43-077 (2) A
enelgystar.nrcan—rncan.gc.ca
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Remove label.atter final inspection; SAVE for future reference
. Weather Shield .
4�1 'CPO# 050A-172
r1eModel 8108 Double Flung Operating
Alum clad Thermal Frame
Iaar•>i F-.haarorin 314 inch Glazing
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Argon Fill Grille in Air Space
ENERGY PERFORMANCE RATINGS
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110ME RMOVEMM CONTRACT
PLEASE READ TIRS
.�� �tjj, Sold,Furnished and Installed by;
lall'atwh Name:Boston North&Sooth pate: !'L.J L . THD—At-Home:Services,Inc.
ditga The Home Depot At-H%no Services
Branch Number:31 and 33 908 Boston Ttumpike.Unit 1,Shrewsbury,MA 01545
. Toll Free 677-903 7376fi
3Fedetal lD W 73-2698460:141 UC#C 02439;RI Curt.liict 16427
CT Lac#WC.0505rr22,;__MA--Hom lmpwvciimnt Cootiogtos Reg,#126893
Installation Address:
City $rate zip
Purchaser(s): Work Phone: Home Phone: tSeli pblooe'
Home Address:
Of difFemt from lnatailatioa'.Address) - — - City State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑1 DO NOT wish to receive any marketing cattails from The Horne Depot
Protect 7nPo Undersigned("Custowee),the owners of the property located at the above installation address,agrees.to buy,
and T�etvicm Inc.('"The Rome Depot"}agrees to furnish,deliver and atrange for the installation("Latstalladon")of
aU roatrials described on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contract by this
reference.along with any applicable State Supplement and Payment Summary attached hereto and any Change Ordets(collectively,
"Contract')!
Job#: C14—**46�w Products: S s #: Fro' ct Amount
Rovfm3g Siding Windows LJ Insulation
-7�E ' ❑clatters 1 Covvxs BntrYPaots ❑ D Cad
Roofing Siding 0 Windows LJ Insulation
OG;=rs/Coven❑Entry Doors f-1 r� /n
RouW Siding windows Insulation �J r '
❑Gut=/Covers❑Entry Doars❑
Roofing USi ding 0 Windows LJ Insulation
❑GuttersICovers'❑H»tryDrxxs E]
Mtdmum25%nepm h af Conlrael Ammadue upon eacimdmt of this eoutract. 'l`otal Contract A,motatt $
Marne Purchasers nay not dWaxat more than oes-third of the CoubudAmonm
Custo mer agrees that,immediately upon coprpletim of the work for each Product,Customer.will execute a Completion Certificate
(one for each Product as defined by an individual Spec Sheet)and pay any balance due, As applicable,each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Homc.Depot reserves the right to i6sue a Change Order or terminate this Contract or any individual Ptoduot(s)included berein,at
its discretion,if The Home Depot or its authorized service provider deterzuines that 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 errors or because
work required to complete the job.was not included in the Contract.
Payment Summary- Tine Payment Summary 4 .A L�2co included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final payments by Product(as applicable).
NO'T'ICE TO CUSTOMER
Yau are eril6o d to a comppletely Rillted 3>A copy of the Gmtract at bTp a time you alga: Do not sign a Complettoon Cerdflcate()vote;
there is One Cornpletiotr Certificate for each listed Product as defined by individual Spec Sheets)before work an that Product
is complete.
in the event of termioation of this Contract,Customer agrees to pay The Home D t the costs Of�materlals,labor,expenses
and services provided by The Houn Depot or Authorized Service Provider thr tht date of termination,plus any other
amounts set forth in this Agreement or ailorVed areder applicable law. THE HOVI DEPOT MAY WITHHOLD AMOUNTS
S
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DUCT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS,
ACce�p,3n�.$�gLizan Customer agrees and understands that this Agreement is the entire agreement between Customer
a� c orne epOt With regard to the products and lostallation services and supersodes all prior discussions and agroemcntr,,either
oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing Signed
by Customer and The Home Depot_Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the
terms of and has received a copy of this Agreement.
Accepted by: Submitted b
Customer's Mature Date Sales Consultant's t r Date
X Telspbone No-
Customer's Signature Date Sales Consul ice o.
CANCELLATION: CUSTOMER MAY CANCEL THIS tvs rpplicn6k}
AGREEA'IENT WTTSOU'T PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS =J
DAY AFTER SIGNING TMS AGREEMENT. THE
STATE SLTPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SORCMCA,LILY PRESCRIBED BY LAW IN
CUSTOMER'S STATE-
NOTICE:ADDI'1TONAI.TERMS AND CONDITIONS ARE STATED ON THE REVM9J&SIDE AND ARE PA1rT OF TIM CONTRACT
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/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): � ?Q�7]L
Address: J�� �t,e S J'"t�f•�-� koAP
City/State/Zip: t 303 Phone#: l `" 75 - ,-2 t,
Are you an employer? Check the appropriate a: Type of project(required):
1.F] 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. DemoLtion
working or me in an capacity. employees and have workers'
g Y P tY• $ 4. ❑Building addition
[No workers' comp. insurance comp.insurance.
required.] 5. We are a corporation and its I0.❑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' 13.0 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. Mew / /3
Insurance Company Name: MLM
Policy#or Self-ins. Lic.#: kA/C- 0 Ll Q g g Expiration Date: /5�
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensa on p icy 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
Invest/ ations of the DIA for insurance coverage verification.
I do hereby certify th sin nd hies of rjury that the information provided above is true and cor ct.
Signature: Date: 1 / _
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 er�s� � � Not Applicable £� ,+
Name of License Holder:
License Nu ber
/ate
Address tJ �� ,r ,, Expiration Date
Signature \ Telephone
9.
Registered=Home Im "rove ent Contactor __;. _ ... „ � �."�, „ ;; �: . Not A licablQ E ���
r-1 Z 2
Company Na a Registraf mum er^/�
q-w— ei d ess f iration Date
(/ Telephone !�I
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 per
Signed Affidavit Attached Yes...... No...... £
11 -:Home Owrier:Egemption
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 s Alterations) Roofing El
Or Doors [H
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[O]
Brief Descrip � tC�`�0' 'Z
Work: vim/
Alteration of existing bedroom Yes No Adding new be om Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
._
6a._If New house and or addition to existing housing,'complete the followiing:
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 4� � a%J
to act on my behalf, in all Ptters ork auth this building permit a plicatio/n.�/
Signature of Owner Date
I, as Owner/Authorized
Agent hereby declare hat the statemeh s and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under th s an p alti of u
Print Name ,f
Signatur 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 r--
Rear
Bldg. Square Footage % i---
Open Space Footage r- %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Varia/ce/Rmding ever been issued for/on the site?
� �
NO t_.�� DONT KNOW «_�~�� YES �~~�
�
|F YES, date ioued:
IF YES: Was the permit recorded at the Registry ofDeeds?
NO K � DONTKNOY� YES
�
�
IF YES: enter Book and/or Document#
�� ��
B. Does the site contain a brook' body uf water orwetlands? NO �~��� DONTKNOVY �~� YES �_�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained v_�xr� Obtained »-~�� Date� ' '
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
�
IF YES, describe size' type and location:
E. Will the construction activity disturb(clearing, gradingexcavation,or filling)over 1 acre orisit part ofa common plan
' bhat will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
^ —
'
��
,.a � Departmeht use only
of Northampton Sta#us ofPermr# h '"
-----��-"�? Iding Department ,Curb Cu#/Drive�uay Perrrttf � -
D -
12 Main Street SewerlSeptrcAvaita61lrty
2014 Room 100 water/VltellAvarlabrlrty
rth mpton, MA 01060 Two Sofs of S#ructural Plans
Piumbin r� 18 -1240 Fax 413-587-1272 Plof/Site Plans s'
Electric, ton,®A
rvorthamP ;Other 5peorfy' !.._
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Thrs section to be completed by office
1.1 Property Address:
Map Lot Unit
Zone Overlay Drstrrct
Elm St District CB Drstrrct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
l � fl//�vs�%✓ ulysj(Y/
Na (Print)-e y�� r �� Current Mailing A dress:
wCU�`/��✓/ Telephone
Signature
2.2 Auftrize
Nam t) Current 7Mailing Address: !�
Signature Illy Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant licant
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
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
57 DUNPHY DR BP-2014-1318
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:43 -077 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A,
Category: window replaced BUILDING PERMIT
Permit# BP-2014-1318
Project# JS-2014-002217
Est. Cost: $1245.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 15855.84 Owner: GIRARD KIMBERLY C&CHRISTOPHER E GARNER
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT. 57 DUNPHY DR
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.611012014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 5 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 Occupant 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