38B-002 (2) Sep 0715 07:42p p.1
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
it Sold_Furnished and lri=lled by'.
Branch Name.Boston North&Sa th Date:/ 6/_tC THD At-Home Services,Inc.
d,'b/a Tic Home Depot At-Home Servioas
Branch Number.31 and 33 948 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free 877-903-3766
fccicra�iD#75-2598460;ME Uc 9 C 02439;RI Cont.DO 15427
CfpLii�c 4 HIC.05655;2ANIA Improvee�rneit Contractor Reg.9 126893
installation Address: i 1 �lL+ f 11r12 11 'xm1' � 11�
City Slata Zip
1'urehaser(sl: Work Phone: Hone Phone: Cell Phone:
Home Address:
(If different from Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑1 DO NOT wish to receive any marketing emails from The Home Depot
Proiect Information: Undersigned("Customer").the owners of the property locates]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")of
all materials described on the below and on the referenced Spec Shect(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"): lX
Joh#: (rue a 1 Rer.m J Products: Spec Sheets 9: Project Aoouut
Roofing iding W 11dows Insulation G ���^^yy i
f <52gJ 2 ❑Guncrs?Covcrs ❑Entry Doors ❑ �?06 V '�; [;2 /Y
Roofing Siding OlKindows Insulation $
❑Guttors!Covers ❑Entry Days ❑
Rooting Siding U Windows U Insulation
(�Guuers I Covers ❑Entry Doors❑ $
Roofing LjSidinm 0 Windows Insulation $
❑Gutters I Covers ❑Entry Doors ❑
Minimum 25%Deposit of Contract Amount due upon execution orthis contract.
Total Contract Amount 5
71ancPurehasenmay Put deposit roore than one4hidofMe Contract Amount.
Customer agmcs that, immediately upon completion of the work for each Product,Customer will execute a Completion Certificate
(one for each Product as defined icy an individual Spec Shect)and pay any balance due. As applicable,each Customer under this
Contract agrees to be jointly and severally o ligated and liable hereunder.
Tltc Home Depot reserves the right to issue a Change Order-or terminate this Contract or any individual Product(s)included herein,al
its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home,environmental hazards such as mold,asbestos or lead point,other safety concerns,pricing errors or beccusc
work requircd to complete the job was not included in the Contract.
L
Payment Summary: The Payment Summary # 6-2 2ct L-"I , included as part of this Contract. sets forth the tots!
Contract amount and payments required for the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely frlled4n copy of the Contract at the time you sign. Do not sign a Completion Certificate(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 Home Depot the costs of materials, tabor,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 OFSUCH AMOUN'T'S.
Accetttanee 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 and supersedes all prior discussions and agreements,tither
oral or written,relating to said Products and Installation.This Agreement cannot b signed or ameridad except by a writing sighed
by Customer and The Home Dcpet.Customer acknowledges and agrees that CLLSt as read,understands, voluntarily accepts t}.,
terms ofand has received a copy of this Agreement.
Acce teed-b Submitted b
-Cim
Custom is Sint are Date Sales Consults ature Date
X Telephone iV
Customer's Signature Date
Sales Consultant Liccnso No.
CANCELLATION: CUSTOMER MAY CANCEL THIS (ns apFticahlet
AGREEMENT WITHOUT PENALTY OR OBLiGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME (d t � �. f 2
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS 11`
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
The Comnzanwealth of_114ssachuseits
Department of1ndustrialAccidenis
a
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electriciaris/Plumbers.
TO BE FILED WTTH TBE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):--_-- �' U
ailAddress:
City/State/Zip: 3MJ Phone#:
Ar;you employer?Check the appropriate box: Type of project(required):
1. employer with COI) employees(full and/or part-time).* 7. New construction
2.❑lam a sole proprietor or partnership and have no employees working for mein $. Remodeling
any capacity.[No workers'comp.insurance required.]
9. Q Demolition
3.Q I am a homeowner doing all work myself[No workers'comp.insurance required]t
4.❑I am a homeowner and gill be hiring contractors to conduct all work on my property. I will 10 Buzlding addition
ensure that all contractors either have workers'compensation insurance or are sole 1.1.[]Electrical repairs or additions
proprietors with no employees.
. 12,E]Plumb' epairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. R re airs
These sub-contractors have employees and have workers'comp.insurance.$ P
6.Q 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 workers'compensation policy information
t Homeowners who submit this affidavit indicating they aro doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors 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.
lam an employer that 1s provkUng workers'compensation insurancefor my employees. Below is thepolicy andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic,M. } Expiration Date: c7 ,
Job Site Address: V City/State/Zip: I rr
Attach a copy of the workers' compensation p 'cy declara oa page(showing the policy num er and expiration ate.
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 co of this statement may be forwarded to the Office of Investigations of the DU for insurance.
coverage verification.
I do hereby cerdb unit the airs atti perjury that the information provided above is true and correct
Si ature• Date:
• Phone#:
Official uose only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Towri Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
8
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor.. Not Applicable ❑
Name of License Holder: I 1
License Number ,
MCI
Uignat Expiration Date
Telephone
.Registered Home Improvement Contractor: Not Applicable ❑
Company Name ' '� Registration 17=15er
Address Expiration Date/
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,F 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 ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 171
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks Siding[p] Other[a
Brief De f o
Work: )✓J
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 toexistina 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 constr tion 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
I, ,L 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.
Signature of Owner Date
I' 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.
•�
PH a
r--
A Znvrl,Sign 61 61 Agen Date
Department use only
-- Bt� f Northampton Status of Permit
I
FElectri ng Department Cur b Cut/Oriveway Permit
2V Main Street Sewer/Septic Availability P 17 201 oom 100 Water/Wefi AvailabiliNo la pton, MA 01060 TWO Sets of Structural Plans
umbi y ups ._ 240 Fax 413-587-1272 Plot/Site Plans
h"mpton, lti9A 01060 Other SpEGfy
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
Eim St District CS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Rec rd:
Name(Print) Current Mailing Ad re :
Telephone
Signature
2.2 Authorized A ant:
e.
Name(P t) Cuiretlr l ailing Ad�dreesss:
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) 1,Check Number
This Section For Official Use only
Date
Building Permit Number. Issued:
Signature.-
Building Commissioner/Inspector of Buildings Date
16-18 PAQUETTE AVE BP-2016-0387
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B -002 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl g BUILDING PERMIT
Permit# BP-2016-0387
Project# JS-2016-000625
Est.Cost: $15104.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 99209
Lot Size(sg. ft.): 95962.68 Owner: WALLACE GERARD R&JEAN M C/O BARBARA HAVERSAAT
Zoning:URC(100)/WP(14)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 16-18 PAQUETTE AVE
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.912112015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING
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 9/21/2015 0:00:00 $60.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner