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38C-039 (3) HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: 47/9/V llloston Date: THD At-Horne Services,Inc. / cl/b/a The Home Depot At-Home Services 908 Boston Turnpike,Unit I,Shrewsbury,MA 01545 Toll Free(800)657-5182;Fax(508)845-6017 Blanch Number:31 Federal ID#75-2698460;ME Lic*C 02439;RI Cont.Lio#16427 CT Lic#HI__C.056`532:MA Home Improvement ment Contras Rcg.#126893 Installation Address: t T\ T V,�ry„1,ljY_'f.'i l�' y+3 City 3tate Zip Parchaser(s); Work Phone: Home Phone: Cell Phone: 1 X t ho tia_ 11 hj M 60 bit-) [ ] C ] [ ( _ [ l [ I [ l Home Address: (If different from Installation Address) City State Zip P.-mail Address(to receive project communications and Home Depot updates): ❑1 DO NOT wish to receive any marketing emails from The Home Depot 'roieet Int oration: 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 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 S: ixawKr Spec Sheets)#: Project Amount °Roafng aiding 'Windows' U Insulation '-?t 4'l2( ❑Cutters/Covens DOOM 731 $ ❑Roofing(Siding Windows❑Insulation [cutters/Coven [Envy Doors rl Citoofing ['Siding ❑Window ❑Insulation $ _ °Gutters/Covers[Only Doors ©Roofing❑Siding jJ Wad4wa 4J lnsuta)on ❑outtars/Covers pEnt y Doors R hl( ZS%Repast of'Contract Amount due won a ecutionetthis mania Total Contract Amount $ Mabee Per+due=may mat/goat mare than000 idrdof the CatkedAeinuck. 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 Hoare Depot reserves the right to issue a Change Order or terminate this Contract or any 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 lead paint,other safety concerns,pricing errors or because work required to complete the job was not included innjthe Co tract. PPa t Sonunar,: The Payment Summary# 8 3V'1 6 , 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-In copy of the Contract at the time you sign. 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 termination of this Contract,Customer agrees to pay The Home De of the costs of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the data of termination,plus 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 OF SUCH AMOUNTS. Acceptartcttaend Authirization: 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 he 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. A c c e by: cA � V\02)\ , Su4mli ' CCgnature Date Sales Consultant's Signature Date Telephone No. Customer's Signature Date Sales Consultant License No, CANCELI ATLON: CUSTOMER MAY CANCEL THIS (an applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME ] C / DEPOT BY MIDNIGHT' ON THE THIRD BUSINESS t O 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, NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT to-i1-12 While—Branch File Yellow—Customer The Commonwealth of MassachusettJ Department of Industrial Accidents -, ►i s_ Office of.Investigations =foittt= - 600 Washington Street • ,._ Boston,MA 02111 't*rva • www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors(ElectrieiansfPlunibers A•,lieant Information PIease Print Le'.ibi Name(Business/Organization/individual): . , •'' 'if: • •Address: pl) 6-1 (rf �Y 49s' City/State/Zip: Ad d ..� f; .,, Phone.#: 11`C a)Are yoa an employer?Check the appropriate b Type of project(required): 1.0 I am a employer with 4. I+ I am a general contractor and I 6: Q Ne,�,construction employees(full and/or part-time).* have hired the sub-contractors .2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me in any capacity. employees and have workers' �. Building addition [No workers'comp.insurance comp.insurance 10.0 Electrical r• required.] • 5. 0 We are-a-corporation and its repairs or additions 3.❑ I atn a homeowner doing all work officers Have exercised their 11.0 Plumbing repairs or additions . right of exemption per MGL myself[No workers comp. p 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.0°then _ - i; comp.insurance required.] *Any applicant that cheeks box#1 must also 011 out the section below showing.theli workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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. Mille sub-contractors have employees,they must provide their workers'cramp.policy number_, i I am an employer that is providing workers'compensation insurance my employees Below is the policy andtob site - z information. .._._..,• s Insurance Company Name: 1.'.!_11 11'.; /111P4i l Policy#or Self-ins.Lie.#: j zj j r Expiration Date: .. 1 j i Job Site Address: City/State/Zip: a Attach a copy of the workers'compensation policy declaration page(showing the policy number 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 s 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 1. 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 I3 ,•r'a . •veraae v_„1„,-*a catio I. I do hereby certify"Pr fr and : ,erjury that the information provided abo • is true and correct e Si_.ature• � � 7 1� Date: % is. Phone#: °E`S 115--dC57'33 Official use only. Do not write in this area,to be completed by city or town official • i City or Town: • Permit/License# € Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1 6.Other _ . • _ Contact Person: Phone#: t I E r • SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable £ Name of License Holder: .il .2 jir ,Ii `mod 1 License Number ` 72- -Tom%€/ /r- �7 '9 Address p� 6'71 �j / � Expiration Date V/ t / ' 'n� v /` C l�/-s Signature I Telephone 9.Re'•istered sr Not A72/ 76/9 licable £ �i� ►'' % �' . Comme Registration Number Addre s Expiration Date 4011.. / j :1� 7 Telephone] SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§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 buildin .permit. Signed Affidavit Attached Yes.. No £ 11. =:Home OwnerExemtrtion 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 Zo ' g L ws and State of Massachusetts General Laws Annotated. Homeowner Signature. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition [,] Replacement ows Alteration(s) n Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs (D) Decks [E] Siding[D) Other[DI Brief Description of Pr posed �]�` /� ik. 0 Work: ��/�► y1-l U"�� � ���� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Ga If New house.and.or:addition to erstinq'itousing;comp`lefe'tFie foflowira : 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 , as Owner of the subject property � Tai31)hereby authorize 43Y�'-�-' gfr to act on m behalf,in all ma/t�ers relative p work authoriz d by this bbuildir)g per itit a� n. erk Signature of Owner ate I, / ePr-P `7 /'J , 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 'end p'alties of perjury. 1 .11 ! PO Print Name AV� fp- 0.75**.'9"n•• 3 Signature frowner/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 1 1 ` ! Frontage L ( ___ I I i- Setbacks Front I I t 1 1 Side L: R:? 1 L:1 I RA __—^ I .___ Rear .i I 1 t Building Height k_____I I, I I 1 Bldg.Square Footage ri 1--7 % F-1 r 1 1 I Open Space Footage % (Lot area minus bldg&paved {{ tt t , parking) _ - #of Parking Spaces 1 1 = Fill: I (volume&Location) 'I '` 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 Q DO NT KNOW Q YES Q IF YES: enter Book _ ___ I Page and/or Document#I 1 B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO Q 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: L T �� 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. • *,r":7} :,3tu : L iw -W? I A` 3epatfrl ent'Use only 'Y,;r„'} „G,*_...I -- City of Northampton Status ofPQ,rmd� : g� r<2,ti to n d r ra s t oE s }ti i Building Department 212 Main Street Gbr6 Cut/Dxewaerrrt# t r �g 1 z ti r get-i o ri 4 ,L , s n u Saler/septwGAvalabllty ' l ,,a S-` _ 5 `Z013 J Room 100 Waterlt/lrettAbrlahlity i y m.a�pN I rthampton, MA 01060 Two sets'ofStru�tur iPtalns ' 1 3 `, _ ;''I a liclectric,Plumbi o&M ct4�3 587-1240 Fax 413-587-1272 Pt9,y,,A a Ptyans `04ISyr.-"i 5 'u{' K A gee Northampton, Oder 5Vec�fu a5 , k emu., 4 M p APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: Th ta' is section be completed by office L m p ot U4A4 77^ Zone Overlay District Elm St_Dlstrlct . CB District r , . SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT:' 2.1 Owner of Record: �/I -99 / i..� /4727-14,9 -1( Aw. PerFokAA [II/Name(Print) 6.71. i Current Mailing Address: Telephone Signature 2.2 Authorized gent: t Name(Pr. Current Mailing Address: , ..i" / .• dy...--7—• 02/-695---... 6-3 Sig,leture Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS. . • • Item Estimated Cost(Dollars)to be • • . Official Use Only completed by permit applicant . 1. Building ° 271 ' (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 /2 6. Total=(1 +2+3+4+5) 2-71 " ---1 Check Number 1 6 I 1 . 1 T-.) This Section For Official Use Only . Date Building Permit Number: . Issued: '•Signature: • . _ . Building Commissioner/Inspector;of Buildings : ,Date • 354 SOUTH ST BP-2014-0275 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38C-039 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-2014-0275 Project# JS-2014-000471 Est.Cost: $3276.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sq. ft.): 4791.60 Owner: WIJNHOVEN DEBORAH K Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 354 SOUTH 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