06-003 HOME IMPROVEMENT CONTRACT
PLEASE READ
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Sold. Furnished and Installed by
Itratali� 1 , Boston DM THD At -Home Services, Inc.
_ d/bfa The home Depot At -Home Services
345A Greenwood Sum Unit 2, Worcester. MA • 01607
Toll Pree (800) 657 -5182; Fax (508) 756 -8823
Branch Number. 31 Federal 117 475-2698460; ME Lit # C 02439: 9.1 Cont. Lie# 16427
CT Lit # HIC.0 036 __r2(x 5522: A Home /viol
I m m
roveent Contractor Reg. # 126893
Installation Address: (0 b_ ft Aid e+~? t11 I � 00 l-s
City State Tap
Pe'chseelfeh Week Home Phone: ►
1 l [ 1 t V 31 565 - .a mil.
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Home Address;
(1f different from Installation Address) City State Zip
&&mall Address (to receive project communications and Home Depot updates):
(] 11,0 NOT wlab to recNVC any marketing entails from The Home Depot
Project info Undersigned (`Cuatamtlrn), the owners of the locatad at the above iestaiiation address, agrees to buy,
and THia At- vices, Inc. Mlle Hoare Depot') agrees to furnis deliver and arrange for the installation (" Installation") of
all metersala &seedbed 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.
Job* rar...rad cad ts., imam - #; eta Amount
minoring ■ Siding !t ` meows • Insulation
let &'() D0u ,/Covers (ZIP-my Doan D • S! 650 S t 3
■Roaiing !Mang et Windows ■ Insulation
Mutters / Covers D > n $ G '�
[Roofing [Siding D Windows ❑ Insulation $
CP:Judas/ Cavas Dewy Doors l
DRooliAt DIding Windows 0 bounder) -
(Covets DPeny Doom 0
Miglawla 25% lit" gleltC411fraaA11113.114111 "Paroea"lira esareaet Total Coalraet Amount $ 1
meinePordwaersnwymtdeposittneeedasonaildrdettbeCestreetAaratent
Customer agrees that, immediately upon completion of the wont 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 liable hereunder.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Productts) included herein. at
its disemtion, if The Horne Depot or its authorized service provider determines that k cannot perform its obligations due to a structural
problem with the home, envizodme*al hazards such as mold, asbestos or lead paint. ether safety concerns. Pricing errors or because
work required to complete the job was not included in the Connect.
ect.
Pavmesd So w The Payment Summary # ik included as part of this Contract. sets forth the total
Contract amount and payments required for the deposits and final mutants by Product (as applicabk)-
NOTICE TO CUSTOMER
Yea are added to a y axpp of the Contract at the tone you sign. Do not sign a Completion Certificate (note:
there is one Completion for each listed Product as defused by Individual Spec Sheets) derore work on than Product
is cxuapieete.
In the event of termination or this Contract;, Customer agrees to pay The Home the coats of materials, labor, expenses
and services provided by The Home Depot or Aaahn+ zed Sere** Provider through dare of terminsuitm, plus any ether
amounts set tarot is this Agreeineat or allowed under applicable 1.w. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT PROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING TOE H 1MB DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
b,cseotance and Authorizadoje: 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, anderatands, voluntarily accepts the
terms of and has received a copy of this Agreement,
Accepted by
Customer's Signature Date Sales Consultant's 5 ;+ Date
. /1 . , :. Telephone No.
Customer's ' ipptattrre Dale Sales Consultant License No. ,
CANCYBLLATION: CUSTOMER MAY CANCEL THIS (as applicable)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
uf LEC,IVERINC 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 IF ONWE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICE_ ADDITIONAL TERMS AND c ON"D*I1CNS ARE STATED ON THE REVERSE SIDE ANO ARE PART O6 THEM CONTRACT
M.iZ YY f ASe Wh&R —Rmnrh Fan Yellow — Ouat/aaaer
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MIa, >achu ctt, - Department of Puhiic Safety
'; Board of Buifding Rc2ulation.. and StantI :u•c1s
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Construction Supervisor Specialty License
License: CS SL 98785
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Restricted to WS
'IVAN KOSOBUTSKYY
72 STAFFORD ROAD
MONSON, MA 01057
Expiration: 4/27/2012
('ntni:�iner Tr t: 98785
je' `1
• City of Northampton
otyn
l - 4 Massachusetts ' '.c; . SZ,., ''1'$
DEPARTMENT OF BUILDING INSPECTIONS a to
212 Main Street • Municipal Building U, �.
"'' ` Northampton, MA 01060 ;j y'''
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
I'�Ishe resides intends to - be; one or ivv6 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 requiredl 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
The Commonwealth of Massachusetts
.�_ :.� Department of Industrial Accidents
tr b t ' Office of Investigations
600 Washington Street
" Boston, MA 02111
, --..z,-.0.7. www mass gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
`
Name ( Business /Organization/Individual): II' 11140 _ - A'i
Address: a .,r t'r.i ; . . i
City /State /Zip: a1, •_ AL _ ,r /Phone #: 5DO `r5 ]
Are yo . n employer? Check the appropriate box: Type of project (required):
1. PI I am a employer w' 4. 0 I am a general contractor and I 6. - l New construction
.......... ._....
employees (full and/or part-time).* havelfiired the "sub - contractors
2. ❑ I am a sole proprietor or partner -
listed on the attached sheet. 7. ❑ Remodeling.
_ - ship and have no eiriployees These sub-contractors 8. D. Demolition
... � -� _
working for me in i employees and have workers'
g any capacity. tY 9. ❑ Building addition
comp. insurance.$
[No workers' comp. insurance 'r
required.] 5. D 10. We are a corporation and its ❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL _ 12.0 Roof 's
c. 152, §I.(4), and we have no
insurance required.] t
employees.' [No workers' . 1 they c ,)jtn .4
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.
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
.information.
Insurance Company Name: ) \ :' 3 - -1,16.
Policy # or Self-ins. Lic. #: ..O1 l (CO5 Expiration Date:.
�! Ci /State/Zi
- Job Site Address: E - h J 1) tY P: I hal4e /1 kJ
I
Attach a copy of the workers' compensation policy declaration page (showing the policy number and exp' 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 :Aar insuranc y overage verification.
I ereby ce %y • under :. , f d pe ' lties of perjury that the information provided above is true and correct.
Si i a I, . f , .. /, D a t e: a -
Phone #: 41 Z
sAINIMINI
-- - Official-use only : - --Do- not write -in -this areas 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 #:
4
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:SECTIO 5"DESCRIPTI a ft OFPROPOSED WORD chec alt • • lica . le ,.
V s •
New House ❑ Addition ❑ Replacement Wi • • ows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [p Siding [0] Other [0]
- --rte
Brief Description of Proposed 1^
Work: .,�� { + 1 (' t C , t 4 l th� S 1\ G
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet rr
Fr 'jar. jrilTi Drz. :::,- eJ, a e %�' - i , a'�s V 4 6 I eF':.:1` q i'' ate', ra;,° .: 1
a. Use of buildin O ne Family Two Farnily Other __.._. .- -_ - - - __ _—
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
,,,
I, fZe , 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. l
Signature of Owner Date
1, �. , as Agent hereby declare tha ? i T ! o rie . 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 ' •f perjury.
:.t i_1
Print Name � /f �� ...
,,,,....
Signature of s er/ • ' ent j Date -
r J
S r EC -700l B CO STRt1 CTION SERY ES i"
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : i 1 1 . ∎
41P l License Number
e' l' a ) 'if
Address ! P / Ex iration Date
, -
-
Signatu . F Telephone
ove= ga-on y K Not Applicable ❑
Co 5q5
Company Name r ~± Registration Number
,Address , Expiration Date
j • r:ligitif ., if) /I elephone ! iaC
, ..
E Tlt �1 + WORKERS' C Ml?E Ait10 1NSLfRANt . Al= lt?AttF. M` _. 1 ct.
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 buiIdin ermit.
• "Signed Affidavit Attached Yes No ❑
r-
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" °submit - 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 1 Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Deathj of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you Under this peen it.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
__ , Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws "Annotated
Homeowner Signature
Section 4. ZONING. Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by'Zoning
This column to be filled in by
Building Department
Lot Size r 1 1
Frontage 1 1 1 ! 1
Setbacks Front
1 ! I 1 1
Side L:! 1 R: 1 L:1 . 1 R.:1 1 I I }
Rear 1 1 1 1 1 !
Building Height
1 . _: ... 1._ .. .. 1 1 1 1
Bldg. Square Footage
! 1 l ! ° f ° 1 1 1 1 1 1
- - , Open $pace Footage - ._. % — (Lot area minus bldg & paved 1 1 1 1 1 1 1
Puking)
# of Parking Spaces
I 1 1 1 11
Fill: "
(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'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book . Page; l and /or Document # I
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 ' YES 0
IF YES, has a permit been or need to be_obtained from the Conservation Commission?
Needs to be obtained Q Obtained , Date Issued:
C. Do any signs exist on the property? YES Q NO 0
IF YES,' describe size, type and location: '
-- D. Are there any proposed changes to or additions-of-signs-intended for the property ? YES NO
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
___ ,........,....iimmorrrimirimmimorir eralmormasrimirriouilsei rwrolviwoursit
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600 HAYDENVILLE RD - Route 9 BP- 2012 -0235
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 06 - 003 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 -0235
Project # JS- 2012 - 000363
Est. Cost: $2153.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: _ HOME DEPOT AT HOME SERVICES
Lot Size(sn. ft.): 28357.56 Owner: COGGSWELL RUSSELL & PATRICIA
Zoning: SR(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 600 HAYDENVILLE RD - Route 9
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 0
WORCESTERMA01607 ISSUED ON :9/9/2011 0 :00 :00
TO PERFORM THE FOLLOWING WORK: 3 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 9/9/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner