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12C-087 (2) I� '`;���/(r Sold,FufritAed eitdiTista1led'by: Brandt Name: �����.� Date: Q THD At-Home Services,'Inc. 7-7 d/b&The Home Depot At-Rome Services - 345A Gttt(mwood Street,Worcester,MA 41607 Branch Number: Job th Q Toll Fteg{800)657-5182; Fax:508-756-2859 Fedead ID#75-26�t460 ME Liz#C 02439 RI Cam.Lich 16427 C'r Lie#565522; MA tfomc Improvemaot Contractor Reg.#126893 Installation Addrus: tJ j City State Zip Pn rchaaer(s): Last 4 IN to of Driver.. .. Lie.#& x .WYE-. Work Phone: Home Plane: { } ( } Home Address: (If different Liam Inatatlatiop Aresr) ity, state Zip T Erman Address(to receive:upd9tm and pnimotions from The Ionic Depot): Project Information: I/WerYou(^Purchaser'),the owners the property Located at the above installation address,otter to contract with THD At-Boa*Sel-ices,Inc. "Home Depot's to furnish,deliver and arragge for the installation of all materials as described on the attil'8pec Sheet# incoeporated hercifi by reference and made a part bcveof. Home Depot reserves the ogittto cancel this coorl It u Pon re=inspection of the job,Home Depot determiner that it cannot perform its obliglritonaWilie to a structural problem with the home,pridlog errors or because work required to complete the jab was not_iiyelu*A in the Spec Sheet or Coal ct. DEPOSIT(PAYMENT OPTIONS (Sabiecl to filed milicaliou anNor crodit approvoiJ CONTRACT AIKOUI T Check-,Cashlen Check to 1k5 Postal Service Money order (Meefc payable to The Home t1cpot). tLE.SS DEPOS,T S 2. tAedit Card—snoVotr other ps)ment gateau.Ctttre()re Below BALANCE;DUE C() Visa MasterCard Qiieove• Amedee t EVreu. ON COMPLE H(* '-S «J t5 'fame Depot Homo tmpmvMett Loom The Home Depot Credit Cmd tMinimum 25%of Cotllilactjkutotsat due upon 0 fevrAv eottnt *her Aecoena (Hn.oil HDCC ONLY) execution of ibis c"tract.- ,t - - iAe.IFl�bl4tdi3'• i11iL ds HDCC ONLV) Indicate Ac BALANCE DUE ON COWLETION: — r Rap.Dotc - No sc as it appern on end: •• lly mytour signature bcI0*I/W a agree to allow Dome Depot to 035 3 18 �7 3 3�� c �Verefb d xedit card for the cape i1 iodic tail. •Wlteu you prmide a check or pYymMl,you emhol at tithe to use information fmoo your oleo$to mffite a one-time electronic " e fend mor afa from your account or to process the payment as a chedt tnnuctitn.wsmt vre usell6wrtet:on from year chock W AIL nT IIDC Authorization Coded onake an elersroaic fond transfer,;Aatde;may be withdrawn ftm your.account ae stories to peylri.i is:�eived,and yeu will net Deposit roetivt your check tank. - Final Pa went 4 Q # Purchaser agrees that,imttu4diatity upon ion of the wol r,,Purruhaser will elxccut*.p Completion Certificate and pay any balance due. Purchaser atu&vF*ss to be=and severally ligsted and liable hon-u*et. Eptlr'e Anreemerit:This aWeeroent and its attachments,inclu ling any Stlancing agreetjtent,cooWn the complete agreement between the parties 41l cannot 6 amended or[modified unless d writing in a separate agreement signed by both parties. NOTICE TO URCHASER Da not sign this contract. eye you read it. You are enthial a completely finejlitin w of the contract at the time you sign. Keep it to pr $lour rights. Do not siga a n Certificate Were this project is complete. Law prehiblts home repair a�r[Yom t�gsest[ttg or . ettg.a'Completto t Cer�Mcate signed by the owner prior to the actual completion oft ` tvrk to be performed racer th contract You may cancel this trsn*ctlon any time prior to midnigh the third business da�+after the date of this contract. See Notice of Cancellation fog an.4iiphtnattoa of this right. re will be a service charge equal to 10%or the contract amount If job Is tunnenedlby ftrehaaer AFTER the third day,but BEFOG$materials are ordered.There will be a service charge equal 2 /.of Lire aoatraet amount it b-cancelled by Prrch4ser AFTER materials are ordered. SY MY/Olrit SIGNATUR},BULOW,11WE UNDERSTAND T THE AGREBME14T MAY BE SUBJECT TO REVIEW OF MY/OUR CREDIT !#STORY AND IIWE AUTHOR( HOME DEPOT TO VERIFY AND REVIEW MY/OIIR CREDIT RECORD WITH:AN INDEPENDENT CREDIT R 'PORTING AGENCY AND RELEASE,THEM FROM ALL LIABILITY INCURRED Fj[O[yL INADVERTENT O.WSSI() S OR ERRORS. BY MYIOUR SIGNATU U ALOW, [AVE AGREE TO Bi BOUND BY THE TEAMS OF THIS CONTRACT. I/WE ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONT ACT AND TWO CON&LETBD COPIES OF THE NOTICE OF CANCELLATION. 1 SUBMITTED BY: xLAb`r I Date: Corso _—..-'....-- _.. ACCEPTED BY; Noo Date: 19irch.. NOTICE:ADORTIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART 01'MIS CONTRACT 6-1-07 1ev 4.2.07 C-SC Wtdte-Brandt File Yellow Culgorrlar Plnk-6alea Ceinsullara C; -C1 }geld 1317N3SU I dH WUSO :9 8002 T Z I nr i 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 sour) 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 r i The Commonwealth of Massachusetts s 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 Leaibh, Name (Business/Organization/Individual): _ Address: rrJ City/State/Zip: Phone#: A�7am n employer?Check the appropriate box: Type of project(required): 1. a emp loyer with_D(„_ 4. ❑ I am a general contractor and I 6. ❑New construction employees (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 working for me in any capacity. employees and have workers' 9. F-1 Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.Fj Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.7 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. ther�A� ([r) 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 insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: 2tA t IG►YYl f1 !(-P ,LN?S �C� Policy#or Self-ins. Lic. #: 19755 Expiration Date: J / Job Site Address: a RICV City/State/Zip: 11Ce I W�- 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 d e p ns and penalties of perjury that the information provided above is true and correct. Signature: Date: -�Z)l log Phone#• O.frcial 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#: { L SECTION 8-CONSTRUCTION SERVICES s 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9. Registered Home Im rovement Contractor:. Not Applicable '❑ Company Name Registration Numbe Address ©1 b07 Expiration Date ( i Telephone 14D 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 buildi permit. Signed Affidavit Attached Yes....... No...... ❑ I. - 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-vear 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 s SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Win s Alteration(s) F7 Roofing F7 Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[0] Other[O] Brief Description of Proposed r Work: fi Tn4 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housin-g, complete the followin 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 1, "'( 1 DI , as Owner of the subject property hereby auth �.. to act on in all matters relative to work authorized by this building permit appli tion r Sign of 0 ner 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 under the pains and penalties of perjury. Print Name i. Signature of 0 ner/Agent Date f Section 4. ZONING AR Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information t Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front � Side L R:.... . .._s L:'...,.__. R ..,., Rear Building Height Bldg.Square Footage -- % Open Space Footage ° (Lot area minus bldg&paved #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 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 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , 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 Q NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. i Department use only >' City of Northampton Status of Permit_;-. Building Department Curb_Cut/Driveway,Perm+t 212 Main Street SewerlSeptic Availability Room 100 WaterJWeil Availability Northampton, MA 01060 Two Sets,ofStructurai Plans phone 413-587-1240 Fax 413-587-1272 Plot7Slte Plans r- Other Speclfyr (; } APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING AUG �008 SECTION 1 -SITE INFORMATION This sectioln to bebreted by offpe 1.1 Property Address: F, Map Lot _.. Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _ Name(Print) ' Current Mailing Address: Telephone Signature 2.2 Authorized A e Name(Pr t) Current Mailing Address: 40 r Si g n1aTL a Telephone SECTION 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) 23603 C /-L) Ov 5. Fire Protection — 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: IIsssued: Signature: Building Commissioner/inspector of Buildings Date BP-2009-0125 G"t S#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2009-0125 Project# JS-2009-000158 Est. Cost: $1588.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES Lot Size(sq. ft.): 10018.80 Owner: JONES ELIZABETH E Zoning: URA/WSP Applicant: HOME DEPOT AT HOME SERVICES AT. 28 RICK DR Applicant Address: Phone: Insurance: 345 GREENWOOD ST UNIT 1 (508) 341-9401 WORCESTERMA01607 ISSUED ON:81512008 0:00:00 TO PERFORM THE FOLLOWING WORK.-4 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 8/5/2008 0:00:00 $25.0023603 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo