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PRODUCER 7MIS CERTf WATE n ISJUED AS AMATTER Of]INFORMATION CRY MO CON/IRS
MARSH USA INC. NO RONTS U►OH THE CERTIFICATE MCLDER OTME■TMM TMOfIPIOVOEO M INC
ATTN BRENDA BOOKER POLICY.THIS CERTFICATE;00ES MOT AMEMO,EXTEND OR ALTEI ME COVERAGE
3475 PIEDMONT ROAD,N E. AFFORDEO EY THE POLICE JOESCRMCI"EREW.
(404)995-2594 OFFICE
(404)760.5766 FAX COMPANIES AFFORDING COVERAGE
A TLAN TA30305 SOAP ANY
1004A2•IMASTR-RMA• RMA A STEADFAST INSURANCE COMPANY
INJURED COMPANY
THO AT-HOME SERVICES,INC B NIA
D8A THE HOME DEPOT AT-HOME SERVICES
2455 PACES FERRY ROAD NW COMPANY
BUILDING C-0 C AMERICAN HOME ASSURANCE COMPANY
ATLANTA,GA 30339
COMPANY
0
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NOrltAlW4TANONG ANY RF0 UTAEMEAIT-TERM OR pONDITTON CIF ANY CONTRACT C R OTHEN DOCUMENT WT4 RESPECT TO VMNICN T)NE CERTFICATE 1Av EE IS41ED OR MAY
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LIMITS 9.CTVW MAY HAVE REEK REDUCIE-O Br PAD CLAMS
CO TYPE OF INSURANCE POUCY MUMRER POLICY EFFECTIVE POLICY I PIRATION LRITJ
LTR OAIE IM81COIYY) DATE(RMR)DAYT)
OEMERAIL UASIRT GUFNStAL AGGREGATE f 4,000.000
A X COMMEROA.GENERAL LIABILITY IPR 3757 606-00 02/01/04 02/01/05 PRODUCTS•CCNIPP PAGG S 4,000,000
OLAMSMAOE I Gccim LIMITS OF POLICY ARE EXCESS' PERMNR a ADVIAIJURY f 4,000,000
CAWER'S A CONTRACTOR SPROT OF SIR. SI,000,000 PER OCC' EAOI OCCURRENCE f 4,000,000
FIRE OHMAGE(MY MIf IT14 S 4,000,000
MEDETIP(Amy MIM som $ EXCLUDED
X IC111OBLI LIABILITY
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EAON ACOOE14T f
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I CEIJ IIAALIT/ EAON OCCURRENCE f
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EL EACH AM DENT f 1,000,000
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D PAIITNER9EUFCLM%f 1,000,000
CFrICERSARE EXCL ELOISEASEEAONEMPLOYEE f
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CERTIVICATI HQORR MIMED W ANH MLR PAALAE TO MYL SM4 MUnCg sRYL INFO!TO OMIGTICTAI OR
u AIRiT 1 CI A4'I RIMp V l7N TIC INSAF R Af TOAOIHG CCLFRAOf.IT S AQMM OA REMF W MTATMT S OR rI*
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Double Hung - VinYl
Argon/Um C SC
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Vith Grids
1-800-746-6686
NFRC- 2001
GY PERFORMANCE RATINGS
U-Factor(US A-P) Solar Heat gain Coettfcient ry
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text Size: 44 x 60
Order 0:3744 148030001 40260 BS
i
:'l/re �ooianra�surc4t�ll a�;:'f�.a�ucc�ueeas
- Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Regtstratloet: 126893
Expiration, W=006
Type: Supplement Card
THE Home Depot At-Home Servic
MCHARD FALLONE
3200 COBB GALLERIA PKWY#20
XL,TANTA,GA 30339
Adndaistrator
ALTANTA,GA 30339 Administrator
HOME IMPROVEMENT CONTRACT
Sold,Furnished and Installed by:
Branch Name: f 7n _ Date: ���c/ THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
3 7 345A Greenwood Street,Worcester,MA 01607
Branch Number: Job#: 7 Toll Free(800)657-5 182; Fax:508-756-2859
Federal ID#75-2698460 ME Lie#C 02439 RI Cont.Lie#16427
CT Lic#565522; MA Home Improvement Contractor Reg.#126893
Installation Address: (n 3 �Y_(��U ' ' `e � /t-1 4 0 J0 o,
city State Zip
Purchaser(s): Driver's Lic.#&Es p.Date: Work Phone: Home Phone:
7v( t, f: Sc�S; S 30 2'T7 13 f I- 2-3—u (Yi515�7 i 3yy cv�b 5'x=3:it
( ) ( )
Home Address:
(If different from Installation Address) City State Zip
Proiect information: UWe/You("Purchaser"),the owners of the property located at the above installation address,offer to
contract with Home Depot U.S.A.,Ina(°Ho Depot")to ff ish,deliver and arrange for the installation of all materials as
described on the attached Spec Sheet#: rL��'yZ /1 ,incorporated herein by reference and made a part hereof.
Home Depot reserves the right to cancel this contract f,upon re-inspection of the job,Home Depot determines that it
cannot perform its obligations due to a structural problem with the home or because work required to complete the job
was not included in the contract.
DEPOSIT PAYMENT OPTIONS
-7 (Subject to fund verification and/or credit approval.)
CONTRACT AMOUNT s 3�/ L� 1. Check,Cashiers('heck or e Postal Sen lee Money Order
(blade payable to The Home Depot).
*LESS DEPOSIT $ N 2 Credit Card*and,,or other payment options-Circle One Below
Visa MasterCard Discover American Express
BALANCE DUE i
ON COMPLETION S The Home Depot dome Improvement Loan The Home Depot Credit Card
Available Credit:S (HLL&HDCC ONLY)
*Minimum 25%of Contract Amount due upon execution
if this contract. Acct#: Esp.Datc:
Name as it appears on
Indicate Payment Method For *By my/our signature below,t/we agree to allow[ionic Depot to charge the above
BALANCE DUEn ON COMPLETION: referenced credit card for the deposit indicated.
Cardholder's Signature Date
HII,or HDCC Authorization Codes
Deposit Final Payment
# #
Purchaser agrees that,immediately upon satisfactory completion of the work,Purchaser will execute a Completion Certificate
and pay any balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder.
Entire A rreement:This agreement and its attachments,including any financing agreement,contain the complete agreement
eavee i the parties and can not be amended or modified unless in writing in a separate agreement signed by both panics.
NOTICE TO PURCHASER
Do Hot sign this contract before you read Et. You are entitled to a completely filled-in copy of the contract at the time y'ou sign. Keep
it to protect your rights. Do not sign an Completion Certificate or agreement stating that you are satisfied with the entire project
before this project is complete. Law prohibits home repair contractors from requesting or accepting a Completion Certificate signed
by the owner prior to the actual completion of the work to be performed under the contract.
You map cancel this transaction at any time prior to midnight of the third business day after the date of this contract. See Notice of
Cancellation for an explanation of this right. There will he a service charge equal to 25%of the contract amount if the job is
cancelled by Purchaser AFTER the third business day.
BY MYOUR SIGNATURE BELOW,1/WE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. IiWE AC'KNOWLE'DGE
RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATION.
BY MY OUR SIGNATURE BELOW, UWE UNDERSTAND THAT THE AGREEMENT IS SUBJECT TO REVIEW OF MY-OUR
CREDIT HISTORY AND UWE AUTHORIZE HOME DEPOT AUTHORIZED CON"FRAC'TOR,TO VERIFY AND REVIEW MY/OUR
CREDIT RECORD WIT AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL LIABILITY
INCURRED FROM IN. .RTENT O IONS OR EKRORS.
SUBMITTED BY: ?'7� Date:
.ACCEPTED BY: Date: __
omwwner
Dote:
J011lek—ner
NOTICE:ADDITIONAL.TERMS,CONDITIONS AND WARRANTIES ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT
White-Branch File Yellow-Customer Pink-Sales Consultant
a: o
5-18-04 C-SC y
Z
I�ASSAL}tli4ttt4 -
Y of Northampton
x
DEPARTMENT OF BUILDII\G INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
North,unpton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as l:is/her construction sup<":vi sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two farm _
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 fegulations. 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 buildine 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.
Daze
Address of work
location
i
i
-
`� Crif of Porflia)itP1011 - —
gf -El x:$S cchntcIIs'
o DEPARTMENT OP BUILDING INSPECTION's r
212 Main Strcet - Municipal Duilding
Northampton, Mass. 01060
«'4R.CERIS Co,\IIPENSA770N LNSURANCE AITl7)AVI-1"
I
�i perm�ttcc)
\trith a principal place of businessfresidence at: - --
�-lt�
(sa>~t/cat}'/sZatcfzip)
do hereby certify, under dic.patns and penalties of pc>7ury, hat
I am an employer providing die following itvorkcr's comocnsado cove age for lily
emplovices worlong on this job:
dde
(I=U-ran=Coorzzy) (Polio: Nu--z�cr) (_ i tion
Dzt^.
( ) I am a sole proprietor, general contractor or homeowner(ci tie one) and have hired
t_he coau-actgrs listed below vgbo have the following worker's coO- perLarion policies:
\`+flfI1C Oi Co^':acior) (InStrant: CojnoaT]}'f-!GUCi ?�tL12I1LC:) �_?:JIiJ Q Datc)
(Name of Cootraor) (Ins-ara.nec Comoaa`vPo!ic- Numcrr) (L»it-bon Date)
(Name of Coacmcro;) (insura.ncc Compan)-fPoliq- Nambzr) (Expifsrioa Datc)
(1`'2tne of Cootrdetor) (Lnsuran(r Company/Policy Numb r) k p� -doo Date).
(aaac3 ad�i�oczl i'xc,ifncca.�-to mcvcL iaforn�:ioc perin.iniaS to.0 ccc=-=nn) -
{ ) I am a sole proprietor and have no one worf3ng for me.
( ) I am.-a home owner perform- all the work myseif.
NOTE:plea be eP zrL t4*•�.1 Je k�emrn even..bo cr�toY Pezom u& ='.=e oa c rrau w-oric ca a d-,J1:-L of
not moot than L�:c tnt r in«$icb the bomcowoc raid=oc oa the p-o..,.c,zppvrtcO=t , �--ar-Uy oc,&-cd m Uc beev ooc
cirptoy=3 trade the Act(GO 52,=1(5)�:-ppritabon by a bomeo-oa for a Gc=__or Parmit rr_y e%idcO=tl e
Icgs1—of en errloyx uod.cr ttto W--k--c A�
I uadcszyod tha a*In of thi.mt--m.y b.foc-,.ord.d to tb.D,9ortmac¢of Ivdu icl.A—d.aty Off,=.or t,>tir.00e far Lt.
°7YC7�VcriGc=ioa-d a-L-ittae w sceu+=bO-- a u n&--=czion 23A of h(GL 152 c=tad to the impwu on of aic i peailsir
coa—ma of a fiat orup to s 1.�oo.00-nd/or o(up to ooc yc-r iod ci,t p=xp�a is dS room or.Stop Word ordc and a
Gm o(S 100.00.day a Xinzt
For&p-=m u+c onJY
Pcrmit NUMLcr
map.- Lot '
S Unaturc ot Ltc--Mscr crmiucc e )
SECTION 8-CONSTRUCTION SERVICES t '
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
S.Recsfered.Home.lmiiiayement Cartt`r`actor 5 ^ � Not Applicable ❑
Company Name Registration u er -- -
-I Cipnl L kt uo
Addaes s d , y Expiration at
D �.. Cti �(�/ Telephone'-i���3��
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVif(M.GL.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....... Q1 in No...... ❑
1 . { onre Owx>nergemai>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-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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicableY
New House [] Addition [] Replacement Windows ration(s) Roofing
Or Doors F-1
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[C]] Other[C7]
Brief Description of ProposecL
Work: t
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa .ff=Nevi kro`use'�and�iic�ctdr�ia�r�a��x�stln��Eiousnct..�cornp�tete thefiatfQV�ing:
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 ORCONTRACTOR 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, as Owner/Authorized
Agent here y 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 pai and penalties of perjury.
L
Print N e
:)J)44A)'L_
Signature f Owner%e t Dat
Section 4. ZONING All Informatioh 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:f--_ ` L R.=
Rear
Building Height
Bldg.Square Footage I j i %
Open Space Footage �_— % I -----
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume-&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q 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; w and/or Document U
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T 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 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 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 Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
. wt
c .Y
City of Northampton Sta
Building Department Cirb e ,
ain Street we 5e twit►
om 100
r�pton; 'MA 01060 0 e s o 5� �tar►ss
phone 413 5874l1t40 Fax 413-587-1272tetanv�
r
n !1� �..'`� � �,ft18 Ca�?IIeG►fyti1 A'" "��n�t' a�„�,Mr ry«3r������2.� .���
APPLICATION TO CONSTRICT, lLTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -
1.1 Property Address r`= Thrs sect►on to be completed lay office
NMap Lot tJn►t
`� � , +� � Zonie Overlay Drstrrct
C�
D,
SECTION 2-PROPERTY!OWN ERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailingss `
— ('63 W "
1
Telephone
Signature
2.2 Authorized Acient.
Nam Pr t Current ailing Address:
I Cf ��(��i
Si u a at Telephone
SECTI N 3-ESTIMATED CONSTRUCTION COSTS
Item . Estimated Cost(Dollars)to be Official Use Only
com I ed 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. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
'
'Date
Building Permit Number..' Issued:
Signature:
Building Commissionerlinspector of:Buildings= Date
63 SHEFFIELD LANE BP-2005-0494
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mag,;Block: 17C-041 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-2005-0494
Project# JS-2005-0649
Est.Cost: $3274.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICESL 126893
Lot Size(sg.ft.): 15725.16 Owner: SASS JONATHAN R&CHRISTINE S
ZoningURB Applicant: HOME DEPOT AT HOME SERVICES
AT. 63 SHEFFIELD LANE
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935-2633 () Workers
Compensation
WORCESTERMA01607 ISSUED ON.10121104 0:00.00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 8 SQ FT
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 Occupangy SiLynature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 10/21/04 0:00:00 4311 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo