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23C-096 HOME IlMOVENSM CONTRACT PLEASE RVAD TIIIB Sold,Furnished and Installed by. Branch Name:aoetan Noft&Soufh Date�,�-4ja, THD At-Rune Servioes,Inc, WA The Rome Depot At-Home Services Branch Number:31 and 33 908 Hoston Tumpikr,Unit 1,Shrewsbury,MA 01545 Toll Free 877-903-3768 Federd ID#75-2648450;ICE Lic#C 02434;RI Came,lh*16427 CT Lic#WC•OS65522;M Improvement Ca �a j��r,R�eg#�1�2�93` Iwtallation Address: I ) t) Y' a,. City Stets Zip Pur¢Ga9er(al Work Prone: Howe Pbot:e: Coil Phone: [ l [ 1 ( l Home Address' (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Hoene Depot updates): I DO NOT wish to receive any marketing emails fim The Home Depot ect ' tfadersigned("Customer"),the owners of the pr located at the above installation addrew agrees to buy, add TH�i add I tii?At-Haft xrv►ces,Inc.(",fGte Home DepoC7 sgce<a:to •ddivtx snit atraRge fcs the:insta11a6on(':InalailadoR")of all materials described on the below and on the rely reseed Spec.Sheets.all of which are incorporated into this Contract by this referenda,along with any applicable State Supplement and Payment Summary attached hereto arKf any Change Orders(collectively, ^Contract"): n Job#: atwm a ProdueW spot sheets))1!: Project Amount ]tao$»g Siding Windows ina"on $ p�q ❑Gutters/Covers FXpuy Foots 0 Roofing LJ3iftit U Wn'im U Insulation �- oGuams/Corers OEntry Doors r l $ �, Roofing US id,nB Ll Windows LJ IasulsdOn $ v QGumn/Covers Mary Dome O_ / Roofing USiding 13 Windows U insulation $ ©Gulfs/Covers MEnny Doors 0_,,,._ Minhaam 29%J)quo*otCentradAmom[tduc Pov e*emtioe ofthk contract. Total Contract Amount Is MainePumbasers way not depaeit MOM then onathhtlofthe C'onhadAMMIL � 1 Customer agrees that,immediately upon completion of the work for each Product,Customer Will execute a Completion Certificate (one fbr each Product as defined by an individual Speo Sheet)and pay any balance due. As applicable,each Customer under this Contract agrees.to be jointly and severally obligated and liable hereunder. The Rome Depot reserves the tight to issue a Cbmp Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Home Depot or its authorized smvice provides determines that it cannot pe=its obligations due to a structural problem with the home,envitromumtel hazards such as l mold,asbestos or had paint,other safety eoncems,pricing wrote or bmaust work required to complete the job was not included in the Comam e ment Sammam The Payment Summery# E5C7!3,(�4 included as part of this Contract,sets forth the total Contract amount and payments required for the deposits and fetal payments by product(as appEcablc). NOTICE TO CUSTOMER You are entitled to a comp�lIof*XW in copy of the Contract at the time!r sign. Do not sign a.Compledon Certificate(note: there is one Completion Cetidcats tier each listed Product as defined by individual Spee•Sheets)before work on that Praduet: is complete. In the event of termination of this Contract,Customer agrees to pay The Rome Depot the Coifs of materials,labor,expenses and services provided by The Home Depot or Authottzeid Service Provider through the date of termination,pins 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. Aece ee and zs on: Customer agtm and mderstao4e that this Agreement is the entire agreement between Customer and The Home Depot iMM rid to the Products and Installation services and es all prior discussions and agreements,either oral or written,relating to said Rroduats and installation.This Agpcement carro4a 4ped or amended except by a wri ft sided by Customer and The Homo:Depot.Customer acimcwlcdges and agrees that has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement CCepud � Submt Customer's Signature Date / ( S C s Signature Date X T epptme o. Customer's Signature Date Sales Consultant Lianas No. CANCELLATION: CUSTOMER MAY CANCEL THIS (ss aDDlieahk) ny onVt]&NT WITHOUT PENALTY OR OBLIGATION ^53 BX AEL1v>SRING WRITTEN NOTICE TO THE HOME �,]4. DEPOT By MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE ' SUPPLEMENT ATTACK&D HERETO CONTAINS A FORM TO USE IF ONE I$ SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATL NOTIC&ADDITIONAL TERMS AND CONNDMONS ARE STATED ON TM RVERM SIDE AND ARE PART OF TMS CONTRACT 00-19-13 0hite-Sranchl'19 Yellow-CusWM& The Commonwealth of Massachusetts Depar tinent of Industrial Accidents O,o' ce of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Name(Buss CW0rga=&bodlndividusl): ~ Address: ! 1�' City/State/Zip I Phone#: ! Are y6u an employer. Check a appropriate box: Type of project(required): 1.FA 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. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for the in any capacity. employees and have workers' 9 ❑Building addition [No workers'comp.insurance camp-msurance.l required.] 5. [] We are a corporation and its 10.❑Electrical repairs or additions 3.❑-I am a homeowner doing all work officers have exercised their 11.[]Plumbing repairs or additions myself 'comp. of exemption MGL 12.0 Roof repairs ce orb-]t cc...11552, §1(4),d we have no employees.[No workers' 13.[]Other comp.insurance required] "AnY applicam that cbcclts box#]must also M out the sectionbelow showing their wod=,compensation policy information. tHo meownc:s who submit this affidavit indicating they are doing,all work and then hire outside contractois most submit a new affidsvit Ming sack $Contractors that check this boat must attached an additional sheet showing the nine of the sub-contractors and soft whether or not those eaiities have employees. If the snb-con�have capk7ces,thay must provide their workers'comp.policy mumbo I am an employer that is providing workers'co ' n huWWWefir my employees. Below is the .—_ and Job site information. Insurance Company Name: Policy#or Self-ins.Lic.M. y� '�/.� Expiration Date- Job Site Address' % '`�� City/State/Zip: °�'�` D�9 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 U14A ommeat,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(ice of Investigations of the DIA for insurance coverage verification. I do hereby certify 11 of perjury that the information provided above u true and corm Si Date: Phone#: Dffiew use only. Do not wrhe in this area,to be cong4ded by city or town of f jiciaL City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Chyffewn Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicablee E Name of License Holder: '�/�y" �" 6 ✓y ��"" �j�� hw� Licens�Nu � / Add re s �s Expiration Date si a ure Telephone 9.Re isfered Ho Imo ent'Contractor Not Applicable £ Comoanv Name Registration Number A s Telephone U/ s Expiration Date fh� °�� 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 buildin it. Signed Affidavit Attached Yes...... No...... £ ll. . Home Owner Elemption 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 Windows Alteration(s) ❑ Roofing ❑ Or Doors -Efr- Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[O] Other[EJ] Brief Descri 'o ro d J ��7►' 0�C// 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 douse and or:addition to existing housings 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 as Owner of the subject property f hereby authorize /R— to act on my behalf, 11 11 m tters elative to thorized by this building permit application.�� Signature of Owner Date r / 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 p ' ftnaltlies -Print Name /Signature of ner/Agen Date 7 ' Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning TIiis column to be filled in by Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg.Square Footage Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Permit/Variance/Finchng ever been issued for/on the site? NO �~»~�� DONTKNOW x x°�`�� YES «�x�� � IF YES, date issued:, IF YES: Was the permit recorded at the Registry nfDeeds? NO ~=K � DONTKNOW 0 YES IF YES: enter Book Pagel and/or Document# �� �� �� B. Does the site contain abrook, body of water o/*et\an� ��'� NO DDN7KNO@/ «�� YES �~� IF YES, has permit been or need to be obtained from the Conservation Commission? Needs to be obtained _��~� Obtained �-v��� Date Issued: ' � ^ C. Do any signs exist on the pnoperty �� ��� Y[� �,� NO �~� |F YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 / IF YES, describe size' type and location: E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre orinit part ofu common plan ' that will disturb over 1acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ^ '. Mepartment City of Northampton Status of Perrntty "�s�aiiL Tj � yeE s i 3 Building Department crl CuvDrf�ce�ua "Fermi# � y t ti 212 Main Streeteyuer/SepticAvaiCabfity Room 100 1!!/atereTlAua�lal�ility �_ �, _21 It,Ril>rv1131ME iL �' 'i.^6 rt k�4 J5a,i Northampton, MA 01060 Tws2ts4clf5trtctcs ail Pia€>s 4+ aL , �i� 15. phone 413-587-1240 Fax 413-587-1272 F?Ioflsife Plans �L t �' r 4 iIP 'q LYTa 7 '�F I �1 d t .� ., k+ ri fi le y 3 c. at N t PIyt�w d2r� APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE.INFORMATION This sectiorrto be completed by off ice , 1.1 Property Address: } Map Lot r Umt P! " or M }Zone Overlay D►strict 3- �. i k , J 2 4 Elm St District _CB DlStnct SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ,c Name(Print) , Current Mailing Address: Telephone Signature 2.2 Au4horizo Agent: Name 1 Current Mailing Address: ignature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a)Building Permit Fee 2. Electrical d (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 Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 193 WARNER ST BP-2014-0815 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23C-096 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-2014-0815 Project# JS-2014-001403 Est. Cost: $2900.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 67121 Lot Size(sq. ft.): 88862.40 Owner: KRACAUER ROBERT Zoning:URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT. 193 WARNER ST Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCER102908 ISSUED ON:112212014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT ENTRY 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 1/22/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner