31D-243 (2) Nov 10 15 07:17a p.1
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
r f Sold.Furnished and Installed b}^
Branch Name:Boston North&South Date<<1_l 1 G? THD At-Home Services.Inc.
dthk The Home Depot At-Home Services
Branch Number:31 and 33 908 Boston Tumpise.Unit I.Shrewsbury,MA 01547
Toll Free 877-903-3768
Federal tD h 75-20,98400.RIE lie#C 02439;RI Cunt.Lie#16427
t N 1.� # �i1 :� ume Improvement Contri cto t Re�g.#
126893
Installation Andreas: 139 s C n� of o c
City
State Zip
Purcbaser(s): Work Phone: Home Phone: Cell Phone:
[ J C l [ l
Horne Address:
(If different from Installation Address) City State Zip
F-mail Address(to receive project communications and Home Depot updares}:
❑I DO NOT wish to receive any marketing errecils from The Home Depot
Pro'eect Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
and THD At-Horrw Services,Inc.('The Horne Depot")agrees to furnish,deliver and arrange for the installation("installation")of
all materials described on the below and on the referettxd Spec Shect(s). all or whicli arc incorpor-atcd into this Contract by this
reference,alms with any applicable State Supplement:and Payment Summary attached hereto and any Change Orders(collectively,
"Contract'):
Joh*' 00a "k^'" Products cc Shcct(s)# Prri eci Atrwunt
-�q Rooting Siding Wic�luws Insulation I
517 f ❑Gutter.:/Covers (.1 Entry Doors ❑ ((j Z�c-9� $
Roofing 'Sicfrne Winduivs L3 Insulation
t
❑Gulls'~!Covers ❑Entry Door; M
Rnoling Siding Window~ El Insulation c5
❑GuucrslCcncrs ❑8mry Dour%C_
Roofing Sidiap 0 Wirtims LJ insulation
❑Guteene Covers ❑Entry D,rors Cl
I
Mniwi=25%Deposit ofContractAinaunk due upon execution of this contract. Total Contract Amount $
Maine Purchasers may not deposit more than one-third of the Cotrtrad Amoont.
Customer agrees that. immediately upon completion of the work lint each Produci,Customer will exe ate a Completion Certificate
(one for each Product as defined by an individual Spec S'.teet)and pay any balance due. As applicable, each Customer under this
Contract agrees to be jointly and severally obtigated arid liable hereunder.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(;)included herein.a:
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 mod,asbestos or lead paint,outer safety concerns,pricing errors or because
work required to cotnptete the job was not included in the Contract.
Pavrneot Surtemary: The Payment Summary 4t l JJ.7:5C1 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 are entitled to a completely Mled-in copy of the Contract at the time you sigh. Do not sign a Completion Certificate(note:
there is one Completion Certificate for each listed Product as defined liy 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,labor,expenses
and services provided by The home Depot or Authorized Service Protider 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 agrL s and understands that this Agreement is the entire agreement lrcnvccn Cltslomer
and The Hare Depot with regard w the Products and Installation urviccs and supersedes all prior discussions and agreement"either
oral or written.relating to said Products and Installation.This Agreement car assigned or amended except by a writing sisneC
by Customer Lind The Home Depot.Customer acknowledges and age is.that ust to has read,understatds. voluntarily accepts the
terms of and has received a copy of this Ar cement.
�Atcce ed � Subs"led' y:
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Custom' Siggnaturc DIle Sales 't - nt'sSigna:arc Dale
X Telephone No.
Customer's Signature Date
Sulcs CtwsutL'art License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS
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 SUPPLrMENT ATTACHED HERETO z j
CONTAINS A EO%M TO USE lF ONI; LS
SPECIFICALLY PRESCRIBED BY I.AW IN
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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: UAO) I
The debris will be transported by:
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The debris will be received by:
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
The Commonwealth of tllassachusetts
Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston,M-A 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERAffrMG AUTHORITY.
ADDIicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: �� ;�
City/State/Zip:{ ��� Phone :
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full andior pa.-time).' 7. ❑New construction
2.F_1 I am a sole proprietor or oarmc.sttip and have no employees working for me in g. F1 Remodeling
any capacity.[No worker'comp.insurance required.)
3.71 I am a homeowner doing all work myself.[\o worker'comp.isutance required.}t
9. F1 Demolition
4.❑I ant a hoy=owner acd will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractor either have wor::crs'com_oeasatton insurance or are sole 11.0 Electrical repairs or additions
n. netoa�;�no employees. 12.�Plumbing repairs or additions
3. I am a gcoeml contractor and I have hired the sub-contractor listed on the a�cbed sheet r
i nese stitrconuactors have employees and have workers'comp.insur.�ce 13.[�Other
repairs
6.7�G'e are a corporation and its of-ccr have exercised their right of exemption per NIGL c. 14. Other
1521§1(4),and we have no employees.[No worker,'comp.insur a-ce required.]
°Any aaolicaat that checks box rl must also fill out the section below sbowing weir wor ers'compensation policy information_
t Homeovse„who submit this affidavit indicating they are doing at1 work:and*ten hire outside connector must submit a new affidavit indicating such.
-Contractor that check;this box must attached an additional sheet showing theme of the sa -conzactors and state whether or not those entities have
employees. Uthe sub-contractors have employees,they must proNide then wrorse.�'cpmp.policy number.
I am an employer that is providing work-ers'compensation insurance for my employees. Below is the policy and job site
information. /
insurance Company Name: 1/�F�/l(/i/t�
Policy or Self-ins.Lic.r: � ��� 2— Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and ecpiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00
and/or cne-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 certi and naltie erjury that the information provided above is true and correct
Sisna /`� Date:
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Phone r' i/
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License
I Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Towit Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone R:
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisory:,, Not Applicable £ f )
Name of License Holder: y//v !e ` 6_"N 7,dam/
License Number
—/4�
Address r— Expiration Date
Signature Telephone
9 'Re istered::Home m rovement" ontractor: ., Y_,_ ____..,._ Not Applicable £
Company Name Registration Number
ACV
Addre Expiration Date
�`"�� y /��;r✓ Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§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�Egempton'
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.CNM 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 buildine 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.
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement Wi Alteration(s) E] Roofing F7
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other[o]
Brief Descriptip o 0 o
� ed ��,(� � ��j��r����►� J�1 �6 �j,�G! ®�+�( /
Work:
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.ad a,.complete fYie followmc:
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 TOR.BUILDING PERMIT
as Owner of the subject
property 12)ddep hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, T�OL& 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 and a pa; and penalties qury. '
Print Name t
)7
Signat Owner/Agent Date
f
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:` ) R: I L:? _R:I
Rear --
Building Height E
Bldg.Square Footage
Open Space Footage _ % — r---
(Lot area minus bldg&paved I I parking)
#of Parking Spaces ---- -----`
Fill: a
E I`
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES Q
IF YES, date issued:; {
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book Page ~ ^J and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained O , 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 Q NO Q
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.
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58 �Lggm g.LL j Department�use Drily , 1
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ity of Northampton Status ofPerfn�t " ' 1 r� 1' µ'�
i q Nk t'; LI I 02R.
Ilding Department crta CuTlCrnrteway�Perrri#
12 Main Street Sewer/9eptic!4vai1a611rty 5 .�
L Z t J
Room 100 abilitj s�
cL ti, t�, r'oso ampton, MA 01060 TwaSS�ts ofStF�cturai Pla[rs 1 L 4 e "1
o
X5
one one 413-587-1240 Fax 413-587-1272 RIM] it elPlans` 1 hr "k
Jam. J. .k
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
-= 7his secfiorr to be completed by office
1.1 Property Address: =— j
f i
J �, Map � Lot Unit.
�/J 1
Y
Zone Overlay Disfrrct
111Nj�� 1�,tJt 4 6 r t
!�--
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=:Elm St D.st...ct CB District
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED:AGENT:
2.1 Owner of Record-
Name(Print) Y Current Mailing Address: _.
Telephone
Signature
2.2 Authorized ent:
Name(Pri Current Mailing Address: t'7
Si a ure Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 7� /�. �� (a)Building Permit Fee
2. Electrical L� / (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) Check Number
This Section For Official Use Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector`of Buildings Date
2 WEST ST BP-2016-0808
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 D-243 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-2016-0808
Project# JS-2016-001360
Est. Cost: $2634.00
Fee_$40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 4878.72 Owner: SAXE JOEL&ANNE
Zoning: CB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT. 2 WEST ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.1211712015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 6 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 12/17/2015 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner