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HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Furnished and Installed by:
Branch Name:Boston North&South Date:6((-/1 1A THD At-Home Services,Inc.
dlb/a The home Depot At-Home Services
Branch Number:31 and 33 908 Boston Turnpike,Unit i,Shrewsbury..MA 01545
Toll Free 877-903-3768
Federal ID#75-2698460;CIE Lic#C 02439;RI Cont.Licx' 16427
CT lic#HI�C..•0565522;MA Home Improvement Contractor Reg#126893
Installation Address; qo (A t c'}: C-4—
City State Zip
Purchaserts): Work Phone; Home Phone: Cell Phone:
LIz.Aebgi 0-1NS6 rJ [ O [ J
[ J l I [ 1 LJ
Home Address:
(If different from Installation Address) City State Zip
E-mail Address(to receive project ccmrnunications and Home Depot updates):
(]I DO NOT wish to receive any marketing emails from The Home Depot
Project laformati=: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
and T6ID At-Horne Services, Inc.("The Home Depot's agrees to furnish,deliver and arrange for the installation("installation")of
all materials described on the below and on the referenced Spec Sheet(s),an of which are incorporated into this Contract by this
reference,along with any applicable Stare Supplement and Payment Summary attached hereto and any Change Orders(coilectively,
"Contract"):
Job#: n,w."ia.r<rMKt Products: Spec Shee s #: ProectAmoant
Roofing Siding indows i Insulation
-7 7 a 9 ❑Gutters!Covers OEntry Doors Q V 7: 3!5 qlwpl
Roofing Siding 0 Windows 0 Insulation L $ f
j]Gutters 1_Covers StEnuvDoors []
Roofing USiding Ll Windows U Imulation ry Tim
QGutters 1 Covers ❑Entry Doors 0 S
Roofing Siting 0 Windows Insulation a v vts
OGurters/Covets (]Entry Doxs $
Nhnimern ZPA Deposit of Contract Amount due upon excention of this contract. rata!Contract Amount S
Maine Purchasers e chasers may not deposit me than one-third or the ContractAmona
Customer agrees t?tat,immediately upon completion 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 Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,ifThe Home Depot or its authorized service provider determines 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.
rr �
Payment Snmmarv: The Payment Summary#_ [^z q� . included as pan of this Contract, sets forth the local
Contract amount and payments required for the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there Is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product
is complete.
In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other
amounts set forth is this Agreement or allowed under applicable law. THE HOME DEPOT MAY WI'T'HHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING TIME ROME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Aece tonic and Auth9pzatiact Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Lorne qw.with regard to the Products and Installation services an su rsedes all prior discussions and agreements,either
oral or written,relating to said Products and Installation_This Agreemen of assigned or amended except by a writing signed
by Customer and The home Depot.Customer acknowledges and agrees ha sto has read,understands,voluntarily accepts the
terms of and has received a copy of this Agreement.
Ace ezk Sub tt
!S lL X . -
Customer's Signature Date S Itant's Signature Date
X Telephone No.
Customer's Signature Date Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS ( applicable)
as a !liable
AGREEMENT WITHOUT PENALTY OR OBLIGATION q t '3 �- —
BY DELWERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE --------
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED) BY LAW IN
CUSTOMRR'S STATE.
j«� i Uri<<�cUtcil'cct�uL UJ LUUJ5UC!IUSLMS
Department of Indiistrial Accidents
- Off ce of Investigations
_ X Congress Street, Suite 100
Boston;MA 02114-2017
www nzass gov/dia . '
'Mlorkers' Compensation.-Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information' i Please Print Le 'blv
� g .
Name usiness/Or anization/Individual): -+' - A-7
Address:
f4?City/State/Zip: �� � Phone#: °�J�9
Are you an employer? Check the appropriate bo . • Type of project(required}.
1.❑ I am a employer with 4. I am a general contractor and I 60 New construction
employees (full and/or part-time).* Have hired the sub-contractors
2.❑ I am a sole' roprietor or partner- listed on the attached sheet. 7. [l Remodeling
These sub-contractors have Demolition
ship and have no employees 8• ❑
working or me in an capacity. employees and have workers'
g Y P n'• 9. ❑Building addition '
[No workers comp:insurance
. comp. insurance.$ •
required.] 5. We are a corporation and its 10.❑Electric it repairs or additions
officers have exercised their 11. Plumbi..,,repairs or additions
3.❑ I am a homeowner doing all•work ❑
ri t of exem tion per MGL
myself, [No workers'.comp. :. �' P. p 12.❑Ro f repairs
t c. 152, §1(4);and we have no
insurance required.] r-
1h '
,. 'employees. [No workers'' 13.
`comp. insurance required.]
Any applicant ti:.:`checks box;V 1 al,. fill out the section below showing.iheir workers'compensation policy information.
t Homeowners who subm;t tcis 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 an:an employer that isproviding workers' compensation insurance for my employees. Below is the policy and job site
•ilzformation. •��� _. Are /�Insurance Company Name: , l
Policy#or Self-ins. Lic. #: t/�/ 0 Expiration Date:. ^ /
Job Site Address: C__/ City/State/Zip: !✓1 ,
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 certi pa' and ei alti ;rjurT that the information provided above is true and correct
Si Mature: Dat e:
Phone TM•
I ��� z �--
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: PernutlLicense#
Issuing Authority(circle one): y
L 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: q'q Aze"-" d )
The debris will be transported by: 16
The debris will be received by:
Building permit number:
of Permit Applicant f4 -
Name pp
�- '
Date Signature of Permit Applicant
City of Northampton
/p k- Massachusetts w s l�`•
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
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 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 massacnuseazs
Department of Industrial Accidents
Office of Investigations
` 600 Washington Street
r. Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ 1 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 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.$ 9. F-1 Building addition
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' 13.❑ 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. Lie. #: 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#:
A '
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not blef£
Name of License Holder: ^ �/qg�k� -
License Number
Address� � ) � Expiration Date
Si nature / Telephone
9. Re istered Home I Foveme`t Contractor.J_ Not Applicable £
Company Name �Zs� Registrati n Number
A%,r Expiration Date
Telephone
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 't.
Signed Affidavit Attached Yes....... No...... £
11. -Home OwnerExemption
The current exemption for"homeowners"was extended to include Owner-occupied DwellinEs 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,
i
A
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement ows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[❑] Other[E3]
Brief Desch ti [:,r 'o d`) Jh�
Work: `t �✓i °�
Alteration of existing bedroom Yes No Adding new bedroom Yes o
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 City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
ERR.
�� ��✓'�fls ► as Owner of the subject
property °
hereby authorize 4--t4pm-P
to act on my behalf, in all matters rel�a�ork authorized by this building permit application.
Signature of Owner Date
�- AAP 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.
Signe der he pains and penaltie f erjury.
Print Name
Sign re 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
This column to be filled in by
Building Department
( t
Lot Size
Frontage _J
Setbacks Front ' j F-711 _
Side L:= R: 1 L:i__ R:F
Rear -
Building Height - '�
Bldg.Square Footage % —
Open Space Footage(Lot area minus bldg& aved
arkin )
#of Parking Spaces l
Fill:
1,
(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:' —w
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES C
IF YES: enter Book Paged -^ and/or Document#1 i
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW C) YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued: _
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location: j
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 Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
k k J
_ City of Northampton Status ofPermrt �" s F
building Department Curb Cu#/t7rl�euvay Perrrttf ,
212 Main Street Sewer/SeptiAvaira5[hty '
IPll��— r Room 100 1NaterlUtfellAvatlabillfy
� SP 2014 rthampton, MA 01060 twdll Sgig"of s#ructural Plans_
hone 413 587-1240 Fax 413-587-1272 P[ol/Slte Plans
Electric, Plumbing&Gas Inspections
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMA TION
:his-sett
10 d by office
1.1 Property Address:
RAMate^ ; Map Lot Unit
Zone. Overlay D�sfrict
Elm St°District.: CB q�stuct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
1
Name(Print) ���7!/ Curre ng Udr
67�;C
Telephone
Signature
2.2 Authqri3ed A 'ent: `
✓ 1r A/P• =�
Name(Pr Cut ailin Address:
Si ure 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 r✓ !/ (b) Estimated Total Cost of
Construct ion`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 Commissionedlnspector of Buildings Date
40 ALAMO CT BP-2015-0279
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 129 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catep-ory: windows replaced BUILDING PERMIT
Permit# BP-2015-0279
Project# JS-2015-000539
Est. Cost: $12358.00
Fee: $74.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 98785
Lot Size(sq. ft.): 81892.80 Owner: ROBINSON ELIZABETH M
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT. 40 ALAMO CT
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON:911212014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 14 REPLACEMENT WINDOWS & 2
ENTRY DOORS
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 9/12/2014 0:00:00 $74.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner