24A-219 HOME IA PROVEMENT CONTRACT
PLEASE READ THIS
Sold, Furnished and Installed by
l c Nagae: Boston Date: THD At -Home Services, Inc.
�, d/b(a The Home Depot At -Home Services
345A Greenwood fit, Unit 2, Worcester, MA 01607
Toll Free (800) 657 -5182; Fax (508) 756 -8823
Branch Number: 31 Federal XD # 75 2698460: ME Lic # C 02439; RI coat. Lie# 16427
C r Lie # HtCA • 522; MA H. Improvement Contractor Reg. # 126893
lnitanatlon Address: )1 b v (t -, L_.. -.1 f) it 11 • o OG 6
City State Zip
Pterehaserla): Work bone: Home phone: Cell Phone:
[ 1 [ 1 [ l
Howe Address:
(If different from Installation Address) City State Zip
E-mail Address (to receive project communications and Home Depot updates):
❑ I DO NOT wish to receive any marketing emails front The Home Depot
Project Information: Undersigned ( "Customer"), the owners of the property located at the above installation address, agrees to buy,
and THD 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 (collectively.
"Contract "):
Job #: S • _ #: set Amount
• Roofing • Siding Windows ■ Insulation
5619 2,ce comp r c ov«s DEnt ❑ — 1075 $ 13 ( 6Z /tA)4
Roctfu S idin g Windows 9Insulation
Daubers, Covers 9Enty Doors r1
°Roofing °Siding ❑ Windows U Insulation
Demers /Covers pantry Doors C1
URoofing °Siding Q Windows ❑ Insulation
['Gutters / Coved ❑Ent y Doors 0
11' Cnioum, 25% Damask aCSntatt Amours due upon mead= of this contact Total Cen Amount $ /
MalutPurchaaersarray ant depi* marathon °Re ardottheContract Amami. 8133
Customer agrees that, immediately upon completion of the work for each Product, Customer will execute a Completion Certificate
(one for each Product as defined by as individual Spec Sheet) and pay any balance due. As applicable, each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Rome Depot reserves the right to ionic a Change Order or terminate this Contract or any individual Product(s) included herein, at
its 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 Contr act.
Payment Summon The Payment Summary # :St
h 3 7 5 , included as part of this Contract. sets forth the total
Contract amount and payments requited for the deposits and final payments by Product (as applicable).
NOTICE TO CUSTOMER
You are canned to a completely feted-in copy of the Contract at the time you sign. Do not sign a Completion Certificate (note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets) before work on that Product
Is complete.
In the event of termination of this Contract, Customer agrees to pay The Home Depot the costs of materials, labor, expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any other
amounts set forth in this Agreement or allowed under app1i e law. THE HOME DEPOT MAY WITEIHOt ) AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSITT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements, either
oral or written, relating to said Products and Installation. This Agreement cannot be assigned or amended except by a writing signed
by Customer and The Home Depot. Customer acknowledges and agrees that Customer has read, understands. voluntarily accepts the
terms of and has received a copy of this Agreement. _ } �
Accep Submitted b�: �lUl] II�
X Z7 1 ( x l -
Cum `s S ttaiure Date Sales Consultant's Si Date
X — Telephone No. ,
Customer's Signature Date Sales Consultant License No.
gANCELLATION: CUSTOMER MAY CANCEL THIS (e.¢vocable)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
SY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AP ER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE . IS
SPECIFICALLY PRESCRIBED BY LAW ' IN
CUSTOMER'S STATE.
NOTICE: ADDITIONAL 'matt Atlb CONDITIONS ARE STATED ON TUE REVERSE SIDE AND ARE PART OrTrtia CONTRACT
04 -11 -11 C-SC Whoa - Branch flu Yetltr++- Customer
• City of Northampton '
A NAM T` _ 15 +w- '
a. ' J
f s ; ; Massachusetts
F r ir
0,:,'4:1 ' DEPARTMENT OF BUILDING INSPECTIONS . , 73
xk t 212 Ma Street • Municipal Building 1
p ,... -r• Northampton, MA 01060 �6� �
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
liershe resides OT j ntends to - be; a one ortwo fainily 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 understand the above.
(Home owner /resident's signature requesting exemption)
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
— — Department of Industrial Accidents .
Office of Investigation s
, ! 1 600 Washington Street
Boston, MA 02111
�>. s www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
`
Name ( Business /Organization/Individual): ii ' t .4 _. - ki
Address: .a i N., ,,
City /State /Zip: jj� _ . /Phone #: D 75?
Are yo . n employer? Check the appropriate box: Type of project (required):
1.6 I am a employer with 673 4. ❑ I am a general contractor and I
- ---- - -.___ - - - - -- - - - -- -- - - -- - -...- -- - - - _ -b: - -(� New construction -- ._.....
employees (fall and/or part- time).* havered the sub contractors
2. 17] I am a sole proprietor or partner-
listed on the attached sheet.- .7. ❑ Remodeling
— - = These sub- contractors: have -
ship and have no - employees ❑- D
8.
working for me in any capacity. employees and have workers' . 9. ❑ Building addition
[No workers' comp. insurance comp. insurance..
required.] 5. [1 We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised. their 11.0 Plumbin epairs or additions
myself. [No workers' comp. right of exemption perMGL 12.0 Ro epairs
4 1 152
c. 152, , and we have no
insurance required.] t _ §` �) 13. flier
- employees.' [No workers'
- comp. insurance required.]
`Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
Iam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site •
.information. V --�"_'
Insurance Company Name: - '►�1 1 Pe ' _ 5 CO
ss
Policy # or Self -ins. Lic. #: // __ Q( j 3-, Expiration Date::
- Job Site Address: PE ._:_ City/State/Zip: , '3 a i i
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expi ation 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 • :. inst the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of flier insuranc j overage verification.
I - hereby ce ' • under t : . �d pe . !ties of perjuly that the information provided above is true and correct
Si la a - _
i, .1f�/ - I - - - - - -- -- - Date: ∎.
Phone #: 4 � - crl �
--= - Official-use only; Do not write in- this area, -to - be completed by city ortown- 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,
SE TIt7N 8 CbNSTRtjcfloN t.ERVICE ;
8.1 Licensed Construction Su. e._... or: Not Applicable ❑
Name of License Holder : F ' 1 d l-- (P7I ;?
License Number
ILI ql?f/
Addr =. I Expiration Date
Aar& , � _
Stu Telephone
", a•'i5 tired t 'on es m.royerne 1.06fitigeror , " .. `_, : it ,
_ ,,..z,�;- Not Applicable ❑
-�- o �
Company Name _ Registration Number
•
:-- -: .Address ,_ .. __ Expiration Date
i 1
rGJ �7 4
�:.�g/��f �` �� � elephone 1- 16 O
f t CI�
4r¢ . mot. GmT '.� � ", r r �i� � '�. y z- -c
AblEig
ESLRi3 0. WORKERS M PENSATIOWINS RANC .AFF M Zt, G(6y �
'Workers Compensation Insurance affidavit m be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin ermit.
" Signed Affidavit Attached Yes No ❑
f E q i4 re 99'�pII F:!!,9 Cis! 1
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 108.35.1.
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 two -year period shall not be considered a homeowner.
Such " homeowner" - shall submit 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 Cliapter-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
------ - —
• -
•
•
•
•
??� 3 .. ; itti �L.S'Y „M-. h� �.t s t �F'�'s.. F g.,7 r,'s R� �g'v &. titiyS� �s s ASI '+ _g _ -
SECTION 5 DESCRIPTION OF PROPOSED WORK (checleali apphcafrle] -'i 2 a .
fi j `� - ':n 1 +. -' 's+ *.+ -- K�. p + ao! T .'°t� �' -' aL '7� M--wi � }`�l*J��gr � MC�s �: � t
X2�'t ite `�'�rA A' v . x E ti .. er, r�.ya`, t t t - l� r 2 T� ` Ft�"�II� v} t Sftt�� '' � y s�. ` t - P ^ `
�'
New House ❑ Addition El Replacement Wi ows Alteration(s) [J Roofing n
Or Doors
Accessory Bldg. ❑ Demolition El New Signs [D] Decks [q Siding [D] Other [Dl
Brief Description of Proposed
Work: ,,�(1� t 11 (� ' /-� ►'Irr' . C.( t � E�\
� G Alteration of existing bedroom Yes No ' new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
• 2 - 1 iTe.. T. 4° t' -- ;: 'i ;1 ;;; di la ;' ex Iti i ;'6 ' sin's ,Qir e ' - s F . -. [ ..: , ,'
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
` - E01101* IIVIL�lER A`t]t'li0J117.010 f ,;;B E El. fly �' :
.QWNEF EI Q C IIbit PP ES--T ERMI , g ' 4 �.
.. -
1,4. coil
` , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
,- 1
Signature of Owner Date
as Owner/Authorized
Agent hereby declare tha the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
__ -- - -Signed. under-th and pe ' gfperjury.. ..--.---- - - - -.. _ -
.
Print Name rr�f
ci/a3/1i .
Signature of s en/ ` tent hate
Section 4. ZONING. Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
_
Existing . Proposed Required by Zoning.
This column to filled in by
Building Dep ent 434 . 1
Lot Size 1 1
Frontage
Setbacks Front 1 I 1
Side L:1 I R:1 1 R:i 1 1 1 1
Rear J I I 1 I I
Bitilding Height I
Bldg. Square Footage I I I % I I I 1 I I
Open -% - - -
(Lot area minus bldg & paved F I I
parking)
# of Parking Spaces I 1
Fill:
1,
(volume & Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book • Pagel I and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
- IF YES,_has a permit been or_need to be_obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, typeand 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, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
City,or Northampton �,d ,�_ - . _
RECElV uiiding Department ;F,� s�i r 9� ��
212 Main Street ' Room 100 4,s ,rAr
� •rthampton, MA 01060 r
pho - 41-587-124O Fax 413 - 587 -1272
APPLICATION +` T OO C. TRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECS BFI SIT t=OR Q r
1.1 Property Address: O:
7 ( 31 r
t q '
SEC ON ROEERT �I?WNERMP[A'U�T ;fORI�ED, GEN R� _
2.1 Owner of Record:
Name (Print) Current Mailing Address: ` .
Telephone
Signature
2.2 Authorized a L t:
1 i Sri rdlli .A -749 ..)t ( • t:d 1& AF
Name (Prinjrf � Current , ,ai!!ng Address:
4 Signature Telephone
SEGTIOHE ES'!'IMA Ell CONStTREIGTIpN GUSTS :
Item Estimated Cost (Dollars) to be } s O cat. = gnl
completed by ermit applicant $ ae F r4
1. Building s � 4
r xc
2. Electrical
s1 d 0 0 $
ortwcb n e. 6) . a
3. Plumbing £ r
S . y G:u` r '"C - n +fl -'" T3 $.Std •'3 ^ ....�.,. 't w4x
4. Mechanical (HVAC)
5. Fire Protection
6 Total (1 + + + +
2 3 4 5 t 7 i�`I1eG [lrbet�w w gw� x
t . �.� 2c",�, ., ""•.7 - ' �' F +r .5'.isr^?c. +�r c'w+i� eta,, +�t� 4 w
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nd" ,a w Y �"�, a "`'"�as§ -i -�2.. a... sax °'r �ate� - �}- ��°"� s r �u+d`• u �5�x"'tt'�us� 4 �' � i �a Fx
Buildrn 'Derr t Nurn1e - ,
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.w +.4x a kq�..,:6 ' �3 r+".§: a.es r4 ,.- . -.�_. ..rs�+•�..1...efiM++rt �.. ,... EKG . - 'r..'., m+nerdas.iu�+ .. %'skA;J,'. $E... w� .vYMy ., .,..,YSc+�` :R' 3'.±K bd& �. 'Y�Art$r cn ., ate .�b�`iN,'e �S�.. aas.s� �h ans+��'en. ':
178 NORTH ELM ST BP- 2012 -0259
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A - 219 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- 2012 -0259
Project # JS- 2012 - 000411
Est. Cost: $8133.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 6490.44 Owner: ALIX KEVIN L & BARBARA A
Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 178 NORTH ELM ST
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 0 Workers
Compensation
WORCESTERMA01607 ISSUED ON:9/15/2011 0 :00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 12 REPLACEMENT WINDOWS
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 9/15/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner