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HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Furnished and Installed by.
Branch Name:Boston North&South Date/(Sl 1 THD At-Home Services,Inc.
d/b,a The Home Depot At-Home Services
Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free 877-903-3768
Federal ID'75-2698460;ME Lic.4 C 02439,Rl Cent.UO 16427
1 (� C(T�Lic#HIC.0565522:MA Homc lmprovrtrent Contractor Reg.#126993
I
Installation Address: (oc S(J `✓ n�S r t F-OND-3 MA
, �
City State Zip
Purchaser(s): Work Phone: Home Phone: Ce1lPlione:
Horne Address:
(If different from Installation Address) City State Zip
E-mail Address(to receive pTojcet communications and Home Depot updates):
❑1 DO NOT wish to receive any marketing entails from The Home Depot
P-iect information: Undersignee("Customer"),the owners oFthe property located at the above installation address,agrees to buy,
and THD At-Horne Servies,Inc. ("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installation")of
all materials described on the below and on the referenced Spa Shcet(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 p' oO1 .L Rd.—,) Products: See Sh s #: Pruiect Amount
Roofing Siding LJ 1r.':ncows LJ Insulation
j 31ct 7-)- ❑Gu Do
tters;Cevcrs ntry ors Q $
Roofing Siting 0 WndowsLl Insulation
❑Gutters;Covers ❑Entry Doors ❑
Roofing ElSiding Windows Insulation
OGurcrs i Covers [I Entry Doors❑ S
goofing E1Siding'C3_%V__in(k__)w_s_0 Insulation
QGutters i Covers ❑Entry Doors ❑ 5
Minimum25°/.Depusk ofCantra d Amount due upon execution ofthiscontract. Total Contract Amount $ 5�
Maine Purchasers may not deposit taore than oat-third orate ContraetAmount.
Customer agrees that, immediately upon completion of the work for each Product,Customer will execute a Completion Cerificatc
(one For each Product as defined by an individual Spec Shect)and pay any balance due. As applicable, each Customer under this
Contmci agrees to be jointly and sevsraily obligated and liable hereunder.
The Hotnc Depot reserves the right to issue a Chang Order or rerminatc this Contract or any individual Product(s)included herein,at
its discretion,if The Homc Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home,crnyirocmerial hazards such us mold,asbestos or lead paint,other safety concerns,pricing errors or because
work required to complete the job was not included in the Contract.
Payment Summary: The Payment Summary ri C 6� _. included as part of this Contract, sets forth die 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 von sign. Do not sign a Completion Certificate(note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product
is complete.
In the event of termination of this Contract,Customer agrees to pay The Hone 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 a)Eowed 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 FOR RECOVERY OF SUCH AMOUNTS.
Acce tance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
an The Home Depot with regard to the Products and installation services and su rsedes all prior discussions and agreements,either
oral or wrmen,relating to said Products and Installation.This Agreement c of assigned or amended except by a writing signed
by Customer and he Home Depot. Custemcr aeknowledgws and*Sub mer h is read,undcrs4nnds,voluntarily accepts the
terms of and ha txived a copy of this Agreement.
Accepted 1b � 'Custom s Signatu pate s Signature Da-e
x
ustomer's Signature Date
Sales Consultant License Na.
CANCELLATION: CUSTOMER MAY CANCEL THIS (a5 appli.6lc)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
DE DELIVERING MIDNIGHT NOTICE THIRD THE HOME H( 3 / ��DEPOT BY MIDNIGHT ON THE THIRD BUSINESS tjV~
DAY AFTER SIGNING THIS AGREEMENT, THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE 1S
SPECIFICALLY PRESCRIBED BY LAW IN
City of Northampton 212 Main Street, Northampton, MA 01 060
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 transported by: � i �`� )II'�T� '
The debris will be received by:
Building permit number:
Name of Permit Applicant 1�l�DIJ
2-
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Afridavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMTITMG AUTHORITY.
Applicant Information Please Print Le 'blv
Name(Business/Orgaaization/Individual):
Address: D
City/State/Zip: M��Phone#:
d
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
2.7 I am a sole proprietor or partnership and have no employees working for me in g. Remodeling
any capacity.[No workers'comp.insurance required.]
9. Demolition
3.['j I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
❑
4.F-]I am a homeowner and will be hiring contractor to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
p netors with no employees.
12.[-1 Plumbing repairs or additions
5. t am a general contractor and I have hired the sub-contractors listed on the attacbed sheet 13.[]Roof repairs
These sub-contractors have employees and have workers'comp.insurance.'
14.�
6.❑We are a corporation and its officers have exercised their right of exemption per i IGL c. ther ,4'
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box R 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-connector and state whether or not those entities have
employees. Uthe sub-contractors have employees,they must provide their workers'comp,policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information. J
Insurance Company Name: &� z - -- . .
Policy#or Self-ins.Lie.#: WLi- D 15�-0 22- Expiration Date:
Job Site Address:_ /f� "/ /�f/�—Z 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
an4lor 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.
Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
{ City or Town: PermitUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
t 6.Other
f
1 Contact Person: Phone#:
l _
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �, Not Applicable ❑
Name of License Holder: � j �� l/G-/
License N m be
7 AWL 14
Addres Expiration Date
ignat r Telephone
9.Registered Home improvement Contractor: Not Applicable ❑
jb
��
Company Name Registration uml5er"'
r
Address Expiration Da e
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 buildingpermit.
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
4
SECTION 5-DESCRIPTION OF PROPOSED WORK check all applicable)
New House Addition ❑ Replacement wiadoWs Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks
[lam Siding[pj Other[dj
Brief Descri do f rop'
Work: f � �)
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 J9&xIstIng housing,complete the 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 PEER-MIT
1, ��.LZ��r[.l as Owner of the subject
property
hereby authorize C
to act on my behalf in all matter lative to work authorized by this building permit application.
Signature of Owner Date
1, as Owner/Authorized
Agent hereby declare that th6 statements an information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed and e pa ins
ppenalties of perjury.
Prin a
Sign r of Own Ag 3 Date
Department use only
City of Northampton Status of Permit
Building Department Curb CutlDriveway Permit
Z 212 Main Street Sewer/Septic Availability
Room 100 Water/Well.Availability
. Northampton, MA 01060 Two Sets of Structural Plans
e phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
AVKLICATION 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
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Omer 91 Record.
45 2,57 P,2 tA�) 114 r ff"
Name(Print) �.�. Current Mailing Address:
Cab/fi-t
Telephone
Signature
2.2 Authorized A ent:
Name(P t) Cu4effi k4ailin'g Address:
Signa pre 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)
5. Fire Protection
6. Total=(1 +2+3+4+5) P-0 Check Number AYO
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
1250 BURTS PIT RD BP-2016-0327
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-205 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-2016-0327
Project# JS-2016-000522
Est. Cost: $2857.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 62290.80 Owner: MILLER GEORGE A&THERESA
Zoning: Applicant. HOME DEPOT AT HOME SERVICES
AT. 1250 BURTS PIT RD
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.911412015 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:
FeeType: Date Paid: Amount:
Building 9/14/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner