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12-017 (2)
Sold,Famished and Inscalled by_ Drano Namet Boston Date; Q,141_P6111 THD At'Home So vices,Inc. dRt/a Ttre home spot At Home Scrvicet Branch Number-. - $ASA utcaawoad Street.Unit 2,Worcester.MA 01607 ` E]N'orth 33 14vtl,31 Toll Free(9000)657.51$2; l~art(508)756-9823 Federal t U#75-2698460;Iv E Lie#C 02439;R1 Coat LSc#16427 n , CT Lic#S65522;MA Hw-improvement C mactwr Reg.#126893 )<nsrstluuon Addxras: (%A t11r!e arty .su tc Zip Peehuser(s): 'Work P6oae: Hoare Ptieaae Cell Yhoee: Home Address_ , (It diftreut from fnstallation Addrfts) city Scatc .Zip �rz / T-arms Address(to receive pmjeet communications aced Home Depot updates): �/ ❑I DO NOT wish to receive airy marketing emaiis f-om The Howe.Depot b9k Undcrsigasd("Customer"},the owners of the property located at the above installation address,agrees to buy, acrd THD At- ome Services,InC.("The Houle Depot")agrees to fWaish,deliver rmd arrange for the installation of ail materials described cm the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by tws Tefcrenoe,along with aqv applicable State Supplement and Payment Summary attaahad hereto and any Change Orders(collectively, "Contract"): fob#: Amemd P"anets: Spec #: Pro Amount rr8 Siding VTindows krsulanon $ a( f552- c boors ❑ hoofing L]Sidiog L3 Windows U insuistion $ C]Oatters l covws; CIPA"Door. Cl—._ a-Ro-f-g priding Vriudeas insulation ©o„nmt I CaVcm ORMry Doors E1.-.- okooimg osiding ET winnows n lnantatlm $ QGutmrs/cavers 0&tly boors C-i lyliidwrrm 251A])4100 of Cootraet Amos at due apm®ec>rtisrt otthhs midracR Total Contract Amount S Maine hadiams may sot depwit more than onb4WVd of tie CouWirtAmottat. I Custor'ncr agrees that,immediately upon completion of the work for each Pmdnet.Customer will execute a Completion Certificato (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 rewrves the n&to issue a Cbange Order or terminate this Contract or any individual Product(s)included herein,at its diame cm.if The Borne Depot or its authorized service provider detaminas that it cannot perforna its obligations due m a structural problem with the home.environmental hazards such as mold,asbestos or lead pram,other safety concerns,pricing earns or because work required to oomplcto the job was not included in the Cantmt- Pa tit Snmmarv; The Payment Summary# � �J' included as part of this Cormaet, sets forth the total Contract amount and payments mqurrcd for the deposits awl 1oal payments by Product(as applicable). NOnC)E TO CUSTOMER, `Y'ou are entitled to a completely>]]W-in copy of the Contract at the tide yon stipn Do not sign a Completion C-Ca ticate(note: there is one Completion Cerefieate for each 110M Product as dermed by mdlvidnal Spec Sheets)before work on that Product I, iS coraplete. lln the event of termination of this Contract,Customer agrees to Thv Ronne D ppot the costs of mataerikla,lobar.expenses surd services providod by The Houle Depot or A.ntheriwil Service Provider throaglr the date of termination,plus an other amounts act forte in this Agreement or aborted ender Applicable law. TUE ROME DEPOT MAY VVn7EMOLD AMOUM OWED TO T9E HOMF: D)Emr FROM THE DE"IT PAXMENT OR OTMR PAYMlENT5 MArifE.VATHOUT L1 STING TE(R HOME D)EPOTIS OTFCER REMED19S FOR RECOV)RRV OF SUCK AMOUNTS, Ace,lotance And�Autori_zation; Cusoemer agrees sad understands that this Agreement is the entire agreement hetw e t Custon- an Tlr a ;omc epotfi t with regard to the Products and histallati n.services and mpersedts all pion discussions and agrec,ments,tither oral or written,relating to said Products sad brstsllatian.This Agreement camrot be assigned or amended except by d writing mgoed by Customer and The Nome Depot-Customer w1wowledges and agrees that CustomCr hay read,understands,voluntarily scopes the terms of and has received a cagy ofthis Agreement Aecep Dy: ���- Snbmftfi y: Customer's Signature Date Sates Conwdta,u.'s S tore Date x _ Telephone No. — — - Customer's Sigaanrre Date Sales CcrosWunt License No. CANCELLATION: CIUSTOMER MAY CANCEL 'TfT'[S Opp AGREEMENT WITHOUT PENAL'T'Y 012 OBLIGATION DY VeLIVERING WV1TTF.N NOTICE TO THE HOME DEPOT BY MMMGHT ON THE TKMD BUSINESS SDAY AFTER SIGNING THIS AGR1?EMENT. THE STATE "PLEMENT ATTACKED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSrO 'S S'TA'TE. .N1bT1L'E:ADDLTIQNAI.'f"MS AND CONOMONS APE STAnD ON TUC REVEu17SE-SWE AND AM PART OF rkm COh1TRAcr' 10-4-08•ev4$-05-0a C-Sc 13itnchF1e Yelbw-Cuatpmer PMrk-3alesCOnsuaant" 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 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 z The Commonwealth of Massachusetts Department of Industrial Accidents .4 Office bf In vestigations 600 Washington Street _ Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: one#: �-- Are y an employer?C ec t e 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 propri etor 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 are a corporation and its 10.F-1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.E]Plumb' repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Ro repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. they comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners 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 insttrance for my employees. Below is the policy and job site information. e ----- Insurance Company Name: I _ Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: f Attach a copy of the workers' compensation o icy decla ation page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of GL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 andlor 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. 1 do hereby certify and r t p 'is a pe alties of perjury that the information provided bone 's true and correct. Signature: Date: Phone Vii- U;ficial use only. Do not write in this area, to be completed by city or town official Citv 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 Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Reg istered Home Irn roVemenf Contractor. _.' Not Applicable ❑ Company Name Registration Numbe Addres Expiration Date 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. Failure to provide this affidavit will result in the denial of the issuance of the building pwr6t. Signed Affidavit Attached Yes....... No...... ❑ 11. -Nome Owner Egemptl©n` 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 Win s Alteration(s) E] Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[0] Other[[3] Brief Description of Proposed i Work: fiur) Alteration of existing bedroom Yes No Adding new b6tlrn Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition toexisting,housing,corn`"fete the fotfowin 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 all matters relative to work authorized by this building permit application. Signature of Owner Date I, P / 'Pf iJl as Owner/Authorized t t e Agent hereby declare tha statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under thp4kkys and genalties of perjury. Print me S of 0 rl gent �� 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 Frontage Setbacks Front Side L.'_.,__..._. R..,._.___ L: .µ......._ R Rear Building Height ° Bldg.Square Footage % _ _...,. Open Space Footage ° (Lot area minus bldg&paved m -�- parking) #of Parking Spaces - '-• "•• Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document# 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 0 , Date Issued: . C. Do any signs exist on the property? YES 0 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. 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Dp4[k r City of Northampton Statukof Perm{t� Building Department Cri txput/Dhyeway Perrrirt u 212 Main Street ue Sevr/RepfcvElafltty � � , Room 100 WaferfWeil Availability Northampton, MA 01060 V€aI Plans i phone 413-587-1240 Fax 413-587-1272 Matte>=ians ©thee Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot Unit tZone Overlay District Y11 Elm:St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing ddress: rtl�� Telephone Signature 2.2 Authorized nt: F,Av 014 Nam (Pn t) Current Mailing Address: / l (�� atu f a Telephone SECT 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed 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. Totai= (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 k° BP-2009-0647 GIS#: COMMONWEALTH OF MASSACHUSETTS ; 2- I CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildir;_q DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:REPLACEMENT DOOR BUILDING PERMIT Permit# 13P-2009-0647 Project# JS-20109-000707 Est. Cost: $1771.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 126893 Lot Size(sq. ft.): 2304:x.24 Owner HESTON FRANK C&ANNE Q Zoning: RR/SR(100)//W'SP Applicant: HOME DEPOT AT HOME SERVICES AT. 19 COUNTRY WAY Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341-9401 Workers Compensa-tion WORCESTERMA01607 ISSUED ON:112012009 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE FRONT ENTRY 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 Occ.l ancy si nature: FeeType: Date Paid: Amount: Building 1/20/2009 0:00:00 $35.0025334 212 Main Street,Phone(413)587-1240,Fax: (413)5874272 Building Commissioner-Anthony Patillo