37-010 (4) -� 545A Greenwoo Street Wirfr'e ter MA+hal
Branch Number: 2 -*-' (' a — Job #: J i I 5 Toll Free (8D0) .57-5182; Fax: 508- 756 -2859
Federal ID 0 75- 26984&) ' Lk # C 02439 kJ Cont . Lic!! 16427
(4:7 v)- 1�
�" CT Lk 0 565522; f Home ! provement Contractor Rcg. 9126093
Installation Address: � k O (QC„ iS 17 ` -. , " La ' ., d'
(
City State Zip
last 4 Digits of Driver's
Purckaser(s): Lic. t* & E . • MofY: Work Phone: Hoare Phone:
% a'f 1 ''Tu Milgil, ( ) (Li 5 - 5.4 1 1
Home Address:
____
(If different from Installation Address) City State Zip -
E -mail Address (to receive updates and prornotionkfrom The Home Depot):
Project Information: UWe/You ( "Purchaser"), the owners of the property located at the abo e installation address, offer to
contract with THD At -Horne Services. Inc. l Hgtpe .S� pypot ") to f imisb, deliver and arrange for the installation of all materials
as described on the attached Spec Sheet # \ `I. 3 , incorporated herein by re erence and made a part hereof.
Dome Depot reserves the right to cancel this contract if, upon re,inipeetion of the job, ` . me Depot determines that it
cannot perform its obligations due to a structural problem with -the home, pricing errors or because work required to
complete the job was not included in the Spec Sheet or Contract.
DEPOSIT PAYM T OPTIONS
` (Subject to fund verification and/or credit approval.)
CONTRACT AMOUNT $ 1 l 1. Check *, Cashiers Check or US Postal ice Money Order
L { i � rr ''' (Made payable to The Home Depot). DEPOSIT S r IL il l
J
2 . Credit Card" and /or other payment• •tions - Ctrck One aetow
BAd.NCE DUE Visa MasterCard Discover Am.' • Sirpress• - - -•�-
y
ON COMPLETION $ �✓ 39.0. • The Home Depot Home Improvement , • The Home Depot Credit Cant
tMlnlmum 25% of Contract Amount due upon 0 New Account ❑Existing Account (1111 & HD -a . •
execution of this contract Available Credit: $ (Ii1L & HDCC ON I. Y)
-.
Indicate Payment Method For Accdt e 7„P... ars
BALAN DUE N COMPLI TIIOPlVti • ; iv ,..
\ /. i► y Name as it tootaia' ' tb ik ' • ..0r f !., �-1
O , ���� V p(si a '**ttl,k yty
"By t our signature beloww, I/W agree to allow Home Depot to
633 - 3 . � , ` 2 , 4 4 f 03g --) t ge a e refernie for th,e t indice
•when you provido a eh ck as payment, you authorize ua either ` .. Y �. C )
50 use information from your check to make a one-time electronic ; tit' , 9 to
fund transfer front your account or to process are payment as a - -
chock transaction. when we use isfucrnetloe from your check to
make an electrook fund transfm, funds may ba withdrawn from HIL or HDCC Aut ortznlion Codes
your account as soon as the payment is received, and you will rot Deposit I Final Payment -
receive your check back. # 1 t - 7,4,1 I # «34. a . .
Purchaser agrees that, immediately upon completion of the work, Purchaser will execute a Co. pletion Certificate and pay any
balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder.
Entire Aereernent; This agreement and its attachments, including any financing agreement, contain the complete agreement
between the parties and can not be amended or modified unless in writing in a separate agreem nt signed by both parties. .
NOTICE TO PURCHASER
Do not sign this contract before you read it. You are entitled to a completely filled -in c . • y of the contract at the time
you sign. Keep it to protect your rights. Do not sign a Completion Certificate before t Is project Is complete. Law
prohibtta borne repair contractors from requesting or accepting a Completion Certifica signed by the owner prior to
the actual completion of the work to be performed under tae contract.
You may cancel this transaction any time prior to midnight of the third business day aft- the date of this contract. See
Notice of Cancellation for an explanation of this right. There will be a service cbarg: equal to l0% of the contract
amount if job is cancelled by Purchaser AFTER the third business day, but BEFORE m terials are ordered. There will
be a service charge equal to 25% of the contract amount if job is cancelled by Purchaser - FTER materials are ordered.
BY MY /OUR SIGNATURE BELOW, EWE UNDERSTAND THAT THE AGREEMENT 1' Y BE SUBJECT TO REVIEW
OF MY /OUR CREDIT HISTORY AND I/WE AUTHORIZE HOME DEPOT TO VE • a Y AND REVIEW MY /OUR
CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND - LEASE THEM FROM ALL
LIABILITY INCURRED FROM INADVERTENT OMISSIONS OR ERRORS.
BY MYIOUR SIGNATURE BELOW, UWE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. I/WE
ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLE D COPIES OF THE NOTICE
OF CANCELLATI N. .. /
SUBMITTED BY: , I 1 �� C ^ Date: t • I' b
.:s ma an r r b
ACCEPTED BY: _ � r l / D ate: 5.•
T
((( eerenfdilr
:....//_r _ =2.r /Ni1.I.,i. Date .. in t
• urc . er
NOTICE: ADDITIONAL TERMS AND CONDITIONS ARE STATED ON E REVERSE SIDE
AND ARE PART OF THIS CONTRACT
6-1 -07 rev 4-2-07 C -SC Mite — Branch File Yellow — Customer Pink — SalesConsul.nt
t
L ' Cl XFid 13C? BSH1 dH WUB T c S LOOZ tr T unC
i rctYAMp i
�� �? 'lit (rt of Northampton = *=u —.
�� j ail iassadiusetfs I _ - -1— -
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DEPARTMENT OF BUILDING INSPECTIONS _'• /%
INSPECTOR 212 Main. Street • Municipal Building '
Northampton, MA 01060
. I'
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as Lis /her construction sup ::.. sor. 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
Department of Industrial Accidents
/ .
Office of Investigations
I 600 Washington Street
=4
Boston, MA 02111
`,M �, www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): 1EE th-i
Address: r9 - - ‘ai e
. c;(1',,i0
City /State /Zip: r a ,
Phone #: "ATI (67 ,5
Are y an employer? Check the appropriate box: Type of project (required):
1. r u t / I am a employer with ja) 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part- time).* have hired the sub contractors
listed on the attached sheet. 7. ❑ Remodeling
2. [1 I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. ❑ Demolition
for me in any capacity.
employees and have workers'
working Y P ty. 9. ❑ Building addition
$
[No workers' comp. insurance comp. insurance. r
required.] 5. Li 10 . We are a corporation and its ❑ 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' cou right of exemption per MGL
m
Y [N t c. 152, § 1(4), and we have no 12. ❑ Roof repairs
insurance required.]
employees. [No workers' 13.der
i Oil
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. f „_
Insurance Company Name: t\i j t) (7(r.( //,�'� (Y6 L 6/
Policy # or Self -ins. Lic. #: gi , Expiration Date: ? j ilf
Job Site Address: 42-23 Flb � �� City /State /Zip: D /yl Qt-� r
Attach a copy of the workers' compensation policy declaration page (showing the policy number and ex iration 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
Investieations of the D • or insurance coverage verification.
I do hereby certify de t s ai 4 and penalties of perjury that the information provided above is t ue • nd correct.
/
Signature: 01111 ..Date: ,j'
Phone #: a c
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 #:
r
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor,: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Reeistered'Homedmproveinent Contractor: Not Applicable ❑
----P2VIT I (5
Company Name Registration um e
Address -� Expiration at
�� D 7 Telephone ________
SECTION 10- WORKERS' COMPENSATION INSURANCEAFFIDAVIT'(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 permit.
Signed Affidavit Attached Yes ❑ No ❑
11
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 EJ Addition [J Replacement Windows Alteration(s) n Roofing ED
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [[] Siding RP] Other [D]
Brief Description of Proposed ( '� ' / k, Work: 1-1 , / /r,
Alteration of existing bedroom Yes No Adding new be• nom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house or addition} t6 isttna` toueiinct 5 C6ii pteterrthe=fottowiInct:
a. Use of building One Family Family Other
9 Y Y
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
I, C c 1 1 artL1 , 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, ( ) , as Owner /Authorized
9 hereby Agent hereb declare that tatemen an ...1.2_ d information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the p and pe s of perjury.
• _ tI .
Print Nam
Signat f f r iiwnerlAge t Date
i
r
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
LotSize _._ .._._----- ----- .... ---- _________
Frontage ._.------- - -____ __--
Setbacks Front _
Side L:._._....._ R :!__ L : _ _ R:`____- _
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 DON'T KNOW 0 YES 0
I
IF YES, date issued:•
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DON'T 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 Q
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 i
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® 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.
• 1
f ry
Departmentuseonty
City of North ampton Status of Pe rm it `:
�_ -. - D e p artme nt urb Cut/DriyewyP e nnit
.- t � � Street •SewerlSeptt f i ify � 100 Ua f er /Wet 6 Avaita btttty
JUN �Q�} Nortf ampton, MA 01060 T wo S of Str Plans
pho 41 3.587 =1240 Fax 413 -587 -1272 OtherSpe Piot/Site Plans
P L _ �_ c i f y
DP -,, ,-
( APPLICATION T1 C ,IQ ( STRUCi T, ALTER, REPAIR, RENOVATE OR DEMOLISH A O OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This s ection to be completed by office •1.1 Property Address:
�/ Map t ot U ni t _
��
FID'YF-e Zan ` . Overia Distrac
E im S t District C @Ais trrct
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
Ri 2.1 Owner of Re d
4:111_ 1)4 rt.(
Name (Print) Curren Mailing Address: ', i
me All -101
Telephone y
Signature
2.2 Authorized Agent:
J r
Name (Print) Current Mailing Address:
1
Signature
SECTION 3 -
Telephone
ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by perm
0 it applicant
(a) Buildin Perm it Fee
1. Building ��� O 9
2. Electrical (by Estimat TotalCost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
5)
6. Total = (1 + 2 + 3 + 4 + Date
� �--- Check Number / $7 t2?5
This Section For Official Use Only
Building Permit Number
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
BP- 2007 -1242
GIS #: COMMONWEALTH OF MASSACHUSETTS
x 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- 2007 -1242
Project # JS- 2007 - 001980
Est. Cost: $12585.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 126893
Lot Size(sq. ft.): 26571.60 Owner: MARTULA ROBERT A & SHARON A
Zoning: SR Applicant: HOME DEPOT AT HOME SERVICES
AT: 623 FLORENCE RD
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 () Workers
Compensation
WORCESTERMA01607 ISSUED ON:6/20/2007 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS & SIDING
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 6/20/2007 0:00:00 $25.0018728
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo