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36-180 (4) GATE(MM1D0NYYYI A�° CERTIFICATE OF LIABILITY INSURANCE 02/19/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 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), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)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 the Certificate holder In lieu of such endorsement(s). PRODUCER CON ACT MARSH USA,INC. NAME: TWO ALLIANCE CENTER PHONE FAX N. A1C No): 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC I{ INA92-HomeD•GAW-14-15 INSURER A:Steadfast Insurance Company 26387 141SURED INSURER a:Zurich American Insurance Co 16535 THD AT-HOME SERVICES,INC. DBATHE HOME DEPOT AT-HOME SERVICES INSURER C.New Hampshire Ins Co 23841 2455 PACES FERRY ROAD INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: ATL-003242685-01 REVISION NUMBER:3 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. ILTR TYTYPE OFINSURANCE A DL POLICY NUMBER- POLICY FF POLICY D/YYYY _ LIMITS A GENERAL LIABILITY GL04887714-04 - 0310112014 03/0112015 EACH OCCURRENCE S 9,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES nce $ 1,000,000 CLAIMS-MADE M OCCUR LIMITS OF POLICY XS MED EXP(Any one person) f EXCLUDED OF SIR:$1M PER OCC PERSONAL E ADV INJURY S 9,000,000 GENERAL AGGREGATE f 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS.COMP/OP AGO $ 9,000,000 P7OLICY PRO• LOC f X B AUTOMOBILE LIABILITY BAP 2938863-11 03/01/2014 03101/2015 COMBINED SINGLE LIMIT 1,000,000 Ea accident) X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE f Per en S UMBRELLA LIAR. OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE f DED RETENTIONS f C WORKERS COMPENSATION WC049101882(AOS) 0310112014 0310112015 1 OTH- C AND EMPLOYERS'LIABILI Y YIN WCO49101884 AK,AZ,VA 03!01!2014 0310112015 1,000,000 ANY PROPRIETORIPARTNERIEXECUrIVE NIA A ( ) E.L.EACH ACCIDENT S D OFFICERIMEMBER EXCLUDED? WC049101883 FL 0310112014 0310112015 ,000,000 (Mandatory In NH) ( ) E.L.E DISEASE•EA EMPLOYE S H yes,describe under EL DISEASE•POLICY LIMIT S 1'000'000 DESCRIPTION OF OPERATIONS below C WORKERS COMPENSATION WC049101885(KY,NC,NH,VT) 0310112014 0310112015 (EL)LIMIT 1,000,000 C WC049101886(NJ) 0310112014 0310112015 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE IDEA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE or Marsh USA Inc. Manashi Mukhedee ©1988-2010 ACORD CORPORATION, All rights reserved. A roan )s(9ni-nlns) The ACORD name and logo are registered marks of ACORD Tite Co:�rnonweaith of lllnssachusetts Dearfr�tent o ,=rdtestric�Aecirie its Office of Lnvestigations 600 Washington Street _ Boston,M-1 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):, 8j�� tq j/�r! $ Address: City/State/Zip:__6 alfv� _ b�. X 03�' Phone t 1 Are you an employer? Check the appropriate a: Type of project(required): 1.❑ I am a employer with 4. LEI 1 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, E] Demolition working for me in any capacity. employees and have workers' 9 F� Building addition [No workers' comp, insurance comp•insurance.: required.] 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself o work ' right of exemption per MGL y � workers' comp. 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.[_1 Other 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. 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. /� � Insurance Company Name: / Y�'� /7 c 1 5`j�Jt, �i/1/'S (�O , Policy#or Self-ins.Lie.#: W C 0 Expiration Date: 2 Job Site Address: V v City/State/Zip• 1177 s Attach a copy of the workers'compensatio4 policy declaration page(showing the policy number and expi(ation 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 certi er l pains es of perjury that the information provided above is true and correct Signature: Date: Phone#: 40) Uffcial 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#: r enetgys tat.nrcaa—mcan.gc.ca *; t)uslllltd Remove label.Aar final Inspectichi SAVE far future reference . Weather Shield CPO# 050=A-172 ' 11 FRC Model B10B Double bung Operatinb Alum clad Thermal Frame 314 Inch Glazing rwNC;4ae1:ta ZO—E .022 Low—E Argon Fill Grille in Air Space ENERGY PERFORMANCE RATINGS !!—Fader Solar Neal aitt Codticient 0.30 1.70 0.1 1fKlridS► ADDITIONAL FERFORMAKE RATINGS Yislble iransarlilapce CrmdeDSAipll Resistance E 0.40 0 Yeavlrcburer stpulettt hat*best ntngt tmlorm m apprItshhr NFflC pmtedurts lot dettmdalnp Thole pmdett nirgr periarnwrt.NFRC retnp are debennlned lar e'' trod gel at 4ar1mnmtnW csndatcAs and 3pQWic pndtrti slttr& NFK does eat mtarmw+d any produci and'dOtt flit runnI ha eulublay of any pmdod bo+any spedic us,. C4asvll menul,cmni't Atrnw+s tar ethn pmducl pet hwt;t bnlomula+. www.nrrr. a Maeh or axtecds M.E C., C.E.C.,and I•E.C•C. Air lntlltratsoa As utramenls rrs�� /�SLt ltcedto ANSVAAUAIMKWDJ.tO1lS.2-!7 (\U .` O M-LC35 44X!0 b esr ei la AA N A/W D b1 AX&A Ipin S2rAA4D'-pS UH-LCIS IttaMAN"X901 -- 35 Use Ynbt 9rtetsrtt hdenet-4 Ft,MU 11% plDalb ' r-rnr,'AA7d-9i-1—1 btOESCO2A11HSTl) a I �1�� (!�niN iiln7ilY'C��C� [/n:Y�n:f.JCir�Ii:Jr'��91;I. trice of Consumer Affairs& Business Regulation License or registration valid for individul use on1v " - OME IMPROVEMENT CONTRACTOR ' before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation - ' Registration: 126893 . Type' 10 Park Plaza-Suite 5170 Expiration: 802014 Supplem=rt ,a rd Boston,MA 02116 The Horne Depot At-Home Services i RICHARD TROIA 2690 CUMBERLAND PARKWAY s GA 30339 -�- I Undersecretan i Not valid without signature r }y24,8 5 f ^ i J � - }4 i3ii ,m s 1 R �(R mil �' _ _ i�• - - f HOME IMPROVEMENT CONTRACT PLEAS READ TATS //�� l Sold;Purnished and lastalled by: nc Brah Nam vBostm North a South Dated?/�J - THD At-K mie Servimr Im- XWa The Home Depot At^l;ome Services Branch Number;31 and 33 9o$.Bostort Tlmrp"Unit I.Shrewsbury;lvlA 01545. Toll Free 877-903-3768 Federal ID#7372698460;ME llc#C 02419;RI Gant Uc#16427 CT Nc#W-0568S°,t-MA Home DWrowm m Contractor R-9.'#li6893 IDStallation.Address: IpS o t 1 4e �YK_3 yt+Ll�� Y 4 city state Zip Purchaser(s): Work Phone: Rena Phol k: Cell Phone: Home Address: (If different from Installation Address) City State zap Email Address(to receive project communications and Home Depot updates); _- ❑I DO NOT wish to receive any marketing emails from The Nome Depot o'ee rnian: Undersigned("Customer"),the owners of the Property located at the above installation address,agrees to buy, and TH Ao-Home Services,Inc_(`The Home DepoC" agws to flunish,diva and strange for the installation("Itoetaitatiotf)of aJj-amoairsis bed on the below and on the referenced Spec:Sheet(s),all a£which are incorporated.into ibis Ctmtract by this reierenM along with any applicable State Supplement sad Payment Sumutary attached hereto and any Change Orders(collectively, "CotttracE"}: Job#; a,k..d ttUrrew* g sc shows)f/: Protect Amount J(005119 usidsigNZ Windows XrasulaUm $ {} 01UMO c9 I Covers Elfintry boor9 In- * Roofing Usi&ng Windows r)asul__on []{luttets/.Covers 01int y Doors ©�- Rocfing MSLding Windows: Inanl m [3Guttm t Covers OF-wry Doors Q Roofing Sidrng Vnindoav tosulsuoa $ EIGuttar9/Covers DEMay Doom Maimmm 25%Dapow 4 Catdrad Anowtdue wp*emm, oo a9 to otwt 4d- Total Contract Anto wt MWeerunbisers owy not dq?mkinaws dm mo-thhd cube Cozad Amami. Customer agrees thK imroediaWy upon oompletiou of the work for each product,Customer will execute'a ComPletion Certificate (one for each Product as defined by an individual Spec Sbeet)and pay any balance due. ,Aa Apptieable,'dich Ciwtoiner wider this Contract agrees to be.joiady and severally obligated and liable hereunder. The 2Tcarte Depot reserves the right to issue a Change Order or terminate this Contract many individual Product(s)included herein,at its discretion,if The HomeDepot or its authorized service provider detemines that it cannot perform its obligaActis due to a structural problem with the bome,environmental hazards such as mold,asbekos or lead paint,other safety corlogms,pncin8 errors Or because work requimd to complete the job.was not included in the Contract yavment.Stmuusn; The Payment Summary* y`o'7 0%(=� , included as part of this Contract, sets forth the total Contract arwmt andpaytnews zegdired for the deposits and final paymenm by product(as applicable): NOTICE TO MTOMER You are entitled to a cointpletely#died-in COPY of the CmAraet st the timb you sign. Do not sigh a C900atien CerMicste(rioter there is one ConTletion I ert-tficate for each listed Product as defined by individual Spec Sheets)betere work an that Product is complete. In the event of termination of this Contract,Cnatorder•agrees to pay The;dame Depot the touts of materials,labor,espeuses and serv,was pprrovided by The Home Depot or Authorized Servit'e Provider through the date of termination,Pius any Other amounts set forth in this Agreement or allowed tinder apppplicat7le law. 'T'M HOME]DEPOT 74AY WITHHOLD AMOUNTS OWED TO '7TTE HOME VXPOT FROM T*M DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WX•TEIOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. ACCeStaWe a ut ation: Customer agmea and understands that this Agreement is the entire agreement between Customer and T e Home Depot with regard to the products and installation services and supersedes all our discussions and agreements,either oral or written,relating to said Products and IMWt ation.This agreement cannot be assigned or amended except by a writutg signed. by Custrnxttsr and The Home Depot.Custotrmr acknowledges and agrees that Customer has read,undermnds,voluntarily accepts the terms of and bas received a y of this Agreement Accepted by: t Submitted byr `t� Y � l 9� Cusromer's Signs Daw Sales Consul=t's Signature Date 7X Telephone No, Cwtomer's Signature Date Sales Consultant License No. CAN ')ii Ojai: CUSTOMER MAY CANCEL TWS (aeaPPticsblcl AGREEMENT WITHOUT PENALTY OR OBLIGATION VBRX WRITTEN HOME DE POT BY MIDNIGHT ON THE THIRD B t&INESS � it DAY AFTER SIG"G THIS AGREEMENT, THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECMCALLV PXESCRM9D BY LAW IN CUST'OMER'S STATE. NOMCE.AAA1110NAr,TERMS AND CONDMOM ARE STATED ON THE REVERM SIDE,AND AR$)PART Or IMS CONTRACT City of Northampton k i Sps ,sib Massachusetts 4 -' 11' ROM y'i to DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Jjr J�S�b` Northampton, MA 01060 rby) y711 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 1, 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 t ax The Commonwealth of Massachusetts --► Department of Industrial Accidents # Office of Investigations x 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lelzibly 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 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 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.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E] 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.El 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 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#: r SECTION 8-CONSTRUCTION SERVICES �— A 8.1 Licensed Construction Su ervis Not Applicable £ Name of License Holder: r , License Number A�o ?2 Addres / Expiration Date Signature Telephone _....._....._ 9 Re istered Home Im rovem nt Contractor. Not Applicable £ 3 Com an a Registration Number Ad '�['� _ Expiration Date Z� he' P / 5 Telephone o/ —: 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. H ome 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 Wind Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [❑ Siding [0] Other[131 Brief Des ri f Pr N��S 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 to existing thou"sing, complete'the fo`Ilowinq': 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 y' ��– ,r�-7r L✓ as Owner of the subject property hereby authorize to act on my behalf, in all mat rs relatigt�authorized by this building permit application. Signature of Owner Date PdZD as Owner/Authorized --k&1yK Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. c Signed under t ains d penalties of perm—, Print Name Signat wner/ gent Date A 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 . 1rry r Frontage Setbacks Front Side L:r�---�� R:�.__......- L:L Rear #• -- f - "_" Building Height Bldg.Square Footage % Open Space Footage i __{{ % (Lot area minus bldg&paved -- azkin ) � 4 #of Parking Spaces Fill: (volume&Location) 4 A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW Q YES Q IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES Q IF YES: enter Book Page and/or Document# M B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES C) IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES Q NO Q 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 or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Ir , ,. ., D art ht us onl ep me e y , of Northampton Y T MK 1 uilding Department Curb Cut/Driue+tiay Permif �1 .. - 212 Main Street SewerlSeptle,4vaitaFi}I�ty 1 + ► ' fl�0�� `"� ` Room 100 labihty nnII hampton MA 01060 Two Sefs of Structtir rtharn rig 8 C, Insp ectld ton, oe�41 - 87-1240 Fax 413-587-1272 Rlof/Sltesplans t ' ;k i Northam ' APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This ectwrrto be completed by office ` Map Lot Unit D � Zone Overlay D►strict Elm St District CB District SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �qPklh�- D)A IP)4 Name(Print) CurrMg A Telephone Signature 2.2 Auth 'zed ( ent: -r JA_ __4 Name Pri Current Mailing Address: r^ Zell Sig re f Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building '; 2g r (a)Building Permit Fee 2. Electrical ��/ (b) Estimated Total Cost of Construction from 8 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) ' Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector'of Buildings Date 103 DUNPHY DR BP-2015-0044 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36- 180 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-2015-0044 Project# JS-2015-000085 Est. Cost: $2809.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 082485 Lot Size(scpft.): 14984.64 Owner: PATEL SONIYA M&MAHESH Zonin : Applicant: HOME DEPOT AT HOME SERVICES AT. 103 DUNPHY DR Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCER102908 ISSUED ON.711112014 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 5 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 7/11/2014 0:00:00 $35.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner