29-562 (2) Department use only
�tirr�r City of Northolt on ` 1
v Status of Permit:
Building Dep nt � �,� Curb Cut/Driveway Permit
212 Main Stki c_,� ,. Sewer/Septic Availability
L' r
Room 10q =; a�.. Water/Well Availability
Two Sets of Structural Plans
Northampton, MA 10
phone 413-587-1240 Fax '-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 t> Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) / ►/f� �. Current MJAddress��G�_T��',
Telephone cLLL
Signature 7
2.2 Authorized Aqent.
-T -�
Name Curre��iliAddress:
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building r/ 912 (a)Building Permit Fee
2. Electrical G' (/ !� v (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection 1
6. Total =0 +2 + 3+4 +5) Z P c.� Check Number
/This Section For Official Use Only
Building Permit Number: �� `� Issued:
ed:
Signature:
Building Commissioner/Inspector of Buildings Date
�.
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement W' ows Alterations) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[0] Other[U
Brief Descri tion o opp�ed � �
Work: -`J
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
1, (-"*/!� 6 l //V/ as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
•�� 3--11
Signature of Owner Date
JZ17 - M,
/(rte /7 ,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 ansa penalties of p�yuty'.
10-
Print Name �^ 1
Signature of Owne Agent Date J
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / Not Applicable ❑ L
t VC
Name of License Holder
I / �� �� _l License Number /
��> y/ c 7
Address Expiration Date
m�Al�i-o
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
A-�22--z1
;Addrjss !) r �. Expiration Date
Telephone
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 buildin_qpermit.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
r•R'` Massachusetts ��?r
�G\
R. DEPARTMENT OF BUILDING INSPECTIONS y�
212 Main Street •Municipal Building
Northampton, MA 01060 rf�v-• ,�o
Debris 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.
The debris from construction work being performed at:
(Please print house number and street name) -,
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
f
Home Improvement Agreement: Pagel
Home Depot License #'s - For the most current listing www.Homedepot.com/LicenseNumbers
MA: 107774, 112785
Kyle Harmon
Salesperson Name: Registration No. (if applicable):
Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/
or service the equipment listed below at the price, terms and conditions as outlined on this form.
Collins Chris New England South 1-U4G674Q
Customer Last Name Customer First Name Store # / Branch Name Customer Lead/ PO#
62 birch hill road Florence MA 01062
Customer Address City State Zip
(413) 237-6686 maureen.collins0508@gmail.com
Home Phone# Work Phone# Cell Phone# Customer Email Address
NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY
OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT:
908 Boston Turnpike Unit 1 Shrewsbury MA 01545
Address City State Zip
Or Email: I customercancellationnortheast@homedepot.com
Service Provider Email Address
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME
DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE
SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED
TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN
SHIPMENT AT HOME DEPOT'S EXPENSE.
THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOTICE OF rUR RIGH NCEL.
Acknowledged by: 02/29/2020
Customer's Signature Date
Contract Price and Payment Schedule : Payment of the Contract Price is due upon signing unless a
different payment schedule is required by law, specified below or in a payment addendum.
Contract Price: $ 110012.00 Includes all applicable taxes. Excludes finance charges.*
Sales Tax: $ 10.00 (if applicable)
*Maximum deposit ONL Y applicable in MD, MA, ME(33%), NJ, Wl(99%)
Dep. 1 25.0 % Deposit Amount $ 1 2503 Remaining Balance $ 7509.00
The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337
460 Fl HIDE Customer Agreement(24 Jul.18) Generated Date Lead/PO# v 0,1 11
Home Improvement Agreement: Page2
Finance Charges:
*Any interest payments or other finance charges will be determined by Customer's separate cardholder
or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's
payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or
loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service
Provider may collect Customer's payment(s) made payable to The Home Depot.
Insurance proceeds will will not -/ be used to pay some or all of the total amount of sale.
Description of Work to be Performed:
Installation of 1windows
A more detailed description of the work to be performed is included int the section entitled cope o
Work which appears on page 0 of this Agreement.
Anticipated Delivery Date/Installation Schedule
Approximate Start Date: 04/25/2020 Approximate Finish Date: 05/23/2020
All dates are approximate and subject to change based on unforeseen events including inclement
weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if
applicable.
Electronic Records Authorization:
You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your
consent applies to this Agreement and all subsequent documents and written communications related to
this agreement. By contacting your Service Provider, you may update your email address, withdraw your
consent, or obtain a paper copy of the Agreement or related documents at no charge. By providing your
consent and verifying your email address above, you confirm that you have access to a computer that can
receive and open emails and PDF documents.
B ialing this paragraph, I consent to receive only electronic records related to this transaction.
Initial
Acceptance and Authorization:
By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation
and/or (b) order and arrange for the delivery of special order merchandise, including special order
merchandise that may be custom made, as specified in this Agreement. Do not sign if blank or
incomplete. (Service Provider's/permitting information may need to be provided to You later.) By signing,
you acknowledge that you have read, understand, and accept this Agreement in its entirety, including
the General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a
complete copy of t is AQreement. Keep it to protect your legal rights.
X 02/29/2020 1 The Home Depot
Customer's Signature Date Service Provider Name
X02/29/2020 908 Boston Turnpike Unit 1
licable) Date Service Provider Address
X 102/29/2020 Shrewsbury MA 01545
S ature n Beha of Home Depot Date City State Zip
Service Provider Phone Number Service Provider License Number
The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466.3337
460 Fl HDE Customer Agreement(24 Jul.18) Generated Date Lead/PO# v 0.1.11
Andersen Wood SPEC SHEET SC: Kyle Harmon Measure Tech: INSTALLER-
Branch Name: New England South Job#: 1-U4G6744 Prepared By: ISM:
Ship To Location: Customer Name: Chris Collins Date: 02/29/2020 Pa
NEW WINDOW UNIT
Screen
(Standar
is
FULL DH Frame included
Existing Window Andersen FRAM INSER Sash Glass in Base
TEM Type Window TYPE Color/Finish SC SIZE SOLD(Tip to TIP) MEASURE TECH SIZE ONLY ONLY Option Casement Handling Options OPTION price) Grille Options(PER SASH PRICING)
TOTAL MT/ISM
Interio TW SC UI Standard #Bars #Bars #Bars #1
Location Existin Series indo Exterio Finis Jam Standar (WIDT Size Grid Exterior Interior Vert Horiz Vert H
Windom Type Style Color Color Liner Size A + CODE WALLSILL Sash Hing Temp Screen Type Grid Grid Pattern (per (per Locatio (Per (F
Roo Floo Code CODE COD CODE COD Coto Code Widt Height HEIGHTWidth Height DEPT ANGLESplit Venting/Handing Style CODE Options COD Color Color CODE sash) sash) CODE Sash) S;
1 LIV 1st PD4- SPR- FWG White Whit 138. 77.00 215 Fine
FR-C Anders D-4-1 a 00 light
en A- 11068 3/4
Series
GBG
all
panel
s
BAY/BOW WINDOW SCAnirtaller Notes:(lnriuds Ulm.Labor,Mull Stack Options,special conditions,Use Item p to Id
Projection Angle:(Bay:30°or45°) Top of Window to Soffit(in SPR-(1)-Add.Info.:Top Hung gliding screen(2)w/astrogal kit
Bay Window Flankers(DH/Casement) Width of Overhang(inches) Newbury Hardware/trim pieces-Bright brass
Construct Roof 1(Yes/No) If tied to Soffit,color of Soffit material HP Low-e4 temepered glass
1 There is no guarantee that new shingles will match existing color.
NEW DOOR UNIT
JITEM Andersen MEASURE FULL FRAME Glass Scree Hinge MULL/STA
Existing Door Type Door TYPE Color/Finish SC SIZE SOLD(Tip to TIP) TECH SIZE ONLY Grille Options(PER SASH PRICING) OPTION Option Option Hinged and Gliding Door Options OPTION;
PD
Assemb
TOTAL (200,
Location Interio UI RO/ Inswing PD PD Gliding Hinged 400,&
TExisting Series Exterior FinishStandar (WIDTH TIP Ext Extensior Grid Exterio Interio #Bars#Bars Door Door A-Ser Lock Lock Optiona
Door Type Style Color Color Size AW + to Jambsc Jamb Type Grid Grid Patter ert( riz(P bscur Screel IN or # Venting f Venting gliding HRDWR HRDWF Keyed Mulled/ Sp
R. Fl., Code CODE COD CODE CODE Code Width Heigh HEIGH Width Heighl TIP Size Location CODE Color Color CODE Sash)Sash CODE CODE OUT Panels_Handing Handing only) Type Finish Lock Stacked Nc
Approval Prim Name Chris Collins Tit1e Home Owner
The Commonwealth of:�Iasstri ftlr;e/is
; .1 a a"ttnznt �f industrial-4--^idents
a� 1 Congr%ss Street, Suite 100
Boston, MA 01114-201.7
www.mass.sov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers.
TO BE FILED WITH THE PER�(ITTIIYG AUTHORITY.
Applicant Information Pease ?rine Lei:ibiv
N ante (Business/OrganizationiIndividual); e—
Address: �-q 17� lesFecnB
City/Stalte/Zip: 30 3 Phone #:
Are you an amplover!Check the appropriate box: Type of project(required):
l.Q[am A amployer with ahnployees,"full and/or part-cunei. 7. Q New construction
2.Q f Arn i iota proprietor or parmership and have no.mployees working for me in d. Q Remodeling
any capacity.(Yo workers"comp.insurance required.]
9. Q Demolition
3.0 f Stn a homeowner doing all work myself.(No workers'comp:insurance required.}'
10 Q Building addition
4.Q Lim r homeowner and will 5e hiring ronttacrors o--onduc:t all work on my property. [will
insure hat all contractors tither ave workers'compensation insurance Jr: are sole I I.Q Electrical repairs or additions
proprietors with no 4niployees. 12.Q Plumbing repairs ar additions
J.�t an a general contractor and:have hired die iub-contractors listed an rhe Attached sheet (3 Q Rao[repairs
These hub contractors have amp[oyees and lave workers'pomp. insurance.-' 1her /
,
6.Q we arc a corporation and its ot'ficers:rave axercised their right of exemption �f
per GL
t'/tiO
i 52,}t(a),and we Save ao-mployees.[No workers'comp.insurance required,
4'atny ipplicanrtbat checks yox:*l must also fill out the lection below showing their workers'compensation policy,information.
'Homeowners who iubmit his affidavit indicating they Are doing all work and then hire outside contractors must submit i aew affidavit aidicating such.
*Contractors fiat check this hox must attached are Additional sheet showing the name of the hub-contractors and State Nhether or not chose entities'ave
employees. If"Im iub-contractors have-inplayees,they must?rovide heir xorkers'comp.policy lumber.
f am an employer that is providing workers'compensation insurance for my employees. Below s the policy and job site
information. } Cosurance Company Name: 1VA,C WV�1 V V7 1�
Policy#or Self ins.Lic.#: W V /v g-S' 3A Expiration Date:
Job Site Address: � e/�A � CitflStaE�Zip: 0�—�°r`� ��L9
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expirati n date).
Failure ro secure coverage as required under vfGL c. 152,425A is a criminal violation punishable by a Eine'up to 31,.100.00
and/or one-year imprisonment,as well as civil penalties im the form of a STOP WORM{ORDER and a rine of up to 5250.00 a
day against t[te violator.h copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance
coverage verification,
C do hereby cerci under tAe pains es of rjury !kat the information provided azzbtsve is true(etiti,:o',rrecr
Si ature: a Date: J �Ul�
Phone#: $
l7JYI-ciaf use only. Do not write in this area, to be conepleted by city or town offxciat
City ar fawn.- Permit/License#
Issuing Authority(circle one):
1. Board -if gealth 2. Building Department 3.City/Town Clerk #. Electrical [nspector i. Plumbing (nspecror
6. Other
Contact Parson: Phone#: