35-243 (3) 2015-06-02 00:21 2662-PHN SLS 4137311304 >> Home Depot AHS P 115
HOME IMPROVEMENT CONTRA("P
PLEASE READ THIS
Sold.Furnished and Installed try:
Branch Nance:Roston North dlc Struth Date: / TIII)At-H(mlc Services,Inc.
d/h/a The Home lh:pot At-Horne Services
Branch Number:31 and 33 908 Bosttorl Turnpike.Unit 1,Shrewsbury,MA 01545
Toll Free 877.903-3768
Federal 11)#75-269846();M t'l.ic#CO2139,RI Cant,l.ic4 16427
CT I.ic#i IIC.0565522;;M,A t luuac Lnprovement Coniractor Reg.#12[;8!13
Installation Address: C���� t r l.N— QI ( ! 01 y fi off-
U Ctiy State Zip
Purchaser(s): Work Phone: Nara Phone: C'em Phone.
onr►� Pe, tat 3J s g I J r J - -
r J- -_ 1 r }
Home Address:
(II'different tipm Installation Address) City State Zip
&Mit Address(It)receive pmjmt cotmntmications and Inane Depot updates):
A T DO NOT wiah to receive any marketing cmaiis from The Horne Depot
Pro formgtili: UntLvxigned("Customer'"),the owners of the properly located at the above installation address,agrees to buy,
and At-Horne Services,Inc.("The Home Repot")agrees to furnish,deliver and arrange for the installation("Installation")of
all materials de-wribed(Nl the below and On the referenced Spec Sheet(s), all of which are incerrlwrated into d)is Contract by this
reference,"long will)any applicable State Suppleneru and Payment Summary attached hereto and any Change Order.(collectively,
"Contract"):
Job#: ❑owrn.IR«Pcrrnre( Products_ S Sheet(s)#: Project Amount
Rvufng❑Siding Windows sedation ��� '
0 dv 1 Ip��D ❑(,uurry/Covers ❑RntryDoors ❑ row 30 3
Z4 0
❑Rox�fing tii3ing Windows ❑insulation
❑Gutters/Covers ❑Entry IA'xmr; ❑- _ $
Ronfing ❑Siding Windows U Insularism --
06-ulters/Covers ❑Entry Doors El- $ -- 2D
k.,A g Siding Wind(nvs Tnsulatirxt
❑Gutters/Loom ❑Envy 0oos ❑_
Mirrieurrrn 25%Ik:puait trf Comtracl Arrr>trnt lore toper ex(YVliun of this c(rNrati, n
Mahrc PtIRUL crs me ac rra�tlp)r onr�tddrd of the Codratt Anxnrt Total Contract Amount Ov f V q
v� O
Customer agrees thin. itnniediaiely upon completion of the work for each Product,Customer will extrute a C(mopletion Certificate
(tine for each PrM uct as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under-this
Contract agrees to he jointly and severdly obligated and liable hereunder.
The Home Delxrt reserves the right ut issue a Change Order or terminate this Contract or any individual Peoduct(s)included herein,at
its discretion,if The Home Depot ur its authorized service provider determines that it cannot perlorm its obligation~due to a structural
problem with the horns,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors(w K(c4iuse
work required to complete thejob was not included in the Contract.
Payment Summary: The Payment Summary # t uCt S5 :5 5— , include.[ as part of this Contract. sets berth the total
COntract amount and payinents required for[tic dc7x»its and final Payments by Product(as applicable).
NOTICE TO C USTOMER
You are entitled to a completely Mied-in copy of the Contract at the time you sign. Do not sign a('(rniplc ion Certificate(mite:
there it,one Completion Certificate for each listed Product us defined by individual Spec Sheets)before work on that Product
Is complete.
In the event(if termination of this Contract,Customer agrees to pay The Home Depot tine costs of materials,labor,expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination,plc,tiny other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT' FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WtT'HOI.1T
idMI'1'1NG THE HOME DEPOT'S t71'HER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
lance and Authorisation: Cu umter agrees and understands that this Agreement is tote entire agreement between Cusunner
and The Home Depot with regard to the IY(Aucts tmd Installation services and supor sc des all prior discusNims and agreements,either
oral or 'lien.relating to said Products and Installation.'this Agreement cannot toe assigned in'arnended except by a writing signed
by Cu. O cr and T' ( epos.C'ustumcr acknowledges and agrees(flat CusWmer has read,understands,voluntarily accepts the
lcrmg f< d has rec iv opy of this Agreement.
Acce Submitted b
S�3( !3 2L
SUrmer'S IgnaI a Date Sales Coat Av etetRrt- Date
x _ Tcleplicne No. 3`
Customer's Signature Date
Sales Consultant i.icense No.
C ANCEf.f.AT1ON: CUSTOMER MAY CANCEL THIS (xF appticabtc) _
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DFLIVERING WRITTEN NOTICE TO THE HOMN;
i hIjOT BY MIDNIGHT ON THE 'THIRD BUSINFIS
DAY Ai'WR SIGNING THIS AGREEMENT. THE
STATE SLIPPLEMFNT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONF iS
SPF.CiFIC'ALI.Y PRESCRIBED BY i,AW IN
CUSTOMER'S STATT.
NOTICE:AD01110NAL TERMS AND CONDITIONS ARE STATED ON THE RENTRSF SIDE:AND ARE PART OE'THIS CONTRACT
DS-17-15 White-Branch File YeAow-Customer
°\ The Commonwealth of Massachusetts
Department of Industrial Accidents
0
1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMMING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organ ization/Individual): v
Address: p
City/State/Zip: • Phone#:
Are you an employer?Check the appropriate box:
Type of project(required):
I.❑I am a employer with employees(full and/or part-time)."
7. E]New construction
2.❑I am a sole proprietor or parmership and have no employees working for mein g, ❑Remodeling
any capacity.(No workers'comp.insurance required.]
9. ❑Demolition
3.7[am a homeowner doing all work myself,[No workers'comp.insurance required.]t
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 F-1 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
P netors with no employees.
❑
12. Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑R f rIbese sub-contactors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Othe
152,§1(4),and we have no 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 thec 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 n or Self-ins.Lie,r: w� D Expiration Date: 6 /(�
Job Site Address: City/State/Zip:
: �/ � ---
Attach a copy of the workers' co pensation policy declaration page(showing the policy number and expir tion date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00
aad,lor 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certi and naNg erjuty that the information provided above is true and correct.
Siaita
Date: L
Phone r• �"'J
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 S.Plumbing Inspector
6.Other
Contact Person: Phone 4:
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 of the work:
The debris will be transported by: � � -
The debris will be received by.
Building permit number:
Name of Permit Applicant
Date Sign-ature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor; Ai.Ar-�-hl of Appli able £ / �_�
Name of License Holder: ��
s•
i"nse Number
Address � ��� � Expiration Date
f
Signature Telephone
istered ome.Im ovement Contractor; Not Applicable £
12A44�3
Comoanv Name Registratibn Number
r s Expiration Date
Telephone ^•
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c-152,§25C(6j)
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 buildipc ermit.
Signed Affidavit Attached Yes.. -. £ No...... £
11. mHome Owner'Ei6hiption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [O] Other T�
Brief Desc' Proposed ✓Work: 3 1 / '
���. C '
Alteration of existing bedroom Yes No Adding new bedroom Yes No � y
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ose and'orditn to xistinq 6a f New h o h"o6if g; complete the followmg!:
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
1 as Owner of the subject
property
hereby authorize y— 0 fd
to act on my behalf, in 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.
r
Signe er t " pains and penalti rjury.
Printy,
sign ure of O ner/Agen Date
` ~
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This colunm to be filled in by
]Building Department
-
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage 0�0
Open Space Footage %
#of Parking Spaces
(volume&Location)
A. Hasa Special Permit/Vahunce/Finding ever been issued forlon the site?
NO 0 DONTKNO# 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry ofDeeds?
NO K J DON7KNOYY Y[5
~°
IF YES: enter 8noh Pag and/or Document#
�� ��
��
B. Does the site contain a brook' body of water orwetlands? NO ��/ DONTKNO\V «�� YES ��/
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained »�� Obtained «-� Date Issued:
��« �~� ' .
C. Do any signs exist nn the pmperty �� ��� YES «�� NO v_�
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, gradingexcavation,orfi||ing)over 1 acre orieit part ufo common plan
' that will disturb over 1acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
^ ''
� s`^��Department use only `
k F
ity of Northampton Status of Prrnit �` ` `� '� r
uilding Department Ct7rla Cut/tlriicevuay�Perrrt�# �
212 Main Street Sewer/Sep#�cAvaiCabil�ty
t � u
JJN �7 N Room 100 WaterJVlte�Cay.....
g.No' hampton, MA 01060 Twa Sets of 5#ructe;ral Pla
pone 413x 7-1240 Fax 413-587-1272 PIoflS�te Ptans r '
Sil
1 i
2 - •a #
Oder Specify n "3
Electnc, --
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE,INFORMATION
This section to be completed by office.
1.1 Property Address:
Unit
!.7�.' !�.' Zone Overlay District `
Elm St Distnct CB Dlstncf
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
( ay '
) y �-,� Current Mailing dress: ' A�
Name Pnnt
Telephon
Signature j
2.2 Autho ' ed ent: 1
— -7 700 e
Name( Curr nt Mailing Address:
P
S' toe 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
1C
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 Commissionerlinspector of Buildings Date
35 LADYSLIPPER LN BP-2015-1312
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-243 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2015-1312
Project# JS-2015-002404
Est. Cost: $2086.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 102535
Lot Size(sq. ft.): 42558.12 Owner: BLOOM PETER A&CATHERINE M
zonine: Applicant. HOME DEPOT AT HOME SERVICES
AT. 35 LADYSLIPPER LN
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON.611612015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION
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 Deuartment 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 6/16/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
35 LADYSLIPPER LN BP-2015-1312
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-243 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2015-1312
Project# JS-2015-002404
Est. Cost: $2086.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 102535
Lot Size(sq. ft.): 42558.12 Owner: BLOOM PETER A&CATHERINE M
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT. 35 LADYSLIPPER LN
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON.611612015 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION
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 6/16/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner