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14-016
HOME IRIPRDVIIMENT CONTRACT PLEASE READ THIS Sold, Furnished and Installed by natatory Basta Date: THD At -Home Services, Inc. d/b/a The Home Depot At -Home Services 345A Greenwood Stmet, Unit 2, Worcester, MA 01607 Toll Free (800) 657 -5182: Fax (508) 756-8823 Branch Number: 31 ' Federal ID T73-2698460; ME Lie * C 02439; RI Cont. Lid* 16427 ` � CT Lie 4 HIC.0565522: MA Home Improvement Contractor Reg. # 126893 Installation Address: 1 7 e7S A ,\ L'3 S (y44- City rate Zip > n*: worst Phone: Home fie: cell Phone: t ors () 1610 t [ ] II( & `t - (Ub [ ] [ I [ ] [ ] Home Address: _ (if different from Installation Address) City State Zip E-mail Address (to receive project communications and Home Depot updates): ©I DO NOT with TO receive any marketing emails from The Home Depot Protect Information: Undersigned ( "Customer"), the owners of the property located at the above installation address, agrees to buy. and THID At -Home Services, Inc. ('"lure 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 (collectvely, "Contract "): Joh ak a ..aa+ma _ Stec Sheets) M: Project Aimee* [)Roofing DSdiag @lrindowa 0 Iaauimian •� / 5 Es ( oegq (]Qtruere l cove.: Cerny Doors p r w 4111 OA $ 8 730 o �+ C7Roofinng' QOirmdo es insulation -r Dctam./0. s ID r'aryDooas fl 6'7 t2 $ _ OReafin ❑snag Vlrradoaa 01.4.60. 5c:56 O Mutters iCovets Obey Doom n (1 bt $ i52.c `9p k . 7 / Ijitoofing pSSding 0 Mndons p Insulation $ Dam=s Moms Dsaoy Doors n • t� b ® zs96 DereeFrDUxaetAtrmtrtdrenpanrleeeali tisR elMattar& Toatcontract Aatroot $ • 1 �tt� M aim Prrelmarsmay eedepaet tameAss are .ttiirdat the CaetrattAmoont J`,y 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 — t Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Orange Order cc terminate this Contract ar any individual Product(s) included herein, at its discretion, if The Home Depot or its authorized service provider deerstnines that it cannot perform its obligations due to a structural problem with the home, eaviroanteetal 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 Contract. Payment Smoau r: The Payment Summary if ' Si i t S Z . 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 Yoe are entitled to a completely filled -in copy eat Contract at the fluor you sign. Do not sign a Completion Certificate (note: there is one Completion Certificate for each listed Product as deemed by individual Spire Sheets) before work on that Product is complete. 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 Authorised Service Provider through the date of termination, plus other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMING TOE HOME DEPOTS 01111111t REMEDIES FOR RECOVERY OF SUCH AMOUNTS. nt rm r� Canonic: agrees and understands that this Agreement is the entire agreement between Customer and The one Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements, either mat or written, relating to said Ptndncu and Installation. This Agreement cannot be realigned or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and agrees that Customer has read, nnnderstauds, voluntarily accepts the reruns of and has received a copy of this Agreement. by Sub®ktdr X j 7 /i /If X t bum -- a s iguana d Date Sales Consultant's Si Date x Telephone No. Customer's Signature Date Sala Consnhant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (ae appisable) AGREEMENT 'WITHOUT PENALTY OR OBLIGATION BY DELIVERING wan - TEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE "TRIM BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE iS • SPECIPICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. mum morn r AL 'IERMS AND CONDITIONS ARE STATED 014 THE REVERSE SIDE AND ARE PART Of MIS OOMIRACi' 04.1611 •SC Whae— Stanch File Yellow— Customer The Commonwealth o, f Massack:usets Department of Industrial Accidents Office ofInvestagatcons ..� 600 Washington Street . Boston, MA 02111 ` . www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): t i. Address: a A A A C ,. � 1. City /State /Zip: . •_ ` . ',Phone ft: g DO j Are yo n employer? Check the appropriate box: Type of project (required): 1. I am a employer with GO 4. ❑ I am a general contractor. and I — 6 ❑New construction employees (full and/or part-time).* have hired - 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 capacity. employees and have workers' g any p tY t 9. ❑ Building addition [No workers' comp. insurance comp. insurance. 10.0 Electrical repairs or additions required.] 5. El We are a corporation and its d their i h ffi ocers have exercised 11. Plumbing re 3. ❑ I am a homeowner doing all work ❑ g airs or additions p myself. [No workers' comp. right of exemption p erMGL 12.❑ R f re airs and we have no 4 c. 152, 1 , insurance required.] t e (. ) 13. 0th I 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 n of 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. \ _ - ---� — co Insurance Company Name: l`�t:3 11 1 re -- i Policy # or Self -ins. Lic. #: „,0 71-73 .V(' Expiration Date: -- - Job Site Address: `t �. ..: City /State/Zip: 6414_ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expi I 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 th Ir insurance overage verification. Id" hereby ce y • under t ins - d pe lties ofperjuty that the information provided above is true and correct. Si a .-.: Date: // Phone #: E- 4D -- = 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 #: K.SECTION $ „ CONSTRUCTION SERVICES,. , s"-yi. 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder : , J Y ! 14:YilAirik9k71 �5 License Number Ad. - Expiration Date d/ , _ ` a Sig ur Telephone _ , ; ._ . . -,.n . iLx � ,k eit r �” t 1 -Y' , { Ch's tk' 16i E: i 1; 0 eredli orne� r�ri • Goveme >E�ari'tcactar ' - ,, , .,� ,.: �, r � .,.,.� , kt , ��; , , �,., .,,,.._�, . ,. •,k , >� Not Applicable ❑ Company Name � T Registration Number ;Address ? � Expiration Date . g ?AP . b. �:.�1�1�Ji` �I elephone L f l ?h , ''�'�'`'��,+. , SECT IQN4 ; W. { RKERS' INSURANCE AF IQA1[1T (M 41444 -§ 25q , 7n 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 ❑ HII2 II K a 9 r1 t 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" - shall submittorthe 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 referenceto Chapter l52 (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 SECTION 5 DESCRIPTION O PROPOSED WORK (check all apptrcabte} ,, • New House ❑ Addition ❑ Replacement Wi ows Alteration(s) I I Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [p Siding [p] Other [0] Brief Description of Proposed• . - - � ' rti . Work: - `5 AI °` 4t, �5 1 ' 1 r C , , 6tela) '1 ,Ki Alteration of existing bedroom es No Adding new bedroom Yes u rr N i '� ? � Attached Narrative Renovating unfinished basement Yes No K t Plans Attached Roll - Sheet �� '� +.® . -rt. it :clitioriit®.ezii itiola•i sihq '"timpa a he-, .a(to4iirtq: -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 SECTION 'a,DWNER.AUTHORIZATIO `TO BE COMPLETED WHEN OTIW NERSl0E(T OR CON FOR PERMIT k I, - .22e CD,7)7 �� I as Owner of the subject property hereby authorize to act my in all matters relative to work authorized by this building permit applicatio Signature of Owner Date I, 4 ,'.� 1 v,i, , as Owner /Authorized Agent hereby declare that the statem iv ,i, information on the foregoing application are true and accurate, to the best of my knowledge and belief. SignesWnder_thepai gs a pen ' / eerju � ry. Print Name ) —✓ Signature :• Ag-1 Date / . • r' , 120 KENNEDY RD BP- 2012 -0631 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 14 - 016 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 -0631 Project # JS- 2012- 001087 Est. Cost: $14755.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sq. ft.): 87120.00 Owner: NICHOLS DOUGLAS Zoning: RR(100) //WP/WSP Applicant: HOME DEPOT AT HOME SERVICES AT: 120 KENNEDY RD Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers Compensation WORCESTERMA01607 ISSUED ON:1/5/2012 0:00:00 TO PERFORM THE FOLLOWING WORK :INSTALL REPLACEMENT WINDOWS /DOOR 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 1/5/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner