18D-021 Jul 31 1405:46a p.1
HOME 11141PROVIDAIE.NT CONTRACT
PLEASE READ THIS
� �k Sold,Furnished and Installed by:
Branch Name:Bastw North&South Date.- THD At-Home Servi;m Inc.
dWa The Home Depot At-Hane Services
Branch Number:31 and 33 908 Boston Tumpike,Unit 1,Shrewsbury.MA 01544
Toll Free 877-903-3768
Federal ID#75-2699460,HIE tic 4 C 02439;RI Cont.Lir#t6427
C QCT Uc At HIC_05 55'n:MA H ore Improvement Contractor Reg.#126891
Installation Address: SIA _ �' A V e �4��Aq'I I� (�U_
City State Zip
Purchwer(s): Work Phone: Home Phone: Wl Phone:
Home Address:
(If different from Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates);
El I DO NOT wish io receive any mz_keting ernnik from The Home Depot
Project information: Undersigned("Customer",t-te owners of the property located at the above installation address,agrees to buy,
and THD At-Home Services,Inc.("The Home Depot•')agrees to furnish,deliver and arrange for the installation("Installation')or
all materials 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 Supplemml and Payment Summary atwched hereto and any Change Orders(collectively.
"Contract"):
Jobti:nukrntndw.1 Products: Spec Slx*L(s)0: Pro'ectAmutmt
Roofing LjSiding El Windows 1 Insulrtion
-7L, r 5 ❑G;rnerN 1 Covers Any goers C3 Zq� $
Roofing S:dinc Windows Insul:uioa $
QGuttemiC(Wers ❑P-oryDoors 4-1 ____.__, _
Roofing S:din Windows EJ Insul.aim T
❑Gutters 1 Corers ❑Entry Doors❑ __�
Roofing Siding bVirrlow; hisulation
❑GutterslCovens ['Entr}:Doors
Mtimrmt25roDepotiturContrad Amount due upm execution rithisrnMrntt Total Contract Amount
Matne Purchasers may not di.Vo5it mime than wte-thtrd or the Cunlratt AralooL ` 1
Customer agrees that,intrtied:ately vpo n completion of the work for each Product,Customer will exccute a Completion Certificate V
(one for each Product as defined by an inditrydual Spec Street) and pay any balance due. As applicable, each Customer under dots
Contract agrees to bejuintly and;eve-:illy o'oligared aid liable hereunder.
T)te Home Depot ne m-cs the right W issue a Change 0:der or rerntinate this Contract or any individual Product(s)included herein,at
its discretion ifThe Home Depot or its authorized service provider dctotmincs that it cannot perform its obligations due to a structural
problem with the haute,environmental hazards such as mold,asbestos oi�lead paint,other salcty concerns.pricing errors w bocause
work required to complete thcjob was not included in the Contract racc
Payment Summary: The Payinent Summary it tri 7C_Jt included as part of this Contract.setS fortis the fatal
Contract amount and payments required fcs the deposits and final payment%by Product(ac applicable).
NOTICE TO CUSTOMER
You are entitled to a completely rdled-in copy or the Contract at the time you sigh. Do not Sign a Completion Certificate(note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before>,art,on that Product
is complete.
In the event of termination of this Contract,Customer agrees to pay The Koehn Depot the costs of materials,labor,erpenyes
and services prmided by The Home Depot or Authorized Service Provider through the date of terrninution, plus any other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LL%•IITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUVI'S.
Aecephance and Aulborization: Customer agrees and uuder.;,wnds that tbic Agreement is the entire arrr-•ement between Cus!caicr
and oo re Depot with regard to the Products and ln:•talla lion services and supersedes all itrior discussions and agreement,.either
or ar wrist ,rela to said product and]nsta[latiun.This Agreement cannot he assiguc•tl or aivrardcd cxa pt by a writin,signed
Custpme and T H Depot. Custurter acknawkdgcs seed rgrees that Curt s nod,understands,voluntarily accepts the
rms or an has re i �opyofthis Agrenneri.
Ac ?� � Submitted
1 tl`� ---
Customer Tonazare Dale Sales C is Signature bate
41 1
Telephone No.
Customer',Signature Datz Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCFI, THIS In.r:pp!"
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THC
STATE SUPPLEMENT ATTACHED HERl;•I'O
CONTAINS A FORA'I TO USE' IF ONE IS
CDIIrrPWAI t V DDr'Cf`prR4'Yl nY t AW T1V
Ti e E°_.ollP7nrJ,Ewez"Ui4�
DepcftT33e."1i�2flndzdS'�i7LC?�rY'cc. !3
0ffxe of?nvestigatdons
610 Wasriington .Streea
Boston, MA 02111
-aY www.mass.gov/dia
Workers' Compensation Insurance affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):, �Q�[?. Q � j� Q,x1 _ Lf-'j//C_Z>
Address:
City/State/Zip: �2�N`{{L 614, 3033 Phone#:
Are you an employer? Check the appropriate z:
4. �I am a general contractor and I Type of project(required):
1.❑ I am a employer with g 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 9. Demolition
working for me in any capacity. employees and have workers' 9. []Building addition
[No workers' comp. insurance comp.insurance.
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 I LE]Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑R f 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 isproviding workers'compensation insurance for my employees Below is thepolicy and job site
information. /� f
Insurance Company Name: / �/C
Policy#or Self-ins.Lic.#: W Ci 0 (' Q g Expiration Date: .3 51
Job Site Address: � � � `�– City/State/Zip46q—
Attach a copy of the workers' compensation policy declaration page(showing the policy number and a ration 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 cert' nder e p s an n erVury that the information provided above is true and correct.
r l J1�
Signature: / f6j� 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#:
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work:
0
The debris will be transported by:
Axq
The debris will be received by:
Building permit number:
��� �=� / ✓���'
Name of Permit Appli cant
Date Signature of Permit Applicant
.. City of Northampton
f
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
6% 212 Main Street • Municipal Building J1 bpi
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 any 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 pour) a rough buildinq 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
1, 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
" 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/Organizatiorvindividual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: 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' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.1
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
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' 13T] Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy 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 DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
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
8.1 Licensed Construction Supervisor:
Not Applicable £
Name of License Holder: vim/V � �'1'v � ���2
f/v License be���
Address ��✓ / � �� ��D/�/'✓ Expiration Date
Signature Telephone
1W 2--
A Re i§tered Home I m rov ment Contractor. ' Not Applicable £
TXf
Company Name �— �—� Registration Number
ddr s �) xpi,ation Date
Telephon �")
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 Owher EX—mption
The current exemption for"homeowners"was extended to include Owner-occupied DwellinQS 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 buildinL,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 Windom Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding(0] Other[[31
Brief Description of Proposed
Work:
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 addit ion'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.
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, 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
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 un pai and penalties 24a',ury.
i _
Print Name
Signatu of Owner/Agent Date
. .
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
TIiis column to be filled in by
Building Department
-
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved L--j
#of Parking Spaces
A. Has a Special Permit/Varia nce/Fi riding ever been issued for/on the site?
NO ��
�� ����DON7KNOW YES t����
IF YES, date issued:', >
IF YES: Was the permit recorded at the Registry ufDeeds?
NO 0 D-� . .. _ . YES 0
IF YES: enter Book i Pagel and/or Document#
B. Does the site contain a brook, body of water orwetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been o/need tobe obtained from the Conservation Commission?
Needs tobeobtained \���-\ Obtained �-�~�\ Date' '
C. Do any signs exist on the property? YES 0 NO 0
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,orfi0ng)over 1 acre oriait part ofa common plan
'
that will disturb over 1acre? YEG ���� NO ����
IF YES,then a Northampton Storm Water Management Permit from the DPW ia required.
' Department use only
r t xt.
City of Northampton Status afPermrt "'
w [E- Building Department ctrr6 CutIDrl�eway Perrtlt#
212 Main Street SewerlSepticAvaifabtltty
! + ZQ+� Room 100 �JUater/VifetCAvailatiihty
l
Northampton, MA 01060 TV a Set's of Structural Pfans ;k
-587-1240 Fax 413-587-1272 pho e 413 Ste PEans
Electr' . Fio-qL r c R r r--ctions K
� Over 5peelfy - �
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
�t� of � (/' Zone O.verla _Distrtct � -
Elm:St District .. _ CB Distnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Rec rd:
ta
Name(Print) Current g Addry �)
Telephon
Signature
2.2 Aqtkorized A ent:
Nam t) Current Mailing Address:
Z._ �
nature IV Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Feb
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) o Check Number G°'
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector'of Buildings Date
154 COOKE AVE BP-2015-0179
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18-021 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2015-0179
Project# JS-2015-000317
Est.Cost: $2260.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 92937
Lot Size(sq. ft.): 22128.48 Owner: CIACH RICHARD
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT. 154 COOKE AVE
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON.811112014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT DOOR
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 Sisnature:
FeeType: Date Paid: Amount:
Building 8/11/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner