31A-097 (11) .� `�., � � Ix;lt1' [.1; er,ugy;liLn an--►n�an.Qc.ea ''
labf:! a",.r f1:1Z SAVE !rr ;Utur: relef_r�
c�D, c&O-A—S Z
? ✓� , IA °I c10c �Dubi'
i �lu7 lad Tre„ 1 =
r= rr_-1., ?JS ln:h G;z?i g
r;eOn Fill 1,7 Alt 73:_
ul
u.3� i_70
,DDITIDN'1,_ r�.�n-0R.Nei AN.G
,J 1'ia*,1;1^t�1(t:.—. � ,._.•._�::fi:n Rctislct.::
.o ( ��
. cnvlrc unr ncufl Ct htt ate nt-:,t zbrn= +;p7:mat Xf F�}nalvrct ar
1.7y clop .1..rt pnit;(K;2-t jta^r r.:a,HFt.:nln(t rn lntr>rLnrf 6r t
2.H cl el rs nr�,n urW c-rdlv.l �i >r+alt FnGc�e:r %F F"lo:� ro(rc-�.+•.-x.-+!
.nt lr„L rt! v.C'frti nU rt.—�l ht utti ttY cf '}}ndetl br .•q qsy 1: ,
+Yc,ll r^..nvLt�n!•1 iUn L'n br r1u lnLva}u�nw+n tole r:-vton.
Ail Irtl tlfrJ en R.eWrr nr ntc
�` �} J,l�•. _ It-tl tt 1%±i'll it UVXVL2 I::S.7-tt
t J
r-t.:5 rt7:
Ctt:n
::G?L7, L11`:3 15
Aug 06 15 06:30a P.
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
/. Sold,Furnished and Installed by:
J3r2ncb Name:Boston North&South Daterl 5th THD At-Home Services.Inc.
dib/a The Home Depot At-Home Services
Branch Number:31 and 33 909 Boston Turnpike,Unit 1.Shrewsbury,MA C 1545
Toll Free 877-903-3768
Federal iD S 75-2698460;ME Lc 4 C 42439;RI Cont.Licit 16427
CT Licit HIC.056552 - Horn k-4novcmcnt Contractor Rcg.4 126893
Installation Address. 1 1
Citv State Zip
Purchaser(s): Work Phone: omePhone: Cell Phone:
[ l ] [ l
Home Address:
(If different from Instalation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑1 DO NOT wish to receive any marketing tanails tram The Homc Depot
Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
and THD At-Home Services,inc. ("The Home Depot")agrees to furnish.deliver and arrange for the installation("Installation")of
all materials described or. the below and on the referenced Spec Shcet(s), all of which arc ncorporated into this Contract by this
reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively,
"Contract"):
Job 0: W—ae.r.-4 p nds; Spec Skee s ti: ProjectAmount
Roofing Siding • W'indows Insulation S
�}4 t+ �� ❑Gutters;Covers❑Entry floor; ❑
Roofing Siding 0 Windows Insulation S
[]Gutto�s i Covers ❑Entry Doors ❑
Roofing PSiding Windows Insulatlon $
{]Gutter.i Covers ❑Entry Doors Q
Roofing Siding LIMinclows Insulation $
❑Gutters?Covers ❑Entry Doors ❑
Minimum25:'o Deposit oft'.ontmd Amount doe upon executi000f this matract. Total Contract Amount $ —2 135-
}3 5-
MAiRePureffirsers may not deposit more than one-third of the Contract Amour*.
Customer agrees that, immediately upon completion 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 applicable,each Customer under this
Contract agrees to bcjointly and severally obligated and liable hereunder.
The Home Depot reserves the right to issue a Change Ordcr or terminate this Contract or any individtcrl Product(s)included herein,al
its discretion,if T'se Hcmc Depot or its authorized scr•rtce provider determines that it cannot perform its abl igations 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.
Payment Summary: The Payment Summary 4 LQ2 _2 G 2 .included as part of this Contract, sets forth the total
Conn:ter amount and payments required for the deposits and final payments by Product(as applicable).
NOTICE TO 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 default 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 under applicable 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 OFSUCH AMOUNTS.
Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Products and Installation services and supersedes all prior dis:ussiotis and agreements,either
oral or written,relating to said Products and Installation.This Agreement cannot be -" ed or amcrdod except by a venting signed
by Customer and The home Repot_Customer,acknowledges and agrees that C cr .n read,understands,voluntarily accepts the
terms of and has received a copy oa'th's Agreement.
I
Accepted by: ! �- Submitt
X C v�f to 3 f S x
Customer's Sign Date' 1 Sales C tilt 's Signature Date
X Telephone No.
Custornc:'s Signature Date
Sales Consultant License No_
CANCELLATION: CUSTOMER MAY CANCEL THIS (as ayplicahlc7
AGREEMENT WITHOUT PENALTY OR OBLIGATION
i3Y DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS r �
DAY AFTER. SIGNING THIS AGREEMENT. THE � 1l
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE Is
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
i
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:
The debris will be received by: �, -C��
Building permit number:
Name of Permit Applicant IGr��1nh�
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department oflndustrialAccidents
1 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 PERNffrMG AUTHORITY.
Applicant Information Please Print Le ibly
Name(Business/Organization/Individual): �v /
Address:
City/State/Zip: • Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
IQ I am a employer with employees(full and/or part-time).' 7. New construction
2F-�I am a sole proprietor or partnership and have no employees working for me in g. Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Q Building addition
4.❑I am a bomeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
P netors with no empioyees. 12.Q Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.7 oOf repairs
These sub-contractors have employees and have workers'comp.insurance.•
6Q W'e are a corporation and its officer have exercised their right of exemption per h1GL c. 14. Other/
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their worker'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hue 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-cout actors and state whether or not those entities have
employees. Uthe 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. ,]/I,�
Insurance Company NL'ame: f , , /�"
Policy r or Self-ins.Lic.r �/: � O`7'yJ!�! � Expiration Date:
Job Site Address: City/State/Zip:/y'l � '
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ex ation date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
andror 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 and naltie erjury that the information provided above is true and correct
Sim / Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
I City or Town: PermibUcense#
i Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Tovvm Clerk 4.Electrical Inspector S.Plumbing Inspector
} 6.Other
j Contact Person: Phone#:
i
1
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: l� Not Applicable ❑
Name of License Holder: -�'� l �
License Number
44r ^/ 143-)R2
Addres Expiration Date
int r/
Telephone
8.Rerilstered Home improvement Contractor: Not Applicable ❑
H �yy�r-�
� kyj?/�
Company Name Registration WumUerp
Address Expiration Da e
Telephone
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
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 Win w_ s Alteration(s) [__J Roofing
Or Doors dtfl
Accessory Bldg. ❑ Demolition ❑ New Signs [L7] Decks [Q Siding[0] Other[O]
Brief De cription p%yx
Work: G- L _ C
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 t9&xisting housing, coin fete 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
I, �(��(�[ as Owner of the subject
property {�
hereby authorize
to act on my behalf, in all m ers restive to work homed by this building permit application. �-
Signature of Owner Date
I, as Owner/Authorized
Agent hereby declare that the statements an information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed and e painsandpena lties of perjury.
/IeR'VVF1. 1J
Prin a
A.
r
Sign r of 0 , Agen Date
3
r� ( ' Department use only
1== City of Northampton Status of Permit.
Building Department Curb Cut/Driveway Permit
s 2 212 Main Street Sevier/Septic Availability
Room 100 WaterMell Availability
&Gas ins��ec1 ons orthampton, MA 01060 Two Sets of Structural Plans
Electric;o thamp on,f AA 01060
ne 413-587-1240 Fax 413-587-1272 Plot/Site 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 be completed by office
Map Lot Unit
Zone Overlay District
Elm St District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Record:
Name(Print) Current Mailing Address:
L Telephone
Signature
2.2 Authorized A nt: _
Name(P' t) urre ailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION CQSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building l , (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=0 +2+3+4+5) 7, i e7 Check Number 1dq 070 1 4410
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
I f_
Building Commissioner/inspector of Buildings Date
63 VERNON ST BP-2016-0322
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A-097 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-2016-0322
Project# JS-2016-000515
Est. Cost: $2175.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 99209
Lot Size(sq. ft.): 34804.44 Owner: ROCKWELL LINDSAY E
Zonin :URB(100)/WP(33) Applicant: HOME DEPOT AT HOME SERVICES
AT: 63 VERNON ST
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 () Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON.911412015 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 Sienature:
FeeType: Date Paid: Amount:
Building 9/14/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner