17C-251 (5) HOME IMPROVEMENT CONTRACT
.-- ----1 t "i� PLEASE READ THIS
r, I ,,.t Sold,Furnished and Installed by:
Branch - North&South Tlate:w r2 r 437_ TI)At-Home Services,Inc.
JUL - 124 ,b :31 and 33 d/b/a The Home Depot At-Home Services
908 Boston Turnpike,Unit I,Shrewsbury,MA 01545
Toll Free 577-903-3768
•s C;:,s Inspections a1 Piet ID#75-2b9&t60 MEL;e#C 02439i RI Cost tic#16427
r 'i CT Lie#HIC.0565522;MA Home Improvement Contactor Reg.#126893
01060
City State Zip
Work Phone: Heave Phase! Cell Phpae:
11 040(4,_.______....'1___?. e-_}3. tOAt?v t , [ I [ ] [ ]
[ ] , [ ] [ ] ,
Home Address:
Of different from Installation Address) City State Zip
E-mail Address(to receive project cturnnunicatiats and Home Depot updates):, —
I DO NOT wish to receive any marketing emails from The Home Depot
ProiecLlaforg ation: Undersigned("Customer").the owners of the property located at the above installation address,agrees to buy,
and THD At-Home Services.Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("llasmllation")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,
"Contract"):
Job#: ona.,t anm..et ".■acts: S ,..,a fh Pro ect Amount Rootiing •Siding t indows U Insulation
a+.Ian °G utters i Covers C7sr,try Doors p_ -- 3�� $ . e s 6
•Roofing N Skiing ■Windows • Insulation
DGueeers l Covers Pantry Doors Q_ a '/);'(-4`P MEM—!"jRoofing Sidii ij Windows U Insulation
DGuttets f Coves!]Entry Doors p $
Roofing Siding U Window/51_1 Insulation
[]Gutters/Covers ❑Enn Doors 0 $
MLniaaus2S%Deposit of Ammuutdoe open execution ofthiscontract. Total Contract Amount $ 3is 1 ww
MeiMein Purebesers may cot d mere than eoathira Otto Contract Amount.
I
Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Cerifoate --,
(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 hcreuadar.
The Home Depot reserves the right to issue a Change Order or terminate this Contrast or my 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 mold.asbestos or toad paint,other safety concerns,pricing errors or because
work required to convicts the job was not included in the Contract,
Snmwarv: The Payment Summary# Oti it 3:7(0_ ,included as part of this Connect,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 tam l etely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:
i
there is one Completion Certifcate for each listed Product as defined by individutal 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 ServlpeS provided by The Home Depot or Authorized Service Provider through the date of termination,pis 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 DEPOT'S OTHER REMEDIES FOR RECOVERY OP SUCH AMOUNTS.
�cce utanee and Arttberi ation: Customer agrees and understands that this Agreement is the entire agreement between Customet
and The Hone Depot 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 gannot be assigned or amended except b a writing signed
by Customer and The Home Depot.Customer acknowledges and agrees than a,••er has read,understands,voluntarily accepts eptstthe
terms of and has received a copy of this Agreement,
Aece■red t it/ f Subm
Gustomer's Signature Date Safes ' tant's Signature Date
X Telephone Na
Customer's Signature Date Sales Coneultarrt License No.
.0 JCELLATIONt CUSTOMER MAY CANCEL THIS Omappllea6lel
AGREEMENT WITHOUT PENALTY OR OBLIGATION qt-b BY DELIVERING WRITTEN NOTICE TO THE HOME 6' - s DEPOT BY MIDNIGHT ON THE THIRD BUSINESS t�
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.
Nome,.ADWrIONAL TERMS AND CONDITIONS an STATED ON TIUE REVERSE SIDE AND ARE PART OF MS CONTRACT
0507-13 Welts-Branch File Yellow-.Customer
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IV Ali KOSOOVICSKYY rA.'eta.:•
•2 STAFFORD ROAD
VIONSON14 01057
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a4!2712014
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,
City of Northampton
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_ Massachusetts ��' �- {�
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4,d-4''' DEPARTMENT OF BUILDING INSPECTIONS e x
"' ' W y' 212 Main Street • Municipal Building r rJtk AC"
+' Northampton, MA 01060 ,d�'YY 5l.t
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
Department of Industrial Accidents
0:4.....=,.. '1` Office of Investigations
.
f 600 Washington Street
Boston, MA 02111
,w� +
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 1 77 ���—■�4 '� ),N. . f�-� —
Address: Q', )F(.7 ,11,-7/' '11 PIS) J
City/State/Zip # R -Jr� 19 Phone : 47 '-'qj --�6 3
Are you an employer? Check the appr rate 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 ❑Ne onstruction
2.El am a sole proprietor or partner- listed on the attached sheet. 7. emodeling
These sub-contractors have
ship and have no employees 8. ❑ Demolition
working for me in any capacity. employees and have workers'
comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance P
required.] 5. n 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.❑ 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.❑ 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 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:
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.
I do hereby certify u, ,: th ins 1,enal • of perjug that the information provided above is true and correct.
Signature: � Date: 7
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#:
SECTION 8-'CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
,(�/ Not Applicable ❑
Name of License Holder: " �%' G_ "42!4! 3�t/ �-
License Number
'J-64936 >
Address Expiration Date•P' O71 )A1 Al& �
c/
Signature Telephone
_.,,...._._.-.iii _ ...._ .. �.., ,._.._,.._-_,i,._.....__ Not Applicable ❑
9. Registered HomeImprov ment Contractor .._emu ...�? ` : _.. pp
�.. /2! q�
Registration Number
Com an Nam�)�• 2 )/
Addre Expiration Date
✓'����;;CSC®'✓2� t
15 t9 PO Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(It 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. 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 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) n Roofing n
Or Doors
Accessory Bldg. ❑ Demolition [Ti New Signs [I1] Decks [[] Siding[O] Other[DJ
Brief Description ofP a h am-L 2,11',, !�' ,',� G �/" '�L / I/(/)v.Z)�
Work:
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.additionto exism housing,.¢
_-_ tinq complete he followtriq;
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 FORBUILDING_PERMIT
7 ` J r:-�'! -e)
I, i ,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 .---/
1, 06)‘04#- _p 1 ) ,e-
, as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains _;. •enalti•s of perju . E__
Print Name <-----_
Aliedol if'
J '— P/
--7-2 —13
Signature "Owner/Agent Date
.,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by'Loning
This column to be filled in by
Building Department
-
Lot Size I r I_ 3
i - f
Frontage
Setbacks Front 'T" L! i i
Side L:: R:! _ L:i.�_.I R: t t
Rear
Building Height — 3 j
Bldg. Square Footage j I % 1 j
---. Open Space Footage I
(Lot area minus bldg&paved 1
parking)
#of Parking Spaces , !
Fill: i 1
(volume&Location) E I� __ _.. •
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T 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 I and/or Document#
t
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES I
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued: q
i
C. Do any signs exist on the property? YES 0 NO i
IF YES, describe size, type and location: I ~�
D. Are there any proposed changes to or additions of signs intended for the property? YES i NO
IF YES, describe size, type and location: x
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 of Permit ' a
Building Department Curb Cut/Driveway Permit i. 5 . } 4 '4v`
212 Main Street • Sewer/SepticAvailability _ , y
Room 100 Water/Well'Availability w=3 3 -
Northampton, MA 01060 i Two Sets of•Structural Plans ., +r ;: ;.-„
phone 413-587-1240 Fax 413-587-1272 •Plot/Site Plans t '*
Other Specify `„.= ' 1 1 3'S
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -'SITE INFORMATION
; ::This section to'be completed,by office
1.1 Property Address:
91 ,'/ fiv /I.i / Map Lot - - Unit
F10,��e1 � /�).0 2 'Zone Overlay District
G'/ 6s
f:
' Elm St Distric - CDistrict ,t
SECTION 2=PROPERTY
OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name( nnt� ) r_ a-,t7-1---fe4=4-e-7---
Current M ailing Address:
��_✓y,_ Telephone
Signature
2.2 Authorized A ent: r A), blUo
T►& A--e P `7i2-Q)p-
)-7'--- ` 1 1 r =- y
Name(P. / - e Current Mailing Address:
_ zs 90) -->> — 19 .--2---
Si.lrature Telephone
SECTION 3-ESTIMATED CONSTRUCTION°COSTS
Item Estimated Cost(Dollars)to be Official-Use Only ,
completed by permit applicant
1. Building 5�s3 -� (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
This Section-For Official Use Only
Building Permit Number . '"" t ,.IDssued: 7/9
Signature � ...
Building Commissioner/Inspector of Buildings: Date
41 NORTH MAIN ST BP-2014-0003
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-251 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: windows replaced BUILDING PERMIT
Permit# BP-2014-0003
Project# JS-2014-000034
Est. Cost: $3856.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: Licriisr:
Use Group: HOME DEPOT AT HOME SERVICES
Lot Size(sq. ft.): 29969.28 Owner: VITOLS ELSA C C/O HPMG
Zoning: URB(l00)/SI(0)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 41 NORTH MAIN ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR (401) 935-2633 ()
PROVI DENCERI02908 ISSUED ON:7/9/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:8 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 7/9/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner