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23A-228 (3) > q ��1J '"sr.�irJe23^�?ihh �o=lf.,',:i.`i oS2dS Depart,T3ent-of!,",duse7ial'1it^1&? .3 Of 1 Of�� 't J?Stdg�a'?LiiBS 600 Washington Street Boston,Ml-4 02111 aw www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name (Business/OrganizatiorAndividual):, Address: City/State/Zip: C2.�t1` _ , 303 Phone#: Are you an employer? Check the appropriate x: Type of project(required): 1.❑ I am a employer with 4• LJ 1 am a general contractor and I employees(foil 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, ❑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.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself o workers' co right of exemption per MGL y � comp. 12.❑Ro (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. 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. /� I / Insurance Company Name: / �/f- /7 czfm Policy#or Self-ins.L ic.#: N/ C% 0 y 9 Q / g g Expiration Date: 2 ff� �J! l Job Site Address: City/State/Zip! �% V/� D� /P Attach a copy of the workers' compensation policy declaration page(showing the policy number and piration 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 DLA for insuiance coverage verification. I do hereby certify un e e ins and na f perjury that the information provided above is true and correct. Si afore: Date: Phone#: L L��,"�i� ltl2— Lam" 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#: DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02119/2014 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 THECERTIFICATE 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 certlficate holder In lieu cf such endorsement(s). PRODUCER CON ACT MARSH USA,INC. NAME: FAX TWO ALLIANCE CENTER PHONE AIC No 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRE59: INSURER(S)AFFORDING COVERAGE NAIL fl 100492-HomeD-GAW-14-15 INSURER A:Steadfast insurance Company 26387 INSURED INSURER B:Zurich American Insurance Co IE535 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 ��E�B�Y PAID CLAIMS. ILTR TYPE OF INSURANCE A DL U - POLICY NUMBE0. MM/DOYIYYYY MMIDD"Y _LIMITS LTR A GENERAL LIABILITY GLO48B7714-04 - 03101/2014 0310112015 EACH OCCURRENCE S %000,0OD DAMAGE To RENTED X COMMERCIAL GENERAL LIABILITY PREMISS 1E,Q=rrancel 1,000,000 CLAIMS-MADE D OCCUR LIMITS OF POLICY XS MED EXP(Any one person) 5 EXCLUDED OF SIR:$1M PER OCC PERSONAL d ADV INJURY $ 9,000,00D GENERAL AGGREGATE $ 9,000,00D GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 9,000,000 X POLICY PRO: LOC S,Cj B AUTOMOBILE LIABILITY OAP 293BB63-11 03101/2014 03101/2015 COMBINED SINGLE LIMIT 1,000,OOD Ea accident X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS P ra cIdent S UMBRELLA L1AB. HOCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS S C WORKERS COMPENSATION WCG49101882(ADS) 03/012014 03/01/2015 WC STATU- 0TH C AND EMPLOYERS'LIABILITY YIN WC049101884 AK,AZ,VA 031012014 03/012015 1,000,DDD ANY OFFICERIMEM ER EXCLUDED?ECUTIVE� N/A ( ) E.L.EACH ACCIDENT S . D (Mandatory In NH) WCD49101883(FL) 03/0112014 0310112015 E.L.DISEASE-EA EMPLOYE S 1,000,000 K es,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S C WORKERS COMPENSATION WC049101885(KY,NC,NH,VT) 03/012014 0310112015 (EL)UMIT 1,000,000 C WC049101886(NJ) 031OW014 031012015 DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,N more space Is requlrod) EVIDENCE OF)NSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DSA 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 of Marsh USA Inc. Manashi Mukher)ee ©1988-2010 ACORD CORPORATION. All rights reserved. -- -- -- - - TLS A r nDN ror.Iefarari marks of ACORD rermlt sery ices % 4U1 Z40,0500 P.Z Office of Consumer Affairs and Business Regulation . ...... 10 Park Plaza - Suite 5170 y,3�ti Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 126893 Type: Supplement Card THD AT HOME SERVICES, INC. Expiration W312016 RICHARD TROIA -- -------- 2690 CUMBERLAND PARKWAY SUITE 300 ---- ATLANTA, GA 30339 Update Address and return card,h1ark reason for change. sca I G 20141-0---111 Address Renewal Employment `i Lost Card Office of Cussuner Affairs&Business Regulation License or registration valid for individul use only T-w-fit` before the expiration date. If found return to: �: DOME IMPROVEMENTCONTRACTialt Office of Consumer Affairs and Business Regulation Registration: .126693 Type: 10 Park Plaza-Suite 5170 "L">> ratiore. Expi _ 8l3/2016 . Supplement Card gostoa,MA 02116 THD AT HOME SERVICES.INC. 1 / THE HOME DEPOT AT"HOME SERVICES A RICHARD TROIA 2690 CUMBERLAND PARKWAYS �Z ATD^GA30339 undersecretary Not valid ithoutsignature F q.. - S -99209 _ `� a - f L 03 I Off el i Jul 30 14 04:04a p.1 HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,FLIrniShCd and Installed by: Branch Name:Boston North&South Date ?/ THD At-Home Services,Inc. dibla The Home Depot At-Hcme.Services Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toil Free 877-903-376Es Federal ID#75-269844W&1E Lie#C 02439;RI Cont.lick 16427 AA CT Lie#HIC.t7s65522,MA Horne ftwo+remeat Conuactor Reg.4 126893 n Installation Address: _ _ ; 1VC=t� 114'1 is � \1 A 2 t O(c,Q City Stale Zip Purchaser(s): Q Wort Phone: Home Phuee: Celt Pltnne: Home Address_ (If different from Installation Address) City Statc Zip E I Address(to receive projea communications and Horne Depot updates): I DO NOT wish to receive any marketing emai.s from The Home Depot _ Project Information: Undersigned(Customer"),the mwic"or the property located at the above instillation address,agrees Lo 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 Pay-rrtaant Summary attached hereto rind any Caangr Orders(collccuvely, "Contract"). Job 1: $Lv and rarerotRr PmducLs; Spec Sheet(;]#: Pro jec t Amount M LjRcofirig Siding Windows U Insulud".1 y r o ❑Gutter;i Covers-WnUy Doors ❑ l+o $ Roofing Siding Wintlaws El Insutauoa ❑GuucN i Covu's ElEntry Doors ❑ Roofing Sdin S Wincuws u ton � t EIGuuers/Cuvcrs :]EntryDjors❑� $ Roofing Sidin? Lj Wincows L LISaIJttOn l ❑Gotten l Covers ❑Envy Doors ❑ N lnimnm 25%Drpo*of Contract Amoura dnL upon mcution of thLS contraCY. Total Contract Antotmt $ �� Nfaioe Partdlxwrs tray not deposit mrrrmthan tr¢e-third ofthe(onhact AimmnL l� Customer agrccs that, immediately upon completion of the work fir each P*roduci.Customer will caecute a Completion Certificate (one for mch Product as defined by an individual Spec Sheol)and pay any halauce Jue. As apItliwble.each Customer under dti.s Contract agrees to be jointly:md scvcrally obligated and liable hereunder The Home Depot reserves the right to iss,te a Change Ordtx or terminate this Contract or any individual ll:od act(s)included hcran,at Its discretion,if The Horne Depot or ils authorized service provider determine;hat it cannot perform it:s obligations due to a structural problem with the home.environmental hazards suzh as mold.a.heslos or lead print,other saluty concerns,pricing errors or because work required to complete the job was not included in the Contract. PaYawnt Summa-n,: The Payment Summary #____ bq]bI�(1I , included as punt of this Conn-act. set, forth the total Contract amount and payments required for the deposits mud final payments by Product;'iN applicable). NOTIM TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time you sign. Do rmt 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 connptete. In the event of termination of this Contract,Customer agrees to pity The Home Depot the costs of matcrialL labor,expenses and services provided by The Home Depot or.Authorized Service Provider through the date ttf 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 THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'SOTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Cuctomcr agrees and undetvmids that this Agreement is the enure agt•ccment bctwcea Customer aan The dome Depot with reward to fic Products and Installation ser�riccs and.supers ces all(rr3nr discustiions urdagrt�emerns,either oral or written,relating to said Products and InstaLatitm.This Agreement caunoi as'gttc<1 or amended exempt by a writing signed by Customer and The Horne Depot.Customer acknowlodgc_e and agrees that Cu lamer as read, understands,voluntarily accepts the terms of anti has rceei1kvb a copy of this Agreement. ` 1 � Accep «� 77 t r Submitte h X ! L� X Cut,omen's ignature Date I Sales Co st is Signatrre Date X Telephone No. Customer's Signature Date Sales Consultant Licence No. _ CANCELLATION: CUSTOMER MAY CANCEL THIS ta+nppticrmcl AGR10-MENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THF,HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINLNS DAY AFTER SICKING THIS AGREEXIENT. THF STATE SUPPLEhIENT ATTACHED HERETO CONTAINS A FORM TO USE ti: ONE 1S SPECIFICALLY PRESCRIBED BY LAW IN City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: I l `� L�� i The debris will be transported by: The debris will be received by: AL Building permit number: Name of Permit Applicant Date Signature of Permit Applicant City of Northampton Massachusetts zi DEPARTMENT OF BUILDING INSPECTIONS h: 212 Main Street • Municipal Building r Northampton, MA 01060 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 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 Legibly 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 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. E]Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 9. F1 Building addition 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 1 l.❑ Plumbing repairs or additions myself ' right of exemption per MGL y �o workers comp. 12.E] 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 Office 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 Supervisor: I� � " � No Applic a ble / Name of License Holder 1/ l�i V License Number -� Address �4 -34) Expiration Date Signature Telephone N 9 Re istered HomIm'e rov merit Co tractor. of Applic b e £ company Name � Registra io n Number Expiration Date Telephone r' 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 p Signed Affidavit Attached Yes..... No...... £ 11: -Home OwnerEgemption 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 Wi s Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding [❑] Other[0] Brief i ti o ped � � L)RA Work:: L— Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa.`If Neriv`house and'or:add'ition to existing housing, complete the foilowinct 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 s / as Owner of the subject property )5 hereby authorize to act my be a I rs relat ve to work authorized by this building permit application. -72 G7 Signa re 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. t Signed under ins ynd penalties of per' / r�l Print Name Signature-o Owner/Agent Date / � ^ ^ Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Tliis column to be filled in by Building Department r Lot Size Frontage Setbacks Front Rear 1—Ji Building Height Bldg. Square Footage Open Space Footage % ------ (Lot area minus bIdg&paved (volurne&L cation) A. Has a Special Permit/Variunce/Findinq ever been issuedfor/on the site? �� �� NO ���� DON7KNOW �� YES �� |F YES, date issued:1 | IF YES: Was the permit recorded at the Registry ofDeeds? NO � ) D YE �� IF YES: enter Book Pagq and/or Document# �� �� B. Does the site contain abrook, body of water nrvet\andx7 NO �~��� DONTKNOVY x�� YES k~� IF YES, has a permit been or need tobe obtained from the Conservation Commission? Needs to be obtained ~��~� Obtained �~-�� Date . � � ' C. Do any signs exist un the pmperh/ �� ��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: � v E. Will the construction activity disturb(clearing, grading, excavation,or filling)over I acre oris it part ofa common plan that will disturb over Iacre? YEG0 NO � IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ���� r _ ` t Department use only City of Northampton Sfatus of Permtt 4"� Building Department Curb Gut/Dn�ceway Ferrrt�# 212 Main Street Sewe[/Septicavaita611tty ' Room 100 Water/VMfeitAva�lablhty ortham ton, MA 01060 Twa Sets of S#ructurai Plans p F Iectr No ire " F� 3-587-1240 Fax 413-587-1272 P[o#/Site Plan ' o OtFier Specify' = ' 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 completetl by office �' Map Lot Unit - :::Zone::.: Overlay D�sfnct -= - `EIm St;District : - - CB District :_ SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: r� ® hip— 0/ PCX Nam;(Print) /� Curre 4' irf 7 � �e� '- Telephone Signature /� 2.2 A ized 040 Y/ ent: t � ,/� ` /� f Name( int) Current Mailing Address: _ ell Sig ture Telephone SECTION 3-ESTIMATED CONSTRCICTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com Ieted b ermit a licant 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=(1 +2+3+4+5) 14�9 Check Number This Section For Offlcaa#Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector'of Buildings Date 113 NONOTUCK ST BP-2015-0175 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A-228 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Catego , : REPLACEMENT DOOR BUILDING PERMIT Permit# BP-2015-0175 Project# JS-2015-000310 Est. Cost: $4173.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 99209 Lot Size(sq. ft.): 10715.76 Owner: PAPOUCHIS ALEXANDER Zoning:URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT. 113 NONOTUCK ST Applicant Address: Phone: Insurance: 5 RIVERVIEW DR (401)935-2633 O Workers Compensation NORTH PROVIDENCER102904 ISSUED ON:811112014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT DOORS 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 8/11/2014 0:00:00 $35.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner