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25A-037 • itMPROV Eltrr cwt r V . Q :::`::_ PLEASE-READ TW , ' . Sold, Furnished and Instaiied bye . Branch Name: Boston ' . Date: ,_/ 27 .. THD At -Home Serviaes;'1nc. . r' • . d/b/a , The Iome Depot At -Home Services . 345A(ecnwood.Street, Unit 2, Worcester. MA` 0 Branch Number: 31 • • Toil Free(800)657- 51'82; •Fait,(508) 756- 8823 Federal ID # 1 ' 75:2641t4ii0 ;.ME Iic. # G'02439; 81-Cont- Lde #' 16427 �-� # 22; lead a ' or R eg. # 6193 ) � Installation Address: 4� «\ 7S.. CT Lic . s... ..: .0. VII ..6 ... .. ... . . City • • .. Zip. . �v. Parchaser(sy,, w Phone • Ronde P .. :. ell Pion: !PAid y ur% 'Ke.v izenok [ . J . .{ . ... '. [. C '. ] ;, . . . . . [. 1 [.. . [' .1. J . ;acme Address: , . . .. . (If different from installation Address) City . State Zip E-mail • Address Oct receive project cornrrmnicationa and,Hotne Depot updates): • • ❑ i DO NOT wish to twelve any marketing ensailS from The.plop ii Depot . .. , • Proms' t' lnfaruoa onl: Undersigned ("Customer"), the owners of the located at the.abore mstalledipn ad&esa, agrees io .buy. ' and TIED At -Home Services, Inc. (`"the Home Depot") agrees to ftrr deli*ier aid atfange. ;fen ;tl�a installacions(`Iust�ation ") of all materials described on the below and on the referenced Spec Shoct(a), all. of wbich.are ` ated into this Contract by this reference, 'along 'with any applicable State Supplement and Payment Summal•y a ttached-,ltete'ki y:C1tairge Orders cgikecsftvely, "Contract "): Job #: taw..n": Mateo) ' • R s2. L211. : , : f lust A>moa ■Roo iSiding 7 Windows U Insulation s L g i - 0 oGiutters /Covets n . .. , , rs o : . . _ 1' I y I :', ■Roofing ■Siding • Windows • Insulation DOutters,'/ Covets Othtry t)oora n . '• Roofing •Siding O Windows DInsolation . • 1111111111111 DCrutters / Covers Dt?ntry Doori ❑ - S II ��• p(. poling r Covers Entry Doors p Insulation __;_ _ Mialzar m 25% Deposit of Contract Amount due apon,eretatieri Odra MutCac> . ' ` •, mane torero/ma may not dcpoet more Man mecum gt mopontred Amou rt. . a $ �[a. �t m.. Customer agrees that immediately upon'oonrpletion.q •tl i roa iar'.gal,,F odn C maf',!d1I.! rein . } , (one for each Product as defined. by an indi aditak'Spee'Slteet.) pay avY l ialaznce due -, ,As appifcable, each Cusforrie't: under this Contract agrees to be, joitndy and Severalty obligated and' liable hereunder. - . The !Tome Depot reserves the'ight to isatie a Cbanga Order trr'tertninite 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 perfotrit.tts.obligations due to a stnict:Mil problem with the home, environmental hazards such as mold, a#bestos or lead paint, oiler safety Concerns, pilling errors or because wor)crequired to complete the job was not Included in the .Contract. Payment Summery: The Payment Sununary # t L5 3 . included, as..part of this'Contract, sets forth. the total Contract amount and payments required fbr the deposits and.f1nul payments by Pnodnat (aaapp(icable): '.... . • NOTICE TO CUSTOMER ` You are entitled to a completely filled-in copy of the Contract at the time you: dim 'Do not tigri a Coiieptetion Cer e.(nate: there is one Comptetlon Certificate for each listed Product as deflated bY, obiuidtial'spec $Ireetsyb'atbre weds w 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 termhtation, plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE }TOME DEPOT FROM THE DEPOSIT PAYMENT OR OTITER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authofizatinu: Customer agrees and understands that this Agreement is the entire agreement between Customer and 'The House Depot with regard to the Products and Installation services and supersedes all prior discusaiona and agreenamtts, either oral or written, relating to said Products and Installation. This Agreement cannot be assigned or upended except by a writing signed by Customer and The Horne Depot. Customer acknowledges and agrees that Customer has read, understands, voluntarily accepts the terms of and has received a copy of this Agreement. pt by. Acre S Dtl DLI 4.2- 7. Custumtz 5 Signature Date Sales Consultant's Sign tare Date ` X • - Telephone No. Customer's Signature Date • Sales Consultant License No. . CANCELLATION: CUSTOMER MAY. CANCEL THIS (asaop)tcabk) • AGREEMENT WITHOUT PEN,&LTY OR OBLIGATION . BY DELIVERING WRITTEN NOTICE TO THE HOME ' DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AMR SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE I5 ' SPECIFICALLY PRESCRIBED BY LAW IN . CUSTOMER'S STATE. NOTTCa: ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS COretnatT ' 4-20 C-SC • Mute — rancnFile Yellow 7 Customer Pirtk— saws ccnsudtaunt . . .‘A. B a • o i i : . afindk, a a r 's (jel6 One Ashburton Place - Room 1301 - •=1.3!_ ) Boston. Massachusetts 02108 . •_. .. Home Improvement Contractor Registration Registration: 152156 Type: Individual Expiration: 8/4/2010 Tr# 0 DUN PRO . .. JOHN MCNEE 15 MRECEDES STREET CHICOPEE, MA 01020 " Update Address and return card. Mark reason for change. Address Renewal : ! Employment ' Lost Card b'S-CA1 o 60M-07/07-PC84G0 1 Cr ' -: '' _ 11 -.s , k0Ile , k.'it. : rn.':' li'l ), 0 , ' '' *' ;•,: ',;. i: , 130,in) 4 1iiih1;n!. LIcense: CS SL 98461 — Restricted tc: WS JOHN MCNEE _. ';,' 4- • 15 MERCEDES STREET CHICOPEE, MA 01020 q. --............ ___--,.......-..,. E.pir3t;on: 9/30/2011 Tr 98461 The Commonwealth of Massachusetts OM _ Department of Industrial Accidents 1_ Office of investigations _= 600l ashg Street Boston, MinA to 02111 ° www.inass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Con tractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business / Organization/Individual): E of Address: . j1 ii . 'IL, e City /State /Zip: OtI4 ) , � J 7i' Phone. #: % T (767 5 Are you 4. an employer? Check the appropriate box: tt —C�j/ ❑ I am a general contractor and I Type of project (required): 1. I am a employer with i0 6. [7] 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 aci employees and have workers' g any capacity. �' 9. 1:1 Building addition [No workers' comp. insurance comp. insurance. required.] 5. El We are a corporation and its 10.0 Electrical repairs or additions 3. [1 I am a homeowner doing all work officers have exercised their i i.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. tier t-te) [` ©U3e> 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: Li ) ' 1 16' . S LLi Policy # or Self -ins. Lic. #: J,( Expiration Date: / 1 Job Site Address: L4(, 3r' 1A City/State /Zip: , A dig „ /I s, V a.. Attach a copy of the workers' compensation policy declaration page (showing the policy number and expir. ion 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 civi D - :. = t • . - . • . • _ ! ' . ! ! '_S : ' .. of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi un •r e p s an penalties of perjury that the information provided above is true and correct. Si• ature: ‘. /Se • aft Date: _A 0 " Phone #: 1 19, j v( 3 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: The Commonwealth of Massachusetts -- Department of Industrial Accidents .4" Office of Investigations 600 Washing ton Street Boston, MA 02111 www. mass.gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors /EIectricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Address: City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ 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 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other 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 nacre 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. 1 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 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: 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 #: 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 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 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Numbe 15 rzalles C ts op oae3 qi?C14/ Address Expiration Date 149135? U3'3 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑/ Company Name Registration Num p an v 9 Address Expiration Dat Telephone 1- 10` 5a//y33 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 mit. 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 buildine 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 • f r SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Wi ows Alteration(s) n Roofing n Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [O] Other [D] Brief Description of Proposed �11 Work: �"'t' -� (4) � 01%6 11 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 additio o existing 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 , 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 c?le'VQ , as Owner /Authorized Agent hereby declare thhe statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the p alp nd pe -= • •erjury. _ Print Nam '1 . �' � � J A' l / ' Signature • Ow 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 ...................... Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 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 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 0 Obtained , Date Issued: C. Do any signs exist on the property? YES NO I IF YES, describe size, type and location: !; 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status i of Permit Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /SepticAvailability Room 100 Water/ Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans Other Specify 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 14 q47a( Zone Overlay District EIm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Oliof Record: v, m\fiCr Name (Print) Current Mailing Address: Telephone Signature 2.2 Authoriz •ent: F 16-a !IL . a . r:.�� Old Name (Print Current Mailing Address: 41 . 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) ° i9to - ° r Che ck Number69S eo This Section -For Official Only Permit Number: Date Building Issued: Signature: cT772- Z,/ J 0) Date Building Commissioner /Inspector of Buildings l .46 MARSHALL ST BP- 2010 -0081 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25A - 037 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit # BP- 2010 -0081 Proiect # JS- 2010- 000087 Est. Cost: $1396.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES Lot Size(sq. ft.): 5270.76 Owner: KEVREKIDIS PANAYOTIS & MARIA E NIKOLAOU Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 46 MARSHALL ST Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 0 WORCESTERMA01607 ISSUED ON: 7/22/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: W indows 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 7/22/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo