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35-122 Jul 28 2008 6: 28AM HP LRSERJET FRX P. 5 / Sold F [shed and Installed nc. 3ranch Name: t Date: Z7. O T[3 At Home Services,Inc. ci/b/a.3 he Home pot At-11ome Services Branch Number, Job 345A Greeikwood St Worcester,MA 01607 {�}', Toil Free 00)65745 82; Fax:508-756-2859 Federal 117 015-264460 ME Lie A C 02439 RI Cont.LieW 16427 " CT U�#565522 K4AHc,1w[1,1PWV1 en Contractor Rcg.4126993 Installation Address: ��-� ti Df � P[Ort, ')<L,. StaV Zip Last 4 Digits uf*lver's Parehaser{s): Lk.N&Esp,.NtOr: Work Phone: Home Pbone: Nome Address: _ (If different from Install ationddress} -..W City_. S Zip_•-� E-mail Address(to receive ttpdatt's and promotions from The Houle Depot): Project Information: I/Wt-1Yo*("Pwchascr'%the owners of the property located at th6;above i llation address,offer to contract with T.H)At•Hotnci Sarvaces,Inc.( Horne Depot' t fwrush,deliver and arrange for the i talladon eE all materials as described on the attached $peg sheet 1#�js_. �� _ ,incorporated herein�sy referen and made a part hereof Home Depot reserves the r ht tt cancel this contract, I[,upop r�lhspectlon of the jj*,Home- epot determines that it cannot perform its obligati6ns title to a structural problem with the hame,pricing ei^ro"or b ause work required to complete the job was not inAlud„d in the Spec Sheet or Contract. _ DEPOSIT PAYMENT ,PTIONS �7''`) (Subjutto fund vorf eationan&or. ditapprovul.) CONTRACT AMOUN* & / ( 1 LI .,k- Cayhlcra Check r Ub Postal Sorvi Money Ordor (Mack payable to n.Home Depet). [LESS DEPOSIT 2 credit Card**antYor other p"nem options•10rete One Below BALANCE DU$- G�( -Vlsa. M-U-C rid D ekover A TT(N &Fv. ON COAiPLET1011li $ ..> 1 7heHOtnclxpor HumoM i ov.gpmt Loan ome Depot Credit Card r: tlltiulmum ZS Yi of ContrJ►ct Amount due gtlVR.. . 0:14e Account xlltina Aeownl I IDCC ONLV) execution of tlltb:eotttiracC Arallihle Cr�dlts S iD L&KDCC ONLY-) " Indicate PaymLn*Me�hod For Ant# Up_ le: BALANCE DUE ON CO#FLETION: Nune at:jt eppeara an caul:: P-b.-1 --By tr4,^nur signature below±'I1V0 a to allow Home Depot to � charge the abov refer cc d 0[lit car the deposit'ndica� `when you provide a c�k asp n �yao authorize ua.oither _ $ 17.,. ffffff [a use infonuntion from iv cheo ito e a one-time elocttvnic Cafdhdl bi,?Si nriaitre nett fund"431br from your account C.4W PiOMM Ilse paytacnt AS n check trwaaraon.Wlm we use vat ttigormil on from your check to Il1i OC".HDCC$.Uthar 4n Codes make an»lectronic fmd wlrr,l&d. 1lMy be witbdraan from Your Account ns noon sp tim paymeP. is rppcived,and you will not Deposit Fin Pa,.. cut m receive your cheek beck Purchaser agrees that,imon"atalq upon completion of the work Ptit chaser will exe�att it Compleb o Certificate and pay any balance due. Purchaser alw"tigra"to Be jointly and severally obligattid and liable-hercuri Entire Agreement:This agiecmeinl and its attachments, includtng.ppy financing agreem rat,conta1�the complete agreement between the parties and can itot bk amended or modi fled unless in writing in a separate agtement sieiEred by both parties. NOTICE TO PURL--LASER �Il Da not sign this contract b>iorg;yau:read it, You are:entildelt tole completely lie "n copy o the contract at the time you sign. Keep it to prota,�l:y4tµr rights. Do not sign a Completipn Gerti$pptc bre thin jest is complete. Low prohibits home repair con aetyirs from requesting or aeeepdgg.a Compledon CLrt[Clcate rig 4d by the owner prior to the actunt'.completion of&,wtiiik to be performed under the eanitact. You may eancel:this traustS#io%any time prior to midnight at the 1hird'business doy�,after the etc of this contract. See Nonce of Cancellation fortif�n ostplanation of this rigliG Tht>re-will be a service clitrge equ" to 14"$of the contract amount>IT job is cancelled i4i P tirchaser AFTER the third bueitrecs day,,but.BEFORE materia are ordered.There will be a service charge equal Oq 15%of the contract amount if job isr'ca[celled by Purchaser AFT materials are ordered. BY MY/OUR SLGNATU1tE��E OW,I1WE UNDERSTAND TR'AT.TI;E AGRREMEI�.MAY B SUBJECT TO REVIEW OF MY-11JUR CREDIT Hj[IT . Y AND VWE AUTHORU AOME IMP& TO I.IRIFY D REVIEW MY10UR CREDIT RECORD WITH,*1 W DEFENDEN-17 CREDIT REPcAmNG.AGENCY 46 RE SE THEM FROM ALL LIABILITY INCURRED 1740 AAUERTINC T OMISSIONS OR!ERRORS, BY MY.rOUR SIGNATIJR 13X OW, IlWE AGREE TO.BE BOUND BY TN2 TFRn1S OF . IS CONTRACT. I/WE ACKNOWLEDGE RECEII!T Mr COPY OF TRIS CONTRACT AND TWO COMAETED PIES OF THE NOT CE OF CANCELLATION. SUBMITTED BY: :4ti .f S` D ob . --7 ACCT PTEDBY: — — D n.`^�r -7 /-✓ D L.. .. NOTICE:ADDl7f'A&AL TERMS CONDITIONS.ARE STATED 0�1T THE R VERSE SIDE AN ARE PART OF TMS CONTRACT t 9-21-07 rev 4-2.07 C-SC Wtdte-Branch File Yellow-Cukotoor Pink-Sales Cd4tidtant 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 your), 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 Department of Industrial Accidents - � _--- Office Of Investigations r. 600 Washington Street _.a,. Boston, MA 02111 www.mass.govl dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: a Phone #: Are you an employer?Check the appropriate bog: Type of project(required): 1.Imam a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* 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 an ca employees and have workers' Y capacity.t1'• 9. F-1 Building addition [No workers' comp.insurance comp.insurance.# required.] 5. F-1 We are a corporation and its 101 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [_No workers' comp. right of exemption per MGL 12.❑ Roo re airs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. the 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: 021 --7 x Policy#or Self-ins. Lic. #: t9w / Expiration Date: Job Site Address: \ ���-a City/State/Zip: HID P W 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 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 D for insurancvoverage verification. I do hereby cert' nder th p nd alties of perjury that the information provided above is true and correct. Signature•. Date: Phone#: Official use only. Do not write in this area,to be completed by city or town offeciaL 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#: 4 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9. Re isteted'Hnme Improvement Corttract&L Not Applicable ❑ Company Name Registration Number I a0I`�; Address r r �j�, Expiration Date C O Telephone 1135-, � SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG.L.c.152,§25G(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....... Izz, No...... ❑ I1. - Dame Owner Riernpti©n 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 Win s Alteration(s) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[O] Other[O] Brief Description of Propose�� Work: ( Wl �Y 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 add[tion to exis ' 'housin com'lete the fallowing: 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 stones? 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, C©of-.I c _, 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 as Owner/Authorized Agent hereby declarelfhat the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed unde the ains and_Q_Qnalties of perjury. Pri VaVe S re of Owner/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 _, ..._..n '.. .. . ... ...... . __, ,. _ .. Frontage ,....._ m. �_... Setbacks Front Side 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 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 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 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. De it Ease only b City of Northampton Status of Pert ,ta c Building Department Curb GDn ufiy E'errrteei 212 Main Street Se,,,ter�vep#errarla6rG#y� � r Room 100 WafgrWelf rra�tab�Iaty Northampton, MA 01060 T e Setso€Structurawlans 1 ,... '. phone 413-587-1240 Fax 413-587-1272 PlotfStte Plans "" " APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE 0T±f"TWO FAMILY DWELLING I I AJU SECTION 1 -SITE INFORMATION U This sectio to be c9_00 the 1,by office---, 1.1 Property Address: F, _ 4 t;. Map Lot Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) �} Current Mailing Address:�� ^ ,�� G(All bA Telephone Signature 2.2 Authorized nt: Name ri Curninf Mailing Address: `4f u ure Telephone SECTIO 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a)I Building Permit Fee 2. Electrical (b)Estimated Total'Cost of Construction from 6 3. Plumbing Building Permit Fee( r 4. Mechanical(HVAC) � '22 Y3) 0_LS.C70 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 D BP-2009-0127 GiS#: COMMONWEALTH OF MASSACHUSETTS a 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-2009-0127 Project# JS-2009-000160 Est.Cost: $5774.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES Lot Size(sy. ft.): 9016.92 Owner: ST GEORGE CHRISTOPHER T& Zoning: SR Applicant: HOME DEPOT AT HOME SERVICES AT. 25 DREWSEN DR Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341-9401 WORCESTERMA01607 ISSUED ON.81512008 0:00:00 TO PERFORM THE FOLLOWING WORK.-Replace 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 8/5/2008 0:00:00 $25.0023631 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo