29-416 (5) LV/T IV VL VJ• I! LVI Vr 1% T IJl rTLV IIVIII� Vi vw, I111V r 1
HOME IMPROVEMENT CONTRACT
PLEASE.READ THIS
0 2 1'-11 Sold,Ftunished and Installed by:
Brandt Name:Boston North tit Swath Date:_J_J__ THD At-home Services,Inc.
d/b/a The!Home Dep(a At-Home Services
Branch Number&-d 33 908 Boston Turnpike,Unit 1.Shrewsbury.IVIA 01545
Toll Free 877-903-3768
Federal 11)#75-2698460.ME Lie#C 02439;RI Cont.U0 16427
Q ("r laic N IUC.0565-5-22;MA Home hnporivenrcut Ccntractur Reg.tt 12(993
Installation Addterns: So k7r>A, aa: ` b, I 1�,e..r�_ � 0 1 a to-a-
City State Zip
P`rchuver(s): Work Phone: Rome Phone: Cell Phone:
Home Addressn
Of different from Instillation Address) Cily State Zip
E-mail Addresn(to receive project communications and Home Depot updates):
❑1 DO NOT wish to receive any marketing emails from The Hume Depax
P-ee 1 Undersigned("Ctistomc.r").the owners ul the property located at the atx)ve installation address,agrees to huy,
and THD AtHome Services, inc.('"i'he Hume Depot")agree to furnish,deliver and arrange for the installation("Installation")ol"
all materials described on the below and on the referenced Spec Sheet(%), 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#: aw-1 R, rmtt. Products: Sec Shect(s)#: Prri ect Amount j
Rtmting USiding ❑Windows Lj insulation
❑Gttttets/Cuvcrs DEntry Doors ❑
Kouling ❑Siding Windows hwulatitm
❑Clutters/Covers DEntry Ikmrs ❑
Rcwling ]Siding U Windows Insulation � $$
❑Gutters/Covers ❑Entry Uuor%❑
Roofing OSiding=Witidows U Insulation
[]Gutters/Covers []Entry Doom ❑
Minimum 25%i epndt of Contract Amount due upon execution of ft contract. 1'otal Contract Amount
Maine Paremsem may not deposit mute than une4bird o(the C mmirt Amoutlt L,
Cu%tonwr agrees that, inunediately upon completion of the work for each Product,CttelOrncr will execute it Completion Certificate
(onc for each Product as defined by an individual Spec Sheet)and pay any balance duc. As applicable,each Customer wilder this
Contract agrees to be jointly and severally obligated and liable hereunder.
The florae Depot reserves the right to issue a Change Order or terminate this Contract or any individual Woxtuct(s)included herein,at
its discretion,il'The Home Depot or its auUuniicxt 4Tvice provider determines that it cannot lxvlorm its obligations due to a structural
problem with the home,environmental hazards such as mold,asbestos or lead paint,other satety concerns,pricing errors or be au%c
work required to complete Unc job was not included in the Contract.
htiment Summary; The Payment Summary# D7 -1-9 74Y included as pan of this Contract; sets forth the total
Contract amount mitt payments required for the deposits and linal payments by Product(as applicable).
NOTICE TO CUSTOMER
Von are entitled to a completely fulled-in copy of the Contract at the time you sign. Do not sigh 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 casts of materials,labor,expenses
and services provided by The IIome Depot or Authorized Service Provider through the date of termination,plus any other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THF: HOME DEPOT FROM TIIE DEPOSIT PAYMENT OR OTiIER PAYMENTS MADE, WITHOUT
LIMITING THE HOME.DEPOT'S OTHER REMEDIISS FOR RECOVERY OF SUCH AMOUNTS.
Attie tunee t Authorization: Customer agrees<uld understands that this Agreement is the entire agreement between Customer
nn ld TI a ltotne pun with regard to the lh'oducts and lusutllaLi n urviccc and supersedes all prior discussions and agreements,either
oral or written,relating to said Products and installation.This Agreement Cannot be as%igned or amended except by d writing signed
by Customer and The home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily acccpls the
14vms of and has received a copy of this Agreement.
i
Accepte by: Submitted b
X X
Q.Customer's Signature Date Sales Consultant's Signature Date
x, Telephone No. 1//3 6 �j(a �3&---
Customer's Signature Date
Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL TIILS tusupp°cshic)
AGRERMF:NI'WITHOUT PENALTY OR OBLIGATION
BY DELIVERiNG WRITTEN NO1'10E'1't) THE HOME
DEPOT BY MIDNIGHT ON THE THIRD ROSINESS
DAY AFTER SI NING THIS AGREEMENT. THE
STATE, SUPPLEMENT ATTACH'E'D HERETO �
CONTAINS A FORM TO USN', iF ONE IS
SPECIF'ICALi.Y PRESCRIBED BY LAW IN j
CUSTOMER'S STATE.,
NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE Rk VERSE SIDE.AND UtE PART OT TINS CONrRACr
- P\ , ,ae �,vnu,cviz�l c cuc�t vd ar1UJ'J'UL'ltUJ'('Cf /
Depar•trriertt of'Iiidustr•ial�4ccide►r7'
Off
cc of Ii;vestigati� � ,
_ X Coll r•ess str•ee to 100
c: Bbstorz'AfA'6114-2017
-- - - :_ mass.gov/dia
Workers, Compensation.InsTfrance davit: Builders/Contractors/Elects icians(Plumbers
ADDlicantlnformation' / Please Print Lizibl y
Name+ ss/0rganizariowIndividual):
Address:
Ci&s/ ate/Zip: �L 'f Phone m: � 9.
Are you an'employer? Check the appropriates b5):'
,o/� Type of project(required}.
1.❑ I am a emplo er with 4. Sd 1�a general conrracior and I
y 6.- ❑New construction
employee's (full and/or part-time).* have hired the�sub-contractors
listed on the attached sheet. 7. ❑Remodeling
2.❑ I am a sole•proprietor or partner- •
ship and have no employees These sub-contractors have' g ❑Demolition
worEn, for me in a-ny capacity. employees and have workers' .;• .
[No workers comp:insurance
comp. insurance.i 9. ❑ butlding addition ,
5. ❑ .We are a corporation and its . 10.❑ Electricll repairs or additions
required.]"• .
Gn5cers have.'exercised their 11. PI .. repairs or additions
3.❑ I am a homeowner doing all•worh ; . ❑
m self, o woriters'.com right of exemption per MGL ooi.reaairs'
p--;'I 1-
irsurance required.] t c. 152, §1(4)> and,we have no '
'employees. [No workers" 13•❑ Other
comp. insurance required.]
'Any appiicznt ti:.:�hecls box-1 rest au, nll out the section below showing Choir workcts'compcnsatioa policy information.
t*Homcowncts who submit t is afndavit indicating they arc doing all work and then hire outside contactors must submit a new affidavit indicating such.
tContmctors that check:this box must attached an adaitional sh:ct showing the ita.•nc of the sub-contractors and'statc whether or not those ctititi shave
cmployces. If the sub-eon actors have employees;they must provide their workus' comp.policy number. .
r ant'a;i employer that is providing workers' con'Eli, tion insurance for my employees. Below is the policy and job site'
"iirformation. � . . � �•--�
Insurance Company Tal-ne:
Policy"r or Self-ins. Lic. �: / �! Expiration Date:
Job Site Address: Ciry/StatJZip
nA- t�f
—Z
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure cov ,age as required under Section 25A of MOL c. 132 can lead to the imposition of criminal penalties of a
nne'up to S1,500.00 an&or one-year immasonznent, as well as civil penalties in the form of.a STOP WORK ORDER and a Em:
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Once of
Investi.gatiors of the DLk for insurance,coverage.vmincidon —
I do hereby ccr-n pa'. and e� alri�� f cr)U7 that the information provided above is true atsd correct r
L7
.� -�
Si
Pnon
4
• t
Off=ial z:sc only. Do not write in tits arc.,to be completed by airy or town official.
City or Town: V Permit/Li--east f
Issuing Authority (circle one): y
1.Board of l=ealth 3.Building Depar t;nent 3. City/Town Clerk: 4.Elect:lcal I>;SD^ctor S.PIumbing Inspector
6.Othtr
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:
The debris will be transported by:
N l
G L�
The debris will be received b y
Building permit number:
Name of Permit applicant ev,
Al
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable £
Name of License Holder: ' �� d 1�0
�-_ license Number
Add s Expiration Date
ignature Telephone
9.:Re istered Home Im "rov ment Contractor ?,.. Not Applicable £
Com any
N'ame Registration Number
A a s Expiration Date
A/ Telephone /4:y- �� °
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 buildingpermit.
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 E] Replacement Windows Alteration(s) 0 Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[o) Other[[31
Brief WorkDesorkition of
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No C- �
Plans Attached Roll -Sheet
t,a:If New house an' "orA dition to ezistinq h"oustng, complete the'fotiowind:
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, i II mat s relative t k 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 Xr e pa' sand penalties f�y
Print Name
Z-0
2
Signa of Owner gent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To incomplete Information
Existing Proposed Req 'red byZoning
This lum to b y
menTBuil g D art "
s
Lot Size
t
Frontage
Setbacks Front A! �
Side L:= R:=.____,.._.! L:= R:F i'
Rear
Building Height
Bldg.Square Footage
Open Space Footage _; F_ _ % --
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
E�
(volume&Location) """"" -
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q —
IF YES: enter Book j Page _ and/or Document#!
B. Does the site contain a brook, body of water or wetlands? NO Q DONT'KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q
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 O NO C
IF YES,then a Northampton Storm Water Management Permit from the DPW is required..
I
RECEIVED r r 3 )Separtment Use Orly
k
ity f Northampton Status ofPerrrltt "� `
fi f
1M1
uild g Department Garb Gut/Driyeway Permit
21 Main Street r L
OCT 2 3 sewer/SepticAyaliablllty
gi
oom 100 WaterlWeilAuarlablllty
ton, MA 01060 Two Set`st of StFtrctural'Pia[ts r
DEPT.OF BUILDING INSPE ha p `
NOR7HAM 0 ht
1240 Fax 413-587-1272 Plof/Slte Plans , � x ` ,
Other SpeclfjF' a. � " �-
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
1.1 Property Address:
Th1s section to be completed by office
lob ?.'
Zone Overlay Dlstrrct
Elm St I]istnct CB I)IStnct
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
e.
Name(Print) MaiIin j j /2,
lelepl5one
Signature
2.2 AuthDeAd Ment:
Name ri r.. Current Mailing Address:Z 2
Onature-_ Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
com feted 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
ate
Building Permit Number: IDssued:
Signature:
Building Commissioner/Inspector of Buildings Date
106 BROOKWOOD DR BP-2015-0490
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-416 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2015-0490
Project# JS-2015-000924
Est.Cost: $10380.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 088261
Lot Size(sq. ft.): 14941.08 Owner: TENNYSON DALE L&LINDA I
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT. 106 BROOKWOOD DR
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON:1012812014 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF
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 10/28/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner