07-061 (5) The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of laivestigations
1 Congress Street, Suite 100
Bbston,MA 02114-2017
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information y, Please Print Le' Lriblv
Name (Business/Organization/Individual):
Address:
City/State/Zip: �G ��" L4?3—?Phone#
9
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'
insurance.$ 9. Building addition
[No workers' comp: comp.P•
required.] 5. 0 We are a corporation and its 10.[] Electrical repairs or additions
3.❑ I am a homeowner doing all officers have exercised their work 11.❑ Plumbing repairs or ac+ a;tiors i
myself. [No workers'.comp.' right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we Have no
employees. [No workers' 13.EaOher
comp. insurance required.]
`Any applicant that checks box 41 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 ani an employer that isproviding)t,ork-ers' compensation insurance for my employees. Below is thepolicy and job site
infonrration.
Insurance Company Name:
Policy#or Self-ins. Lie. #: f/v� 0�4 2 Expiration Date:
Job Site Address: 10 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for insurance coverage verification.
I do hereby cern pa and er alti erju7 that the information provided above is true and correct
Si--nature:
na � L� � —'GL`'
Date:
Phone
Official use only. Do riot write in this area, to be contplcted by city or town official.
City or Town: Permit/License
Issuing Authority (circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Aug 0914 06;04a P 1
HOME IMPROVEMENT CONTRACT
PLEASE.READ THIS
Sold,Furnished and Installed by:
Branch Name:Button Korth 8r South Date6—Jalu_ THD At-Home Services,Inc.
dlbla The Home Depot At-Horse Services
Branch Ntunben 31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,VIA 01545
Toll Free 377-403-3768
Federal ID#75-2698400;ME Lic#C J2439;RI Cont.Link 16327
CT Li c#HIC_665522:MAHome improvement Coatract w Rc-#126893
Installation Address: 3F ^7 4&AAA GkLm Etmsa}m 01 W 4r
City State
Zip
Purclmser(s): Work Phone: Howe Phune: {{ Cell Phone:
Home Address:
(If different from Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
I DO NOT wish to receive any marketing emails from The Home Depot
Project Information: undersigned('Customer"j,the owae,of the property Imated at the above installation address.ae ees to buy,
and THD At-Home Services,Inc.("The Horne Depot")agrees to famish,deliver and arrange for the installation("Installation")of
all materials described oa the below and on the referenced Spec Sheet(s).all of which are incorporated into this Contraci by this
reference,along with any applicable State Supplement and Payment Summary anached hereto and any Change Orders(collectively,
"Contract'):
Job#I: aae w iz,*t ) Products: Spec Sleet(s)#: Project Amount
Roofing LjSiding D Windows 0 Insulation
b
[]Gutter!Covers$Ontry Door, [
Roofing ElSiding El Windows Insulation
❑Gutters/Coven ❑Entry Doors❑ $ �•;U/-/✓TrI��
Roofing USiding El Window's insulation $
❑Gutters I Co"-i DEntry Doe,0
Roofing USiding Ll Windows El L•hsulatica ,A
❑CItlticts I Covers Entry Doom ❑ S ✓1
hSnixuurn 7 5F Deposit of Gmtnxtct ArronM due upon execution or this ctixntrad' Total Contract Amount $
Maine Plurehasers may not deposit rrxrre tltwt onnthird dthe Co�ttrad lmnuW Q1 1
Customer agrees that,imnxdinely upon completion of the work for each Precinct,Customer will execute a Completion Certificate
{erne for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicablc,each Customer under this
Contract agrees to be jointly and severally cthligated and liable hereunder.
The Home Depot reserves the right to issue a Ch u:ge order or terminate this Contract or any individual Wnduct(s)included heroin.at
its diseret if 11,if The Holm:Depot rx-its authorized service provider determines that it canna peribrm its obligations due to it structural
problem with the hone.Environmental hazards such as meld.asbostos or 1krad Mot,other stfery concerns,pricing errors or because
work required to complete the job was not included in the Contract. �f
Payment Summary: The Ptvnicnt Summary# ���� f , included as part of this Contract. sets forth the total
Contract amount and payments required For the deprnits and Final payments by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely fitted-in copy of the Contract at the time you sign. Do not 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 complete.
In the event of termination of this Contract,Customer agrees to pay The Home Depot the cods of materials,labor,expenses
and services provided by The Horne Depot or Authorized Service Provider through the date of ternuturtion,plots any other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
O"WED TO THE HOME DEPOT FROM THT DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMfTING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorisation: Customer agrees and understands that this Agreement is the entire a;rcetnent between Customer
and The Home depot wall regard to the Prmiums and installation services and supersedes all prior discussions and nVeemenm either
oral or written,relating to said Products and installation.This Agreement ctuonot signed cr amended except by a writing signed
Depot.Customer and The Horne pot.Cu mu
sto acknowledges and a_-ccs tl t C he has curd,understands,voluntarily accepts the
terms of and hits received a copy orthis Agreement.
Act by; Suhmitl
}( It/ ; JI /� X
Custntnc. '•.Si ature, Date ' / Sales C s S Signature Date
X Telephone No.
Customer's Signature Date
Salts Consultant License Nu.
CANCELLATION: CUSTOMER MAY CANCEL THIS t""pplcabt`t
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY N4TDNIGHT ON THE THIRD BUSINESS J
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE iF ONE IS
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.
;-2
Address of the work: �� �
The debris will be transported by:
The debris will be received by: �GC,�i
Building permit number:
Name of Permit Applicant ) �- /
Date Signature of Permit Applicant
_ City of Northampton t
Massachusetts {S s c
DEPARTMENT OF BUILDING INSPECTIONS x
212 Main Street • Municipal Building wj bj'
\ 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
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
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. ❑ 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.1 9. ❑ 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 11.❑ Plumbing repairs or additions
myself o workers' comp. right of exemption per MGL
y t p c. 152 1(4), and we have no 12.❑ Roof repairs
insurance required.] , §
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 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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Sue 'sor: r— Not Applicable £
Name of License Holder: 6✓Apj
License Number
Address Expiration Date
Signature Telephone
9.Re istered Home Im i^ovement Contractor: Not Applicable £
Company Name Registration Number
Add �} / Expiration Date
Telepho .- A �
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 per it.
Signed Affidavit Attached Yes...... No...... £
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 buildins 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,
4
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement dows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [M Siding�[,❑]] Other[❑]
Brief Description of Proposed / `J Jv
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 adtltlon to existing housing`complete the following:
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
1 G �,/ as Owner of the subject
property
hereby authorize
to act on my be alf, in a matters relative to work authorized by this building permit applic atio .
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 a pags and penalties of per u r
/ ✓���
Print Name
Sign re of Owner/Agent Date
�
�
`
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required.by-Zonig
TIiis column to be fill�a in-by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
�~�
NO t�/ DONT KNOW �_�~�� YES k~�~�
�
|F YES, date issuedJ �
IF YES: Was the permit recorded at the Registry nfDeeds?
YES NO �� DON YV
\~� / KNOW
IF YES: enter Book i Pag and/or Document#1
�� �� ��
B. Does the site contain a brook' body of water orvvedands? NO �_� DONT KNOW �~/ YES �~�
IF YES, has a permit been or need tobe obtained from the Conservation Commission?
Needstnbeobtained ^—
\ Obtained �~� Date �
�_� �_� '
C. Do any signs exist 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:
' ' ' L__' ____----_—_------------_---]
E. Will the construction activity disturb(clearing. gradingexcavation,nrfiKing)over 1 acre orish part nfo common plan
' that will disturb over 1acre? YE80 NO �
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
^ —
,-wx I ��,� . � r Department use onlx
-- City fl, orthampton Statgs ofPermrt x
r
20`�uildrpkj Department CUrta CuvDn�eway Ferntl# r
2 /1 in Street SewerlSepticAvairabtElty
0 100 Water/V�le?C Ryailablhty
ctions
mbi n, MA 01060
Electri NoPtu ton.&G MA Twa Sets of 5#ructural Plans
-1240 Fax 413-587-1272 Plof/Slte Plans
Other 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 6e completed by of fice
/I Map Lot Unit
Overlay Disfrrct
Elm St District:: -! CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT -
2.1 O ner of Record:
N me(Print) _) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(P' Current Mailing Address: f�(
Sig ature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building / `'n (a) Building Permit Feb
2. Electrical (/V (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection Oar
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
367 NORTH FARMS RD BP-2015-0218
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 07-061 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2015-0218
Project# JS-2015-000405
Est. Cost: $2141.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 082485
Lot Size(sq. ft.): 24567.84 Owner: WOODMAN MARILYN J
Zoning: RR(l0o)/WSP(100)/ Applicant. HOME DEPOT AT HOME SERVICES
AT. 367 NORTH FARMS RD
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON.812212014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT DOOR
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 8/22/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner