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38B-278 HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold, Ftunished and installed by; VI Naprle Boom Dane: TAD At -Rome Services, Inc_ ll �I d/hla The Home 1?epot At-Horne Services 345A Greenwood Street, Unit 2, Worcester, MA 01607 Toll Free (800) 657 -5182 Fax (508) 756 -8823 Branch Number: 31 Federal to # 75.2698460; ME Lic # C 02439; ltx Cont. Lic# 16427 CT � � � 1 � ry . ! c MIIIC4�${S�me Ice vament C� � Reg. # 126899 Installation Address: A Pc' Q Irl,/I �V � 7 City State Zip i(s) vt'Ork Phone: Home Phone: Cell Phone: [ l [t1131 z2L-317 I l c.r +rte [ Home Address: (If diffetess Om Installation Address) City State Zip ) Address (to receive project communications and Home Depot updates): t to NCrr wish to receive any marketing entails from The Home Depot Project Ii: Undersigned ( "Customer "), the owners of the p Y located at the above ingtallation address, agrees to buy, and THD At-Houle Servicaa. Inc. (`The Home Depot") agrees to furn s' h, 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 i ncorporated into this Contract by this reference, along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively. lob*: (Wow a.rnra Suer Sheets) a: Project Amount Q Uttoo le8 L7siding ❑ Insulation p r a /� — 7Q.tt(�L ' fCinsers /Covers ❑lsntuy ❑ �4 1tz _ $ L{ 5q V LiRoollag L iSiding ❑ Windows L1 Insulation pct Mtwara C?Bnuy Doors f L IR g osiang 0 Windows 0 Insulation pennon ! Covers C]EUty Doors - pnnofiag ❑Siding 0 Windows 0 insulation Ds/Covers DyDoors l mlidumn25 DtptthofC0aactAmraatdaeapanet toad Ib smotrart Total Contract Amount $ 1459 a Mti Pettbreessnaynotdepo it mom tan on Urn e- ddrdafU onhstAneina Customer agrees that, immediately upon completion of the work for each Product, Customer will execute a Completion Certificate (one for a ch 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 Product(t) 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 of lead paint. other safety concerns. pricing errors or because work ramified to complete the job was not included in the Contract �r ^+ Payment Stmtma The Payment Summary # 7 r 3 S , included as part of this Contract, 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 filled -cot espy of the Contract at the that you s�igpp.. Do not sign a Completion Certificate (note: there Is one Gomplet for each meted Product as defined by hndivi Spec Sheets) before work on that Product Ism In the event of termination of this Contract, Customer agrees to pay The Home the costs of materials, labor, expenses and services provided by The Home Depot or Authorized Seale Provider thro the date of termination, iplus any other amounts set forth in this Agreement or slowed under applicable law. THE HOME DEPOT MAY wrnmow AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT 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 Act Submitted by: D25/9/ Sales Consultant's Signature Date AW Costo ,a Telephone No. Sates Consultant License No. _ CANCELLATION: CUSTOMER MAY CANCEL THIS toe applicable) AGREEMENT WITHOUT PENAf.TY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE TIM/ BUSINESS DAY AFTER SIGNING MS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A POEM TO USE IE ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE; ADDMONAL TARNS AND commons ARE STATED ON TEE REVERSE SLOE AND ARE PART OP THIS COMTRACr 04 -11 -11 C-SC Mite - Branch He Yellow - Customer City of Northampton a Ha 15 p. - Massachusetts S . �i' a 7i 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 - Nestle resides or intends - to - be, - a one or^twa fartily'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 i 7. . .= 1 • 600 Washington Street t V = ' Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/PIumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual):.e- -t-\Dve'q ______ 0 Address: 1 AA t'� , . la City /State/Zip: ti.. A A _ ,r / Phone #: c( j 6 Are yo . n employer? Check the appropriate box: Type of project (required): 1. I am a employer with ao 4. ❑ I am a general contractor and I 6: ❑New construction - - - - employees (full and/or part-time) hµve liired the sub-contractors 2 ❑ I am a sole proprietor or partner listed on the attached sheet.- 7. ❑ Remodeling ship and have no employees - These sub= contractors: have 8. Demolition working for me in any capacity. employees and have workers' . g Y P ty. 9. 0 Building addition [No workers' comp. insurance . comp. insurance.$ required.] 5. 0 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 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Ro epairs insurance required.] t c. 152, § 1 and we have no employees: [No workers' 13. Other N ) (y) 92', 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. IContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have em to ees: If the sub - contractors have employees, the must provide their workers' co policy number. ' PY they P comp. �' - I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information.' -- �-^ • Insurance Company Name: ). , . iiir i1/.I - . __ I 1 l Policy # or Self -ins. Lic. #: )1q()'" s Expiration Date -- - Job Site Address: .._. _ . __ '9); : � VP ( ( A11.e_. City/State/Zip: i , . in 4 .■ ii , / i ,--...% Attach a copy of the workers' compensation policy declaration page (showing the policy number and expi : tion 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 $250.00 a day - . inst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of tl- : r insuranc/ overage verification. —_rd hereby ce ',, • under t , , . " d p , Ides of pe that the i nformation provided above is true and correct Si y a • , ./� / . Date: r - _ , Phone #: 1 -1D14 -- is - Official-use only ; - Do not write -in - this arearto be completed by city-or town - officiaL City or Town: Permit/License # _ ; _Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Tor.n Electr Inspector { Plumbing p ` Clerk 4. ✓. Ii.$ Inspector 6.Other Contact Person: Phone #: i E�w SECTTION 8 CONSTRUCTION SERVIC ES a k raF7 -+a .^:"• ,., +, K:a ulr ....fi... xa^ _,..�1 ▪ .. r .S -w..Y f • • O. 8.1 Licensed Construction Supervisor- Not Applicable ❑ Name of License Holder : \) Li /_/ � l m (r56J % 04V .117 0 License Number ith � i,��.r f At -' 'I • G 96/J � Address Expiration Date / i [� 40 .. � r ' ' Telephone c8: :. e • is eye - trac or , ; 3 c „ F Not Applicable ❑ � , , d" orneflm coverne � .t�Aa .., . „ . � : . . ��� .. � ,� ; ,. . ;,, ��_ � ..':, PP Company Name Re istration Number CMG! Fitt g ��-- _Address i Expiration Date LA Pr 0'4 r)go elephone S .4044/DRIkERS ,COM ENSATIO/ INSURANCE.AFFIDAII M Gi o 52a § - 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 ❑ 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 108.33.1. 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 Building Officials 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 • a ,. w . � ,- F, r i . y J r . g .9 ^ R. .. k' s' r zk� 4 :x r -- -1 i r�or ■g r ,e ?` . Pi-• x"si -,� , ,d w -if 'v .r = az-1K',� + J4 ' tAk 4. y : -.4. # SECTi 5 DESCRIPT I ®N PROPOSED WORK checicall �� icable i �. { � R . tsie. i to r o, a . fY ' .. �..sitii * ' 3 x 01 _ ito1 " , 'Jm..°!?T7��1+0.4 4-}.. v , : ::,%1 ;. CMS`.. New House ❑ Addition El Replacement Wi ows Alteration(s) n Roofing [ Or Doors Accessory Bldg. El Demolition ❑ New Signs [❑] Decks [❑ Siding [❑] Other [❑] Brief Description of Proposed — ) , r Work: _lei , '1". a1 . , -/A_' . . 4 a._ ( \,R l� 1 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet • :Awe. e. •'i® `p xi^ rv';'''e ill. W , .ex1st6T14 ? ; 6 sin F obi: a , clae; . 'o ; tfi ; i a Use of building : One Fam -- 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? V Yes No . I. Septic Tank City Sewer Private well City water Supply i „Ep lC)N»'�aZ 1ElINE ,'yU {O tlZATIO B O9$ ST D - , , W ' t , ti{OWNERSTAGE ?R CI^JNiRA _ ��P ti ORI3Ut 'Q1N C.'ERMl I ( 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. Signature of Owner Date I — — I, jl® 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 and pe • •f perjury. - Print Name + . 424 � i/ 1I .� Signature of! er / Agent Date • Section 4. ZONING. Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by't'oning . 'r This column to be filled in by Building Department 4 Lot Size 1 I f I � , Frontage 1 1 i 3 1 Setbacks Front 1 ` ( _._ : 1 Side L:i (R:1 L:I . I R= 1 1 1 1 Rear ! I I I = . _ :Building Height :: I _ ... I : . ( 1 1 Bldg. Square Footage Open Space Footage - - ^ _o -_ 1 l ' 1 I 1 (Lot area minus bldg & paved r parking) # of Parking Spaces f ( i Fill: 1 __._ 1 (volume & Location) I 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 Pa 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 © 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 ® NO Q 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. ` • R�� , City.oi Northampton - x ou' . - t 4 . uilding Department 40 !J ti ag „ )41-P 5?;; @- tia �� 1151‘ A 212 Main Street • f e, �� i,v,,° .� r � t Room 100 1 0. t )?. p E Crto Nort' - mpton, MA 01060 . I •• rART. " -�1 ar , of o' 1 Q6Q, - 587 -1240 Fax 413 -587 -1272 a • toc -. APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING y lvk7'?.ttet ro r c S.. e fa. ligiOttikft-It .�..` i*-44; �,4'e'L' ' £i. ` ; _SIECTICII "I SITEINFORMATION� ' ' "se ton t o 4r' 1Tet a office' 1.1 Property Address: t- >F x r 4!( ' t-L s " SS 5 5m =S',2 1, -,' $1 € r. r' R '� .d,.I T T4 I k � z" `t 4 T,4 L:., '"')L � - ( . _ . i A-0___ _ . _... _.. y r_ ' i . , S l-. �`` t -1- a YF }" S J N . .,T .v l F _ ' - J- +,., ' �Cr • rct k ' t uDtstr�ct z � h "= a� -- SECTTION ' PRO ERTTIFOWNERSHIP /AUTHORIZED'AGEN q` g • 2.1 Owner of Record: ' ' _ 1 1,A . _ I1 1 _.L -- :' _ i■ j r ' � j � / /d` O 14____..t Name (Print) Current Mailing Ad ' as 1 '1 "7� - a c f Telephone - Signature 2.2 Authorized :►:E t: RI Name (P� in Current . ^ailing Address: igithiP di o 1 - 10 1. 5 4 3,63 Signature Telephone SECTION S- ESTIMATED' COSTS Item T �e t: s�xr� - °' �` Estimated Cost (Dollars) to be I sr y Tr Affic , ' completed by permit applicant _ .` : ' . m •- � t , . . 4-r.., sx , .s 1. Building e. 4.„4„; g , A mp' : ; tr ee A `" ' 2. Electrical �..� 4 r . < u y� onsru�tioFifi of �6j `�� 3. Plumbing > �Tr.,� -h, ,- a } g Bhrldtng` � � ~ r 4. Mechanical (HVAC) .. � 1 . ,i , ,� a 5. 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'Q' °w µ'0` t33 t'� ^"'H;, 4 i x.,, [ .� i k .r . 2x"... "?.s r, Y .Y . r ` afwwn•S- .rv.3',.'�°a �" r ,�1.w 8" �`}l., ,n_.>�•f ��.^? -' c . N .; ^n3IUre t 4 M� `� n41,t,'mq * -a}, y q'" ; ;;;;; ;- ▪ { ,5- vteW yMr .r . t c, a x 7 , m,r1 � '�. -jar. TdFYY�� A ?dt.p'f-�a�Y'"'rrn "! f'. 7.- ry�mSt 4 �� .:. a3 'S� . -x- " l°�'�" 4. w r 7m `Q' m"+'L"u dt'n'ut .,,'"¢ _"+ ,� Y.Gfia .- i+E"3'r � U „, -. 4 ei.. ,�, �w� -`u' rt '-'.rnr�l ”. 7 • F y .-y y.'• �. � *; "'K� 1:£rIAv� x r' esF• g rC ..i z Tt { k S gTe4#; tr �r : Yr� - '3 .ia` t ;,;, . 4 5 xsdih ° .0 r x j .y u r g a` y w t. , LL Buildin g -PorntillSi net0 42ectono W51 ne Aird .� kai ..,,, 1, a; y,�...._. :. ,, ▪ r.; } s 35 REVELL AVE BP- 2012 -0501 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 278 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 -0501 Project # JS- 2012- 000837 Est. Cost: $4590.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 99209 Lot Size(sq. ft.): 7187.40 Owner: JACOBSON STEPHANIE Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 35 REVELL AVE Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers Compensation WORCESTERMA01607 ISSUED ON:11 /18/2011 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 11/18/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner