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Are you an'employcr? Chccl;the zppro_uriat� Type of project(required}:
1.(� I z t a e-1ploycr AiLh 4. 1 ara a ecnera1 ;-On=cior and I
have•rii ed the' 6., N:w constuctlori
:rnp)o s null and/orp1t-ti :).K sub-cOn4actOis
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mysaf. TFo , a uhf of ee.; tion per MGL
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suba i;: is z_`Iidav t indiezdng th:y z-e doing all wo.k. b- than hire outsid::on�-:ors must sub nit 2 n:w z�edzvit indi: c og sue
Con:rz::c>that e..eeh this box:rust z-aoh:d an ad�iticnzl sh:ct showing the tea :of tt:sub-any-a>and z ::wh:h:r or aot those:stiffs hav:
:mploy:= if the rilb•oo=zcto:s haw:moloy:s;th:y mczt provid.:th:ir wor};:s'comp.policy n,_mb::.
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Policy=or Sel i^s. Lic. "' !/y L� �`i';/ ////G � =xauamon Dat
Job Si::Address: yy� ''V �' ! Ciry/StatJLip' �/" �l(/!l/�
Attach a cony of the workers' :ompensation policy d'tclzr3tion nacre(showing the policy number and expiration e2te).
i'ailur-to s-cut zc)�c�ag: as r:auirtd und:r Section 25A of MGL e. 153 can 1-ad to the imposition of Of?
Ir:'up to S1,500.00 and/or one-y:ar impr`-SOrI:.:nt, as w':11 as civil p^nalri^s in tht form. of.a STOP WORK ORD=R and a Ent
_ ^:^1�' -. 3t zdv�-d that a cony of the s`�t:t^-1t M-y b:forward:d to tht Om`c: of
I v:s6ntio=s of t_:DL4 for irsuranC:•COV:rag:•v:incatio� —
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6.Or :-
Con'_z:t Person: Ph on:4:
P.1
Jan 1615 06:48a
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Furnished and Installed by:
Branch Name:Boston North&South Date: THD At-Home Services,Inc.
dfb/a The Home Depot At-Home Services
Branch Number:31 and 33 903 Boston Turnpike,Unit 1,Shrewsbury.MA 01545
Toll Free 877-903-3768
Federal ID#75.2698460:ME Lie#C 02439;RI Cont.Lie,#16427
CT Lic#HIIC05655222-,MA Hone,Improv�cmcnt Conn-joor Reg.#126893
Installation Address: f�� Q>1 's'1 ► 1 CwIt3—�L_ �l U l n o t (�,-
City State Zip
Purdnascris): Work Phone: Home Phone. Cell Phone:
Hdme Address:
(IfdiJerent from Installation Address) City Statc Zip
E-ruail Address(to receive project communications and Home Depot updates):
❑I DO NOT wish to receive any:marketing emails from The Home Depot
Protect Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
and THD At-Hone Services,inc.("The Foote Depol")agrees to furnish,deliver and arrange,for the installation("Installation")of
p1l.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 Supplemem aril Payment Summary attached hereto and any Change Orders(collectively,
"Contract"):
Job#: �t,kma tdere�sl roducts: Sec Sheet(s)k: Pro ect Amount
�n Roofing LjSiding, rkdo-xs Ll Insulation
FlOoHers t Covcrs Entry Doors Q 02 $ r, { tit I
Ruatu:g Siding Windows insulation
]Guttem/Cuvm [:Entry Doors ❑ $
Roofing CSiding Windows U Irmulatitm
0Gatters i Covers❑Entry Doors Q $
Roofing j Siding Nindows 0 lr,suU%6on
❑Gutters J Covers❑Entry Dours 0 $
Minimum 25%DepWtofCadract Amount due upon execution or WiseontracL Total Contract Amount t �
Maine Purchasers may not deposit more ihan one-third orthe Contractdntount. 2i-7
Customer agrees that, immediately upon cornpletion of the work for each Product, Customer will execute a Completion Certificate
(one for each Product as defined by an individual Spec Sheet)and pay any balance due. As app:icable,each Customer under this
Contract agrees to belointly and severally obligated and liable hereunder_
The Home Depot reserves the tight to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,if The Home Depot or its authorized service provider determines that it canna 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 Conlntract. l I
Payment Summary: The Payment Summary#__Q( l7�� �l , included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and Final payments by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely tilled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(noter
there is one Completion Cer lificate for each listed Product as defined by individual Spec Sheets)before work on that Product
is Complete.
In the event of terroination 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 terminafion,plus any other
amounts set forth in this Agreement or allowed under appusable 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'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Autborizatitm: Customer agrees and understands that this Agreement is the entire agreement betwzan Customer
and The Hone Depot with regard to the Products and installation cervices and edes all prior discussions and agreements,either
oral or written,relating to said Products and Installation.This Agreement- not be signed or amended except by a writing signed
by Customer and The Home Depot.Customer acknowledges and agrees o Custom r has read,understand:+,voluntarily accepts the
terms of and has received a copy of this Agreement.
Y: Sub
1 t ` x
OM s Signature Date Itant's Signature Date
X Teleph (e No.
Customer's Signature bate Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS 1,tsEplic:mb1c)
AGREEMENT UT PENALTY OR OBLIGATION
BY DELIVERING NG WRITTEN NOTICE TO THE HOME �-
DEPOT BY NJIDNIGHT 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
41Vrc�rn■rcr.le rrAIry
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:
The debris will be transported by: gA;��Eir
The debris will be received by:
Building permit number:
r
Name of Permit Applicant
Date Sign-ature of Permit Applicant
-- ;4 UILY of Nortnampton
J, k" Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS � b,
212 Main Street • Municipal Building
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
1 he Commonweaun of iviassacnuseus
Department of Industrial Accidents
Office of Investigations
u . 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 M
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 g. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp. insurance.# 9. Building addition
required.] 5. F] We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I L❑ Plumbing repairs or additions
� ' per MGL
myself. o workers comp. right of exemption p
Y p 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. Lie. #: 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 Su ervisor: J Not Applicable £��
Name of License Holder: /
`i// yG�r" f �L��
License Numb
LOU
Address pirate�- fm 4 lk�UD
Signature Telephone
9..Re istered Home Im rovement ontractor: ,,. y Not Ap licable £
Company Name , \ 1 Registratior�NytIIl;2er /
qjpl-�- e %jam^
AOAr s �1 1 E 'ration Date
Telephone%�/ 2
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 e
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 buildine 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 W' ows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[01 Other[a]
Brief Descr' ti o d '
Work: 1�v��
Alteration of existing bedroom Yes No Adding new be oom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa, If New'house'and or°addition to existing housing; complete tt a followingl:
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 my behalf, ' a 1 mat relativ rk authorized by this building permit application. �-
Signature of OwneT Date
as Owner/Authorized
Agent hereby declare fhat the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed er t Ppains and pen f perjuRy.
Prin Na
Date
Si "f ture of Owner/Agent
f ,.
^
�
» ��u
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
—
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variance/Fimding ever been issued for/on the site?
NO 0 DONTKNOW 0 YES C)
IF YES, date issued:
IF YES: Was the permit recorded at the Registry ufDeeds?
��
NO �_/ DONTKNOV/ � }
_ _�� __-
IF YES: enter Book Page; and/or Ducument#
B. Does bodyofwaterorme�iands! NO �-� DONTKNOY/ x—� YES y~�
. ' �^� «_� �=/
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ^~��-\ Obtained �~~�� Date� ' �
C. Do any signs exist un the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ~��~\ NO �~«_��
�
IF YES, describe size, type and location: � !
____--------__---______.... __......_............ ..............
_________ '
E. Will the construction activity disturb(clearing, gradingexcavation, or filling)over 1 acre orimit part ofa common plan
'
that will disturb over 1 acne? YES ��� l NO �-���
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
'.
\A
i1 Y City of Northampton Status;ofl?ermrty4 11
Building Department Curl;CurEDr«ceway Perirtt# 4 212 Main Street SewerlSgpticAvaitabpfity ' r
F
1 i , li
Room 100 WaterllltteilAva�labilly.
i t
4 ;r o rthampton, MA 01060 Two Sits ofi Sttuctuzal Plans
0ecific, 1'r. 0n t`�P L� one 413-587-124Q Fax 413-587-1272 PIo IStte Plans "r I ' ;1 f
Other 5pecifyOTANI i I
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE,INFORMATION
Th'
..........
isilsec,►on to be completed by`off�ce '
1.1 Property Address:
Map - Lot
Umt'
-
Y
Elm St:f3rstrrct _ CB D,istnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
/A✓�
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Auth rize iVA ent:
Nam ( ) Current Mailing Address:
n ure 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 (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) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: _
Building Commissioner/Inspector of Buildings Date
73 WARNER ST BP-2015-0741
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D-081 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-2015-0741
Project# JS-2015-001447
Est. Cost: $2687.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 106953
Lot Size(sa.ft.): 6229.08 Owner: KERSTEN ELAINE RENATE
Zoning.URB(100) Applicant. HOME DEPOT AT HOME SERVICES
AT. 73 WARNER ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON:112212015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOW
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:
FeeTyue: Date Paid: Amount:
Building 1/22/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner