23C-066 HOME DIMOVEMEN'T CONTRACT
PLEASE READ THLS
Sold,Furnished and Installed by.
Branch Name;Bostort North&South Date; �1+7 ( � T14D At-Home services,Inc_
d/b/a The Home Depot At-Homo Services
Branch Nwmber:31 and 33 968 Boston Turnpike,Unit 1,Sbrewsbury;MA 01545
Toll Free 877-903-3768
Feral ID 6 75-269WO;ME Lic#C 1)2439;PI Cont.Lio#1642?
Cr Lic#HIC.OSb5522;MA Home Improvement Contractor Reg.#126893
bmsWlatiou Address:
City State Zip
Purchaser(a): workphone: 11otgePhom: Ce111ra0ne:
Home Address:
(if different from Installation Address) City State Zip
E-mail Address(to raceive.project communications and home Depot updates):
El I DO NOT wish to receive any marketing emails from The Home Depot
Proiegt jo[ertnation: Underaigned("Customer"),the owners of the property Iacawd at the above installation address,agrees to buy,
and THID At-home Services,Inc.(-0w Home Depot")agrees to furnish,deliver and arrange for the installation("Installation")of
all materials described on the below and on the referenced Spec Sheat(s),all of which are incorporated into this Contract by this
reference,along with any applicable Suite Supplemsnt and Payment Summary attached hereto nod any Change Orders(collectively,
"Contract"):
rob : ndrrora�ra„�, Pr9fluctr. spvt Street #: Pealed Amount
y Rooftop Siding indows Insulation
-)q / ❑Gutters/Covers ❑entry Doors ❑ $
Ronfing QSiding oor Ci�124
inds $
❑Guners/Lovers ❑BnnyDoors 0.__
Rams OSidins LJ Wrido-w-t-n Insulatim
[]Gutters/Covers ❑Entry Doors C] $
Rooting LjSiding Lj Windows Lj FAauiation
OCrutten i cawv rs ❑Entry Doors❑ $
Waimum 25%Deposit or Cosdrad Amountdce upon erecudon of this corRruty
Total Contract Anotmt $NIWnePardaers neq notd epa*Aoetao aoe#ltird of
the Contract AarwenL
Customer agrees that,iaunediately upon cornpietion of the work for each Product,Customer will execute a Completion Certificste
tone far each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer tinder this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depot reserves the rigbt to issue a Change Order or terminate this Contract or any individual Product(s)included herein,aL
its discretion,if The Home Depot or it%authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home,environmental hazards such as mold,usbestos or lead paint,other Safety concerns,pricing errors or because
work required to complete the job was not included in the ContracL
Payment Summary: The Payment summary# Q 471 S-7 i _ included as part of this Contrast, wts forth the total
Contact amount and payments required for the deposits And fwAl payments by Product(ap�applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filled-ln copy M the Contract at the time you sign. Da not sign a Completion Certificate(notes
there is one Completion Certificrtte for each listed Product as defined by individual Spec Sheets)before work on that Product
is complete.
In the event of termittstion of this Contract.Customer agrees to pay The Home Depot the costs of materials,labor,expenses
and services provided by The home Depot or Authorized Service provider through the date of ternainat1w,plus any other
amounts set forth in this Agreement or allowed under applicable law. TIM ROME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR O'THKR PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Ajrce i g ®uthorization: Customef agrees and understands that this Agreement is the entire agreement between Customer
and a Depot with rcgafd w the Products and Installation services and supersedes all prior discussions and agreements,either
oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amendcd except by a writing signed
by Customer and The Home Depot.Customer ackriowledges and agrees that Customer has read,understands.voluntarily accepts the
terms of and has received a copy of this Agreement.
Ac pted : Submitted by.
X � /I
e
Cu omen's Signature to Sales Consultant's Signa Date
X J Telephone No,
Customer's Signature Date Sales Consultant Lice,
CA;+If4UJ.ATI N: CUSTOMER KAY CANCEL TIRES (as itppncablc)
4GIREEMENT WITHOUT IPIENAILTY OR OBLIGATIOIN
BY DELIVERING WRJITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE TRI.RD ROSINESS f —
)DAY AFTER SIGNING THIS AGYREEMENT, THE 1
STATE SUPPLEMENT .ATTACHED HEU'TO
CONTAINS A FORD] TO USE IF ONE Ts
SPLCIFIGAGLY PRESCRIBED BY LAW IN
CUS'TOMER'S STATE.
NOTJCS:ADDrrIONAt,TERMS AND CONDITIONS ARE STATED ON TIIR REVERSg SIDE AND AM PART Or TM3 CONTRACT
t1-911-13 Write-Branch F7la Yeuow-CusMmar
609
NuLxaw
A
Applicant lAformation -11"n-lit Lciaibh'
ullndividnal):
.Nanllc (Rusiuess/0r9a.ni2mtio ii j z V
V
Address: A 4
144L
city/state/zip:. h ae 4: J c
Lrl :14 r K,
-OL
—A
g ropriatte hox. of Project(required):
gtL' I 0011tcact-or.md I
I am PTP* I.am
t.qyt. 1 6. El New constraction
. --jo CZ
hail
I am A sotepropn-p t or,or P t--t n er listed on the attached,sheet.
7. Remodeling
ship and h ave no em p oyces mse sub-contraq s h aAre
Demolition
working f1dr me in an,y,capacA3,. —7iploy6es, and have workers'
insurance comp. insurance.i -L ilding addition
9. L]1-3 1
0 workers, comp.j
e are a corp6ration and its 10.0 Electrical repairs o
re�quiredj El YV I .. . 1, 1.additions
3.[D I am a h'ome'owner doing all work officers have exercised their Plumbing-repairs or additions
myself. [No workers' comp. right of exemption per MGT,
12 Roof repau,
insurance,reqiiired.1t C". 1152, §1(4),and we have 110
employees.:[No workers' 13.F] Otber----
comp.Lnsuranc!,required.]
*Any applicant that checks box#1 must also fill out the section below showing their w.or kers'compensation policy information.
t Homeowners wbo,submit this affidavit indicating they am doing all work and d then hire outside contractors must. submit a new affidavit indicating such.
:contractors that chepk this:box zrazst attached an idditional sheet showing the name ofthe subcontractors and state whether or not those entities have
empigypes.....Ifthc sub-contractors have employees;they must provide their workers'comp.policy number.
I am an employer thatiq surance for my employees. Below is the policy and job site
pravlarng 19orkers'compensaflon in
in
Insu.rance,Compapy.Name-
.
Policy 4 or'Self-ins.Lie.#: L Expiratibil Date, -::z
✓-7
Job Site Address City/State/Zip: 17
Attach a copy of the workers'.com the policy declaration page(showing t e policy number anti expiration date).
Failure to secure.coverag.e.as requwed under Section 25A of MGL c. 152 can lead to the imposition of crirriinal penalties of a
fine lip to$1,500.00 andJor one-year imprispxulient,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.OD a day,against tlie yi6latpr. Be Advised that a copy.of this statement may be forwarded to the Office of
Investigations of the OTA,f6r insurance coverage_ c
. verification.
atiqn..
I do heM4 certify of Periliq that dee information provided above is to' e .7nz correct.
-;;-7, L-
Phone Date:
Phoh6
Official use only. Do,not.write in this area,to be completed by city or town officiaL
City or Town PerinitfLicense
Issuing Aut4ority(circle one):
1.0040 of Hea''Ith 2.Building Department 3. CitylTown Clerk A.Electrical Inspector 5..Plumbing Inspector
6.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su isor: Not A plicable ££, �-
Name of License Holder:
License Number
Address �` Expiration Date
Signature r Telephone
9::Re istered Home.lm"rovem nt Confractor Not Applicable F-
Companv Narri Registration umber `
es' r' Expiration Date
Telephone
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 Dwellines 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 buildine 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.
t
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Wks Alteration(s) E] Roofing
Or Doors Q"
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [O] Other(01
71 7
Brief Descri tion _
ti
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 house and or addition to existing housing; 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.
1. 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
as Owner of the subject
property (� / ) "
hereby authorize `�
to act on rn%;a,,-in IYn e ativ rk authorized by this building permit pplic tion.
Sig ure of dwner Date
l / 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.
r
Signed under a i o rlury;
Print Name
Signature wner/Agent Date
" ~
Section 4. ZONING AR Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Ibis column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage "0
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Pemnit/Yarianoe/FlncUng ever been issued for/on the site?
x~� ~�
v—� �
NO ��/ DON7KNOVY «�� YES �~�
|F YES, date issued1
IF YES: Was the permit recorded at the Registry of Deeds?
NO �� \�DON7KNO YES
�_/
IF YES: enter Book Pagel and/or Document#
B. Does the site contain a brook, body of water nrwetlands? NO 0 DONT KNOW 0 YES C)
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained _��~� Obtained �~~�� Date Issued:
� � ' �
C. Do any signs exist on the property? YES �^��� 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 0
^ u
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre orisit part ofo common plan
' that will disturb over 1acre? YES NO K D
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
^ '.
D City Northampton
y of Noampton k
Building Department CtlrbCt�iTlDriewayPermit sv � f
!' MAY 2 3 2014 212 Main street
{ SewerlSepttoAyairab�llty`'�-`� � �' �
Room 100 4Vater/1A�eliAvaila lity F''' " i "1 '
Electric, PiumLing&Gas Inspect&0 hampton, MA 01060 Twa'Sets ofStrttcttrtal Piarts
n°'h ,r,°n, M 87-1240 Fax 413-587-1272 Plofl$ite Plans
r f i
fJtfrer 5pec�fjl fi
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 E Lot Unit
4T
-
Y
Elm StDistnct Ce plstrwt
SECTION 2. PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
� .
Z�
'r— 7 fil�a- Aj Pk,
Name/�rkntt)) /� Current Mailing Address:
Telephone
Signature
i
2.2 Au oriz d Agent:
fZ4t,�A 'v4a F/'�L")Pr- - -
Name(Pri Current Mailing,Address:
2
Sig n6Tu 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
6. Total=0 +2+3+4+5) Check Number
This Section For Official Use'Only
Date
Building Permit Number: Issued:
Signature:
Building Commissicner/In.spector.of Buildings Date
93 BLISS ST BP-2014-1240
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23C-066 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit# BP-2014-1240
Proiect# JS-2014-002085
Est.Cost: $2387.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 082485
Lot Size(sg. ft.): 80019.72 Owner: SCHAMESS GERALD&STEPHANIE
Zoning.URA(100)//WSP(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT. 93 BLISS ST
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON:512312014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 3 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 Signature:
FeeType• Date Paid: Amount:
Building 5/23/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner