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HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold. Furnished and Installed by
Branch n oaton Date: THD At -Horse Services, Inc.
d/bla The Hots Depot At -Home Services
345A Greenwood Street. lint 2. Worcester, MA 01607
Toll Free (800) 657 -5182; Fax (508) 756.8823
Branch Number: 31 Federal MO 75- 2698460: ME Lie # C 02139: RI Conti Lic# 164
LT Lic # HtC.0565522; Home Improvement ` Contractor R. 1 126891
Installation Address:' Mt9+t 3 4'Y`,t ltVl V l ► t
Cityte Zip
Funehider(s): r Work Phew HOME Phone Cell Rene:
7 _ Etdote_n. C 1 E 3l5 e(.5`(. _ 1
[ 1 [ 1 [ 1
Horse Address:
(If different from Installation Address) City State Zip
E-mtdl Address (to receive project communications and Home Depot updates):
El 1 DO NOT wish to receive any ntarar:tiing entails from The Home Depot
Protect Information: Undersigned ( "Customer"). the owners of the 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 incorporated into this Contract by this
reference. along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively,
"Contract ").
Job#: o.rard aeh eacr Spec Smogs) #: praise Amount
QRocting USidng Iftt ❑ Insulation n
{�i� 7 � j ❑Go / Cove ocrs s DEntryD ❑ g67a35 $ tc
Roofing idiots Indoors Insulation
Matteis Mows L18mi boom Ci $
OCl
rROoting [Siding 0 Widows ❑ hawlatioe $
.
❑Tunas / Covers [Entry Damn
URootmm= ❑Siding 0 Windows ❑ Insulation / /
❑Cromem / Covers Pauly Doors ( $
2516Depait Contract Animist due was saesntianGabb mnatL T Mal CootractAmount $ (
Made Panderers may not depot *nerreduo aoihkdof the CanaattAm u& kWbE)
Customer agrees that, immediately upon completion of the work for each Product. Customer will execute a Completion Certificate
(one for their 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 Omer or terminate this Conimact or any individual Product(s) included herein. al
its discretion. if The Home Depot of its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home, environmental hazards such as mold. asbestos or lead paint, outer safety concerns. pricing errors or because
work required to complete the job was not included in the Contract.
Payment Summers The Payment Summary # L4 �,a 5 , included at part of this Contract. sets forth the total
Contract amount and payments required for the deposits and final puycnenta by Product (as applicable).
NOTICE TO CUSTOMER
You are entitled to a need -in copy of the Contract at the time you sign. Do not sign a Completion Certificate Mote:
there Is one Completion te for each listed Product as defined by Individual Spec Sheets) before work on that Product
Is complete.
In the event of termination of 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 throw 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 OIL OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acreptante and Authorisation: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home 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 Homo 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;
X 1 - :r daA- 41 y ji.. X i ti Date Customer's Signature Date Salm Consul*aot's Si.' u ���
Telephone No.
Customers Signature Date
Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS ea writ-sew
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO ILSE 111 ONE- IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICE. AOD*IRIONAL T1*RMS AND cosrn'rMONS AItR STATE") ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT
1044 CSC White- &arch File YelIoW - Customer
u j ibr { L )(/l/jI( ,ri.J,-' 1/"' /1'1 )/' IIV1Id 1/ i;? p6 2
; Department : of Iild strla ,r i e t t 5
'
,` :' Office afInvestigat on
600 Was a gto.i StreeZ fi .
i.A. - .a B osfoji MA 02111
44- www,mass.gov/dia
Workers' Compensation 1115 e Affidavit ailde si ontrEct, rsiElettricians/'lumbers
A e .1a ant Information Please Priat Leatij
Name ( Business /Organization/Individual): rThe -t-A
Address: a _Ili If
Ci /State /Zi-- -
Are yo n employer? Check the appropriate box: Type of project (required):
I. t
I am a em o er with ^, 4. 0 I am a general contractor and I
_ - - -_P._ - Y _ __ _ �v 6. Q New construction
employees (full and/or part- time).* 1iave 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. D Demolition
working for me in any capacity. employees and have workers' .
comp. insurance.$ 4. 0 Building addition
[No workers' comp. insurance P
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
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 R repairs
insurance required.] t c. 152, §1 ( 4 ) , and we have no ��p
employees: [No workers' 13- Other �1 tli
, Dl4...Y'
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infor.nation.
t Homeowner who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
tContractors 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. lithe sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
.information.
Insurance Company Name: . t� m 1 r - e ' g CO
Policy # or Self -ins. Lic. #: 01,q(, -9 g j Expiration Date:.
._Job Site Address: ..-----
1 -r-- ' City/State/Zip:
��� +1 30._ „ G i --...a
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expi ation 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 - :. inst the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of th l r insuranc — overage verification. •
Id hereby ce under t d pe - Ides ofperjury that the information prov above is true and correct.
Si. a'. _ mot, 1, „J / Date: --------------------- - - - -_, 4. ■ . //0 1
.
Phone #: .!Z
VIMIIIMICUMEM
- — Official - use only: Do not write rnthis -areas to -be completed by city town-official
City or Town: Permit/License #
: .:.Issuing Authority (circle one):
1. Board of Health 2 l par t 3. City /Town t Electrical tr c l T t Plumbing . BL•i ding L'e tmer. : ,�/T,,.3:. Clerk 4. �..ec..:..a..ngYec Inspector 5. Inspector t
or
6. Other •
_ ... Contact Person: Phone #:
N . . CTiON SER�IICS i , , i
ii
SEi„TION $ CONSTRLIC
.1 Licensed Construction Stsoerviscr, _ u d_- Not Applicable D 1
Name of License Helder : �a l ,.o01/ , . r — ,:45 —
License Number
A•• ss Expiration Dat
IIP 1 /
Signatur Telephone •
r c rarr C �r, - raa#1 ti ,p. } r , ,t ,,,AE , ,
,9: r e> • ss, eredk ore lm • covers ,b • ontrac ar ,,,, . tW _r. „ k , r , .,,;M , Mr ,s �,,. 7 - Not Applicable ❑
• 1 d1- at /, • , �0 l
Company Name Registra Number ,__
114 ..
' g ?/).2---
-Address + _,,... .- Expiration Date
ezaliihJii.. ill i // elephone L IO ! (24
S'.sw , "+'1 ?.i7.'r'�"-s'.d:'a R r 1 4 ffwk°S" �+y'�'- ' .ti T-�' .6 a1' ;1:4 - 4ga dsaiggtiv mAtilE .Rffi3'it' �ou4i,
,SECTION 1�_ WOR,KERS COMPENSATIO INSURANCE AFF,1134 IT (M G C` 452, § 5C(6 }) � �7
Workers Compensation Insurance affidav m be c and s w th appl Failure to provide this affidavit will result
in the denial of the issuance of the buildin ermit.
" Affidavit Attached Yes No ❑
tip,
ta Q:11 wne ° e t r 0H
� ® - . 73.E
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 strictures 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" - shallsubmittcrthe 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 to Ch apterl 2 (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 y tinder this perm -
,_ -____. _..... 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 _
•
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
Mew House 0 Addition ❑ Replacement W ows Alteration(s) [ Roofing
Or D oors
Accessory Bldg. ❑ Demolition u New Signs [D] Decks [E Siding [0] Other [01
Brief Description of PropoeE --- i-y
Work: _14 401' I . I. 0 is ► W I to
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to istin • housin • com • lete the followin •
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
I,
�( , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit appli .tio
Signature of Owner Date
' A T £ / •e.— , as Owner /Authorized
Agent hereby declare that t e stateme and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the p-- d pe - - - •erjury. �I 1 _
Signature of 0 gent Date afirif
DE
Cit of
BiJl ding eort - h
RECEI'J Se
R oom -'
E\9 5ao'L P
ortham ton, MA 0 1 06 0
t
ph o e 4 3_.:87_124 Fax 413-587-12
.-..-. o$'••
. ION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1.1 Property Address: The Lofl O b c9!flptetedi oIfice
- L- - -
ID-3. 1
., -
SE&IO2 pROgERyOwNERSHIP1AUThORIZED GEN ; '
2.1 Owner of Record:
its .
Name (Print) Current Ma Address:
Telephone
Signature
22Authorized t:
W
A 'i - - AA 4 ; tdY
Name (Piln Curent .iiauing Address:
Signature Telephone
• Telephone
SECTON 3-ESTIMATED CONSTRIJCTIQN COSTS
Item Estimated Cost (Dol{ars to be
completed by permit applicant
1. Building r: 1
1 4 '
2. Eiectncaj
SUM
• 1±
3. Plumbing
N
MR - . -: • _ :.,
4. Mechanical (HVAC)
5. Fire Protection
6TotaI(1+2+3+4+5) l&j::; _- -Cirb P PM
;: - .-.----- -- -- - -..-- - . -,-----.'---- --
-- -i --Ths Section ForMfffcial Use OnIy i*-
kt Date -
__-
d
IS
----- ------ --.------. ......
- 4 =a ‚4 - _• 'tt3 .-P"_ 1r"' a, -
t''
G
103 MASSASOIT ST BP- 2012 -0757
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 105 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2012 -0757
Project # JS- 2012 - 001336
Est. Cost: $1688.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 98785
Lot Size(sq. ft.): 14331.24 Owner: FLEISHER A NICHOLAS & PHOEBE M
Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 103 MASSASOIT ST
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 () Workers
Compensation
WORCESTERMA01607 ISSUED ON:3/5/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 4 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 3/5/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner