18D-053 (21) Jul 2715 05:20a p.1
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Famished and Installed by:
Branch Name:Boston Korth&South DatetA TED 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 877-9013-3768
Federal ID#75-2698460;ML"Lic#C 02439;RI Cont.Lic#16427
/�,C/�T Lic#HIC.05655°_ :AAA Home I(mprovc at CO2 r R 126893
Installation Address: �L 11* lr�Y, N l 31b( &I
City State Zip
Purchasers), * Work Plmne: Home Phone: CCU Phone:
1 [ 1 (IjM41L l [ l
[ I Fr ] C
Rome Address:
(If different from Installation Address) City State Zip
E-mail Address(to receive project eommunictuions and Home Depot updates):
❑I DO NOT wish to receive any marketing emails from The Horne Depot
Protect Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
and THD At-Home Services,L•ic.(`°Tice Home Depot")agrees to furnish,deliver and arrange for the installation ;"Installation")of
all materials described on the below and on tits referenced Spec Sheens), 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 4: :m a.rmm t ets Sheets)#- Project Amount
i Roofing Siding indows Insulation
[]Gutters/Covers❑Entry Doors ❑ � 1
Roofing ElSiding Win:low-: Insulation �A
i
[]Gutters(Covers ❑Fairy Doors ❑
Roofing ClSiding El Windows EJ la ulatlun �
❑Gutters I Cavcrs El Entry Does❑
Roofirtg Siding C Windows El Irnulation
❑Gutters I Covcr% ❑Envy Doers Q S
Mininm in 25%Deposit of Contract Artraunt due uponexeauton of this contract. Total Contract Amount
Vhune Pnrehasem pray not deposit nxtre than one-third or the Contract Antotntt.
Customer agrees that, immediately upon completion of the work lbr each Product,Customer will execute n Completion Certificate
(one fer each Product as defined by an individual Spec Shect)and pay any balance duo. As applicable. each Customer under this
Contract aerces m be jointly and severally obligated and liable hereunder.
The Home Depot reserves the right to ixsuc a Clumpe Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,ifThe Home Depot or its authorized service provider dote nines that it cannot perform its cdtligations due to a structural
problem with Lhe home,environmental hazards such as mold,asbestos or lead paint.other safety concerns.pricing errors Or bceaLlSC
work required to complete the job was not included in tl.e (C,ontractt.
Payment Summary: The Paymteni Summary# �,( '1f 5U-0(0 included as part of this COUtcaO. sets forth the lotal
Contract annoant and payments reck6ed for the deposits and linal payments by Pnxluct(-t%npplicablei.
NOTICE TO CUSTOMER
You are entitled tea complUely filled-in copy of the Contract at the time yotr sign. Do not sign a Completion Certificate{note:
there is one Completion Certificate for each listed.Prodvet as defined by individual Spec Sheets)before work on that Product
is complete.
In the event of termination or this Contract,Customer agrees to pal°The Hoax'Depot the casts 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 law. TILE HOME DEPOT MAY WITHHOLD AMOUNTS
ONVED TO THE HOME DEPOT FRONI THE DEPOSIT PAYNIENT OR OTHER PAYMENTS --MADE, WITHOUT
LIMITING THE.ROME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Aulborization: Customer agrees and understand; that&7.,;Agreement i�the entire a_rcemcnt between Customer
and The Home Depot vritb regurd tt?the Protlucts and Installation services and supersxlcs all prior discus,,ioos and agreements.cithcr-
oral�u written.relatimo to said Product:noel lnstalLttiOtt. Pais Ag*rxntent cannot t;xigneJ or amcndtxl exec x by a writing si mat
by Customer and The Homc Depot. Cu,lixacr acknowledges and tigress that C. ,m 'has read.understanJs,voluntarily accepts the
terms of and itas received a co ol'this Agrwntetu.
Xt v /,,-I Submit d h h <�e
Customer' tgnature Datc Sales 'txnst at's Sicnature Dale
N Telephone No.
Custonter'S Si=nature Dal,
Sales Consultant License No_
CANCELLATION: CUSTOMER MAY CANCEL THIS t:n:,pplcah'c)
AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME �- 53a`l
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS ` 63
DAY AFTER SiGNI14G THiS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORDI TO USE IF ONE iS
SPECIFICALLY PRESCRIBED BY LAW IN
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-\ The Commonwealth of Massachusetts
Department oflndustrialAccidents
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 PERMITTING AUTHORITY.
Applicant Information I Please Print Le ibly
Name(Business/OrganizatiorvUdividual):
Address:
City/State/Zip: /,-�4- M&Phone#,:
Are you an employer?Check the appropriate box: Type of proj7(req�u7ired):LF❑I am a employer with employees(full and/or part-time).' 7. ❑New c2.❑I am a sole proprietor or partnership and have no employees working for me in g. [-Remo
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.Q I am a homeowner doing all wort:myself.[No workers'comp.insurance required.]t
10 Q 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
p netors with no employees. 12.F-1 Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheer. 13.❑Roof repairs
lbese sub-contractors have employees and have workers'comp.insurance.-
14. the,jj &
6.❑We are a corporation and its officers have exercised their right of exemption per MOL c.
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 WDeKC_rs'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 air employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. A41/W / f'
Insurance Company Name:
Policy r or Self-ins.Lic.r: W�1- � Expiration Date: 6 �/
Job Site Address: 'l City/State/Zip
Attach a copy of the workers' compensation policy declaration page(showing the policy number and a iration 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
an /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 �1
am Date:
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/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone H:
1
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:
The debris will be received by:
Building permit number:
Name of Permit Applicant iG �1Ph�
y
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: f] Not Applica le ❑
Name of License Holder: l� / L ► /_ � �L
License Number
Addres Expiration Date /
ignat r Telephone
9.Registered Home Improvement Coontrraac�ttorr::,.,.}.. Not Applicable ❑
Company Name Registration um er
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 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 [] Repiacemen W' doves Alterations) [] Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [E:3] Decks [M Siding[o] Other[CA`4�
Brief Descript, f o o i ,
Work:
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 t9&xist1nq housincil,complete the foiiowin
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
f, as Owner of the subject
property 1�l
hereby authorize vr�
to act on my behalf, in all matters rela�ve�.wArk authorized by this building permit application.
, �Zz f L�� x(-,f q r/-5
Signature of Owner Date
i, 4�vl/ 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 and e pains"penalties of perjury.
Pri a
Sign a r of Ok Agen Date
City of Northampton Status of Permit Department use only
Lam= Building Department Curb CuUDdveway Permit
212 Main Street Sewer/Septic Availability
2QI3 Room 100 Water/WellAvailabili
ILI ty
_ Northampton, MA 01060 Two Sets of Structural Plans
06WIC,P10rr bing—a G a5 I ne 413-587-1240 Fax 413-587-1272 Plot/Site Plans
plortharn ton,MA 0106u Qthgr SpeClfy
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
# -P,4 Map Lot Unit
f1 I Zone Overlay District
�J Elm St District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: !�
Name(Print) Current Mailing Address-
A417 .
Signature
- Telephone
2.2 Authorized Aaent.
94Z_V'_w'I,
Name(P t) urre ailing Ad�dre�ss: �j ,-�►
JJA
Signature
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) `7 L -1 Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature:
Building CommissionerAnspector of Buildings Date
80 DAMON RD#3101 BP-2016-0324
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D-053 CITY OF NORTHAMPTON
Lot: -000 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-2016-0324
Project# JS-2016-000517
Est. Cost: $5290.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 99209
Lot Size(sq. ft.): Owner: WIENER DANIEL
Zoning: GI(88)/SC(12)/WP(12) Applicant: HOME DEPOT AT HOME SERVICES
AT. 80 DAMON RD #3101
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 10 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 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