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17C-100 (4) Sep 0715 09:29p p 1 HOME IMPROVFMENTCONTRACf PLEASE READ THIS Sold,Furnished and Installed by: Branch Name:Boston.N'twth&South Date:& IJI—_ THD At-Home Services,Inc. d,'bla The Home Depot At-Home Services Branch Number.31 and 33 908 Boston Tumpike.Unit 1,Shrewsbury,MA 01545 Toil Free 871-903-3768 Federal ID 4 75-269860;ME Gc#C 02439;RI Cont.Lic#16425 CT L:c#H)C.0565522;MA Homc Imp rovemo.t C tractor Rci#1268993 Instatlation Addres: ' l�� City State Zip Purchaserfs): Work Flint; Home Phone: Cell Phone: LWQOi W- j{ fie. I ] ] [ l Home Address: (if different front Installation Address) City State "Gip E-mail Address(to receive project commuoicatiois and Home Depot updates): ❑I DO NOT wish to receive any marketing emails from The Horne Depot Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and THD At-Home Services,Inc.("Tbe Hume Depot")agrees to furnish,deliver and arrange for the installation("Installation")of all materials described on the below and on the referenced Spec Sheet(s), all of which arc incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): I� job 41: nv_ M—) raducts: Sec Sheets #: ProjectAmount L Roofing Siding A Windows El Insulatior S []Gutters/Covers[]Entry Doors© Roofing Siding C3 Windows L3 Insulation ❑Gu:rcrs!Cmcrs ❑Entry Doors ❑ Roofing ElSiding 0 Windows Ej insulation []Quasi Covers ❑Entry Doors❑ Roofing Usiding Alincows Insulation ©Gutters/Covers ❑Erury Doors ❑ Minimum 25%Deposit of Contract Amount due upon exertion of this contract. Total Contract Amount ii �r Maine Purchasers rosy Aug deposit more than one-third of the Coutrad Amount 1 b Customer agrees that, immediately upon completion of the work for each Product, Customer will execute a Completion Certificate (one for each Product as defined by;!n individual Spec Sheet?and pay any balance due. As applicable, each Customer under this Contract agrees to be jointly and severally obligated and Gable hereunder, The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individuai Product(s)included herein,at its discretion.if The Horne Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home,environmental IiV.ids such as mold,asbestos or lead paint,other safety concems,pricing errors or because work required to complete the job was not included in the Contr^acct.`j Payment Summary' The Paymcnl Summ.ny# (D2 L. lCca>S included as part of this Contract, sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You arc entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certifiente(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 Horne 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 allowed 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. Aecentance and Authorisation: Customer agrees and understands that this Agrcement is the cndre agreement between Customer and The Home Depot with regard to the Products and lnstallaiior services and s cs all prior discussions and agreements,either or or written,relating to said Products and installation.This Agreement can be a signed or ametdcd except by a writing signed by Customer and The Home Depot.CLstomc-acknowledges and agrees d at L�01!nc has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. Accepte Submit x �,1e t� zt�. �'.3 x t Customer's Signature Date Sales ConsVWt s Signature PD X TcicpI Customer's Signature Dar Sales Consultant Liccnsc No. CANCELLATION: CUSTOMER MAY CANCEL THIS ia>applimble) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO C+SE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. 7'hz Corn.;lonw2a1Yh of Massachusetts -Department of Industrial Accidents a 1 Congress Street,Suite 100 .Boston,MA 02114-2017 www.mass.gov/dia `Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE YMED WITH THE MIN TE%AUTHORITY. Applicant Information Please Print Legibly Name(Business/Orp nization/lndividu^al): Address: City/State/Zip: Phone#: A?YDU.' employer?Check the appropriate box: Type of project(required): 1. m a emp loyer with 4 employees(full and/or part time),} 7. ❑New construction 2Q r am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[Noworkers'comp.insurance required.] 3.[]I am a homeowner doing all workmysel£[No workers'comp.insurance required.]t 9. Q Demolition 4.❑I am a homeowner and*ill be hiring contractors to conduct all work on my property. I will 10E]Building addition ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. . 12.[J Plumbing repairs or additions 5.0 1 am a general contractor and I have hued the sub-contractors listed on the attached sbeet. 13.�R epairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We ate a corporation and its officers have exercised their right of exemption perMGL c. 14. -Other 'VAI � e 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 TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state vhe#her or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that isproviding workers'compensation insurancefor my employees. Below is the policy and job site information. �- Insurance Company Name: ' Policy#or Self-ins.Lic.#1: Expiration Date: Job Site Address: 1-* CitylState/Zip. 0-Ile!�pI TA Attach a copy of the workers'com ensation policy declaration page(showing the policy number and ti li date). Failure to secure coverage as required under MGL c,152,§25A is a criminal violation punishable by a fine up tp$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. I do hereby certify der t e 'ns d p hies ofperjury that the information provided above is true and correct t Si atur — Date: Phone#: in I Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# t Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Towri Clerk 4.Electrical Inspector 5.PlumbingInspector b.Other a SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: ` < <" License umber Addres Expiration Date rr ignat r Telephone 9.Registered Home Improvement Contractor• Not Applicable ❑ Company Name Registration umUer'° Address Expiration Da e Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(fi)) 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 buildin mit. 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 Repiacementg9ldows Alteration(s) Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks ([] Siding[p] Other[p] Brief Description of Propose Work: XVJOA� 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 xlstin 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, �(Z��jL as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. R Signature of Owner Date 1, as Owner/Authorized Agent hereby declare that the stat ments an in on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed and e pains penalties of perjury. Pri Za Sign of Agen Date -- �_ Department use only f Northampton Status of Permit ng Department Curb Cut/Ddveway Permit $EP 1 Main Street Sewer/Septic Availability.L0j� l Room 100 Water/Well Availability, _ Npltl. mpton, MAO 1060 Two Sets of Structural Plans E+ecirrc, F,u - 5 -1240 Fax 413-587-1272 PlotlSite PlansL. Nerth f cns Other Specify b; 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 CS District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2A Owner of Record t , Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Ar`,te/nth�( Name(P t) Crre a�ili�ngg-Add/res�s: -f1S./ Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION CASTS 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 r 4. Mechanical(HVAC) 4D-- 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commissionerlinspector of Buildings Date 37 STILSON AVE BP-2016-0388 GIS#: COMMONWEALTH OF MASSACHUSETTS MU:Block: 17C- 100 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-2016-0388 Project# JS-2016-000626 Est.Cost: $1336.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 92937 Lot Size(sq. ft.): 12980.88 Owner: DEVINE RICHARD A&LINDA E Zoning-: URB(100) Applicant: HOME DEPOT AT HOME SERVICES AT. 37 STILSON AVE Applicant Address: Phone: Insurance: 5 RIVERVIEW DR (401)935-2633 O Workers Compensation NORTH PROVIDENCER102904 ISSUED ON:912112015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 2 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 SiEnature: FeeType: Date Paid: Amount: Building 9/21/2015 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner