24D-243 (10) I
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
i
�+,
Sold,Furnished and Installed by.
Branch Name:Boston North&South Date:b ai� THD At-Home Services,Inc.
dAVa The Home Depot At-Home Services
Branch Number:31 and 33 908 Boston Turnpike,Unit I,Shrewsbury,MA 01545
Toll Free 377-903-3768
Federal ID*75-2698460;ME Lie#C 02439;RI Cant.Lic#16427
CT Lie#li1f.05655 MA Home Imppro_vemem.Contractor Reg.#126893
Installation Address: (�.t C S'�` k1,- tR�tV1 '0 v 1110 0iLW,0
City I State Zip
i%Purehnser(s): CC Work Phone: rr Home Phone: CellPhona
L
Home Address:
Of different from Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑I DO NOT wish to receive any marketing emails from The Home Depot
Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
and THD At-Home 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 Spec 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#: fi-i ,,tav o Products: Sec Sheet(s)k. Pro'ectAmount
Roofing EjSiding Windows U Insulation
',_)a e)3D l OGuttets t Cowers ❑Entry Doors El (`�Q
Roofing Siding Lj Windows Ej Insulation
❑Gutters/Covers []Entry Doors ❑ $ l
Roofing LjSidieg Lj Windows Lj Insulation S
[1Gutters I Covers ❑EntryDocts[I
Roofing LISiding C Windows Insulation S )
❑Gutters I Covers []Entry Doors ❑
Minimum 25%Deposit of Contract Amouni due upon execution of this contract. (/
Total Contract Amount S
Maine Purchasers may not deposit more than one-third of the Contract Amount
Customer agrees that, immediately y upon complet:an 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 ary 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 Contractlor any individual Products)included herein,at
its discretion,if The Home Depot or its authorized service provides-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, /-�
Payment Summary: The Payment Summary# (q 16&° ii � 1 included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final payments by Produ (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 Hone Depot or Authorized Service Provider thrargh 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.
Acceptance and .Authorization: Customer agrees and understands that this.44reement is the entire agreement between Customer
and The Home Depot with regard to the Products and Installation services and supersc2cs 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 i has read,understands,voluntarily accepts the
terms of and has received a copy of this Agreement.
A t b : --}} Sub t V-S-blt-vs X P 1, 1 jG x I �-- 'k Cu mars 'gnaturc Date S S:anaturc Date
X Telephone No.
Customer's Signature Date I
Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS l (asappticable;
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING 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
CUSTOMER'S STATE.
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Workers
Comp ensation'Ir1�c„A.ulda-vit: Builders/Contractors/Electi-i6aas/PIumbers
AID 1)licant Inform ation' Please Print LegibIv
S
Nam,q� ss/0rgaru:ztion/Indir;dtzaI):
City/St te/Zip: ) / 'fe PbOne T:
Are you an'employer? Check the appropriate bo Type of project(required}:
1.❑ I am e employer with 4. I am a general contraeioi and I ' '
ernploytts (full and/or part-time).*
Have hired the'sub-contracto s 6• New construction
2.❑ I am a sole'propritior or partner- listed on tht attached sheet. 7. 0 Remodeling
ship and have no cmplo s These sub-contractors have g Demolition
worling for mt i*r any capacity. °mployees and have workers' • .
[No wor}ters' comp:ir.suranc° comp. insu;anc 9. El Building aadttion
r°ouirtd]' v b. .�7Jt are a corooration and its . 10.[] Electrical repairs or additions
3.❑ I am a homeowntr doing all"worl: o5cers have extrcised their 11:❑ Plu-nbi:.;repairs or additions
�; - isht of exemption per MGL 1� Roof r�pairs'
m s°1f. o word:ers .
insuranct reauired.j t c. 152, X1(4}1-'nd.we have no
"employtts. [No workers' 13,fT(Dthtr
:comp. insurance required.]
'Any box;V? r:, st air. fill out t1)'c section below shoving their workc:s' eompersation policy infomtation.
t'aom ovine s who submit: is zfzidavit indieaong hey z c doing all work and then lure outside contactors must submit a new a davitindi adng such.
tCont�e:oa that check this box must attached an adai6onal sheet show fig the tia.^n-of the sub;onta-tnis and stet-whether or not those uidn=havc
cmployr_s. If the sub-con=actors havc employees;,they must provide their worl:c s' comp.policy numb=,, ,• ,
I kni a;i employer that is providing>vor;:ers' compensation insurance for iny'employe_>S. Below is the policy and job site
• '•i`izjarmation. ' �•_,'
Irsuranct Company Na_mt:
Policy E or Stlf ins, Li c. =' 1� ✓ l/ �`7�'1 =xpi ation Date:.
JO°D Silt Address: L[✓ I ( s e "/
. ' City/StattlZip•
Attach a copy of the workers' compensation policy dtclarotion page(showing the policy numbtr and piration date).
Failurt to secure covcage as requirtd undtr Stc6on 25A of MOL c. 132 can 1^ad to tht imposition of criminal ptnaltits of a
at up to S1,500.00 and/or one-ytar impr'sonment, as well as civil ptnalrits in th^ form of a STOP WORK ORDEER and a fmt
Of up to S230.00 a day against tht violator. Be advised that a copy ofthds stat-mcnt may bt forwarded to the OEct of
Invcsri.gatiors_of the DL4 foru^surance coverage,verincation. ; • ., .— .
I do hereby c_rn f crjur,chat the information provided ebove Es 1VC dnd carrccL
--iSi�aturc _r— Dal^
Of-ia1 csc only. Do not virile in iizs agcy fo be con>.plcled by city or fDwn oficia_l.
City or Town PtrrnitlLicenst
Issuing Authority(=is=le ont):
1.Board of Yezlth 2. Building Depz.-ur:ent 3. City/Town Clerk Elt: ical 1=sp2ctor S.Plumbin;LasDtctor
6.Otatr
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:
The debris will be received by:
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
City of Northampton
Massachusetts
b
{ ., DEPARTMENT OF BUILDING INSPECTIONS 5`
212 Main Street • Municipal Building vj�4 S,b
Northampton, MA 01060 SyjY1��
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 finaU building inspection.
The building department requires these inspections before the work is concealjed, 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
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 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
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' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.1
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. 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 ervi or: ",/
Mlicable £Name of License Holder:
License Nu mber
Addre Expiration Date
Signature Telephone
M
9..Re4istered Home Improvement"Contractor:._ _ , . ;w. , __.. Not Applicable £
Company Name Registration Number
dress Expiration Date
Telephon :�
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§26C(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 '
Signed Affidavit Attached Ye .... No...... £
11.'-:Home OwnerrEgempt �on
The current exemption for"homeowners"was extended to include Owner-occupied Dwell4gss 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)saws Annotated.
Homeowner Signature.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Wi s Alteration(s) Roofing ❑
Or Doors 2T I
Accessory Bldg. ❑ Demolition ❑ New Signs [CD] Decks [p Siding[o] Other[0]
Brief Descri tion of
Work �w '/�� � �! , �� ' fZ✓C�I�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa If.New house ancle r addition to"existing h'ousinq; complete the follow>Inct:
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, in ll matters relative to work authorized by this building permit pplication.
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 e p ins and penalties of er'u '
�,,D 112 �
Print Name
i�� c 0, ' :7�
Signa re of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To IncoMplete Informatj9,[„ , q.
Existing Proposed Require by Zoning ...
This col to b;°flied in by
Building lgep"ent
x�
Lot Size { i
1
Frontage
Setbacks Front
Side L:-= R:= L:= R:=
Rear
Building Height
Bldg.Square Footage l—l�_1 —W'; % L____l
Open Space Footage t� %
(Lot area minus bldg&paved
par kin )
#of Parking Spaces
Fill: _._...__....�_._.—.w.._,....,�._.W....._... '.�. ,._..�...._-..�,_....._...�.,A____ �_..._...._ �...._.�...v...._....�.
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES 0
IF YES, date issued:i_�—_�^
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book _ — — Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES i
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: I
D. Are there any proposed changes to or additions of signs intended for the prop jerty? YES Q NO Q
IF YES, describe size, type and location: i
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 Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
�r .. t �',e vnH, tiaeparfineht use only rE t
�
wkC r 1i iii — ''44"'�y� fr r"`�—e1t iii ix 1.t x i
City of Northampton 5tatusIV PeMA"', �
E ED Building Department Gt1r)�Cut/Un�e�nrayetrril#
212 Main Street SeyrerlSeptle avail a�llity F i It t1 F M
OCT Room 100
atel $� u`dlla6ll t t
i` C orthampton, MA 01060 Twos�#safstructuFal�Pta�s
ph ne 13-587-1240 Fax 413-587-1272 PlofiSite plans seµ �n urr�' U {i
Ut>ier5 epi r� s
DEPT.OF BUILDING INSPECT1oNS
No"A - -
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -,SITE.INFORMATION
This sect►on to be completed by office
1.1 Property Address:
U
Map Lotµ Un
µ Zone ,. ,._ Overlay Dlsfrrct
.Elm St District t
CB Dlstnc
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current) Mailing Address:
�� � ���� Telephone
Signature
2.2 AutKwized ent: "
.J� �� -- ko
Name(Pr' Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit a licant
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/Inspector'of Buildings Date
61 CRESCENT ST BP-2015-0485
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D-243 CITY OF NORTHAMPTON
Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit# BP-2015-0485
Project# JS-2015-000919
Est.Cost: $1401.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 99209
Lot Size(sq. ft.): Owner: CARR PATRICIA H
zoning: URC(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT. 61 CRESCENT ST
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 3 REPLACEMENT WINDOWS
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