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HOME IMPROVEMENT CONTRACT'
PLEASE READ THIS
Sok!. Furnished and Installed by:
Beaton Datm Tlfri At-Home Services, fire.
dlb/a The home Depot At -Home Services
345A Greenwood Street. Unit 2, Worcester, MA 01607
Toll Free (800) 657-5182; fax (508) 756 -8823
Branch Number: 31 Federal 10 s 75 2698460: ME Uc e C 02439: RI Coat. Lice 16427
8 .0565523 MA Hone Contractor Reg, N 126843
Installation Address: . C�I VPV 11.e.� - , on 64 mt n 45t 0 60
City State Zap
t k Week Phone: Home Phones Celt Phone: • •
r ilia AQrn [ l W']
r *> ►��[ ) I l I I
Home Address:
(if different from Installation Address) City State Tip
E-mail Address (to receive project communications and Home Depot updates):
❑ 1 DO NOT wish to receive any marketing ematis from The Home Depot
Protect Imfornmtiin: Undersigned ( "Customer"), the owners of the property located at the above installation address, agrees 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
e e ferance, along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively,
ively,
Job*: (aorarwemo Products: ;), : -• s W , ~ Protect Amount
• Roofing .7: - ding • Windows • Insulation i
5e. `� Dauuos / ceveaa May Doors Q ► "'1 ^ ? ` f r( 12.
Roo EJS Wing Insulation
['Gutters covers Orlotry Doors n
DRoofiae Elsiding ❑ Vibtoow D insulation , ,
['coccus! Covers ['Party Doors I'1 ke/ y,.07
Roofing QSiding U Windows 0 Insulation $ /
DGutters / Covens ['Entry boors n
> 2S% Daps* efCantrautArrantdneepeeesoatioua fthheonhaet Total contract Amount $ t to 42 he t/ Ma inerurhasers waxy mat depedtmsteti aro4hhdertbeCmQ ea
ateAmar. _ l l r 1
Customer agrees that. immediately upon 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 pay any balance due_ As applicable. each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home 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 that 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 complete the job was not included in the Contract.
Payment Sumo®rv: The Payment Summary r1• 5.7 I &1 , included as pan 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 retitled to a filled in copy of the Catenet at the time you �. Do not sign a Conapledoa Certificate (note:
there is one Completfwf� ate for L fisted Product as defined by Individual Spec Sheets) before work on that Product
is complete.
In the event or 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 Provider through 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.
Acceatance and Autharizatiog: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Ifome Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements, either
oral or written, relating to said Products and Installation. This Agreement cannot be assigned or amended except by a writing signed
by Customer and The Home Depot. Customer acknowledges and agrees that Customer has read, understands. voluntarily accepts the
• terms of and has received a copy of this Agreement.
Accepted Submitted by;
X
- ,rrrrrMIO -
cwt . met s . , . Date Sales Consultant's Signature Date
4 4 Telephone No.
•
a -mat's tgoature Date Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS Oar applicable)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
• DAY AFTER SIGNING THIS AGREEMENT. T(IE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICE: ADDITtoNAL Tamar: AND colernONS ARE STATED ON THE REVERSB ME AND ARE PART OF Tiita CONTRACT
Ot 11 - 11 !r-SC
Vast* - wench File Yellow - Customer
City of Northampton •
`'
Massachusetts 'r{
Ult
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building rC
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his /her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
lie /she resides or intends 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 home owner."
The building department for the City of Northampton wants any person(s) who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection
(before work is concealed), insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
•
• The Commonwealth of Massachusetts
,,..,,, Department of Industrial Accidents
` . Office of Investigations
- TA' , 600 Washington Street .
it a: ,> Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): t E° �
Address: 900 Ginib2ctouQW,A\I
City /State /Zip: � _ , g 4 g Phone #: ' 114 II _ 1 i •
Are yo employer? Check the appropriate box: Type of project (required):
1. I am a er w
y em p to with ^ , 4. n I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).* have hired the sub - contractors
2. Ill I am a sole proprietor or partner- t t have on the attached sheet. 7. El Remodeling
These sub-contractors ave
ship and have no employees 8. El Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ f repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. Other
1 comp. Insurance required.; 1 1 1
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t 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 or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. 4„..--_ /`
Insurance Company Name: Q01.4414/14 (rte . I C D
Policy # or Self -ins. Lic. #: � no-559- Expiration Date: *1-,DX- J ob Site Address: t J t l4\ City /State /Zip: O tt rf
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of th- ! .• or insurance coverage verification.
Ido hereby certi under t ep j s and penalties of perjury that the information provided above is true and correct.
Si!, ature: ■ ■ it. c st Date: i icibi
Phone #: q01 j a 3.3
Official use only. Do not write in this area, to be completed by city or town official
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 #: —
0-
J
SECTION 8 CONSTRUCTION SERVICES!
8.1 Licensed Construction Supe isor: 1 Not Applicable ❑
Name of License Holder : V 1 l'M r V � 6 1 ( 12o9
License Number
Address WA
Expiration Dam
Signatur Telephone
' e is rte • , ti ria •'r,'oye ontradto „ , , a4 . ; , i, Not Applicable ❑
►r9(!
Company Name Registration l 3/J2
mr
WO ,) - f mo d
Address Expiration Da
l
) w.7 Telephone 1 35
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G L c x 152, § 25C(6)} r -„
Workers Compensation Insurance affidavit st be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi permit.
Signed Affidavit Attached Yes No ❑
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
•
S ECTION 5= DE OF PROPOSED WORK (check all applicable) w
ay '
New House ❑ Addition ❑ Replacement Windows Alteration(s) [J Roofing n
Or Doors E
Accessory Bldg. ❑ Demolition ❑ New Signs [I]] Decks [p Siding [ Other [p]
Brief Description of Proposed
Work: r ._ L. & 17 ll 7I
Alteration of existing bedroom Yes No Ad , ing new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
a 3 e use, hd •r addition o. 'istiiag# . iiisinq timale #tithe ortlo ur "nq:
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
r
S 7a OWNERAUTHORIZATION "tO BECOMPLETED WHENw Mi ,
OWNERSAGENT OR CONZRACTOF APPLJE F OR BUILDING PERMI
I, X..CJ�fi('1- , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative 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 the pains - id penalties of p rjury.
Print Name ip /
� � , r . 1
Signature of e •r /Arent Date
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information '-
Existing Proposed Required by 'Loni •
.
' :7
..
This column to,be fill` r "t.8
w
Building Depttment
I '1 :I ; e
Lot Size ' .,I
Frontage `
Setbacks Front i 1 j
i
Side L: R: L: R: I I I 1
Rear
Building Height 1 I I I 1 i
Bldg. Square Footage % I i 1
Open Space Footage % l i
(Lot area minus bldg & paved I
parking)
# of Parking Spaces t-
Fill: I _ . __ --- 1 _
(volume & Location) { i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I # Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
0 , Date Issued:
1
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: ■ 's
I
-- - -- - - - - - --
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location: € 1
( E
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 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
17 VALLEY ST BP-2012-0554
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 302 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit # BP- 2012 -0554
Project # JS- 2012- 000925
Est. Cost: $19462.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 99209
Lot Size(sq. ft.): 6490.44 Owner: WILKINS - CARMODY DONNA & KATHRYN WILKINS - CARMODY
Zoning: URC(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 17 VALLEY ST
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers
Compensation
WORCESTERMA01607 ISSUED ON :12/7/2011 0 :00 :00
TO PERFORM THE FOLLOWING WORK :INSTALL VINYL SIDING
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 12/7/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner