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Department of Industrial Accidents
r
Office of I.tivestig ations
I Con,i•essStreet, Suite 100
Boston,MA 02114-2017
www mass gov/dia
Workers, Compensation Insurance Affidavit: Builders/Contractors/Electticians/Plumbers
Applicant Information ] Please Print Le ib�l/y/
Name (Business/Organization/Individual):
Address: Azn�
77� �� q
City/State/Zip: -FL T� Phone#: /
Are you an employer? Check the appropriate bo . . Type of project(required}.
I.0 I am a employer with 4 UI am a general contractor and I
employees (full and/or part-time).* Have hired the sub-contractors 6. ❑ New construction
2.0 I am a soleproprietor or partner- listed on the attached sheet, 0 Remodeling
ship and have no employees These sub-contractors have 8. F-1 Demolition
working for me in any capacity. employees and have workers'
> . comp. insurance. 9. ❑ Building addition
[No workers comp:insurance
5. 10.0 Electrical repairs or additions
required.] 0 We are a corporation and its
3.F_1 I am a homeowner doing all'work officers have exercised their 11:0 Plumbi..;repairs or additions
myself. [No workers'.comp. right of exemption per MGL 12.0 Roo °pairs
insurance required.] t C. 152, §1(4);and we have no
employees. [No workers' 13. Other
comp. insurance required.]
Any applicant u:_`Ihecks box#1 —sE au. fill out the section below showing their workers'compensation policy information.
t Homeowners who submit tnts 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 ari employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information. j� ��
Insurance Company Name:
Policy#or Self-ins. Lic. #: i/v Expiration Date: ^ /
fZJob Site Address: G/ 'lam o�" / 40 7 �` 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 e. 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 pa' and e� al& erjur�that the information provided above is true and correct
Signature: / Date:
Lhone
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: v 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 1414 03:48a P.
HOME&IPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Furnished and Installed by:
Branch Name:Boston North&South Date:(�ad-�L THD At-Home Services,Inc.
dlb/a The Home Depot At-Horne Services
Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free 877-903-3765
Federal ID#75-269IWio:ME Lie#C 02439,RI Cont.Lie#16427
Cf tic u H41-C..70r565522-,MA Homc lmpruvemew Contractor Reg.S 126893
Installation Address: S GJ 1 C S A 6Q- I" o(QL)ccl_ 61 A O(c6 4
City State Zip
Purchaser(s):
Work Phone: Horne Phone; Cell Phones
[ l [ }l
J f
Hotta Address:
(1f different from installation Address) City State Zip
E-nail Address(to receive project cornmanications and Home Depot updates):
]1 DO NOT wish to receive any marketing cmails from The Horne Depot
Protect information: Undersigned("Customer-).the owners of the property located at the above installation address,agrees to buy,
and THD.At-Home Services,inc. C'The home Depot*')agrees to furnish,deliver and arrange feu the installation("Installation")of
all materials described or the below and on the referenced Spec:Sheet(s),all of which are incorporated into this Contract by this
reference.along with any applicable Statc Supplement and Payment Summary attached hereto and any Change Orders(collectively.
.,Contract"):
slob#. 'w-.g&r"w Products: Sec Shect(s) Pro ect Amount
Roocng Siding' Windows Insulation
❑Gutters l Covers[]Entry Dams ❑ -7q ` 3! D (_
RoeRng Siding , Windows lnst:huion $ v
]Gutters;coven []Entry Doors ❑ /
Rooting ElSiciing El Windows Insulation 1v//
]Gullets 1 Covers []Entry burs❑
Roufanr Siding LJ Windows El lnsulat")
❑Guttcts,Covers ❑Entry Doors ❑ S
lW htiinum25%Depti6tofContraet Amount dim upon c:xcctttitmofthiscottrut- Total Contract Amount $
Maine Ptmchasers nm f not deposit mote than one4hkd of tht Contract Amount a7
Customer agrees that, inmtediately upon completion of the work for each Product. Customer will execute a Completion Certificate
(one for each Produ d as defined by an individual Spec Sheet)and pay any balance due. As applicable, each Customer under this
Contract agrees to be jointiy and severally obligated and lie.bic hereunder.
The Horne Depot rtserms the right to issue a Change Otdcr or tcrninate this Cuntrat:L or any individual Product(s)included herein.at
i rs discretion,if The Have Depot ar its authorized service provider-determines that it cannot oerform its obligations due to a structural
Problem wilh the home,cnviromnental hazards such as meld,asbestos or lead paint,other safety concerns, pricing errors or because
wort:required to complete thcjob was not included in the Contract.
Payment Summary: The Pavtne:nl Seminary 4 (� -1 1`3( I included as part of this Conintet, sets forth the total
Contract atnouat and payments requi ed for the daposit5 and final p yments by Product(&%applicable).
NOTICETO CUSTOMER
You are entitled to a completely filled-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 cotrplele.
In the event or termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses
and services provided by The Ham Depot or Authorized Service Provider through the date or termination,plus any other
amounts set forth in this Agreement or allowed trader applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAVMEVT OR OTHER PAYMENTS MADE WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Custoter agrees:rid understands that this Agreement is the emir agt-centent between Customer
and The Home Depot with regard to the Products and Im illation%ervices and;upc sod a31 prior discussions and agreements,either
oral or written,relating to said Products and installation.This Agreement cannot •lined or amended except by a writing signed
by Customer and Th:;Home Depot.Customer acknowledges:and agrees that Co;t er h• read,understand,volunnrily aeoepts the
learns of and hays received a copy of this Agreement.
Accepted by: r Submitted b}
X �fa � y.~ l4- X I l i b
Customer's Signature Date Sales Cons Signature Date
X Telephone Nn.
Customer's Signature Date
Sales ConsuFtan[Liceosc No.
CANCELLATION: CUSTOMER MAY CANCEL THiS
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME ' �j 3
DEPOT 13Y MIDNIGHT ON THE THIRD BUSINESS ✓✓
DAY AFTER SIGNING THiS AGREEMENT. THP
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS f
SPEC[7CALLY 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: �� � )Z��� ��r
The debris will be transported by: 1�� / Z— 7�r_
The debris will be received by.-
Building permit number:
Name of Permit Applicant
pP
Date Signature of Permit Applicant
City of Northampton
Massachusetts
F-
f !f' 4':
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060 sg�—V„-1
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
r 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 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.
required.]
5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ 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.❑ 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 Supervisor, � Not/kppl ica e�£
Name of License Holder:
License Number
Address„ Expiration Date
Signature Tele ne
.2,
9:Re isfered Home m `"rove ent Contractor _.. Not plicabl £ f,
ComDanv Marne Registration Number
Add s' Alq' Y7 Expiration Date
e ,�' Telephone �2
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§26C(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 I.
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 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 ows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [m] Other[o]
Brief Description, op e /,
Work: !C� k-5
Alteration of existing bedroom Yes No Adding new bedroom _Yes No (�
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a:If New hous and or addition to,existing,housing,Tcomplete th
e fdllowin'g'
e
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
as Owner of the subject
property
hereby authorize
to act on may behalf, ' all mat s relati; to work authorized by this building permit application.
Signature of Owner Date
�r 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.
r
Signed de p e p sand enalti, pe 'uryj
1
Print Name
Sigddure of Owner/Agent Date
. .
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
TIiis column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear L--J
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special. Permit/Variance/Finding ever been issued for/on the site?
�� ��
NO x���/ DON7KNDVV �� YES �~�
IF YES, date iouedd >
IF YES: Was the permit recorded at the Registry ofDeeds?
NO �� D NTK nvn YES
�=� u
IF YES: enter Book j Page and/or Document#
�� �� ��
B. Does the site contain a brook' body ofvvatororwedands7 NO �~� DONTKNOV� �~� YES �~�
IF YES, has a permit been or need 10 be obtained from the Conservation Commission?
Needs tobeobtained v~� Obta|ned x-� Date
k_� �~� ' '
C. Do any signs exist on the proporty �� ��� 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 �
' ' .
E. Will the construction activity disturb(clearing, gradingexcavation,or filling)over 1 acre orisit part ofa common plan
'
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
repartmeht use only
City bf Northampton Status of Permrt 3 ;" "
u! SEi — $ 2014 'ui ng Department Curt?CutfDrl evuay Permit
Main Street SewedSeptrcAvaiCabll�ty {
Room 100 Water/VsfelfAyatlablgty
Electric, Plumbing&Gas In ctrif7'�p�
Northampton, MA o10 pton, MA 01060 Twa Sefs of5tructu`ral Plans.
phone 4 - -1240 Fax 413-587-1272 PIoflSite Plans
Drier Specify ;
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION :
This section to be completed by office
1.1 Property Address:
Map Lot Unit
�1 f
Zone Overlay Dtstnct
Elm St.Distract. CB:Distract
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Ammar °
Name(Print) Current Mailing Address:
Geje (j ���c / Telephone
Signature
2.2 zed ent: I
!� ��0/cam��• � /�j• _ ,
Name ri ) Current Mailing Addres
ir lAf 7/W o;y
Sig ture Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ` ,�'— (a) Building Permit Fee
2. Electrical (f (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(I +2+3+4+5) ' Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Corn missioner/Inspector'of Buildings Date
50 STILSON AVE BP-2015-0255
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 114 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit# BP-2015-0255
Project# JS-2015-000488
Est. Cost: $3686.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 105953
Lot Size(sq. ft.): 11979.00 Owner: RICE ROBERT T&SUSAN M RICE
Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT. 50 STILSON AVE
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 () Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON:91512014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 6 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 9/5/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner