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Aug 13 1505:49a P•1
HOME I\1PROVEMENT CONTRACT
PLEASE READ THIS
jj�-- 1r Sold,Furnished and Installed by:
Branch Name:Dostnn North&South Date:�t� l THD At-Home Services,Inc.
d/bIa The Home Depot At-Horne Services
Branch Number:31 and 33 9138 Boston Turnpike,U-tit I.Shrewsbury,MA 01545
Toll t=ree 677-933-3768
Pederah ID*75-269840:ME Lie#C 02439:RI Cont.Lick 16427
CT Lk:It MC: 15522::,MA HHotnc imprroovm
eent Connbaor Reg#!126893
Installation Address: 4 �TYt 6L 3Uti
City state Zip
Purchaser(s): W rk Phone: Home hone: Cell Phone:
Horne Address:
(If different from Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑I DO NOT wish to receive any marketing entails from The Home Depot
Project Information: Undersigned("Customer"',,.the owucr's of the property located at the above installation address,agrees to buy,
and THD At-Home Services,Inn("The Home Depot")ug eet to Furnish,deliver and arrange for the installation("installation')of
all materials described on the below and on the referenced Spec Sheetts), all of which are incorporated into this Contract by this
reference,"[long with aty applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively,
"Contract"):
Job#. am—A Kdr, .) }ducts: Spec Sheets)#: Project Aromint
(j(� !^ + Roc+fir.g Siding Windows ]nsulation /
�'L- ❑Gutted l Covers - Wiry Doors ❑ 3� 3 l/./�/J�
Roofing Siding Wirwow,0 lnsuhtion
❑Gutter;/.Covers ❑F,rt y Datrs ❑ J $
Rooftag ElSiding -El Windows Insulation
❑Gutters I Covers ❑Entry Daors❑ $
Roofing ElSkling El Wi;x_kws Irsulation
❑Guners/Covers ❑EntyDaors F1 s
4
Minimum 25%Deposit of CoWatet Amout due upon execution of this coutract. Total Contract Amouil $
Mnine Pur lasers may net deptAt more than one-third orthe Contract AnwmrL
Customer agrees that,immediately upon completi-m of the work for•each Product,Cusionter will execute a Comoletion Certificate
(one for each Product as dcfired by an individual Spec Sheet) and pay any balance due. As applicable, each Customer under thk
Contract agrees to be jointly and scvtvully obli;awd and liable hereunder.
The Home Depot reserves the right to issue a Change Order or terminate this Cottiract crony individual Product(s)included herein,at
ita discr,-cion,if The Home Depot or its authorized;ervice providcr determines that it cannot perform its obligations due to a structural
problem with Lite home,environntentai hazards stt<h as mold, aslmsdc:s or lc-,-d paint,ether salety concern;.pricing errors or because
work rerluircd to complete thejob was not included in the Cattract. ``
Payment Summary: The Payment Sutntmaiw# t�O�i R�t , included ns part of this Contract, sets forth the total
Contract amount and pat}•mends rquired for tiro deposits and rwA payr-eats by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely tilled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there is one Completion Certificate for each listxd Product as defined by individual Spec Sheets)before work on that Product
is complete.
In the event of termination of this Contract.::mdomtcr agrees to pay The torn!Depot the casts of materials,hihor.expenses
and services provided by Tire Home Depot or Authorized Service Provider through the date of termination,plus airy other
amounts set forth in this Agreement or alkwed ender applicable caw. T4E HONIF DEPOT MAY WITHHOLD A\161:NTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT 11,YVNIIENT DR 01-HFR PAYMENT'S MADE, Wn-116UT
LIMITING THE HOME DEPOT'S OTHER RM_IEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agrees std understands that this Agree ienl is the entire aurcement bc'.tvetn Customer
and Tire Haire Depot with regard to the Products and Instail:aion services and rsedc all prior'discussions and afire }rents.either
0�r'sSigznatwure k ti _ said Products and Installation,This Agrc4ntcnt crtni It assi,n d nr aittcndul except b} a writing signexl
- omc Dcpei. Custcmter acknowledges and ngrws drat a rn>.,cr li i s rcud,uredersturds wr[untarily accepts the
ed a copy of[his Acteeirmt, 1 Suhmi ed p:x b'turr Dale Salos Cut.ul S Si nadure Date
X Teicplta c N(.
Customar'S Si,;nature Date
Sales Consultant License Nn,
CANCELLATION: CUSTOMER TAY CANCEL THIS t e: t crotch
AGREEMENT N4'iTHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT 3Y MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE iS 1
SPECIFICALLY PRESCRIBED BY LAW IN
r.1)STO M VR IS S't'A 7'F
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
}
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of lndustrialAecidents
1 Congress Street,Suite 100
Boston,AM 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers,
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information i Please Print Legibly
Name(i3usiness/Organization/Individual):
Address:
City/State/Zip: ' � Phone#:
Axe you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full andior part-time).* 7. ❑New construction
2.M I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.❑I am a homeowner doing all wo-,k myself.[No workers'comp.insurance required.]t
Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 []
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
pr netors with no employees.
12.M Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.[]Ro f repairs
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. Other /
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 wo ker'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-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. /�/ V Insurance Company Name: / Y /G � � T� .
Policy#or Self-ins.Lic.#: 1/t/�- V /�� O 0 2_ Expiration Date:
Job Site Address:
� 7_J %'I `� l City/State/Z- "
Attach a copy of the workers' compensation policy declaration page(showing the policy number And a piration 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.
1 do hereby certi and naltie erjury that the information provided above is true and correct.
SiQna // 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):
L Board of Health 2.Building Department 3.City/Tov+m Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
j Contact Person: Phone#:
SECTIONS-CONSTRUCTION SERVICES
8_1 Licensed Construction Supervisor: , Not Appli ble ❑
Name of License Holder
License Number
P2 6- bi)44PIA�. [lc%;[l iZ, -12_
"Addres Expiraation Date
Telephone
9.Reaistered Home Improvement Contractor: Not Applicable ❑
r t rt'" 49!2!�
Company Name Registration um er
4--Ira&��, n !j6 -1 /
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 building it.
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 strictures 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 Alterations) Roofing
Or Doors �d
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks
[M Siding[[3] Other[ag
Brief Des i too r p '
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 addition t"xisfing housina. 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.
1. 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 behalf,in all afters Wive to work authorized by this building permit application.
Signature of Owner Date
1, ffi as Owner/Authorized
Agent hereby declare that the statements an information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed undeMe pains penalties of perjury.
-�
Pri a
Sign r of Own Agen Date �07-*— —
f Department use only
City of Northampton Status of Permit
Building Department Curb CuVDriveway Permit
212 Main Street Sewer/Septic Availability
u Room 100 WaterMell Availability
EI��,plumbing 6- Northampton, MA 01060 Two Sets of Structural Plans
Nprthampton.w' a 413-587-1240 Fax 413-587-1272 PloVSite Plans
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
Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Record:
6L�p�9�6
Name(Print) Current Mailing Address
Telephone
Signature
2.2 Authorized A ent: _
Name(P. t) C6iTerll Mailing Address:
A#A —& X'Z==Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building /���j ,�� ) (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 a 2u
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature:
Building CommissionerlInspector of Buildings Date
183 BRIDGE ST BP-2016-0323
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-235 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeory: windows replaced BUILDING PERMIT
Permit# BP-2016-0323
Project# JS-2016-000516
Est.Cost: $4930.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 99209
Lot Size(sq. ft.): 19079.28 Owner: RANSON FREDERIC
Zoning: SC(67)/URC(33)/ Applicant: HOME DEPOT AT HOME SERVICES
AT. 183 BRIDGE ST
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON.911412015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 6 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 Ri 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