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City of Northampton 212 Main Street, Northampton, MA 01 060
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.
_ J ,
The debris will be transported by.
The debris will be received by:
Building permit number:
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Name of Permit Applicant �� � J
Date Signature of Permit Applicant
Sep 2615 04:43a p•1
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Furnished and installed by:
Branch Name:Boston North&South THD At-Home Services,Inc.
&b/a The Home Depot At-Home Services
Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free S77-903-3768
Federal 10#75.2698460:ME Lic#C 02439;RI Cont.Lic#t45427
CT Lie#HICA565522-MA Home Improvement Contractor Reg.#126893
I astallation,Addt ess,. 7 I It /Jl
City Stale Zip
Purchaser(sj: Work Phone: Home Phone: Cell Phony.
a
Horne A ss
ddre :
(If different from installation Address) City State Zip r
E-mail Address(to receive project communications and Horne Depot updates): I`
❑1 DO NOT wish to receive any marketing cmails from The Home Depot
Pro' ct Ieformati • Undersigned("Customer"),the owners of the properly 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 on the below and on the referenced Spec Shect(s), all of which are incorporated into this Contract by this
reference,along with any applicable Suite Supplement and Payment Summary attached hereto and any Change Orders(collectively,
"Contract"):
Job#: o..a pw a o P oducts: S Sheets #: Project Amount
Roo)fiag Siding Window; Insulation L,,+,1 �?7t.� $
[❑Gutters I Covers ❑Entry Daors ❑ �/"1 E;� 7 I-7/0
��y/(
Roofing Siding Windows Insulation $ ��J,l
❑Gutters I Covers ❑Entry Doors ❑
Roofing ElSiding 0 Windows 0 Insulation
0Guuers/Covers ❑Entry Doors[I
Roofing LjSiding LJ Windows 0 Insulation //
$
[]Gutters I Covers ❑EttryDoors ❑
Minimum 25%Deposit of Contract Amount due upon execution ofthis contract Tots]Contract Amount
Maine Purchasers may not deposit mare titan ate-third of the Contract A mount ff i
Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate
(onc for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Producl(s)included herein,at
its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home,cnvisonmental hazards such as mold,asbestos or]cad paint,other safety concerns,pricing errors or because
work required to complete the job was not included in the Contract. J
Pavment Summary: The Payment Summary 0 `fo��t included as pm-t of this Contract, sets forth the total
Contract amount and payments required for the deposits and final payments 1)),Product(as applicable).
NOTICE TO CUSTOMER
You are entitled t02 completely Pdled-in copy of the Contmet 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 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 OF SUCH AMOUNTS.
Acceptance and Authorization. Customer agrees and understands that this Agreement is the entire agre:nmcnt between Customer
and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either
orzi or written,relating to said Products and Installation.This Agrcene be assigned or amended except by a writing signed
by Customer and The Home Depot.Customer acknowledges and agrees \t Cu Comer has read,understands,voluntarily accepts the
:cans of and has received a copy of this Agreement,
Acee led bv: Sabi ' d b
-- x
t men's Sigfiat c �j��. Sales C Ita Signature ature Date
Teleph No.
Customer's Signature Date Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS (msappliattet
AGREEMENT WITHOUT PENALTY OR OBLIGATION �l 3 5✓ !�
BY DELIVERING WRITTEN NOTICE TO THE HOME t;, � ✓-tJ(
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
CUSTOMER'S STATE.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,3r`u to 100
Boston,M4 02114-2017
vawtiv.to ass.go v/d.i a
Workers'Compensation Insurance Affildavit:Builders/Contractors/) lecu icians[Plumbers.
T O BE F ED WITH THE PERMITI'1PIG AUTHORITY.
Apalicant information Please Print Legibly
Name(Business/Organization/Individual): n ���✓ � y'��
Address: �/i'✓'^ �'� 1�6"`�f �° =% l/
amity/State/Zip:� LRb Phone :
Are:ou an employer?Check the appropriate box: Type of project(required):
l.❑I am a employer with employees(full and/or part-time).
7. ❑New construction
24❑I am a sole proprietor or partnership and have no employees working forme in S. Remodeling
any capacity.[No workers'comp.insurance required.]
❑3.❑I am a�omenwner doing all work myself.[h�o�.vor es'cemp.insurance required.]' 9. Demolition
10 E]Building addition
e.�i am a homeowner 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 11.0 Electrical repairs or additions
pr P`2tors with no employees. 12.7 Plumbing repairs or additions
5.[t am a general contractor and I have hired the sub-contractor Iisted on the attached sheet. 13.E}Roof repairs
These subcontractors have employees and have worker'comp.insurance.
6Q we a e a corporation and its officers have exercised their right of exemption per MGL c.
14. ther
152,§1(4),and we have no employees.[No worker'comp.insurance required.]
'Any applicant that checks box#1 must also BE out the section below showing their workers'compensation policy information_
Homeov zters 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 sbeet showing the name of the su'o-contmctors and state whether or not those entities have
employees. if the sub-contractor have employees,they must provide their workers'comp.policy number.
I azn an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: r��
Policy N or Self-ins.Lic.4: J � Expiration Date:
Job Site Address: �� '� " City/State/Zip
Attach a copy of the Workers'compensation policy declaration page(showing the policy number and, iration 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 DLA for insurance
coverage verification.
I do hereby certi' pi and naltie ezjury thatthe infot7nation provided above is Jtrue and con•ect
Siena _ v— Date:
Phone;
Official use only. Bo not write itz 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 Cleric 4.Electrical inspector 5.Plumbing inspector
6.Other
Contact Person: Phone#:
SECTION 87 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor- Not Applicable E
Name of License Holder: V %/V ei�l^ " �
License Number
Address Expi ation Date
Signature Telephone
9.'Re istered Home':Im rovement;G ntraefor _ _. Not Applicable £
� / e93
Company Name r Registration Number
Addre /) Expir ion Date
r 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 pezm1t.
Signed Affidavit Attached Yes... . No...... £
11✓ .. Home_.=4wner Egempt>lon
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. CNM 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/sbe 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,
i
i
i
I
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House F] Addition Replacement W' ows Alteration(s) E] Roofing F7 Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [[O] Decks [❑ Siding [p] Other[M]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa; If eV.house antl or.addition#o exisflng.:housmg .corri¢ fete_fie.followlna:
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 APPLIESTOR.BUILDING PERMIT
as Owner of the subject
property
hereby authorize
to act on my behalf, in al atter ve to worFiorized by this building permit application.
Signature of Owner Date
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 under eins penalti s of perj
Print Name
Signature of gKer/AgIfnt Date
a
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information y i
Existing Proposed Required by Zoning
This column to be filled in by
Building Depamrient
0
Lot Size 1 ! I ! l
Frontage Setbacks Front
Front
Side L:' ) R:€ I L:! 1 R:? I )
Rear
Building Height (
Bldg. Square Footage i
Open Space Footage
(Lot area minus bldg&paved _
parking)
#of Parking Spaces 1--- `
Fill: r I
(volume&Location) I'
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES Q
IF YES, date issued:] i—J
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book — ! Page, 3 and/or Document#i
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i a
J
::. 1�_,, , � M1 peparfinent use only 'j
Cil of Northampton 5-fi u ,ofPerrnrt
Bu Iding Department Cl7rb CurEDrl+�e�tvay Perrnlf
OCT 2015 .
�2 Main Street Sewer, eptieAvalra611rty J '
,
z r.
Room 100 -Auatiabillty
DEPT OF BUILDING IN3PECTI ' f e
NORTHAMPTON MA -RA,
mpton, MA 01060 Two-Sefs afStl'gaigaa al Purrs
phone 7-1240 Fax 413-587-1272 t
- - -
.:._.,; .:..-.:.-- f..:_.:_ ir__•-?-�!ii::_.cr.:�-�: -�y._Y__ru::.--ie:I?:.-...�-r_^_-F:--•ll�v:!'-i:�:-:'.=:e
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
-This secfiorrto be c-----6 dil by offi ce
1.1 Property Address: _
�T/1✓ ��'
� � T
Zone _ Overlay Dlsfrtct
.2
EIm St DISt�ICt r CB 171stnct
. SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED:AGENT:
2.1 Owner of Record:
Name(Print) / Current Mailing Address:
Telephone
Signature
2.2 Authpfincl 8&i±
T(2v)
Name( ' Current Mailing Address: �9�r
slqKture T lee phone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use-Only
completed by ermit applicant
1. Building // q h .� (a) Building Permit Fee
2. Electrical (1 (6),Estimated Total Cost of
Construction from fi
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 Comm issioner/lnspector'of Buildings;.: .. Date
26 CRESCENT ST BP-2016-0549
GIs#: COMMONWEALTH OF MASSACHUSETTS
ME:Block: 3 1 B-312 CITY OF NORTHAMPTON
Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:windows replaced BUILDING PERMIT
Permit# BP-2016-0549
Project# JS-2016-000906
Est. Cost: $18921.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 98785
Lot Size(sq.ft.): Owner: MAGNA HOUSE CONDOMINIUMS
Zoning URC(100) Applicant: HOME DEPOT AT HOME SERVICES
AT: 26 CRESCENT ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.1012112015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 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 10/21/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner