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32C-301 (2) Mar 19 15 06:05a P.1 HOME IMPROVEMENT CONTRACT PLEASE READ THIS ;-- `� Sold,Furnished and Installed by: Branch Name:Boston North 8:South Date: THD At-Home Services,Inc. dlb/a The Home Depot At-Home Services Branch Number.31 and 33 908 Boston Turnpike,Unit I,Shrewsbury,MA 41545 Toll Free 877-903-3768 Federal M#75-2698461 ME Lic*C 02,434,Rl Cont.LiC#1642' CT iic N HICAt565{�22.M.��,om^c Improver feat Cvotractya�/Rey#(26893 Installation Address: t `� (1)i�a a � f t'I.� City SAC Zip PterhaseKs): Work Phone: Horne Phone: CeU Pbone: Home Address: (If different from Installation Address) City State Zip E-nutil Address(to receive project communications and Home Depot updates): ❑I DO NOT wish to receive any marketing etnails from The Home Depot ProjT ect IMormation: Undersigned("Customer"),the owners of the propeny located at the above installation address,agrees to buy. and H At-Home Services, Inc.(-Re Home Depot )agrces to runtish,deliver and arrange for the installation("Installation")of all materials described on the below and on the references!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 ne'—i Products: spm sheet(s)# Pro'ctAmotmt Routing Siding El Windows Insslatiun J OCuicers/Covers OEnu y Dix rs ❑ Rooting Siding 0 Windows El in.uiation { / ©Goiters/Covers 06ntry Doa.; O Roofing Siding Windows 0(nsc:lat"on OCutters/Covers ❑Entry D+xxs❑ $ -CIR—en6rig Sidinz Wind( Insulation QGcttcrs f Covti❑Enuy Doors ❑ Wahnum 25%Delius[of Contruct Amount due upon meadion of this contract. Total Contract Amount $ Maw Pumhasers noy not deposit more than one-third of I.'te Contract AmnuN, Customer agrees that,immediately upon Completion of the work for each Product. Customer will execute a Completion Certificate (one for each Product us defined by an individual Spec Shect) and pay any balance due. As applicable,each Customer under thi% Contract agree,to be jointly and severally obligated and liable hereunder. The Nome Depot re,4:rves the right to issue a Change Ordu or terminate this Contract or any individual Producl(s)included herein,at its discretion,if The Home Depot or its;t_tthori2ed service provider determines that it cannot peribrin its obligations due to a structural problem with die home.environmental hazards such as mold,asbestos or lead puinl,other udcty concerns,pricing errors or because work requivW to complete the job was not included in the Contract.` Payment Summary: The Payment Summary#. C,W t incluckd as pan of this Contract,sets birth the total Contract amount and payments requir«t for the deposits and rinai payments by Product(as applicable). NOTICE,TO CUSTOMER You are entitled to a completely tilled-fo cope-or the Contract at the tirne you sign, Do not sign a Completion Cert3ticate(note: thuxe Is one Completion Certificate for each])sled Product as defined by individual Spec Sheets)before work on that Prod net is complete. In the event of tertnination of this Contract,Custorer agrees to pay The Horne Depot the costs of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other amounts set forth in this Agreement or allowed under applicable late. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE[TOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUMMS. &C-"and Autl `nation: Customer agrees and understands that this Agreement is the entire agreement between Customer and me Depot with er�gard 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 be assigned or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and agrees that Customer,I ;read,understands,voluntarily accepts the term.of and has rueived a spy of this A;reeracnt. , 11, t Accepted by: //- Submitted b X Cimomer'sSignature ate 3f/,F/,�5- Sales Consul tan ys d ature Date Telepaone No. CusomeCs Sigtrature Datc Sales Consultant License No, CANCICLLATION CUSTOMER MAY CANCEL THIS tp,.tprtcan l AGREITgENT WITHOUT PENALTY OR OBLIGATION ' BY DELIVERING WRITTEN NOTICE TO THE HOI~fE DEPOT BY MIDNIGHT ON THE THIRD BUSINESS iI DAY AFTER SIGNING THIS AGREENWNi T. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAIV IN a y 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 byrMMGG-L�c 111, S 150A. Address of the work: The debris will be transported by: �-le!5 T.,r_ Ar7-k " be received by: The debris will Building permit number: Name of Permit Applicant Date Sign-ature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Off lce of Investib ations 600 Washington Street Boston,M4 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information _— Please Print Legibly Name (Business/organizaboaqndividual : Address; City/State/Zip: Ail, hone '.IV -- ,v - - 1 - / f Are an employer? Check ropriate ba Type of project(required); am a employer with 4, am a general contractor and I 6 ❑New construction employees(full and/or par-time).* have hired the sub-contactors .❑ J am a sale proprietor or partner- listed on the attached sheet_ « ❑ Remodeling ship and have no employees These sub-con:;actors have S. ❑Demolition working for me in any capacity. workers' comp, insurance. g, 7 Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.71 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑Pium inn repai'; or additions myself. [No worker' comp, C. 152, �1(4),and we have no 12.❑Rgot repairs insurance required.]t employees. [No workers' comp. insurance required.] 'Any applicant that checks box#I must also fill out the section below showing their worker'compensation policy infomtation. t Homeowner who submit this affidavit indicating they are doing all work and then hie outside contractors must submit a new affidavit indicating sueh. ;Conn-a:.tors that check this box must attached an additional sbcet showing the name of the sub-contra:tors and their workers'camp.policy information, I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and fall site information. Insurance Company Name: Policy r or Seif-ins.Li--.Y: Exp atian Date: 53)) .lob Site Address: ;�- Attach a copy of the workers' compensation policy deciaration page(showing the policy number and ea tion date). Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead to the imposition of criminal penalties of a fine up to`01,500.00 and/or one-year i,-nprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 c under a poi d p les ry that the information provided above ' true and correct Sienature: Date: Phone x: 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 s.Plumbing Inspector 6. Other Contact Person: Phone : SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Super rviissor1: a�� /�7 Not Applicable £ Name of License Holder: 1�' `AVA ✓ � e:.)�� ?&-4 License Number �► f ' - � � Address ` �� Expiration Date Signature Telephone 9 Re istered Home Im `rove nt Contractor `` Not Applicable £ 22 Company Nafne �� Region Number Expiration Date Telephone ,:?0 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§25C(6)) Workers Compensation Insurance affidavit t be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the bui permit. Signed Affidavit Attached Ye ...... £ No...... £ 11. -`Hame Owher.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-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 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 Windows Alteration(s) F7 Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Sidin Other[p] Brief Descri tion of Propo d l `- ap��W ork: y })0 T i Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a, 1 0 New€house and"or.adc9 Lion to'exisf'ng.h"ousing, cornptete t1�e 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. 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 J as Owner of the subject property , hereby authorize to act on my behalf, i all matte-La-relative tow authorized by this building permit application. , 3 Signature of Owner Date i as Owner/Authorized Agent hereby d6clare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under"ins ins a. penalties of per' k ► a� Print Name A,I rte. Si e of O ner/Age Date ^ ^ Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information ^ Existing Proposed Required by Zoning Ibis column to be filled in by Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg.Square Footage Open Space Footage (Lot area minus bIdg&paved of Parking Spaces (volume&Location) A. Has a Special Perm /Variance/Finding ever been issued for/on the site? NO 0 D0N7KNOY 0 YES 0 |F YES, date issued:| IF YES: Was the permit recorded at the Registry ufDeeds? NO �.� } D YY YES � IF YES: enter Book Page and/or Document# B. Does the site contain abrook, body of water nrwetlands? NO 0 DONTKNOW 0 YES - IF YES, has permit been or need to be obtained from the Conservation Commission? Needs to be obtained ^~� Obtained x—� ' Date Issued: �� C. Do any signs exist on the property? YES 0 O 0 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, gradingexcavation,or filling)over 1 acre orioit part ofu common plan ' that will disturb over 1acre? YES NO ) IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ` ' Depart ert use onl � Y [;CEI Ep ity of Northampton uilding Department 212 Main Street 2 6 2015 Room 100 �lVaterellAvatlabihty . .:. No thampton, MA 01060 UT Sets ofS#ructutal Plans oEnr or nu t nin;IN' p7l`ib4413 587-1240 Fax 413-587-1272 Plof/Site Plans MvRTl-L !:FJ,A4KC9 �i� - �_..N.�._.v._. _ Other 5pedifjF x3 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This sectrorr to be completed by office 1.1 Property Address: I _Map Lot Unit ! vp = { =Zone : OvertaX D�strect Elm St District CB District - -. SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 O,wrmr of Reco d: Name(Print) Current Mailing Addr s: `, � �� Telephone Signature 2.2 Autb=ized A ent: if A Name 7(P Current Mailing Address: Si ature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS. Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building r (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=0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit NUmber: Date Issued: Signature: Building Commissioner/Inspector'of Buildings Date 21 VALLEY ST BP-2015-0905 GIs#: COMMONWEALTH OF MASSACHUSETTS MM:Block: 32C-301 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-2015-0905 Project# JS-2015-001742 Est. Cost: $17832.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(ss .ft.): 6708.24 Owner: CRONKITE HERSCHELL A Zoning.URC(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT. 21 VALLEY ST Applicant Address: Phone: Insurance: 5 RIVERVIEW DR (401)935-2633 Workers Compensation NORTH PROVIDENCER102904 ISSUED ON:312712015 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE VINYL 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 3/27/2015 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner