29-406 ' l 34$A Greenwood Street,Worcester.MA 01607
Branch Number. Go job 4. + 14'6 Toil Free(800)657-5182. Fax:508-756-2859
i — Fedmal Ln N 75469846o MF,Lie 0 C 02439 Ill Coal-Lieti 16427
CT Lie 9 56552''';;M.A TkNUC Imprrr 101 Coaraclor POW 0126893
installation Address-. 1 � �1 t ' 1 SO E`er-'�' M�—_�
City State Zip
Part;h Y; Unt4 nt ha of0riV4r'a rda 8&E yYr. work M#14.- Hu a Pho,.ei
Q
Hutne Address:
(If different from Installntion Address) City state Zip
&malt Address(to receive updates and promotions from The Plome Depot): _
Mt VLen on: I/WcVYou("Purchaser"},the owners of the property located at the above installation address,otter to
ibrltraCt with IiotDC Depot U.S.A..Inc Ip�r p kaidl,dct6iver and arrange for the installation of all materials as
described on the attached Spec Sheet#R_h�5 1 ,incorporated herein by reference and madc a part heroof.
Rome Depot rrsterves the right to cancel this contract if,upon re-inspectlon of the jab,Rome Depot determines that it
cannot perforal its obligations due to a structural problem with the home,pricing errors or because work required to
complete the job was not included In the Spec Sheet or Contract.
DEPOSIT PAYMENT OPTIONS
r (Subjcctto fund ved0catim amtfor credit rq pro*a6)
CONTRACT AMOUNT S C 1. Check,Cashiers Check or US Postal Sarviee Money Order
i (Mndc payable to 71to Boise DgmQ.
i *LESS UEPOSTT S ( •�• z Credit Card"andrar other psymsat oaliona-ClIck Otre Bdow
Vila Mn UK:&M Dim= Aemriuu
BALANCE DUE 7'rw Hume pajiot Heine improvement Lou a llama Detest Credit Card~
ON COMPLETION S
❑New Aamuot rt Utsdog Account (eta.dr
`Mlubsum 25%of Contract Amount des upon Avail"C■edB S_ taiL A t7DCC ON1,10
l execution of mis coatrack
Accts: _ Eskp.Uatc
Houle as is ePPasH on cord: 44 W, t'.
Indicabe Payment Method For 'By my/our signature below,I/We agree to allow Home Depot to
BALANCE DUE ON COMPLETION"*: le above ace ered'u card for the dcposit indicated.
� St 1 6 -0'7
VS
GmQBot ■9�ttarore Dtle
""May be subject to Credit Approval,Fund [ SiL or HDCC Authorization Codes
Vorillcation and/ar Credit Card Authorization De osit Final Pa went
PurdWa agrees that.immedlatcly upon completion of the work,Parcha er will cxocute a Completion CediCtcatc stud pay any
balance clue, Purchaser also agrean to be jointly and severally oblta aced mad liable hereunder
I •
&WLr
p.AgMe_wentx This agreement and its attachments,including any financing agreement,contain the complete agreement
between the parties and can not be anamded or modiQod unless to writing in a separate agmcment signed by both parties,
NOTICE TO PURCHASER
Do not sign this contract before you read it. You are entitled to a completely fitle&in copy of the twatmet at the tine
you sign. Keep it to protect your rights. Do not sign a Completion Certificate before this project is complete. Law
prohibits hone repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to
the actual camplation of the work to be performed under the contract-
Yon may eased this transaction any rise prior to midnight of the third busdneas day after the date of tits contract Sea
Notice of Cancellation for an explanation of this right. There will be a Service Cbnrpa equal to 10%of the eanh'aet
amount if job Is cancelled by Purchaser AFTER the third business day,but BEFORE materials are ordered.Them will
be a service charge equal to 25%of the contract amount If job is cancelled by Purcbaser AFTER materials are ordered.
BY MYIOUR SIGNATURE BELOW,M AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. VWE
ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE
OF CANCELLATION,
BY MY/OUR SIGNATURE BELOW,VWE UNDERSTAND THAT THE AGREEMENT 1S SUBJbCT TO REVIEW OF
MY/O(JR CREDIT HISTORY AND VWE AUTHORIZE HOME DEPOT TO VERIFY AND REVIEW MY/OUR CREDIT
RECORD WITH AN INDEPENDENT QkZDIT REPORTING AGENCY AND RELEASE THEM FROM ALL LIABILITY
INCURRED FROM INADYEB344 OMIONS OR ERRORS.
SUBMitTED)3Y: Date: F
so l4sa r �•r-t _ t n ._r
908-d 900/900-d 981-1 9298 991 809+ MIMS 30 lb alll-waA 19:21 100Z-12-£0
d 'Branch Number: �j(�J Job#: Tali Free(RoQ)657-5152. Fax:508•-756-2859
Fcdc t ID M 75.269a460 Mk Lie k C 02439 Ri Cont.I.iclt 1G4Z7
LL ' F 365 MA Nmnc lmproovlemrnt Contractor Rte.0126903
lastailtttinn Address; `{ s r Oi �--
City I Stam Zip
PurCba e s: Task 4111 is nr Driver' le.ll&Ex ,rtJWN. Work Phv.e "ame Phone:
Horne Address:
I (If difiarcrrt from Installtrcion Addrem) City State Zip
E-mail Address(to receive updates and promotions from The Home Depot):
grniect Lfiarmatian: VWe/You CT=hasef'),the owners of the property located at the above installation address,offer to
contract with Horne Depot U.S-A_,Inc.("H Dogt")to fiunish,deliver and artange for the installation of all materials as
idesen'bcd on the attached Spec Sbect# _72*'-e /_/ ,incorporated herein by reference and made a part hemof.
Rome Depot reserves the right to cancel this contract if,upon rc-Inspection of the job,Home Depot determine%that it
cannot perform its obligations due to a structural problem with the house,pricing errors or because work required to
complete the job was not induded in the Spot Sbeet or Contract•
DEPOSIT PAYMENT OPTIONS
(Subject to Anal vartfi atlon andice cralit rppmvpt.)
CONTRACT AMOUNT 5 / �4../`L.7 1. Check.Ca,hiars Check or U5 Ponni Service Money Order
(Made payahia to The Rama Dgmt).
*LESS DEPOSIT $ � 2. C.0 Card•padroto dror pm.apl.-Md.truenelaw
Visa MratarCard Diewver American
BALANCE DUE f f Tha Homer DOW Roma t
ON COMPLETION S _ * t1O a,prowromt Lams Hoow bepat Credit
0 New Account ❑E%Itting Account ("IL&HDCC ONLY)
*Minimumn 25%of Contract Amount due upon AWM01e Credit:S.
execution of thia ptraet I (�1k tmCC(SNL]T
AGO* EScp.Date:
Narne pe It appears oo mwn t P.
Indicate Payment Method For ..gy our sibmature below, c agree to allow Hotne Dcpot to
BALANCE VVE ON COMPLETION''*: a above txodit card for the deposit indicated.
of SigrmWra De �cp
"" be subject to Credit HIL or ADCC Authorization Codes
May r Approval,Fund
Verification and/or Credit Cud A,uthorhx6on Reeds I Final P meat
# #
Purchaser agrees that,immediately upon completion of the work,Purchaser will execute a Completion Cerdt5catc and pay any
balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder.
Entire Aztffmw t:This agreement and its attachments,including arty financing s@reemcnt,contain the comploto agreement
between the parties and can not be amended or modified unless its writing in a separate agreement signed by both patties.
NOTICE TO PURCHASJ{
Do not sign this contract before you read it. You are entitled to a completely filled-ln copy of the contract at the time
you sign. Keep it to protect your rights. Do not sign a Completion CertMente before this project is complete. Law
prelabit9 home repair cvntracton tram requesting or accepting a Completion Certificate signed by the owom prior to
the actual completion of the work to be performed under the contract.
You may cancel this transaction any time prior to midnight of the third business day after the date of this contract. See
Notice of Cancellation for an explanation of this right. There will be a service charge equal to 10%of the contract
amount if job is cancelled by Purchaser AFTER the third business day,but BEFORE materials are ordered.There will
be a service charge equal to 26%of the contract amount It job is cancelled by Purchaser AFTER materials we ordered.
BY MY/OUR SIGNATURE BELOW,VWE AGREE TO BE ROUND BY THE TERMS OF THIS CONTRACT. UWE
ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF Tk1E NOTICE
OF CANCELLATION.
BY MY/OUR SIGNATURE BELOW,VWB UNDERSTAND THAT THE AGRL•EME-NT IS SUBJECT TO REVIEW OF
MY/OUR CREDIT HISTORY AND IIWE AUTHORIZE HOME DEPOT TO VERIFY AND REVIEW MY/OUR CREDIT
RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL LIABILITY
INCURRED FROM VVEERT�ENT ISSIONS OR ERRORS.
SUBMITTED BY• Date- 3 ' ;A
c Gmsut sot —•�
ACCEPTED BY1
Date:
108-d 900/900'd 981-1 E288 921 809+ S30IA03S 3ROH ld OHl-MI I 80:91 10OZ-12-80
O4St�MpTO +�\
C, itg Jaf Xort4a111pt-011
$ � +,�i'+iassaci7useffs
s a
q _ -
DEPARTMENT OF BUILDING INSPECTIONS l_=
INSPECTOR 212 Main.Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act aS 1-is/her construction sup<;.• nor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends 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
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 backfill),
sonotube holes (before pour) a rough building inspection(before work is
concealed), insulation inspection (if required) and a final building inspection. 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
I 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
Office of In vestigations
e 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibly
Name(Business/Organization/Individual):
Address: e
City/State/Zip: Phone.#: �(�
Are Zam n employer? Check the appropriate box: Type of project(required):
1. a e mployer with�_ 4. E] I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling
ship and have no employees These sub-contractors have g, r_�Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp.insurance comp. insurance.$
required.] 5. F� We are a corporation and its 10.0 Electrical repairs or additions
3.] 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.❑Ro f repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13. ther
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.
(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 am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:'
Attach a copy of the workers' compe sa 'on 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 DIA for insuranc coverage verification.
ISiumattuire:
o heeby certify u der h sins d nalties of perjury that the information provided above is rue an correct.
Date: o�
Phone#:
Official use only. Do not write in this area,to be completed by city or town 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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.R'e"istered Home'tni'revement.-bn"tractor � �. Not Applicable ❑
IaL.GJ 3
Company Name Registration Numb r
Addre 41 D ��.�/ �� Expiration Date
fiTelephone °c/0
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 buildinsLtrmit.
Signed Affidavit Attached Yes....... No...... ❑
orii O >rr
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 ❑ Addition ❑ Replacement Window Alteration(s) E] Roofing F-1
Or Doors OF
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [C] Sidin Other[oj
Brief Description_�repos
Work: l�1 oa Dl&fv Pj
Alteration of existing bedroom Yes No Adding-1w bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
§a `New tiouse:aetdor-actit fa= rstInn.: ro�rsin - o fefe#h
dier fcs owrrt`:
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
L 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- BE
TO _COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOIi 113ULDING 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 applicatio .
Signature of Owner Date
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 and pains d penalties of perjury.
not N
ignature o Owner/Ag t Date
, ~ . ft ,
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
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Varia nce/F i ndi ever been issued for/on the site?
�� ��
NO �_��� DONTKNOVU �~� YES �~�
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO ~=� ) DON7KNOVV 0 YES
IF YES: enter Book
Page, and/or Document#� !
B. Does the site contain u brook, body of water orwetlands? NO 0 DON 7KNOV 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobmobtained �~\ ���a�nmd � �-\ Date
�~� �_� ' �
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 0 NO 0
IF YES, describe size, type and location:
/
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre oris it part ofo common plan
that will disturb over 1acre? YESK��> NO K��}
IF YES,then a Northampton Storm Water Management,Permit from the DPW is required.
`
Department,use only ;
City of Northampton status of Permit
' ? cg Department
Cu€I�Gut/Drtvewa Perms
� , 9-2'Main ;
2 Main Street Sewer�Sept<cA�a��abdity
�
} ti
Room 100 Wafer/We[IArcatla6tlitSr ti zv
MAN 2 6 2C07Northampton, MA 01060 f8t€uctarat`Plans
phone 413-5+ 1240 Fax 413-587-1272 PIotlSite Flans �'
_ Offer Specify
APPLICATIOLTO ,QTRUCT ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This
sectio[tta be cornpCetedt�yofce
Map- tot C1nit
L� C L�,1I Zane Oyerfay. striaf
Elitr St District CB.Distrrct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT''
2.1 Owner of Record•
+�-U We
Name(Print) Current Mailing Addres�ET
Telephone
Signature
2.2 Authorized A ent:
A=�V-1 1V Va- b�e—.
Name(P nt) Current Mailing A dress:
ignature Telephone
SECTI 3-ESTIMAT.ED CONSTRUCTION COSTS,
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit 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) Check Number
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2007-0898
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit# BP-2007-0898
Project# JS-2007-001464
Est. Cost: $13370.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 126893
Lot Size(sq. ft.): 26310.24 Owner: MILLETTE RAYMOND H&NANCY L
Zoning URA Applicant: HOME DEPOT AT HOME SERVICES
AT. 45 SANDY HILL RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935-2633 O Workers
Compensation
WORCESTERMA01607 ISSUED ON:312712007 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING & 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 3/27/2007 0:00:00 $50.0017438
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo