17C-083 (5) Nov 041507:28a P.1
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold•furnished and Installed bw.
Branch Name:Boston North&South Dater�a l K THD At-Hemc Service,-.,Ine-
d/Wa The Home Depot At-Home Services
Branch Number:31 and 33 906 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free 877-903-3768
Federal Ill#75-209");ME Lic#C 02439;RI Cant,t.ie#16427
cwt CT Liicc$HIC(t56552?:MA lionieglmpnrownient Co t actur Reg.#125893
Installation Address: ' J+ 1R D_ttQooQ_ CVLWr c>t��
--� City State Zip
Purchastr(si: Work Phone: Home Phone: Cell Phone:
SA! A [ l C l [ I
Hoene Addrew
(If ditTerent li•txn Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
0 1 DO NOT wish to receive any marketing emails from The Home Depot
Proieet Infotmation: Undersigned(-Customer").the owners of the property ionated at the above installation address.agrees to buy,
and THD At-Horne Services.Inc. ("The Home Depot')agrees to furnish,deliver and arrange for the installation("Installation")of
ull materials described on the below and on the referenced Spec Sheens),all of which are ineorpometed into this Contract by this
reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively.
„Contract"):
,lob##: Ir-M ws nxr' oducts; Spec Sheet($)#: Project Amount
Roofing S.ifi+igJ insulatio.r
Vv_5 1 4 ❑Gutteri 1 Covers t❑Eniry Doo s ❑ �t l2..3 7 $ ✓�� ` /n ,
Roolin; Siding, Windows Insulation U
❑Gutter~/Covers[]Entry Dxrs ❑
Rnoting []Skiing C3 Windows Insulation
❑Gutters/Covers ❑Entry Doris El $
Roofing Siding V15nr.owz Ll Insulation
❑Gutters/Covers ❑Entry Doors ❑
NUnlimum?5%Deposit of Contract Ara w t due upon ertecvtim of the contract. Total Contract Amount 1%
Maine Purchasers may nit deposit more than one-third orthe Contract Amount
Customer agrees that,immediately upon completion of the work for arch Product,Customer will execute a Completion Certificate
(one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this
Contract as ces to be jointly and severally obligated and liable hereunder.
The Horne Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,if The Home Depot or its authorized service provider determines:hat it cannot perform its obligations due to a structural
problem with the home,environmental hazards such as mold,asbestos or lead paint.other safety concerns.pricing errors or because
work required to conipicte the job was not included in the Contract.
Payment Summary: The Payment Summary# [d2�2!EnL:�? . included as part of this Contract.sets forth the total
Contract amount and payments required for the deposits and final paymiettts by Product(as applicable).
NOTICE TO CUSTOMER
You art 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 detltted by individual Spec Sheets)before work on that Product
is emplete.
In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses
and services providLd 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 DBPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH ANIOUNTS.
Acce�tece and Authorisation: Custorer agrees and undersunds that!hiss Agreement is the entire agr•eentew between Customer
an 'fate Home[?c pot with regard to the Products and Installation services and mu.xrsotles tall prior discussions and agreements.either
oral or ua-iucri relating to said Products and Installation.This Agrccmcnt cant . assigned or amended except by a writing signed
by Customer and The Nome Depot.Customer acknov,ledges anJ agrees ilia uston r La;read,understands,voluntarily accepts the
ternis�of• d has received a copy of this Agecmcnt.
A cc awl by: Sttbni'
C er s Sigrtantre Date S es Ilant's Sitnature Date
X Telephone No.
Ci+l()nler,S;. nature Date
Sales Consultant Lie-cc scNo.
CANCELLATION: CUSTOMER MAY CANCEL THIS
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME ���� JV b
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFT911 SIGNING THIS AGREEMENT. THE
STATE SUPPLEINIENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPEC IFICALLY PRESCRIOED BY LAW IN
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The Commonwealth of Massachusetts
(� Department of Industrial Accidents
j I Congress Street,.Suite 100
Boston,MA 02114-2017
wj iv.nzass.gov/dia
'Workers' Compensation insurance Affidavit:Builders/Contractors/EIectricianslPlumbers.
TO BE MED WITH THE PERIIV=G AUTHORITY.
Anolicaut information Please Print Leaiblv
Name(BLSineSS'Oreanizationllndividual): / � y✓ �� SIB
Address: � �� L--�e
City%State/Zip 1L:! -� iQ' �� Phone : �1 ����
kre you an employer?Check the appropriate box: Type of project(required):
1.7 I Sri a employe:x;th employees(full ardor pa n-tits^_).'
7. ❑New construction
2.l,_1 t am a sole prow etor or partnership and have no emnloyccs worl y_ for me in S: ❑Remodeling
a1v capacity.rNo workers'comp.insurance reau.,_d.]
3.7 r;: a hameow n.,r d^ir.7-'!,rar'.:rt,self[\o v:or::ers'comp inn rnnc:required i t
1 ❑Demolition
4.7 1 am a homeowner and will b:;hiring contactors to conduct all wort:on my prone j. I will
10 j�Building addition
tasrrre that all contactors either have workers'compensatioa insurance or are sole 11.❑Electrical repairs or additions
M=rietor writ no employees.
12.❑Plumbing repairs or additions
a general contractor and i have hi,---d the sub-contactor listed on the attached sheet. 13.❑Ro i repairs
I nose sub-con�ctor,have employees and have•.vo.tiers'cot=p.L-surnce.r
o.L j'�G'e arc a corporation and its o*_iicer have exeriscd their right of exemption per hiGL c.
14. ther �9��
j
152,F 1(4),and we have no employees.[\o workers`comp_insurance required.]
f v applicant that check box=i must also a1 out the section belo x showing their wo,-ker'compe nsation policy information.
Homeov,-ners who submit this ari_da;it indicating they are doing.,tt worl:and then hire outside contactors must submit anew afndavit indicating such.
=Contr_-ciors that check tis box must atzac'n°d an additional sheet show•ina the name of the sub-contactors and state whether or not those eetiris have
employers. Ii me sub-ceatru-ctors have cmployecs,they must oro%ide t'ae w orkcr'come.policy numbcr.
1 am an employer tisat is pravidirj!+arbors'cainpensatiox iiisrn mice far iiry emplol ees. Below is the polio; and job site
information.
Insurance Company Name: I�G( t/ / ✓ ' ' /t/��� y ���� ' �'
Poliey or Self-ins.Lic. G �f-//fG �Z>- Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the`5•orlcers' compensation policy declaration p a a='shoeing the poli cy number and expiration d?te).
Failure to secure coverage as required under iAGL c. 15 2,§25A is a criminal violation punishable by a fire up to 51,500.00
and/or one-year l,-apnso=cnt,^s "eL as^i•:'il penalties in the fc^t of a STOP WORK.ORDER and a fine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DL4 for insurance
coverage verification.
1 do hereby cer ti nald eijury that the information provided above is true and correct
Sigma / ��r�✓— _ Date:
Phone;-
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License r
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Pltmbinb inspector
6.Other
Contact Person: Phone r:
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 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:
The debris will be Y
transported b
P
The debris will be received by:
Building permit number:
Name of Permit Applicant
c
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £ �--
Name of License Holder
knt? 7 ��^�� �
License Number
Address Expiration Date 122 P-10121-71
Signaturi Telephone
9.Re'is.tered Homeam roveme t Contactor __,__.:�� .___.:__ _._..__ :__ Not Applicable £
Company Name T Registration Number��
Add e s /'- Expiration Date
goy-A-11 ® �� A I 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...... £
'll : Home Qwner.<.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 ows Alteration(s) ❑ Roofing ❑
Or Doors em J
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks Siding[❑] Other[❑]
Brief Description of Proposed lyre"
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa;``lf New house:and:oradtli#ion to existing:houslrng, comtolete_ 6&716wlncf.:
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
L 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 al matters lative to work authorized by this building permit application.
Signature of Owner Date
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 pains ,nd penal'es of per' `
Print Name
Sign e of Owner/Agent Date
AN
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Tl�is column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
B dg. Square Footage 0
Open Space Footage %
(Lot area minus bldg&payed
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
v�� x�� ����
NO �� DONTKNO� �~� YES
/F YES, date issued:
|FYES: Was the permit recorded at the Registry ofDeeds? /
NO �� YY D�NTKNQ YES '
�_/
/F YES: enter Book Pagel and/or Document#
��
B. Does the site contain u brook, body of water nrwntiands7 NO ����� DOH7KNOYY ��/ YES .4����
�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �-� Obtained �~� . Issued:
k_� �~� ' ~~^~ '
C. Do any signs exist nn the pnoperty �� ��� YES �,� NO �,�
IF YES, describe size, type and location:
D. Are there any propo.sed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E VViU the construction activity disturb(clearing, gradingexcavation,or filling)over 1 acre orioit part ofa common plan
' that will disturb over 1acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required. �
/
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City of Northampton ?� .�
Building Department ay
yL!
l
l-ermi# "
n der 4 r
212 Main Street j r$ptieAvallabi► y '
Room 100 t/Vater/Vrfel�Rva�lability ' F t il 3
Northampton, MA 01060 TwaSet`s ofStruc#urai Plans y _ 1 "
— .. ._ -:-:.:r,.et`S„r="s-v.;;
phone 4 ax 4 -5 - PloflSite,FPlans � �,t
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE,INFORMATION
:::_::_.-:____:�r____::�-,This.sectiorr:fo:,be:com le ed.b:'-office'-;.:_.
1.1 Property Address. _,:_a,:.,_.__.;:_:__.__:_,-_::::-:.—:_.,:::,- _:.._,_.:._.�.--
ZzTl
= 1
SECTION 2—2.=PROPERTY OWNER..SHIP/AUTHORIZED AGENTT-
2.1 Owner of Record:
Name(Print) JJyJ Current Mailing Address:
{ ►�� Telephone
Signature
2.2 Authorized ent: r^
O.
Name(Pri Current Mailing Address:
Sig re 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 (6)'Estim6ted Total Cost of
Construction'from fi
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 Onl
Date
Building Permit Number: Issued:
Signature:
Building Comm issioiier/Inspector'of Buildings: Date
53 11161-I ST BP-2016-0733
GIS#: COMMONWEALTH OF MASSACHUSETTS
MapBlock: 17C-083 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Cat2soi-N,: windows replaced BUILDING PERMIT
Permit# BP-2016-0733
Project# JS-2016-001230
Est. Cost: $3989.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Coast. Class: Contractor: License:
Usc Group: HOME DEPOT AT HOME SERVICES 98785
Lot Size(sq. ft.): 10715.76 Owner: KIRITSIS SARAH F
Zoning. URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT. 53 HIGH ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.12/1/2015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 4 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:
DriNeway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
TIIIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeTvne: Date Paid: Amount:
Building 12/1/2015 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner