24D-144 12/10/2010 17 :38 15087568823 THD AT HOME SERVICES PAGE 01/06
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold, Furnished and Installed by:
MD At -Home Services, Inc.
M N u Bristow - dlbla T b e Home Depot At -Hoare Services
l 345A Greenwood Street, Unit 2, Worcester, MA 01607
Toll Free (800) 657 - 5182 ;.Fax (508) 756 -8823
Bttaneh Nwebax: 31 Federal ID # 75- 2698460; ME Lic # C 02439; RI Cont. Lien# 16427
{{ C � T Lic � H , � I ^ C.0565522; MA Hoax hoproveanent Contractor Reg. # 126893
Installation Address: v 5 cm !J g4 Iii o t t 7 t o41 14 61.08
City U State Zip
Purr haaer(s); Wort Phnom Haase Phone: Cell Phone:
WI C . niz n S A A.14 119 n [ ] [ ] � t 1
Home Address:
(If different from Installation Address) City State Zip
E•urail Address (to receive project communications and Home Depot updates):
D I DO NOT wish to receive any marketing ernails from The Home Depot
Protest tnfornmstton: Undersigned (Customer"), the owners of the property located at the above installation address, agrees to buy,
and THD At -Home Services, Inc. Moe Hoene Depot') agrees to furnish, deliver and arrange for the installation C'indallation') 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 (collectively,
Job*: aw.,,.r a.r...y Pte Spec Sheet(a) # Project Amount
°Roofing °Siding ❑ Windows'- J.psutattc $
S3 - 7 - 7P-C °Cone / Covers DEaayDoors D 54 b' 6cr 1 n
� fing °Siding D Windows ❑ Insulation
/Covers cmaayDoors n 1 0 1 N3 $
°Roofing °Siding 0 Windows 0Insulation $
❑Gutters! Covers °Enhy Doors n
DRS °Siding ❑ Windows 0 Insulation ? $
° /Covers aEntry Doors n
Mho..,. 2496 Demob ofCouractAnotnedeetpanepxv6en antis contract. Total Contract Amount $ -•?_ . 4
Maine Purchases may net deposit more than asellird of the Cataract Amami. - }
Customer agrees that, immediately upon completion of the work for each Product, Customer will execute a CompletionCertificate
(one for each 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(s) 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 timid, asbestos or lead paint, other safety concerns, pricing errors or because
work required to complete the job was not included in the Contract
Paymuart Shmrmam The P a y m e n t Summary # 41 t ( 4 , 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 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 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 'nitre DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance anSi Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home pot 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.
Submitted by. /��
/.�.. . Cry_ X �1 t �J (r-`
Caato ../. Si a Sales Consultant' Signature Date
X Telephone No.
Customer's Signature Dam
Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS (as applicable)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE. ? ' .7;2; -
NOTICE: ADDITIONAL Timms AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF TJ1LS CONTRACT
8 C-SC White - Branc*h Yellow - Customer
- .
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 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
iliermits 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
Date
Address of work
location
,
. . .
• The Commonwealth of Massachusetts
= I -.. ■ ,..! Department of Industrial Accidents ,
1 =,== a
=7,4ii :44' Office of Investigations •
t rg-sunt_= 5
600 Washington Street
i =n49-4
f =. 47 . Boston, MA 02111
....–..-
www.mass.gov/dia •
_..
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name pusinessiorganizationandivirhi.o:
•
- • Address: .. •
City/State/Zip: .. Phone.#:
Are you an employer? Check the appropriate box: Type of project (required): /
• 1. 0 I am a employer with 4. 0 I am a g-•.e . ontra :or and I
6. 0 New construction
employees (full and/or part-time).* have hire. ii e sub-co . ctors
listrd o . .. e a .. , "A sheet: 7• 0 Remodeling
2. 0 I am a sole proprietor or partner-
These . ontractors have
• ship and have no :)Ioyees 8. El Demolition
working for me m any "
capacity. ePoPloYePs 4.4c1ba ,..r workers'
- _ _ - ,, 9. IDISTuildiiii addition
[No workers' comp-. insurance _ comp.nas , ir . . . - .
• El We are a COlp a - . II • ■ and its 10.n
recluire4-1 Electrical repairs or additions
3. 0 I am a homeowner doing all work officers have txercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. Hen of exemption per MGL 1—/ – ..
12.0 Iwo' repairs . •
insurance required.] t c. 152, §1(4), and we hav ..
13.0 Other
eniployees. [No wo ..-, '
- • comp. insurance =quit . /
*Any applicant that checks box #1 mist also fill out the section belatv showing their woricers' . ... -_,..4.- .. . dicy information.
t Homeownera who submit this affidavit indicating they are doing all work and then hire outside .. . • - ..,. must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-con • .4f. ,• d state whether or not those entities have
employees If the sub-contractors have employees, they must provide their worimrs comp policy number. •
lam am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. • .
Insurance Company Name:
•
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:" • " ' - .
Attach a copy of the workers' compensation policy declaration page•(showing the policy number and date).
Failure taste= coverage as required utiditr Sectidif 25A Of MGL c 152 can lead to the iinPositiOn of Criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonmeng as well as civil penalties in the form of a STOP WORK ORDER. and a fme
. . .
of up to 5250.00 a day against the violator. Be advisecithat a copy of this statement may be forwarded to the OfEthe of
afeitiiiiiOffs of thiDIA iiitnce coverae coverage irelifiCiii: -
_ /do herelyycertift under the pains and penalties ofperjray that the infornuttionprovidediaboveisinte_amliorrect— _.
_ . .
Si • znature: , Dalr: • ,
f
Phone it: -
. . .
Official use only. Do not write in thLs 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: �� � 1 � � ^ & Not Applicably
Name of License Holder : (�
License Number
.. 11,..
�. - q iy,
Address ,/ Expiration Date
Signatur: Telephone
.:;tie sFtbmi3 tti 40i a ' " "ent Goritiiactiie _. r : Fr : Zigii Not Applicable ❑ C
Company Name e_ 1 Registration Num
`C/
Address �� Expiration Date
A k O(r?' ( Y 01 14:07Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building p it.
Signed Affidavit Attached Yes q No ❑
11rz Im hiciteriaxefitiitioit
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 - near 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 Windows Alteration(s) [J Roofing E]
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other
Brief Description of Proposed
Work: .ii 11 11 Mo. ■ ,
Alteration of existing bedroom Yes _ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
a te -:
a [ e o s and or a ct are xi� ttnQ ht�usi ia atrit l + €i�llr nit:
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 la'- OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , v ` 2 j j'4 rr , 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.
ft Q
Signature of Owner Date
I 1 l 0h� — , as Owner /Authorized
Agent hereby declare that the stments and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under th- ns and penalties of perjury.
Print Nan >//4.
ardi MI. Al&
Signature of Own= /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
1 j _ .
Lot Size E 1
Frontage ( ' - .--- --
Setbacks Front I i ("'
s
Side L:{ ! R:i ' L: ..__ R:` __i
Rear
l
Building Height { !
1
Bldg. Square Footage 1,--1 r I% ( ; I j i
Open Space Footage %
(Lot area minus bldg &paved i„ t u.-
parking)
}
# of Parking Spaces t -i _
Fill: . � _ ..,_..w ._q_.. - _ a_ .... �._�
(volume & Location) I ' I
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
1
IF YES, date issued:; 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book Pagel 1 and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained fQ Obtained
0 ,Date Issued W,.
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location: 7
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
IF YES, describe size, type and location: 1
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 iQ
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton I `
Building Department g - 1
n 2 212 Main Street
Room 100 -
Northampton, MA 01060
phone 413-587-1240 Fax 413- 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
Map Lot .Unit.
{ 1.1/16 i Zone Overlai(Distrct
1 I ELM St. District' ? CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) �+ Current Mailing Address:
p.e' C 1 i ,C. Telephone
Signature
2.2 Authorized • =nt:
! �►� t ��1 r _ If
Name (Pri . Current Mai ing Address:
+a * 1 4(3 / I,1 `
Signature Telephone
SECTION 3 - ' ESTIMATED ..CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) ) -71e Check Number 6,4
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
BP- 2011 -0564
GIS #: COMMONWEALTH OF MASSACHUSETTS
• CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP- 2011 -0564
Project # JS- 2011- 000931
Est. Cost: $11176.00
Fee: $30.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES
Lot Size(sq. ft.): 12327.48 Owner: SANTIAGO CARMEN M & WILFRED
Zoning: URC(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 25 FINN ST
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 () Workers
Compensation
WORCESTERMA01607 ISSUED ON:12/21/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 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:
FeeType: Date Paid: Amount:
Building 12/21/2010 0:00:00 $30.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner