31B-031 38 MYRTLE ST BP-2016-1175
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B-031 1CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate. : windows BUILDING PERMIT
Permit# BP-2016-1175
Project# JS-2016-002023
Est. Cost: $11287.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 4704.48 Owner: THORN SYDNEY N
Zoning: URC(lOo)/ Applicant: HOME DEPOT AT HOME SERVICES
AT. 38 MYRTLE ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON:4/7/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 18 REPLACEMENT WINDOWS &
ENTRY 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 Signature:
FeeType: Date Paid: Amount:
Building 4/7/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
r �
Department use only
�. City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
PR 7 2016 212 Main Street Sewer/Septic',Availability
t'► Room 100 Water/Well Availability
oEPrr.fl` c,ras N rthampton, MA 01060 Two Sets of Structural Plans
too, r�����cr. -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 CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Maili g Address: l
<"�(� Telephone
Signature
2.2 Authorized ent:
Name(Pr t Current Mailing Address:
Sign ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit 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 TV
This Section For Official Use Only
Building Permit Number: DateIssued:
Signature:
Building Commissioner/Inspector of Buildings Date
r
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
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES i
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
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 0 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 Ws Alterations) 0 Roofing 0
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks (L7 Siding[0] Other[o]
Brief Descr p o f P oo ``� ►' /✓ .5
Work:
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 existing housing, complete 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
l
as Owner of the subject
property
hereby authorize
to act on my behalf, in all masters relative to work authorized by this building permit application.
Signature of Owner Date
op 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 the p n and enalties of per'u . f "
Print Name
Signat of Own r/Agen Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su�perrvis)oor,,, Not
AA plicable ❑
Name of License Holder: Y�r—l�'�/V �%/" ' t.✓ �����/
License Number
Address Expiration Date
m Ion
Signature Telephone
f-� --/ --
9.Reclistered Home Im roveme t'Contractor: Not Applicable ❑
Company Nam6 Registration Number
Address Expiration Date
)9�UTelephone t ,
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 pe mit.
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 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
n
1'he Ca m»zonweaith of Alassachuseas
DEpartr,2ent of IndusirldAcddents
e - Qjfzee ofroves gatioM
II 7 co?lvess street s7l_ate 00
utrn�ty 3nass�;av/d a i
VVo.;.�Ctirs'Lem?t,2Szd u7A insurance ASR&-iit: sit yrs/'Cfl tractrr�s/ Iyc# �cfaasi?i �vls
� ize i a_ a€rw 'lease Frim Lg bh
"czE28(BLsiness/ cnizadou/iad"rridueli. Ii�J { J j{i 1 I" t`?e-�9 `•�✓%`�i'v
-
Addxess: ft U% .'
Cis r/-Siciz/lip:j;! ��i.?%'-f _ J�'I� d ✓� Phone it: • L`v '? C 9
use you an employer?Check e a ropriate box:
IType of project(required:
i.❑ I a eraDlaver with A. "" I as a general contactor and I
hrre hired tip sub-contractors
6• E]New construction
e=DI0Vees Cfsit mc/oz part time).=
2.n I as a sole aroaretor or partner- listed on the attached sheet. 7. Remodeling i
sh: and Lave no emplo ees These sub-coat actors have�P y S. (]Demolition
ti-tozc. s for mein any capacity. employees and have wonders' i
[SIG i-rorc��' iO'L'+L7.in312IcLCZ CDMD.h-�ce.-
9. Btailding addition
regui:ed,] 5. 'Te are a corporation and its III Electrical repairs m additions
3.[:11 a>r~a homeowner doing all wcr'_:. oracers bava e;Lercised their II.Q Plumbing repairs or additions
T;jselr_ [l to workers' comp. right of exemption per yIGL
insuT-,,.ce reauirtd]t c.152,§I(^),and we have no
employees. (leo wor'kers' 13 i~►Ode
I comp.inzaam required]
`.-'.,:!4aoIiC&TIit.'!2r C_heCs boo 4l£nmtalso�!I ogt'uesection 4elory shaping thtir wor>kSs'compensation ooticy infarination.
t rlomeo-mos who sebmitthis afdzvit indic;tingihey a.--dokm ail Fort and thin hire outside coutractommust submit anew affidavit mdicaZngsurtt
Connectors that check this box must atirchcd an sddi5onai sheat shoving&a name of the sue-conhretors and state wneiher or not those entities bane
cmoioyers. if toe sub-cn—a-rs nave cmplov=,they most?nvidc their woti rs'camp.polieynnmher.
l a;w mi employer tlaai Is prnuiding workers'compensation bmirancE for my employees. -Below is the policy and job:site
inj onnerioir_ _ 7 _ `ter , •�
Iasurauce,Company Ni ame r:� f i:�7/' ;
Policy it or Self-ins.Lic.r: W in' i J _/ l� % Bxp itntion Date:
1L) �� '
lob Sire?address: City/smote/Zip: �
a Bach a copy of the-workers' compen 'on policy declaration page(shoving the policy n•nmber and a iration date).
Failure to secure covetagc as required under Section 25 A.of MGL o.152 can lead to the imposition of criminal penalties of a I
fine up to 91,500.00 antler one-year imprisonment;as well as civil penalties in the form of a STOP WORD.ORDER and a fine
of Ug to J�SOAO a day 2oainst the violator. Be advised that a carry of this statement may be forwarded to the Office of
zvestigations of the DIA for insurance coverage verification.
Ido hereb fy r d !Ic ufs p alti r ofperjury that the bt ormation provided above is true and eorrea
Sianatirre: Data: i
Phone T: r5 69 8 6ri b_I;,_
Official use only. Do not write&this area,to be completed by city or toren offidaL
City or Town: Permit/License# j
Issuing Authority(circle one):
i
I.Board of Health w Building Department 3.City/Torrn Clerk d.EIectrical Inspector 5.Plumbing Inspector i
b.Other
Contact Pcrson: Phone af:
i
1
Feb 291610:26P
HOME IJMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Furnished and Installed by:
BoanchName:New Engtand Datex"K9—LL THD At-Home Services,Inc.
d/bla The Home Depot At-tiome Services
Branch Number:31 908 Boston Turnpike,Unit 1,Shrewsbury,NIA 01545
'roll Free$77-903-3768
Faderat ID 4 75.2698460,ME Lie#C 02439:RI Cont.U0 10427
C1 Lie# C. 56552A,NIA Rome ImproNement gontractot Reg.#126893
--f - A4
Installation Address: 3emq Ac" TU��-�6 I f A 3-ce
City I State Zip
Work Phone, Horne Phone: Cell phone:
36
Rome Address---
(If different from I nstalladoo Address) City State Zip
F-mail Address(to rrecive pro.,ect Communications and Rome Depot updates):
El 1 DO NOT wish to receive any marketing email-from The Horne Depot
ProLtet Inrormation: Undersigned("Customer'),the owners of the property located at the above installation address,agrees to buy.
and THD At-Home Services.Inc.(-The Home DepoV)ugrecs;to furnish,deliver and arrange for the installation("Installation")of
all nwiterizis described on the below and on the referenced Spec Shect(s),all or which are incorporated into this Contract by this
reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Order,,,(collectively,
"Contract").
Job M.- kw—w m.—: Ponducts; Spec Sheets)0: PTject Amount
�Roufin.-TFS—iding;ff-Windows n llns�dation (Q2— $
9 03 V [,(Gutters i Covers []Emry Doors []__ Q�I%0
Rooting[JS-1-cJFn.- 0 Windows Insulation
1.1)D [JGsupm/Covers 996uy Doors0-- ("t 6 0 $ a5-71
Roofing F ISiding U-1 W�Mdows El lasaintion $ JoAl
FlCutters:Covers Dairy Do"D
!:JRooTJ;og01;idHg Windows Insolation $
[}Gutters i Covers EjEntry Doors C]--
Minimum 25%Depadt of Contract Amount due upon execution of this contractract Aubount Total
Maim Parchaws may not deposit more thin one4bird ofthe CondractAmoi $4 611z-
Customer agrees that, immediately upon completion of die work for cant product,Customer will execute a lompietion Certificate
(one for each Product as defined by an individual S;3ec Sheet)and pay any balance due. As applicable,each Customer under this
Contract agrees to be-jointly and severally obligated and liable bercurdcr.
The Home Depot reserves the right to issue ii Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,if The Home Depot or its authorized service provider determines that it cannot pe-,form its obli tin -,due to a structural
ga n:
problem with the home,enVirotroliCaEal hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because
work required to complete the job wzs not included in the Contract.
Payment Summary- The Payment Summary 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-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 derived by individual Spec Sheets)before work on that Product
is complete.
In the event of termination or 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 Agretment or allowed under applicable lam THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMIT ING TIIh HOME DCPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptancepad Authorization: Customer agrees gaol AACTS104S that this Agreement is Jw entire aprecincra between Ca.,;tioncr
and The Home Depot with regard to fi%-Product`;and Installation servicL-,and svm-sedLs Lif Prior diNCL!kSi00S.Lnd a,'NCITICAIN,either
oral or written.relating to said Products and IrkstiflLtion.This Agn:cnient Cannot be,as�-i L Z anictwied except by a wjitiag signed
cannot a.
by Customer and The Horne Depot.Customer acknowledges and a�'TCCS that Ustomet z,,retie urtdcritand.,,voluntarily accepts the
,en-rs ofand has received a copy of this Agreement.
t,d
Accep by: Submitted b
X
rt c S'Zit""ie
Cas u%.'e 1,11377 Date Sales Cc:n I Signature Date
X Telephone No,
&0cii Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS
AGRFEMENT WITUOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN, NOTICE 310 THE HOME
DEPOT BY MIDNIGHT ON TffE THIRD BUSINESS
DAY AF-MR SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
IS CONTAINS A FORM TO USE IF ON S
SPECIFICAUY PRCSCRIRF3) BY LAW IN
CUSTOMER'S STATE.
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