31A-236 2014-04-01 17:28 8923-EXPDTR/PHN SLS 4135643514 >> Home Depot AHS P 1/7
HOME IMPROVEMENT CONTRACT'
PLFASF READ THIS
Ll ..
;L3 Sold,Furnished and Installed by:
Branch Name:Roston North Rc Smith Date: / / j TIID At-Homc Services,Inc.
dibla 'I he Home Depot At-Home Services
Branch Nunther 31 nd 3 909 Boston Turnpike,Unil 1,Shrewsbury,NIA 0154,5
Tall Fret:877-903-3769
Pedtra)11)It 75-2698460;ME Lic 4 C 02439;RI Cont.Lic,#i 16427
4 l'1'11 Jc tf HiC._056 522;MA HOtlie l nvement Contractur Reg.#!12(.189?
Installation Address:
City Slate Zip
Purchwer(s): Work Phone: llotne Phone: Cell Phone:
HoneAddre,%,; cr _
(if different from Installation Address) (,try State Zip
E-mail Address(it)receive project cornutunications and Home Depul ulriates): ------
❑I DO NOT wish m receive nny marketing entails frunt The IIoule Depot.
Project Information- Undersigned("Customer"),Uic owners of the property locatet at the above installation address,agrees to buy,
and THD At-lionte Services,Inc.(`Ttic Home Depot")agrees to funtish,dclivLT and an•ange for the installation("Installation")of
all materials described on the below and on the referenced Spec Shucl(s), all of which are incorporate!into this Contract by this
reference,aicmg with any applicable State Supplement and Payment Suniniary attached her to ar d any Change Orders(colJcchvtly.
"Contract"):
.Tab#: (t. n i Rt fr 1 Products: Spec Shcet(s)#: Pruiecl.Amount
ty I cx,ttn( Siding❑windows Lj Insulaliun
❑flutters/Covets ❑Entry Doors ❑
Reuling []Siding Cj Windows Insul;then —�
❑Clutters/Covers
❑Entry Thrtu'.ti ❑
0ltuottog Siding Lj Windows ❑lnt,uhilion �-
❑Queen 1 t'uvrrs ❑hntry Doors❑ I _
Roofing Siding❑windows C1 insulation
❑(;urtetc;Coverx ❑EntryTkors ❑
Nintinuun2g%Deposit afConlrwtAnintint due uptin execution dlhisty*!tract. Totni Contract Arnount
Maine Punhaar.rs may not deptxsit more than onrthirti of tin C Ontrntl Amount.n /
Customer agrees that, tmmerli.nely uptm completion of the work for each Prmiuct,Customer will cxccutc a Completion C'.Crtilicate
(one for each Prmlucl as defined by an individual Spec Sheet)and pay:uty balance due.. As applicable,each Customer under"lis
Contract agrees to lie joini.ly and severally obligated and liable hereunder.
The Home Depot rescrve�,the right 10 issue a Change Order or 1crrninalc this Contract or any individual 1'toduct(s)included herein,at
aN discretion,if The TTome Depot or its aulhoriztA'service provider determines that it cannot pertbrm its ahligal!oil&due,to;l-Structural
probICni with Ile finale,environmental hazards such as mold,aslxsios or lead paint,other safety conco-ns,pricing errors or N cause
work rcyuirod to complete'the.job wax nal included in lice Contract.
Pavnent Sutnttttn•s• The Psyrncnl Sunuttary* q C 3 included as earl of this CA-11trICt, sclx furlh the.total
Contract atrtount mad payments requircd for the deposits and final payntcnls by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there is one C'omplelittn C;erlilicale for each listed Product as defined by individual Spec-Sheets)before work on that Product
is complete..
in the event of terwinatiort of this C'oniraet Customer agrees to pay The Home Depot the costs of ntaterittls,lahrtr,expenses
and services provided by The Home Depot or Authorized Service Provider through the date ttf termination,plus any other
atuouats set forth in this Agreement or allowed under applicable law. 'TILE HOMF.DEP(YI'MAY WITHHOLD ANIOUN1'S
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT' OR OI'IIER PAYMENTS MADE, WITHOUT
LIMITING THF.HOME IH:POVS OTHER REMEDINS FOR RECOVERY OF SIJC:II AMOUNTS.
Acceptance and Authorization: Customer agra:s and understands that this A�nee ant is the entire aIRCCVtettt betWeell Cuvtomcr
stnd't'he 1 tome T)epctt wt[h regard to the Froducts and Installation services and..upersede%all prior discussions and agreements,either
oral tie written,relating to said Products trod Installation.This Agreement cannot lx assigned k"'mnendcd cxccpl by n writing signed
by Customer and The Hnmc Depot.Customer acknowledges and agrccs that Customer has read,understands,voluntarily accepts the
terms of and has received a copy ol'this Agreement.
Accepted by: _� Submitted It,�
AC�e _ y I
Customer's Signature7alc Sales .unsulhun's iilntatwn 17atc
N Telephone No. k —V 03
Ctibtomc:r's Signature bale Sales C'onsullanl License No,
CANCELLATION: C.IISTOMER MAY CANCEL THIS as apylican r.}
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO 111E HQMF.
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AHTER SIGNING THiS AGRItEMENT, THE
STATE SUPPLEMENT A'19'ACIIED HERI:'10
CONTAINS A NORM TO USE IF ONE iS
SPEC VICAlA,Y PRESCRIBED BY LAW IN
CUSTOMER'S,'PATE. ��. L
.... .....................,.,.n...,..,...,..,..�..,T.., ,. ..sr,raw,n auv ufvr r1/3•rHtc r'f7rv'I'11 4r'T
The Commonwealth of Massachusetis
_ Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
.mass.gov1dia
Workers' Compensation Ins mace Affidavit: Bu.i]ders/Contras:torn/Electricians/Plumbers
Applicant Information _ _ Please Print Legibly
Name(Business/Organization/Individual): i
Address: AAJ N"MI
City/State/Zip: Phone#:
Are you employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1, am a employer with _ ❑ 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition,
[No workers' comp.insurance comp.insurance.$
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.❑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.
#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. .
lam 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.#:_ 1 _ Expiration Date:
- wl� Ci /State/Zi
Job Site Address: fi5' p'
Attach a copy of the workers' compensation policy declaration page(showing the policy number ankApiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimmal 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 insurance coverage verification.
I do hereby certify d r t elves d lees ofR jury that the informadon provided aabove is a can correct
Si afore: Date: --
Phone#:
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Perinit/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
�l7/-�33
. ...
9.Re i§ter d me In r' emerit�ntra ` ,. ... �.---ri :; ?, a;. .. ' Not Ap�cable����
Cominai N e Registration Number /
e T �/ xpiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§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 building 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 ❑ Addition ❑ Replacement Windows Alteration(s) ED Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [O] Other[m]
Brief Des 'on of Prpp / S
Work: di
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
iia:If New tiotise and or'addifion to e''" in .liausn corn fete the followir
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
���� ►� as Owner of the subject
property '
hereby authorize f
to act on my behalf, in all m ers relative to work authori d by this building permit applicati
7i
Signature of Owner Date
as Owner/Authorized
Agent hereby declar6 that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed ert sins an n o erlury.(
%�1!t3-
Print ame / 1
/`�'
Signa f Own r/Agen Date
. .
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Tbis cohimn to be filled in by
Building Department
Lot Size
Setbacks Front
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved F77-1
#of Parking Spaces
(volume&Location)
A. Has a Special Pennit/Variancp/FincUng ever been issued for/on the site?
NO 0 DON7KNDY 0 YES 0
IF YES, dateissuedJ /
IF YES: Was the permit recorded at the Registry of Deeds?
��
NO DON 0 YES�_� / KNOW
IF YES: enter Book Pag and/or Document#
�� ��
B. Does the site contain abrook, body nf water orwetlands? NO �~��� DONTKNO\� «�� YES ��,
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tubeobtained �~� Obtained �-t Date Issued:
�~� ��' ' .
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 type
' ' ' | .........
___________________�
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre oriait part ofa common plan
that will disturb over 1acre? YES NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
�
� _ p rfrpe t
IDity of Northampton
uilding Department Carta CUt1Dri�reway Perrrsit h'
APR
2014 212 Main Street S,ewerlSeptic�kvairabl►tty
Room 100 VVaterllAtelEAva�lablllty
Northampton, MA 01060 Two,S+rts ca�Structural Plans „a F
Electr;c, P.,)nn bic q&Gus f s
r.:� !UrP± r., I0Apee�$ -587-1240 Fax 413-587-1272
i
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 completetl by office
w Unit
T
:
Zone lay District
Elm St.District _: `CB Distinct _ :�
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Dzz,m7t 6db�v�
Name Print) - Curr Mailing Add �-.
It f Tel ne
Signature
2.2 Au4korizecl A ent: c //,�4 , /�����
Name P' / Current Mailing Address: t
x/-5 3-�--,;V6 73�
nature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building / / (a) Building Permit Fee
2. Electrical G (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 Commissionedinspector'of Buildings Date
35 KENSINGTON AVE BP-2014-1043
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A-236 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2014-1043
Project# JS-2014-001798
Est.Cost: $16766.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Gronn: HOME DEPOT AT HOME SERVICES 96194
Lot Size(sq. ft.): 4965.84 Owner: GILLMAN DONALD&HANNELORE
Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 35 KENSINGTON AVE
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON:411112014 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 4/11/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner