25A-082 (11) l� Sold,Furnished and Installed by:
BFMXh Name:Boston Nottb&Soath Date/1 `-1_ T14D At-Rume Scrrices,inc.
Wa The FTorne Depot At-Home Services
Branch Number:31 and 33 908 Boston Turnpika,Unit 1,Shrewsbury,MA 01545
Toll Free 877-903-3768
Fcdcrat 0#75-2696460;7,M Lic#C 02439;RT Cont.Uco 16427
CT'Lic#HIC.b565522;MA ome rovement C actor Re #126693
Installation Address. cc�d �t A V—Q—
City State Zap
rumbMer(s): Work Phone Flom + Cell Phone:
t
Home Address,
(If different from Installation Address) City State Zip
E mWI Address(to receive project communications and Horne Depot updates): _
❑I DO NOT wish torcceive any rr mXctjni smalls from The Home Depot
ect Infor gQll: Undersigned("Cuatotner },the owners ot'the property located at the above installation address,agrees to buy,
arra At-klotnc Services,Inc.("The Hoare Depot")agrees to fumihh.deliver and arrange Aw she imt4ation(`Installation")of
all materials described on the below and vn the reftmcea Spec Sheet(s),all of which are incorporated into thin Contract by this
reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively,
Contract"):
-Job*; uaw-w aer-< ) Yrndvctst S eC Sb. s)# Emect Amount I Roofing Siding 1Ytndows Insulation
pOuiters I Co-mrs❑Entry Daass G $ 'S I
Roofing aiding Wiaduws lnsutatiun
❑G;mr-m/Covers ❑EnIXY DOOrs ❑ $ t I I
Roofing Siding Windows irisr'latiory i
GJGatte6 I Covers(r},Erisry Doors❑
Roofing Siding Windows ttuttlatian
❑GutteiX/Covets ❑6nlrYDOM ❑ _
Mioimuna 25%Dcpotat of Cmtuact Amomnt due upon vmw1 oa of this soar- Total Contract Amount
Maine Furchmers may not depneit mare than our4Wd of the Contract AMMM 7
Customer agrees that,immediately upon cvmtplefian of the work for each Product,Customer will execute a Completion Certificate
(one for each PnAuct m defined by an individual Spec Sheet)and pay auy balance due. As applicable,each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depot rcgerves the right to is.ue a Change Order or terminate this Contract or any individual t't'oducl(g)included herein,at
its discretion,irThe Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the)Some,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because
work required to complete the job wai not included in the Contract,
Pik,vimnt gummarY, The Payment Summary# 114�01� _ included as part of this Contract, sets fortb the total
Contract amount and payments required for the deposits and final payments by Product(us applicable).
NOTICE TO CUSTOMER
You are entitled to a Completely tailed-in copy of the Contract at the time you slM Do not saga+a Completion Certificatt(wrote:
there is une Completion Certificate for each listed product as defirned by Individual Spec;Sheets)before work an that Product
Is complete.
Twt the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of matcriala,labor,expenses
and services provided by The Hoare Depot or Authorised Service Provider thro the date of termination,Plus any other
amounts set forth In this Agreement or allowed tinder applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM TRP DEPOSIT PAYMENT OR OTHER PAYMENT'S MADE. WITHOUT
LIMITING TIRE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCK AMOUN'T'S.
Acs lance and A rization. Customer agrees and uoderswri&that this Agreement is the entire agreement between Customer
and a oats Depot wit regard to the Products and Installation services and supersedes all prior discussions and agreements,either
oral or written.telatu)g to said products and Installation-This Agreement cannot be assigned or amended except by a writing signed
by Customer and The Home Depot.Customer ac►;nowledges and agrees that Customer has read,understands.voluntarily accepts the
terms of and has received a copy of this Agreement.
Ac d by; Submitted by;
>�rZ
C titer's igna a Date Sales Consultatifs Signature hate
Telephone No.
Cu'amet's Signature Date Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS (as appt;cabl¢1
AGREEMENT WITHOUT PENALTY OR OBLIGATION
DE I]I3LIVlEItING WRITTEN NOTICE IM T R THE HOME
DEPOT BY MaANIGHT OTtt TKIItTI $U$INL$S
DAY AFTER SIGNING THIS AGREEMENT. THE
S'T'ATE SUPPLEMENT ATTACKED HERETO
CONTA.JVS A FORM TO USE IF ONE IS
SPEC TCA1LY PRESCRIBED BY LA6W IN
CUSTOMEWS STATE,
N077CE:ADDITIONAL TERMS AND 00NDITJQN1,i ARE STATED ON TAB RF VERSE SIDE AND ARE PART OF THIS CONTRACT
11-0IMS Whits-BranthFlle Yellow-Custaner
City of Northampton
Massachusetts
�.,
DEPARTMENT OF BUILDING INSPECTIONS �y"y ;y
t' 212 Main Street • Municipal Building
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 any 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
-t x The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
M www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbei•s
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am 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 any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp.insurance.$
required.] 5. ❑ We are a corporation and its 10.0 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.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 131-1 Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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: _
Job Site Address: City/State/Zip: _
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 DIA for insurance coverage verification.
I do hereby certify under the pains and penalties 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 official
City 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 ervis Not Applicable £
Name of License Holder
1 / v�l/v C
License Number
/!� A 6 -
Address Expiration Date k11zAA1 *
/-m- -
Signature Telephone
_.. ,
/
Not Applicable
9 e is red Ho ��
,Rterrid rn rove nt Contractor
Com an ame � Registration Number
A -� Expiration Date
f �
Telephon
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 building permit.
Signed Affidavit Attached Yes..... No...... £
11. - Home Owner.Exemption`
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 W' ows Alteration(s) ❑ Roofing E]Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[0] Other[O]
Brief Des P /r s
Work: /l/
Alteration of existing bedroom Yes No Adding new bedroom Yes No >
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.if Newhouse and or ad, i#ion to ezistilnq.hou"sing, complete the foilowlng
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 �j---�
J /
hereby authorize
to act on my behalf, ' II matteis relative to wor sized by this building permit application.
Signature of Owner Date
r41'7i� 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 t ins enaltie perjur���
Print:Nam:e -/
Signature of ner/Agent Date l
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
Rear
Building Height
Bldg.Square Footage 0110
Open Space Footage %
^
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variance/Rnding ever been issued for/on the site?
NO 0 DONTKNOW 0 YES 0
IF YES, dateissupdJ �
IF YES: Was the permit recorded at the Registry ufDeeds?
NO �
DONT KNOW 0 YES
IF YES: enter Book i Pag and/or Doc ument#
B. Does the site contain a brook, body of water orwetlands? NO 0 DON7KNOY 0 YES 0
IF YES, has 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 �~� NO v��
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 0
(F YES, describe size, type and location: i
E. V@||the construction activity disturb(clearing,gradingexcavation.or filling)over 1 acre orisit part ofa common plan
�hatwi||diotudbover1acne? YESC ) NO K~~�l
' `~�
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
- '-
pepartn2ent use onl�r
Q ity of Northampton status ofPermtt f
wilding Department Ctrrb Gut/DiewayFetrrtit
7 2014 212 Main Street SeyrerlSepticAvailabllity f
Room 100 Water/IAfeltAvatlabihtj ..
Electric,Plumbin N rthampton, MA 01060 Tut�txSefs ofS#ructural'Pia[ts
Northam r to Ga 8 587-1240 Fax 413-587-1272 Plot/Site Plans r
---.:....,_.............__ n. MA n Luc - r t
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
6PIA Z,
=;Zone Overlay Disfrrct
;Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current M 1113 Address: �.
Teleph e
Signature
2.2 Authadzed ent:
Name Print) Current Mailing Address:
4/v/�-� /
Sign r Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ~, r (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 F _
6. Total=0 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/In.spector'of Buildings Date
23 COOLIDGE AVE BP-2014-1080
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A-082 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2014-1080
Project# JS-2014-001851
Est.Cost: $2342.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 082485
Lot Size(sy. ft.): 6621.12 Owner: PACKARD JOSEPH JR&GERALDINE
zoning: URB(100) Applicant. HOME DEPOT AT HOME SERVICES
AT. 23 COOLIDGE AVE
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON:411812014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT 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 4/18/2014 0:00:00 $35.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner