Loading...
32C-305 (2) numr,uvirKUVEMhY T UUN TACT PLEASE READ THIS Sold,Fuinisbed and Installed by: Branch Name: Boston bate: 3 /t / Q TED At-Home Services,Inc. d/b/a The Home Depot At-Home Services Rrnnch Number: 345A Greenwood Street,Unit 2,Worcester,MA. 01607 ❑North 33 ❑South 31 Toll Free(800)657-5182; Fax(508)756-8823 Federal 117#75-2698460;IvX Lie,#C 02439;111 Coal,Lie#16437 `` T Li #565922;M A Home lmprov/e�mont Contractor Reg#126891 Installation Address: �.�Pi c e y 4i,4t City State zip Punhaaer(s): Work Phone: Home Phone: Celt Phonc; I ] [ l I 1 HomoAddre!w B-7 VJ'O!ii-klL;7i (if different from lustallation Address) City State Zip E-mall Address(to receive project communications and Route Depot updates): ❑I DO NOT wish to rcccive any marketing emails from The home Depot Pro ect Informa tot g: Undersigned("Customer"),the owners of the property located at the shave installation address,agrees to buy, an 1ID At-1 omt Services,Inc.("The Rome Depot")agrees to tbmislr,deliver and arrange for tGc installation('JustallAtion")of all materials described on the below and on the refemaoed Spec Shoat(s),all of which are inoUr1wrated into this Contract by this refa'renec,alotL with any applicable State Supplement and Paytncnt Summary attached hereto and any Change Orders(collectively, "Contract"): "rob n: only-.a kd.—) Products: Spec Sheets #: Pro'eot Amount Rnnfing Siding endows Insulation �a+ t a.(Q ❑Gutters i Covers ❑Entry Doors ❑ I l i ) I-1 2-",a t: Roofing Siding idows Insulaation �! �I C� QGUttcra/Covers QRntry t]onrs ❑ (] 2-C:�9 y Rooting ElSiding[�Windows O Insulation $ []Cmttras 14overs ❑Entry Doors❑ Roolint Siding Wino—o ❑Insulation QGatters!Covers ❑r=etry boors i] $ Minimum 25%btposit of C ttAmount duo upon execution of this contract Total Contract AmOUIIt $ i LA Milne ft-d asers array out da more Ihm a tb"of tke Cantraot A-ount 1 Customer agrees that immediately upon completion of the work for each Product,Customer will ex.;eute a Completion CcrtiIIcata (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 hercuader. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Products)inoluded herein,at its di&.Micm,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structival problem with the home,environrnenml hazards such as mold,asboe4s or lead paint,other safety concerns,pricing errors or because wort required to complete theiob was not included in the Contract. P2"mcn ti A The payment Summary ti (•�.`✓` � included as pan of this Contract, sets forth the total Contract amount and payments required far thG deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-io 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 Ind "dual Spec Sheets)before Work on that Product is complete. in the event of termination of this Contract,Customer agrees to pay The Houle Depot the coats or materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other amounts sot forth In this Agreement of Qlowed under applicable law. TIIE HOME,DEPOT MAY W CTHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITIING TIIE ROME DEPOT'S OTIIR 12EDIEDIES)FOR RECOVERY OF SIKH A.MOXINTS. eptanee 2nd Authorization: Customer agrees and understands that this Agreement is the entire aueement between Customer and The ome Depor with egani w Lire Products and Installation services and supersedes all prior disoussions 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 at d The Home Depot,Cusiumer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. Acccgted bye Subm I Customer's Signpture Dow Sales Consultant's Signs Date _, Telephone N"o. _ Customer's Signature Cate Sales Consultant License No. .. CANCELLATION: CUSTOMER MAY CANCEL THIS (xs applicable) AG12EENIENT'WITHOUT PENALTY OR ORLTGATION 9Y DELIVERING WRITTEN,NOTICE TO THE ROME DEPOT AV MIDNICUT ON THE T1ll7-RD 'OVSYNESS DAY AFTER SIGNING THUS AGREEMENT. THE STATE SUPPLE1v1EN T ATTACH=ED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NO'1.10E:ADDITIONAL TIZ MS AND CONDITIONS ARIL STATED ON THE REVERSE SIDE AND AIth PARTO6 THIS CONTRACT in-i-0a rpy 8-oa-0A cse White-Branch Fite Yellow-Customer pink-Sakti Consultant' ACORD,M CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD WYY) 02/20/09 PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequest@marsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 347 5 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 Fax (212) 948-0902 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Steadfast Ins Co 26387 THD At-Home Services, Inc. INSURER B:Zurich American Ina Co 16535 2690 Cumberland Parkway INSURER C:NATIONAL UNION FIRE INS CO OF PITTS 19445 Suite 300 Atlanta GA 30339 INSURERD:New Hampshire Ina Co 23841 NSURERE:Illinois Natl Ins Co 23817 COVERAGES 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 CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR OD' POLICYEFFECTIVE POLICY EXPIRATION LTR POLICYNUMBER AT MMDD ATE M LIMITS N R A GENERAL LIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACH OCCURRENCE $4•,000,000 X LIMITS OF POLICY ARE EXCESS DAMAGE O ENTED 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea cccurerice - $ CLAIMS MADE OCCUR "OF SIR: $1,000,000 PER CC" MED EXP(Any one person) $EXCLUDED PERSONAL&ADV INJURY $4,000,000 GENERAL AGGREGATE $4,000,000 GENT AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OP AGG $4,000,000 X POLICY PRO- LOC JECT B AUTOMOBILE LIABILITY SAP 2938863-06 03/01/09 03/01/10 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) X ANY AUTO ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person)- HIREDAUTOS BODILY INJURY $ NON-OWNEDAUTOS (Per accident) X SELF INSURED AUTO PROPERTY DAMAGE (Per accident) $ PHYSICAL DAMAGE GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY - IPR 3757 608-02 03/01/09 03/01/10 EACH OCCURRENCE $5,000,000 X OCCUR EI CLAIMS MADE AGGREGATE $5,000,000 $ DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATION AND 3566916 (CA) 03/01/09 03/01/10 X T/RY IM T O R D EMPLOYERS'LIABILITY 3566915(AOS) 03/01/09 03/01/10 El EACHACCIDENT $1,000,000 ANY PROPRIETORiPARTNER/EXECUTIVE E OFFICER/MEMBER EXCLUDED? 3566917 (FL) 03/01/09 03/01/10 E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $1,000,000 OTHER D Workers Compensation 3566918 (KY, MO, NY, WI, 03/01/09 03/01/10 F TX Empldyers Excess TNSC45694422 (TX) 03/01/09 03/01/10 ccurrence/SIR 25M/2M C Workers Compensation 4801323(QSI) 03/01/09 03/01/10 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THD AT-HOME SERVICES, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 2690 CUMBERLAND PARKWAY SUITE 300 REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2001/08)ckomraus hd ©ACORD CORPORATION 1988 11172180— 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 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 Departtent of Industrial Accidents Office of Investigations � 600 TVashinpon Street �F Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): _ Address: City/State/Zip: fi")jj� Phone#: Are you employer?Check the appropriate box: Type of project(required): L am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or pap rt-tune).* have hired the sub-contractors 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 me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [-No workers' comp. right of exemption per MGL 12.❑ Roo a' s insurance required.] t c. 152, §1(4),and we have no 13 there employees. [No workers' 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: l h-D Job Site Address: City/State/Zip: Attach a copy of the workers' compensation p y 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 nder aii an penalties of perjury that the information provided above 's tAn d correct. Si>rnature: Date: ' Phone#: Official use only. Do not write in this area,to be completed by city or town official. Citv 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 Su Not Applicable ❑ Name of License Holder: mor.e.: C//��] I�2,1 4 License Number V Address Expiration Date e Signature _ Telephone 9_Registered Home Ir`rove ent Co tractor•` Not Applicable ❑ Company Name Registration Numb r Address ( 1 Expiration Date / l� l 1 �a) Telephone IC s-)f, SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit 7d9t 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....... all, No...... ❑ 11. - Home Owner Ege npf on 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 � 4 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Wi ows Alteration(s) Roofing F7 Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding[ED] Other[E-1] lee Brief Descriptio ro se " �tP Work: t f r4 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 addition to existing housinq, romplete 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 hereby authorize to act on my behalf,in all matters relative to work authorized 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 and pen;ALQsof perjury. Print Name t Ai— Signature ofowne'rZicient 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: U (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 0 DONT KNOW 0 YES 0 IF YES: enter Book Page, and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO 0 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 0 NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton States of Permit: ` Building Department Curb Cut/Driueway Permit 212 Main Street Sewer/SepficAvailability t Q� --Room 100 WaterNVell Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413- 7-1240 Fax 413-587-1272 Plot(Si.te plans, Other Specify APPLICATION 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 Map Lot Unit K 1� Lam}— Zone Overlay District I Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 4me C -- Name(Print) Current Mailing Address: 5Ce_ Telephone Signature 2.2 Authorized Agent: Na Gnfent Mailing Address: Si 79n 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 (b)Estimated Total Cost of Construction'from 6 3. Plumbing Building'Permit Fee 4. Mechanical(HVAC) 5. Fire Protection /�- 6. Total=0 +2+3+4+5) Check Number This Section For Official'Use Only Building Permit Number: IIsssued: Signature: Building Commissioner/inspector of Buildings Date I - BP-2009-0730 GIS#: COMMONWEALTH OF MASSACHUSETTS :131ck: 7C_ CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2009-0730 Project# JS-2009-001088 Est. Cost: $4414.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 126893 Lot Size(sq. ft.): 5183.64 Owner: ROCHE CARRIE Zoning: URC(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT. 1 VALLEY ST Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341-9401 Workers Compensation WORCESTERMA01607 ISSUED ON:311112009 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 Si nature: FeeType• Date Paid: Amount: Building 3/11/2009 0:00:00 $35.0025605 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo