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29-092 (8) VVI VV IT VT. INQ N. HOME IMPROVEMENT CONTRACT PLEASE READ THIS 1.h t J 1 1 q Sold,Furnished and Installed by: Branch Name:Boston North&South Date: t`7-1 T TED At-Home Services,Inc. d4da The Home Depot At-Home Services Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free 877-903-3768 Federal ID#75-2698460:ME tic#CO2439;RI Coat.Lie#16427 �C1T Lic#HIC.0565522;MA Home improvemernnt Contractor Reg#1.26893 ]installation Address: �*s?.��le' t4''�9 Q t C ELAn �. f-�R fil a 0 MC- Z_ City State Zip Purchaser(s): Work Phone: Hone Phone: Cdl Phone: C', Lj [ ] I ] [ ] ] r ] Home Addres : (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Horne Depot updates): ❑I DO NOT wish to receive any marketing entails from The Home Depot Pr ect In oration: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and T At-Hone Services,Inc.("The Home Depot'?agrees to famish,deliver and arrange for the installation("Installation")of all materials described on the below and on the referenced Spec Sheet(s), all of which arc incorporated into this Contract by this reference,along with any applicable State Supple-nent and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): Job#: (E.—W NO—) fig; See Sh s #e Proiect Amount �j Roofing Siding windows Insulation �j $ Vfj -163 6✓� l ❑Csvtters;covers Etmy Doors Q v� Roofing Siding C1 windows 0 Insulation $ ❑Gutters;Covers []Entry Doors 0 Roofing Siding Lj Windows U Insulation $ �( ❑Gutters:Corers OEntry Doors© Roofing Siding Windows Insulation $ (]Gutters 1 Covers DErtry Doors n- hfinimuat 25%Nposit of Contrwt Amountdue upon execution orthis contract. Total Contract Amount Maine Purchasers may not deposit more than one-third of the Cotttracl Amount Customer agrees that, 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 Products)included'herein,at its discretion,if The 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. t Payment Summarv- The Payment Summary 4 _q b J7 , included as part of this Contract, sets forh the total 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 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. cce mt nee a d utho 'z do : Customer agrees and understands that this Agreement is the entire agreement between Customer and Cbe one Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and installation.This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Cus s read,understands,voluntarily accepts the terms of and has received a dopy of this Agreement. Accep d bu: I Submitted Cu• gnatur Date Sales Consyllr5vignaturre Date / y / Telephone No. Customer's gnature Date Sales Consultant License,Io. CANCELLATION: CUSTOMER MAY CANCEL THIS (as applicable), AGREEMENT WITHOUT PENALTY OR OBLJGATION `�l� BY DELIVERING WRITTEN NOTICE TO THE HOME -1 13 �3 6— 5 3 °c 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 SPECIFICALLY PRESCRIBED BY LAW IN ri l RT0M F.R'.S.RT ATR. _ 0. \ AiJL: L,vJILntV/ct1'c;t441-r1 V./ 111 t1 S'J'UC!!llJ'L'f15.. / Departnzetzt of•Ihdzistrial,4ccidey.:�'�' Office of Irvesti� 1 Corz;r ess Sh ee�;% `ucte I00 c •.Bostdiz 2114-2017 ww.niass.-ovIdia 'Workers' Comp ensation-YDSttranceAuidavit: Builders/Contractors/EIectricianslPlumberi ADDUcant rnformatiori Piease Print Lezibly N3II1°..1, �:ss/oranoaandividtul): % /v'` t d ess: 1:!5_2� City/State/Zip: ) L �� / -�Phone'f Are you an'employer? Check the appropriate box Type of project(required}: 1. I nut a employes with 4• I am a general contractor and I ' • employee's (full and/or part-time).* have hired the'sub-contractors 6� New construction 2.❑ I am a sole'proprieior or par' :r- listed on the attached sheet. 7. []Remodeling ship and have no employ°°s - These sub-contractors nave g Demolition worhLril- for me in any capacity, employees and have workers' [No workers' comp:insurance comp. insurance.+ 9. ❑ Building addttton S• L `ae are a corporation and its . 10. Electiic 11 repairs or additions 3.❑ 1 am a homeowner doing all*worl; ofncers have exercised their 11.17 Pluinbi:.;repairs or additions n phi of exerritition per MGL myself. [No won};ens .conp.'% 12.❑ Roof r°pars' i^durance regu red.) t C. 152, §1(4); and.we have no ' employees. [No workers'' 13 Other v �� - - coL•tp. insurance required.) A-ny applicant ti:::'11=1Z box-1 7c1"t au, fill out Aic section below showing their won}te ' compensation policy iniomiation. r'Fiomcovm:rs who submit: is affidavit indicating they arc doing all work and then hire outside eon-acto.s must submit a new affidavit indicating such. 'Contractors that cheek this box mud;attached an atiLtional sh::t showing the na.•n:of the sub ante to and sat_whether or not those entities have cmploy::s. If the sub-contactors have cmploy::s;they must provid:their workers'comp.policy nUmbcr. , lani a;i employer that sproriding workers' conipensafion utsurance for my,employees. Below is the policy andjob site' Insurance Company Name: Policy=or Self-ins. Lic. '�: �"7�I =xpiration Date:^/ �- Job Site Address: 4 _City/Stat-jzip: �� �' 01PI 2— h a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to s-cure covcage as required under Section 25.4 of 1viGL e. 152 can I-ad to the imposition of criminal penalties of a nne'up to 51,500.00 and/or one-year imprsonment, as well as civil p°naiti°s in the form of a STOP WORK ORDER and a nne of up to 5250.00 a day against•the violator. Bc advised that a copy of this stacment may bt;forwarded to the OEcr of Investi.gz.tions_of the DL4 for irsurance.covcrage,vcnfi:ition. I do hereby ccrti pa;?9- and eJ altihat the information provided above is true atsd carrccL Sienatu- i t � bat P n on- t . i Of-icl--sc only. Do not 1V,ate in Zits ai cz, to be con,plcted by city or town official. City or Town: Pt- rtit/Li=east r Issuing Authority (circle one): 1.Board of�ezlth 2. Bu.Udizc,Deazrt;z ent 3. Ci y(I o%rn Clerk EIt: izal T-SDector S.PIumbing Inspector 6.Otaer Contact Person: Phone n: 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 MG-L c 111, S 150A. the work: 7 C ��6�TT - 6 ' Address •f 4 // The debris will be transported by: The debris will be received by: Building permit number: r Name of Permit Applicant / 162 Date Signature of Permit Applicant City of Northampton ,rte Y Massachusetts 4 cl�c c, 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 awns 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 I uilding 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 occupancy4until 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 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 M Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. E] 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, 0 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 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. tAo 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: Not Applicable £ Name of License Holder: License ber Address �„ Expiration Date Signature Telephone 9.Reoistered Home Im movement Contractor _, _ Not Applicable £ Com an I y Name I Registration Number Address r� Expiration Date elephone !/ ^�J SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... No...... £ 11.'- Home 0wfi&,Exempt10n The current exemption for"homeowners"was extended to include Owner-occupied DweHin2$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,Yu may liable 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 C] Replacement Wi Alteration(s) ❑ Roofing E] Or Doors 1211— 1 Accessory Bldg. ❑ Demolition ❑ New Signs ([3] Decks [[] Siding[O] Other[0] Brief DescriP on of A Work: %/0 �G / Gj4�;M Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a, lf"New house and"oraddif on to'existing h"oustng; complete tha'following: a. Use of building :One Fa i 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 behalf, in al matter ative to work authorized by this building permit application, Signature of Owner Date I, 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 upMthe pAins and penalties of perjury: Print Name /D °-2�-/ Sign a of OCner/Agentl, Date Section 4. ZONING AR Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Requir �y Zoning This col to be filled in by n,sl col to be 11, Building 1partinent Lot Size Frontage 'Setbacks Front Rear Bldg.Square Footage % Open Space Footage r-7 % (Lot area minus bldg&paved #of Parking S aces (volume&Location) I A. Has a Special Permit/Variance/Finding ever been issued for/on the site? ~� �_v VY «��� � NO �~� DONTKNO Y�� �~_� � |F YES, date issued: | IF YES: Was the permit recorded at the Registry nfDeeds? � NO v-=/ VUMlxnuW YES ' � IF YES: enter Book end/or Ducument# B. Does the site contain a brook body of water nrwetlands? NO 0 DON7 KNOW 0 YES IF YES, has permit been or need to be obtained from the Conservation Commission? Needstobeobtained � - \ Obtained x-� Date Issued: �.� ' C. Do any signs exist on the property? YES �~��� NO x=�� � 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre=is it part ofa common plan ' that will disturb over 1acre? YES � ) NO ) � — K |F YES,then o Northampton Storm Water Management Permit from the DPW isrequired. ^ ~ - �it Department use only ,' t 64 ]'�� of Northampton Status of Perntt 'S �' �' £i CE3"" � e 1<� B ilding Department Curb CutlDrleuteyPerrrti# 12 Main Street ' Sewerf5eptlaAvaiCa7�Illty r _ F OCT Room 100 WaterltetfAVa�lablllty 2 3 2�+1 o amp ton, MA 01060 7waSetsofS#r�rctuFa3-Pfarrs , x k 3- 7-1240 Fax 413-587-1272 P[ot/Site Ptans T DEPT OF 09LO—M Other Speci#j!`}` , APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This sec#ion to be completed by gff�ce r ' Map Lot Unit KwD.ten ::Zone Overlay D�strtct '' Eim St Wstnct CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Curr(gY/ Add e'di_7 Telephone Signature 2.2 AutbDrized A ent: Name t) Current Mailing Address: nature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building v (a) Building Permit Fee 2. Electrical (b)Estimated Total Post of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Cam missioner/Inspector'of Buildings Date 46 BRIERWOOD DR BP-2015-0487 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-092 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categ_oa: REPLACEMENT DOOR BUILDING PERMIT Permit# BP-2015-0487 Project# JS-2015-000921 Est. Cost: $3020.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 92937 Lot Size(sg. ft.): 13198.68 Owner: DREW JEFFREY Zoning: Applicant: HOME DEPOT AT HOME SERVICES AT. 46 BRIERWOOD DR Applicant Address: Phone: Insurance: 5 RIVERVIEW DR (401)935-2633 O Workers Compensation NORTH PROVIDENCER102904 ISSUED ON.1012812014 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT PATIO 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 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