11C-047 SEP-17-2015 22:44 HOME DEPOT 413 543 9407 P.001
HOME IMPROWNIENT CONTRACT
PLEASE READ THIS
Sold,Furnished and Installed by:
Branch Name:Boston North fi South• Date:_/ /, THD At-Horne Services,Inc.
dtWa The Home Depot At-Horne Services
Branch Number-Fsl aba 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
.&W Toll Free 877-903-3768
Federal ID#75-2698460:Mr Lic#C 02439;RI Cant.Lie:#16427
tQ�T_Liic,ff RIC.0565522;MA Himv_im�-prAovement Contractor Rcg.#126993
Installation Address: ^� ` ow,'r'�'! "^�"✓ I` /Q�
City State 'Lip
Purchnsei'(s): Work Phone: Home Phone: Cell Phone:
Hoax:Address:
(If different from Installation Address) City State "Lip
E-mail Address(to-receive project communications and Home Depot updates):
❑I DO NOT wish to receive any marketing etnails from The Home Depot
Prot ecS1 I&Wdon: Undersigned("Cmgtomer"),the owners,of the property located at the above installation address,agrees to buy,
and Tiff)At-Home Services,Inc. ("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installation")of
all materials described an the below,and on;the referenced Spec Sheet(s), all of which arc incorporated into ibis Contract by this
referent:;along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively,
"Contract"):
,lob#: n uanMl s.rrwrq Products: SRE Sher s)#• Amount r J
R 'n idin Lj Windows U insulation Y
s
y ora�Q�
Roofing Siding Windows ation y ) LV
Z [joutters/covets O-rntry Doors Q.. �^ f G
Pmf..g Sidin�Windows insulation $
T f 3c.utters/.Covers C EWy Dxw,Q_
Renting Siding 'Window, U'Insulation
[]Gutters/Cowers [Entry Doers 0- $
Minimum 25%Deposit of•Comtruet Amount due upon execution or this ontrnct. Total Contract At gount $
Maine Purchasers may not deposit more than w"hird of the Conuart Amount
Customer agrees that,immediately upon corripledon of the work for each Product.Customer will execute a,Completion Certificate
(one rot each Product as detincd by an individual.Spec Shcct)and,pay any balance due. As applicable, each Customer under this
Conti act agrees to be jointly and severally_ob)igated and liable hereunder.
The Tlexnc Depot reserves the right to isxuca Change Order or terminate this Contract or any individual Pnxiuct(s)included herein,at
its di::cretion,if The Home Depot or its authorized:service provider determines that it cannot perform its.obligations due to a structural
probl nn with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because
work requircxl to complcle the job was not included in the'Contract.
.pMient Summary.: The Payment Summary# •�` 1:11 included as:7xt of this Contract, sets forth the total
Contracr amount and paymentsregtrircd lei the deposits tuTddPftnWpa' crtts by Product(as applicable).
NOTICE TO CUSTOMER
Yoti are entitled to a completely filled-hi copy'of the Cowitriict.at the time you sigh Do notsiltn a Completion Certific Ate-(note:
them is one Completion Certificate for each listed Product as deffined by.individual*Spec Sheet,.)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 Hone Depot or Authorized Service Provider through the date of termination,plus any other
amoitnts set fortb in this Agreement or allowed under applicable law. THE,HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE ROME. DEPOT FROM THE DlE'PL1tiSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIM[TING,THE HOME DEPOT'S OTHER REMEDLES FORRECOYERY OF SUCH AMOUNTS..:
-Acee tance and_Authorization:�Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Products and Installation services es and supersedes ull pricy 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 Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the
term:.of and has received a copy of this Agreement.
Accepted by:
,y Submitted b _
TC , '� Si Qty X rrnc 's gn lure Date Saks sul&nt's Signature ( Date
X i _ Telephone No.
Customer`s Signature Date: Sales Consultant License No.
CANC`Fl.LATION: CUSTOMER MAY CANCEL THIS 0 apphcube)
AGREEMENT WITHOUT PFNALTY OR OBLIGATION
BY 1)ELIVFRTNG WRITTEN NOTICE TO THE HOME
DRPO'r BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STA'L'E SUPPLEMENT ATTACHED HERVI`O
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY i.AW IN
CUSTOMER'S STATE.
NOTICE:ADDITIONAL.TERMti AND CONDITIONS ARE.ti rATeD ON THE REWRSF SIDE AND ARE PART OF THIS CONTRACT
O5 7A-19 White-Branch File Yellow-Customer
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 Buildinci Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
s o
Address f the work: f�
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
7
Date Signature of Permit Applicant
°-\ The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
___ svww.mass.gov/dia T
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers-
TO BE FILED NVITH THE PER UTTING AUTHORITY.
Apalicant Information z _ Ne'a'sse Print Legibly
Name(Business/OrganizatiomIndividual):
e
Address: 6;�
City/State/Zip: �D Phone':
Are you an employer?Check the appropriate box:
Type of project(required):
L❑I am a employer with employers(full andibr par•,-rime).• 7, New construction
2. 1 I am a sole proprietor or parmea''^p and have no employees working for me is $. Remodeling
any capacity.[No workers'comp.insurance rcquimd.]
9. ❑Demolition
s'.7 t act z hemcox•acr doing all work myself.[No wor}:e�'comp.insu.�nce rco�u d.]t
10 []Buiiding addition
4 tam z homco"mcr and will be hiring cont zctors to conduct all work on my prop-my, I will
Lswc that all contractors either have works s'compensation issuance or arc sole 11.❑Electrical repairs or additions
p ncto ss with no cmployecs.
12.Q Plumbing repairs or additions
S. 1 zm a gcn,-a1 contactor and 1 have hired the su';,-cones actors Lst°_d on the at,acbed sheet ]3.❑Ro ePZtrs
i nese sub-cont�ctois have cmployecs zad bane wor're:s'comp,insttraace.t
6.[]We a a corporation and its o ie
cs have exercised their rift of exemption pe h1
r GL c.
14.
irs ih r
::2,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Psy applicant that checks box r i must also fill out the section below showing their workers'compcasation policy information.
1 7oaeou Lers who submit this affidavit indicating they are doing all work and thca hi-rP outside contractors must submit a new affidavit indicating such.
:Conran o s that cbeck this box must attached an additional sheet showing the name of the sub-contactors and sate whether or not those entities have
employees. If the sub-contractors have employees,they must provide their worker,'comp.policy number.
I ant an employer that is providing workers'compensation insurance for my employees.. Below is the policy and job site
information.
Ln
surznce Com �p4 y n �Nzme: V
Policy r or Sell-ins.Lie. C�7 Expiration Date:
Job Site Address: ffi� �� i (� 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 tinder VGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00
aaW'or one-year imp-isonment,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 fonvarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certi
andp6nnitie erjury that the information provided above is true and correct
ena - / Date:
Si
/ - ^
Phone=: �-
1 Official use only. Do not write in this area,to be completed by city or town officiaL
iCity or Town: PermitUr-ease r
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Toiim Clerk 4.Electrical Inspector S.Plu-mbing Inspector
6.Other
Contact Person: Phone tt:
i
J
A.,,
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: 1 Not Applicable £
Name of License Holder: / t�/ ice /�/v✓
License Number
I � -6-/l
Address Expiration Date
Signature Telephone
9-Re istered:.Homeam rov " ent"Contract Not Applicable £
ComDany.oanje � � RegistratioNumber
Address
Expiration Date
Telephone �^ Z—
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,.Egemption
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 Windows I Alteration(s) ❑ Roofing ❑
Or Doors (]
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [0] Other[
Brief Desc' f n of Proposg/d
Work: , C l/�l- 1L /� ,r�}� �„/� 7j� �f� ✓�% ✓
�l �V r !/moo f� d►' d�
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 to extstlnq-housinq, cornplete'the followlng:
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
Alz 9✓ as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters re ative to work authorized by this building permit application.
Signature of Owner Date
.� v� 112-v �� as Owner/Authorized
Agent hereby dec are that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under th ns an penalties of perju
Print Name
Signature wner/Age t Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information ll
Existing Proposed Required`by Zoning
This colurni to be filled'in by
Building D paitment 1i
Lot Size
Frontage
Setbacks Front
Side L:'_ R:= L:l.___! R:=
Rear t---
Building Height
Bldg.Square Footage �"I % —
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces l —
Fill:
k
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES Q
IF YES, date issued:l �--��
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
IF YES: enter Book Page and/or Document#�'
l
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location:
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: j
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.
j
J
C7epartent use only'
i� ut , � k-,I�� k !s„+ i,—� st• a !, h r+' +! I
D of Northampton Status of Permit 2 x
ing Department Curb CuTlDrl�teyga Perm(#
2 Main Street SewerlSept(cAvaifabllrty r vF a!r ! '
SEP 2 9 2015
Room 100 11UaterlV�feTiR�a�la$(I(ty „
rth mpton, MA 01060 Twal8ef`s of StriTctural°Piaris 4 1
:iie".3:ti:53rZ=:��.-�-•.:i.__]I:i?'i�-:=:5-1'�—iil�_:L:,Y,.:4.:i::!N:!:.:]':iu!::!i_= -` '—':.v,::-r:::_:?i. '— —
psWc,Plumbing -1240 Fax 413-587-1272
Northam affil
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
completed
1.1 Property Address: Th(s sectiorr to be by office
Urnt
1KMi Nj
1
Zone ! I Overlay!D�strtctF t I
z
Elm St awls tnct I! '_CB District
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT.
2.1 Owner of Record: ° Adle JOul'
Name(Print) n}t fyLailingddre(s��
Telephone c/
Signature
2.2 Aut4prizee Agent:
Yrzi rr�-- _ I✓ l etas
Name(Print) Current Mailin Address-
Sig Lei, Telephone
S CTION 3 ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Feb
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) 0 Check Number
This Section For Official Use Only
Building ermit Number: Date
9 Issued:
Signature:
Building Commissioner/Inspector'of Buildings Date
File#BP-2016-0430
APPLICANT/CONTACT PERSON HOME DEPOT AT HOME SERVICES
ADDRESS/PHONE 5 RIVERVIEW DR NORTH PROVIDENCE02904(401)935-2633 Q
PROPERTY LOCATION 8 WARNERS ROW
MAP I I C PARCEL 047 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tyneof Construction:_INSTALL ATTIC INSULATION _
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 102535
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
D olit'
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
8 WARNERS ROW BP-2016-0430
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I IC-047 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-0430
Protect# JS-2016-000701
Est.Cost: $1776.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 102535
Lot Size(sq.ft.): 7100.28 Owner: ALLEN AMY
zonin-: 100)/ Applicant. HOME DEPOT AT HOME SERVICES
AT. 8 WARNERS ROW
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON:913012015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION
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 Denartment 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 9/30/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner