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12C-027 (4) 54 BURNCOLT RD BP-2017-0168 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12C-027 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 it BP-2017-0168 Project# JS-2017-000273 Est. Cost: $3749.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 92937 Lot Size(su. ft.): 11630.52 Owner: CAMERON JOAN Zoning: RI(100)/URA(1001/WSP(l00)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 54 BURNCOLT RD Applicant Address: Phone: Insurance: 5 RIVERVIEW DR (401)935-2633 0 Workers Compensation NORTH PROVIDENCERI02904 ISSUED ON:8/9/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 2 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 8/9/2016 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only l kr of Northampton Status of Permit: RECENED B ilding Department Curb Cut/Driveway Permit •12 Main Street Sewer/Septic Availability QUA g Room 100 WaterNVell Availability .rt :mpton, MA 01060 Two Sets of Structural Plans 8-58'-1240 Fax 413-587-1272 Plot/Site Plans orYon..�rcn.na°trcn 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 3R/ F �//-NKL Lr CJ Zone Overlay District Elm St District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 94' edit��(7 f L't t e 04 Z J)Pi (On /1 OT l{ I( 9/yGLhN Name(Print) �/ Current MzJllJny_t4s53 � {/D S€ - W' Telephone -b5 �t11 Signature 2.2 Authorize •e / /419426) 4144( ey-A-75* -rec 5E4,4,4bripp. Name(Mft Ib ICurrent Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant Building 7/ /L • /Ur;i (a)Building Permit Fee 2. Electrical `7 �[ (/ (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection y �qs 6. Total= (1 +2+3+4+5) 3,71f' . liz) Check Number //73 & This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to he filled in by Building Depanment Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage .m (Let area minus bldg&pa%ed patk'wal #of Parking Spaces Fill: (velrmc&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES 0 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 DON'T 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 © , 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 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 O 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 ❑ Replacemendows Alteration(s) ❑ Roofing El Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks HZ] Siding[0] Other[0] WBroierfkDescriip/t/ rotedv /eL 'p! 46 „,77,00-,-724.1k$ 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 lID^P )/ (fiir . as Owner of the subject property hereby authorize itlm_/(ejs/] l M !�� � to my "� to act on my behalf, in all matters relative to work authorized by this building permit application. 77 i G0-AT J-G Signature of Owner � Date I, � /J,IT/ ,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 un.- he •.;ins and penalties of perjury, I .Aya/ b I12.0I1 Print Nam�eri'', { --3- Signa .r-of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ -52-1917 Name of License Holder: fr 9 �g�gJ7 6(, ''✓✓,e/^ Pr ✓ atg ice n so Hum b& Address Expiration ate .1447-1/-114 Dloi�S Signature Telephone 4LDI Z?�-13/72- 9. 13/7Z9.Registered Home Improvement Contractor: Not Applicable ❑ )24199 Company Name f ) Registration Number rA4 Address ,(.-/y�')r if, , L r Expiration Date omiin --Q413 pi or Telephong Di" 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 permit. Signed Affidavit Altacrym Yes Na ❑ 11. - Home Owner Exemption The current exemption for homeowners"was extended to include Owner-occupied Dwellings or 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 ofd and on which he/she resides or intends to reside,on which there is. oris 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 he 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 Nlassachusets 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 Commonwealth of Massachusetts Department ofIndustrial Accidents ib 1 Congress Streel,Sirite 100 �_ ✓i " f " Boston,MA 02114-2017 www.mass.gov/rlia \\urkers Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A. slieant I form tion Please Print Le.11,1 � p Name(Business/OrganimuoNlndiivviidual): Z4ss-i{f-�t 17 4.27 *T - f_ C�4" •�ief-9. Address: /�''(lI�--�7>0� ;J n"5Dr7“\ ) ///- /� City/State/2ip!J)iaft5 < 11! M&•DJ hone N: .19'5 -'`f62 —66(0— Are you nn employee Cheek the appropriate box: Type oft(rd): I'❑'urn employer vh employees(fob and/or rz-time” 7. 9 New construction 79 l am a sole proprietor ur partnershipand have no employees working Forme in 8. 9 Remodeling ' any cap ciy. No workers'comp.insurance required.) a-❑I em a homeowner doing all work myself.[No workers.romp.insuremerequiad 11 9. El Demolition u❑lam a homeowner end will bep hiring contractors to conduct all work on my pro I wvil lB❑BWiding addition ensure that all contractorseither hoveworkers compensation insurance ur arc sok Il.❑Electrical repairs or additions .�vsynropriemrs with Tio employees. 12.0 Plumbing repairs or additions 5X am a general contractor and I have hind We subcontractors listed on We attached sheet. 17 Rnofrepairs TT These sltwanuaelorshave employees oN havew orkers`comp insuioncej1 ❑4�Olher (t/af/y,/fdg j��' 69WeereacorporationanditsofpcershewexemisedtheirrightofexemptionperMac 152,51(4),and we have no employees.fNo workers'comp insurance required.) `Any applicant that cheeks box 91 must also fill ma the sectionbelow showing their workers'compmwmior policy inrornaiion. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside mnuaemrs must submit a newaffidavit indicating such. :Contractors that check this box must attached an additional sleet showing the name or the subcontractor nod state whether curet Moose entities have •employees. If the subtontradon have employees.they must provide their workers'comp policy number. 1 am an employer that is providing workers'Compensation insurance for my employees. Below is the policy ford job site information. t r Insurance Company Name: '` I/')S " ORYI9h� TNS, CO }�7 Policy H or Self-ins.Lie.^d; ' I )(-- 0 )55 � 2-) Expiration Date: �/f//( / yf'�),, r� 7 lob Site Address: ✓ 4 aro al-" City/Stale/Zip ,flz t - iPw &JOea Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiratib0 date). Failure to secure coverage as required under MOL c. 152,§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 offhis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby - 'srerr/ epi"t.-Iti"--laid- of perjury Mal the information provided above is true and correct. Sinahue: Date` b P ane@: S fr. se.i2—6 .2--- Official use only. Do not write in ibis area,to be completed by city or town official City or Town: Permit/License# issuing Authority(circle one): 1.Board orHeaith 2.Building Department 3.City/ own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone g: 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: Jry Mir11J(QGrgf h /L&t1 , {4140w/t The debris will be transported by: / Ti '� �( " The debris will be received by: JA}frC-(2 ,'V4 Building permit number: �j� y� Name of Permit Applicant ►�-V/, �Pea> f Date Signature of Permit Applicant 7/29/2016 The Home Depot At Home Services 3:45 PM Lead Detail-9406193 CIUtomer Information Joh tninrmabnn Homeowner M.Joan semen's ' .Sale Amount 5374900 I lomeowner ' Product 6500/6100 Shia Windows t8%1 doh Site Address...... 54 Bnmcolt road Status SA/Material Ordered /, iAi/ FLOKhNCIL MA 01062 Branch Boston North L� LCJ SM. ROBE RT R OCOIKT1.1. County HAMPSHIREISM David R' Billing Amm tltlrcxs 54 Nult road ', FS JasonTimm II OItENCl�NIA 01062 PC Cassandra Monsio i I Measurer PETER TALBOT I Home Phone (413)923- 9IA BIM Russell A.Johnstone • Work Phone Ext 041 OM Unassigned Cell Phone PS PS I lnassignc.l Pager PIN Installer SLAV MOKAN MIA 146 7 5 6 71 Work Phone 2 I Crew Slat Mokan Cell Phone 2 Cross Street SeloI _.._ . ' Commission Key Dante Consultant Name Term Dale Soul Conic,Plan Sale Date 7/16/2016 RIP Dere Timothy Oast 100.00 Straight Commission Credit Plate 796/2016 FPD-Customer RTP Date FIN 2016 Post Install Date... Start Date 3102016 FPD-Home Depot. No Cross BRO.., I-7794417114 Siehel Ord.. 112350 Inspection Markctine ''. Final Foment InformationReferral Store A452-I IA 1)I.F\' Source Morava)Code Base Stare 8452-HADI.ES" Lead Source 0335 SEM-Tech Shed ' L.. ED Consumer 1... IID Store Associate 3... 2... • Assigned SC I 3... _._ _._ .. 1••• AVPL Generator Lead Generator Installer Referral ^+ s/ cys " Transmitted Payments /M., ,/`TtC- Received Tender Type Cheeldt Payment Aunt Payment Type Deposit Date Entered by Entry Date Date //1677016 HD consumer 11.249 W Customer Deposit 7/16/7016 I motto/Urost //16/'1)]6 History Date 'Iiine Lead Management Agent Sums Appt Date Appt Time Correction 1124/201b 1'.34 PM Ashley S Aslgbey Material Ordered //16/2(1b 4:00 PM No 7/21/2016 617 PM PETER TALBOT Measure Complete 7/16/2016 4:00 PM No 7/21/2016 617 PM PETER TALBOT Order Received-PSG 7/16/2016 4:00 PM No Page I of 3 A'- il s._0m _rYq-1 .______ __ _ T_ ii 11 di 1I.i . ;dtagUe=u=0 ssrr j; is "e0-�lt.e. 'v&w:,�.rs.A... ..v_rz.,•v.-Wliiu. ., s. 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