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Sep 2215 05:00a P.
HOME IMPROVEMENT CONTRACT r
PLEASE READ THIS
o / Sold,F� urn ished and Installed by:
Branch ltiame:Batton Nort4&South Date:!t�� THD At-Home Services,Inc.
dlb/a The Home Depot M-Home Services
Branch number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,USA 01545
Toll Free 877-903-3766
Federal ID 9 75-2698460;ME Lic 4 C 1)2439;R1 Cont.Lich 16427
j� CT Lic#HIC.0565522:MA Honta Improvement Centracter Rc*.4 126893
Installation Address: ( ..(= 12iA �� f76,0_6.� �
City State Zip
Purchaser(s): Work Phone: Home Phone: Cell Phone:
[ ] C l Cyi31tS o7C
Home Address_
(if different from liistalla�ion Address) City State Zip
E-mail Address(to receive project communications and Home Depot updztes):
100 NOT wish to receive any marketing emnils from The Home Depot
Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
ant THD At-Home Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installar•on ("Installation"I of
all materials described on the below and on the referenced Spec Shect(s), all of which arc incorporated into this Contract by this
-efercnce,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively,
"Contract"):
Jobtl: q" ""`ua'r`"": raducts Spec sh s d: Pro'ectAmount
Roofing LjSiding Windows Lj Insttlatiw:
❑Gutters;Covers ❑Entry Doors ❑
Roor"ng Siding Windows lnsulatiat
❑Gutters/Covers ❑Entry Doors ❑ S
Rooting LjSiding Windows 0 Insulation r J/
❑Gutters;Covers ❑Entry Doors❑ $
Roofing Siding Windows L3 Insulation $
❑Gutters l Covers ❑Entry Doors ❑ �..' l
"nimum2i%Deposit ofContract Amount due upon execution ofthiscontract. Total Contract Amount
Maine Purchasers may not deposit more than cat-third of the Contract Amount.
Customer agrees that, immediately upon completion of the work Por each Product,Customer will execute a Completion Certificate
(one for each P7MUCt as defined by an individual Spec Sheet)ant pay any balance cuc. As applicable,each Customer under this
Contrct agrees to bejointly and severally obligated and liable hcrctmder.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,of
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 paint,other saf:ty concerns,pricing errors or because
work required to complete thejob was not included in{{tic Co tract.
Payment Summary: The Payment Summary is ll�7 1 lJ included as part of this Contract, sets forth the total
Contract amount and payments required for tEc deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filled-in 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 ternsination of this Contract,Customer agrees to pay The Home 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.
Acce lance and Authorization: Customer egrcos and understands that this. cc nt is the entire agreement between Customer
and The Horoc cpoiwiwit t regard to the Products and Installation services an s ersed all prior discussions and agrcemc:tts,either
oral or wriaen,relating to said Products and Installation.This Agreement n t e as igned or amended except by a writing signed
by Customer and Tits Home Depot. Customer acknowledges and trt,7.re :th : in has read,understaands,voluntarily accepts the
terms of and has recciv opy of this Agreement.
Ac b Submit
X ,,�
;C
Custom 's Signature Datc S on Ita"s Signature Datc
X Telcphcne No.
Customer's Signature Date
Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS as applicablc)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME ) ',
DEPOT BY MIDNIGHT ON THE THIRD BUSINES -5,3,
1
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO US13 IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
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 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:
:
will be transported b V�' a ��
The debris p Y Tz
The debris will be received by:
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
RL Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.rnass.gov/dia
'Workers'Loma_ensation.insurance davit:Builders/Contractors/}lec triciansiplumbers,
TO BE FT ED WITH THE PERMITTING AUTHORITY.
Applicant Information PIease Print Legibly
Name usiness/Or anization/lndividual : �✓ / !/f ' -PO
Address: i�j�✓ �'� 7r u' 6��''� �"
Ci /State/Zi / ��->✓� Phone : I'
Are you an employer?Check the appropriate box:
Type Of project(required):
LE]I am a employer with employees(full and/or part-time).= 7, 0 New construction
ion
I am a sole proprietor or partnership and have no employees working for me in S. E]Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.❑I a a'eomenwner do ng all work myself.[IQo.vor e 'camp. r suraace required.l'
10 ❑Building addiiion
k.�I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractor either have workers'compensation insurance or are soh: 1 I.[]Electrical repairs or additions
ppfri=nwith no employees. 12.F ]Plumbing repairs or additions
d. i/I am a general contractor and I have hired the sub-contractor listed on the attached sheet. 13.[ f repairs
T-aese sub-contractor have employees and have worker'comp.insurance.-'
6.�we area corporation and its officer have exercised their right of exemption per rulGL c. 14. Other
152,§1(4),and we have no employees.flQo workers'comp.insurance required.]
'`Any applicant that checks box.--'I must also fill out the section below showing their workers'compensation policy information.
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 ornot those entities have
employees. if the sub-contractor have employees,they must provide their workers'comp.policy number.
1 ant an employer that is providin a workers'compensation insurance for my einployees. Below is the policy and job site
ri1f01711 rttipt:. ` ,y ' i-
Insurance Company Name: ( �k2 e l/�
Policy 4 or Self-ins.Lic. `: �I/C� D� �C?2� Expiration Date:
�'
Sob Site Address: !/ ELF 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 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 DLA for insurance
coverage verification.
I do hereby certi and nahle ejury that the infonnation provided above is/true and correct
Siena Date:
Phone—l"':
Official use only. Bo not write in this area,to be completed by city or town offi=rano,
City or Town: PermitlLicense #
Issuing Authority(circle one):
1.Board of Iffealth 2.Building Department 3.City/'I'own Cleric 4.Electric
6.Other
Contact Person: Phone�:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Appli able £
Name of License Holder
License Number
Address / Expiration Date
Signature Telephone
D)4 �✓ /-�
9 fRe' isferedHome lm roveme Contractor: ... Not Appl able-4
Company Name Registr 'on �be
b
Ad e �j I Expiration Date
' (f�
Telephone O)
SECTION 10-WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c..152,§26C(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 = Hone owner Egelnption
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.
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition [] Replacement W_ �ws Alteration(s) F7 Roofing
Or Doors 2
Accessory Bldg. ❑ Demolition ❑ New Signs (❑] Decks [M Siding(❑] Other(01
Brief Descriptio of Pro
Work: J Ale
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ea If New house and_or.-addlfion to existing:flousin'q, coripfetefhe..fo lowing:
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 900 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 TOR,BUILDING PERMIT
I, as Owner of the subject
property
hereby authorize � !�
to act on my behalf, in all matters relative to wor uthorized by this building permit application.
Signature of Owner Date
I, ,'� as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under tDoVains penalties of
r
Print Name
d >-�1 -�
Signature of Ow r/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size '
Frontage
Setbacks Front
Side L:° I R:= L:i ? R:I 1
Rear i----�
Building Height
Bldg. Square Footage )- Yo T--
Open Space Footage
a-
(Lot area minus bldg&paved
parking)
#of Parking Spaces --- r =--`
Fill: i rt
Y
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES 0
IF YES, date issued: -- II
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#z
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q 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 Q NO 0
IF YES, describe size, type and (ocation:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
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 9 acre? YES Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
• i
J ;I
- I
'' pepartment use only � ,+
MIT City of Northampton State$of Perrrrit
Building Department c�rrh CI�r�Drirteivay I?ermif r i r
212 Main Street Sewe�lSepcAuaila611rty u i
Room 10 y 0 �liJeteral�Ruailabill Northampton, MA 01060 Two Set 'one 413 587 1240 Fax 413-587-1272 O CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This sectiorrfo be completed byoffice
1.1 Property Address: - - - _
-_:_;
Zone _ d ,_., Overlay D�sfrict = _ -
-EI Mr.St:District GCB-Disstrict
SECTION 2-:-PROPERTY OWNERSHIP/AUTHORIZED:AGENT:
2.1 Owner of Record:
yA
Name(Print) Current Mailin Ad ss: �!/r
Telephone
Signature
2.2 Authorized ent:
Name( rin Current Mailing Address:
Sig ture Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed b permit applicant
1. Building 7p
'(a)Building'PermitFee
2. Electrical (b)'Estimated Total Cost of
Construction from(8):'
3. Plumbing Building Permit Fee
k 14. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Officiaf Use Onl
Date
Building Permit Number: issued:
Signature:
Building Ctlmmissioner/lnspector.`of Buildings: Date
560 BURTS PIT RD BP-2016-0548
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30C-075 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-2016-0548
Project# JS-2016-000905
Est. Cost: $5370.00
Fee: $40.00 PERMISSION IS HEREB Y GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 105953
Lot Size(sq. ft.): 33279.84 Owner: DUNN JENNIFER L&SETH J
Zoning (100 WSP(100) Applicant: HOME DEPOT AT HOME SERVICES
AT. 560 BURTS PIT RD
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.10/21/2015 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 Signature:
FeeType: Date Paid: Amount:
Building 10/21/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner