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Oct 2615 05:57a P.
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold.Furnished and Installed by:
Branch Name:Boston North do South Date:AZ-; l THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
Branch Number:31 and 33 91.18 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll FA-cc 577-903-3768
Federal 11)#75-2W8400:ME Lic#C 02439:R[Cont.U0 16427
CT Lac it H[C.0565522.MA Fkmie Tmprovcmeni Cantracto Reg.it 126893
Installation.Address: 3 ��cs�C S+ AL jv Q fo.�,L _
City State Zip
I'urch stet(sl: Work Phone: Home Phone: Cell Ptmne:
Home Address:
(If dill'erent from Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑1 DO NOT wish to receive any murketing emails from The Home Depot
Project Information: Undersigned("Customer-).the owners of the property located at the above installation address,agree 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 Sheet(s). 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"):
Joh ti: I,a""e.t.r...ra 1' gets: slug:Sheets)# Project Amount
57OLt) Ronf.ag Siding Windows IrrsuladOO
V f OLt! ❑Gutuxa/Coven ❑Fnnry Dax ❑— Q Z S 2 C' 4
Roofing Sidinc U Windows Insclation
❑Gunors/Covon []Entry Doors ❑ $
Roofing LISiding 0 Windows [nxtlatiun
❑Gutters/Covers ❑Entry Doors❑
Roofing ElSidine LJ Windows LJ Insulatitm
❑Gutters/Cover.❑Entry Drxnrs ❑ I
hliralnwnn25%DeposildCootract AmonntdueWonexecutionofthiscontract. Total Contract Amount
Maine Purchasers may not deposit more than une4hird of the Coulntct Amount. $
Customer agrees that, immediately up m completion of the work for each Product,Customer will execute a Completion Certificate
(one for each Product as defined by an individual Spec Sheet)and)ray any balance due. As applicable,each Customer under this
Contract ag ees to be jointly and severally obligated and liable hereunder.
The Home Depot recerveN the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,ifThe Home Depot or its autharized 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 the job was not included in the Contract.
Payment Summary: The P.tymer.t Summary # ti 2-3 Z 7C included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and linal 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 Produe
is complete.
In the event or termination of this Contract,Customer agrees to pay The Home Depot the costs or 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 alloyed under applicable taw. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROMI THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPO'T'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance 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[nstailation services and supersedes all prior discussions and agreements,either
oral or written,relalin,to said r3•oducw and Installation.This Agreement cannot be assigned or amended except by it writing signed
by Custorncr and The Home Depot.Customer acknowledges and agreeg that u 'r has read,understands, voluntarily accegntS the
terms of and has received a copy of this Agreement.
Accepted h I Sub ed *0 -TTM
CuStoller's Signature Dote r Sal . C tart's SigraCure Date
X i Telephone No.
Customc:-s Signal tre Date
Sales Consultant[,ieense No.
CANCELLATION: CUSTOMER MAY CANCEL THIS
AGRLri:MENT WITHOUT PENALTY OR OBLIGATION rrr
BY DELIVERING WRITTEN NOTICE TO THE HOME � ( � 636 -� ��
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS 1 [
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORNI TO USE IF ONE IS
SPECIFICALLY PRFSCRIII'a3D BY LAW IN
City of Northampton 212 Main Street, Northampton, Na 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 Bui lding 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: � � y-
/w,
The debris will be received by: Yv�✓� h\
Building permit number:
of Permit 2,e2
Name Applicant
Date Signature of Permit Applicant
i
`�� ___
The Commonwealth of MassachuseUs
(' Department of Industrial Accidents
j. I Congress street,suite 100
Boston,MA 02114-2017
wr.>f mass.gov1dia
Workers' Compensation Insurance davit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERIMITTING AUTHORITY.
r licant Information Please Print Legibly
1\a>ile(Busines:.rOrganizatioi)!Individual): �! v✓ � sr� �i-'�
)2"24P
Address: /r� ��'; � _' s
City/Staff:./Zip: 7/V 4 t4, � j Phone n: i ���e
Are ou an enplocer?Check:the appropriate bps: Type of project(required):
1.n 1 aura a=ploycr with employees(full anal or par time).' 7. F�New construction
2.1 1 ant a sole proprietor or partnership and have no employee_wo kin_ for me in 8. F�Remodeling
e y capacity.PKo worker'comp.insurance renu:rrd.]
3.(� ,m o r ,t- p. ❑Demolition
(.... 2 F, men uv° d^r� -..•!•ar..n;s_L.(tip v:a..�^rs'cars. -!❑ranee rqu!rer!�&
i 10 j7 Building addition
❑4. I am a homeowner aad will be hirng contractors to conduct alt wort:on illy proper_:. I will
e-sr:re that all contractors either have worker'compensation insurance or are sole l l.❑Electrical repairs Or additions
p rietor with no employees.
12.0 Plumbing repairs or additions
II 5. I..n a general contractor and!have hiied the sub-coanctor listed on the attached sheet. 13.❑rRrf repairs Tnese sue-contractor,have employees and'nave��o ^-rs'coil^_.i.surance? 14. t er 1�f i,vl��
I n.�j',Ve are a corporation and its o*_i�cers have exercised their rigtt:of exemption per,n•fGL c.
152,,'1(14),and we have no employees.[\o worker'comp,is seance required.]
'Any applicant that checks box=1 must also 51 out the sec;ioa blow•showinn their worker,'compensation policy information.
Homeowners who subn_i:this aricda.it indicating they,are doing all):corl_and then hire outside contractors must submit a new affidavit indicating such.
=Contractors that check guts box.must attached an additional sheet show•ia_the name of the sub-contractors and state wbcthcr or not&rose ee7ties have
employees. Iftu sub-contn-ctorhave employees,they must provide this workers'comp.policy maiubcr.
1
am an Ci??p1Ck'CY that is prOYidi7rJ)i'orn-CI-S'conrpellsatiorl inSUra;ice for n)y enrploi'eeS. Below is the policy and job Site
ItIfoY11IQ11oti. /t / � U)1 .�--
Insurance Company Name: !�L i/ % ✓ j / / �� __L�V t ��'
Policy or Self-ins.Lie.-: (i d /U_1�LC� Expiration Date:
Job Site Address: L�/ City/State/Zip: .
Attach a copy of the ivorkers' comp cation policy tieciaratiort pag:=(shor inb the policy number and e. 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
and/or one-year intpriso^rear;,s:"°ll up o£2 0ru a p iY fi -
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DLk for insurance
coverage verification.
1 do hereby ce;ti r aJrl�atld raltiec - erjul} that the infonnation provided above is true and correct
Siena _ Date:
Phone
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: PermitlLicense r
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':
SECTION 87 CONSTRUCTION SERVICES
8_1 Licensed Construction Sue issoo(r: Not Applicable £
Name of License Holder. ft/�" ""
License Number
Address Expiration Date
Signature Telephone
9 Reaisfered-Homearr rovement.Contracto Not Applicable £
Comnany Name Registration Number
AddrWs Expiration Date
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 Hone owner Egenpton
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 lomeowner.
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' Coreapensation) 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 Wi ws Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[[31
Brief Desc d �-�,l
Work: I .r�/' �i ✓ /� �' �'Y/ �°�J1 rJ T✓
Alteration of existing bedroom Yes No Adding new bedroom tes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.if New house and oradd! f' W to exlsfinq houslng,-'cornpfete fhe:following:
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
as Owner of the subject
property
hereby authorize
to act on my behalf, in all maters relative to work authorized 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 th"ains nd penalties of per'ury. `
Print Name '^
Date
Signature of 0 e ent
I
t
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:'-- f R:= L:—� R:
Rear
Building Heights
Bldg.Square Footage
Open Space Footage __3 %
(Lot area minus bldg&paved
parking)
#of Parking Spaces �-3
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES Q
IF YES, date issued-r-
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 1 YES Q_
IF YES. enter Book I Pagef- and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES Q 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 0 NO Q
IF YES, describe size, type and location: _
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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
� ,t
Y
f Northampton
ta1U&, ��rFllft
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uild ng Department ,Curb cui'IDr ova ;P _
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a'�.;.1!,: :�'.;=;�-
21 Main Street Sewer/SepCcAvatrafilhty t ;
MAI
Room 100 3/VeterlVVeiA'va,lability i i 1 i a a v i7'
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L_ _-, N rth mpton, MA 01060 Twa�SefSaflSt>uctur'a}Plays ::iii �I t!
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r o, -58 -1240 Fax 413-587-1272 P[ot/Slte Plans"
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i,l 0'f r0 Other S'�eClr' !Rua-
MAN 1 r F r 2 Uie I t 1 1
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This sectiarrltobe°c:om'°lefe.duti.:-office`- ? `i ;=# ; .,:;
Pro a Address.
it
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�� � Zone [ , Overlay Disfrtctr _ �
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED.AGENT:
2.1 Owner of Record:
L �
Name(Print) / Current Mailifig Address:
/ Telephone
Signature
2.2 Authorized ent: IWA
Name rir Current Mailing Address:
S' ature Telephone
SECTION 3-ESTIMATED CONSTRUCTION"COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building --'����yy�J �y /� (a) (3uilding Permit Fee
2. Electrical (b) Estimated TotalCost of
Construction from(8):!
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
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 Commissfoner/Inspector of Buildings Date
36 HOLYOKE ST BP-2016-0691
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-248 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-2016-0691
Project# JS-2016-001163
Est. Cost: $2044.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 92937
Lot Size(sq. ft.): 4181.76 Owner: ALTSHULER DANA
Zoning: URC(103)/ Applicant: HOME DEPOT AT HOME SERVICES
AT. 36 HOLYOKE ST
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON:11/18/2015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 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 11/18/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner