16A-020 Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRA.TOR before the expiration date. If found return to
aI Registration:. 126893 • Board of Building Regulations and Standards
One Ashburton Place Rm 1301
Expiration: 8/3/2010 Boston, Ma. 02108
Type: Supplement Card
The Home Depot At Home Service •
RICHARD FALLOIVE
3200 COBB GALLERIA PKWY 420 f
. TLANTA, GA 30339
Administrator Not van, without signature
, ROME IMPROVEMENT CONTRACT
PLEASE READ THIS
6 Sold, Furnished and Installed by:
Branch Name; Boston Date: , / t - / 41 I,) THD At - Boma Services, Inc.
d/b/a The home Depot At-Home Services
Branch Number: 345A Greenwood Streak, Unit 2, Woreeater, MA 01607
North 33 ❑South 31 Toll Free (800) 657 -5182; Fax (508) 756 -8823
Federal ID # 75- 2698460; ME tie 4 C 02439; kX Cont. Lio4 16421
CT Lic # 565522; MA Home Improvement Contractor Reg. a 126893
Installation Address: 1 L Ffil f Kct3A V LG t-.ER f y t 1 A 010 53
City State Zip
Porchaset(s): Work Phone: Home Phooet Cell Phone:
I i M _ ®11111 [ 1 [ 1
[ 1 [ 1 [ 1
Homes: Address:
(If different from Installation Address) City State Zip
E -mail Address (to receive project communications and Home Depot updates):
El I DO NOT wish to receive tiny marketing =ails from The Home Depot
Protect Information: Undersigned ("Customer"), the owners of the property located at the above installation address, agrees to buy,
tool TIM rut -Horne Services, Inc. ( " The Home Depot") agrees to Runisb, deliver and mange for the installation ("Installation ") of
all materials described on the below and on the referenced Spec Sheet(s), all of which ate ineovoratod into this Contract by this
reference, along with any applicable State Supplement and Payment Summary attached hereto and - any Change Orders (collectively,
"Contract"):
Job 9: tmw•da.n......) Products: Spec Sheet(s) #: ' Ptpieet Amonet
� {r., [Mooring '[Siding [] 'Windows natation ' \ Q
3 Y 6 I I �+� ❑Ot nets / Covers QEntty Doors ❑ 5 1 $ . Y i, (p
°Roofing []Siding ❑ Windows ❑ Insulatim ----
❑Qutters / Corers ❑entry Deora CI $
Ultoo6ag [Sliding ❑ Windows ❑ Insulation
❑Queers / Covers ❑Envy Doors n $
• ❑Roofing Usiding ❑ Windows 0 ens ilatioo $
:Putters / Covers Davy Doors ❑ ,
Mlnimnm 25% Depot of Contract Amount due upon e1etwiam adds contract. Total Contract Amp $
Maine Puethasras may not deposit more than onc�hhd oftho Contract e...o...,, unt ' 1 t
Customer agrees that immediately upon completion of the work for each Product, Customer will execute a Completion Certificate
(one for each Plnduct 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 ter into this Contract or any individual Products(s) included herein. at
is discretion, if The Home Depot or its authorized service provider determines that it cannot perform its obligations duo to a structural
problem with the horde, 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 Contract.
Payment Summary: The Payment Summary # i") P , L , •included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final payments by Product (es applicable). .
NOTICE TO CIJSTOMER
You are entitled to a completely filled -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 D of the costs of materiels, labor, expenses
and services provided by The home Depot or Auther'i2ed Service Provider thrpou the date of termination, plus any other
amounts set torus in thla Agreement Or allowed pader applicable law. THE HO DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE ROME DEPOT FROM TUE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HODS DEPOT'S OT13ER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Aeeejyta D AythorizatloR: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The oII me epot with regard to the Products and Installation services and supersedes all prior disctlsslons 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 leas read, understands, voluntarily accepts the
terns of and has received a copy of this Agreement.
Ace ., by_ �� /j+.f /� Submitted y -
4.1, n y y l • x Tel t_ r1 L.1 i " L.7
,. .• - 's Signature Date Saks Consultant's Si turn Date
X Telephone No. . -_ -
Customer's Signature Date Sales Gent License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS (at aspacsek)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO 1101 HOME
DEPOT BY MTDNIGiIT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE .I5
SPECIFICALLY PRESCRIBED $Y LAW IN
CUSTOMEWS STATE. . '
NOTICE: ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE l'ART OF TRU CONTRACT
8-0548 C-$C Mute BrachPlsa Yariow- Cuabmer pink - Sales Consultant
The Commonwealth of Massachusetts
Department of Industrial Accidents
- Office of Investigations
r = q 600 Washington Street
t 'i`" Boston, MA 02111
-•. `* www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): •- $jjiy,l Pa
Address: 5 Vg( J f' !
City /State /Zip: �� , / . ,ar,ZAT Phone #:
Are an employer? Check the appropriate box: Type of project (required):
1. I a a employer with rr 4. 0 I am a general contractor and I
I 6. 0 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. Q Remodeling
ship and have no employees These sub - contractors have 8. Q Demolition
working for me in any capacity. employees and have workers'
t 9. Q Building addition
[No workers' comp. insurance comp. insurance. repairs 5. [] We are a corporation and its 10. ❑ Electrical ep atrs 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 r airs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. er
comp. insurance required.]
*Any applicant that checks box #1 nest 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: 1\IP_L31.1114r1Q1-CP---1--65(4C)
Policy # or Self -ins. Lic. #: G 1 g (/ 75-5 Expiration Date: //
Job Site Address: tLI- l G t 'ti i t q City /State /Zip: t ( V 0 l�
Attach a copy of the workers' compensation poy declar on 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 ' er e p 'ns and penalties of perjury that the information provided abov is tr and correct.
Signature: .Q, {/Z Date:
Phone #: d
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 Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor Not Applicable ❑
'Rev 14N-1c Ike? Company Name Registration t �Tumb r
(-,Xemad51- !alio
Address- + / _,J 4014,3_2403
Expiration Date
) �� f Q 160 / Telephone 41
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit m t be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi ermit.
Signed Affidavit Attached Yes No ❑
11. — Home Owner Exemption
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 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House (l Addition ❑ Replacemen •ws Alteration(s) ❑ Roofing n
Or Doors sf"
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [O] Other [•�
Brief Description of Proposed . n �'
Work: _.t,�r7., i •1I ', O t) ' 1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition 't xistinq housing, complete the following:.
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 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
L c ) rirocfi , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit applica 'on.
Signature of Owner Date
I, LAC 1 1lcti- - , as Owner /Authorized
Agent hereby declare t at the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed unde •- • -ins and penalties of perjury.
Aft gr.
Prin , ame / R
Signature of • -r /Agent Date
Section 4. ZONING ALL 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
Frontage
Setbacks Front
Side L: _... ..... R:'.. L: R
Rear
Building Height
Bldg. Square Footage
Open Space Footage °
(Lot area minus bldg & paved m
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:
YES: Was the permit recorded at the Registry of Deeds?
NO (3 DONT KNOW 0 YES 0
IF YES: enter Book ' Page 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 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES ( 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 l 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.
i t
t e
partment " use only
� r \� C%fiy^o No rthampton Status of Perm
�� t 1 _ - Bthlid D Curb CuURn P
21 Ma S treet SewerfSeptcAvaiiability
Q $ ,,Ro 100 Water/Well Avail
�� 2 2 2- N ` n, MA 01060
Two Sets of Structural Plans
phon 4 13. 58 1 24 Fax 413- 587 -1272 Plot/Site Plans
�aJ
a �� Otlier Sp e c ify
APPLIC ATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY D WELLING
SECTION 1 - SITE INFORMATION
This section to be com p l e ted by office � 1.1 Property Address: / f � Map l � j Lot vv Un
'3 t �- � � f Zone ii I A I s tri ct
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
. cl 1 ru �►O tC VI D1055
Name (Print) / - +� Current i ing Address ����� Telephone Ma V.I
r y` ° }
Signature
2.2 Au •
era: r._ , sw
Il Name (Pn Current Mailing Address:
rr
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
9 1. Building t ('C'''' ( Building Permit Fee
2. Electrical ( b) Estimate Total Co o f
Cuildinonstruction erit from (6)
3. Plumbing Bg Pm Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) i �his '--S Check Number gg 6
T- ection For Official Use Only ��/"'�✓
Building Permit Numbe r:
Issue d:
Signature:
Building Commissioner /Inspector o Buildings Date
W Y L BP- 2009 -0191
GIS #: COMMONWEALTH OF MASSACHUSETTS
°= CITY OF NORTHAMPTON
Lot: -044 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP-2009-0191
Project # JS- 2009 - 000247
Est. Cost: $2916.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 126893
Lot Size(sq. ft.): Owner: HARRETCHA STOW MARIA
Zoning: URA/WP/WSP Applicant: HOME DEPOT AT HOME SERVICES
AT: 314 FAIRWAY VILLAGE
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 0 Workers
Compensation
WORCESTERMA01607 ISSUED ON:8/22/2008 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL BLOWN IN ATTIC INSULATION
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:
FeeTvpe: Date Paid: Amount:
Building 8/22/2008 0:00:00 $35.0023815
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo