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32C-128 , ' • c.) Ad- e 0 Public ' Board if BuUiJin Reu tions :tm.1 IflI:l Construcrion S rvIsor License: CS 67121 • Restricted to: 00 • E3F21:- C THOMPSON 38 WI LLCA LANE . WESTFIELD, MA C5 ff Expiratiot%: .41•30/2012 • Tr: 21015 —4444*04,131.3 • • Cry you ( (c _w HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold. Furnished and Installed by Ntti Boaters Data THD As-Rome Services, Inc. h dibla The Home Depot At -Home Services 34.5A Greenwood Street. Unit 2, Worcester, MA 01607 Toll Free (800) 657-5182; hex (508) 756 -8823 Branch Number: 31 Federal ID *75-2698460; ME Lic *C 02439; RI Coat Lk* 16427 ],ic # HIC.0565522: MA Bono Improvement Contractor Reg. it 126893 Installation Address: -1— ' t 1" t j� Y)d 0 • , 15 a Ci State Zip Porclottm(s): Work Phone: Rome Phone: Cell Phone: .1�1 � � +�. .► [ 1 [4(41 sew,' [ � [ a [ �. [ — Home 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 from The Home Depot Iutbrmatioto Undersigned (" Customer") the owners of the property located at the above installation address, agrees to buy, and MD 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")' Jab #: ammo euwww Sett Stases) Lk Prsf eel Anwamt ORoofing DsObu* BI ❑ Inwlaiioa A� 506a4b Meters /Covers Plenty Doors 0 'Ada tc3-7 $ tunic 1` Ljhoufing aSiding 0 ❑ hnsulatioa C]c;twers r cove, Chintzy Doors 11 CJRootiag ■ •+ •lag ■ Windows m Iosstation °GraterstCovets phony Door fl $ DRS ❑Siding ❑ Windows U Insulation O /Covers CIEotry Doan n A)eai� % Dept* otCeo raetAuwt+edoeopenimagist rands — ebl Contract Amount S ` �,�+�e++ Mole Perdition aay otdtpeslt mane anti tem 4hirdofthsCadtastAmerra. `C) 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 an individual Spec Sheet) and pay any balance due. As applicable, each Customer under this Coact agrees to be jointly and severally obligated and liable bereurtde r. The Home Depot reserves de right to issue a Change Order or terminate this Contract t or any individual Product(s) included herein, at its die , if The Houle Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home, eovironmennal hazards such as mold. asbestos or lead paint, other safety concerns, pacing errors or because wont required to complete the job was net included in the Comma. ftto let Sa ner .. The Payment Summary # a u‘ included as pan of this Cataract. sets forth the total Contract amount and payments required for the deposits and final payments by Product (as applicable). NOTICE TO CUSTOMER You are entitled to a emmpleteIy filled -ia copy of the Contract at the time yes sign. Do not sign a Completion Certificate (note: there is are Completions Certificate tar 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 of the costs of materials, labor, expanses and services provided by The Home Depot or Authorized Service Provider through the date of termdnation. plus any other amounts set forth in this Agreement or allowed under a law. THE ROME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE IT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance alga Arrt oriaatiott: 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 A ment 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. X ` br '1 l i ., 7- .yap, � 's S', Date Sales Consultant s - Date X _ Telephone No. • Agrm Signature Dare Sales Consultant License No CANCELLATION: CUSTOMER MAY CANCEL THIS (as applicable) AGREEMENT WrrHOUT PENALTY OR OBLIGATION BY DELIVERING !WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE 137 ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. No'17Cf: AroorrtartAt. TERMS AND CONDiTEONe ARE SPAYSD ON THE IlEvERSZ SIDE ANN ANA PART OF THIS CONTRACT turiyl CSC While - Branco Flo Vasco- Customer City of Northampton 6 .1 Mas sachusetts . ST DEPARTMENT OF BUILDING INSPECTIONS a (= '1Z is 0% 212 Main Street • Municipal Building ~ °' Northampton, MA 01060 r s ` b"j y ^ -y r 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 understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents �.. Office of Investigations ::: 600 Washington Street P Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): Address: City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ['New construction 2..❑ I am a sole proprietor or partner - listed on the attached sheet. 7. El Remodeling These sub- contractors have ship and have no employees 8. Demolition working for me in any capacity. employees and have workers' 9. n Building addition [No workers' comp. insurance comp. insurance. required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions q ] 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 12.0 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 of perjug 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 8 - CONSTRUCTION SERVICES . 8.1 Licensed Construction Su isor: Not Applicable ❑ Name of License Holder : �y e- 1 - 10 0 141 CJr7) e License Number 41 IA IM 1 J ° 4 j am_ ' ao Z" Ads Expiration Date 41111.��._ i. • . ture Telephone eyed o mprove ti' Con ° e<or , < ;. ; . ., , { {s . ", , s Not Applicable ❑ I 4° Bo -41 FIAMI 11,41 Company Name Registration um.-r G .:- evy) n ,4110. Address Expiration Date 01( %)/ 7relephone t SECTION 10- WORKERS COMPENSATION INSURANCE AFFIDAVIT (M •G t- c. 152, 25C(6)j Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes ❑ No ❑ b 'OmeMwnerA 9 9 9 ` on 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 1083.5.1. 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 • r► J SECTION 5= DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Wind Alteration(s) n Roofing n Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [D] Other [O] Brief Description of Proposed Work: Ara de .�lC .ir1, , qs Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet calf' ernsotseandaradd�tion to.,e , ` frig aitompletthef 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 /Yes k. Will building conform to the Building and Zoning regulations? No . I. Septic Tank City Sewer Private well City water Supply ;SECTION 7a OWNERAUTHORIZATIO BE GOMPLETED WHEN r OWNERS AGENTOlt, co TRAGTOR`,APPLIES FOR'BUICDINgp.p , 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. q 17 O Signature of Owner Date ��J/��, , as Owner /Authorized Agent hereby declare that a statement d ©finformation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the ID and pe - o lerjury . P' a a Signature f O er /Agent Date f o t .4 Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information b Existing Proposed Required by'Loning This column to be filled in by Building Department i{ i ! Lot Size ! 1i i i Frontage Setbacks Front l _ j = E Side L: 1 R: i L: - R: i R Building Height Bldg. Square Footage = 1 1 % I Open Space Footage "/a (Lot area minus bldg & paved I 1 1 parking) { j 1 # of Parking Spaces I ' Fill: { —I _ __ _— (volume & Location) t' 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:! IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book 1 1 1 Pag E a /or Document #1 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 Obtained 0 , Date Issued: : C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 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. N • . i 4 Ida artin l tSe Z ly, 4 ; i @t , Ci I, of Northampton Sta Us z eGli17 � > ; �9 ZOl Bu (ding Department _ ' 12 Main Street e er F t �lbt[ Room 100 a DEPT OF BUILDING INSPECTION - " ' u, M ort ampton, MA 01060 NORTHAMPTON, MA 01060 `� & � pone - - : 7 -1240 Fax 413- 587 -1272 a ' : 1 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE' IN FORMATION .. .-,,,4--, ¢ h This section to be completed by office 1.1 Property Address: . , , . , w.. . � � M �x :. Lie/ s' n h 'k �. r.r Y rl ri 5�z Lbw'* r 5?a = y " yrc "'�lr Fi ' Lz.s y�4� '�'� �S`r 'd ;� °x'�. � -�. � z,Yn,^5 nt," -�."� ,�"7 Elm St.,[ istrict ` � , +"vs� Pf CB Dis `r, " ,, `k ` = . SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: l '��f � jn� "n L -- 42 �y r �[ r> fr Name (Print) Current Mailing A 5�su -p � rAL-1 Telephone �`��'' Signature , 2.2 Authorized A.,;: : Name (Pri C urrent Mailing Address: �- / / Telephone Signa ure �� SORDDY SECTION 3 --ESTIMATED CONSTRUCTIO COSTS Item Estimated Cost (Dollars) to be Of icial Use Only completed by permit applicant 1. Building 13/95--- (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost o - Construction from (6) . . 3. Plumbing Building P erm it Fe , : ___ ,,,,,:. .:, ,,,,,- - -- _...,;:: 1 _ 4. Mechanical (HVAC) 5. Fire Protectio 6. Total = (1 + 2 + 3 + 4 + 5) �' Check Number " This Section or Official Use Only Date Building Permit Number ` I s;u ed , ; Signature. - Buil ding Co /inspect o Bu i ld in g s Date • 42 FRUIT ST . BP- 2012 -0355 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C - 128 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit # BP- 2012 -0355 Project # JS- 2012- 000576 Est. Cost: $1095.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 67121 Lot Size(sq. ft.): 8319.96 Owner: JOHNSTON LELAND P JR & PATRICIA A TRANT Zoning: URC(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 42 FRUIT ST Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 () Workers Compensation WORCESTERMA01607 ISSUED ON:10 /11/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 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 10/11/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner