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11C-064 rl4 ASE READ MIS Sold,Furnished and installed by: Trial Boston pate THD At-Home Services,Inc. dlb/a The Home Depot At-Home Services 908 Boston Turnpike,Unit 1.Shrewsbury,MA 01545 Toll Free(800)657.5182;Fax(508)845.6017 Branch Murtha::31 Federal 1A#75-2698460:MP Lie CC 02439;RI Cont.Lic#16427 CT tic#HIC.0565522:MA Home I gvement Contractor Reg.#126893 Install3tinn Address: ,� �f Cs+�l r4,_ •°S t 053 # City State zip P'vrr3asts#): Work Phone: Hems Phone: Cell Pboae Hogue Addre (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑I DO NOT with to receive any marketing entails from The Home Depot ftoltglaftegggey. Undersigned("Customer"),the owners of the property located at the above installation address.agrees to buy, and THD At-Home Services,Inc.CTlse 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 are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Stuamary attached hereto and any Change Orders(collectively. 'Centime): Sob#: anima&Immo Sheetia #: .Amount 111 Gut 11 'A; iDko ■inaatatioa "( _ ©Gutters l Cavers CEouy Doom ■ ,,g ■ ding I•Windows if Insulation Ot3utters/Covers Crony Doan n °Roonmg L7Siaing 0 Windows D Insulation [ME °Guutera l covers °Entry Doors ■Roofing ■Siding U Windows U Insulation [fitters/Covers°Entry Doors 0 _- Minimum 25%Depas'tef Ceo4act Amon*due upon execution of this coned, Total Contract Amount $ 3 C1 M a i n e Paehtmera mray got deposit mem than owned dare Commit Amount. Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate (one for each Product as defaced 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 beane 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 the Con pant ant Snrrtmarr: The Payment Summary 4k ,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 You are entitled to a completely filled-an copy of the Contract at the that you alga Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the event of imagination of this Contract,Customer agrees to pay The Home a the costs of rnateriakt,labor,expenses and services provided by The Home Depot or Authedved Service Provider thorn_ the date of terminnation,plus any other amatmts set forth in this Agreement or allowed under a le law. THE HO r DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DE�PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LINMPTING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceutans arid!Au of tioa: 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:ill 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 r , .> this A-greemj.ent. A i S a..1) r • Customer's Signature Date Sales Consultant's Signature Date Telephone No, Customer's Signature Date Sales Consultant License No CANYt I.LA'TION: CUSTOMER MAY CANCEL THIS 1 / / (as avpliicabk) -AGENT WITHOUT PENALTY OR OBLIGATION 1 f. t C7 b'�' i f BY DELIVERING WRITTEN NOTICE TO THE HOME �-l(f 1 c7� DEPOT BY MIDNIGHT ON THE 'I':HIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE LP ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. /VOTICE:APDITtoNAI.Max AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT 10.11-12 Whim—Branch Flip Yaw Customer The Commonwealth of.M`assachusetts Department ofIndustrial Accidents j �� Office�= o Investigations =_ifeti •• �f f • 600 Washington Street =:ti Boston,MA 02111 ~' ,„ wmv.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers A• r licaunt Information PIease Print Le ibI Name(BusinesslOrganization/Individual): 'II f •Address: p' vc(e� (i th ilea! W� . I_ �_ City/State/Zip: ma 4 1 .� Phone.#: ,2_,.,7c__ 1 l` I�� Are you an employer?Check the appropriate b' : -Type of project(required): 1.0 I am a employer with - 4• (r I am a general contractor and I ,� have hired the sub-contractors ti. ❑New construction employees(full and/or part-time). 7. Remodelirt 2.0 I am a*sole proprietor or partner- listed on the'attached sheet ❑ g • • ship and have no employees These sub-contractors have 8. 0 Demolition . working for me in any capacity. employees and have workers' 9. 0 Building addition• [No workers'comp.insurance comp.insurance 10.0 Electrical repairs or additions required.] • 5• Q We art-a-corporation and its ❑ s •3.0 I aura homeowner doing all work officers have exercised their . 11.0 Plumbing repairs or additions myself[No workers'comp. right Of exemption per MGL 12.Q Roof repairs insurance required]t - c. 1 52,§1(4),and we have no employees.[No workers' I3:Q( tber comp.insurance required.] I *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy iaformaticei. 5 I.Homeowners who submit this affidavit indicating they arc doing all wort and then hire outside contractors must submit anew affidavit indicating such, i :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'camp.policy number.-•. . - t I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site. - } information. f 'rr7$I'1,t 1 s�'Insurance Company Name:_ r ,v ---•- 1 Policy#or Self.ins.Lie.#: 'a..31:1-7 i?„-3) Expiration Date: / Job Site Address: City/State/Zip: I Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). I Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 1 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 I 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•., yi average v • :•cation. �_. I do hereby certifj► ,jr d :; 'es erjury that the information provided abo: is true and correct• Si:•a e: L' ��%7 l - Date: A P — 1 13 o i Phone#: t .� i Official use only. Do not write in this area,tb be completed by city or town official } City or Town: - Permit/License# i i Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector I • - F 6.Other - • _ - 4 t Contact Person: Phone#: i E I r SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: � Not Applicable £ Name of License Holder .51-A0 /2 66,4L -- / P24 License Number pi,/pinez Address Expiration Date 0//a7 Signature t� Telephone 9.Registered H. - Im�rove = Contractor _,. . _,..,_, _.... ...,._,... ..'' Not Applicable £ M � r �� � Com•an Nam q3 Registration umber rikk_ 9..,ess '9p11W 33 Expiration Date Af' �/ i h„,-, Telephone 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 buildi rmit. Signed Affidavit Attached Y £ No £ 11 Home Owrier 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 ws and State of Massac etts General Laws Annotated. Homeowner Signature. ' J SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Repiacement Wews Alteration(s) n Roofing ❑ Or Doors Accessory Bldg. El Demolition El New Signs [D] Decks [0 Siding[D] Other[0] Brief Description of Proposed 0 e64, ) y✓)PQI/""5r" A/V Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa. if New a ouseand4or�addition to existil q.hot sing; complete tFieIollow nq: 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 BUILDIG PERMIT I, - etr/Cre'r-- ,as Owner of the subject property r• / �`° hereby authorize r p,p to act on mz hal '• all ma - elative to work authorized by this building permit application. i - 1� 57--/3 Signature of Owner Date 1' �°P 77-00 1 f , 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 t —. s an./•enalties of perjury. • r /_4%%/,/�) &,,. )%' Print Name Q --/3 Signature of•p•er/Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This colunm to be filled in by Building Department Lot Size E 1 t _I 1._.___. FrontageL____ ____ ._____I f______-------------f __... ._r__ ___-_I Setbacks Front —.a ! 1 1 Side L:rI R:1 1 L:I. j R:= 1 I 1 Rear , Building Height 1 1 Bldg.Square Footage % 7-1 - Open Space Footage } % (Lot area minus bldg&paved [__w__ �__._.. ! [ ._..>_ r----_J parking) #of Parking Spaces r----- L Fill: I 1 I (volume&Location) I --- A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q 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 1 —— Page and/or Document#1-- I B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? i Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO 0 IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q 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 Q NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. . ,, i i ''"L ;. lla M M ri,O phK a e Ue n 6 , 1 , @ y 1 u 3m11.A.i is City of Northampton $Ya s 9 P0$r , r i ' w L kgy , 4 Building Department Gf Gut/DO4 a Pert t:nt ^v ;41 a.9I ti r NM w O r�n s� itigr bi4 ili yY i Jr Y 212 Main Street See/SepFc va+ aIyr ;.. i r n e v l`r Room 100 Wate8 # a9abllv s n r I , L 7 17 r 1p fFi t yaPas a i a M K o , ir 000, q:I U � _ II orthampto0 n, FMA 01060 TwolS� "ofsiltcur 7 ii: £'mNa `e ` e _ mSkK 2r y r P4oSiYplan ;L r a 1 11111 1 a 1. 2 .pon ax 413-587-1272 j }Sr 4'r 6 +' A4,--Elr a i4� W y it A rOepe'ly ! r4 .) - ,„ .S P 2013 ,., IAPPLICATION TO ••NS RUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING Fl ctric. Plumbing&Gas Inspec ion Northam ton,MAVi06G - a • - ' •- ATION • I This setion ot o be completed b i oie , r 1.1 Property Address: t ' Urnt Map 4, 6 1/0/7 ,ive 4-7—' `Zone- " ., Overlay District Fi _ in P ,, , �a A r : I. Elm St.District ;+ CB D.istnct l ; . ,„ .. . . SECTION 2 PROPERTY OWNERSHIP/AUTHORIZEDAGENT •2.1 Ow per of Record: .. &- el j 1/xi,),,f,i3.10.4)....).. -96 6abcf d9i:Name(Print)}7L% �.� Current Mailing Address: ...,,---3 ( j2 & Telephone Signature 2.2 Au • ed A• nt: ‘ P12/3 V }z - Name(Prig Current Mailing Address: 4/9)-.1b.."------ i7-- ,.„„e,zza. .....,i -. Sign• ure Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS. . Item • Estimated Cost(Dollars)to be Official Use Only completed by permit applicant . 1. Building (a)Building Permit t Fee . •2. Electrical . (b)Estimated Total"Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection t,r 6. Total=(1 +2+3+4+5) � Check Number j'1�% This:Section,For Official Use Only . • Date Building Permit Number: Issued: • • Signature: . Building Commissioner/Inspector•of Buildings : . Date• • 86 FLORENCE ST BP-2014-0274 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 11C-064 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit# BP-2014-0274 Project# JS-2014-000469 Est. Cost: $3453.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 105953 Lot Size(sq. ft.): 26832.96 Owner: DESMARAIS LAWRENCE E&DONNA M Zoning:URA(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 86 FLORENCE ST Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCERI02908 ISSUED ON:9/6/2013 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 9/6/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Louis Hasbrouck—Building Commissioner