36-056 (12) 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: AP6 rett) Dyz- .
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
101,/o�74
1 "-F(20,
Date Signature of Permit Applicant
P.1
May 301510.20a
HONME LMPRON1 PENT COVTRACT
PLEASE READ THIS
Sold,Furnished and Installed by:
Brunch Name:Roston North&South Date—TIRJ/�C THD At-Home Services,Inc.
dfbla The Home Depot At-Horne Services
Branch Number:31 and 33 908.Boston Turnpike.Unit L Shmw5buiy,MA OIS45
Toll Fret.877-903-3768
Federal iD#75-2Cf3WO6 ME Uc#C 42419:RI Cont.tic"""16427
CT sac#RIC.0565522;MA Home Irnprovernent Contr&-tor Reef.#126393 _
Installation Address: q t k few o Ro�=a--%;' Dmk. 7
City State Zip
Purchaserfs):. W7 ork Phone: Home Phone: Celt Phone:
, 1
Home Address:
(If different from installation Address', City State Zip
Email Address(to receive project communications and Horne Depot.updates);
❑1 DO NOT wish to receive any marketing emails from The Home Depot
Proiett Jnffartnatkw: Undersigned("Customer the owners of the property located at the above installation address,agrees to buy,
ar,d THD At-Home Service,. Inc.("The Horne Depot")agrees to furnish,deliver land arrange for the instalation("Installation")of
all materials described an the below and on the referenced Spec Sheet(s),rill of which are incorporated into this Contract by this
reference,along Mth any applicable State Supplenlert and Payment Summary attached hereto and any Change Orders(collectively,
"Contract";r:
Job# a Q n i ltdw—' le Products Spec Sheet(s) #.- Project Amount
Roofin it&ng C1 Windows LJ lnsulatio, t
❑Gutrers,Covers[]Entry Doors ❑ s
RoofingSid ng 1�indays In
on
OGuiters l Covers ❑Entry Dow,, ❑
Roofing Siding U windows 0 insulation
❑Gunen(Covers❑Entry Doors Q
Rooting Sisiug Windows Insulation
t]Gutters i Coven E:Entry Dms ❑ $
Misimum25%Dcposltor Contract Ar nmutt due upon execWonof this WntrwL Total ContractAnwunt $
Maine Putchasem mey nol deposit mac than one-third ri the Conttnet Amount
Customer agrees tha4 imrnediatcly upon completions of the worn ror each Product.Customer wilt execute u Completion Certificate
(one for each Product as defined by an individual Spec Sheet)and pay any fralunce due. As applir�ibhc. catch Customer under this
Canuact agree.~to be jointly and severally obligated and liable hereunder.
The Rome Depot reserves the right to issue a Change Orckr or terminate des Contract or any individual Prtaluct(s)included•herein,at
its discret.ios.if The Home Depot of its authorized service provider determines that it cannot perform its obligation'.,due to a Structural
problem with the htmv—environmental hazards%m:h as meld,ashcctos or lead paint,odier se,reiy concerns,pricing errors or beatuse
work required to complete the job v ass nca incladeti in the Contract.
Payment Summary: ''nw Rsymett Summary#�FA 5", included as part of this Cotttaet. .etS rNths the fatal
Comiract nmount and payments re,uired for the dc". sits and final payments by fkmuct(its applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy ti the Contract at the time you sign. Do not sigh a Completion Cc-titicate(note'
there is one Completion Cer irw4e for each listed Product as defined by individttut Spec Shectsi before work on that Prodnet
is complete.
In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expew-es
and services provided by The Home Depot or Anthorirexl Service Provider through the date of termination,plus on) other
amounts set forth in this Agreement or altowtd under applicuhle laFv. THE HOME DEPOT%1AY 1i FrHHOLD AMOLNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT 1!RY{v1FN1 T OR OTHER PAYNIF PS MADE, WIT1110VT
LIMITING•THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY(A'SUCH AMOUNTS-
Acceotance and A.uth erization. Custotncr up-ces and understands tsai this Agr:emcni is the entire b::tuwen Cststo:ncr
;us[L ll�e Honsc ihpot with raga.d to the R'aducts and Instal ration services and supersedes ill print'[lisetrxsions and atTc•[mcnts.ci.110
oral tv written,relating to said Yro[lucis.txl Imtallativn.This Aea'ecrtent citnnx 1 assignor or amended eaccpt by a vn hint signed
1av Customer and The fiome Depot.Custamcr acktsnwledCes and agrctis that Cu u:r •r ha+read.undastands. voluntarily a cepts the
term.of and Inns rcpt'�d a copy of this Agroctnenl.
,
Accept by ' Suhmitted
X �I 2�/is X 4
Cuv s Si Date Sales ism is Signature Dille
X Tcic one Vt?.
Cu torner's Signature Date Sales Conwluint License No.
CANCELLATION: CUSTOMI:R MAY CANCEL THIS ray apptitiahk)
A(,REEi41ENT WITHOUT PENALTY OR OBLIGATION
BX DELIYEMM,WR1TIMN NOT"CETO'St1E110iv11. t✓',j J
DEPOT BY &IlDNiGHT ON THE THIRD BUSINESS
DAY AFTER SIGHING THIS AGRMMENT. THE
SfATF. SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM T'O -USE IF ONE IS
SPECII•`ICALLY PRFSCRIBE,D BY LAW IN
The Commonwealth of Massachusetts
Department oflndustrialAccidents
a
I Congress Street, Suite 100
Boston,MA 02114-2017
_ www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers-
TO BE FILED WITH THE PERMMING AUTHORITY.
Ao licant Information Please Print Legibly
Name(Business/Organ ization/Individual): �r1
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box:
Type of project(required):
I.n I am a employer with employees(full and/or part-time).* 7. F�New construction
2.F-1 I am a sole proprietor or parmersbip and have no employees working for me in g. Remodeling
any capacity.[No workers'comp.insurance required.]
9. Demolition
3.7[am a homeowner doing all work myself.[No workers'comp.insurance required.]t
❑
4Q[am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.7 Electrical repairs or additions
p netors with no employees.
12.0 Plumbing repairs or additions
5.LZ I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs ��
'These sub-contractors have employees and have workers'comp.insurance.
6.F-1 We are a corporation and its officers have exercised their right of exemption per MGL 14, ther c. —
152,§1(4),and we have no employees.[No workers'comp.insurance required.] 1/jilt I
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.V
r 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 ant an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site
information. / l 3�lt5 ,Insurance Company Name: �//W /v// 2�
Policy#or Self-ins.Lic.M wc�- 04101 65�_C?2— Expiration Date:
Job Site Address: f24ep66D City/State/Zip VXP1Q
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to 51,500.00
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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certi 04t,� andp6naltie erjury that the information provided above is true and correct.
Sitrrta 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 S.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable £
Name of License Holder:
License Number /
r "-
Address Expiration Date
aeZ�b� A 0 -� )
signa ure Telephone
9.Re istered Home Im rovement Contractor >,.„ Not Appli able
Company Name Registration Number
A r 4--Telep Expiration Date
h ones°
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 Ye ... No...... £
1L . 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 108.3.5.1CMR 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 buildinaermit.
As acting Construction 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 Windows Alteration(s) ❑ Roofin ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding Other[[3]
Brief Del i 'o of ro osed r :/� L J�/�.
Work: G`G h e j�gyy�
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 house and or addition to existinq Housuiq; cornp[ete 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
(�• as Owner of the subject
propertyj�
hereby authorize
to act on my behalf,in all n1aUrs relative to work authorized by this building permit applicatio .,.--
Signature of Owner Date
7 "Ppp �fW 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 M=al ti es
o
Print Nam
Sig re of Owner/ Date
"
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
�
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size L--
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage 910
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?
��x~� Y[6 �~���
NO v x,� DONTKNO�� YY
|F YES, date
issued� �
�
IF YES: Was the permit recorded at the Registry nfDeeds?
NO �� DONTKNO� YES�=�
IF YES: enter Book Page and/or Document#L
B. Does the site contain a brook, body of water orwetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need Lobe obtained from the Conservation Commission?
Needs tobeobtained x~� Obtained x~� Date
��/ �_� ' �
C. Do any signs exist on the pm �� ��perty� Y[6 �_� NO «��
IF YES, describe size, type and location:
U. Are there any proposed changes toor additions of signs intended for the property 7 YES 0 NO 0
|F YES, describe size, type and location
�
E. Will the construction activity disturb(clearing, grading,excavation,or filling)over 1 acre orioit part ofo common plan
' that will disturb over Iacre? YES NO 0
|F YES,then u Northampton Storm Water Management Permit from the DPW iorequired.
^ '^
City of Northampton
i Budding Department Ctrr) �uv riveuva�rPerrrti# a �_
t JUN '
6 2015 212 Main Street SewertsepticAvaira�il�ty �' ' �, f
1
Ere trt Room 100 Water/FntellAvatlabillt
NorilL �'ns a Northampton, MA 01060 TWa$ets�fStruetul�I
u
arripron aS Jn t r {4
��A o�os 413-587-1240 Fax 413-587-1272 Plo#/Site Plans
Other2Spec�fy '; ,ri;
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
1.1 Property Address: This sectiorr to be;completed by office
,
kipr Zone r .:, ,� Overlay District
Elm$t Dlstnct CB District
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
� -
Name(Print) C rr t Ma'in Add
z
elephone �
Signature
2.2 Autho •zed A ent:
ot
f�-
a ri Current Mailing Address:
A/p/� � �--�
ignature 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
41 REDFORD DR BP-2015-1311
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-056 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit# BP-2015-1311
Project# JS-2015-002403
Est. Cost: $10547.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 105953
Lot Size(sq. ft.): 12501.72 Owner: ALHASSAN SOFIYA
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT. 41 REDFORD DR
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.611612015 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE VINYL SIDING
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 6/16/2015 0:00:00 $35.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner