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29-302 (6) Dec 191510:13p p'1 HOME IMPROVEMENT CONTRACT PLEASE READ THIS • 1 } � �'� Sold.Furnished and Installed by: Branch Nume:New England Date: THD At-Horse Services,Ire. d/b/a The Home Depot At-Horne Services Branch Number:31 908 Boston Turnpike,Unit 1.Shrewsbury,:VIA 01545 Toll Free 877-903-3768 Federal ID M 75-2698460;NIE Lic 4 C 02439;RI Cont.Licit 16427 j� CT Lie*HIC.0565522:MA Home Improvement C c;or Reg.It:26843 Installation Address: t-1L- t �1 e)jtQDK d� �. Q�LQ,�; �� �� bj()( City State Zip Pnrchaser(s): Work Phone: Horne phone: Cell Phone: ALA i t,r-5 Horne Address: (If different from Installation Address) City State Zip Entail Address(to receive project ci mrnunications and Home Depot updates); ❑I DO NOT wish to receive any marketing emails from The Horne Depot Protect Itilorgtation: Undersigned("Customer"),the owners of the property located at the above im7altation address,agrees to buy, and TI{I7 At Home 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 Sheet(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 fcolle.Kively, "Contract"): ,sob#: m•.rn,•aN.R.ua Products: Sec sheet(s)#: Protect Amount �{�,[ oofing [(Siding El Windows Insulation G�CJ7�b 3 ©Gutters:Covers ❑En ry Doors ❑ 31`4 } 2_ 2-16 3 Rooting 03iding Eym ndows Insulation 0Gutters;Covcrs C7&"Doers C1 ❑Reeling Sid ng ❑Windows Insulation �L(/,}'` ❑gutters 1 Covers QEntry Doors C] $ ❑Roofing OS.dn. ❑Windows Insulation ❑Cutters/Covers ❑Entry Doors ❑ $ NWmurn 25%Deposit of Contend Amount due upon emmtk n of this contract. Mame Purchasers uuty not deposit more t)anal-thirdorthe ContractAtnotmt. Total ContractAmopnt $ Customer agrees that, immediately upon complexion 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 Gable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at i s discretion.if The Home Depot or its authorized service:provider determines that it cannot perform its obligations due to a structural problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because work required to complete the job was not included in the C ntracl. at Payent Summary: The Payment Summary# �� � included as part of this Contract, sets forth the total Contract amount and Daymeats required for the dcpceits and final payments by Product(as applicabie). NOTICE TO CUSTOMER YOU are entitled to a completely rifled-in copy of the Contract at the time you sign, Do not sign a Completion Certificate(note: their is acre Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs or materials,labor,expenses and services provided by The Home Depth 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 ANIOUNTS OWED TO THE HOME DEPOT rRoM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THF.HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance nod Authorization: Cusuaincr agrees and understands that this Agrecmenr is the entire agreement between Customer t,.ne The Home Depot with regard to the Products and installation s4tivices and , seder all prior discussions and agreements,either oral or written,resoling:n lid Prtxhtcts and installation.This.�tgreetnent ua t assigned or amctxled except by a signed 05 Customer and The Hume Depot.Custonx r exknotvledge:and ogre s that -to cr has read,understands, voluntarily accepts the tome o,and h s received a;;coy of chi.Agreement. Accep by Sub tte by ---� h l X It M � Custcrrter's Si*nature Datc Sales t ant's Sign Lure Date X Tele :o No. Ctuctorm is Signature Date Sales ComuRanr License No. CANCIELI.ATION- CUSTONM MAY CANCEL THIS i lz ,aWhuablo AGREEMENT RIT T PENALTY OR OI 13Y D ELIVER ING WRITTEN NOTICE TO THE HOME 2 `j`} DEPOT BY MIDNIGHT ON THE THIRD BUSINESS /) 3 6 DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF O'VE IS i SPECIFICALLY PRESCRIBED BY LAW IN I r�s ICTrlha T.'P 112 Q7 PC -` The Commonwealth of Massachusetts Department of TndustrialMccidents 1 Congress Street, Suite 100 Boston,MM 02114-2017 UV wi+w.mass.-0v 1dia Workers'Compensation Insurance Af fida-vit:Builders/Contractors/Electxicians/Plumbers. TO BE FMED WITH THE PERMTI"I'ING AUTHORITY. AnnlicantInformation Please Print Leaibly Name(&sin;ss/Organization/lndividual): address: P��-6 ► B'lr< ��}� / p1 - City/State(Zip: l�I i l � �� Phone�; Arc you an employer?Check the appropriate box: - Type of project(required): 1.❑I am a employer with employees(full and/or par-time).' 7. ❑New construction 2.❑1 am a sole proprietor or parmcdnip and have no employees worldzg for me in g ­y capacity.[No workm'coop.insurance rcauir-d.1 8. �Remodeling 9. ❑Demolition is.n(am a homcowacr doiag ail wor'.:�.yscl:.[tio u•orl.•-;'comp.irs!t,ACC rnaui:Cd.l' 10 F]Building addition 4.(�I an z bomeow"per and will be hiring con�ntors to conduct all work on my prop•;7•. !will =sure that all cone ctos either have.vods;'compensation insw,cc or ar:soic 11.F�Electrical repairs or additions with no employees. 12. Plumbing repairs or additions 1 am a gcocral coauactor and I have hir°d the sub-connectors listed on the attached sbect. i ccsc sub-counctors have employs and have worKc,;'comp.insurance.: 13.j❑Roof repairs o.17 We=a corporation and is o-ilc^s have excmucd thcii right of exemp6oa p-:-,MGL c. 14.- _"""er- 1:2,§1(4),and we have no employees.[.?No wori;er'comp.iasurazcc required.) py applicant[eat check bax !mus:also fill out the sc doa bclo•.v sbo•.ring thcir workers'compensation policy information. t.^omeow=—s who submit this a5davit indicating they am doing all wort"and tbca hire outside con-tractors must submit a new aGdavit indicating such. Canna;ors that check this box naast a=ched an additional sae°t showing the aam=of the sub-connector and state whether or not those cutiti:s have mployccs. L the sub-con recto h vc employees, hey mu t provide their Nvor cr,,Conn.pobcv numacr. I am an employer that is providin.workers'compensation insurance for my employees. Below is the policy and job site information. ' r-I sc. �um.Dany\ame: �� ('/yv /l✓ y /VL�� t5' ' Sell-ins.Lic.-: O f2 Expiration Date: G �/ Job Site Address: City/State/Zip: � � /�✓�I Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to coverage as reamed under MGL c. 132, §25A is a criminal violation punishable by a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 naltiec erjury that the information provided above is true and correct- Date: Siena '�� ^l / < / Phone r: I Official use only. Do not write in this area,to be completed by city or torn officiaL I City or ToTtm: PermitUcense i Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Pltunbing Inspector 6.Other Contact Person: Phone n: 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. Address of the work: 2-- L { debris will be transported by: The d p The debris will be received by: � -L ' Building permit number: 1 Name of Permit Applicant / �I l Date Sign-ature of Permit Applicant City of Northampton Massachusetts - Y { WR -ter DEPARTMENT OF BUILDING!INSPECTIONS 212 Main Street • Municipal Building 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 I I The Commonwealth of Massachusetts Department of Industrial Accidents ®ffice of Investigations 600 Washington Street - f Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizatiowladividual): 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' 9 ❑Building addition [No workers' comp. insurance comp. insurance.$ 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. [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. tHo 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 for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: 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#: 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#: SECTION 87 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor-,or-y,� Not Applicable £ Name of License Holder: I ��" �' / .4,1— License Number Address E;Vration Dater Signature Telephone 9 Re istered.Home l ovement. Not Applicable Company Name Registration Number Expiration Date A s �— Tele hone4b/,f 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 pe Lmit. Signed Affidavit Attached Yes....... No...... £ Home owner=:.Ege npti6 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 buildine 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, i SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Wi s Alteration(s) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[0] Other[0] Brief Descripti Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and=or.aiitlltfon fo ext5tlnq:housinq; cocnwfete ff e followlnd: 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 N-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, i 9119 ma relative to work authorized by this building permit application. Signature of Owner Date as Owner/Authorized Agent hereby declare at the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under th i)7.an enalties of erJ2 Print Name l Signature o er/Agent Date Section 4. ZONING All Information Must Be Completed. PerrMt Can Be Denied Due To Incomplete Information Existing proposed Required by Zoning This column to be filled in by Building Department Lot Size � t Frontage Setbacks Front F-7 Side L:�--� R:= L:=R:= Rear Building Height .} i Bldg. Square Footage `z % Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces --� L— Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW O YES 0 IF YES, date issued:] IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES Q IF YES: enter Book �_.. .i Pagel, and/or Document#S B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: --? C. Do any signs exist on the property? YES 0 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: t 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. I� JAN r pepartment use Drily ME i City of Northampton S'tatusofPermrt , 'x'11 4 — -- Bul din Department ;e�rry CurEDri e+riay Perm# �1 rr I --;., .-�y .m}l�r� RE t ,. u I .gin 212 1aln Street 5ewerlSepticA..... llrty Room 100 ;wV t rlV!fe�iAva�labilityr'L r III , it Northampton, MA 01060 Twa,Sef`s ofS#ryiictr,ral PraBSI 4� ,i = 'yjJ�_ 5'�v:r-�-=-_.i.��.^ ii 11.:_:v..:'4e: !ui�-:vn,l:'���Ii:N_c_. phone 413-587 1240 Fax 413 587-1272 _I?IoflSite ptans BMW. r, I APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION - This sectiorrto be completed by office M:-, ; 1.1 Property Address: L°= ' �'����/•,�// � �� � Map s Lot t L�. Unit 4 L . 1!vpy L ZZ r Zone Overlay District �' ElinrStnct. _: CB District GL . SECTION 2.=PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: S 122 4 Name ) -) Current Mailing Address: Telephone Signature 2.2 Authoriz en i Name ri Current Mailing Address: ^ �� ature 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 (b) Estimated Total'Cost of Construction from fi 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection ,C 6. Total=0 +2+3+4+5) Check Number [/ This Section For Official`Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector.of Buildings: Date 422 ACREBROOK DR BP-2016-0888 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-302 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit# BP-2016-0888 Project# JS-2016-001506 Est. Cost: $2203.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 67121 Lot Size(sq. ft.): 10497.96 Owner: TREMBLAY STEPHEN J&TINA M Zonin : Applicant: HOME DEPOT AT HOME SERVICES y, AT. 422 ACREBROOK DR Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCER102908 ISSUED ON.1/11/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOW 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: Cas: 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 1/11/2016 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner