29-209 (4) Aug 1514 04:33a p.1
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Famished and Installed by:
Branch Name:Boston North&South Date!i�t� THD At-Home Services,Inc.
dJbla The Home Depot At-Home Services
Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free 877-903-3768
Federzl ID#75-2698460:ME Uc#C 1124'_9;RI Cont.lick 16427
���,� CT Uc#HIC-056555222tt;MIA Hoax tntprovemetngt�Cowactor Reg.,#1�^268933
Installation Address: yc�' f-t�_s +3iz �r Da Rt-) Q IJC� f y 4 4 6 4
City State zip
Purchascr(s.): Work Phone: Home Phone: Cell Phone:
Home Address;
(if difforcnt from Installation Address) DIV State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑I DO NOT wish to receive any marketing etnails from The Home Depot
Proiect Information Undemigned("Customer").the owners of the property located at the above,installation address,agnccs to buy,
and THIS At-Horne Services,Inc. ("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installation")of
all materials described on the below and on the referenced Sp= Sheet(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#: urrndRcre v r cls: Sec Sheet(s)f. Project Amount
Rocrrng p
Siding inflows Lj Insulation
❑Gutters1 Covers ❑FFvtry Doors El
Rwflrg USiding Windows El Insulation
❑Gutter;I Cove s❑Entry Doors ❑ S
Roorirg Siding 0 Winnows lnsulation
❑Gutter;!Cove-s ❑EntryDoor%[1 $
Rocrrrg LjSiffin.- Windows Ll Insulation
❑Guam i I Covers ❑Entry Doors (3 $
Mini main Z5%Deposit ofCootract Amount due upon execution of thiscoatract- Total Contract Amount $
Maine Purchasers may not deposit more than orw 4bird of the Contract A mount
Customer agrees that,immediately upon completion of the work for etch Product, Customer will execute a Completion Certilicatc
(one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this
Contractagrm to be jointly and severally obligated and liable hereunder.
The Home Depot reserves tv right to issue a Change Order or terminate this Contract or any individ ai Product(;)included herein,at
its discretion.if The Hotnc Depot or il.;acdnotized service provider delermineN that it cannd;t perform its obligations due to a structural
problem with the home,envireruneriml hazards such as mold,a,bestos or lead paint,other safely concerns,pricing errors or beciiuse
work required to complete the job was not included in the Contract.
Payment Summary: The Payment Summary# qj,L j(,J--, included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final payments by Product(as applicable;).
NOTICE TO CUSTOMER
You arc entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(state:
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 tern»nation of this Contract,Customer agrees to pay The Home Depot the costs of inateriuls,labor,expenses
and services provided by The Home Depot or Autborived Service Provider through the date of termination,plus any other
amounts se4 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
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agree.,and understands that phi,Agreement is the entire ap ecmeet bctwcct; Cu lonict
and The Home Depot with regard to the Products and Installation Sea-vlees and su'persedcs all prior discussions and agreements.either
oral nr written,relating to said ProdtKts and lnslal.alion.'Th,%Agreement a anndK be assigned or amended weep:by a writing signed
by Customer and The Horne Depot.Customeur acknowledgeN and anreM that Customer has read.understands,voluntarily accepts the
terms of anVim, glued a copy of this Agreement. 1
Accepted � 5ubmitt d�b
Customers Signature Ilene Sales q n is Signature Data
X Telephone No.
Customers Signature Dale
Sales Consultant License No.
CANCELL4,TION: CUSTOMER MAY CANCEL THIS ta.�ppticameh �;
AGREEMENT WITHOUT PENALTY OR OBLIGATION C.
BY DELIVERING WRITTEN NOTICE TO THE HOME 1
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS 1
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
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.
A r
The debris will be transported by: � !
The debris will be received by: ��ac� l✓-/ - r
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
r „ 212 Main Street • Municipal Building
y 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 Massachusetts
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.❑ 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 8. ❑ Demolition
working for mein 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
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#:
r
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Sugn2rvviisor: g Not Applicable £
Name of License Holder:
License Number
Address Expiration Date
_ w1� �
Signature Telephone
9.Re istered Home Im provement Contractor: Not Applicable £��,
Comi)anv.Name , K2�/��� � Registration, um� /
re �� it tion Date
r
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 buildin
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-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.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement WjpOlews Alteration(s) ❑ Roofing ❑
Or Doors Teff
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [O] Other[O]
Brief Descri tion f s �h
Work: p � '
Alteration of existing bedroom Yes No Adding new bedroom es No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa:'If Newhouse and or addition to existinq'hbus nq, 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
as Owner of the subject
property
hereby authorize
to act on my behalf in all ma.Uers relayae-work authorized by this building permit application.
ignature 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 u he p ns and penalties o
Print Name
Signature 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
Lot Size
Setbacks Front
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location) IL
A. Has aSpecial Permit/Variance/FincUng ever been issuedfor/on the site?
�-\ �~x�j� �~�
NO �� DONTKNO� YES \��
IF YES, dateissued:| >
IF YES: Was the permit recorded at the Registry ofDeeds?
NO _� � DONTKNOYY 0 YES C)
�-- -- -=_-- -----------
IF YES: enter Book Page and/or Dncument#
�� ��
B. Does the site contain a brook' body of water nrwed ��wetlands? NO �_� DONT KNOW «�� YES �~�
IF YES, has a permit been or need tube obtained from the Conservation Commission?
Needs tobeobtained v~� Obtained �� Da�e (ssued.�
�~� �~� '
C. Do 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 size' type and location:
E VWU the construction activity disturb(clearing, grading, excavation,orfiUing>over 1 acre orioit part nfa common plan
' that will disturb over 1acre? YES C) NO N
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
^ —
-y1 ; ;Deparfineht Use only
` r k
of Northampton Status of Permit s; �' 4F i',
fi
J� '-SEP _8 2014 i l Iding Department Ctirlr CurlDnveuvay Perrrtif't s
n,t r ,
12 Main Street SeyvedSepticAyaifabi(cty F
LLJ
`— — -- Room 100 Water/VlFeiiAvatlablhty
- Jor ampton, MA 01060 Twa Sets of 5#ruetur,:al Plans
"p 7-1240 Fax 413-587-1272 FIoUSIte Plans
OtherzSpeo�fy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This ection fo be completetl _ office
Unit
i �
Zone Overla :Distract
Y
Elm St Distract CB.DISWict
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Record:
��a JQ1?z
0 Ampo
Name(Pjrint) Current Mailing Address:
:/i6/� �d___7 Telephone
Signature
2.2 ALtthorizj A ent:
Na a(Print) Current Mailing Addres
Y-2 1-1
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Cost(Dollars)to be Official Use Only
completed b permit a t
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/In.spector of Buildings Date
88 ACREBROOK DR BP-2015-0256
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-209 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-2015-0256
Project# JS-2015-000489
Est. Cost: $2184.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 92937
Lot Size(sq. ft.): 29664.36 Owner: ROTH BARRY
zonine: Applicant. HOME DEPOT AT HOME SERVICES
AT. 88 ACREBROOK DR
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON.91512014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL PATIO DOOR REPLACEMENT
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 9/5/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
88 ACREBROOK DR BP-2015-0256
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-209 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-2015-0256
Project# JS-2015-000489
Est. Cost: $2184.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 92937
Lot Size(sq. ft.): 29664.36 Owner: ROTH BARRY
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT. 88 ACREBROOK DR
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON.91512014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL PATIO DOOR REPLACEMENT
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 9/5/2014 0:00:00 $35.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner