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Jul 2815 05;33a HOME IMPROVEMENT CONTRACT PLEASE READ THIS � Sold,Furnished and Installed by: Branch Name:Boston North&South Date/7h'I THD At-Home Services,Inc. dib/a The Home Depot At-Home Services Branch Number:31 and 33 908 Boston Turnpike,Unit 1.Shrewsbury,MA 01515 Toll Free 877-903-3768 Federal ID#75-2698460;ME Uc#C 02439;RI Cont.Lich 16427 CT Licit HIC.0565522;N1 Hem-Impiovcmc��ritt�Co�nntractor Reg.v 126893 Installation Address: 3 EAS-r ' �-4 �S 1 4i 4 0(©S3 City State Zip Purchasers): Work Phone: Home Phone: Cell Phone: P c all 3 t Home Address: (I'different from Installation Address) City S'atc Zip E-mail Address(to receive project communications and Home Depot updates): Q 1 DO NOT wish to receive any marketing emails from The Home Depot Proieet Information: Undersigned(Customer'",the owners ofthe property located at the above installation address,agrees to buy, and THD At=Home Services, Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation{"Installation")or all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Suattnary attadted hereto and any Change Orders(collectively, "Contrnct'�: Job#: n,,.r rtr.a—,) Products: Spec Sbec s 4: Protect Amount Roofing OSiding Windiew-s-F7 insulation 1 ❑Gutters i Covers ❑E:tny Dcors ❑ 3 �p S Roofing Siding C3 Lyindows Insulations �f/ [DGuttcrs t Covers (]Entry Doors ❑ //'�� __ ` , } Roofing osiding 0 N'intlaws Insulation []Gutters i Covers ❑Entry Doors❑ Roofing LISiding Wind_ws C3 Insulation ❑Guters l Covei s E]Entr}t Doers F1 $ Nlinimum 25%Deposit ofContract Amount doe upon execution oftbis contract. Total Contract Amount S t C Maine Purchasers may not deposit more than one third of the Contract Amount. '( Customer agree;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 Sheet)and pity any balance due. As applicable, each Ctistomct under Ibis 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(§)included herein,at its discretion,iFTite Ho:ttc Depot or its authorized service provider tic,,crmincs that it cannot perform its obliga:ions due to a structural problow with the home,cnvirormetual hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because work required to complete the iob was not included it the Contract.�7 Payment Summary: The Payment Summary 4 1 l S 1 , included as part of this Contract, sets forth the total Contract amotmt 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: them 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 Home Depot the costs of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus guy other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMEIN"rS MADE, WTTHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acct tance and Authorization: Custo:ne:•agrees and uncerstands that this.Agreement is the entire agreement between Custontcr ar, The Home Depot with regard 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 Customc-and The Herne Depot. Customer acknowledges and agrees;hut om has read,undcrsunds.voluntarily accepts the terms of and has received a copy of this Agreement. Acce'ed by-, Submi ed y! ------ 'b. n Cusco igna Date Sal . Co llant°S Signatcrc Date X 4 Telephone No. Oust `ter a ign tc Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (as.ppixable, AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING T141S AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOM ER'S STATE. -` The Commonwealth of Massachusetts Department of IndustrialAccidents 1 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 PERMPIT]NG AUTHORITY. Applicant Information Please Print Le ibly Name(Business/Organization/Individual): �-Ir" iij�g& Address: City/State/Zip: ��� Phone#: Are you an employer?Check the appropriate box: Type of project(required): l.❑I am a employer with employees(full and/or part-time)." 7. ❑New construction 2,O I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.71 I am a homeowner doing all work myaclf,[No workers'comp.insurance required.]t 4.F-1 I am a homeowner and will be hiring contractors 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 pr netors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Ro f repairs 'nese sub-contractors bane employees and have workers'comp,insurance.- 6.0 NVe are a corporation and its officers have exercised their right of exemption per hIGL c. 14.Utthed l��f����`� 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. Contractors that cheek,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 then workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy mid job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: D l� 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 aaw war one-year imprisonment,as well as civil penalties in the form of a STOP WOra 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 - ^L ^ Date: �3 Si,-ma 2 Phone#: Official use only. Do not write in this area,to be completed by city or town official j City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/To,%-n Clerk 4.Electrical Inspector 5,Plumbing Inspector s 6.Other Contact Person: Phone#: a 1 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, 1 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: The debris will be received by: Building permit number: Name of Permit Applicant 1P�� r - } Date Signature of Permit Applicant SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su rvisoe Not Applica/b/),e ❑ Name of License Holder: 15;;�-I/ � `" / 2-1 IJ � � License Number — Addres Expiration Date ignat r Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name V Registration um er Address Expiration Date-/ 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 building 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 applicablel New House [__J Addition E] Replacement Wi ws Alterations) r__J Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding[p] Other[a Brief Descripti of Pro y -- 1&�6iC44 Work: 1 L 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 toexisting housing— 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, as Owner of the subject property hereby authorize to act on my behalf, in all matters rela a to work authorized by this building permit application. �- Signature of Owner Date I, In 11.0 as Owner/Authorized Agent hereby declare that the statements dric7information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed and a pains,�,penalties of perjury. lL �_ Pri a A.r-- Signa of Own Agen Date NNW n `\ Department use only City of Northampton Status of Permit Building Department Curb CutlDriveway Permit f 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans m� Other Specify APPLICATION 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 r� Map Lot Unit Zone Overlay District Elm St District CS District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Cr & Telephone Signature 2.2 Authorized A ent: _ R��F4t I" Name(P t) G�urre ailin(ng^Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com leted by ermit applicant 1. Building >Lim (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 Building Permit Number: IIssued: Signature: Building Commissioner/inspector of Buildings Date 53 EAST CENTER ST BP-2016-0328 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 11A-070 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:windows replaced BUILDING PERMIT Permit# BP-2016-0328 Project# JS-2016-000525 Est. Cost: $5745.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 105953 Lot Size(sq.ft.): 31798.80 Owner: PUNSKA HEATHER Zoning_URA(l00)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 53 EAST CENTER ST Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCER102908 ISSUED ON.911412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 8 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 Si nature: 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