38A-061 (6) DOME MPROVEMENT CONTRAt
PLEASE READ THIS
ii(� Sold,Furnished and Installed by:
Brameh Nance:Boston Norte:&Son* Date: _J 1 ` TM At-Dome Services,Inc.
d/b/a The Home Depot At-Home Services
Brattrcb dumber:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free 87)-903-3768
Federal M#75-269MO;ME Uc f C 02439;FU Cont.Lid*16427
t�
CT'! Lis#MC 0565522;MA{HHome lr p ment Con rasaof Ileg.#126893
Installation Address: iJ 64-- A" 1 S {Y� Ql 4Ea�
City State Ztp
Parchaser(a): Work Phone: Kom phone: Cell phom
�-6mask [ J [ J I [ J
[ J [ J [ l
Home Address:
(If different from Installation Address) city state Zip
E-mail Address(w receive project communications and Home Depot updates):
❑I DO NOT wish to receive any nsarketing emai)s from The Home Depot
er��n_ Undersigned("Customer'),the owners of the property located at the above installation address,agrees to buy,
At�3—t-Horne Services,Inc.("The Home Depot")agrees to Furnish,deliver and arrange for the installation(-Imtallatioa")of
all materials described on the below and on the referenced Spec Shed(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 Orders(collectively,
"Contract"):
Job#: anwrai Rd"m) t'sodvcty: Sm Shee(s)th PMJM Amount
Roofing idiog windows Insnituion
'7 � C7Gnttets r Covers ❑Entry Doors ❑_. [�j $ 7 4 0 (iG''
Roofing USiding U Wipddows LJ Insulation .�
❑Gutters/Covers ❑Entry Doors ❑ $ I
Roofing USiding LJ Wiadowa 0 'nsulation t r,
pGutters I C"rs ❑Entry Dom❑ �
Re:vf+ng 0slang ETW—i-V—d0W-S-,0 Zasulation
❑Guaers/Covers C lE:try Doors ❑— S
Mlmraunt 2Sob Total Contract Amonnt $ ( ^
Milne Pinduver s may act deposit mote than ore-Q*d of the Cornrad Amount, t 1
Customer agrees that,immediately upon completion of the work for each Product.Customer will execute a Completion Certificate
(one for caLb 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 Home Depot reservett the tight to issue a Change Order or tertttinate this Contract or any individual Product(s)included herein,at
its diction,if The Rome Depot or its authoOmd service provider deterrrtiries that it cannot perform its obligations due to a structural
problem with the home,environmental hazards Such as mold.asbestos(r lead paint,other safety concerns,pricing errors or because
work required to complete the job was nut included in thhyee�Contract.
Payro t SuMWary: The Payment Summary# l`tIN2 included as part of this ConUu-t,sets forth the total
Contract amount and payments required for the deposits and Final payments by Product(as applicable),
NOTICE TO CUSTOMER
'You are entitled to a coropletely t'dled•in copy of the Contract at the time you sign. Do not sign a Completloa Certifleate(note:
there 1s one Completion Certificate for each listed Product as deIIned by Individual ftee Streets)before work on that Pr�oduet
Is complete.
In the event of termAnation of this Contract,Customer agrees to pay The Room Depot the costs of materials,labor,expenses
and services provided by The'Home Depot or Authorized Service Provider through the date of terminadw,plus any other
amounts set forth In this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE ROME DEPOT FROM THE DE"IT PAYMENT OR OTHER PAYMEN'T'S MADE, Wi ROUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OP'SUCH AMOUNTS-
1ccW d Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
d c one epot with regard to the Prvduets and Installation services and supersedes all prior dincussions and agreements,either,
oral of 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 agteen that Cu xto cr has read,understands,voluntarily accepts the
terms of and has received a copy of this Agreement.
p
Acre to Submuted
Customer's- tine Date --- Sales C e's Signature Date
X Telephone No.
Customer's Signature Data Sales Consultant License No,
CANCELLATION- CUSTOMER MAY CANCEL THIS (es cppticable)
AGREEMENT WrMOUT PENALTY OR OBLIGA,170M st ��
BY D01VERING WRITTEN NOTICE TO THE I10ME `}1
DEPOT BY MIDNIGHT ON THE TMD BUSIIc1ESS
DAY AFTER SIGN010 TSIS AGRMVtF,N'T, THE
STATE SUPKEWNT ATTACHED HERETO
CONTAWS A FORM TO USE Il'' ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICE;AAAITIQIVAl,TERMS AND CONbMOKS ARE STATED ON THE REVERSE WE ANA ARE PART OF TR75 CONTRACT
The Commonwealth of Ylassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organizati on/Indi vi dual):. 1�nmol— Aj`
Address:
City/State/Zip: a,,v . 3o.3 Phone#: f7 7 `" 1_9 1l
Are you an employer? Check the appropriate X a: Type of project(required):
1.❑ I am a employer with 4. M am a general contractor and 1
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
$ 9. E]Building addition
[No workers' comp. insurance comp.insurance. 10. Electrical repairs or additions
required.] 5. ❑ We are a corporation and its ❑ P
3.❑ 1 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.❑ 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.
$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: //��/ew //cuii di-le– J�Ns` i�o ,
Policy#or Self-ins. Lic.#: W C, 0 Y q /Q g g o2 Expiration Date: 3 r 5�
Job Site Address: City/State/Zip-
Attach Attach a copy of the workers' compensation policy declaration page(showing the policy number an 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 D or insurance coverage verification.
I do hereby certify n r p ns a ies of per' ry that the information provided above is true and orrect.
Si nature: 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 Supervisor: ���bl
Name of License Holder: r
License Number
Address Expiration Date
Signature Telephone
9..Re`istered Home lm rovem nt Contractor: ` .... Not Applicab e
Company Name Registration umber
��—. E p�tion Date
s
7 Telephon /!�W
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 builqjag.permit.
Signed Affidavit Attached Ye ...... £ No...... £
11 '- Home Owrier:E'emptiiol
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 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,
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding Other(O]
Brief Description o d
Work: ✓)-��
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 andbr addifion to Asting:housing, complete the foliowing`
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 '
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I y'=" I✓ / , as Owner/Authorized
Agent hereb declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
t
Signed unde pai and pen, Ities of /
Print Name
Signatu Owner/Agent a �/J
'
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
71is column to be filled in by
Building Department
Lot Size
Setbacks Front
Rear
Bldg. Square Footage 01"o
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&L cation)
A. Has a Special Permit/Variamce/Rnding ever been issuedfor/on the site?
�� ��
NO �_��� DONTKNO\� �~� YES v��
IF YES, date issued:! �
IF YES: Was the permit recorded at the Registry ofDeeds?
NO k � DO YY YES
��
IF YES: enter Book Pagel and/or Oocument#
�� ��
B. Does the site contain a brook, body of water orwetlands? NO �~��� DON7 KNOW �~� YES �~�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ~��~� Obtained �-� Date� �~� '
C. Du any signs exist on the pmperty �� ��� 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 type
' ' ' | |
E. VW||the oono�u�iono�hhydi�udb(clearing, gmding Uon. orfiUing)over 1o�enrio�pa�ofa common plan
' that will disturb over 1acre? YE8 `�/ NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
^ ''
�t
Depa�finen(use onhy
ity of Northampton
�7p�
i uilding Department Gtrr�Cut/Dnveniay Perrrstt �a
2 5 2a
212 Male Street Sewer/Sep�leAyaira'F�rlrty
' s
Room 100 Water/kteilA�a�latiilrty
ampton, MA 01060 TvVo S2ts 41`Structural Pians r
ft
z
Etieo�� W ,f, one 413-587-1240 Fax 413-587-1272 PIotlS to Pkans ; ' ,
Other 5pec�fy �:: �'
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 bygffice
Map � � Lot - Umt
a -
:..Zone - Overlay D�strtct ' �
Elm St District CB Distri ct
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner gf Record:
Name(Prin/t)' /7 Current Mailing Address:
Telephone
Signature
2.2 Auth rize A ent:
Na P. ) Current Mailing Address:
'gnature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be w Official Use Only
completed 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
6. Total=0 +2+3+4+5) Check Number
This Section For Officlal Use Onl
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
188 WEST ST BP-2014-1388
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38A-061 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catego : vinyl siding iding BUILDING PERMIT
Permit# BP-2014-1388
Project# JS-2014-002343
Est. Cost: $12740.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 98785
Lot Size(sq. ft.): Owner: Smith College
Zoning URC(110)/RR(0)/ Applicant: HOME DEPOT AT HOME SERVICES
AT. 188 WEST ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON:612512014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING
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 6/25/2014 0:00:00 $35.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner