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12-013 (3) PLEASE READ THIS Sold,Furnished and Installed by: ranch Name Boston Date: THD At-Home Services,Inc. rat r<t _ drb)a The Home Depot At-Home Services 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free(800)657-5182;Pax(508)84$-6017 Branch Number:31 Federal ID#75-2698460:ME Lie C CO2439;RI Cont.Lie#16427 �b, - CT Ice#HIC.0565522;MA Home Improvement Contractor Reg.#126893 InstallatienAddress: t✓ JA . ' '0.j• i . r �1 Cs1a67y try State Zip Purchaser(s): Work Phone_ Home Phone: Cell Rhonet L,l st6 (4505 [ 7 [ ) [ I [ 1 [ l [ ] Home Address_ (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): [l i DO NOT wish to receive any marketing entails from The Home Depot Project Inf t at'on: 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("Installation")of all materials described on the below and on the referenced Spec Sheet(s),all of which arc 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#: iLtemi arr.�e� Pr, '- Sheets #: Pro ea , •Roofing II Siding • endows U laudation 7 3e.1 1/4.1 OGuness l Covers . ,try Doom ❑ 7 a _ $ 2-76 - ( __.p — DRoofing III Siding •Windows •Insulation $ )]Gutters/Covens l]Eoay Doors D URoofing-OSiiding 0-Windows i]Insulation $ Datums/Covers 05ntry Doors❑, �JRoofing[rSiding a windows •Insulation $ OGutters/Covers DEntry Doors Fl • — a Miouann2%DepositofCaothactAmoturtdueupoaaersdonofthiscootraet. Total Contra tAmount $ r� Maine Pm-Masers tray not deposit mere r one-third of the CattractAatouatt. 70 t Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate (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 Products)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 lead paint,other safety concerns,pricing errors or because work required to complete the job was not included in Vitra cc Pavwent_Summarv: The Payment Summary#_ 3 , 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 Yon are entitled to a y filled•in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is Completion )care for each listed Product as defined by individual Spec Sheets)before work on that Product Is 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 ha this Agreement or allowed under tcable law_ THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DI IE IT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. tcCeatance and_luthi f atfou: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home 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 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, Acce �r Submitted dy- X t(GUt 04 — C stom Consultant's er'a Signature Date Sales Consulta 's Signature Data Telephone No. Customer's Signature Date Sales Consultant License No. CANS LATIQN: CUSTOMER MAY CANCEL THIS (ns app5eabiel AGREEMENT WITH PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME f t I( DEPOT BY MIDNIGHT ON THE TIllEZ.D 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. NOTK.F, ADDITIONAL TERMS ARD CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE FART OF THIS CONTRACT 10.11.12 White-Branch File Yellow-Customer 1 e9 _____. _. DATE IMMfCDIYYY!) A D CERTIFICATE OF LIABILITY INSURANCE 0212720,3 i THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). -PRODUCER CONTACT MARSH USA,INC. NAME: (NO. FAX Not TWO ALLIANCE CENTER ( C.PHONE EMI:E 3560 LENOX ROAD,SUITE 2400 EMAIL ATLANTA,GA 30326 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL is 100492-HomeD-GAW-13-14 INSURER A:Steadiest Inswance Company 26387 INSURED Zwldt Ame6pn Insurance Co 16535 THE HOME DEPOT,INC. ' INSURER B. HOME DEPOT U.SA,INC. -INSURER C:New Hampshire Ins Co 23841 2455 PACES FERRY ROAD,NW INSURER D: ^ois National Ins Co 73817 lE BUILDING C-20 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-00315954504 REVISION NUMBER:7 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND.CONOLTIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE eiiiii^,,Ti7 POLICY NUMBER Mil:MeigillIlF"' IEEIIIIIIIIIIIIIIIIIIII�aue A GENERAL LIABILITY GL04887714-03 03/01/2013 . 03/01)2014 EACH OCCURRENCE S 9,000,000 •r1•F • 'dq . �� ' f �li , �� $ EXCLUDED © COMMERCIAL GENERAL UABIUTY �U�..16 l ,-.,<<... ■' CwMS-MADE L 1 OCCUR LIMITS OF POUCY XS MED EXP(Any one person) S OF SIR:51M PER OCC PERSONAL s ADV INJURY S . — GENERAL AGGREGATE S • 9,000,000 GENT-AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO S 9,000,000 ® POLICY■ PR' ■ LCC S AUTOMOBILE LIABluTv LL NE SCHEDULED AUTOS Immei AUTOS 1111 HIREe 0 AUTOS 01•11 AUTOS t III OED 1111 R NTION 03/01/2013 03/01/2014 3 SELF INSURED AUTO PHY DMG 1,000,000 hillillINJURY S - BODILY INJURY(Par=Went) S EACH OCCURRENCE AGGREGATE S S S • C WORKERS COMPENSATION 'eriTkT. •( • ) rkri1 61 ,k1.I I1 STA U- AND EMPLOYERS'LIABILITY TORY I1M1 FR C ANY PROPRIETORIPARTNER/EXECUTIVE Y!N WC033575315(AK AZ) 03/01/2013 03101/2014 EL EACH ACCIDENT S 1,000,000 ill OFFiCERAAEMBER EXCLUDED?D (Mandatory In NH) WC033575316(FL) 03101/2013 03101)2014 EL DISEASE•EA EMPLOYE=s 1,000,000 1 Ayes,dseaibeundo 1,000,000 DESCRIPTION OF OPERATI• .bebw EL DISEASE•POLICY Miff S 111 WORKERS COMPENSATION WC033575317(KY,NC,NH,V i) 03101/1013 03/01/2014 (EL)LIMIT 1,000000 WC033575318(NJ) 03/012013 03101/2014 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more spice Is required) EVIDENCE OF COVERAGE s. CERTIFICATE HOLDER CANCELLATION THE HOME DEPOT INC. SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE HOME DEPOT USA.INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS. 'BUILDING C-20 ATLANTA GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. I Manashi Mukherjee u a m 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD r / ,-4ND N f • y • 1 iNt 2, , / 1 rr 0.‘„,L Massachusetts - Department of Public Safety Board of Building Regulations and Standards C:um■zruction Superviaor License:CS-067121 r°441i * • . . BRIAN C TIFIG14SON " • 36 WIL,WW#ROOK LANE WESTETEL#1144 010;85 "7:4 Nc"" -6 —c'on-r- nsioner 04/30./2014 • 04/24/2011 03:50 FROM 45'46822 TO P.01 ... r�7"//u•. r(.iGntoyf2ct+c.r �...v..�...ti........... • ' •nice of Consumer Affairs&Business Regulation ? License or registration valid for indivIdul use only before the expiration date. If:found'return to: '=�u1=•--'-�ME IMPROVE]�IENT:•CON'i;RACTOR Office of Consumer Affairs and Business.Regulation T 1 ;�R99istratiosr� g4 Type: •,)0 Park Plaza-Suite 5170 ^ :ration:;:.,' a4;1.': Supplement Boston,MA 02116 r The Noma Depot 1 i e ery o, es • / • RICHARD TROIA %::, .jr•`A;t.`' N . re"2690 CUMBERLAND PA'�Kyl6R' Sl«^ -- . , �/ .i i,.'" A AIricrA,.GA 30339 Uadersc Teary Not valid without signature 4,` The Commonwealth of.Massachusetts w Department oflndustrial`Accidetsts fi Office of Investigations - =I ., = • 600 Washington Street €=;:iii= ° Boston,MA 02111 '''a:.,r�," • www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricialas/PIumbers A. slicant Information Please Print Le.ibl Name(Business/Organizationfndividual):. e, •t Ju t, • •Address: a � (1-, '1 d' -rid. 04 9k City/State/Zip: , ilk � G Phone.#: ° a)"�7� Are you an employer?Check the appropriate b' : -Type of project(required): 1.❑ I am a employer with - 4. /! I am a general contractor and I have hired the sub-contractors 6: ❑New construction • employees(full and/or part-time).* 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. ❑Buding d addition [No workers'comp.insurance comp.insurance t ur required.] • 5. ❑ We area-corporation and its 10.[]Electrical repairs or additions •3.❑ I am a homeowner doing all work officers have exercised their . 11.0 Plumbing repairs or additions - mmyself[No workers'comp. right Of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no i employees.[No workers' 110( then i • comp.insurance required.] I i *My applicant that checks box#1 must also fill out the section below showing their workers'comgrensation policy iaforsration. s t Nor ners who submit this affidavit indicating they art doing all work and then hire outside contractors must sutanit anew 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 I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jobSite information. ° 1 i't Insurance Company Name: ► R Expiration Date: Jc,/ Y Policy#or Self-ins.Lic.#: _ - KP 6� k Job Site Address: City/State/Zip: 1. Attach a copy of the workers'compensation policy declaration page(showing the policy numbet and expiration date). F 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 t of up to$250.00 a day against the violator. Be advised .•t a copy of this statement may be forwarded to the Office of ` Investigations of the t) 'r•• 4! average v '.cation. i I do hereby certiffyy ' ' -and : i erjury that the information provided abo:•.is true and correct. Si:.ature: L' �,�—� 411111r - •ate: _/ ., _ { F • Phone#: 41)1 IY,--. -‘ '33 Sp 1 Official use only. Do not write in this area,to be completed by city or town officiaL Permit/License# ' City or Town: € • 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 • I, I t r SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction S rvisor: /"' 7�� Not p icable ❑ 2/ Name of License Holder: ✓ �" f �C,� License Number -111/ Address Expiration Date t Vir6- Tig:0) /19/ Signature Telephone 9.Registered H• Im•rov -nt Contractor: Not Applicable ❑ t ► e- rn lf 4? Co •an Na Registration umber jth/A 7/2# AslOr_ . / 1 Expiration Date Telephone G'PP54 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 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 W ows Alteration(s) n Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Ca Siding[0] Other[O] Brief Description of Prop•se• )� , Work: ;.��� i � it 1 �� '' Alteration of existing bedroom Yes No Addi g new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to 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 I, �'.1021 as Owner of the subject property ri J/ fr 'j _ hereby authorize / I r to act on m�behalf, in all matters I 've to work authorized :y this building permit application. / Signature of Owner Date I, / i--o,f , as Owner/Authorized Agent hereby de are th t he st tements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under al ains -nd penalf-s of per t. , ijir 0 br) iA AAiiiJ10 / G Print Name J `� / Signature',+'rtei^/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 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 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained 0 , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O 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 O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: E7 Building Department Curb Cut/Driveway Permit C. Main Street Sewer/Septic Availability f Room 100 Water/Well Availability AUG w f�. 22013 Nort ampton, MA 01060 Two Sets of Structural Plans phone 41:317-1240 Fax 413-587-1272 Plot/Site Plans pE r.c Other Specify Now;',If V--,., PPLICATION 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 ( 4tT) i Map Lot Unit e l/1/' Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �"� /1/(V_ AV--. 2:, )6.19-Record: Name(Print) r� /�_/,. Current Mailing Address: . tft/I Telephone Signature 2.2 Autho •' ed pent: T.. • 3 07 Name{P j( . t)'� _.,,,,t Current M.P g Address: ty/ rr. 1`" X73 135 1_ Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building ''� ; 7-',20/' (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) !; `7 ) ' Check Number 4019 $35' This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 48 COUNTRY WAY BP-2014-0230 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12-013 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:REPLACEMENT DOOR BUILDING PERMIT Permit# BP-2014-0230 Project# JS-2014-000382 Est.Cost: $2701.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 67121 Lot Size(sq.ft.): 24262.92 Owner: GIBBS ELISSA S Zoning: Applicant: HOME DEPOT AT HOME SERVICES AT: 48 COUNTRY WAY Applicant Address: Phone: Insurance: 908 BOSTON TPK Workers Compensation SHREWSBURYMA01545 ISSUED ON:8/27/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL PATIO REPLACEMENT DOOR 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 8/27/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner {