29-109 DOME Ill4PROVEMIINT CONTRACT
PLEASE READ'
Sold, Fumiateed and Installed by;
Wooten Date. THD At -Home Services, Inc.
1 dlbi"a The Home Depot At -Home Services
34$A Greenwood Street, Unit 2, Worcester, MA 01607
Toll Three (800) 657 -5182; Fax (508) 756 -8823
Branch Number: 31 Federal 'Den-2692460: M6 Lie I C 02439; RI Coat Lice 16427
CT lac I H C.0365522: MA Home impeevement Contractor Reg. # 126893
Installation Address: S? t "t ( ibr3 R 0 es:L-- rel lc) d t Cfeti
city State Zip
: _ WorkPbo Home Phone noon
� A it I to Jc tete [ ] [ l t l --
[ ] t l [ ]
Home Address:
(If different from Installation Address) City State Zip
E-nmil Address (to receive project ootatmuaicadons and Home Depot updates):
❑ I DO NOT with to teethe any marketing entails from The Home Depot
Frejus Itatbrntasloa: Undersigned ("C . the owners oldie property located at the above installation address, agrees to buy,
and THD Ai-Ho services. Inc. ellse Home Depot") agrees to furnish, deliver and arrange for the inatallation ("Installation") of
all materials described on the below and on die referenced Spec Sheegs). all of which are incorporated into this Contract by this
reference, along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively.
'Contract"):
her f: memo aee,s„p Prudach: SP8e (s) Sr Prefect Amount
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Customer agrees that, immetTnerly 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 Customer 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 Comma or any individual Product(s) included herein, at
its discretion, if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home, eavimnniental hazards stech as mold, asbestos or lead prim, other safety concerns, pricing tarots or because
work requited to complete the job was not included in the Contract
Payment Summaiv: The Payment Summary # 8C3 included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final permits by Product (aa applicable).
NOTICE TO CUSTOMER
Yon ore entitled to a amploetelq fil ed -in ropy tithe Contract at the time yo em raga
. u. Do not a Completion Certificate (note:
there is one Completion for each listed Product as defined by individual Spec Sheets) before work ea that Product
is complete.
In the event of termination of this Contract, Customer agrees to pay The Home Depot the costs of earterisls, labor, expenses
aud services provided by The Home Depot or Authorised Service Ptovider �p the date of termination, plus other
aaoonts set forth in this Agreement or allowed under law. THE HOME DEPOT MAY WITHHOW.D AMOUNTS
OWED TO THE HOME DEPOT FROM THE A t PAYMENT OR OTHER FA1lMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCK AMOUNTS.
p� g„g_n4,Authorrmtion: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The H ome Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements, either
oral or written, relating to said Products and Installation. This Agreement cannot be assigned or amended except by a 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.
Accepted by- w x� 4) �
• f - 'a Signature ► Sales Consultant's Sig bate
Telephone No- ll
Customer's Signature Date Sales Consuhatit License No-
CANCELLATION? CUSTOMER MAY CANCEL THIS ire s ` k)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO 111E S HOME
DEPOT BY MIDeNIGETT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIEIID BY LAW IN
CUSTOMER'S STATE.
NOTICE: Almmoteou.T6Aact Ate COMMONS ARE STATED ON TUE REMISE SIDE AND AU PART OF THE CONTRACT
04 -11 -11 0-SC Waite —blanch Re Yellow— Customer
City of Northampton
YAK HA '4' A J
Massachusetts
al'
DEPARTMENT OF BUILDING INSPECTIONS tp
212 Main Street • Municipal Building J
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his /her
construction supervisor. The state defines "Homeowner" as " Person(s) who owns a parcel on which
irefshe resides or intends to be - a one or" family d ee/tinq, 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 person(s) 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 backfillj, sonotube holes (before pour), a rough building inspection
before work is concealed insulation ins • ection if re • uired and a final buildin • ins • ection.
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
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
The Commonwealth of Massachusetts
Department of Industrial Accidents a
le v ....7 .4.,* ' " a' Office of Investigations �� f i
f g ations
600 Washington Street
t a 5 Boston, MA 02111
,
"$ A ' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
`
Name ( Business /Organization/Individual): C1.4vYker ii r all G '* A Address: .2610 R
City /State /Zip: s 1, . • A _ , / Phone #: CO q &bj'7` -j li9-
Are yo n employer? Check the appropriate box: Type of project (required):
1. I am a employer er with G(� 4. 0 I am a general contractor and I
6. 0 New construction - employees (full and/or part- time).* have the sub-contractors
2.0 I am a sole proprietor or partner
listed on the attached sheet. , 7. 0 Remodeling
ship and have no employees
These sub- contractors.have 8. 0 Demolition
working for me in capacity. employees and have workers'
g any p ac tY 9. ❑ Building addition
comp. insurance.
[No workers' comp. insurance 10. ❑ Electrical repairs or additions
required.] 5. 0 We are a corporation and its
3.0 I am a homeowner doing all work officers have exercised. their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their 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.
1 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 workers' comp. policy number.
I ain an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
.information.
Insurance Company Name: . K2tit� '�i r 1 '1 I e _ `'J CO
,
Policy # or Self -ins. Lic. #: +01(I g Expiration Date:.
-
-- - -- - Job - Site Address: _._. _ - _ `_ ._. - [■ City/State/Zip: i i t di 4,o, di , 011 i ,i ..„
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expi • lion date).
Failure to secure coverage as required under Section 25A of MGL c. 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 penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day - . ' 1 st the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of th : r insuranc overage verification. \
I hereby ce 'y • under t = , ins d pe , hies of perjury that the information provided above is true and correct. - ___ _ _ „ / / ___ _ 0911/1—
Si Y a � i , Ai Date:
Phone #: L f (0 l q 6
— — Official-use only: Do not write -in -this areas to-be completed by city-ortawn official
City or Town: Permit/License #
____ ::_Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
MEW
l'ost`.-51•4•47q
4ECTION:8
8.1 Licensed Construction Supervisor: Not Applicable 0
771-)
Name of License Holder: \k
7 License Number
Address Expiration Date 77 I
Ali 14 GO A -
Signature ir Telephone
q0
is re , P • e m • .eme ° r ' Not Applicable 0
- at mit I,
Company N ame Registration Number
U
Address Expiration Date
4 UP) lelephone 0379
_
ECTIO •1ty.yaliFIM MPENSA; aftINSURANC 11: IDA.% 1, C. • ,
Workers Compensation Insurance affidavit m be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin errnit
Signed Affidavit Attached Yes No 0
_
11 48 ‘•-' :Ar Et'. r )1rD
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 resideon which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or firm
structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such "homeowner" shall sabmit 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 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 t� 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
•
.
YSEC�TION 5•Z DESCRIPTIONtOFBROPOSED `,WORK.( chec`Ikalla . •'li:cable• ' •1^
t V A r T ro t N .01 r ■
a M .,! r . as Vg '': W
New House El Addition ❑ Replacement Wi . • ows Alteration(s) n Roofing n
Or Doors P
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [c] Siding [Dl Other [DI
Work: Description of Proposed V `� , `�� 1\)0516444r4
Work: ,.lii : _ / ` s7.
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
1�Yia' 'A r, Aerl w` ,�,Y9 7 gy
, .. . v i iilt l o ' ' ®t:ie ®. ..I < .. la '• CW, ra i 0 : i
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
OWNS GE r is. r 9 ' V ® b : a " 0 °I i R .4
1,,a.. cortrz 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.
Signature of Owner Date
I, L e - , - —� , as Owner /Authorized
Agent hereby declare tha the statements and infor on the foregoing application are true and accurate, to the best of my knowledge
and belief.
-_ _.Signed_underth and pe tics .f perjury.. ___- _____
- - -_ -_ - .
VII
1.t . �/
Print Name f IN/
Signature of a'�' ed. !ent Date
•
Section 4. ZONING. Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
a
Existing Proposed Required by 'Lonin ,
This column to be filled in by
Building Deparhnent
Lot Size 1 1 1 i .
Frontage 1 I I
Setbacks Front I I ) I
Side L : I R.:1 -----1 L: I R:I
I I I
Rear ,
Building Height : ...
Bldg. Square Footage
I I I I I I I 1
Open' Space Footage r . _oh
I l
(Lot area minus bldg & paved ( I I I 1 I 1
parking)
# of Parking Spaces I I I I 1 I
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
I
IF YES, date issued: I _
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book • Pagei and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF. YES,_has a permit been or_need to be_obtained from the Conservation Commission?
Needs to be obtained ® Obtained Q Date Issued: I
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 ( 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 overt acre'? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
574 RYAN RD BP- 2012 -0502
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 109 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit # BP- 2012 -0502
Project # JS- 2012 - 000838
Est. Cost: $2139.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 98785
Lot Size(sq. ft.): 21170.16 Owner: NAHIOUSKY JOANN
Zoning: URA(100) //WSP II Applicant: HOME DEPOT AT HOME SERVICES
AT: 574 RYAN RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers
Compensation
WORCESTERMA01607 ISSUED ON:11/18/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE 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 11/18/20110:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner