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25C-069 (2) Oct 121508:52a P•1 HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: Branch Name:Boston North&Suuth Date:_,._ THD At-Horne Services.Inc. d/b/a The Home Depot At-Home Services Branch Number:31 and 33 908 Boston Turnpike,Unit I,Shrewsbury,MA 01545 Toil Free S77-903-3768 Federal m 4 75-2599160:ME Lic tt C 0243;)-RI Cant.Lic#16427 CT LicA# 'C 05 22:MA Home Improvement t Crntractra•Reg.P 126893 Installation Address: 2` +�+ L City State Zip Pmrttaser(s): Work Phone: Home Phone. Cell Phone: I ] [ ] [ I Horne Address: (if different from]nstallation Address) City State Zip E-mail Address(to receive project eommtmications and Home Depot updates): ❑1 DO NOT wish to receive any marketing email s from The Home Depot Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,a_qees to buy. and THD At-Home Services,Inc. ("The Berne Depot")agrees to furnish,deliver and arrange 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 retereace,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Qmtract"): ,Inh#: Uma*K.I _m acts: Spec Shcet(s]#: I'mirct Amount Riwfing Si ing Window. ?nsulation rT_ — 0b6Mc ❑Guttc s!Covers OFntry Doors D $ Roofing Siding Windows Lj tnsuladon $ ❑Gutters l Covers []Entry Doors Roofing Siding Windows Insulation $ t� ❑Guam!Covers[]Entry Daum❑ h Ra ling Siding i Windows C1 insulation ©Gntteri-Coven ❑Entry Doors ❑ S ) Minimum 25%Deposit of Contract Amount due upon execution of this contract Maine Purchasers may not depudt own Ihm oneAhird of the Contract Amount Total Contract Amount $ Customer agrees that, immediately upon completion of tht:work for each Product,Customer will execute a Completion Certificate gone 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 nereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual R-oduct(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 Contract.. n Payment Stumary: The Payment Summary p l__t I rs q 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 filled-io copy or the Contract at the time you sign. Do not sign a Compledon Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Proeluct is complete. In time event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses and services provided by The Horn 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, WTTIIOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees anti 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 discussions anct 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 azrees th •tamer has read,understands,voluntarily accepts the terms of and has reeeivod a copy of this Agreement. Acceptrd Su Y�-". 2 er Date Sale. sultant's Signature Date X Telephone No. Ctmomer's Si.onaturc Date - Stiles Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS BY AGREEMENT E R WITHOUT PENALTY OR OBLIGATION r � ^�Q 13Y DELIVERING WRITTEN NOTICE TO THE HOME � ✓�S J7 DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENTT ATTACHED HERETO COATAiNS A FORM TO L'SE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN ® CERTIFICATE ®F L6TiBI L I B 8 INSURANCE SUR1ANCE DATE 12015 DfYYYY) 02242015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER— IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(ies) must be endorsed- If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSH USA,INC. NAM``: T1'9O ALLIANCE CENTER PHONN c AJC No): 35M LEENOX ROAD,SUI t 24'00 E+hall ATLANTA,GA 3032-6 ADDRESS: INSURE S AFFORDING COVERAGE NA1C# 100492-HomeD-CAW 15-76 I INSURER A!Sbadiast Insurance Company 1266387 INSURED i Zurich American Insurance Co 16a?3 rtD AT-H0..!=SERVICES,1141— rISUR£R s ORA t;E HO:4E DEPOT AT-H0%'.E SERVICES INSURER C:New Hampshire Ins Co 23841 2690 CUMBERLAND PARXVIAY,SUITE 300 ATL!,I T A,GA 303339 INSURER D:Illinois National Insurance Company---- 23877 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003242665-09 REVISION NUMBER:7 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOjWTHSTANOING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE t,4?Y B� ISSUED OR MAY PERTAIN, iris INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TlIwS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LNTR I ,YP=OF INSURANCE IADDLI 1u1 POLICY NUMBER 11 EFF I MM/ODY EXP LJMr rs A GENERAL LIABILITY I vlC4BSTJ7 ti^5 1 9,000,000 �� I031D72015 `031012016 EACH OCCURRENC`c s CONWER GENERAL LIABILITY ; I I A en e I 1,000,000 �� PREMISES tco otrrrranCal `- I I CLA6!:S,.IkD=_ I�OCCUR I LIMITS 0=°O ICY XS ! c a( r Jf !TED x w one Person) I S EXCLUDED i I I 10C SIR:S111,PER OCC i PERSONAL L A7='INJURY 1-S GENERAL AGGR�_W E 5 9.000.000 (GEN'L AGGREGAT=UTAIT APPLIES?ER: � I I {PRODUCTS- - 9.DOD.DDa- I X I PODCY 1 1 c�T 1 1 LOC 1 c 3 j AUTOI,OBILELIABILIT". BAP 23-38353-12 {C3212D,5 0310120116 COMBIN=DSRaGL=LIMIT I S 1000000 1 (Ea acadent) I l j{ ' "' tTO I I I BODILY INJURY(Per person) is A_Ov 1cD SCI=r7ULED 'SELF INSURED AUTO?PY DMG I ILY INJURY(Per accident) S AUTCS t i H.RED A::TCS IL_J!:YOi4-0A9]ED I ` [P�ROPEFTY DA!6:.G° S AG I ! P.r]'r:JCPnll- j Ut!SR_LLA LIAB f OCCUR l F—i 1 EACH OCCURRENCE S I 1 EXCESS LiB i tt AGGR=G.tTE �S I DED I I Rcr=NnOrIS C I VIORKERS COkPENSATiDN 4VC017731493 (ADS) 10WI2015 1031112016 X WC STATU- I oT-rt-I t AND EMPLOYERS'LIABILITY _ 1,000.0`D^� C ANY PROPRiF r.ORJ?AFTN=R/EXECUTIV= Y J� 1 5NC01773149-6(AK,l^:,NH,NJ,�1 031012013 03/072016 =—L EACH ACCIDENT I S f oFPICER/!hr-JdIB°_R EXCLUDED? rJ tJ IA O (Mandatory In NH) I Vti'C017731494{=L} !03/0120/5 03!012016 E-L DISEASE-EA EMPLOYEd S 1,DD3,OOG it zes, IPSQDBunder i ` 7,000,pnn D_SCRIPTION O'r OPERATIONS Oelo+, ConRnudt ea Additional Paoe i (c.L DiS�SL-POLICY LIMIT 5 _I i I I I ► ► DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks SchMule,t more space is required) EVIDENCE GE INSURANCE CERTIFICATE HOLDER CANCELLATION l HD AT-HOME SERVICES.INC_ 031 THE HONE DEPOT AT-HOME SERVICES { SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA HEHOI EDEPCTAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS- ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc- - i ManashiMukheijee ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD rermrl services 4U1 [4o�00t$ D.L Al' G!`i:.) ,�.�2fLtf� Office of Consumer Affairs and Business Regulation :. 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 126893 Type: Supplement Card : 8/3/2016 THD AT HOME SERVICES, INC- EXDiration RICHARD TROIA ----------- 2690 CUMBERLAND PARKWAY SUITE 300 . . --- ATLANTA, GA 30339 Update address and return c,-rd.n42rk reason for chnnge. SCAi r, zowto n� Address Renews: iltc;.,_. ' �l ir..i,.?tL l./t..f/..Yl�f/!��"^/irr��frf,/•r�ri�. Office of Cunsurner AM-irs&Rosiness Regulation License or registration valid for individul use only ONE IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office o`Consumer Affairs and Business Regulation RegLstrabon; .1219H93 Typs: I0 Park Pizza-Suite5I7D Ex¢irati0w..&312016 Supplement Card Roston,MA 02116 THD AT HOME SERVICES.INC. THE HOME DEPOT AT HOME SERVICES fl ! RICHARD TROIA 2690 CUMBERLAND PRRKWnY S At `A,CAA 30339 tindersccrcury �� Not valid wa out signature n Massachusetts - Depar t3:s�:, ; : Construction Supervisor Speclall e r License: CSSL-105953 f; n 3i d OIA36 `-Wg Y a !ni ioner 0511$12 '..\ ' � � •�„'` ,,mac. • i uvll)cd ' a:Mov: Izb:l.aticr rmzl In ection; SAVE for h Arc reler:nce -alhcr Shl:ld , Cr D! ObO=A-17Z �'` }Model 6iDB Doub}e {ung Op�ralinp Alum clad Thernzl Fr'am� " ' ,;:,:.�=rr•c:'::n �� Inch GfaZir•,g . .022 Low—:: ,c n Amon Fill Grill_ in Alt Spzce ENERGY PER=ORMANCE RA- �5 0.30 1 .70 D,18 ADDITIONAL FERFORMAUCE RATINGS • 0 Yl:f1:lelt�'ISt:,',it,:; Ghlta::{icn R:tistu.:t ,. r , .40 0 Cnvirtunr r,ou4nt hII eta ntn;t tzbrn b 1;Pnz,.II IfIR:f"cc pnIItI n'c Pcn:rr=:t-XFd-.t,II,II to UH ixf►f cc r—w,W r,+d7twt tnf p::ttc prtdrel r.-rt.1tFR=I°rs.°t rc.+n•nrn! �1 ft.lutl wf't ttt nit♦hurl ht e1rony of�+^�•?nd°,f b+•^J gccttc v•a, ull mc1wU:--n1t tLnUrt bt,fit,lntvcl rttbnn+au Inserm+ton. 'I M.�tl, b c_::,t:t N.,��„ t:.° C., trJ I.F.C.C, t,fr 1nr11Vc11on P.av,r.a+en!: , (CI ai .(��17 Itaclu 1KSt'11,1tIl�CVbL i JLt,1-!7 • �, � t ' w_c:rs ,Itsr^tofurtT C 11;f1� `• � The Commonwealth of Massachusetts a �_ Depar-hrent o;Industrial Accidents % Congress Street,SLLke 100 Boston,MA 02L74-2017 Orkers'Compensation insurance Ai—davit:Btiilders/Gontraciors/-leCL icianS/Plumbers. O BE FILED WIT R TUE PEFtlrtl?'>, GAUTHOPdTlY. ioplicant information Tease Print Legibly "aTme(BusinesJOrganization/Indiv;duai): fJ��1 ✓ �' Y ` % J ��i,� :address: City/State/Zip: W Phone re you nn employer?Check t_he appropriate box: Tyne of project(required): t ` 1.0 I am a employer wi,a employees(full andlor part-time).= 7. E]New construction In I am a sole proprietor or partnership and have no employees wor'ld3g for me in $. E]Remodeling any c=apacity'.two workers'comp.insurance required.] 3.7 ram a icr;:ea vner doing all ivor'-myself[tip rort:e s'ccmc.ipsurance required.] g- ❑Demolition j lamahomeo�.nerandwillbe' I =0 Building addition • °' hiring COntIdCtJrS CO COIIQL'et al:work on my proper'. I r:iL Lsu e that all coati cmrs either have workers'compeasatioa insurance or are sole I Ln Electrical repairs or additions prators with no employees. 12.Q Plumbing repairs or additions d.5 I am a genera'contractor and I have hired the sub-coaitactor listed on the attached sheet —c sub-comae 13.;tth.,I epairs rs have employees and have wott:er'comp.Lnsur�nce: U.1 J'�V e Ze a corporation and its officers have exercised their right of exemption per tiiGI c. I4. !1✓ 'Vii/ j I J?,v!(z},c'^Q t•:t na'i @ n0 emplOVCeS.CVO t40rke6'COB17.tnslL�eIICC reQi!L?d.! -.ay ppiicaa-,that cbec:ss box=1 must also fill out the section below showing their wo:ter,'comaeasation policy information. ! omeo rr,ers who submit this affidavit indicating they are doing all wort:and then sire outside cou-,actors must submit a new affidavit indicating such. Contractor drat c-2ec'•:this box must attached an additional sheet showing the name of the sub-contractors-and state whether or not those entities'nave employees. if tie sub-contzactora have employees,thev must provide their workczs comp.policy number. 1 ain an P711aloyer that is pro v&i7i ;varkers s coinpensation'nsmraiice fib r:its%employees. BeIDw iS tfZe policy and job.Sire in 0rination. Insurance Company NaIIfe: 1 ( V(//; �' � O�I1�I ll� Gar f Policv-or SeI'ins_Lic.:.: a— I p t}�� ___ Expiration Date: Job Site Address: �2-- rPa City/State/Zir A/ `^ A ttac-?a copjr Of tie workers'compensation policy declar at on 5abe h -wm- le peiCze?pig on date).? Failure to secure coverage as required under MGL c. 152,§25 a is a criminal violation punishable by a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WOR_t ORDER and a pine of up to 5250.00 a day against the violator.A copy of this statement may be for,varded to the Office of Investigations of the DTA for insurance coverage verification. i do 7zereoy certi" ni- and-�nal`tz�es e7jsiry that the in omzation provided above is ttrue and con-ect: Sima � `' Date: Phone tsfficlal arse oral;.,. Do not write ill this area,to be completed by city or town offzcial. c7 E City or down: _ermitl�..icensa 1 ssuin.AuthoriLy(circle one): I.Board of Health 2.Building Departm- ent .',C----L O�In Clerk Electrical SDeCtOr S. lumbing 1.11specto-I 6.Other 4 rCoatact Person: ?houe 7: City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, 1 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: debris will be transported by: The deb p The debris will be received by: Building permit number: Name of Permit Applicant Date Sign-ature of Permit Applicant City of Northampton k� Massachusetts vs C. 'off DEPARZT01VT OF BUILDSNG INSPECTIONS : .x 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 i 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 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 4ddress of work location i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations - � ff g 600 Washington Street err. Boston,MA 02111 S �irf www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pl>ilmbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: 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 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.1 required.] 5. ❑ We are:a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.7 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 mustprovide 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.Lic. #: 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 ofperjury that the information provided above is true and correct. Siznature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town of zciaL 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 87 CONSTRUCTION SERVICES 8.1 Licensed Construction Sup ervis r: Not Applicable £ Name of License Holder: License(119ber Address �r�� 'n C r � Expiration Date Signature Telephone 9 Registered;_Home Im rovement Cont actor; T Not Applicab e Company Name �— Registration Number )O A s j Expiration Date 7 / zfTelephone 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 .:=.Hone Owner Egenption 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, i i I SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Wi s Alteration(s) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [❑ Siding[0] Other[MI Brief Descriptio Wok Alteration of existing bedroom Yes !w No new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa If New house.a,d.or ai I,Ion.to ez sF.f housin'Q,.com¢ifete'fhe fo lowing: 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 cf.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 G7 �°�✓ to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date l lD 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. r Signed under the pain pen yes of perj ry. 17 Jr d✓��7 i I/�G/�0% Print Name Signature wner/Ag i Date i 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 . x Lot Size Frontage i -- - ---� - —� Setbacks Front Side L:' ( R:= L:l i RE Rear s Building Height Bldg. Square Footage I Open Space Footage % r-- (Lot area minus bldg&paved ? parking) #of Parking Spaces Fill, f E (volume&Location) �' t A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW Q YES 0 IF YES, date issued:i IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES Q IF YES: enter Book j Paged ? and/or Document#1 f B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 NO Q IF YES, describe size, type and location: f D. Are there any proposed changes to or additions of signs intended for the property? YES O NO Q IF YES, describe size, type and location: j 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 Q NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. i � a j . P J City of Northampton _Stat`usofPerrnrt 'T M. r Building Department Curb Cut/Drirce�vay Perrril# �'j [i(,TQ�5 212 Main Street SewerLSepticauaiia611rfy y 1 Room 100 3lVatedU!fa7�Av'!U ility _. ..._:_ _ OEPTOFgp�Z pjNG�NSPECTI orthampton, MA 01060 TwaSetsofS#> cf�ralPla[rs _" _ .:` =.t p -- NORTHAMP70N MA ° 3-587-1240 Fax 413-587-1272 PIoflSite Plans , T L APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE,INFORMATION Thia section to be compleetl by office - J _ 1.1 Property Address: _ Zone Overlay Disfrict r - Etm St Distract. _ --LCB Distract T.- .�:-:- �• SECTION 2 PROPERTY CWNERSHIP/AUTHORIZED.AGENT:::. 2.1 Owner of Record: Name(Print) Current Mailin Address: l pbv Telephone Signature 2.2 Author' ed A nt: gip- v ro Name in Current Mailing Address: �!r r(aiure Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS. Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. BuildingD , 7 (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) Check Number ThisSection For Official Use Onl Date Building Permit Number: Issued: Signature: Building Commissioner/Inspecto[of Buildings: Date 32 DAY AVE BP-2016-0588 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 25C-069 CITY OF NORTHAMPTON Lot: -001 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-2016-0588 Project# JS-2016-000981 Est. Cost: $1525.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 105953 Lot Size(sq. ft.): 8189.28 Owner: DUFFY HAROLD F JR C/O KIM A DUFFY Zoning. URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 32 DAY AVE Applicant Address: Phone: Insurance: 5 RIVERVIEW DR (401)935-2633 Workers Compensation NORTH PROVIDENCER102904 ISSUED ON.1012812015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 3 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 10/28/2015 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner