31A-097 (5) Sold Furnished and Installed by:
Branch Name:_ Old Date: u!��� � THD At-Home Services,Inc.
""TTT77 ± d/b/a The I{ome Depot At-Home Services
345A Greenwood Strect,Worcester,MA 01607
Branch Number:_2Ce�G�?; Job#: �:? �� Toll Free Q800)657-5182; Fax:508-756-2859
Fxdmal ID#7.1•2698460 ME Lie K C 02439 ffi Coat Gip#16427 ,
( Cr Lic R 56,5522; MA Ftomc improvement Contrann r itch.N126893
installatioo Address: _ Y. ��Q� .� No ,
City State Zip
Last d Digits F's;
Purchaser(s): Lie.#&k s 1VI r irt Work Phone: _Hoare Phone: _
Home Address-
TIT
(If different fur Address) —�- Ci State zip
E-mail Address(to rective updates and pmmotiotts from The 14(me Depot):__
Project Information; liwc(You( Pumhuser"),the owners of t property located at the above installation address,offer to
contract with THD At-Home Services,Inc.("Honi,I ePot' to f irnish,deliver and arrangge��for the installation of all materials
as described on the attached Spec Sheet kl7 incorporated herein by reference and trade apart hereof
Home Depot reserves the right to cancel this contract if,upo at re-laspeetion ef'the Job,Rome Depot determines that it
cannot perform its obligations due to a structural problem N ith'the home,pricing errors or because work required to
complete the job was not ineluded in the Spec Sheet or Conti cL
DEPOSIT PAYMENT OPTIONS
L (Subject to fund verification and/or credit approval.)
CONTRACT AMOUNT $,aeJl[J I Check'.Cashiers Check or US P-W Service Money Order
(Made Payable to The Home Depru),
�I,ESS DEPOSIT 3 4�5 fa 2, Credit C.wd••and/or other peynpoot000ns-Circle One Below
BALANCE DUE Vim MasterCard Diaeover Arwri
ON COMPLETIQhT 8 ``� T�a Home Depot Home lmprowm. a Iq The}{oroc bop of Credit Card
• -0 N w Adeount zlsting Account (NIL&EWCC ONL
tAiinirnusu 25%of Coatrakt Ainouat due upon
execution atlhl8conitact. -�` Available Credit:S
V (H.Q.&HACC ONLY)
Indicate Payment Method For Acc
BALANCE DUE ON lt}OMPLETION: .:
N c ea d api ows on card: LOW
9 a r 2 .• ly y/ r igriaturet below e� ;to liow home Depot to
/- s aoz 1-7 7J ch ge a ove refer credi o deposit i dicated
(2 ✓ y
-When you provide a Chertc an payrgent,.vou authorize us either
a use information from your check to make a ono-dme c4ctmnic tot t" xte
fund transfer from Y acmunt ui to process tho paymnn as a
cheek transaction.When we use idf6nnaaon'fiom your ehcek tis
make andumonic fund tress,ttttltda"y be willutruwn frwn A L or HDCC'Autborization Codes
your"ount as soon as the paymcgt is r3ceived,and you will tau Deposit Final P2yrneut
receive your check back. c'-u Q sc>s # c";?b f-.sides'^
Purchaser agrees that,immediately upon completion of the wo ,Purchaser will execute a Completion Certificate and pay any
balance due. Purchaser also Agreos to be jointly and severally o ligated and liable herewi&r,
Entire Agreement:This agreement and its attachments,in(;lu'ing any financing agreement,contain the complete agreement
between the rallies and can not be amended or modified unless n writing in a separate agreement signed by both parties,
t
[NOTICE TO IVRCHASER
Do not sign this contract bOoreiyou read it_ You are enti ed(&;4 completely tilled in cop.y of the contract at the time
you slgo. Keep it to prottot yoitr rights. Do not sign a mpictlon t:ortificatc bejpre this project is complete. Law
prohibits home repair contt'iett;ks from requesting or acce Ming a Completion Certificate signed by the owner prior to
the actual completion of the.work to be performed under th,contract.
You may cancel this transaction any time prior to midnight,ofthe third business day after the date ofthis contract. See
Notice of Cancellation for an explanation of this right. 7 licre will be a service chttrge equal to 10%of the contract
amount if Job is cancelled by Purchaser AFTER the third t irsfittess.day,but BEFORE materials arc ordered.There will
be a service charge equal u)25%of the contract amount lij)h is cancelled by Purchaser ALTER materials are ordered.
BY MY/OLIR SiUNAITIREBELOW,UWE UNDERSTAND liAT THF.AGREEMFNT MAY BE SUIIIECT TO TZEVIEW
OF MY/OUR CREDIF HISTORY AND t/WF, AUTHORI .E HONTE DEPOT TO VBRTFY AND :REVIEW MY/OUR
CREDIT RECORD wiTH AN INNDEPENDE.NT CREDIT PORTING AGENCY AND RELEASE THEM FROM ALL,
LIABILITY INCURRED PROM INADVERTENT OMISSif) SfJR ERRORS.
BY MYlO[1R SIGNATURE BELOW, 1fW.I ACiRIsF TO BOUND BY THE TERMS OF THIS CONTRACT. VWE
ACKNOWLEDGE REGEiPT OF COPY OF TIiFS C ;W-TiAND TWO COMPL.GTED COPIES OF THE NUT'ICF.
OF CANCFL[-ATION.
SUBMITTED BY i _ 04 Date:
Sat ,a Itant .- - -- �j-_-
ACCErTED BY. _ � '�>------- Date:-
c `�' urchatiY"
Date:
NOTICE:ADDITIONAL TERMS AND COND IONS ARE STATED ON THE REVERSE SIDE
AND ARE PART C F THIS CONTRACT
9.21-07 ricw 4-2-07 C-SC White-Branch File Yellor�.-Customer Pink Sales Consultant
I _
S d Xd3 13C63SUI dH WUSS =9 8002 Be ReW -
• 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
Ani licant Information T Please Print UFO]
Name(Business/Organization/Individual): '
Address: Em I
City/State/Zip: " � Phone#:
Are yon-an employer?Check the appropriate box: Type of project(required):
1. stn a employer with 1, o _ 4. Q I am a general contractor and I 6. Q New construction
employees(full and/or part-time).* Dave hired the sub-contractors
2.Q I am a sole proprietor orpartner- listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. Q Demolition
working for me in any capacity. . workers'comp.insurance. 9. Q Building addition
(No workers'comp.insurance 5. Q We are a corporation and its I0.[3 Electrical repairs or additions
required.] officers have exercised their
3.Q I am a homeowner doing all work right of exemption per MGL I to Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑R of repairs
msurance•req*�d j t employees.[No workers' 13.�ther
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'ara doing all work and then him outside contractors must.submit a new affidavit indicating such. . .
1Contmaors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy iirtbrmadon.
lam an employer that is providing workers'compensation insurance for my employees Below Is thepolicy andJob site
Information.
Insurance Company Name:
Policy#of Self-ins.Lic.#: ,, t7 `'� Expiration Date:
Job Site Address: f���]-1LJG� a ? City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy ni her and expi. ation dateh
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 certo and ep d penalties ofperjury that the Information provided true and correct.
a e: Date:
• J
Phone#: 1!9 56:C?4021
Official use only. Do not write in this area,to Be completed by city or town ofJ3ciaL
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
e ^ALA_.
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 Improvement Contractor: Not Applicable ❑
1?b -, �)
Company Name Registration Nu be J
S
Address Expiration D
1 � J�L f IIJV 7elephone v
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin permit.
Signed Affidavit Attached Yes....... No...... ❑
11. - 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
rr
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [O] Other[❑]
Brief Work:Description of Proposed t14 n OIL S
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 addition 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 I 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
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 under the pains and pe hies of perjury.
i -11a-,
Pri Na e
Signature of Owner/ gent Date
4 �
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: 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 Q DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Date Issued:
C. Do any signs exist on the property? YES 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,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.
IFI�F 6)R��) Ifb
?' Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Ddveway Permit
212 Main Street Sewer/Septic Availability
art] Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
- ` Other Specify
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*
Map Lot Unit
" Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Reco d:
d -
Name(Print) Current Mailing Address:
�7Qe ao
Telephone
Signature
2.2 Authorized nt:
Mir&\
I CV
Name(P int) Current Mailing Address:
(�' ld
gnature Telephone
SECTION -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)
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 ofBui ingfB"s-, Date
BP-2008-1086
GIs#: COMMONWEALTH OF MASSACHUSETTS
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-2008-1086
Project# JS-2008-001605
Est. Cost: $2566.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 126893
Lot Size(sq. ft.): 34804.44 Owner: ROCKWELL LINDSAY
Zoning:URB Applicant: HOME DEPOT AT HOME SERVICES
AT. 63 VERNON ST
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341-9401
Workers Compensation
WORCESTERMA01607 ISSUED ON.61412008 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 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 Occupancy Signature:
FeeType• Date Paid: Amount:
Building 6/4/2008 0:00:00 $25.0022911
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo