38B-274 (2) I I REVELL AVE BP-2019-1312
cls#: COMMONWEALTH OF MASSACHUSETTS
Ma : k:38B-274 CITY OF NORTHAMPTON
Lot: 00.1 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Bath reno BUILDING PERMIT
Permit# BP-2019-1312
Proiect# JS-2019-002120
Est,Cost24S 976.00
Fee:S 163.00 PERMISSION IS HEREBY GRANTED TO.
Const Class; Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 101347
Lot Size(sa. R): 8838.92 Owner: COOK ALLISON
Zoning; URB(100)/ Applicant. HOME DEPOT AT HOME SERVICES
AT. 11 REVELL AVE
Applicant Address: Phone: Insurance.
5RIVERVIEWDR (401)935-26330 Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON.512112019 0.00.00
TO PERFORM THE FOLLOWING WORK.BATH RENO
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Motor:
Footings:
Rough: Rough: House Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department FireplaueiCbimueyt
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:
FecTvpe: Date Paid: Amount:
Building 5121120190:00:00 $163.00
212 Melo Street,Phone(413)587.1240, Fax:(413)587.1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-1312
APPLICANT/CONTACT PERSON HOME DEPOT AT HOME SERVICES
ADDRESS/PHONE 5 RIVERVIEW DR NORTH PROVIDENCE (401)935-26330
PROPERTY LOCATION 11 REVELL AVE
MAP 38B PARCEL 274 001 ZONE URBjlfh))/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATIQN CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out I
Fee Paid
Tyneof Construction BATH RENO
New Construction
Non Structural interior moovations
Addition to Existing
Accessory Structure
Buiidina Plans Included:
Owner/Statement or License 101342
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
`Approved,Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:$
Intermediate Pmjeet:—litte Plan AND/OR special Permit With Site Plan
Major Project: Sita Plan AND/OR ESpacial Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER:
Flnding_ Special Permit .._T- Variances• _
Received&Recorded at Registry of Deeds Proof Bnolosed
—Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
TSeptic Approval Board of Health 1 ' Well Weer Potability Board of Health
Permit from Conservation Commission Femrit from CS Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
5-2)-Z0�9
Sibulitudl5tWuilding Official _ - Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permlts from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
•Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cu1/Dnvewsy Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413587-1240 Fax 413587-1272 Plot/Site Plans
e
APPLICATION TO CONSTRUCT,ALTER REPAIR,RENOVATE OR DEM M A UNL'UK 1 WQF ILY WELLING
SECTION 1 -SITE INFORMATION R MAY 17 2019 3 Pd- d 7C/
1.1 ProoertirAddress: This section to be comp tl office
Map DEPT OF86aB�LD11{G INSPECTIONS -Unit
" ,gy'r& MAY 17 2019 pPll�O
�L Zon Overlay District
DEPT OF SUIL DING 4INSPIION�
NOnrHAMPT EGEkn L Dlabiet CB DISMd
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEDAGENT
2.1 er :
rI6y�l /Dy,L� 11 12�✓ f�/
rd
Nem.(Print) Curren)M 'li 17yL ip O L�
T.lWhone 7/(/
Signature
2.2 Authorized t:
AA�Apfzb Tfl)�r 9y�13�7�17e'
Nam
Current M ling Address:
Signature Telephone _
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
cam eted bImtt applicant
1. Building /J7k" (a)Building Permit Fee
2. Electrical /� (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Peri Fee (/L
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Dale
Building PermitNum r: Issue:
42 1
Signature: 5-21- 201 /
Building CemmiswonerAnspector cf BAdi,gs Data
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
mnr S I YAV
Section 4. ZONING Alt Information Must Be Completed.Permit Can Be named Doe To Incomplete Information
Existing Proposed Required by Zoning
n—autumn b M films m by
Duildiog Deparmavt
Lot Size
Frontage,
Setbacks Front
--,
SideL: R: L: R: L._.___i
Rear
Building Height
Bldg.Square Footage io
Open Space Footage
(Lor arra minus bldg&paved
k'n
#of'Parking Spaces
tFill:
vomme&Iu uvn
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page. and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
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 O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it pan of a common plan
that will disturb over 1 ane? YES O NO O
IF YES,then a Northampton Starm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK ftheCk all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
0r Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [l7 Siding[E-31 Other[dj
Brief Descri{�Ion o(Pro sed
Work:AV) iFDDi �e-'✓a/. /wT,w, ay /GnG l��,°� utrro s ,7oiLaT, whw
/NDJJ4L Li[I' N/NjSs+✓� FZ7�/.trf"�Bli�4�/KfJ�IiU
Alteration of existing bsdrddoom Yes No Adding new bedmom Yes No
Attached Narrative Renovating unfinished basement Yes Nq- �/ S
Plans Attached Roll -Sheet basement
Z4.7, AZ �♦J�'[�
Ga.If New house and or add@lon 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?
L Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
1. Is construction within 100 ft.of weflands?_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 ChySewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOOR�APP{UE/S FOR BUILDING PERMfT
as Owner of the subject
property
hereby authorize
to act on my behalf,In all maters relative to work authorized by this building permit application.
z4-- 7
Sigrwturedowner Date
I � / ��/� as Owns uthodzed
Age hereby declare that the statements and Information on the foregoing application are true and accurate,to the best of m dge
elief.
Signed under Me Ins a penalties of perjury.
Prim Name
D /
Signature d Dale
SECTION S-CONSTRUCTION SERVICES
S.1 Licensed y/ConsTtruct/o/nJ]Syuoevi121;— / �/w��/J,y�}1 NottApplicable 13
Nameof License Holds V/04 /# i%
License
ld�V �/% fi/ 1l/2-�U/�`J�
Address FxPiretion Dela
Signature Taleplwne
qI?3 -/Il0
9.Rellistioned HomeIn r c! Not Apt/ Ne 13
Company Name Registration Number
929/V/ y 22-Z/
Add�rejss �.�/j��/ Expiration Date
®/-///
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,¢25C(S))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in me denial of the issuance of the builtlin rmit.
Signed Affidavit Attached Yes....... No...... D
City of Northampton
Massachusetts
nmmaNlt�trr
OF WILDING IMSPLCErms S. ?
212 Hain 9tz t • 1 icip" Building
9o:tha�pton, M 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC').
M.C.L.Chapter 142A requires that the"reconstruction,alteration,renovation, repair,modernization, conversion,
improvement,removal,demolition,or construction of an addition to any It oxisdng ownaroccupied building containing
at least one but not more than four dwelling unds....or to structures which are adjacent to such residence or budding'be
done by registered contractors.
Note:If the homeowner/has contracted with
la/corporation or LLC,that entity must be registered.
Type of Work / ,��/t5 al.Cost: z
Address of Work: /if �`Z(r'GLC_ / !✓L-
Date of Permit Application: �119
I hereby certify that:
Registration is not required for the following ma uals):
_Work excluded by law(explain):
—Job under$1,000.00
_Owner obtaining own permit(explain):
_Building not owneroccupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
51 -/9 Th1 - 112-
Date Contractor Name HTC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
i
City of Northampton
Massachusetts
' DCPA TNENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Nurthaapton, MA 01060
Massachusetts Residential Building Code
Section I I O R5.1.2
Homeowner: Person(a)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.
Section IIO.R5.L3.1
Any homeowner perforating work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5,provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
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.
City of Northampton
Kassachusetts j�L
c
C
\ lu,'PAa1P6ZN1' D8 BDZI.DZaG SN9PSC9'ZCNa �
212 Mein start •awiciP l Rn 1l W
eoxthrpW., a 01060 r ij1'1
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
r ArV'r2L /'51) �
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Pernift Applicant or Owner Date
If,for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-10177
www massgov/dia
UNIurkers'Conappensarlon Insurance AtDdsvll:BuI1deNContraclors/ElecMdans/Plumbers.
TO BE.FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Bus uss/Orgaoisstion ludividuaq:
Address:
City/State/Zip: Phone#:
Are raa as employer Chests the appropriate box: Type of proJeel(required):
LE]I em a employer with cmployeds(full ardor pan-Mrc).e 7, ❑New construction
2.❑l..auto pmpdebror pmmershiP and have ria employee working for me in 8. Remodeling
any .umacity.Mo workm'comp.immune reyuined.l
3.[]] m mne
I aa horow ,doing ek rs rup,ll wmmyself poo workemimumn¢retuned.!• 9. ❑Demolition
d.❑1 am a homeowcer amt will be huing wnmcmrs m vmduct all worn on m I will 10❑Building addition
Prapa Y.
more dol all cootmcmn eitMhave wwkcm'cnmpeemtioe insurance ur arc sole I L❑Electrical repairs m additions
pmpdcmrs with on rngloym. 12.❑Plumbing repairs or additions
5.[:]l am a general conaeclor sed l have hired the aubcomramors listed on the muched sheet 13.�Roof repairs
nese sub emaractws have amployses and have workers comp.msurmsae.:
h.[]We..doo,surnmexandi itsodcaahavesaimmed Ihevril5hlofowm ioaper MfiLc. 14.❑Other
152,9100 end we hove rm arnpmyas.IN.workers'comp.hatmooa mauimdJ
*Any applicant that clwaks box#1 most also fill hot the section below showing their woken compureatim policy information.
I Hommwncrs who submit Nisi idevit indicating they are doing all work and then hire outside courmaols must submit a new affidavit indicating such.
;Contracmrs Ion check this box most amched an additional sheet showing the name of the sub mura,mrs and smle whether nr not hose entities have
cmployv. If the wbmnhacmrs have cmployca.Ihcy must prmidc flair workers'cump.untie,number.
I now an employer that is providing workers'compeneation insurance for 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 MGL c. 152,¢25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of o STOP WORK ORDER and a fine of tip 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 cerfify under the pains and penalties of perjury that the brimsmaaan provided above is nue 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
Contac) Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation fm their employces.
Pursuant to this stature,an earpfoyee is defined as"...everyperson in the service of another under any contract of hire,
express or implied,oral or written."
An earpitowr is defined m"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives ofa deceased employer,or the
receiver m trustee of an individual,patmership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,constriction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a Ileetue or persists to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements ofthis chapter have been presented to the contracting authority"
Applicants
Please fill our the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)name(s),addross(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are rat required to carry workers'compensation insurance. Ifan LLC m LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidmts fm confmnation of insurance coverage. Alan be sure to sign and date the affidavit The affidavit should
be returned to the city or awn that the application for the permit or license is being requested not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should cum their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has in contact you regarding the applicant.
Please be sum an fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pertnit/licease applications in any given year,need only submit one affidavit indicating cement
policy information(if necessary)and under"lob Site Address"the applicant should write"all locations in_(city or
town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must he filled out each
year.Where a Tame owner or citizen is obtaining a license or permit not related many business or commercial venture
(i.e.a dog license or permit to bum leaves em.)said person is NOT required on complete this affidavit.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.ma33.gov/dia
51M019 Home Depot p.l.jpg
Home Improvement Agreement: Page 1
Home Depot License#'s- For the most current listing visit www.Homedeoot.com/LicenseNumbers
,e.,,.11erm.
Joe Roth
Salesperson Name: Registration No. (it applicable):
Home Depot U.S.A.,Inc.("Home Depot") or Service Provider named below will furnish, install and/or
service the equipment listed below at the price, terms and conditions as outlined on this form.
COOK ALLISON 0452 1.258961909]1
Customer Last Name Customer First Name Store#/ Branch Name Customer Lead/PO#
11 Revell Avenue NORTHAMPTON MA 01060
Customer Address City State Zip
413-096-3250 ALLISON.A.000KQGMAILCOM
Home Phone# Work Phone# Cell Phone# Customer Email Address
NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR
OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT:
35o Resell sl Hadl1—s rtyey tate 01035
Or Email: jce@i c Md I c
ervica Provitler Email Address
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENT(S)WILL BE RETURNED WITHIN TEN If 0) BUSINESS DAYS AFTER HOME
DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE
SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED
TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN
SHIPMENT AT HOME DEPOT'S EXPENSE.
THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL.
Acknowledged by: ai. " _oc g
ustomer's Zignature Date
Contract Price and P : Payment of the Contract Price is due upon signing unless a
different payment sche ule is required by law, specified below or in a payment addendum.
Contract Price: $ 2a,9]s.00 Includes all applicable taxes. Excludes finance charges.'
Sales Tax: $ 0 (If applicable)
'Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, Wl(99%
Dep. 0 % Deposit Amount $ e,325.3a Remaining Balance $ 116,6506]
The Home Depot-2455 Paces F"Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1410008&333]
3,BGw AG (28Ep.10) • 6Y
htlps:/Imall.googls.cwdmai#7tab=mi#inboxtFMlcgxwCgVbNLWpGGwVjQCfvDjwhbKm?projedorl&messagePanid=0.2 1/1
5/712019 Horne Depot p.24P9
Home Improvement Agreement Paget
'Finance Charges: Any interest payments or other finance charges will be determined by Customer's
separate cardholder or loan agreement, to which Home Depot NOT a parry, and will be in addition
to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the
cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider;
however, Service Provider may collect Customer's payments made payable to Home Depot.
Insurance proceeds will❑will not❑be used to pay some or all of the total amount of sale.
Description of Work to be Performed: A detailed description of the work to be performed is included
in the paragraph entitled Scope of Work or Specification which is included in this Agreement.
Anticlpated Delivery Date/Installation Schedule
Approximate Start Date: 4/1/19 Approximate Finish Date: ryynq
All dates are approximate and su lett to change based on unforeseen events including inclement
weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if
applicable.
Electronic Records Authorization:You are entitled to a paper copy of this Agreement if you choose.
If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent
documents and written communications related to this Agreement. By contacting your Service Provider,
you may update your email address, withdraw your consent, or obtain a paper copy of the Agreement or
related documents at no charge. By providing your consent and verifying your email address above, you
confirm that you have access to a computer that can receive and open smalls and PDF documents.
I do❑do not❑consent to receive only electronic records related to this transaction.
Acceptance and Authorization: By signing below, you authorize Home Depot to: (a) arrange for
Service Provider toperform any Services or(b)order and arrange for the delivery of special order
merchandise, including special order merchandise that may be custom made, as specified in this
Agreement. Do not sign if blank or incomplete. (Service Provider's or permitting information may need to
be provided to You later.) By signing, you acknowledge that:(i)You have read, understand, and accept
this Agreement in Its entirety, including the General Conditions and State Supplement, if any; (!I) You
are receiving a complete copy of this Agreement:and (111) all rights and interests under this Agreement
are solely vested in the person listed as"Customer"above.
X ,(j l JRC REMODELING LLC
Customer's Signature '-Date Service Provider Name
X IQ RUSSELL STREET
Co-Signer ' applicable) Date Service Provider Address
X 2/14/19 GREATBARRINGTON MA 01230
Signlfture On Behalf of Home Depot Date City State Zip
a13.95&11/0
Service Provider Phone Number Service Provider License Number
The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3.Atlanta,Georgia 30339-Customer Care: 1800-466-3337
naemnb.url, / r, rn
https://mall.google.conVmalg?lab=rmNlnboxfFMfcgxwCgVbNLkdpGGwVJQCNDIwhbKm?pmisdo,1&mesmgePanld=0.1 1!1
5/7/2019 Gmail-FW:FW:New permit
MGmail dchani bola<dchaMM127@gmwil.mm>
FW: FW. Now permit
1 message
Mike taken]<mike@pemws&rvioaww.wm> Tua.May 7,2019 at 8:0 PM
To dcl and boia<rkhaMl1127@gmail.cam
From:Joe Roth yoe@jrcram der temp
sand:Tues4ay.May 7.21119754 PM
To:Mike bedaN<mrxe@permi1avwicesne.com>
subject:Re:M New permit
Scope of work
COOK ALLISON 18452 1.26898190971
Last Name Riat Name Store p Lead e
Program Name: Bath Remodel
Description:
SCOPE:
Obwn us...Me
Test for lead paint
Site protection
Debris removal
Demo existing balhroom to framing
Supply and install R-20 fiberglass Insulation in exterior wells and R-49 insulation in ceiling
Supply and install all new pkimbing for War,vanity,and shower
Install customer suPPlW1 pre4abrlcatsd shower,toilet,vanity sink and laurel,shower valve assembly
Remove and reinstall steam relator
Supply and Install all naw electrical wiring.switches,and outlets
Supply,install.and vent new beth exhaust tan to exlerbr
Install customer supplied vanity light
Install customer supplied bathroom accessories
Supply.Install,and finish, moisture resistant drywall in new bathroom
Supply and install new ballroom window
Supply and install 5 panel prehung door to bathroom
Supply and install base,door and window thin
Paint bathroom ceiling,walls.trim window and door
Install customer supplied vinyl plank floor
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The Commomvealth of Massachusetts
Department of IndustrialAcciderns
1 Congress Street,Sidle 100
Boston,PA4 02114-2017
wrvw,mussgov/din
will urkers'Compensation Inaummee Affidavit:OuOders/CminclorsMeGricianVPlumbers.
TO BE RILED WIT1ITBE PERMITTING AOTHORITY.
.\ Informal he Please Print Le>fbl
None(BusinesstOrguoivdodimlividual):—�-- ` / r7•-7y` , y� /J T
Address: �QR �i0-,V /UK/U T /Il f.-• 7
City/Stato/zip' Y� :3 l)t Phone 0:
Aremonn empioped Chttk lheepprappo en:
Type of projttl(required):
L❑l am a employer milh_employ=(full anmar pamnowil• 7. ❑New construction i
2Q lama rale pmpriemrvr pannaship andhavxno cngloyem samrkm% fornem 8. ❑Remodeling
vat evm�a.INv rwrV:zrs mm0.msunnex ngvireJ.j
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coniplan all mmrattomd or have rwrkem'compemaion imamam or am mlc 11.❑Electrical repairs or additions
'.9rPtcmrswalarm mploycee. 12.[]Plumbing repairs or additions
.agemmlcmpocm,and l have hired the mbcmanarma limplim pa.melto sae0.
new,mbcmaamas nave cmplyem and have vmdmWrearamsumn¢1 17•❑Roof repairs
&D We aea empomlim road is officers love emmsed dak redo,ofinenption per 1,101.a 14.b Dihv /LL'
in,glued),and rK have no empiq:a.INp+wdzrs'camp insmmm m„uirAl
'Anyupplicold lchecksha[al ramioho nllmn the w,rlipn Mlow ahaving Dur Workers'compemmim polky infomWion
t Homeormen who mbmit thin amdvvis imlimdn{they amdoing all work atk rain h'oe aaside mnnocmrs Inml submit a mwaRJavi1 iedimtm5 suck
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Policy dor Self-ins.Lia 9:w, :5C Expiration Dam: �✓�I !iC/ 'I
Jab She Address: II r.ZY� &(— Ci /SmlefLi /��y�)
Attach a copy at the workers'tompwaalion policy declaration page(showing the policy number and cap' tiondoe). �I I'
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Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a fine up to 311,500.00
and/or ono-yem imprisonment,as well as civil penalties in the farm ora STOP WORK ORDER and a fine of up m 31250.W a _
day against the violator.A copy of Ibis statement may be forwarded in the Office of investigations of the DIA for insurance
covmage verification.
I do hereby c'Vjyy pfide fns 1,d of jnrythnrthein/ormatfonprowdedahoretrtrueennde rest '-
Sianotum'//////
Phoned'
Officio!use airy. Do not write in this area,lobe completed by city armory offic at
City or Town: PermiltLicease d
Issuing Authority(drele one):
1.Board or Health 2.Building Department 3.CitivTown Clerk 4.Eltttrlenl Inspector 5.Plumbing Inspector
G.Other
Contact Person: Phoned: !
AlOORUe CERTIFICATE OF LIABILITY INSURANCE a rA T
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EnEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED,01e polig(ke)must have ADDITIONAL INSURED provisions or be endorsed.
H SUBROGATION IS WANED,subject to the terms and Conditions of the policy,certain Policies may require an endoreemarrt. A statement on
this cartheale does not confer rights to the certificate holder In)leu of such endonamerd(s).
PRoeuceR' Nu1
MARSHUSA,INC. E.
pxOE. FAx
TWUALUANCECENTER
35001ENOX ROAD.SUITE 1100 AJOHL
ATUWTA.CA 3W26
IXAME B AFPokeeNCOVERAGE XNG0
0101612(I6".1)GAN-1430 IIMARERA!DM Re le 1.0 Co N117
M oTHE HOME DEPOT,INC. urauaEa e:N h in Nein 23M1
HOME OEPOTUSA,NC. ABVRER E:Hm1Wik ImsN®
NSS PACES FD1m RM0 McVRER u.
BUILDIRS"D
ATIFNTA SA MN MSVRER E:
RER F:
COVERAGES CERTIFICATE NUMBER: AT-001353130-28 REVISION NUMBER:21
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICTED. NOTWITHSTANDING ANY REOUREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN M SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PND CLAIMS.
TYPEOF MBUMXCF p11EYXYMBt POIJCr EFF Pg1CY P �e
A X COYYERCNLOBIERLLDAYAY MW2r311571 03012019 61012022
FACHOCCInREHCE F I.ODD.OW
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X �LIDr❑.ECT OLOC PRCg1C15-CpRMPAGfs f 1.000,000
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AND EMPLOYERS'LMeLm
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EVOFNCE OF NSUPANLE
CERTIFICATE HOLDER CANCELLATION
HME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
AM PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE LIEU M N
BULDNGC30 ACCORDANCE WITH THE POLICY PROVMICN6
ATLANTA GA 30339
AVMORIXEDREPRESENTATNE
M WnN USA Inc
MarRSTV MukheOee ,KPMPOr+ J4.AIu1�LA.
a ISM3016 ACORD CORPORATION. All right,reserved.
ACORD 25(2016107) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: CNIO1642069
LOC t AManta
ACOKd ADDITIONAL REMARKS SCHEDULE Paye 2 of 3
•eENty NulEe IrNHEH
MAISH LSSA.INC. THE HOME OEPOi,INC.
HOME DEPOT O6A..INL.
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ADDITIONAL REMARKS
THIS ADDITIONAL REIMRKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Cerlifi ate of Liability Insurance
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ACORD 101 (200N01( ®2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: Supplement Card
HOME DEPOT USA INC Registration: 112785
P O BOX 105451 Expiration: 04/22/2021
ATTN: LICENSE MGMT TEAM
ATLANTA,GA 30348
Update Address and Return Card.
SCA 1 o 20uov11
ONks of Consumer Affairs L.Business Regulation
HOME IM PROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:SuoplamaM Cand before the expiration date. If found return to:
RealstradonExpiration Office of Consumer Affairs and Business Regulation
1127M 04222021 10M Washington Street -Suite 710
HOME DEPOT USA INC Boston,MA 0"S
RICHARD TROIAH�/ t
2455 PACES FERRY RD C-11 HSC
ATLANTA,GA MM9 Undersecretary Not valid without signature
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Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
CS -101342 Expires : 08/ 11 /2020
JOSEPH S ROTH .�
40 RUSSELL STREET
GREAT BARRINGTON MA 01230
Commissioner