38A-081 (3) BP-2008-0113
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit# BP-2008-0113
Project# JS-2008-000180
Est. Cost: $2763.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 126893
Lot Sizes . ft. : 32234.40 Owner: SASSO DEA L&MARYANN JENNINGS
Zoning: URB Applicant: HOME DEPOT AT HOME SERVICES
AT: 32 BURTS PIT RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341-9401
Workers Compensation
WORCESTERMA01607 ISSUED ON:8/2/2007 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 8/2/2007 0:00:00 $25.0019301
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
N�� pepartment use:+only 4
Status"Ofperr�l
City of Northampton rt �
Building Department Curb G, tlOnvew Perrrvt
212 Main Street SewerfSepticAvalAlb0ity r
Room 100 Wafer�ll/ellAvatlabiiify "
Northampton, MA 01060 PCat�s `
phone 413-587-1240 Fax 413-587-1272 PIotISlte Plans
Other SpecGfy� � � {
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,, District
EIm St.:District '= CB District'
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Reco
D�4
Name(Print) Current Mailing Address:
} -6111
Telephone
Signature
2.2 Authorized A
Gi E,
Name(Print Current Mailing Address:
Sig Telephone
SECTION 3-ES IMATED'CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by permit applicant
1. Building �1 s�'? (a)Building Permit Fee
2. Electrical pC (b)Estimated Total Cost of
Constructionfrom 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number `r
This Section For OfficiaC UseOnl
Building Permit Number. ate
Issued: c
Signature: I CC '
J
Building Commissioner/Inspector of Buildings Date i
DEPT of eu,.E:r,c INsFEG1IiJNS
NOR'Kkl,`=it?'i,h'in 01060
J
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
Frontage
Setbacks Front _
Side L: R: L:. R:. :.._
Rear
Building Height
Bldg.Square Footage - %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces --—
volume&Location)
A. Has a Special Perm it/Variance/Find�iIng ever been issued for/on the site?
NO G DONEF V111OW ! 1 V€9
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0_ _ .
IF YES: enter Book ; Page and/or Document#I
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on 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 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 I acre? YES NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement�ndows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [ED] Decks [0 Siding[O] Other[Clj
i
Brief Description of Proposed n
Work:
Rlteratien of exi�+_ing nedroorn Yes No Adding-new-bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa !f i+lernr fionsnd or adclitian to xis ira ete.
houslra '.com tthe#olovvin
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?
I l
d. Proposed Square footage v[. new wnjtiti—liO... _Dim e n Cions
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 o. s construction withies - -- 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, in all matters relative to work authorized by this building permit applicati n.
Signature of Owner Date
..._ as Owner/Authorized
Agent hereby dec re t a the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed unde pains and penalt'es of perjury.
l' l7 x
Print Na
Signature f Owner/Agent Date
<� s
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
i Address Expiration Date
Signature Telephone
i
9R rsfered Home 1 tv meet-O ttac€or- �ss Not Applicable ❑
Company Name Regis tr� ato Num er
Address Expiration Date
Telephone
rA �/, t
SECTION 10WORKERS'COMPENSATION iNSURANCE AFRDAViT{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 permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
The current exemption for"homeo-wrmers"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 1083.5.1.
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 ver-son who constructs more than one home in a two-vear period shall not be considered a homeowner.
Such-h,5rneowner"�shali 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
The Commonweal h of Massachusetts
Department of In dustrial Accidents
Office ofIn vestigations
600 Washington Street
Boston,MA 02111
www.ma$s.gov/dia
Workers' Compensation Insurance Affidavits Builders/Contractors/Electricians/Plumbers
Appflealit IufQ1-1UdUun PieaSe Yrl>1t LeLrlblv
Name(Business/Organization/Individual):
Address: ®7 rc
City/State/Zip: �- ,Pho' #: 'J
Ar�yan employer?Check the appropriate box: Type of project(required):
a employer with 4. F� 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 ernployees These sub-contractors have g. Fj Demolition
working for me in any capaciny. employees and have workers' 9. [_f Building addition
[No workers' comp.insurance comp.insuratce.*
required.] 5. E] We are a corporation and its 10.E]Electrical repairs or additions
3.El am a homeowner doing all work officers haveexercisedtheir I L Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.Q R repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13. Other
comp.insure required.]
Any app ican a c ec ox must a o t out a section a ow s owing thqr workers'compensation policy information.
t 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 worker'comp.policy number.
I am an employer that is providing workers'compensation insuronce for my employees Below is the policy and job site
information. '
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: RCity/State/Zip: `
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expill tion date).
Failure to secure coverage as required under Section 25A of MGL . 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 r enalties 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 JXA for insurance coverage verification.
I do hereby cern un i and penalties of perjury that the information provided above ' true nd correct.
Si afar _ Date: _
Phone#:
Offccial use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permjit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PlumbEInspector
6. Other
Contact Person: Phone#:
p¢�n�pTO
Lity of az l� nt #ars
z
$ � �lasaxchnsctfs -
DEPARTMENT OF BUILDITIG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction sups;_ .- sor. 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 persons)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
L 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
t,( 34 AGsean c�-Steeet' 'ocrest6ai,��i{51+��t�
Breach Numb
en :Z Job f): 1 ']loll Free(800)657-5182; Fax 5!)8-756-2859
Federal ID N 75-2696460 ME Lie#.0 02439 RI Core.List 16427
CT Lk
#Sb�522 tmprovwtwxtt Can Reg.#126693
on- dL
Inslallaaen Address: PL: in a OL-0
state zip
Last 4
PvrkMar(sI. 1>�of Driver's
Lie.M&lip,Me/Yrt Work Pitons: Rome Phone:
Mgp, ShssC� 16-2.2'actl( ) ii
Home Address:
(lfdifTamtftmInstallation,Adddre") City State zip
E-mall Addrou(to receive updates and promotions flnm The Home Depot}.
Project Infornant en: I/Wc/Yoq(KAY),the owner t of the property located at the Acme ittstanataian addteas,of m to
eomn&ot with THD At-Home Sarvicx4 C {" s spgt'!W fiuW*deliver}cad atr�four the Installation of all nwoeriah
as described an the attaeha4i Spec Sheet m& mcntporaled hensin by r4ftreinow end made a pan hertwf,
Hone Depot reserves the rigbtte cancel this coamict I;upon re-Inspecatioa+f the3obr Blome Depot.determines that It
cannot perfetm its obiigatbns&ane to a stracturai problem with the beta;pricing error,or because work required to
complete the job was n@4tIncluded In ties Spec Sheet or Cou trueL
DOOSIT PAVM1EHT OPT101ti5
(Subject So fiord wriflea6oa andtor credit approval.)
CONTRACT AMOUNT 5, t. cbeck+,C.M. oc US Pmui Serraro Mency Order
(Made payable to�Ffom Depot).
tLF83 DBPtTSPl S__ + 2. Croat Card••mdiar odd Cirds One aktim
BALANCE DUB � _ Ai 'mn Experos
ON COMPLETION
fiMtahsttm ZS'4 at Goa�at,#raeas!t'�Sto:apo4
t 111)(1 tit RDf C ISI4Lt1) Ml
j L
="11114111 of t4111.0"
Lc��t Avbabre Cnwlq s �'r"�% tBII.A'.#1DCC ONLY)
Iudleafe Payinsiat Method For naw: axp.one:
B D 4N COMPIXTION: ptemnaau?DpeMaoa
040
•OBY my/aur al ttclow,I1VVe agree to aitwx to
3e' + rpt ar e e Move esedjt Bata for the d
•vysw yer pmvian.rh¢ti ar peyn+va you asaaorue as ettber
io tura intormatioo i a.t yru44a check to price a ono6w obcowle s fate 0
timd trm"Im&am your socount or to proctor ctor do pe 7oM w a
oboole tnr.euos warn we res irdurrnaboa[Yom yarn chock to ; r IIUCC tion Codes
roeae an eleamie rood tratsfet, r moy be witbkws#tom .
your scoaom as swim u the p eymest u received,and you WWW not t' I Phial Payment
receivp)mooroheckbrut. '# of # b
Purchaser agrees that,immediately upon cadnpfeti`on of the work,Purchaser will exccuft a Cpmpietion Certificate and pay any
balance due. Purchaser also ap;recs to bo poi y and severally obligated and lishle bactntder,
Entire Agreement'This awoomew No its Httachments,including any firssnnitig agreement,contain the complete agreement
between the parties and can not be amended is modHW unless in writing in s.iieparne,agreeni ent signed by both parties.
NOTICE TO PURCHASER:
Do not sign this contract before you read tL You are entitled to it ccy(Wed4n:oopy of the contract at the three
you ago. Keep It to probct'"00,vfiob. Do tact dgn.a Csmpkelatr eat#before this project is caaplote. I"
prohibits home repair controbters from requesting or accepting a Canplatlim Certificate signed by the owner prior to
tho actual completion of the worst to be perfa mied ander the contract.
You may cancel this tranaaction anytime prior to midnight e f tie third b;nluess day after the[fate of tish contract. See
Notice of Cancellation fbr.an e=phutntlon of this right There wfti be a;service chs equal to lWo of lie contract
amount Kyob Is tameelied by Purchaser AFTER the third buslaea day, t BEFORE'�ftilitFs are ordered.There will
be a service charge equal to 25%of the contract amount ff job Is 4a ace"by Parchaset AFTER matteduls in ordered.
BY MY/OUR SIGNATURE`'BELOW,UWE UNDERSTAND THAT THE AGREEMENT MAY BE SUBJECT TO.REVIEW
OF MY/OUR CREDIT IiTSTORY AND YWE AUTHORIZE HOME DEPOT TO VEPIFY AND REVIEW MY/OUR
CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY ANI?RELEASE THEM FROM ALL
LIABILITY INCURRED FROM INADVERTENT OMISSIONS OR ERRORS.
BY MY/OUR SIGNATURE BELOW,ME AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. i(WE
ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPILS OF THE NOTICE
OF CANCELLATION.
SUBMITTED BY: Date: 7Z
ACCEPTED BY: Date: ' 4-4 O�
Date:
Poreb.aet
NOTICE:ADDITIONAL TERMS AND CONDTPIONS ARE OTATED ON:THE KV*%R5E SIDE
Ai!iD ARE PART OF IMIS CONTRACT
in D7 rev
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