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23D-008 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 1111,, S 150A. Address of the work: The debris will be transported by: D��✓ ' The debris will be received by: Building permit number: Name of Permit Applicant Date Signature of Permit Applicant Nov 0314 05:58a p HOME IMPROVEMENT CONTRACT PLEASE READ THIS t Said,Furnished and Installed by: Branch Name:Boston North&South Date:/2_! 1 Ht THD At-Home Services,Inc. dlb/a The Home Depot At-Home Services Branch Number:31 and 33 906 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toil Free 877-903-3768 Federal lD#75-269846D;ME Uc#C(12439;Rl Cont.Lie#16427 CT Lie Is H1C.0565522,,MA Home Improvement Comraewr Reg.0 126893 Installation Address: St t ?�tlo�lC,—t�Cr� S q E:Aar, �_ 04a City State Zip Purchaser(s): work Phone: Hour Phone: Cell Phone: Djeti4L_ Home Address: (If different from installation Address) City State Zip Email Address(to receive protect communications and Horne Depot updates): ❑I DO NOT wish to receive any marketing emaili from The Home Depot Proieet Information: Undersiped("Customer").the owners of the property located m the above installation address,agrees to buy, and THD.Ar-home Services.Ire. ("Tice Home Depot")agrees to Furnish.deliver and strange 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 appli,:ablc State Supplement and Payment Summary attached hereto and any Change:Orders(collectively, "Contract"): Job#, m.—I XM—) Products: Sec ShMO)ft: Project Amount RootinU Siding Rrindaws insulation Q QGutters/Covers Roofing Sidins Windows Lj Insulation Q Gutters/Coven ElEntry Dziors Q l l Rooline Sidiae Windows insulation QGutters/Covers []Entry Doors❑ $ Roofing ETSiding Windows El Insulation ❑Gtiaer3/Covers ]Entry Doors © $ Minimum 25%Deposit of Contract Amount due upon execution of this contract. Total Contract Amount $ Maine Purehas s may not deposit rnorethan oni Odrd or the Contract Amount. Customer agrees that,immediately upon completion of the work for each Product, Customer will execute a Completion Certificate (one for each Product..s defined by an individual Spec Sheet) and pay any hatanec doe. As applicable,each Cu+comer under this Contract agrees to he jointly and severally obligated and liable hereunder_ The Home Depot reserves the right tc issue a Change Order or terminate this Contract or any individual Product(S)included herein,at its discretion,if The Houle Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home,environmental hazards such as mold.asbestos or lead paint,other safety concerns,pricing errors or because work required to complete the,job was not included in the Contract. ff Payment Summary: The Payment Summary# I ti-I 4 , included as part of this Contract, sets forth the total Contract amount and payments required for the deposits and Final payments by Product(ac applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-in copy or 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 costs of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any other amounts set forth in this Agreement or allowed tinder applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LEMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acce�rtance_and Authorization: Customer agrees and understands that this Agreement is the entire agreement betwmn Customer and 7tte Horne Depot with regard to the Products and installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agrecs at Cu s read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. Ace t by: Suhrnitt X = //'o2 r X t t��'�.�J C omer's Sign, a Date Sales Con.ult• 's Signature Date Telephone No. usromer's Signature Date 5a::es CansuHant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION E BY DELIVEItL'VG WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THiS AGREEMENT. THE : STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN ,:IsL; 1_L111Lljtv1t11'L:tctut of jllu5�'uC11LL5'L'CLS, D°par•tnzcnt ofT 1dILst7•ialAcdde,.,.' (� OeCC of Ir;vesti;ad ' Corr;Tess�Etr•ee -;UCte 100 - BDS1012 2114-2017 sass o ov/din Workers' Compensation ID=tErance ZidaYi : BuildersJContracto;s/El!ctricians[Plumbers Annlicant Inform ation�� Please Print Legibly K8i31e.1?• •.sslOrguti.:z5o��divrdt::1): % /��' � /r'" 1 / �`�71J✓Y �' »: y�� �'�CG� 1`r� lam! Bf�-_� • • City/St~tJZia: L J A-:you an'ernploycr? Check the apprtipriat°bo . • Type of oroje-t(required}: 4. [3/1 a gcne.-al contra:ioi Lid I 1.❑ I 1 a y:r with 6 �New constanctioa e Zp]o s roll andJor pa::-time). have hirt:d tho'•sub-contactors 2.❑ I am a sole drop nor or p W:r_ listed on the atta:hcd shoe. 7. I� i2:nod:ling sp=d'nav:no e-7ploy�es 1'rese sub-conuaDtD S DZVC g D;volition ploy::s and have wort:_;s' ao lei-; foe-:i 1 any capa:iy. 9. ❑ 3uil6ing addition .�` CDD1D. L^S'.li anCC• . ' . gaffs Or adtiitiD^.s S. E1 .W:ate a corporation and is 3. I '_n a nO 7:0�^:r OD n, all w_D::: O�C_r5 1iaV° a:� tl ar i 1:❑�1'�n0:'.,r:Dau-S or a mail)=3 ?°It DI C7.0 AJtiOA per MGL �D ' aWa: :cu :d.) t ana 'A'navenD , • ..^ployea. �owbr}:_:s'. 13. ��=r-r • "coLld. i_nsuren--: nl:__1s'oox=1 r::'Lst al>. F1U 0:1 ti:_s:_ :�below snow:ig the WC:}::a :C��:S2 Cn policy 1r,,,D 71Zt cn. '� zr:doir. all wor}:z;d b nit a n-w a�&avit indi:a:ing snob, ao...cow^::S who sc,,.......is�..• nS =Y g .'rS sio_ ^n-ac:ors^..uststi - 'Con'-.zo._r. zt:.._:1:this box:rust z a:h:d an a:di ti c,al s showing tb:tla.::of L�:ssb a.� cto and s�::�'hc r:r or not.:cos: :apioy:=. !f:h:Sib-: nCaclna t:av::Mp10>,::s;t},:y Host provi-,,t heir woe}::;' coala.polity n_nb:r. , r a r 1 ail _,77pi0 , !i. f is N OY:Q: o iVp,^:_,-S' CD, :D_°1:52I1DI7 / vo oIDW S flie poll end job si!e' y�- *Lzrance jor rny`f117p.oy__s. B_ Polity'' or S:'! :s. Lic. "' �� %�I ///� �� �xa r - . . Job Site Ad-­:­ Ciy/StatdZi Attach a copy of tnn workers' comptrsati0n polity declaration page(show•ino the p01i: umber and e_piration Pate). &0 S:__= COV='ate- as r GnL'L`CL7 under jeC60 1 25A OI MGL C. 133 Can Iced t0 h0 ji:)OSlt)on 01=rnn=11 p:n21tIS 0f a ^:'up tD S1,500.00 andJDr one-year s :':11 s civil -aalc:s in the fon3 of a STOP WORK ORDER.znd z ^c of up to 5250.00 a d_y age;st•:L: olatc:. D:?6.,:s:6 that a copy of:1_s st_>!-�-:i nay b:;o s�ardcd to&,t 0.5:z of _^v:sti.nuq=s•of t^^_DLk for =s r?+�c .covcrao-.v^:�catioa — I dD i:_,_;y__ .. D:'^ d 0'1 r.• �,; ry t17ct tnc ;jDi r:coon prOVi�ed cbove s r.1e Lind cOrrecL s p,:r,- D t- . OjJ__c1 a^ 011Iv. DD r:Ot)v,=te ... is cz, rD be =D:,:)I_l:d�y_ y or ID W.11 o1J:ci=r. City or TOw' x.3:2:d 0,�__lth � B,. 1C=�0- e t j. CS:J'/T 01\^� C:'_:k �. 1._...:zl �5^C:tOi S.71u n}J1_^o T^SDGCtor Cor,,z:t Pt7SOn: phone SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable £ Name of License Holder ���.- ' License Number Address r ; Ex iration Date Signature Telephon 9.Re istered Ho a im-6r,ov ment Contract !; :. . Not Applicable £ M Re istration Number 1 /11-11 ess ¢� r— Expiration Date L�� (/ Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin rrrit. Signed Affidavit Attached Yes £ No...... £ 11. - Hame 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 Wi s Alterations) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding[0] Other[0] Brief Descri fo f, o —J%t Work: 'h;7) 'v 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 ho0S'6 antl or'addition tb exisfind'housing complete the followinct: 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 4fi?hereby authorize to act on my behalf, i all tters relao wor thorized by this building permit application. Signature of Owner Date I 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 un 0 a pains nd penalties of perjuq-�--�� Print Name ure of Ow er/Agent Date / , . Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Ibis column to be filled in by Building Department Lot Size Setbacks Front Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved L......---j #of Parking Spaces (volume&Location) A. Has a Special Permit/Yariance/Rmding ever been issued for/on the site? NO 0 DON7KNOW 0 YES 0 IF YES, date issued::' IF YES: Was the permit recorded at the Registry ofDeeds? NO "_�� ) D NTKNOYY 0 YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook' body of water orwetiands7 NO 0 DON7 KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ���~\ � t Obtained �- ' Date Issued: � x�� 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 IF YES, describe size' type and location: { i E. Will the construction activity disturb(clearing, grading, excavation,orfiUinQ)over 1 acre orisit part ofu common plan ' that will disturb over 1 acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. I3epartment use onlX y k City of Northampton Status ofl'ermtt y Building Department CUrh Cut/fJrf+reway Perrrti# � , E 2fi Main Street Sewer/SepticAvaCab�irry oom 100 Water/kl�tellAvatla61llty L DEC i1 9 Nort ha pton, MA 01060 Two Sefs of5tructural Pla[s r pho i13-5� 1240 Fax 413-587-1272 PlotlSlte PEans r� L �_ i other Specify F hI 1 E Ele __..__ _ :,. ,... : . ._ :... .. . ...__. _.... ..: s 3 orth rr :� "'�ctioi q CDN3TRUG� ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section fo be completed by office 1.1 Property Address Unit �J AIN�v7�� Zone Overlay pisfrict EImSt Disfnct CB Distract SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 'w Current f Name Print) vl�ilipddd Teleph L,el Signature 2.2 Auth d A t: 1 f Name rat) Current Mailing Address: r ,a D T ignature elephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building n (a)Building Permit Fee 2. Electrical (1 (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number O� This Section For Official Use Only Date Building Permit Number: Issued: Signature: — Building Commissioner/Inspec tor'of Buildings Date 54 NONOTUCK ST BP-2015-0679 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23D-008 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-2015-0679 Project# JS-2015-001302 Est. Cost: $4436.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 99209 Lot Size(sq. ft.): 10018.80 Owner: DEIHL DOUGLAS&JANE NIEJADLIK Zoning: URB(100) Applicant. HOME DEPOT AT HOME SERVICES AT. 54 NONOTUCK ST Applicant Address: Phone: Insurance: 5 RIVERVIEW DR (401)935-2633 O Workers Compensation NORTH PROVIDENCER102904 ISSUED ON.1211812014 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 2 REPLACEMENT ENTRY 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 12/18/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner