38B-293 (3) 2014-05-28 19:23 6214-PRO DESK 8602534013 >> Home Depot AHS P 1/7
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
2,5-' rl Sold,Furnished and Installed by:
Branch Name:Boston North tYt South Date:_I_I '114D At-Home Services,Inc..
dl/h/a The Home Depot Al-Htyme Services
Branch Numb- .31 d 3 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free 877-903-3768
Fedaai ID#75-2698460;ME Lie#C 02439;Ri Cont.licit 16427
CT I`.ic�#H1\C.0.5(15522;MA 1lone truprovenreu(Centractur Reg.#126893
Lugtallatitrn Address: j \V V+.W«A,t.,.t3)7, KA-
City State Zip
Purchmmer(s); _Work Phone: home Phone: Cell Phone:
[ l f I [ l
Home Address:
(it different from Installation Address City State Zip
E-mail Address(to receive Project.co nmunicatious attd Ilonie 0q)ot upxdatus):
❑1 IX)NOT wish to receive any m.u kedng entails from The Home Depot
Project Information: Undersigned('Customer"),the owner,of LhQ property located at the above installation address,agrees to buy,
and TI1D At-Home Services, Inc.("The Homc Depot")agrees to fumivh,deliver and arrange for the installation("Installation")of
all materials described on the below arid on the referenced Spec Sheet(s), all of which arc tncttrlxrratul into this Contract by this
reforenec,along with any applicable Staic Supplement and Payment Summary attached hereto anti any Change Orders(collectively,
"Contract"):
lnh#: umernea x t.re wed Products: Spec Sheel(1#: Pru'ect Amman:
7
LfRoofing Si 'ng ❑Windows ❑insulation t
Y✓��D ❑Gutters 1 Cuv s ❑Enny l)nnrs ❑
Rnofut
Ti _.
G El Insulation
❑Clutter;i C e .s ❑Entry Doors ❑
❑Reuling si ling Windows ❑Insulation tin
❑Gutters/Cove s ❑Entry Doors❑ _ I
goofing ❑Silint, ❑Wir,dows Insulation
0C-uIWn/Cvycrs ❑T nt y Urnvrs ❑ f
Ninfintmr25t7.1k1ksA 4 CurntrnG Arru unt due upon executimrot this contrao. Total Contract Anlount
Maim:Purvhmeru rosy not deposit roc rhan nratairxi of the CtnotractAnwunt.
Customer agrees that,immediately u u completion of the wark for each Product.Customer will execute a Completion Certificate
(one for eadi Prdxluet as defined by An individual Spec She t) and lyny any bola nce due. As applicable, each Customer under this
Contract agrees to be jointly and revel lly obligated arid liable hereunder.
The IIoine Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)include(]herein,at
its discretion.if The Homc.D pul or i ;authorized service provider dlcicrmines iha(it cannot perform its obligations due to a structural
problem with the hots,environmenu I hazards such as mold,ashestog or lead paint.other safety concerns,pricing errors or hccailw
work required to ctmipict.c the job was not included in the Conlraet.
Payment Summary: The Payment Summary# t included as part of this Contract, stab forth the total
Contract arnolmt and payments rcquir d foe the deposits and final payments by Product(as applicable;).
NO'I'IC RTO CUSTOMER
You are entitled to a completely fill -in copy arr the Contract at the time you sign. IN)not sign a Completion Certi icate(note:
there is one Completion Certificate roe each listed Product as defined by individual Spec Sheets)hefore work on that Product
is complete.
ill the even(of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expe.rtsen
and services provided by The IIowD Depot or Authorized Service Provider throtrgli the date of termination,plus any other
amounts set forth in this Ag,reemen or allowed wider applicable law, THE HOME DEPOT MAY WTTHI1OLD AMOUNTS
OWED TO WE HOME DEPOI FROM TIIE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
i,iMITING TIIE HOME DEPOT'S OT'HF.R REMEDIES FOR REC OV FRY OF SUCH AMOUNTS.
Acc%W ee and Authorization: C' iomcr aj.7ccs and understands that this A6recmcril is the entire agreement between Customer
aatd'1'he Horns[7sPol with regard to tie Products and 1nslall:dicm services and supersedes all prior discussions and a},Tametatg,either
oral or written,rcl;0ing to said Products and Installalion.This Agreement cannot be assigned err arnendcd except by it writing signed
by Customer and The Home Depot,C usturncr acknawladges and agrees that Customer hati read,understands,volunhirily accepts the
terms of and has reccivud a copy of th s Agreement.
Ac epted by: f,, �! Submitted by:
'uslomer's Signature to Salc, ultiant'%Signature Date
X Telephone No I t3 b 31 P --
Custorncr'x Di to Sales Consultant License No. _
CANCLLLATION: CUSTOMER MAY CANCEL THIS (U.,uppftaWO
AGREEMENT WITH011T PENH TY OR OBLIGATION
BY DELIVERING WRIYIWN NOTICE TO THE IIOME
DEPOT BY MIDNIGHT ON '1'1 IF. THIRD BUSINESS
DAY AFTER SIGNING THIS %GRFFMENT, THE
STATE SUPPLEMENT A'I' 'ACHED HERETO
CONTAINS A FORM TO USF IF ONE IS
SPECIFICALLY PRESCRII E BY LAW IN
CUSTOMER'S STATE.
vnTV•o-rnnrrrnra.r �ron.r —, 1.1.1—I.a....1..11••�mm navcn�o unn,em.nn n.rrr nc+roc rvv.*rn.rT
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):, & e, keol— Ak
Address: lf"�°,LCD
City/State/Zip: 12. VCj., , 303f Phone#:
Are you an employer? Check the appropriate a: Type of project(required):
1.❑ I am a employer with 4. I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
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'
[No workers' comp.insurance comp.insurance.:
9. (]Building addition
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 I LE]Plumbing repairs or additions
myself. [No workers' comp, right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees.[No workers' 13.❑ Other
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.
tContractors 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. j®
Insurance Company Name: //�yew 1 1
Policy#or Self-ins.Lic.#: WC, 0 L1q to g g;2 Expiration Date:
Job Site Address: ! 49 of)) d
City/State/Zip&V
Attach a copy of the workers' compensation policy declaration page(showing the policy number and xpiration 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 u the p ins and nalti f perjury that the information provided above is true and r ect~
f
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 I
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder:
��^D
License�Number
--'
Address Expiration Date^�
Si nature Telephone
9..Re istered Hom <Im rove ent Contractor " Not Applicable £
Comoanv Name �—� Registration m��
r ss Expiration Date
Telepho
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...... £
t . Home Own'ner Eie*mption
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 ❑ FReplacement Windows Alteration(s) ❑ Roofing
Accessory Bldg. ❑ Demolition ❑ ] Decks [Q Siding[0] Other[O]
Brief Des tion of Pro
Work
: �
Alteration of a isting bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a,lf'New house and'"6r`:addi6' ' to exlsting"h"ousmg, complete the fo(lowing':
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 ,�.y�_ ) �
hereby authorize y!E l
to act on my behalf, in all matt relative to work authorized by t is building permit application.
Signature of Owner Date
1 gd� as Owner/Authorized
Agent hereby declare that the tatements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under t a `d penalties of per u
Print Name
Sign;e of Owner/Agent Date
` ^
Section 4. ZONING AR 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
Rear L—i
Building Height L
Open Space Footage %
(Lot area minus bIdg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Vuhance/Rmding ever been issued for/on the site?
x��v~� �~�
NO �x_� DONTKNOYY x�� YES �~�
|F YES, date issued:| |
IF YES: Was the permit recorded at the Registry of Deeds?
NO � 3 DONTKNOYY YES��
IF YES: enter Book Page and/or Document#
�� �� ��
B. Does the site contain a brook' body ufvvaterorwetlands? NO �~� DONTKNOVV «�� YES �~�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �~\ Obtained x-� Date�_� t_� ' '
C. Do any signs exist on the property? YES «=��� NO �=���
IF YES, describe size' type and location: sl
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location.
' f �
E. Will the construction activity disturb(clearing, gradingexcavation,or filling)over 1 acre orioit part ofa common plan
' that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
^ '^
City of Northampton 5fatus ofP�rmit
Il
I, Building Department Curb CutlDrlveway Perrrstf 4
JUN 10 2014
212 Main Street SewerlSepticAvalrabEitty t
E
Room 100 Water/VltellAva�lablllt
lectric, Plumbing&Gas Inspection orthampton, MA 01060 Two Sets o5#tucturai FiaBs
Northam;^'on. NIA 01 q50 ji
3-587-1240 Fax 413-587-1272 Plof/Site Plans
Other S;pemfy
................
u ..
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.0 ffice
Map
Lot Unit
,Zone _: ;. Overlay Disfnct _ '
Elm$t District CB D�stnct..
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Ow r o eco /I
Name(Print) Curren 'I' Addre
Telephone � t
Signature Al,
2.2 Au rize ent: �� /
Nam � Current Mailing Addres 11 - —0 L
gnature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building /�) � j (a)Building Permit Fee
2. Electrical (/ U v (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 Comm issioner/Inspector'of Buildings Date
138 WEST ST BP-2014-1320
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B -293 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2014-1320
Project# JS-2014-002222
Est. Cost: $21913.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group HOME DEPOT AT HOME SERVICES 96194
Lot Size(sq. ft.): 10323.72 Owner: WALLACE GERARD R&JEAN M C/O BARBARA HABERSAAT
Zoning: URC(100)/WP(82)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 138 WEST ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.611012014 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 6/10/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner