person(s)who seek to
use the home owner exemption, to act as thew-own corst ac iw. supe"WISO i 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 worm at various stages, which include foundation./footings (before bacI;filI).
sonotube holes (before pour). a rough buildine insaection(before work is
_co-acealed) i-asulatisn inspection (if reu.uired Tn.)a-nd-a al_buildine.insnection. 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 worl- can-be-insyert-ed__
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
L 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 lY_rassachusetts
Department of bidustriall Accidents
�.
0- ofInvestigations
-r--=
666 Wash in aton Street
z' Boston, 3L, 4 62111
www.mass.gov/dia
Wormers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeaibIv
Nalne(3usiness/Organization/Individual):
Address:
City/Stag/Zip: phone.=:
Are you an employer?Check the appropriate boar Type of project(required):
4. I am a gene-al contractor and I I
i.❑ I am a employer with 6. ❑New construction
employees(full and/or part-time)_ have hired the sub-contractors I
r7 r_ p listed an*}+e a*trc4ed shee� 7. ri Remodeling
I 1 am a SO'Le proprietor or partaer- ! -L
ship and have no_ -1037ees These sub-contractors have ! g- Demolition I
worhz.- for me in any capacity. employees and have work.'
9. Building addition
[No workers'cones.�s..rance comp.msurance.l
� I
required.] 5. L7 We are a corporation and its I0.❑Electrical repairs or additions
=.❑ I am a homeowner doing aD work o icers have exercised their 11.0 Plumbing repairs or additions
myself [No workers'comp_ right of exemption per MGL 120 Roof repairs
insurance required-1 t c. If2, §1(4),and we have no
employees. [No workers' 13.[1 Other
comp.insurance required_]
- --'may aFP i cner noz�..tmzst a:so ED out me section oelaw snowing thetr workc.s'compensanon policy mformanoa -- ---
' Homeowners who subrmt this affidavit indicating they are doing aII work and then hire outside contractors must subrnit a new amdavit indicating such.
*Contractors that check this box tnuscattached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
emplc veer. If the sib-contractors-have cnpioves,they must provide their workers'comp.poncy nutti m
I am an employer that is providin,workers'compensation insurance for my employees Below is the policy andjob size
information.
Insurance Company Name:
Policy rr 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 2fA of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to$1,500.00 and/or one-year iznnrisonment, 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 maybe forwarded to the Office of
Investigations of the DLk for insurance coverage verification-
p do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
��-�o_-- .------- Date-
Phone#:
VULcuu use onty. llo not write to this area, tb be completed by city or town offciaC
-City or Town: ----_ -_-- _ -_-------_-__ _-. —Per.-mit/License
Issuing authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 3_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 Improvement Contractor: Not Applicable ❑
Company Name Registration Numb r
�5 e�1�D 1:�3
Addre ff Expiration Date
G-� _Telephone 4R �
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)j
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....... ❑ tie.... ❑
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 ❑ Replacementows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks Siding [❑) Other[❑]
Brief Description of Proposed"—
Work:
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 house and or addition t xstin housin_q, complete the following
a. Use of building : One Family 11Z 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
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit applicat on.
11 -7 /L
Signature of Owner Date
__ 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 the p nd pen s of perjury.
Print m
- l
Signature f Owner/A ent Date
h
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
Frontage __ �- ... _. ......
Setbacks Front
Side L R: .. L. R:. . .
Rear
Building Height
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 Q YES Q
IF YES: enter Book Page and/or Document#
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 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 0 NO Q
IF YES, describe size, type and location:
E. Will the construction activity dist_irh(niaaring,grading, Pxcavation, 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.
Department use only
f „ City of Northampton Status of Permit:
�V Building Department Curb,Cut/DriveuJay Permit
212 Main Street Sewer/Septic Availability
C Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
F (7`` pherre Xf3-5 1240 Fax 413-587-1272 Plot(Site Plans
-° Other Specify
APPLICATION-10 CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEC-NON 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot Unit
lip Zone Overlay District
Elm St District CB District
[SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
--r
Telephone
Signature
2.2 Authorized A ent:
L-2 F)d
Nam ( �a&L Current Mailing Address:
!B -
Signatur Telephone
SECTI N 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building i (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from L6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6.- Totall=_(1 +2+
BP-2008-0495
GIS#: COMMONWEALTH OF MASSACHUSETTS
rt 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-2008-0495
Project# JS-2008-000742
Est. Cost: $6715.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 126893
Lot Size(sq.ft.): 13198.68 Owner: ADAMETZ WOLFGANG
Zoning: URA Applicant: HOME DEPOT AT HOME SERVICES
AT. 36 DEERFIELD DR
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341-9401
Workers Compensation
WORCESTERMA01607 ISSUED ON.111812007 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 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 11/8/2007 0:00:00 $25.0020993
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo