37-081 LV IT 4V J I V1•L/ VL IT f 1\V VLVI\ wwvL TV IJ 11 11VI(1 WcP/ % I'f11V f 1/ 1
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
i l Sold,Furnished and Installed by;
Branch Name:Ralston North&South Date:_l _/ TIID At-IIome Services,Inc.
d/b>/a The Horne Depot At-Horne Services
Branch Number 31• d 31 908 Boston Tumpike,Unit 1,Shrewsbury,MA 01545
Toll Free 877-903-3768
Federal ID 4 75-2698460;ME Lic 9 C 02439;RI Cont.Lich 16427
CI'I.ic#111C.0565522;MA I tome Impm(v,�en,�tent Contractor Reg.n 1268!)3
Installation Address: "' t J ��4e—e - -AA- 0(C40
Vkb VP1 city Stale Lip
Purchaser) ): Work Phone: Home Phone: Cell Phone:
I .._
Home Address;
(If different from Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
1 DO NOT wish to receive any marketing entails from The Hong Depot
Project Information: Undersil;T(A("Customer"),the owners of the property located at file above installation address,agrees to buy,
and THD At-Home Services.Inc.("The Home Depot)agrees to furnish,deliver and arrange Ihr the installation("Installation")of
all materials described on the below and(m the referenced Spec Sheet(s),all of which are incorporated into this Contract by this
reference,along with any applicable State Supplement and Payment Summary attached 11e17el0 and any Change Orders(collectively,
"Contract"):
•ob `'"°"'°'No ' Pro/luct ; Spec Sheet(s)M: Project Amount
- A rnVing ❑Siding Winduws Insulation L�
77? %7� ❑Gutters/Covers ❑Entry Duo's ❑ 4i t��i� $ I;i t� /
❑Rlriting ❑Siding ff Winduws Lj Insulation /
$
❑Gutters/Covers ❑Entry Door; ❑
RMifing ❑Sidng ❑Wnhduws Insulxdun
❑Gutters/Covers ❑Entry Doors Q $
Roofing Siding Winduws ❑Insulation
I
j ❑Cnhtters/Covers ❑hoary i)oors ❑
Minimum Z%Deposit of Contract Amount due upon exert of this contract. Total Contract Amount $
Maine Purrhawrs tray not deposit atom than ono-third for Ow Contratx Amount.
Customer agrees that, immediately upon completion of the work for each Product.Customer will execute a Completion Certificate
(one fur cacti l'rolucl as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this
Contract agrees to tx:jointly and severally obligated and liable hereunder.
The Horne Depot reserves the right to issue a Chatlge Order or terminate Ibis Contract or any individual Product(s)included herein,at
its dkercliun,if The Home Depot or its authorized service provider determines that it cannot perlbrtn its obligations,due w a strut:tw'al
problem with the home,environmental hazards such as mold,ashesuts or lead paint,other safely concerns,pricing errors or b:cau.vc
work required to complete the job was not included in the C:untracl.,
Payment Summary: The Payment Summary# CA (-% 'f2- _ , included as part of this Contract, sets forth the total
Contract amount and payments required lot the deposits and final payments by Product(is applicable).
NOTICE TO CUSTOMER
Vou are entitled to a completely filled-ill copy of the Contract at the time you sign. Do not sign a Completion Certificate(mote:
there is fine.Completion Certificate for each listed Product as defined by individual Spec Sheets)before work nn that Product
is complete.
In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses
and services provided by The Ilotne Depot or Authorized Service 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 TIIE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITIIOUT
LiMITiNG'IN E HOMO:DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCII AMOUNTS.
Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home i Lpnl with rcgltrd IQ the PrWkicls and Installation services and supersedes all prior discussions and agreements,either
oral or written,relating to said 1 roducts and installation.This Agreement cannot be assigned or amended except by a writing signed
by Customer and The Honic Depot.Customer ucknowledges and agrees that Customer has read,understands,voiuntarily accepts the
terms of and has received a copy of this Agreement.
Accepted by:jo Submitted by:
usto ier's nature Date Sales Consultanl's Signature Date.
X � Telephone No.
4 t 3 6 3(0-t3iY, _14.
Customer's Signature Date
Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS („s»ppheahlc)
AGREEMENT WITI3OUT PENALTY OR OBLIGATION
RY DELIVERING WRITTEN NOTICE TO THE HOMh
DEPOT BY MIDNIGHT ON TIIE THIRD BUSINUSS
DAY AFTER SIGNING TIIIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICAIA.Y PRESCRIBED BY LAW iN
CUST'OMER'S STATE.
N(J'1'10::ADDITIONAL PERMS AND CONDITIONS ARE S7 A'TI I)ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT
\ ,It L; AL,vIILucunil'(;cCtul uJ .01t15SUCIIUSLILIS
Department of Indlistrial Accidents
Off ce of blvestig ations
_ I Con,ressStreet, Suite 100
Boston;MA 02114-2017
www mass o ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electiricians/Plumbers
Applicant Information' Please Print L' 'blv.
Name(Business/Organization/Individual): �
Address:
City/State/Zip: �L / Phone
Are you an employer? Check the appropriate b,ope Type of project(required}.
1. I am a employer with 4. D i am a general. and I
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. Q Remodeling
ship and have no employees These sub-contractors have g. Demolition
working or me in an capacity. employees and have workers'
g Y P h'• � 9. ❑ Building addition
[No workers comp:insurance
. comp. insurance.
required.] 5. El We are a corporation and its 10.�El2bi tric 11 repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11:0 P ;r epairs 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'' 13.0 Other
- comp. insurance required.]
Any applicant ti:::1hecks box*!;:: t ai,, fill out the section below showing their workers'compensation policy information.
t Homeowners who submit unis 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'conmp.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:. ^/
Pb T
Job Site Address: / � "�` City/State/Zip: / - ��-
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 c. 152 can lead to the imposition of criminal penalties of a
fine'up to $1,500.00 and/or one-year imprisonent, 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. Bme 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 certi pa' and eialtfeSnC Ferju7 that the information provided above is true and correct.
Sienature: )at e:
Phone#
Official use only. Do not write in this area, to be completed by city or town offcia_T.
City or Town•
Permit/License#
ELBoard g Authority(circle one): 01
of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
er ct Person: Phone#:
i
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.
0 l l/ I�� C-)P-e/2-7 Address of the work. �G�
The debris will be transported by: �
The debris will be received by:
Building permit number:
Name of Permit Applicant 7r ,11
Date Signature of Permit Applicant
City of Northampton
p Massachusetts f.�s�s�v <<,
DEPARTMENT OF BUILDING INSPECTIONS
��`",r ��, S.A�✓ 212 Main Street • Municipal Building t
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. 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
rh Department of Industrial Accidents
Office of Investigations
600 Washington Street
I Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 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. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp.insurance. 9. [] Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. o workers comp. right of exemption� ' per MGL p 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.
fHo meowners 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 far my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lie. #: Expiration Date:
Job Site Address: City/State/Zip:
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 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 insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: Date:
Phone#:
Of 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#:
a
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su i or: /JJ)/ Not Applicable £
Name of License Holder:
License Number
AAt 4
6
Address Expiration Date
CA
Signature Telephone
9.Re istered Home Im" iovement Contractor:=i,. > Not Applicable
CompanV Name /)- � Registration um r ��
C
Ad es Expiration Date
lam' r Telephon
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 Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [lam Siding (0] Other([ ]
/I
Brief Description of Proposed � ( � /� v
Work:
ion of existing bedroom Yes No Adding new bedroom Yes NoC�
Attach 9 Renovating unfinished basement Yes No
Attached Narrative 9
Plans Attached Roll -Sheet
or addi._ - . .. -
—6 if New and on 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.
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
f, /b C) )9- k)rv .J-- as Owner of the subject
property
hereby authorize `� 1
to act on�!y behalf, ' all matters relative to work authorized by this building permit application., , /
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 pai rand penalties of
Print Name
Date
Signatur Owner/Agent
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Tfiis colinnn to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear L—J
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces i
A. Has a Special Permit/Variorce/Rnding ever been issued for/on the site?
��
�� �� ��
NO �� DON7KNOYY YES t��
IF YES, date issued: !
IF YES: Was the permit recorded at the Registry ofDeeds?
NO � y D
�° _
IF YES: enter Bonk Pagel and/or Document#
B. Does the site contain a brook body of water urwetlands? NO 0 DONTKNOYY 0 YES yD
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeo6tained v�\ Obtained v~� Date
k.� �~� ' '
C. Do any signs exist un the property? YES 0 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
/F YES, describe size, type and location:
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
/F YES, then a Northampton Storm Water Management Permit from the DPW/arequired.
A Department use only ;
--- ity of Northampton Status ofPermrt
uilding Department Gtlrb CuTlDrive�iray Perrrttt x
AR
t N14 !!!, 212 Main Street Sewer/Septtcavairabllrfy
L k �
Room 100 1Nater/VICe�IAya�labillty
Plumbing&Gas Inc pcoN hampton, MA 01060 Two Sefs of Structural:Plans
rthampton.h 87-1240 Fax 413-587-1272 P1 IV Plans
qng,Oder 5peo�#y'r.Ei
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: Thls section to be completed by office
Map Lot Unit
bo (�Lj� ��` /G 1�-� ` ' Zone Overlay Drstirict
U r
Elm St District CB District
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner 9,f Record: " lie
Name(Print) (Irx � Curtent�Nl�ling,S.d�4�' �y P^/,l�/
Telephone
Signature
2.2 A ed ent:
Name i Current Mailing Address:
Si nature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit apgjicant
1. Building (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) c�
5. Fire Protection A V
6. Total=(1 +2+3+4+5) Check Number d
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector`of Buildings Date
60 PLATINUM CIR BP-2015-0280
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37-081 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-2015-0280
Project# JS-2015-000540
Est.Cost: $4760.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 88261
Lot Size(sq. ft.): 30753.36 Owner: NNAJI PATRICIA
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT. 60 PLATINUM CIR
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.911212014 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 9/12/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner