32A-235 YLLASI JCLtf1 1 •
' .Sold. Furnished and Intitalled•by''
Branch Name: Boston • hate: .. .9/V. • 0 . . '1 T ] At- )llama Services, Inc.
. . , , • ... • d/b/a The Home Depot At-Home Service's • `
. . 345A .Greenwood Sheet.: Unit 2, •Wonowtez, MA 01607
Branch Number: 31 . • Toll •Eree (81)e) 657:-5 t82 ;, Prot .(50t1) 7564823
. . , Federal IU #.75- 2698400; ME•Lie.# C.(i2�T39c RI' Cont. LitO 16427
:CT Lk 0 %55 MA ' .. . i " ` .aengK Ce�aunctor. R * 125893
Installation Address: •.T� M (L ..- r� c tom:' ' .. jet i 3'1 0 fpo
7 4 . _:__
City' Staau Zip
rarNUaer(3g. • Work Pheae: : Hem Phone: CellPhonet ' •
. [. ..:.1 •' • ..... I . : ,.1 1,. , ,. • •
R'omeAddress:
(If difltrent from Installation Address) City State Zip i 11, LA)
&man Address (to tecedve project comniunicatharoand Hothe Depot updates):• ' •
u 4 Do al tvisli to receive any rrdrketirrg emaila tom The:Horire;Depot • . . .
Pro e a coat ar: Undersigned OCustomer'); the ownere o£•thdpropetty iacatedat the'above installed.* addre agxebs to boy
an T At- ome ery ices, Inc. ("The Home Depot".) agrees ta' delrvcr pail. arrangel'or the • instillation ' �� lartor'� of • •
all materials described on the below and on th4 re> d' Spec Sheets , .alVef which are ioseep steel mto dtla Contact by this
refelence. along with any applicable State. Supplement and Payment S1>mttaaty.a hens gnn4 aro Charge, Orders (collectively, .
"Contract "): .
Job Sr ltm.,aY taram.e) oductc: sp sha ).let P • eel A • . •
i ORoofulg DSiding, Windows UInsulation -
1105 t )f ;N Datums / Covers QEniry Doors ❑ _.- , ' . ' ".1 . 3 ..
, ❑Roofing, DStdiug 0 Winos "0 Tasulati� $ .
❑Gutre:s ! Covets pFntry boors El.„_,, , . • • .
ElRuo8rrg• USiding U Wir„iaiws Er inwilaiioa i
• DOutters / Covers E•Ettu •Doors ta__. .. •
❑PgoHag OSidmg El Windows UTnsulation' .. , •
00Vlteru / Cuvhxe. DEmry boors Q • •
•
Minimum 25% Drpasitof Contract AmOant due apes emotion of dda contiyeQ; .. , . " '�
T o '
Mail Partllriert may not deposit mare than one ,third afiheCertrh ctAAaooat • tem Co t rict' tkmouut S i i
Customer agrees that, immediately upon completion of the wOr4• for each. Prodnot, Ctistbniter will' executae a Colnp}etion Certificate
(one for•oaoh Product os defined by an individual Speo Sheet) and pay any Tral.n ea
ce due: As appliosble, ch Customer under this ' • Contract agrees to be jointly and severally obligated and liable hereunder. '
The home Depot reserves the right.to issue a•Cbange Order or terminate this Contraeror arly•individual Products) included herein at
its discretion, if The Home Depot or its authorized service provider determines that it Cannot perform its obligations due •te'a.atructurai
•
problem with the home, environmental hazards Sucb as mold, asbestos ,or lead paint, other,aafely conceits, pricing errors or because .
work required to complete the job was not inohtdcd in the Conuvct ..:.....• . •
pavaaeat Samisharvr The payment Surnnrary # "�"- _ • hncl'aded:as :parr Of this' C'ontract,•seta fnrth'the total
Contract amount and payments required for the depoaits'and final paytt5ents by Product (as lip cable):
• NOTICE TO CE'STO>,,,
Yon are eatftted'to a completely tilled -in copy of the Contract at the timts'youssig D'o Mit tai a Cenipletieii C'ertificate (note:
there is one Completion Certificate for each listed product as delint4 by ii 'dMdatd• Sees •Sheehs) before work of *hilt Pred ict
is complete.
In the event of termination of this Contract, Customer agrees to pay The' Home enema the coots of materials, labor, expenses
and services provided by The Home Depot or Authorized .Service Provider tbroogh *rte date of termination, plus any other
amounts set forth in this Agreement or allowed under aapppplicable law- TIME HOME DEPOT MAY WITIDIOLD AMOUNTS
OWED' TO THE HOME DEPOT FROM THE DElsOSIT PAYMENT . OR OTHER PAYMENTS MADE, W�OUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS -
Accsptan Mid d Antbortxatron: Customer agrees and understands that tnis• Agreement is. the enure agreement between Customer •
and T 'he'Home Depot with regard to the products and lnatallaeion services and supersedes ail prior discussions mil agreements, either .
oral or written, relating to soul Products and Installation This Agreementcanaot be assigned or amended except by a writing signed
by Customer and The Homo Depot. Customer acknowledges and agrees that Customer has read, understands, voluntarily accepts the
terms of and has received a copy of this Agreement. '
• rti t �
Accep ■ iy: S
/ ({ ,o9
" tamer ' s Si .... - r ate Sales Consultant Signtu re • . Date • •
• X • _ Telephone No. ` _
Customer's Signature Date Sales Consultant Licence No. w-
CANCELLATION: CUSTOMER 1v1AY CANCEL THIS (ailspelt:able)
AGREEMENT WITHOUT PENALTY OR OBLIGATION .
. BY DELIVERING WRITTEN NOTICE TO THE HOME •
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS , •
•
ISAY A1 SIGNING THIS AGJ B! MENT. TEE •
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO YTSR IF ONE I5 •
SPECIFICALLY PRESCRIBRD BY LAW N' . .
CUSTOMER'S STATE. • •
sort* e Abarr5ONAL TERMS AND CONDITIONS ARE STATED ON TUE REVERSE. SIDE AND ARM PART or TAB CONTCAAC'*
7 -13-00 C -SC While- $ranch Flla Y.ebow - Customer Pinar Sale's Consultant
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_ � ' � 77 r.0127I;io1Zw? alt Of :'Iasszch setts
I ^T # - ./.''%121 ii t r'?. r r .3!x'1 ;'trial fi ( '?de:-I?`.�
L3ptilsCetri ?0y11'atai -s ; kte } F f 'i�
. G 1
Name ( Business /Organizationflndividual):_— J r _ `
• Address: ® _.'..it - ii '. _ . -
City /State /Zip: Y —ter �� phone. #: O (.051_5_
Are yoyt an employer? Check the appropriate box: • Type of project (required):
1 • WWI am a employer with O a_ 4 • L I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. 0 New construction
2.1 1 I am a sole proprietor or partner- listed on the sheet. 7. 0 Remodeling
ship and have no employees These sub - contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.
x • 9. 0 Building addition
required.] 5. Li We are a corporation and its 10.0 Electrical repairs or additions
3.1. 1 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' 13.1g (:(th N t.-114
comp. insurance required.]
`Any applicant that checks box ft1 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 rnust submit a new affidavit indicating such.
tContractors 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-he policy and job site
information.
Insurance Company Name: k ,p • •. sets'
_ L
Policy # or Self -ins. Lic. #: lc ' Expiration Dater
rr�� • • --
Job Site Address: oC d i'o Wl8(' \P(�r Gr City/State/Zip:i6orthothl )" (�
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 ac civil .penalti m_ef -a-STe • • e'_ e! e. - ' • _ . .. • .
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 unn•r e p' s an• penalties ofperjury that the information provided above is true and correct.
Si_ ature: Ad ..L / e • Date: ?/01//0 /''
Phone # /
t
Official use only. Do not write in this area, ter 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
Dhnno it.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : h v.-00Y IDLI (el 1
• License Number I
�: 9dlln
Address Expiration Date
.v. . L • &II . •
Signature elephone •
9. Registered Home ImprovementiContractor _ .ti, ,'' Not Applicable ❑
Company Name Registration N b
. 4 • ea, • . /10
Address " / Expiration Date
Q J4 ,,
[/ Telephone �U` �__
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 buildirermit.
Signed Affidavit Attached Yes CV No ❑
11. - Home Owner Exemptio
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 El Addition ❑ Replacement Wows Alteratiop . • t - oofing r7
Or Doors [yam t
•
Accessory Bldg. ❑ +, . Demolition ❑ New Signs [p]. , _ • •Deck . Siding •O er •
Brief Description of Proposed — . • j ( '
Work: — - .• 1��_ 1 _ '��, - A: #i a� - rtit '
%NW'
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 atld or addition to existing housing, complete,the foiloWIndt:.
•
a. Use of building : Orie 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. iq Signature of Owner Date
, as Owner /Authorized
Agent hereby declare that the s atements an in ormation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pai wiii -4d penalties of perjury.
Print N%j,���I,�/
&g r re .f Owner /Agent Date
r . b I,
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:'
Rear _ , _ ,
Building Height , _ ,
Bldg. Square Footage % _
Open Space Footage %
(Lot area minus bldg & paved .. ...,...,_
parking)
# of Parking Spaces
•
. ..
. ' 7 .. • Il'• -*. .• * ,* - I •
Fill:
,
(volume & Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
-• NO -. 0; ' DON'T KNOW. ,C) ., ' 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
0 , Date Issued:
C. Do any signs exist on the property? YES 0 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 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.
_,
De sa1tment us e only
r �R�
City of Northampton Status cif Permt
Building Department Curb C`utJDnvew E 'srmtt '
212 Main Street sewer/SeptrcAvaabtttty
Room 100 WateriWeirAvaifabtltty -
c'j Northampton, MA 01060 Two Sets of Structural Plaris '✓
norione 413- 587 -1240 Fax 413- 587 -1272 Piot/slte I?ians
� t � Over 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
k fTG4�e Zone Overlay District
C)vorne(riy Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
111,41zr
.. ]� �a - !)_ c----9,34115:3-..
: .1.� A-';'' ill" It:. (Print) Current Mailing Address:
� e 6#r4(1 Telephone
Signature
2.2 Authorized Age";
eel _14DzIM-- I,onr("4i t DI‘
til?CrA 11
Name (Print) Current Mailing Address: ii,i.._
e ir Ai
Signature / Telephone
1
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) >.� —' Check Number 1 �
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
S �
20 POMEROY TERR BP-2010-0308
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map :Block: 32A - 235 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- 2010 -0308
Project # JS -2010- 000409
Est. Cost: $4747.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 126893
Lot Size(sq. ft.): 28401.12 Owner: SHAFFER JUDITH K
Zoning: SC(40)/URC(60)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 20 POMEROY TERR
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 0 Workers
Compensation
WORCESTERMA01607 ISSUED ON:9/22/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 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 9/22/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo