35-123 (3) N• �
HOME IMPROVEMENT COMI'RACT
PLEASE READ THIS
' l Sole,Fumished and Installed by:
Branch Name:Roston Nordt&South Dated /ql_1�'1 _ THD At-Home Services,Inc.
d/b/a The Horne Depot At-Home Services
Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free 577-963-3768
Federal iD*75-2698460;ME Lic#CO24.39-,RI Cont.U0 16427
CT l is 4 HIG0565522;MA Home improvemcnt Contractor Re;-#126893
Installation Address J� S� o( vhQ_IJ1M a 0 tUw>"1
City State Zip
Panhasert* Work Phone: Home Phone: Celt Phonc:
Home Address: L 0Z>T(4 iV( tt l 'Cs2_ Y11 G l O 6
(if different from Installation Address) I City State Zip
E-mail Address(m receive project communications and Home Depot updates):
❑I DO NOT wish torewivc any marketing emails from The Home Depot
Proiect Infprmaticot: Undcrsigaed("Customer").the owners of the property located at the above installation address,agrees to buy,
and THD At-Horne Services,Inc.f"Tbe Horne Depot")agrees to fumish,deliver and arrange for the installation(-Installation")of
all materials described on the below end on the referenced Spec Shect(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*! Products: Sec Sheet(s)#t: ProieLt Amount
tt Roofing t4iding 0 Windows LJ Inwladou
L.� :]Gutters 1 Covcr�' ❑Entry Doors 0 �ro `3 t v $ 9
Rooting E3Sicing El Windows Insulation
CiSuuers!Covets ❑EuuyDoors ❑
Rcorrnc Siding U Windows 0 Insulation $
❑Gutters I Covers ❑Entry Doors❑ / V(
Roofing OSiding 0 Windows 0 Insulation $
CGutmrs I Covers ❑Entry Doors ❑
Minimum 25%Deposit of Contract Amount due upon execution of this contract. )
Total Contract Amount
6iainePurchawex may not deposit more than one4lird of the Conin ct Amount. $
Customer agrees that, immediately upor•completion of the work for each Product, Custonwr will execute a Completion Certificate
(one for each Product as defined by an individual Spec Sheah)and pay any balance due. As applicable,each Customer under this
Contract agrees to be jointly and severally obligates and i iable hereunder.
The Horne Depot tes--r es the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,if The Horne Depot or its authorised service provider determines that it cannot perform its obligations due to a structural
problem with:.he home,environmental hazards such as mold,asbestos or lead paint.other Salle y concerns,pricing cnors or because
work required to complete the job was net included in the Contract- `—7
Payment Summary-. The Payment Summary # l ) .�r� , included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final paymencs by Product(as applicable).
NOTICE TO CUSTOMER
You are entity to a completely Hlkd-in copy of the Contract at the time you sign. Do not sign a Completion Certiflcate(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 Horne Depot or Authorized Service Provider through the date or termination,plus any other
amounts set forth in this Agreement or allowed under applicable Law. THE HOME DEPOT MAY WITHHOLD ANIOUNTS
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 agrees and understands drat this Agreement is the entire agreement between Customer
and The Home 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 lined or amended except by a writing signed
by Custorer and The Hone Depot,Customer acknowledges and agrees that Cu er as read,understands,voluntarily accepts the
terms or and has received a copy of this Agreement.
Acc d by: Submitte
/0 x (Its
Cus:_/_er';(Sihi2ur4 V Date Sal . on:• nr's Signature Date
X Telephone Ito.
Customer's Signature Date Sales Consultant License No.
CANCEL AT1ON: CUSTOMER MAY CANCEL THIS tai�nrl�a�tel
AGREEMENT WITHOUT PENALTY OR OBLIGATION I
IDE OT DELIVERING WRITTEN NOTICE THIRD THE HOME
DEPOT BY MIDNIGHT 0,1i THE THIRD BUSLNESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
,/ liltlJ'J't1L'lIUJ'L.ClS.• /
. __ c` ` •yyiC t�Vllih LUl111'L'LLCc/L U i � •
wS� • Dopar'tlrl elit O,f'.�IZdllsf7•ial�4ccidelr:�'�' '
OfT-ce of Ir vesti;ati� • '
- Z �on;r•ess�h ee�= `uct 100
�ostort' 2114-2017
-_ = nsass.gov/dia ,
Workers' Compensation IDvtiranceAuidavit: Builders/Contractors/EIecti-icians/Plumbers
ADDUcant Inform it please Print Lizibly
.- 1
TIam �=slor an on/IndNidual):
Address:
City/State/Zip: ) L �� l Phone'• ��� °���/
Are you an'employer? Check the appropriate bo . • Type of project(required}:
I.❑ I am a employer with 4• I am a general contracoor and I -
employees (full and/or
ctors 6
have hired the•sub-contraNew construction
2.❑ I am a sole'proprietor or partner- listed on the attached sheet. 7. ❑ kemodeling
ship and have no employe°s These sub-contractors have g ❑ D-;volition
worl ing for me in any capacity. employees and have workers'
[No workers' comp:insurance comp. insurance.< 9. ❑ i3uilding audrticn
5. We zre a coraoration and its . 10. ' Elt, .1 repairs or additions
equ.°d. ❑. ❑
3. I ant a homeowner doinb ell'work of5cers have'exercised their ❑
.:.D.17 r° aus or additions
❑ 11. Plui-nb _p
myseL. [2�o wont°rs'.comp. ' riehf of er.etTiption per MGL
1- ❑ Rooi•repzirs'
inurance require 152, X1(4)', and we have no
employees. [No workers'' 13.7 Other
comp. insurance required.)
'P ny appii=ztt t: shed box-1:):st ala, CID out the sc_•tion b=low showing t heir worltca''co npersation policy info, n.
r Homeown=s who subma t s affidavit indicating they arc doing all work and th=n hire outside cont-a=tors must submit a new afridavit indicating such.
'Contractors that check this box must attached an adLtional she=t showing the na nc of the sub-eonn:tois and'sato wheth=r or not thos=entit=s have
=mployees. If th=sub-con=a=tors have=mployecs;they must provide their Work:Is' eontp,policy number.
rani•a;i employer that:sproviding workers' compensation insurance for iny'employees. Below is the policy and job site'
Insurance Company Name: AA/11 v '
Policy T or Self-ins. Li--. "' V�I =xpi anon Date: ^/
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration paQP shotiving the policy number and expiration date).
Failure to s-curd coverag- as required under Section 25.4 of MGL C. 152 can 1-ad to the imposition of criminal penaltis of a
ztne'up to S1,500.00 and/or one-year imprisonment, s well as civil p-naldts in the form of a STOP WORK ORDER c
and a iin
of up to S250.00 a day against•the violator. Be adv sed that a copy of this statement may be forwarded to the OInCC of
lnvcsti,gztions of the DL4 fortnswancc.covcragc,vcrincadon
I do hcrcoy ccrtipa'. arrd el alri crju7 that the infomtation provided above is truef attd correct
S1E1zilL-e /
Piton--
f
OJjuial l,sc only. Do riot write in this area, to be completed by airy or town oJJtcia_r. 71nsptctor i
City or Town PtrrutfLicense
Issuln°Authority �ClSCIe one):
I.Board of 3ezlth 2.Buildinc,Department 3. City/To«-n Clerk 4.Electrical lnsoector S.
G.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: Ax.�g�f7 �
The debris will be transported by: �
The debris will be received by: � 12 � k�,5,IAIIPT .
Building permit number:
r
Name of Permit Applicant 1 �
Date Signature of Permit Applicant
--_� City of Northampton
r
s s s�
� Massachusetts �
i
its{ i
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 1 Q8.3.4 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-
so
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 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 hermit 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. F� 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, [] Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. � We area corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ 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.
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 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under thepains and penalties ofperjury that the information provided above is true and correct.
Signature Date:
Phone#•
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Appiicab e £
Name of License Holder: 4 11
License Number
AIs Expiration Date
Signature Telephone l
9:Registered Home Im rove ent Contractor _ Not A licable £
P P
Comr)am a Regis r ion Number
Address Expiration Date
�/. y
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c..152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failuro to provide this affidavit will result
in the denial of the issuance of the building
Signed Affidavit Attached Yes... No...... £
11. Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied DWell1IIQ$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 buildine 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 1531(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 Laf s Annotated.
Homeowner Signature.
I
I
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [] Addition Replacement Windows Alteration(s) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks t0 Slding o Other[p)
c
Brief De i tion of Pro 1 �� �'�%f����— w2
Alteration of existing bedroom Yes No Adding ne bedroom es No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa,lf New house and or`'addit on to"ezistittg.housina; 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.
1. 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 A
to act on my behalf, i I matt elative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Agent here declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
f
Signed u he p s and Walties of
Print ame
Signatu Wner/Ag6nt Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incorptety Information.
Existing Proposed Require !by Zoning
This col to 1�fill yt
Building Op ent
s
Lot Size --
Frontage
Setbacks Front � —
Side L:` R:'.__--` L:! R:F !
Rear
Building Height F— — -
E �~
Bldg.Square Footage --" °/U —
[
Open Space Footage =_ __; % --
(Lot area minus bldg&paved
parking)
#of Parking Spaces I --
Fill:
(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 0 DONT KNOW Q YES Q ----- -- ---IF YES: enter Book Page' and/or'', Document# i
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT',KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 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 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 ex
IF YES,then a Northampton Storm Water Management Permit from the DPW is required!
1 D ;" I7eparfinerit use onl�r
C of Northampton Status ofPernt�t 4 ;,
B ilding Department Ccirb Cut/prtyerivay Permtt'n ''i
OCT 2 3 12 Main Street
1
SewerlSepticAvail"a'6Eflty '- :� ;, �, '`
Room 100 Water/til�ellRyatlabihty `
i a `
0 ampton, MA 01060 Twa Sets of Structriral Plats` f 5
7-1240 Fax 413-587-1272 I'[ot/Sit�Plana
>t r
E 4
Other Specify ,f , �x
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
1.1 Property Address:
This sectwn to be completed by`office
.'Zone Querlay Disfrtct
Elm St District CB District
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mai Addres _
Telephone
Signature
2.2 Autherized Acien t.
Na e(P' Current Mailing Address:
ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS _T
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building /z y� (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
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector`of Buildings Date
19 DREWSEN DR BP-2015-0488
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 - 123 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit# BP-2015-0488
Project# JS-2015-000922
Est.Cost: $9806.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 105953
Lot Size(sq. ft.): 8015.04 Owner: HAAS GREGORY
Zoninp,: Applicant: HOME DEPOT AT HOME SERVICES
AT. 19 DREWSEN 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 SIDING
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