25C-145 (5) 33 ORCHARD ST BP-2018-1323
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao-.Block:25C- 145 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv,REPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2018-1323
Project# JS-2018-002349
Est.Cost: $2372.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grouu: HOME DEPOT AT HOME SERVICES 106106
Lot Size(sm.RI Owner: ALI DIAMOND
Zoninw URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT. 33 ORCHARD ST
ApplicantAddress: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.6114/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT DOOR
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 Deasrtment 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 Sienatu
FeeType: Date Paid: Amount:
Building 6/14/2018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
r—
Department use only
�— City of North rcpt n 95
sof mit:
BuildingDe rtm nt Cu Cu rhrevre Permit
p JUN 1 2 201 y
212 Main tree S MSe 'c Availability
F Room 1 0 Wa r/W I Availablllty
Northampton, AB9aunowc wise tAR;•Sets Structural Plans
phone 413-587-1240 a - "1A01 lens
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION .(Sp- l3a 3
This section to be completed by office
1.1 Property Address: 'y Map '2 S--C, Lot L s Unit
L�f Zone Overlay District
Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) ���., Current M ili Atld /
Telephone
Sgnature
2.2 Authorized Agi
Nalf5e(Pd ) r Current Mailg Address:
SlgnaW Telephone
SECTION 3.ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
completed by permit applicant
a mi
- 1. Building ' 3� O Building Pert Fee
2. Electrical ` / (b)Estimated Total Cost of
Construction from e
3. Plumbing Building Permit Fee ,// q(-J T
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3-4+5) Z- JL Check Number �y
This Section For Official Use Only
Date
Building Permit Numb e ' Issued:
Signatu
4BLaIdm,�C94�.erllap.dorBuildings Date
�! C l/Z7 & 1,i CDJy7
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must ee Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
To,,column w be 11161 in by
9uudiag Depur—nt
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot arm minus bldg&paved
urkin
4 o Parking Spaces
Fill:
(volume&location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
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:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it pan of a common plan
that will disturb over 1 acre? YES O NO O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addltlon ❑ Replacement owe Altered n(s) Q Roofing Q
Or Doors
Accessory Bldg. ID DD�e'Jm�o)litio�nJ �/❑ NNeeww Signs/[/[0) Docks
/jpSiding
)[[E:31 Other[C7j
Brief Work: escriPl/h/��e/ / / YL�7t-�/'�/'/ //YO
Alteration of existing bedroom_Ves No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Ves No
Plans Attached Roll -Sheet
sa.If New house and or addition to existing housing. Complete the 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?
J. 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?
In. 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR/BUILDING PERMIT
I, 64� �- �r .as Owner of the subject
property -�-))��--��� y��/p�� T (y
herebye authorize �2) /'7 lzib //K/f�/
to act on my behalf,in all mattersr lafive to we rized by is building permit application.
� /a - /-115K
Signature afb ner -- Date
I, ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are We and accurate,to the best of my knowledge
and belief.
Signed under the pains ay penalties of perjury. "
Print Name
( /(y/
Signature of Owner gent Oat.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction SCuiai isw: Tjy Not Applicable ❑
Name of Lloenaa Heltler: G�I/�d /// 64' �0� /V/,
License Number
23 9�7�
Address Expiration Dale
Signature Telephone �
9.Registered Home m wren C n r ! r: Not Applicable ❑
�iz �
Company Name Registration Number
Address 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...... ❑
City of Northampton
SS G S/C
•a. Massachusetts
L DEPART aer OF EOILOIue INSPECTIONS
212 Min Stmeet • Nunicipal Building
Northampton, M 01060 irYn "e�r,SCe
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.C.L.Chapter 142A requires that the"reconstruction,alteration,renovation, repair,modernization, conversion,
improvement,removal, demolition,or constructr'on ofan addition to anylere-existing ownerbccupied building containing
at least one but not more than four dwelling units....or m structures which are adjacent to such residence or building"be
done by registered contractors.
Note:Lf the homeowner has contracted with a corporation or LLC,that entity must he registered
T � �
Type of Work: �� �t/G,1 Est. Cost:
Address of Work'
Date of permit Application:
I hereby certify that:
Registration is not required fondle following reason(s):
_Work excluded by law(explain):
_Job under 51,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME'I'HE RESPONSIBILITES FOR AL1,WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
(0 T�k f P':-T-
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
.+ Massachusetts Fra �r
A V z
t DEPARTMENT OF BUILDING INSPECTIONS 2 n
313 Nein 6Lieet • Municipal Building CD
\ NozNampton, dA 01060
Massachusetts Residential Building Code
Section I10.R5.1.2
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.
Section I IO.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 1 I O.R5, provided that if a homeowner engages a person(s)
for hire to do such work,then such homeowner shall act as supervisor.
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.
City of Northampton
Massachusetts
I� DEPARTMENT OF BUILDING INSPECTIONS y `s
212 Nein Street a Municipal Building
Northampton, M 01060
Debris 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
?2?� 'gxWW t> "!�>l
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(/CCoom�pany Name and Address)
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
\ The Commonwealth of Massachusetts
WLDepartment of Industrial Accidents
1 Congress Street,Suite 100
Boston, MA 02114-201
www.massgov/dia
R orkers'Comparmatlon Insurance Affidavit:BuBders/Contractors/Electrlclans/Plumbers.
TO BE FH.ED WITH THE PERMITTING AUTHORITY.
Applicant 1 f ti Plunge Print Leeibly
Name BusinesslOrganization/Indiciduap:
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1_[3 lam a cmployerudth employccs(loll and.,pert-limo).' 7. ❑New Construction
2.F l am a sole rropriemmr partnership and have em employees workingformem 8. C] Remodeling
any capacity.[No worked comp.inaurancc rc uire6]
Ivna homeowner and will be haing counacmrsm conductall soon onm ggrope n}
Demolition
3n am o homeownerdainger11 workmYseIf.[No—,kc,,' umP. nsumnremrey] 1O[]Building ad
dition
4.11 . Iwi11
ea ore that all onvaom eitherMve wnnaa,mpmano
im-urmce er are.nle 1LE]Electrical repairs or additions
proprietors with no employees. 12,❑Plumbing repairs or additions
5 I on a general co ens or and I have hired the su4cenrmemra listed on the attached Shen.
u These sub-wntmctoa'have employees and have workee comp.itommoa_ 13.L]Roof repairs
6.❑We are a em,ro me and its officer neve exercised their o bi nfexemptioa per MUL c. 14.❑Other
152,§I(4),and we have no employers.[No workers'romp.insurance required.]
'Any appinun that clerks bas#1 moil also fill out the ecelion below showing their workersece,armatmo policy information.
t Homeowners who submit this amdton thdiea rm,they are doing all work and[hen here outside cuner dors must submit a new affidavit indicating such.
:Qx maemts Wet check this box must.horned w addilioaal sheet showing the name of the sub-coneaelors and state whether or not those entities have
cmplovecs. Uthesob-conmoton have cmpl.'ea'they most protide their wv-k. drag polity number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
infnrmadon.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: Cily/Swte/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$1,50090
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 DIA for insurance
coverage verification.
I do hereby certify under the pains andpenalties of perjury that the information provided above;is true and correct
SignindUm Date'
Phone#:
Oficial use only. Do not write in this area,to be completed by city or town ajjcial
City or Town: Permit/License#
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire.
express or implied,oral or written"
An employer is defined as"an individual,partnership,association,corpomlion or other legal entity,or any two or more
of the foregoing engaged in ajoinl enterprise,and including the legal representatives of a deccused employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented N the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)retracts),address(es)and phone numbers)along with their cettiticam(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees, a policy is required Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-urswed companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. I he Depattment has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the form itllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permitflicensc applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town f"A copy of the affidavit that has been official ly stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
ofthe foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee ofan individual,partnership,as's'ociation or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant ofthe
dwelling house o£another who employs persons to do maintenance,construction at repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,t 25C(6)also slates that"every slate or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter t52,¢25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited I othility, Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be resumed to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers'compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
ofthe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy ofthe affidavit that has been officially stamped or marked by the city or town
may be provided in the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston,MA 02114-2017
Tel. #617-7274900 ext. 7406 or 1-877-MASSA-FE
Fos#617-727-7749
www.mws.govidia
poem R�,k a 02-23-1 5
Home Improvement Agreement: Page 1
Home Depot License Number(s): Visit www.homedepot.cpm/c/SV_HS_Contractor_License_Numbers for latest license info
7'1127Fi5
Salesperson Name: Ronald Engelbreeht Registration No. (if applicable): 0
Home Depot U.S.A., Inc. ("Home Depot') or service provider named below ("Service Provider") will
furnish, install or service the equipment listed below at the price, terms and conditions as outlined on
this form.
Diamond Ali New England South 1-60UF27H
Customer Last Name Customer First Name Store #/Branch Name Lead/Customer Order #
33 orchard st Northampton MA 01060
Customer Address City State Zip
(774) 212-3312 F__ alexandra.diamond@gmaii.com
Home Phone# Work Phone# Cell Phone# Customer Email Address
NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR
OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT HOME DEPOT USA INC.,
2455 PACES FERRY ROAD, BLDG. B-3, ATLANTA, GEORGIA 30339 or EMAIL
Fe Home Depot @ ustomercancellationnortheast@homedepot.com
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENTS WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME
DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE
SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED
TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN
SHIPMENT AT HOME DEPOT'S EXPENSE.
THE LAW REQUIRES THAT HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO
CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND
WRITTEN NOTICE OF YOUR RIGHT TO CANCEL.
Acknowledged by: o5/1anala
Customer's ignature Date
Contract Price and_Payment Schedule : Payment of the Contract Price is due upon signing unless a
different payment schedule is required by law, specified below or in a payment addendum.
Contract Price: 2372.36 Includes all applicable taxes. Excludes finance charges.'
Sales Tax: o.00 (If applicable)
`Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, WI(99%)
Dep. 25.0 % Deposit Amount 593.09 Remaining Contract Balance 1779.26
The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1-800-4663337
C,sbme,P m...a"C,EA)(31 Jan.18) , 50.11
Home Improvement Agreement: Page 2
* Finance Charges : Any interest payments or other finance charges will be determined by
Customer's separate cardholder or loan agreement, to which Home Depot is NOT a party, and will
be in addition to Customer's payment under this Agreement. Customer is subject to the terms and
conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to
Service Provider; however, Service Provider may collect Customer's payments made payable to Home
Depot.
Insurance proceeds will will not be used to pay some or all of the total amount of sale.
Description of Work to be Performed : A detailed description of the work to be performed is included
in the paragraph entitled Scope of Work or Specification which is included in this Agreement.
Anticipated Deliygry-Date/Installation_Sch_edule
Approximate Start Date: 7/13/2019 Approximate Finish Date: oano/zola
All dates are approximate and subject to change based on unforeseen events including inclement
weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if
applicable.
Electronic Records Authorization : You are entitled to a paper copy of this Agreement if you
choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent
documents and written communications related to this Agreement. By contacting your Service Provider,
you may update your email address, withdraw your consent, or obtain a paper copy of the Agreement or
related documents at no charge. By providing your consent and verifying your email address above, you
confirm that you have access to a computer that can receive and open emails and PDF documents.
By initialing this paragraph, I consent to receive only electronic records related to this transaction.
NQJ Initial
_Acceptance and Authorization : By signing below, you authorize Home Depot to: (a) arrange for
Service Provider to perform any Services or (b) order and arrange for the delivery of special order
merchandise, including special order merchandise that may be custom made, as specified in this
Agreement. Do not sign if blank or incomplete. (Service Provider's or permitting information may need to
be provided to You later.) By signing, you acknowledge that: (i) You have read, understand, and accept
this Agreement in its entirety, including the General Conditions and State Supplement, if any; (ii) You
are receiving a complete copy of this Agreement; and (iii) all rights and interests under this Agreement
are solely vested in the person listed as "Customer" above.
XI F5/18/20187 The Hame Depot
Customer' ignature Date Service Provider Name
X 5/18/2018 908 Boston Turnpike Unit 1
Co-Signer (if applicable) Date Service Provider Address
X 5/18/2018 Shrewsbury MA 1545
Signature On Behalf of Home Depot Date city State Zip
HIS 0554523, R-1-073-13-00004
MVendor/Service Provider Phone # Service Provider License Number
The Home Depot-2455 Paces Ferry Road,N.W.Bldg.&3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337
Gusmmerggnamen,(QEI) ]1 Jen.,BJ r 511
WINDOW SPECIFICATION SHEET - Spec.Shl#: 1- ouFnry , Sbei 1 of 1
Cuslomef yl,Dand-1Job#'1-BOuive cool —e-n e ream Del,'. o ll9,Iea `
New Window
.. I Huge Locations
Eveting All MeeaummlO
enta Grids Ives ptW
ians LSr Cull uudynd
Cal10 a",
aeYa Bows
Losaloan Colnr Pougb 0ltenin9 #ol hers #ol ham CarlLP or
. less Mso Items
jS«vans Cade Fa boars law
-_ MJI ..a,.'or
E Nod Wou, # S F g m 3 R # % -eppra4n9
FYof
dor Cabe IYMf SIYIe Cabe Seriea Code _ a7 3 U £ S
,LSI
~ C 100 WH c 6.00 BRA, I'd m ,Pock-SlonoeN 5
SPECIAL CO"IDEFATOrvS:
ei
Will Calor
car Ceaing Typo
eay«eow.mdoer.
atbmm mdebal fvmN onlyamn«oak)
ey 111 Anvil P or 01)
all Flanker Type(OH ST ar Osmm)
op of window la soffit(loca l
Iaid in nal calor o15olfit material Ihave reviewed and agree wM1b all the St sgealkallons aWVe and the
Construct Hoof(Yes or ul- Spaniel Denea and Cal on Me lollowmg page
Cal Window:
IWard Malerial(anall onlyWbke Plonile,Bach orOak)
1
The COM11770ilroli(IIIII f vinssaehnsz!ar =
r9 Department a(rndast adA cidents
I; 1 Co zgt ss Str et,s f to 100
u R "ost.rn-VA d:L42917
Wi,w.wasSavv/f(ia
0 orkers'Camneosa[ian irsuranee ATtl:rv!r:isnilde:c/Con!ractnrs/f,';ectrtcians/Plumbers.
:'G gr'•?Lell R;T;S T,�?4!i\If!"rl\'G nu tl ORIT1'.
litnicant Worn—mi" Please Print is oibir
I:ui::css/Or.v.,:izhri lfidi•ddvail:
u..n�;npiuvvC'CLe¢is lite Jnpl,nsite'voi
Type of project"required):
'.
m. n�alc_.r..vilh_-arnlo>[-;�aliaMNsgn-n^C)• �MC\C COrIsiNCtlOn I
rtncrsidp ane no .toy a6 "r-_.n1
c .-a No can T 8. r Renmduling
in
9. J JC@Ohhan
1 10(��3uilding addition
n : II h.onI14Ca11 a t I1 v - n"mo, "mill -
I :I I cr -tber Luve - s l .. I� I I ❑?Icetrical repmrs or admmns
'a^•a-+ I lar tll a Irce _ vl_.t. I ❑R-"e.Ire pe0JaSpmrs cr adoiiie^._
alidev P it
- II
nJ. Rn.+.l.n \ \..1 lSr.".1501""N(a:'•F[�aa.aUYf StP'Jn�.J:Fe ,. '['Ja p±3JItM AI CY�•:YTulmn"
1. aWsiinJm.ens lny a.�c ucaY„N.:...F - ,...omJna..rmJuutmta nvadda.11fnJ'wting.vCn.
- ''ata v_tmcc:c.a•Il
tahey'
heynal sLS u_anlM:AranJSNL-r'vuC yr n:Jms:'Ai[LLzte`.[
-- - ) e-etrv.anmttor!;Uve emn vR's.I'ney :u;l P:vviue:Ler»ClcIr,'uam' ,.allg nemc:r.
enrp/el'er!!'.l a prroov{ilk!inlyworkers, .6[�7CmnaeJGtltiG�nr l/rny�}rvp�/I�:;/anuY err:ulayees(.�pBdo" !hepo:!Cy/Rndjobsire
m
nsunuc //•��
. Company tiame.
-?oli",'or Self-ins.Lic.':/(.yyL LI /;/� czpirnion Da.' 3�/ ^�
aa. ors=: Cily/sr.Wzip'
22 — 41
mc $coo- o;the\vor!eers'comloinnion noire} decloracon urge jahoarltg the policy namaernnd -pi bndnioy
.atlura m severe coverage xs required'under'MGL c. i 42, J2=A s a^rimmal violation punishable by a nne up to S1.500.00 (/
arcPor ore-year!mprsomnent-as woll as civil peraiaes in the torn of a STOP V.'ORJi ORDeR and a fine ofan to$290.00 a
my mm;Sr ii:e'':iclotnr.A copy UC this sratcmem m y be^Bra:dcd:0lbe 0ince of investigations of rhe➢iA for insarare
c.c:age vennc2tien.
rof -e.J. '"'T uY ' pth�ep/Qin fpe' tGnf ti: ormn(ian provided obmeis frn9e rrntl�ro/rrecJ.
Dole
Olficiel ase nn�% 9vm!.vr/!ein!biraren,:o:ie cwirn/eta)by clN ar fuJvn aJJiciai.
_iry or Town: PamitRicensc o _
' !',o 1 i•taar!ty ic:rde one):
Boars ofAeslth23nildmg Department 3,Cih/'mrn Gera 8Llca'icai lnspecr i.Plumbing Inspector
Other
I
Coasac:Pcnmv phanc m: ...
CERTIFICATE OF LIABILITY INSURANCE F
I
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. )NIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(hs)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WANED,Subject to me terns and conditiole of the policy,terrain polides may require an endorsement A statement On
this certificate does not confer rights to Ula Darnficxte holder in fieu of such endomemerd(s).
PRDODCER coxrACT
MARSH USA INC, Nom'
TWO ALLIANCE CENTER PRONE PAX
svB
3560 LENOX ROAD,SURE 2600 ao L EAU V&
ATLANTA,GA 303M
EBAR
SRSUREIRPRAFF.RDINSCONTRAGE IRS..
CNIM"2069-HuneD-GAW-18-19 NSURERA:Old 1 Nir imwanU,C. 26147
INSURED[HEHOME DEPOT,INC, INSUAEA a:NPS!Ilen slae NSC. 219AT
HOME DEPOT U.SAJNC. NSUREROHvvREd Ca MA1AamXRCo
2455 PACES FERRY ROAD NSURER O:
BUILDING C-20
ATLANTA.GA 30,119 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-001353439a6 REVISION MONISM: 3
THIS iS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN My HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR TYPE°FN6°RANCE 5 RPoNCYNNI®ER TNR. YEFF POLICYEXrWill IlYna
A X cONMmtWLGEXFRAL WNutt MN!ZY 312717 03MI12018 OMM19 EgCN OCCURRENCE f Box,SO
QAILISdUOE O°CCV0. PR 5 IND.=
U1AffSOFP000YXS MED EXP mimxmn) f LXO.UUEU
OF SIR:SIM PER OCC PERSCNALSAW NJuev 5 9.000.000
GEYLAGGREGATE DMTAPPLIES P9E.- GENGRALANGREGATC S 90m UD
X JECT LOC pRON1CT5-COMIP/OPAGG 8 900000)FOLICY�
OTHM f
A AUTOM°BILELWEIIITY MINIB312T18 0318IlMI9 03'lllM19 C°MRNEDSINGI£IIMIT f 10011000
IRA a¢MM
X PINY AUTOBODILY INJURY IParp!wn) f
OWNED
DONLY AUTOS UO SELF INSURED AUTO PH\'D`AG ARDLYSIJORY1PyatnLd) 5
HNED .-CANED PROPERTY DAMOE f
AUTOS ONLY AUTOS ONLr per
S
UMBRELIALWB OCCUR FACHCCCURRENQS S
EXCESS WB CWMSMAOE AGGREGATE $
DEC I I RETEMIONS 5
B WORNERSCONPENSARON WC 014122577 (KNIB NT) 1 1 03'ata0w X PQ+ DTX-
ANDEMPLOYERVUAINUTY R
B NAADPWETONPARTXETWXECUnvE YIN WC 014122578 NJB 03Po1DOt8 D3M12m9
AN5,000000
OFFIPl0.!M[MBCREYCLWEDi xl• EI EACXACCIDpIi 5
IMan6mRyin Np EML
LmSEASE-EAEOYE 5 5.00)0m0
Il yes.6eavl0e u'er CmDNEtl un Xmdual PEW 5000000
OESCWPIION OFOpEMTIONSMmv � EL DISEASE 5
C E.,,,,AUN 292-110011JMEM8 0310112018 0310112019 Limit 0,000,000
°ESCPoPT°H OF OPERATIOx81 L01:>TpMSIVEXICIE4 ENEORDRN.AddNmvlRneeha SCNNuF.may Oa...—,I.,.nno
EVIDENCEOFINSURANCE
CERTIFICATE HOLDER CANCELLATION
HOME DEPOT USX INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
2655 PACES FERRY ROAD THE IXPIRATION OBVE THEREOF, NOTICE WILL BE DELIVERED B
BUILDING C 20 ACCORDANCE SAM THE POLICY PROVISIONS.
ATLAHTk GN 30339
AUTHRO UMOREPREBEIRATIVE
MMaM uaAlnc
Manashi Mukheljee �Yla+..aol.: JIA..�fca.awa«
0 7966-2076 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo am registered marks of ACORD
AGENCY CUSTOMER ID: CN101642O69
LOCA: Atlanta
ACO® ADDITIONAL REMARKS SCHEDULE Page 2 of 3
AEENCv NAMED RISEN I0
IJAkSN UtiF INC -HE HOMEDER INC
HOME DCPCT U.S A,INt
PoCMv NUMBER .
�� 298 PACES FERRI'kCD
BJILDINC WO
AILeN A GA 30339
CARRIER NAIC CODE
ERVEcnvE onre:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 , FORM TITLE: Certificale of Liability Insurance
woM1^•rr.Nl'Prntdlcr rrnlinu`3
n ' Inaennl9lrnmxu Foeoanl u' 1nHpAiw In
P01 NarrL, RIP yJ6'TP A All 1If11.IAE,KSI e a,.UC NF,NM N'11 Ei IDTN,A
EDrclrt, Ca,0'918011
,E:111,H' �E v3mmrl=
011,H'II Is X,
PIrc .e Dzmw.ve I,,:anc,Cnmr—
Yuml 1 '1lE, :J F-0LMp U`.Ji-N`kll
Efi'<1vE Dale OADV231E
_A?alia11" "1011!11,
IGCini11 �:(it I
f, 1 1, a 1.41,r In'aFz'i
F11,"IiL L 1.. i e . IFCR fr 111
FhL,Hae Dale 03I011
Lx ,WrDr, 03/011111
4L;L1m11 E "00,X1
SIR 11 DI ON SIR Im 101st,@t LAE CAL NL CP el VA
N,I.I 1111 D, In,u, ri:
Ed I- 110151=11 'H ( A,4I,q Nl N PA I'T
"all, Dxe OM;2P x
E,ulan.,Dat OY09ROIR
EL),rel 1 f01..T`0
S([r"I i1P 11"I'll n er ISL Nr iw OSI Al, II
£9`OOOOSIk log LOe Gale nl 1,4
EVEOW SlkH, Inr.11111,A,F I
='Na:o'al llrlm F¢Insvara Cwrpen,
Pdal N... ) 41°SV"'[SI :1.^iK
En 1w1 D 13111111,
F v' uantr L mrm m=
0.uNne., a0ET;n
le oya
lOe YSI DEL elv
.0 c ulmlm Ilr 1'.Lumnn0 r.
"ArvNNmee, IN1N1116ewe 1;
LE LED, GIie G3eVNIE
ermm-.Dav mrOlo-nt
ILL LIN I r VIEH
SIP 4 WC OOL
ACORD 101 (2008101) C 2008 ACORD CORPORATION. All rights reserved,
The ACORD name and logo are registered marks of ACORD
`^oCOTe° '.z'=eH n.. 2£cnc :G/05135fi3 ���
il � h
'ii"V'Vzs'VVat Y5JN?�U'cir�ral.'t_a;.d4'�S�i 40L :t
tlSJlt'?COM�tlb'"L6-�S"Y?OL"�73tiFhN'!f�ltis�51:Y �'�t a".^=.tS;�_aewnedr.' �'.I,
i
it
.I n
h
�t��:t:eccyt=nA"~d=ani
a j
1
ii
A .
— '
�'� -ulagnh (sluoifia�eM a ax s`i'lt.
'm
r
:
I
1/'
'I� auuninmoti9aao�alzsati=l=gars iaoc 'm:;::�— "
aJlL-moi 5��1'iPIJJ��d9d =iaiJCLlfl�;,`
is oauaO' M 0 1M;lallm sc mori'l".ITS
it
��[il7i'7a�9iJbMi�6�'>Jsei ne:v� I1S
�' Sd-"F-,W -OV60juy D ij
'+93 Sika
'J.CL'.:c' O%.�I[i L:C�S�.`�'TEJ,.
it
1 .^�Ja'. it i1 i i
h 94hOCU�4j(UCSL'C'_IC -
�3
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: Supplement Card
NOME DEPOT USA INC Registration: 112785
2455 PACES PERRY RD C-11 HSC - -'.y == Expiration: 0 412 2/2 01 9
ATLANTA,GA 30339
Update Address and return card. Mark reason for change.
- 73 Address ❑Renewal ❑ Employment ❑ Lost Card
�- ONlce of Consumer Affairs A Business Regulation
' . . HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Supoleirmt Card before the expiration date. If found return to:
Reals"fid, Excirandon Office of Consumer Attars and Business Regulation
112785 042212019 10 Park Plaza-Suite 5170
HOME DEPOT USA INC Boston,MA 02116
2455 PAC TROIA ��fr„C�,.jx-- �����
2455 PACES OIAFERRY RDC-11 HSC
AT'ANTA,GA 30339 Undersecretary _ Not valid withou signature
Massachusetts Department of Public Safety MASSACHUSETTS ' ' ,- DRIVERS m
Board of Building Regulations and Standards LICENSE +
License: CSSL-106106
Construction Supervisor Specialty w �0911512016_YS45431608
3 DM
FOy12912021 912911982
23 BENHAM STREET
"NONE NONE f
23 BENHAM STREET ' � x�t6 � f 1
SPRINGFIELD MA 01109
BENHAM STREET
. ;. SPRINGFIELD MA 01109.2301
Expiration: ' usFxM 46wTe-ar
Commissioner 09/29/2020 so0osi+wpuwo�opvrms o9�291g2. i