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35-262 11V191L'LLT11 dill V i,01r l 1 q VA I^at I PLEASE RE"THIS � D (I [ Sold,Furnished and Installed by: Branch Name: Boston Dabs:4_/A J THA AwNcne Servion,Inc. d/b/a The Rome Depot At-Rome Services Branch Number: 345A Greenwood Street,Unit 2,Worecster,MA 01607 ❑Nortb 33 outh 31 Toll Free(800)657-5182; Pax(508)756-8823 Federal M k 75-2698460;)dM Lie#C 02939;R1 Conr,Lic#16427 y_ _ CT Lie#565522;MA Home Improvemagr Contractor Reg.#126893 Installation Address: (02,-.. Yt Z` tQt aS 2aA:s�s City State zap, purahaser(a): Work Phone: Home Phone: Cell Phone: Home Address; (1f different front Installation Adduces) City State Zip E-mall Address(to receive project communications and Home Depot updates); 1 DO NOT wish to receive any marketing emails from The Home Depot ro act ation: Undersigned("Customer'%the owncra of the propetty located at the above installation address,agrees to buy,and Home Services.Inc.("The Home Depot')agrees to furnish,deliver and arrange for the installation("InstaLattou"}of all materials described on the below and on the referenced Spec Shcet(s),all of which are incorporated into this Contract by this rrference,along with any applicable State Supplement and Payment Summary attached hereto and any Change orders(coilecnvely, "Contract"), Job#; cwt—,aft i trodueb; Sec shtwall#: Project Amount �RboCine SidiaE El Windows ❑Insulation Cl QQ (]Gutters/Covets Doors Itoofmg LJS1dlAg LJ window,❑Insulation pGutters/Covers pEht y Doors ❑__ 0ROof6 Siding r Windows to so o.on 00uncrs/Covers QEnny Doors Q Roofane Siding Q Windows Imewatiou a EIC lum/Covers ❑Entry Doors Qom_ t� Mtnmtum 25%Depeak of Contract Amount due upon awwdeft of this contract x Total Contract Amount MalaePutthasers m y not deposit mono dan ne dt M hCodtractAmonnt L }' 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 Shoat)and pay any balance due. As applicable,each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Moms Depot reserves the right to issue a Change Order or terminate this Contract or any individual Pruducts(s)included herein,at i8 discretion,if The Rome Depot or its authorized service provider determines ibat 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&—,nT or because work required to eomplotc the job was not included in the Contract. Payment Snmmargr The Payment SumnIary ,�(�, i included as part of this Contract, sets forth the total Contract,amount and payments required for the deposits and fmal payments by Product(as applicable). NOTICE TO CUSTOMRR You are cudded to a completely Celled-in copy of the Contract at the time you also. 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 i5 c—pletc. In the event of termination of this Contract.Customer agrees to pay The Harme Depot the costs of materials,labor,eXptnsts and services provided by The Home Depot or Authorized Service Provider through,the date of termination,plus any other amount§set forth in this Agreement or allowed under aqplicable lava. TAE.ROME DEPOT MAY WITRUOLD AMOUNTS OWED TO THE HOW DEPOT FROM THE DEPOSIT PAYME,1sIT OR OTHER PAYMENTS MADE, 'WTMOVT 11MITING THE HOME DMIOT'S OTHER REMEDIES FOR MCOVERY OF SUCH AMOUNTS. ,acceptance and Aufbotimtlon; Customer agrees and understands that this Agrocmeut is the entire agreement between Customer and The Homo'Depot with regard to the Products and Installation services and supersedes all prior discussions and agrocmcnts,cid" oral or'written,rGlatiag to said Products and Installation.This Agreement cannot be assigned or amended except by a'writing signed by 0.cstomcr and'The Home Depot.Customer acknowledges and agrees that Customer has read,undcrstands,voluntarily accepts the terms of and has received a copy of this Agreement, Accepted by: Subm=&Z) 4 X L omct'9 5i roue Date Sales Consultant's Sign r Date l Telephone Ido. I Customca's Signature Date Sales Consultant Ueanse No. CANCELLATION: CIUSTOMI R MAY CANCEL THIS {ss sppuctLtc} AGREEiNfENT WITHOUT PENALTY OR OBLIGATION BY DRLIVERINC WRITTRN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THC THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. TITS STATE SUPPLEMENT ATTAC11EIl HERETO CONTAINS A FO12M TO USE IF ONE IS SPECIFICALLY PRESCRIB91? BY LAW IN CUSTOI D1 11'9 STATE, NOTICE,-ADOMONAL TERMS AND CONDITIONS ARE STATED ON TM REVERSE 51I)E AND ARE PART OF THIS CONTRACT 6-05-46 C-SC Whh&-Bmnch Elie Yeuo ,OUStomer 110-Sales Consultant .. �TM. CERTIFICATE OF LIABILITY INSURANCE DATOW�D00/YYY`� PRODUCER Ohano: (413)781-N210 Pax 413.731-3630 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION INSURANCE CENTER OF NEW ENGLAND ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P 0 BOX 1175 HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR WEST SPRINGFIELD MA 01090-1175 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Peerless Insurance Company IVAN KOSOBUTSKYY INSURER 3: 72 STAFFORD RD INSURER C: MONSON MA 01057 INSURER D: INSURER E: COVERAGES T C POUCC3 OF NSURANCC LISTED OCUJW I IAVC OCCN SSUCD TO TI IC INC-URCD NAMED AOOVC FOR TI IC POUC PERIOD NDICATCD,NOTVvM ISTANCING ANY REOUIREMEW.TERN CR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WT-H RESPECT TO%VHCH-HIS CERTIFICATE MAY BE ISSU=C CR MAY FFRTAN.THE NSIIRANT:F AFFORnFn Fy TFF 3CI ICIFS OFSCRSFr)HFRFN IS Si IR,IFr'T-0 Al I TH=TFRMS,F:CI i SIONS AM CONDITIONS OF Sl Ini- POLICES.AGGREGA-E LIMITS SHOWN MAY HAVE BEEN REDU:ED BY PAID CLAIMS. NSR ADOL TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR ay9RD DATE MM/DONY DATE MNPDD/YY GENERAL LIABILITY GL8439797 05/15/08 05/15/09 EACH OCCURRENCE $ 1,000,000 X COMMERr1AL GENERAL LIABILITY DMMCE T aENTEO g 100,000 PREMISES(0,e NTEDn:e CLAMS MADE D OCCUR NED.EXP(Anyone person) $ 5,000 A PERSONAL 4 ADV INJURY $ 1,000,000 UcNLRALA3GHtUAIt $ 2,000,000 COL AGGREGATE LIMIT APPL ES PER: PRODUCTS-COMWOPAGG $ 2,000,000 POLICY JECT LOC AUTOMOBILE LIABILITY r:O)MRNFn SNCI F IMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS BOCLY NJURY (Per peson) g SCHEDU_E:)AUTOS. HIRED AUTOS BOCLY INJURY $ NON-OWNED AUTOS (Neracadenq PROPERTYDAMAGE $ (Peracciden0 GARAGE LIABILITY AUTO ONLY-CA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESS IUMBRELLA LIABILITY FACH OM.IRRFNCF $ CCCUR 0 CLAMS MADE AGGREGATE $ $ CEDUCTIBLE g RETENTION S $ aATU YfORKEiR3 COMPENSATION AND WC TOFY TLACTS O-HER EMPLOYERS'LIABLITY E L.EACH ACCIDENT $ ANY PROPRIETOR/PARTMER/EXECU WE OFFICERMEMBER EXCLUDED? E L.DISEASE-EA EMPLOYEE S Nyes,deuribo under E L.DISEAS POLICY LIMIT $ - SPECIAL PREVISIONS below OTHER: DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS THD AT HOME SERVICES,INC.,AND THE HOME DEPOT ARE NAMED AS ADDITIONAL INSURED AS RESPECTS GENERAL LIABILITY AS PER WRITTEN CONTRACT ONLY F#508.791.8047 CERTIFICATE HOLDER CANCELLATION SHOULD AVY OF THE ABOVE DESCRIBED POLCIES BE CANCELLED BEFORE THE EXPIRATION DA-E THEREOF THE ISSUING INSURER WILL ENDEAVCR TO MAIL 20 DAYS WRI'TEN NOTICE TO THE CERTI=ICA'E HOLDER NAMED TO-HE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO THD AT HOME SERVICES,INC. OBLIGATION OR_IABIUTY OF ANY KIND UPON THE INSURER,R'S A3ENTS OR REPRESENTATIVES. 3200 COBS GALLERIA PARKWAY,STE 200 ATLANTA GA 30339 AUTHORIZED REDRESENTATT'VE n .Gallagher Attention: P 9 ACORD 25(2001108) Certificate# 36008 ®ACORD CORPORATION 1988 �Ia�•achusetts_ Board of B BEPartment�yt p Construction Su �`ulations and Standard License: pervrsor Specialty License Restrict CS SL 98785 Restricted to: WS 1VAN 1 KOSOBUTSKyy 72 STAFFORp ROAD MONSON MA 01057 ummi.riunrr Expiratio n: 4/27/2012 Tr#: 98785 lice �-L 1 �- Bfa Meg n Oeg I a�ons an an ar s One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 152379 Type: O BA Expiration: 8/212010 Tr# 0 f & I REMODELING IVAN KOSOBUTSITYY - - ' - -- - 72 SATFFORD ROAD -- MONSON, MA 01057 _.. .. ._ Update Address and return card.Mark reason for change- Address ' Renewal - Employment Lost Card OPS-M a 50"7107-PCaa9° Ro+w�AfH iA�t�ntilran"tl'4lsifftittftf4 License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 152379 Board of Building Regulations and Standards Expiration: g/2312010 Tr# 0 One Ashburton Place Rm 1301 Type: DSA Boston,NIa.02108 I DELING f IVAN AN KOS KOSOBUTSHW / 72 SATFFORD ROAD MONSON,MA 01057 Administrator Not valid wi out signature The Commonwealth of Massachusetts Department ofLndustrial Accidents Office of Investigadons 600 Washington Street Boston,AM 02111 www.mass.gov/dia Workers' Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers Apt)licant Information Please PrintLegibiv Name(BusinesslQrganitation/Individual): 1� Address: City/State/Zip: _ ?� Phone.#• Are y an employer?Check the appropriate bor. Type of project(required): 1. a employer wig _ 4. ❑ I am a general contractor and I 6. ❑New construction • employees( �aad/or part time).* have hired the sub-contractors 2.❑ I sin a'sole p0oprietor or partner- . listed on the-attached sheet: 7. []Remodeling These sub-contractors have a. Demolition ship and h1ve no employees employees and have workers' 9. ❑Butz ' addition working for me y cap�y, t ❑ �g [No workers'comp.insurance cow' or 10.0 Electrical repairs or additions required] 5. ❑ We are a corporation and its ep • 3.❑ I am a homeowner doing all work officers have exercised their 11.Q Plumbing repairs or additions myself:[No workers'comp. right of exemption per MG1r .12f]�fgto fimuzance reepd.J t. c.152;§1(4),and aro have no employees.[No workers' 13. tromp.insurance required.] •AnY applicant dui dmb box Apt mutt alto Sit out du:section belowbowins d*wari0XS'con ch POUCY iaRnawtla�. t.g�owoas who subn>it this.afdavit indlaWas dust are doing tII work and dm him outside contractors Dial submit a new itidavit indicating such. ZConnactor>i that cbcci<d&box'mbt sawhed an additional sheet sbowuias the name of du wb•eactraetors and sua whether or not those ent.i is have employees. If the sub-cm&aeton have employes,dM Duttlxwide Chair wodaers'conR•POft nun I'qm an employer that 1sproviding workers'compensation insurance far my employees: Below is the polity anaifobsite information: ,...-- Insurance Company Nam: Policy#or Self-ins.Uc.#: ! :ExpirationDater . l� Job Site Address' � ' mt • 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 Em up to S 1,500.00 and/or one-year imprisonment,as well is civil penalties in the form of a STOP WORT{GIRDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy,of this statement may be forwarded to the Office of Investi 'lions of the for insurance coverage verification. I do hereby ca idpenafties of'pedwy that the information provided abov is and correct: i •attire' 0 C#•. X use only.- o not write area,tb a comp ete y c or town off iclal City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Phone#: SECTION 8-CONSTRUCTION SERVICES y 8.1 Licensed Construction Supervisol; Not Applicable ❑ Name of license Holder: , Jl Y� qQ "jam License Number Address Expiration Dat Signature Telephone 3 Registered Houle_Im ��overnec�Cantracfar �.w >` . .,_': � Not Applicable ❑ Company Name Registration Numpier , Addre s o Expiration Dat Telepho I q �ac� � ne� SECTION 10-WORKERS'COMPENSATION INSURANCE DA AFFIVIT(M.G.L.C.152,§25CM) Workers Compensation Insurance affidavit mu a completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin rmit. Signed Affidavit Attached Yes....... No...... ❑ I1. - Home Diner��eiri���ar 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-vear 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 buildinP 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 Wi ws Alteration(s) ❑ Roofing F7 Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[01 Other[p) Brief Description of Proposed �� C� 4,emem- Work: I I i t 7n 011-V r on J �tJ 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"'exl9tinct homin' darn"letetfie.fd fawhif 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 _T OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 62S 4:- 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. Irt-J)Ax� Signature of Owner Date ��f 1 C � 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 th s and peoalties of perjury. Pri e Signature 4 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 __..... __,,... ..,.__ ..__ 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: (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 (D YESµ®F 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 Obtained , 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 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Departrrtett use onty City of Northampton W@410oi egP14 m Building Department CuCuD) eyPermtt s 212 Main Street Se...... pttc,�varTabt ity x Room 100 fa#eritt►eit XV,ailals I�t�r Northampton, MA 01060 T"ws Sets o>•Stru'ctoral~Plans ��'_ �� � phone 413-587-1240 Fax 413-587-1272 PI©fSite 'fans Oth' fj3 APPLICATION TO CONSTRUCT,ALTER,REPAIR;RE OV�TE PR 4EII4ALI�i A PNE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION n 1.1 Property Address: 66T 7 s sectfdh to be completed by office w-. .Map ' Lot Unit I Zone --"""Overlay District Elm St District CS District SECTION 2-PRO'PERTY OWNERSHIP[AUTHORIZED AGENT 2.1 Owner of Record: wwp% Name(Print) Current Mailing Address: lee-Cwta�� Telephone Signature 2.2 Authorized A e ` 7 Name irrent Mailing Address: qQ(3��a� 3 Signature Telephone SECTION 3'-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted 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 i 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date MEOW BP-2009-0394 GIs#: COMMONWEALTH OF MASSACHUSETTS 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-2009-0394 Project# JS-2009-000532 Est.Cost: $2490.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES Lot Size(sq. £t.): 32844.24 Owner: SLOVIK NINA Zoning: SR(100)//WP/WSP II Applicant: HOME DEPOT AT HOME SERVICES AT. 62 WEST PARSONS LN Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935-2633 () Workers Compensation WORCESTERMA01607 ISSUED ON:101912008 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT DOORS 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 10/9/2008 0:00:00 $35.0024339 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo