24C-004 Ij HOME LVIPROVEIKENT
READ THIS CONTRACT IM O.% t r ils(Sl`S 4� l
PLEASE p
Sold, Furnished and Inspdted by
TIAN_al�e:Bosten i ' Date; TH A lfome Services, Inc. .
jiJ �� I. •
d1Wa The Home. of At -Home Services
�� 908 Boston T npdre,'Uniit 1. Sluewabw ,, MA 01545
Toll Free (800) 657 -5I82; Pidi'r(508) 845-6017
Branch Number: 31 Federal ID 4 75-2698460; M Lie # C13.243% 81 Cont. UC 16427
CT Lie irr.056 r ; MA No r C of Rag. # 126893
Installation Address: I. 1 g r . t_,+' k — LP I • ( tS t
City k State p
1 'urchaae+(s)e Work Phone home Phone toi ell Phone;
_ — r1 t1
Home Address:
' (If different front Installation Address) City State Zip —
Entail Address (to receive project communications and Home Depot updates): _
0 i DO NOT wish to receive any marketing entails from The Home Depot
P • re form • 'Undersigned Customer"}, the owners of the property located at the above installation address, agrees to buy,
and THD At- c Services, Inc. ("The Home Depot ") agrees to furnish, deliver and arrange for the installation (`Inatrgalun') of
all materials described on the below and on the referenced Spec Sheet(s), all of which are into this Contract by this
reference, along with any applicable State Supplement and Payment Summery attached hereto�Change Orders (collectively,
"Contract"):
dob #e et . nears.«) Prodnets _ Sit • s #e • ect Amount
R ' • • : .5t iding II Windows R insulation i 0,0 4 :3d
[Rootin ❑Siding i] Windows Q Insulation
OD-utters ! Covers Metro. Doors n _ E
• QR.00fin ❑srding ❑ windows U Insulation — S
•
Deemer. / Covers play Doors Q
.Roofin •Sidin swim. ■ Insulation
[
$
Peters l Carers ❑Entry Doors f •
J -
Albinism 26% Dewitt( Catttact Amount true epee execalsnofibis contract .
2.
Main u
ePedera daps* Mere Mae one-ihbd ofliceCaotrset Alum Total Cou4ACt $ 1` '7
Customer agrees that, in each unediately upon completion of the work for 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 linable hereunder -
The Home Depot reserves the right to issue a Change Order or terminate this Contract 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, environmental hazards such as mold, asbestos or lead paint, other safety concerns, pricing errors or because
work re to complete the job was not included in the Contract.
twant Snm mu:, The Payment Summary # 7 9_4
Pt included as part of this Contract, sets forth the total
Contract antount and payments required for the deposits and final payments by Product (as applicable). •
NOTICE TO CUSTOMER
Yet are entitled to a completely filled -in copy of the Contract at the time you siggnn.. Do not sig4 a Completion Certificate (tote:
there is one Compleden Certificate for tech listed Product as defined by indMdual Spec Sheets) before work ou that Product
is complete.
In the event of termination of this Contract, Customer agrees to pay The Home Depot the costs of materiels, labor, expenses
and services provided by The Home Depot or Authorized Serv 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 ROME DEPOT PROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
and Autho atian: Customer agrees and understands that this Agreement is the entire agreement between Customer
and e lri c ilite Depot wad) ward to the Products and Installation services , . . edes all prior discussions and agreements. either
oral or written, relating to said Products and Installation. This Agreement - . sued or amended except by a writing signed
by Customer and The Home Depot. Customer acknowledges and agrees tha read, understands, voluntarily accepts the
terms of and has received a copy of this Agreement
by: Snbtn 'ii: ,
X `' ' ► .nor ••---a ' l, . ��
le .,4 , ` •s SignaAM Date Sates ;y 'Ms Signature t.te
X _ Telephone N.. 'fie at _..r • jig
Cutt6mer'S Signature Date Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS oe eteilicablel
AGREEMENT WTrHIOUT PENALTY OR OBLIGATION '
BY DELIVERING WRITTEN NOTICE TO THE HOME t j f
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS t I '' ` t.j ( 6 Ba 1
DAY AFTER SIGNING THIS AGREEMENT. THE ttt
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICE! AD »ITIONAL TEAMS AND CONM't reefs ARE STATED ON THE REVERSE SIDE AND ARE PART OF TEM CONTRACT
05-10-12 While - oremit File Yatow Customer
._ . ,..,,:ter. _
(2/fife of
.r.J ��- 601) L 9I >Y?
B os M4 02111
'Workers' C crupea :33 xo - - -t uild °5`..
f?-LpDlie I t ltft� .rmatl n _ _ . ' as Frint
Name ( Business /Organizaa.orJIndividual):
r
Address: $ L 5- • •l'i ` OF f? °
City /State/Zip: i t:t4' �0 - ° 3 1 Phone #: . s7 -- /
Are you an employer? Check the ppropriate box: . Type of project (required):
1. r, I am a employer with 0 4. 0 I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6 ❑New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no emplgyees These sub- contractors have g, ® Demolition
working for me in any capacity. employees and have workers' 9 0 Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ eve 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 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
• employees. [No workers' 13.� Other S ( L62
comp. insurance required.] /1.- tL�1� &
Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homedwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job situ -
information.
Insurance Company Name:, 11/4.1 Paw t/ / , ,, . r _ r
Policy # or Self -ins. Lic. #: W 1 _! J / f jL Expiration Date: 3 - / ' /
•
Sob Site Address: /1 MUD' City /StateJZip:/4l //I poi , A/4 x6'6 d
Attach a copy of the workers' compen ation policy declaration page (showing the policy number and expiration 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 against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the • • for insurance coverage verification.
1 do hereby cere fy j the pains and en , ties of perjury that the information provided above 4 true and corned
Si ata _.. j111 I Date: 1442__
Phone #:
'Official use only. Do not write in this area, to be completed by c#y or town official
•
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrica>,Inspector 5. Plumbing Inspector
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ��� / )C y�/� Not Applicable ❑
(/
Name of License Holder : t. Olt la S1T FA f te� 9 2
License Number
676A5ty S , 00160p-eve /27» (5/o/ 3 /' /W 2o/
Address / Expiration Date
—_rail& .. / — • 3 — 26 3
Signatur= Telephone
9, Registered Horne Improvement Contractor: Not Applicable ❑
i e / r57 T Yn eruc cep l a ihef f
Company Name Registra ion Number
?D r /3%7 /) - 7 f /4JS,t3oi/ , "4- otcq ,34e/z-1
Address Expiration Date
Telephone 7/
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 uilding permit.
Signed Affidavit Attached Yes No ❑
11. — Home Owner Exemption
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 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 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 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House J Addition El Replacement Windows Alteration(s) EI Roofing E
Or Doors (D
Accessory Bldg. ❑ Demolition El New Signs [p] Decks [El SidinX Other ID]
Brief Description of Proposed
Work: , VI: I V i S /A/4 -10 -- R/d S7f2GU q,A-1__
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 .
L Septic Tank City Sewer Private well City water Supply
SECTION la - 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 application.
c 4 — C 4 Ce)
Signature of Owner Date
I, A» Q .ktz& W t t i , 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.
Sig - d under the pains and penalties of perjury.
Print Name iv /
d op-4 71 / Signature . 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 be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW (3 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES i0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
i Buildin g Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
Room 100 Water/WeflAvailability
0U 1 12 2012 orthampton, MA 01060 Two Sets of Structural Plans
phonje 413 - 587 -1240 Fax 413- 587 -1272 Plot/Site Plans
£ PT. OF 6UILuwG NTSPECi Other Specify
_���nRTHAAAPTON MA 010ou.
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
I 1 ra 7k-7z- Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
L as Sju-u Z-t 0 i f i1iu7 prf ►� T � , /tJoF mf- 0106
Name (Print) ^ �.,. � / ,, �� Current Mailing Address:
1/3
-( S /1 /7 t2Ift (- -eg7t P -ACT Telephone 1/3 —J o ? G30
Signature
7 lt SAcs'
2.2 Authorized Agent: l ��
n 'Y ,aPs7a� T K— S ZE--t,0s.$w n1A - 0/S-174/ Name (Print) Current Mailing Address:
.e / 0 0/ — 7i1- — 6 F
Si Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 4/ 3 / Check Number 31?3 �j — 4-'3 S This Section For Official Use Only Q
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
11 MURPHY TER BP- 2013 -0436
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 004 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit # BP- 2013 -0436
Project # JS- 2013- 000698
Est. Cost: $3722.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 99209
Lot Size(sq. ft.): 16727.04 Owner: SILLUZIO CAROL L & LORENE A
Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 11 MURPHY TER
Applicant Address: Phone: Insurance:
908 BOSTON TPK Workers Compensation
SHREWSBURYMA01545 ISSUED ON :10/15/2012 0 :00 :00
TO PERFORM THE FOLLOWING WORK: install vinyl siding
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 10/15/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner