36-299 (3) May 0215 06:29a P•1
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Furnished and Installed by:
Branch Name:Boston North&South Date._/ / THD At-Home Services.Inc.
dub/2 'Me Home Depot At-Home Services
Branch Number:31 and 33 903 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free 877-903-3768
Federal ID#75-2698450;ME lie 4 C 02439;RI Cent.Lic#145427
CT Lie#HiC.0565522;MA Horne Improvement Contractor Reg.#12k893
InstallationAadress: tJb� t� nA �t 0 p Fl aN� �IA 0106
City State Zip.
Pmbmer(s): Work Phi; Hone Phone: Cell Phone
Horne Address:
(If different from Installation Address) City State Zip
F—mail Address(to receive prorjea communications and Home Depot updates):
❑1 DO NOT wish to receive any marketing cmails from The Home Depot
Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to bay,
and THD At-Horne Services,Inc.("Me Horne Depot")agrees to furnish,deliver and amtage for the installation(`installation")of
all materials dcscribod on the below and on the referenced Spec Shecl(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#: awrnw xdwv ) Products:
fI Spec Sheens #: Project Amount
Boong Siding Windows Insulation
�} []Gutters l Covers N rs C3 ZA
Roofing Siding Windows Insulation ,XXY
[ironer-/.Covers ❑Entry Doors ❑ S
Roofing ElSiding C1 Windows (itsnlation �
❑Gutters/Covers ❑Entry Door El $ ��,
Boating Siding Windows 0 Insulation
❑Gutter,/Covers❑Fnuy Doors ❑ $
Minimum 25%I)epask of Contract Amount due upon execution ofthis contract
Maine Porelrasers may not dcprxit more thm one-third of the Contruct Amour Total Contract Amotmt $ �+
Customer agrees that immediately upon completion of the work for each Product-Customer will execute a Completion Certificate
(one for each Product as defined by an individual Spec Shea)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 reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,ifThc Horne Depot or its authorized service:provider determines that i!cannot poform its obligations due to a structural
problem with the hone•environmental hazards such its mold,asbestos or lead paint,other salety concerns,pricing errors or because
work required to complete thejob was not include d in the Contract. ��11
Payment Summary: The Payment Summary# , included as part of this Contract. sets forth the total
Contract amount and payments required for the deposits and final payments by Product(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 wont an 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'llte Home Depot or Authorized Service Provider through the date of termination,plus any other
amounts set forth in this A-regiment 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 I'Olt RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Customer ag-rces and understands that this Agreement is the entire agreement between Customer
and The Horne Depot with regard to the Products and Installation services mid supersedes all prior discussions and acrecrue ts,either
oral or written,rda4--to said Producti and Installation.This Agreement cannot he asS12ned or amended except by�a writing signed
by Customer and The Home Depot. Customer acknowledges and agrees thaZb�,
read.under,ands,voluntarily'accepts the
terms of and has received a copy of this Agreement.
Accept by: Submitte X X yzsz�,,Z*� —
C ustomer Signature U Date Sales nsult• s Signature Date
X Telephone No,
Customer's Signature Date
SaEcs Ccrtsultmu Lrcenu No.
CANCELLATION: CUSTOMER MAY CANCEL THIS o",ptdicaNO
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE NOME
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
CT1STtlib ER'S STATE.
The Commonwealth of Massachusetts
Department of Industrial Accidents
0
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibl
Name(Business/Organization/Individual):
Address: y
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
I.❑I am a employer with employees(full and/or part-time).* 7. [:]New construction
2Q I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10 E]Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
ri.netors with no employees.
12.�Plumbing repairs or additions
5. a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑RoOf pa'rS
These sub-contractors have employees and have workers'comp.insurance?
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. they
152,§1(4),and we have no employees.[No workers'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.
tContractors 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.Lie.#: �/� �2— Expiration Date:
Job Site Address: � .YL'J � 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certi and naltie erjury that the information provided above is true and correct:
Si a Date. —�3
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#:
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 trans
Th transported by:p
The debris will be received by:
Building permit number:
Name of Permit Applicant
2
Date Signature of Permit Applicant
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS ?
212 Main Street • Municipal Building
,.w Northampton, MA 01060
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 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
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):
. am general contractor and I
1.❑ I am a employer with 4 ❑ I a 6. F-1 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 g, ❑ 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 of perjury that the information provided above is true and correct.
Si mature: 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 Supe/rvi�sor� Not Applicable_£����
Name of License Holder:
License Number
ZA/ �1�
Address Expiration Date
Sign re Telephone
!9..Re istered Hom 'rove entCor%ctor ' _ � _ Not Applicable
Companx Name Registration Number
Expiration Date
Telephon
p ,.
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil ' permit.
Signed Affidavit Attached Yes... .. £ No...... £
11: 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-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 W' ows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [[J] Decks [[] Siding[0] Other[O]
Brief Descriptio pf,Pro ed �1 7� "�,
Work: �•'
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 and or.add tion torexistinq housing, complete the fol)o i 6_
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 / �'' as Owner of the subject
property
hereby authorize
to act on my mmy�y be If, in all matters relative to work authorized by this building permit applicatiq n.
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 un r e pa' s and penalties of
Print Na C r�
a re o Owner gent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
T1iis column to be filled in by
Building Department ,
Lot Size
Frontage __ __ ------ --� � ---_
Setbacks Front �I
Side L:' R:. L: = R:L_____ ! J
Rear ---� L_
Building Height 1 (-
Bldg.Square Footage
Open Space Footage t %
(Lot area minus bldg&paved I s €parking)
#of Parking Spaces
Fill: _,___.�_..�._�,._.�....._.._..... _,.__,�..._,.W.�..._�........,.-..w.._....__S�_..._..�.F-,_..........,......_...___.._�._..._.....
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO
Q DONT KNOW Q YES
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
IF YES: enter Book Pagel^ and/or Document# J
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued: w�
C. Do any signs exist on the property? YES Q NO O
IF YES, describe size, type and location: I
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q
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 Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton Status,ofPrmd ry � � �k f `
Building Department G�rrb cur/Dr�veaniap Perrrt#" `' i
e► f°�� 212 Main Street Sewer/septleAve�la6tllty 5 f 5 f
Room 100 Water/l/4Fel(Avatlability "
0 ; Northampton, MA 01060 Tvia 1.10t s of Structural Plars T j
phone 413-587-1240 Fax 413-587-1272
a
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE,INFORMATION
This section to be completed by office
1.1 Property Address: ,. . .
�� / � �-� Zone #', Overlay District
Elm St District CB Districts
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT.
2.1 Owner of Record:
Na a(Print)_ �, Curre Mailing
e��r/'Tx*`�// T�phone�
Signature
2.2 Au rize A ent: f
Na rin Current Mailing Address:
ignature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed b ermit applicant
1. Building �J l��/lam /'t� (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 Oq
6. Total=0 +2+3,+4+5) , Check Number
This Section For Official Use'Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/In.spector'of Buildings Date
865 BURTS PIT RD BP-2015-1125
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-299 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2015-1125
Project# JS-2015-002121
Est.Cost: $2168.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 92937
Lot Size(sg.1): 57673.44 Owner: MENDEZ REGINA M
Zoning: Applicant. HOME DEPOT AT HOME SERVICES
AT. 865 BURTS PIT RD
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 Q Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON.511812015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT 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 Occupancy Signature:
FeeTyAe: Date Paid: Amount:
Building 5/18/2015 0:00:00 $35.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner