29-580 159 OVERLOOK DR BP-2017-0167
GIS«: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-580 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2017-0167
Project# JS-2017-000272
Est.Cost:$13927.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 88261
Lot Size(sq. fl.): 20124.72 Owner: ADAMCIK DAVID A& KATHERINE K
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT: 159 OVERLOOK DR
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCERI02908 ISSUED ON:8/9/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 8/9/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
RECE"v,-D u.,/of Northampton Status of Permit:
Bu(ding Department Curb Cut/Driveway Permit
12 Main Street Sewer/Septic Availability
FUG 9 2016 Room 100 Water/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
WT.or BISON tmi'hd 3-537-1240 Fax 413-587-1272 Plot/Site Plans
NORTHAMPTON,MAplee0
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
(� r � 7� Map Lot Unit
I64 1 N` Zone Overlay District
// &V ✓✓✓��, Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
t6c'bv ffi 91, FiDaA1« / oioez
Name(Priin/nt)��>> Current Mailing Address:
//�'
'✓C.T. L1-17 Telephone
Signature
2.2 Authoriy• A•,•nt:
Name(Print) • Current Mailing Address:
2.44' f; 46l z
Signaturf Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
I. Building (7I /f 27 , (a)Building Permit Fee
ll�'/ Vl
2. Electrical (b)Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection ,,77 �,�)
6. Total= (1 +2+3+4+5) X
1# 7'1 Ov Check Number J7.1-14, 0144
e
( This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due Ta Incomplete Information
Existing Proposed Required by Zoning
This column to he filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R'.
Rear
Building Height
Bldg Square Footage
Open Space Footage ro
(Lot area minus bldg&pare
parking)
#of Parking Spaces
Fill:
(volume dr L„Lati(ml
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation. or filling)over I acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
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 n Addition ❑ Replacement Windows Alteration(s) ❑ Roofing [4
Or Doors 0 J'C
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Ip Siding[p] Other(CI)
Work: w ]0 Pr 11l /20Ro 22 o kr 4 ��' �-°v'ttn
/J -DTI'Lr/
Alteration of existing bedroom Yes No Adding new bedroom �L Ye� jrt os
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 APPLIESyIE, FOR�� BUILDING( PERMIT
1 7.r 1 1 6 1 1'/'I r�-c1 [ ._ , as Owner of the subject
property Ara,
.//��'/} ,p/
hereby authorize 1hit N l '-° '
to act on my behalf, in all matte lative to w. - authorized by this building permit application.
Signature of Owner Date
I, �f
11 1120 ,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 u y11 the/.ains and penalties erjury.
Print Name
S,gn. .0 Own r/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: [I- /) // Not
t�App-liicclabblleeL/❑
Name of License Helder_ —1-11n093 LLIA iz / t 6 ly t/l/2el'
/ License Number
2C e nr2 4k. 3 -14-4
Address Expiration Date
C 2 Pl f , //020
Signature Telephone
q0(-573 ->3 2,
9.Registered Home Iroveme t Contractor: / Not Applicable ❑
.1.--
4,4_
T i'fi7Yt4_, Px tv l-- L2e-4 3
Company Namea� /in/✓l.O/4T / -Zc RegistrationNumber Y �
`//yUU j
Addre N,1...O, '_ / Expiration Date
l ' ii-4L"' / /h-.119/ Telephone9152?4
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 offI • - -• permit.
Signed Affidavit Attach'd Ve§ ❑ No ❑
11. - Home Owner Exemption
The current exemption for-homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 andor farm
structures. A person who constructs more than one home in a two-year period shall nut 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 buildingpermit.
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 he liable for persons)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the Stale Building Code.City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
_ The Commonwealth of Massachusetts
rg
Department of InduslrialAccidents
F�etf3tfl_ : 1 Congress Street,Suite 100
--14.=--471 MA 02114-2017
%% m^'
. www.mass.gov/rfia
11tickers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/PI umbers.
'f)BE FILED%PITO TBE PERMITTING AUTHORITY.
Ar dieant Information Plea Print Leoib( �p p C
Name (Business/OrganimtioNlnddiivviiduaf:: _,4n-nt 1 '4 gJ}r *T > t - odintief
Address: ��II�?0,' ;J e0 �S^'/AB-v'\ -r te - /�/- //�
City/Scatei%ip6) C &f7;Ir // M14''t a/1 ane N: ,- e46 'L1C 2 �b 602-
Are you no employer?Check theappropriate boa: Type of project(required):
L❑Iamaemployer withemployees(full and/orpan-time).•
7. ❑New construction
2 I am a sole proprietor or pannershipot'd havens employees working for me in g. 9 Remodeling
vary capacity.[No workers'comp.insurance inquirers] 9. 0Dem0litiom
❑1 awn a homeowner doing WI work myself[No workers camp.insurrwe required l s
10❑Building addition
4❑I am a ensure
end will be hiring contractors to conducing work on my property. I will
that all contractors either hove workers'comperswion insurance or arc sole ILD Electrical repairs or additions
,�.,,//proprietors cola no employee¢. 1 lumbing repairs or additions
51g,Iam a general contactor and I have hired the sub-cuninctors listed on the attached sheet. p Roof repairs
YT'lbs¢mo
ine:m nnrshave emoleyces and have work's'rump insmas;
np
6.0 We are a corporation and its officers have cmised their right of exemption per MGL c. I Other
152,§I(4),and we have no employees.No workers'co.,p.insurance inquired
'Any applicant that checks box a must also 61I ran the section below showing their workers compensation policy intonation. •
•
r Homeowners ono submit his affidavit indicating they am doing all wutk and then hire outsideimoaacmrs mu submit a newaltidavit indicating such.
;Contractors that check to box must attached an additional sheet showing the neme of We sub-contractorsnod sow wheiher or not those entities have
employees. if the subcontractors have employees.they must provide their waiters'comp policy number.
I au in,employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
insurance n. )J Y1 n"'8�t1 T'
insurance Company Name: ���� // Ml �1j ./ Co
Policy it or Self-ins.Liu.S: W(� P551 42-15 3
f-�j ��} ykr /Ca.'��V Expiration Date: 1 //y/ �yw�A�,//t}-
Art
JobSiteAddress: 16 § 1 Y-Iip b- DR ' City/State2ipt , 41 '�A166 s" ojv
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration dale).
Failure to secure coverage as required under MGL c. I52,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office oflnvestigations of the DIA Mr insurance
coverage verification
I do hereby ' Or erj/epi". /(�r+alit of perjury that the information provided above h true and
/correct
Signature: 1'sse� (�///i+-` /,�/ Date: 7 `•2i _/d
Phone#: 'SV / —LF�J2-'e�%T2- •
-
•
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License n
Issuing Authority(circle one): t
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone 4:
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: /4-11 t*'G�7R Pg fibraTn'r 4�4
The debris will be transported by: t l-4741 ,' ''
The debris will be received by: )/ 1/ 72/ 47i F1"I
Building permit number: J/
Name of Permit Applicant
A ' i
Date Signature of Permit Applicant
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
2. 27- 2a Sold,Furnished and Installed by:
Branch Name:New England Date:_I / THD At-Home Services,Inc.
dbfa The Home Depot At-Hmme Services
Branch Number:33 90B Boston Turnpike.Unit I,Shrewsbury,MA 01545
Toll Free S77-903-3'68
Federal IDM 75-Th9R460:ME Lie e C 02419:RI Cont.Lied 16427
CT Lie 4 MC.055655224 MA Home Improvement Contractor Rg.a l25893
Inatapudon Aaarens: 131 _
City
State Zip
Perch er(s): Work Phone: Rome Phone: Cell Phone:
Ads 2t, 1 [ I 1 [ ] I [ ]
! [ ] I [ ] I [ ]
Hume Address. -
(Ifdiffercol from installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates)
❑I DO NOT wish to receive any marketing cmails from The Home Depot
Project Information: undersigned( Customer'),Me owners of die 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 on the below and on the referenced Spec Sheet(s),all of which are Incarppreted into this Contact by this
reference.along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively.
"Contact)'.
Job er lS ..S am...n ?maven: Spa Shea(s)T Project Amount
prornq U6idm8 O windows El mmlatian
:2‘y
S74 OGanrrstones Dunn Demi ❑ S �3
DRa,bidins •WindmvsDhnolallon
_ ICm "_ ❑ 2o1-1
J`—
raOHoOBng DSidirg •Windom •Insolation
DGunere:Covers DEntry Doom❑ _ S
spoofing Osidiag D Window, LI Imuladan
Da !Covers DEany Doom D _.
Minimam:si Deposit ofeanwnetAmnaMaicupon execution an.rtnam
faeet Thai Contract Amount $ l,i? S 3 I � Z.�.C✓t%
Maine Purchasers may not meW
more than FL of the Contract Anent
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 Cnstomer 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 PrMum(s)included herein_at
its discretion,if The Home Depot or its authorized serried provider deMminea that it cannot perform its obligations don to a structural
problem with the home.envimrmkn¢I haearda such as mold.asbestos or lead paint,other safety concerns_pricing errors m because
work required to complete the job was nut included in the Contracts
Paymn't Summary: The Pa)mxnt Summary p )2a r'(f�2 incltged 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 arc 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 defined by individual Spec Sheets)before work on that Product
coni plate.
In theent of termination of this Contract os
Customer agrees to pay The Home Depot the ct,of materials,tither,expenser
and service.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 Authnnzatinn: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Pmducs and Installation cervices and supersedes all prior discussions and agreements_either
oral or written.relating to said Producs and Installation_This Agreement cannot be assigned or amended except by u writing signed
by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read.understands,voluntarily accepts the
terms of and has received a copy of this Agreement.
Ac - Submitted
X //L/ gn mr e � x zaLZ-1c)J'
C•9tom¢ISSigrrannc Date Sales Consultant's Sinecure Dare
x Telephone No. 1113 (036 &3t 3
Customer's Signature Date Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS 2samprsblel
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSLNESS
DAY AFTER SIGNING TUTS AGREEMENT. THE i
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW TN
CUSTOMER'S STATE.
NOTICE:NDOITlORAL TERMS AND CONDITIONS ARV.STATED Oh THG Rd4tRSE SlOT AND ARE PART OF THIS CONTRACT
03-29-16 White-Branch Tile Yellow-Customer