37-004 (11) ROME D"RO VEMENT.CONTRACT
PLEASE RRAD THIS
t� ?j 1 t � Sold,Eurnished end Installed by:
Branch lt,'ama:Boston Nook&5outb DAte:ZI`"J! THD At•Home 3"Ce4,Inc_
dlbfa The home Depot At-Horne Services
Brandt Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Frtx 877-903-3768
Fedmg ID at 75-2698460;ME U-tt C 02439;RI Cont.Lic#16427
,�,�,C�'Uc#M C,0565522;1MA Hama Improve"Of C or Rag.#126893
InstailationAddrew;5—M F101421 a 90 R6�lS2J�C.S
. City State Zip
Parcluiser(s)' w e' Home Phoae: Cell Phony
I J I J t ]
Hoare Address:
(If different from Installation Address) City State Zap
E-malt Address(to receive project Communications and Home Depot updates)_
❑I DO NOT wish to teoeive any marketing emaiis from The 11orne Depot
Project Informaa : Undersigned("Custo:t e'),the owners of the property located at the above installation address,agrees to buy,
and THIS At-Home Services,Inc.("bile Horne Depot")agrees to furnish,deliver and strange for the installation("TrtataAation}of
all materials described on the below and on the referenced Spec Shect(s),all of which are incorporated into this Contract by this
reference,along with any applicable State Supplement and Payment Summery attached hereto and any Change Orders(collectively,
"Coatrset").
Job M. anameRlr-3 Products: e s ati Pty'etdrtremtt
Roofing DSiding Windows iasulataoo
" EIGuttersICovers CJEq yDoors L1 - 3 $
Roofing 0SIding Windo". U ltisulauon
[]Gutters I covers❑Entry mom ❑ _ __
hoofing Siding Windows 0 Insulation
L]Outtam I Covers ❑Entry Doors El-
LJRoofing Siding M Windows El Insulation
❑Gutters/Covers C]EntryDor)m ❑
M mtutttS°1aDet>odtafCm:hedAntomudaeupmrexea>fionaftivscantrart
ToW Contract Aubount s
Ma me PUmbasers may Prot depq*„juice than ane4"eethe Ca dradAmwmt. ka
Customer a,gees ttbat,immediately upon mropletion 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 Contract or any individual Product(s)includes[herein.at
its diacretion,if The Home Depot or its authorized service provider determines d-tat it cannot perform its obligadons duee to a structural
problem with the home,enviromnental hazards such as mold,asbestos of lead paint,other safety concerns,pricing errors or because
work required to complete the job was not included in the Contraccti
Payment Summarvt The Payatent Summary# ' . 19i3 l3 , Included As part of this Contract,sets forth the total
Contract amount and payments required for the deposits turd final payments by Product(as applicable).
NOTICE TO CUSI'OII[MR
You are entlitbed to a completely tilled-in copy of the Contract at the time you sign. Do not sign a Completion Certmeate(note:
there is one Completion Certificate for each listed Product ay defined by Individual Spec Sheets)before work on that Produet
JS Complete.
Irt the event of termination of this Contract,Cwtotuer agrees to pay Thee);Tome Depot the costs of materials,labor,expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other
amorous get forth in this Agreftnent or allowed vnder applicable law. THE HOME DEPOT MAY WUHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PALTMENT OR OTHER PAYMENTS MADE, W(TEIOUT
LIMITING TIME HOME DEPOT'S OTRER WMEDRS FOR RECOVERY OF SUCO AMOUNTS,
AccAe nc and Authotizetton: Customer agrees and understands that this Agreement is the entire agreement between Customer
and a oine—Repot with regard to the products and Installation services and supersedes all pfior discussions and agreements,either
oral of written.relating to said Products and Installation.This Agrcamcrtt cannot be assigned or amended except by a writing signed
by CUStomer and The Borne Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily Accepts the
terms of and has received a copy of this Agreement.
Accepted Submitted by'__V_ T
X L iYi�.� zcaet� X t M 1)&A n
Customer's Signature Date Sales Consultant's Signature Date
X Telephone No, _
Customer's Signature Date Sales Consultant I..ieense No.
CANCELLATION: CUSTOMER MAY CANCEL TWS 0.+appl ta81a)
.ACRI?EMENT WITHOIPI'PENALTY OR OBLIGATION
BY DELIVERING WRITTIRS NOTICE TO THE HOME "
DEPOT BY MIDNIGHT ON THE THIRD RUSUftSS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE. IF ONE IS
SPECXIaICALLY PRESCMED BY LAW IN
CUSTOMER'$STATE.
NOTIM ADDITIONAL TrStelt'IS*ND CONViTWN9 ARE STATED QN TKE RHYER5X 5lDE AND.ARE PART OF IM CONTRACT
whita—Brancnfits Yetlm—Customer
t
i J"'L, I,
6 0 1) PVa-shhn o2i Strrp�
Bf)_710)z M-A 022111
.1,E,ill I I _43 W; !'Si -.1)I.t T DI;J
L �- 1 1 3
'Work-ers' C A
NWAIC
Address:
44L
ti t /State/zip: Ah-D 1-1 f-- 'ff:
Y
Are I C the appropriate box Type,(if project(required):
........
_ . Y, —
am a g�pbrk.ci,)-ptractar ind I
6. F
New consbv
have hired the sub-contractors
listed on the attached,sheet. 7. �,emodeling
2. 1 am a sole proprietor Or Partner-
,liese.sub-mcpatr,actors have Demolition
ship and have no employees
working f6r.we in im"y c.aiacity. f_�mployeqs and,have workers' 9. [].RUilding addition
I o workers' comp insurance Comp. marance.t
:C
L S. -i and its 10.[ llff;HCBI repairs or additions required.] Axle are a,eprp6ratiby
3_ l am a homeowner doing all work
officrs have exercised their IL❑Plumbing repairs or additions
-it of exemption per MGL
myself. [No workers' camp. rigl 12.[]Roof repaii-,
c. .152, §1(4),and we have no
insurance.requ t ired.]
employees.. [No workers' 1311 Other
comp.insurance required.]
*Any applicant that checks box.,41 must also fill out the section below showing their workers'compensation policy intionnation.
t Homeovniers who subr I nit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such.
tco'ntructors;that check 1 this b I ox I must st a.tt I ached an I additional sheet showink the name of the sub-contractors and state whether or not those entities have
employees,, if the sub-contractors have employees;.they must provide ihC.ir,w6rkersi camp.policy number.
I am an employer that U Pr Workers'co ensadon insurance for my employees. Below is the policy and b site
M jo
P.
information.
Insurance Company Name- 411
Policy 4 or.Self- L ins. Lic.#: Expiration Dat
Job Site Address: City/State.
/Zi
!Rsa. on.policy declaration page(showing the policy nu expiration date).
Attach a member and e
copy of the workers': ti
Failure to secure coverage as tequJrpd,under.Section 25A of MOL c. 152 can lead to the imposition of criniinal,penalties of a
fine up to$1,500.00 andJor one7year imprisonment,as well as civil penalties in the fon-a of a STOP WORK ORDER acid a fine
of up to$250.00 a day against the violator.:Be advised thalt.a copy of this statement may be-forwarded to the Office of
f insurance covers e cation.Investigations of t4e DIA,or insw
U n?. p..e
I do
bere,b) certify pen offi riury that the inflormation provided above is IN. e an correct
pe
Signature: Date:
Phone 9:
,
Official use only. Do not this rea,
,write in a to be completed by city or town officiaL
City or Town: Perm' ittLicense 4
Is.S"m
. gAut4or4Y(circle one):
1.Board, of Health 2.Building Department 3. City/Town Clerk A.Electrical Inspector 5..Plumbing Inspector
6.�Oth.e.r
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su or: Not Applicablee E
Name of License Holder: i 4 -
License Number
Address Expiration Date
Signature ifelephone r 2/
:6.Re isteredHom Im "rove -entContrac ;?_ _ ;: ;, ?. _ - Not Applicable
Com an N me Registration TNumb er
..Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§ ))77
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:Eiemption
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.
Y
SECTION 5-DESCRIPTION OF PROPOSED WORK(check ail applicable)
New House ❑ Addition ❑ Replacement VyiMows Alteration(s) ff Roofing
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [O] Other[0]
Brief Descri tion Pro , p
Work:
Alteration of existing bedroom Ye No Adding new be room Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.If Ne '66use and_or addifion to existing housln'g;complete ti a 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.
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
to act on my behalf, in ma er 1Wtive tow thorized by this building permit application.
_—N
Signature of Owner Date
7Agent as Owner/Authorized
hereby eclare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
lief.
tl
Signed un r a pai and penalties of ppjrx9"
Print Name
Signatu f Owner/Agent Date
� S
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
T1iis column to be filled in by
Building Department
I i j
Lot Size
Frontage _._--
Setbacks Front
Side L:? R: L: R:L—
Rear
Building Height
Bldg.Square Footage % j
Open Space Footage % r— ----t I
(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 Q DONT KNOW 0 YES 0
IF YES, date issued.,
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book I Pagel and/or Document# _-- i
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued: ���
C. Do any signs exist on the property? YES Q NO Q
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 Q
IF YES, describe size, type and location: i
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 Q NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
n �
_ � A De artment Lse onl � ,�'
City of Northampton Status ofPerrrttf
4 r 511 i �4
� D
ullding Department Curb Gu#/Driteway Petrrft#
212 Main Street Sewer/SeptlGAVaiCatiillty x' �z
3 a h
1(1 t
MAY 2 3 2014 Imo` Room 100 Vrfate�/VefiiAva31'a6lhty 1
N rthampton, MA 01060 TWO Sfs oFS#r�tctual Piar}s
t_Iectrlc Fi 1-r, in g G oaec 587-1240 Fax 413-587-1272 PtoY/Slte Plans a F
�1 rn. D„1PJiC60
J
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
1.1 Property Address:
This sectiort to be completed by office -
rL J��� r :Map : Lot 4 Umt
Zone r OverlaX D�sfrict
;Elm St,pistrlct G8 Distract
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Recor d:
A/A
Name(Print) Current Mailing Address:
4,”6r � � Telephone
Signature
2.2 AuthMized M ent: !
Name Current Mailing Ad ess.
ignature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Feb
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
Building Permit Number: Date
Issued:
Signature:
Building Commissionerllnspector'of Buildings Date
579 FLORENCE RD BP-2014-1241
GIs#: COMMONWEALTH OF MASSACHUSETTS
MM:Block: 37-004 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate ory:REPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2014-1241
Project# JS-2014-002086
Est. Cost: $2186.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 082485
Lot Size(sg. ft.): 30056.40 Owner: DELUE ANNA M AKA ANNA M POWERS
Zoning: Applicant. HOME DEPOT AT HOME SERVICES
AT: 579 FLORENCE RD
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON.512312014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT 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 5/23/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner