25C-230 HOME IMPROVEMENT CONTRACT
Sold,llunisbled and lastalk.d by:
Branch Nome: d
ate: 7 � THI7 At-!lour Services,Inc.
"/a The HoM-Depot Al-hours Services
Branch Number: 345A GreeuwoW StML,Worcester,fOA 01607
G7t/r Job#: C3 Toll Free(800)657-5182; Fax:508.756-2859
F-derrl 1D#75-2699464 ME Liu/I C 02339 a1 Card.14ch 16027
CT LX:#565522; lVL4llome Iwpmveuyd Cuutta Wt tL g#126893
Installation Address: .r1�/ tj ,y r®, r7 r
City ti: zip
Purchaser(s): Last 4 Digits or Driver's
Lie.#&Ex. Ma`Yr: Work Phoan: Htsa.:Phone:
!
Home Address:
(if different fro
utInstiLllationAddreas) City Shah Zip
E-mail Address(to rocerva updates and promotions from The Home Depot):
Project Information: I/Welyou("Puruhaanr"),the owners of the prupnrty located at the above installation (!dross,offer to
contract with THD At-Home Services,Inc.("!louts Depot" to tirrnash,deliver and a for tlx;installation of all materials
as described on the attached Spoc Shi:cst ki /L^�}�j incorporated bereid referer •and MR&u Pon hmof,
Home Depot reserved the right to cancel this contract if,upon re-in*Ntlan of the job,!roan Depot determines that it
cannot perform its obligations due to a structural problem with tbu bonne,pricing errurs cur heosuse work required to
complete the job was not included in the Spec Shut or Contract.
DEPOSIT PAYMENT OPTIONS
(Subicot to fwd varitkattiuu analur Uwit gpruv„L)
CONTRACT AMOUNT $
l; A',` 211 *It l }iU l 5rfVGts 1441Wy UrtlrY
flA m Dame
BALANCEIIUIi
TMin"moor i due ulwn 3iaR�s14Y�N111lM L4d�l.
Mint due upon Av itubk CC OIVL )
AactY: • �°
BALANCE DUE ON COMPLII;TION: Ns s it aQp ilia on arid:
*.By my/utu sigh oxv baoow,Ifft 41-ce to allow Huno Depot to
4Z1g5TqLXfitC Tar th ilepasie self^Wlr:n you pruvidu a ohxk ua puyi�M you authoruv us uidaor �
to unC irfotainma Craw your chdk to w:tkc a oia;-lien ekx:trauic .
two tn:aeCsr from your aa:aant ar w prw eaa the puymmt as a
clack lrpnvy�ctiau.Wlu-a we uw iufarutation from your clank nl HIL or tfDCC Authoriaa►tiaa Codes
ttydm.anelwtro&fund ttatmtor,furrLs may be withdrawn craw TIC -t l?iaa►l Fa meat
your umouivas.wuu as ire payment 0 W0,;iv4 aryl you will not �y #
nlGViveyaurahuckbauk. # V� ..
Pumbaser ads that,inlmncl'attely uponJointly umpintio11 of the work,P ucl serliwill e h�rn��Ompletiou Certificau and pay any
balance dw:. P WchAs::r a)so s to be and severally abligatatl to Aswelneat
eat:This ag.rent and etc ati:u:irments,,inchxling any fins :irtg agazalam cons a the c uurp
mans si d by both patties.
between tlw parties and can not by amonded or nrixlified unless in writing in a separate a
NOTIC)fi TO PURCH"ER
WPM$ }) W- t
of this+atatrnet. titw
rtC the third husiaMtr rlry xB11r'Most t to
t, There wilt Un a st:rvlw choarBtt aynwi to IUYu of the hose WIV
time prior w mldaigln r.,1401als Ors-rdcr Those wii!
Yon y cancei this tranaOcttoa any of this r10 du but BEFORIE matartale xrn urdotwd.
Nod-e Cantaeliation for as nxplunutioa third business Yr b Purcits"r AFTER
is caa�wifed by Purehasur AFTg t the nt If Job is canoe RFVWW
amount -job is c ,equal to 25%of the contras uslal►u �THp T Tk1E ACfitEBMb:NT MAY BANiUB'��EW MY/OUR
be a Pe t' lJrillLRyTAIJD fiOMF llrl'CYT TU VFRIl1f gl2
13Y?AYJUfnt�S1GNATUIt I BRLOW,VW-
F,
HISTOItY AND YWE t-l" )I 1LIZfi ty'f, 11We
OF MY/OUit CRE►) AN Jr4DEYENDR4T CRF", 1t1 S OR 6RR RS' A1�1J OF THW CON?��
CREDYT Y"IL`l�FROM 1NADVERTS f OM1SSK) 6 OR ItWE AGnV-TO'IV, LT AND TWO cX)MPL'ETL'D CUl'lE i OF Tl NOT
139 AdYf4i iR SIGNA CT nT a CUpv OF rws 66I T ACT RY TLII? CEliivfS
oi?�Cl'LI ATION• .- 'j)ala:
Mute;
suf3l oBY: saran .,d ---
DatE:
ACCEPTED 139: r
77"JOUIT ATED ON THE 'V'ER9J8 SIDL
TERMS Al3F LONDITTONS A" _
T QF T Hls CONTRACT
,oyp ink-Sates Conauttiant _
TILO
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 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 hour) 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
r Office of Investigations
600 [Vashington Street
.�j
Boston, MA 02111
Y www.snass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legible
Name(Business/Organization/Individual): _
Address: 5
City/State/Zip: 19fi Phone #:
Are you employer?Check the appropriate box: Type of project(required):
1. am a employer with I 'DC-�> 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 S. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp.insurance comp. insurance.t
required.]
5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work
officers have exercised their 11.[]Plumbing repairs or additions
per MGL em p
f e
ht ig o exemption myself. [-,No workers' comp. r 12.7 Ro repairs
insurance required.] t c. 152, §1(4),and we have no er `r—D�
.
employees. [No workers' 13. Oth .
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. c----`
Insurance Company Name: —
Policy#or Self-ins. Lic. #: � Expiration Date: `2/)/DJ
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation po i4cy 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,Pa,A for insurance coverage verification.
I do hereby certi un r e is and penalties of perjury that the information provided above is true and correct.
Sianature` Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
Citv 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: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered Home, i6vement Contrac or::' Not Applicable ❑
Company Name Registratior!—Number
I T51 Cl, Dix -P)JM
Address ° Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG.L.c.152,§26C(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...... ❑
I.- 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-vear 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
�f
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [CJ Siding[0] Other[5K—
Brief Description of Proposed Q�Wv>�h f J
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 and or addition to WiSting 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.
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
I, cea f^j 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
fly 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 unde pains and penalties of perjury.
Print Na
Signatur of er/ ge 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
Side L:,.,... .._ R:l.,._ .___: L: .., .._.. R:,,,- _r...
Rear
Building Height
Bldg. Square Footage -- %
Open Space Footage °
(Lot area minus bldg&paved °
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOWN 0 YES v0
IF YES: enter Book Page and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES I
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , 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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excavation-, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only,
City of Northampton Status of Permit:
Building Department Curb Gut(Dpveway Permit '
212 Main Street Sewer/Septic Availability
Room 100 WaterNVel!Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Slte Pkans, ,:
Oth&r Sper fy '' _ i
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLINGL
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This s ction t&`be�completed`b ce j
L_.___ _
Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Addr
Telephone
Signature
2.2 Authorized A t:
Name(Pri Current Mailing Address:
X01
Signature Telephone
SECTIO -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be 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) `*Z3(603
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: IIsssued:
Signature:
Building Commissioner/Inspector of Buildings Date
f ile 4 BP-2009-0124"
APPLICANT/CONTACT PERSON HOME DEPOT AT HOME SERVICES
ADDRESS/PHONE 345 GREENWOOD ST UNIT 1 WORCESTER (508)341-9401
PROPERTY LOCATION 153 BRID GE `:N,
MAP 25C PARCEL 230 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: Attic Insulation
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
BP-2009-0124
COMMONWEALTH OF MASSACHUSETTS
-12wra 25c- CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0124
Project# JS-2009-000157
Est. Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES
Lot Size(sq. ft.): 6098.40 Owner: SHAUGHNESSY HANNAH&MICHAEL
Zoning:URB Applicant. HOME DEPOT AT HOME SERVICES
AT. 153 BRIDGE ST
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341-9401
WORCESTERMA01607 ISSUED ON:81512008 0:00:00
TO PERFORM THE FOLLOWING WORK:Attic Insulation
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 8/5/2008 0:00:00 $25.0023603
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo