29-422 (3) Jul 01 1406:30a p.1
HOME INIPROVEMENT CONTRACT
PLEASE READ THIS
�y�' Sold,Furnished and Installed by:
Branch Name:Boston North&South Date:I;2I�A- THD At-Home Services.Inc.
dAVa The Home Depot At-Home Services
Branch Number:37 and 33 908 Boston Turnpike,Unit I,Shrewsbury,MA 01545
Toll Free 877-03-3769
Federal Ili#75-2698460;ME Lie#C 02439;RI Cone Lie#16327
ll CT lie#HIC.0505522.MA Home improvcinont Conoaaor Rep.#3 26893
Installation Address: �(�I tti_ ti- bF`J:J"J02- fik c
City State Zip
Purchaser(s): Rork Phone: Home Phone: Ceil Phrtnt:
cJ ra � �
Home Address:
(If different from Installation Address) City Slate Zip
E-land Address(to ret:eive project communications and Home Depot updates):_
❑I DO NOT wish to receive any marketing emails from The Home Depot
Proiect Information: Undersigned(''Customer"),the owners of the property located at the above installation address,ai;rees to buy,
and THD Al-Horne 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 Shect(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#: trM mare-l"aA roduclg: See Sheens)#: Pro' ct Amount 44
Rocifing 05-idinL�J Windows L lnsulation
�G j 5 73 ❑Gutters l Covers []Entry Doors ❑ q{ 3 $ ��
Roofing USiding El Windoays U trsulation
❑Gutters!Covers _ S
(]Entry Dcors ❑
Roofing Sidins Wirxlorvti 0 Insulation Y)
❑Gutters 1 Covers ❑Entry Dews❑
Roofing L]Sidlng-0 Windows D Insulation
❑Gettc:s/Coves DEntry Doors ❑_._. $
14 Wmnm25%DepositofCarairrctAmamtdueuponcacutionofthscontract. tT��C- actA mount $ {�f
Maine Perd:�na ney not deposit nuire than one-third or tile Contract Amount t}Uj
Cusmrner agrees that,immediately upon compleben of the work. --(r eachh Product.Cuucmer will extxuLe a Completion Certificate
(one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,mach Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Horne Depot reserves the riiot to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,it'the Hnme Depot or its au:horizcd xrvice provider determines that it cannot pet-16-m its obli-atirnts due to a structural
problem with the home,environmental hazards suer ax mold,asbestos ar lead paint,other sr!'ety cunCerns,pricing amts or because
work required to complete the job was not included in the Contrau.c(
Parment Summary: The Payment Summary It q4�0._`_ included as putt of this Contract sets forth the total
Contract amount and payments required for the deposits and final payments by Pr xluct(acs applicable).
NOTICE TO CUSTOM ER
You are entitled to a completely Mled4n copy of the Contract at the tim you sign. Do not sign a Completion Certilricate(note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product
is complete.
In the event of termination or this Contract,Customer agrees to pay The Hinne Depot the costs of materials,labor,expense%
and services provided by Toe Home Depot or Authorized Service Provider through the date of termination,plus any other
amounts set forth in this Agreement or allowed tinder applicable law. THE HOME.DEPOT MAY WITHHOLD.AMOUNTS
OWED TO THE HOME DEPOT rROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOVI'
LINIITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreuttent between Cusronter
arc!The Home Depot witli regard to the Products and Installation services:md su w:ail prior discussions and u�reem+mts,either
ot.il or written.relating to egad Products and IltSallrtiDn.This.Agreement cannot acs tied or amended extent by c wiling,igned
by Customer and The Home Dopol. Customer act.-TowH- ges anti agree,In.Cu:: meth . read,understands,vorunuuily accepts the
terms of and hips received a copy of this Agreement.
Ace v: s0mitt
�d{) I x
Customer's SrignataCi Date Sales Consul t tgnature Date
X _ Telephone �-
Customer's Signature Date
SelLs Consul ant License Nn..
CANCELLATION: CUSTOMER MAY CANCEL THIS :i.tiapplic�tac)
AGREEMENT WITHOUT PENALTY OR OBLIGA'PION � 3�°�
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY 'NIIDNIGHT ON THE THIRD BUSINESS
DAY ASTER SIGNING THIS AGREEMENT. 'ruE
STATE SUPPLEMENT AT'T'ACHED HERETO
CONTAINS A k'ORM TO USE IF ONE IS
CPR!'rplr"AT r V Duved'"Jusn nv . .•. •.
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address ess of the work:
The debris will be transported by:
The debris will be received :b Y
Building permit number:
Name of Permit Applicant
W—zz– ,—"-4, -
d
Date Signature of Permit Applicant
z Tile co urnonwea h of;vasszzchusea s
Z9e rf te,�t o ;*dtaslrir�i Lcid--t3
Offle'e of investigations
_ 600 Washington Street
Boston,314 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
_Applicant Information , > /- &741 Please Print Legibly
Name(Business/Organization/Individval): ,fir; 7 Le
l-5
�/ �
Address
City/State/Zip: r �Y. - b � X033 Phone#: 77q — u =�f
Are you an employer? Check the appropriate lea: Type of project(required):
1.❑ I am a employer with 4. � I am a general contractor and I
* have hired the sub-contractors 6• ❑New construction
employees(full and/or part-time).
partner- listed on the attached.sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or part
ship and have no employees These sub-contractors have g. DemoLtion
working for me in any capacity. employees and have workers' 9. F-1 Building addition
[No workers' comp. insurance comp.insurance.x
required.] 5. 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.❑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 13 ❑ Other
employees. [No workers'
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. /� /� R
Insurance Company Name: 1 eW //CU" Sf1/ilf- 2 /AIY 0 , _
Policy#or Self-ins.Lic.#: C, 0 - -I Q I g Expiration Date: 371 76 /
Job Site Address: �� City/State/Zip: - /M-4-0 042—
2—
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL e. 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 fo insur nce coverage verification.
I do hereby certify
rr ),ep s p t s of perjurye information provided above is true and correct
Date-
Sign
afore: —
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#:
MW
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction SUgg,visor:
Not Applicable £
Name of License Holder:
License Number /.L�
Addr—ss Expiration Date
Signature Telephone
9.Re isteretl Home Im rove t"Contractor. " Not Applicable £
Co mpa n amd�: yl � Registration Number
Ad ess ��jj Expiration Date
r
�i elephonpb!
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 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 Windaws 1 Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[0]
Brief Descri tion p7e _ r
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No / No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a if New house a4li' ",addition to"existing hous-.�complete the followlnq:
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 J '
hereby authorize `
to act on my ehaIf,in all matters rel a to work au on ed b this building permit application. /
Sig Date
d 00, 4r 'L t �' as Owner/Authorized
I,
Agent he eby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under p ins a penalties of perj�_1
Print Name
r
Signa r of Own r/ gent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning l €"
This column to be filled in by
Building Department
Lot Size E t
Frontage
Setbacks Front
f �
Side L:' R:€.�— j L:._._.__ R:=
Rear
Building Height —I
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&pavedW parking)
#of Parking Spaces —---- I
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES 0
IF YES: enter Book Page! and/or Document# i
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q 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 O NO Q
IF YES, describe size, type and location: j
__.___._...._..__—-----_.......-
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.
-- r
� r � Department use onlX ', '
,� t`il City of Northampton Status ofPermrt A k J � s w
2 t'6 Building Department C�rr6 cut�Dnceray Ierr>rt�t
7 F k
212 Main Street Sealer/SepticAvaiCabtllty
Elec plumbing
&Gas inspPCt1Ons Room 100 4Vater/VILeiCAvatlabll ty
ic, ton, p,01060
Northamp Northampton, MA 01060 Twa;SetsofStuc>ura3 Plans
phone 413-587-1240 Fax 413-587-1272 P[of/slte Pia:ns r
�Dt�ier 5peeify'}F ', '' � ` r •
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section fo be completed by office:
1.1 Property Address:
RiJ
Map f Lot Unit
Zone- -. Overlay District
Elm SS District CB;Distnct'
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: V. a
Name(Print) /7 /;r� c --- TCeul rr p ht o ne
Signature ili�nc Ad
2.2 Authp4zecl Aobnt.
Na rin !" Current Mailing Address: U�
Signature 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
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
39 GOLDEN DR BP-2015-0103
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-422 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2015-0103
Project# JS-2015-000174
Est.Cost: $2063.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 92937
Lot Size(sa. ft.): 36633.96 Owner: STEFANIK ANNMARIE C/O ANN MARIE OSOWSKI
zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT. 39 GOLDEN DR
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-26330 Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON.-712512014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT PATIO 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 7/25/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner