36-233 HOME IMPROVEMENT CONTRACT
PRASE READ THIS
•
Sold. Furnished and Installed by
Now Reston Date• THD At -Horne Services, Inc.
V.J .% dlb/a The Home Depot At -Home Services
345A Greenwood Street, Unit 2., Worms, MA 01607
Toll Free (800) 657.5182; Fax (508) 756-8823
Branch Number: 31 Federal T1 # 75- 2598460: ME Lic # C 02439; RI Cont. Lieti 16427
r CT Lie # HIC.0565522: MA Home Improvement Contractor Reg- a 126693
. Installation Address: ig (l r�. C C !__ i�fb __c, ) e.% t _q E, K
City State Zap
Mwelieserish Work hove: Home Phew Cell Plow
itlt %M T*Zte. Q S f l [ l 1 l
[ l 1 l 1 l
H. Adam -
('If different from Installation Addzess) City State Zip
F.-ma Address (to receive project aomntunications end Home Depot updates): -
0 I DO NOT wish so receive any marketing email& from The Home Depot
"Et Undersigned ("Ca■t the r"), the owners of the property located at the above installation address, agrees to buy,
and MD At -Hone Se vices, Inc. ("The Home Depot") agrees to furnish, deliver and arrange for the inse*IIaton ("I1astaUation ") of
all materials described on the below and on the referenced Spec Sbeet(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,
"Contract "):
Jab* ts..rr reeve 1 Pr duck: Spec Sheens) #: ,Project Amotmt
r r� Roofing CDSidug D Windows 0 tioreanrm V.-----
j { a ,r.J _ N.:.,., . a Windows • Insulation
$ V3 / I ii`e__
Mutters / Cayes ElEary Door- f i
■ Reo6o •,,,•.... ti Windows • butdation $
0Guttaa /Corset DPrny Doors ❑
DReonne Dsidn+t U Windows [I tnmdeece
pGteters1Covaa DEnnyDoes n
Maine= 15% Dive& er anbad Amwatdee upon maiden ands contract. Total Con tract Awottn
Mains Perete es may not deposit more than eat-third urea C Atramet 3 7 5 E
Customer agrees that, irrunediately upon cormpktioa of the work for each Product, Customer will execute a Completion Certificate
( 0-e
tone for each Product as define) by an individual Spec Sheet) and pay any balance due. As applicable. each Costume: under this
Contact agrees to be jointly and severnily obligated and liable hereunder.
The Home Depot meervee the right to issue a Change Older or tsrminate this Contract or any individual Product(s) included herein, at
its discretion, if The Home Depot or its authorized service provider detennioes that it cannot perform its obligations due to a structural
problem with the home. cnvirenmenwl hazards such as mold. asbestos or lead paint, other safety concern& pricing errors or because
wntic required to complete the job was not included in the Contract.
Payment Summary: The Payment Summary # 1 36 t • included as part of this Contract, vets 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 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 fisted Product as defined by individual Spec Sheets) before work on that Product
is complete.
In the event of termination of this Contract, Customer agrees M pay The Home Depot the costs of materials, labor, expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any 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
LIMITING THE HOME DEPOTS 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 aaid Products and Installation. This Ag eement cannot be signed or amended except by a writing signed
by Customer - n Customer acknowledges and agrees that Customer has read, under*tends, voluntarily accepts the •
terms of of this • _ • '
X .i i / • X 1
f ` !7 a Sales Conultant's g nature Date
i Telephone No. . •
Customer's Signature s' Sales Consultant License No,
ggeaCI1L&TION- CUSTOMER MAY CANCEL THIS etas applicable)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WKtITToF NOTICE TO THE HOME .
DEPOT' RY MIDNIGHT ON THE THIRD ROSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS .4 FORM TO USE IF ONE I5
SPECIFICALLY PEED BY LAW IN
CUSTOMER'S STATE.
NOT IM AnnrrIONAL TERMS AND 00MJITTONS ARE STATED ON TUE REVERSE SIDE AND ARE PART Ot TM CONTRACT
1227 -10 0-00 White —Stanch Ale Yellow — Customer
City of Northampton
� `� \ 4 S r
Massachusetts ' � '°` w
i 1q i 4 DEPARTMENT OF BUILDING INSPECTIONS . 4
' 212 an Street • Municipal Building J i`
' 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
he /she resides or intends 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 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
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
i,,* Department of Industrial Accidents
" ' e Office of Investigations
9 -
.r . 600 Washington Street
, m @ Boston, MA 02111 d
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): - 0D
Address: ( ---' � i&'r f
City /State /Zip: Plfrit C.c., 00 3 Phone #: ? O i 9
Are yo an employer? Check the appropriate box:
l contractor and I general am a 4. Type of project (required):
L I am a employer with (93 n g 6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
2. El I am a sole proprietor or partner - listed on the attached sheet. 7. ❑ Remodeling
These sub - contractors have
ship and have no employees 8. El Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. r] 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. ❑ Roof
insurance required.] t c. 152, §1(4), and we have no
13. ther �`
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 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: )\\ 11(7 ) P� __ g C
Policy # or Self -ins. Lic. #: orr -j73 j,2 Expiration Date: ' _ _
Job Site Address: e 'VllZI/41, City/State /Zip: i �. / ��, ii i� �
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
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 insurance overage verification.
I d hereby cerii nder t % Irr d pe - , lties of perjury that the information provided above is true and correct.
Sig a , i . /III/ - Date: ... _
Phone #: lTi _. r AP
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):
I. 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 : 0 (€1� 7i fA (, -14 3. 5
License Number
I , j
Addres b Expiration Date
goli5 7 2/ J3
Si • • :' . re Telephone
9 Retiis erect ome Improve'me Contra . �` „.. ' a Not Applicable ❑
N tc:Qc13
Company Name Registration Number
Address �� Expiration Date C g /),.:--
VA ? , 4 t%�� (J l(elephone f 1 J 2)
-
w
SECTION 10 WORKERS' COMPENSATION INSURANCE: AFFIDAVIT (MG L c 152, § 25C(6))
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 ❑
1. Vii'.- ®4.me Owuer s einption
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 ❑ Addition ❑ Replacement Wi ows Alteration(s) ❑ Roofing [ - I
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [El Siding [0] Other [ID]
Brief Description of Proposed '�_ l r' «r r
Work: _ l i s 1 i lr .if 1 1174.. ( \.i7 G l
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
siAte. , ew*taouse a adoc addition Tt ezisti,n r ou in com e`lete theifolld rini :
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 z < ,
OWNERS AGENT OR CONTRACTORAPPLIES FORBUILDING PERMIT } } >
1, ,Q C � ,C , 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, hai 1Q, , 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 under th and pe of perjury.
Print Name / �/ .
Signature of 1 erfA!ent Date
1 1
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied e To3lnco Information
Existing Proposed Reeuired by bhi g:'0 fi
Tbijoiurin to be filled in by
`"...131iilding Department
Lot Size 1 Ii j i `
Frontage ,
,
Setbacks Front I 1 i
Side L:' ' R: L.�� R:'
t
Rear !
Building Height I i 1
s t
Bldg. Square Footage f I I I% I 1
Open Space Footage
(Lot area minus bldg & paved J i I f
parking)
i 1 TT ' c
# of Parking Spaces
Fill: 1_ ____. _ w _ _ ... _ i _ __ ___.,
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
I
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; 1 and /or Document #1
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 ® , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
GE Qi De a ewtxu ,m-
° ^ se w it n �
opt i of orthampton S a us Perr 3
rt r
o
'� u il•'ng Departme s n�G ® e t �G , i
0 M . n Stree Sewed; .-19,(-41-Z`,,,' rafiabilt
- 100 �£
•
N O a+ •rtham MA 01060 • ®' B ala
P 413- 587 -1240 Fax 413_58,-. 272 P • S e<` lams ,
ri
O e Specif n- ��
APPLICATION TO CONSTRUCT, ALT REPAIR, RENOVATE OR DEMOLISH A O NE OR TWO FAMILY DWELLING
SECTIO 1 - SITE`. INFO
This s ection to be compl b y o y
1.1 Property Address
�,
(-0 / /�('�• - `Ma * t "i +w . '' . ,Y, y Lot, 4',: = ; ;' �C „r c: ;Uni4 :. `°L: 'r
� j( 1/'
U �Cl `Zo `� = Overlay Distr�e t
,sit' "' - o- x> a
°' Eim S ,D i s trict . , , .r ti CB Distract ,
SEC TION 2 - PR OP E RTY OWNERSHIP /AUTHORIZED AG
2.1 Owner of Recrordi , , ;� ,/
nf Name (Print) Current Mailing A ddress:
. C O ` tQ ( Telephone
Signature
2.2 Authorized :ist t :
Name (Prin� Current ailing Address:
4.,,,
Signature Telephone
SECTION 3 - EST IMATED CONS TRUCTIO N COSTS ?._.
Item Estimated Cost (Dollars) to be Official Use.Only
completed by permit applicant
1. Building �� (a) B u il d i n Per
g m it Fe e _
2. Electrical (b Estimated To Cost of
= Construction fro (6)
3. Plumbing Buildi P e rm it F
4. Mec hanical (HVAC)
5. Fire Protection
6. Total = (1 + +3 +4 +5) � � CheckNumber
This Sec F or Of fic ia l Use Onl y:.
Building, Permit Number s I e
suetl:
Sig
Building Commissio /Inspector o Buildings Date
•
18 DIAMOND CT • BP- 2012 -0137
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 233 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
A
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit # BP- 2012 -0137
Project # JS- 2012- 000200
Est. Cost: $3759.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 98785
Lot Size(sq. ft.): 43647.12 Owner: TRIENENS WILLIAM J
Zoning: SR(100) //WSP Applicant: HOME DEPOT AT HOME SERVICES
AT: 18 DIAMOND CT
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 () Workers
Compensation
WORCESTERMA01607 ISSUED ON:8/4/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL REPLACEMENT 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 8/4/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner