17B-016 (3) PLEASE READ THIS
Sold, Furnished and Installed by
B Boston Date: THD At-Home Services, Inc.
1 l • dtila The home Depot At-Home Services
345A Greenwood Street, Unit 2, Worcester, MA 01607
Toil Free (800) 657.5182: Fax (508) 756 -8823
Branch Number: 31 )•ederal ID # 75- 2698460: ME Tic # C 02439; RI Can_ Lie# 16427
' Cr Lk # HIC-.0565524 MA Home Improvement Contractor Reg. 8 126893.
Installation Addresm a w O' • * tom os ti [ M • t.
City State Zap
Purchasee{sk wrack Phew; Dome Phone Cd1 Phone:
I . � .� 1ir _ 1 , E r 3 L i -s`e 1 r [ 1
11 i A e , 11 i'i/l f easel 11110.
alma Address!
(If diluent from Installation Address) City State Zip
Email Address (m receive project communications and Home Depot updates)'
❑ I DO NOT wish to receive any marketing emaila from The Hoare Depot
and THD At H Intot iaa: Undersigned ( "), the owners of the property located at the above installation address, agrees to buy.
all materials described On the below and on referenced agrees to furnish, y all of which � the installation into ("Installation") Contract by s
reference, along with liable State Supplement and Pam s
Payment Sum ante thus Ctr
sn by eli
g any app pp ymwh many attached hereto and any Change Orders (collectively,
LT J
'Yob 61 !Menus - .- y Spec Sbcd(s) #: Protect Amount
- es al • ' • .. ng ■ iding at Windows tai Inmiadm
' DGumcra, covers D try Doors 0 - 'If n d L ?.2. $ 6224_ , /
uRoot USidmg [Wmdowa 0Insulation
(,t) [ ' 3c2 Crimes , Covers DEnuy Doers ❑ `ta. b e ? 5 $ (4Q , - ve
[Audin$ uSidmg LI Windows U Insulation $
0Contra i Covets °Entry Doors n
DRooImg DSid<ag ❑ Windows ❑ Insulation - -- _
p
$
G s /Covers DEnn ' Doors 0
Minimum 69'% Deposit af Contr ®m m
act A tdueuponereastiefthis caminet. Total contract
A rt $ 67C314)\ Mak nt
Maine Pardoners
ideCentredAssgeut
Customer agredc that, immediately upon completion of the work for each Product. Customer will execute a Completion Certificate
(ace for each Product es defined by an individual Spcc Sheet) and pay any balance due- As applicable. each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Horne Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s) included basin, 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 hone, environmental hazards such as mold. asbestos or lead paint. other safety mncerns, pricing errors or because
work required to complete the job was not included in the Contract.
Payment S rv: The Payment Summary # Z 7 . 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 Tamed -in copy of the Contract at the time your sign. Do not sign a Completion Certificate (note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets) before wart on that Product
is ote-
In the event of termination of this Con tract, Customer agrees to pay The Home Depot the casts of matesiais, labor, expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any other
arena ets set forth in this Agreement or allowed reader applicable law. THE HOME DEPOT MAY W1maOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DU'O'I "S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Horne Depot with regard to the Products aad 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 Horne Depot. Customer acknowledges and _ ever has read. understands. voluntarily accepts the
terms of and has received a copy of this Agreement.
I.
`rte / � �
On.. '' -
tt
Date , �I « � saltant's Signature Date
x J i i ! t -- ! Telephone No 1 , '
-
tars . ■ , 's Signature P s - to
Sales Consultant license No .
CANCELLATION: CUSTOMER MAY CANCEL THIS (an applicable)
AGREEMENT Wtfl1OtYt PENALTY OH OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON TUB TIMID BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUST'OMER'S STATE.
40T� A00tf011AL MID COMMONS ARE STATED Ott TII& REMISE SIRE AND *IMPART OP T)US C0NlaACr
12 - 27 - 10 C White — 8ranehFie Yellow— Customer
irrr' ( P) 0 1;
11 7 /fs j).i', PJ ! 1, l�. /)7 1'; {1 N,',(,1 , 11 7 ?l _'..
Department of in,d istf aT Accidents
is
k«;. Qffice of I veszzg
� asio n.S
,- --, 500 Washington :E r.e:et ,
vit, , ; It Z ,$ Boston, MA 02111
Workers' Compensation Insurance .ffii Builders/Contractors/Electricians/Plumbers
A 3acant Information Please Prat Legtbi
Name ( Business /Organization/individual): Vk -6"Cilie17:kpor ,
Address: aC � / a ... " 'Al -nt�_ ,Lf A lr'
City /State /Zip: / ,rt ('x_ 03 ',. Phone # :_ 5 DO / S 7
Are yo an employer? Check the appropriate box: Type of project (required):
1. I am a employer with &L) 4 0 I a m a general contractor and I
.._ _ --
_
_ tors .- - 6 -❑ New construction - - - -
employees (full and/or part-time).*
have - hired the sub- contrac
e.. • listed on the attached sheet. 7. Remodeling
.
2. El I am a sole proprietor or partner ❑ g
These sob- contractors have - `
ship and have no employees _` .. _ - 8. [] Demolition
working for me in any capacity. employees and have workers'
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.[❑ R repairs'
required.] t c. 152, § 1(4), and we have no
employees.' [No workers' , 13. they O J 1)
V,
comp. i nsurance required.]
`Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowne,s who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tCentractors 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. —.
L. Insurance Company Name: 1,3 Wi i'Vlrl 11 g L.(
Policy # or Self -ins. Lic. #: .01054175 S Expiration Date:
fob Site Address:
- City/State/Zip: — , all 4f a A" II
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expi 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
lie 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
)f up to $250.00 a day - .... inst the violator. Be advised that a copy of this statement maybe forwarded to the Office of
nvestigations of th 4, r insuranc- overage verification. .
.
d hereby ce - y- under t ■ ins 'd pe hies of perjury that the information provided above is true and correct.
u a _- •
, ijf ii .e Date: '`� :r e7
hone #: 1 40/e/ .1 7 tr
Official- use only:- Do-not write-in- this - area, -to -be completed by city town - official
City or Town: Permit/License #
:_Issuing Authority (circle one):
1. Board of Health 2. Building nepartment 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other .
Contact Person: Phone #:
:.f.:.± ,-'-'y■Etr 1/4 , :.
S
-, _ _ ,
.--
6.1 Licensed Construction Sirs,- rvisor: Not Applicable 0
.
E:
Name of License Holder : gr O , 1 111 I 1 I im. a 4-27 /D i
License Number
IL ' 1 4 /41_ -40 1 1 . 4 ' e I _ NA -4 A • -; I ) .
AddressW -. Expiration Date
/ Ao ,"
AI d .,i• do,' A .,, / / A
Signa re Telephone •
. .
Fi'": egit ere ;'• ciiiieilnii;Co4thile :itoritira cif !'t'p5;Isrjaider:gfiltiMMtCVM;f1P:74W,if.5,1 Not Applicable 0
' ' 1,02C0915
Company Name Registration Number
• - ' g li..._ irrkti . 1 41111, 11 , ..
Address
E)(piration Date /
i i -..... . -- . - .
.
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. .
elephone
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SECTION & 5V )V
1§25C(6eri
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Workers CoMpensation Insurance affidavit st
m be completed and SUbinitted with this application. Failure to provide this affidavit will result
in the denial of the issu of the buildin errnit.
Epgie
Signed Affidavit Attached Yes No 0
- - -, 73.. - WA• 2, - - `7 ` :*:L•::..XLS
:Aits, 'A ' 0 -1.;e; @) wne• -: . -.t . puran
•
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, dn which there
i; 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 bonieovvner.
Such "homeowner" submit Building Official; on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building perinit: ,:. - . ...
As acting Construction Supervisor your presence on the job site will be required from time to tirne, during and upon
completion of the work for which this permit is issued.
Also beadViied that With refer iiit1iipTer:152(WOrkerS' COMPelisation) 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 this " - -
The undersigned "homeowner" certifies and assumes for compliance with the State Building Code, City of .
_._ .
._ . Northampton Ordinances, State and Local Zoning Laws and - State of Massachusetts General LawiAnnotited..7.
Homeowner Signature _
. .
. .
•
. _ .
. .
•
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•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House E Addition D Replacement W Bows Alteration(s) [1 Roofing fJ
Or Doors
Accessory Bldg. ri Demolition D New Signs [i 7] Decks [EJ Siding [Ell Other [01
Brief Description of Proposed �� i — .
Work: —All. 1 - i :4 "IP � .b t . .) Q 1 �16C,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 to sting 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 5
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
1, . #? L , , 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.
/J
Signature of Owner Date
I, i t .l L Ore _, , as Owner /Authorized
Agent hereby declare that t e statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under •ainsan• 6- lalti:s ofperjury.
►∎ • 0 A
Print Name • � �
ilz.,.......,
19/
Signatur- of • er /Agent Date
"
419 BRIDGE RD BP- 2012 -0720
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17B - 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: windows replaced BUILDING PERMIT
Permit # BP- 2012 -0720
Proiect # JS- 2012- 001265
Est. Cost: $6722.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 43560.00 Owner: SINGH JAGDISH & BALBIR SINGH
Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 419 BRIDGE RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers
Compensation
WORCESTERMA01607 ISSUED ON:2/17/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 6 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 2/17/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner