36-203 HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold. Banished and Installed by:
13:taae
Boston Date: TI;D At -Home Services, Iac.
dMa The Horne Depot At -Homo Services
345A Greenwood Street, Unit 2, Worcester, MA 01607
Toll Free (800) 657 -5182; Fax (508) 756.€823
Branch Number: 31 Federal ID # 75- 2696460 ME Lac N C 02439; RI Cont. Lids 16427
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CT Lie it MC.0565522; meet Contractor * 176693
Installation Address: 471 trot *A( :;i t-sc- uu wt.D4.tv 1i L7l c
City State I Zip
Purchaser(s): Work Phone_ Home Phone: Cell Phone:
_ , -� tsl_2sz [ J [ ll 3 [ ]
[ l [ l [
Home Address:
(If different from Installation Address) City State Zip
Fined Address (to receive project communications and Home Depot updates): _
❑ I DO NOT wish to receive any marketing entails from The home Depot
efbrmation; Undersigned (" Customer "), the owners of the property located at the above installation address, agrees to buy.
and D At -Home Services, Inc. ("The Hone Depot") agrees to furnish, deliver and arrange for the installation ( "Installation") of
all materials described on the below and on the referenced Spec Sheet(a) 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"):
'lob#: oversr e'n'ter M
Spec Malls) #: Protect Atonal
A at
❑Roofing Lt4ra ■ Windows [ Insulation
54CtVA6 Doors ❑ tbl 6'12 $ 22 .e
•,• • • • •.., • Windows • Insulation
can +Coven ❑Entry Dom _ $ ! - �'�.•,
['Roofing Usidina U Windows ❑ Insulation
❑ -ottca /Covers ['Entry Doors 0
Unclean priding Q Windows p lmwa ion $
Pantos moms ❑Sa ry Doors rl
Mi- 2S* PepsdtdCoouaet Amount due up* merminn orals contract Total Con tract Among $
M1iatrummies may aotdepedt dun mcmirdaetbeCentradAnima.
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 individusi Products) 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 otrots or because
work required to complete the job was not included in the Contract. e7
Payment Swammory The Payment Sumn try # : a7i a ._ t included as part of this Contract sets forth the anal
Contract amount and payments required for the deposits and final payments by Product (as applicable).
NOTICE TO CUSTOMER
Yon are entitled to a completely fined -in cry or the Contact 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 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 Atrthoriaed Service Provider through the data of termination, plus any other
amounts act forth in this Agreement or allowed under hie law. 'f Fly HOME DEPOT MAY WITIIIIOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMIflNG THE HOME DEPO'T'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS
AA and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The am 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 his ahlatiao. This Agreement cannot be assigned or amended except by a writing signed
by Customer and The Home Depot. Customer acknowledges and agrees • ustomer has read, understands. voluntarily accepts the
terms of 1 • has received a copy of this Agreement.
by:
...mi. J;, .1434
a - s Signature Date sutant's Signature Date
Telephone Nor `k + - • .
Customer's Signature Date Sales Consultant license No.
CANCELLATION: CUSTOMER MAY CANCEL THIS t )
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE MEW BUSINESS
DAY AFTER SIGNING THIS AGREEMEN'r. THE
STATE S iPPLEMli T ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRFSCRIBI::D BY LAW' IN
CUSTOMER'S STATE.
r' NOTICE: ADDn1O$AL TERMS AND CONDrI1ONa Ann STATED ON Tin REVERSE SIDE AND ARE PART OF THIS CONTRACT
1 2.27 -10 CSC White - Branch File Yellow- Customer
City of Northampton
Massachusetts'
DEPARTMENT OF BUILDING INSPECTIONS e
212 Main Street • Municipal Building
Northampton, MA 01060 8� f w y
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
f ,
FIOME 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
fsf e resides - or Intends to o ortwo 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
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 ,
p r— Office of Investigations
— =7:0=.7" --
" 1 . 600 Washington Street
i�� ?' Boston, MA 02111
` =max www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): i fi
Address: ay 3o C Ptit)si
City /State /Zip: A ;, . A . ` _ ,r / Phone #: 5 DO b
Are yo n employer? Check the appropriate box: Type of project (required):
1. I am a employer with �� 4. [] I am a general contractor and I
_- _- -_ -_ -- - - - -
employees (full and/or part-time).* have hired the "sub - contractors 6 ❑New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
These sub- contractors --- -- - -- ship and have �no employees - t
_ 8. Q Demolition
working for me in any capacity. employees and have workers' . 9. ❑ Building addition
[No workers' comp. insurance, comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL . 12.0 R •
insurance required.] t c. 152, § 1(4), and we have no 13. Other
-. employees.' [No workers'
, . comp. insurance required.]
*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.
Insurance Company Name: • )4145 On 01 1 Pe_____ 6)
,
Policy # or Self-ins. Lic. #: pAq(r7 7 t, Expiration Date:. .
- __Job Site Address: -.- - 7- . _ _ 1 fr l , H City/State/Zip: k ,MI i0; / A i i ��
Attach a copy of the workers' compensation policy dec aration page (showing the policy number and exp' • lion 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 - • . inst the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the r insuranc overage verification. .
-- Id - hereby ce - i - under t = , (d pe ' It ees of perjury that the information provided above is true and correct.
Si ■
.y a ' , , j ' Date: qiQSL_________
Phone #: 0 ! �i.D
-- - Official-use only: -- Do- not- write -in -this area,-to completed by city-or town-official
City or Town: Permit/License #
__ _ . 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 #:
.. ,
kSECtION1-8f4CONSTRUCTOWSERVICEg,ii ,
8.1 Licensed Construction Supervisor: , Not Applicable 0
Name of License Holder : arat-01 1 71117>i k-CC
License Number
4009 ... Ft . 4 / r- v ___ 3.-
tat 1 I ie. . 4 I lie rid 111 Am D eiv-
_ _
Address , 4 - Expiration Date . ...--
,
4111ak ,
- 1 " A• A
Signa'rg■ ' .4 Telephone •
s - i asi moraveme . rt ra ; - '' - ' ' ' - ' r - . Not Applicable 0
• b
1,
) :
tri
Company Name _ Registration Number
_
` "I, .TrorLd . le) I , g ?FP—
-_,, ,flAddress ■ - .- - - Expiration Date
- --
& erfit..allt4 I* Ii elephonee7
•
•
.
Workers Compensation Insurance affidavit m be completed and sbbrnitted with this application. Failure to provide this affidavit will result
. ,
in the denial of the issuance of the buildin ermit
• Signed Affidavit Attached Yes No 0
- --; t - - - ,p--. ' - -:-----.---.---.-
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,s 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 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 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 com_pliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massaelnisetts General Laws Annotated. '
Homeowner Signature . , .
- - - - -
. _
- - .
-- -___
. -
•
SEC:TroN aDESCRIPTIQN OF PQSED WORK chec altw pplica • lel 1 ,,s
'4P& Lt '�N'§�Wr , d -1-1-404
t.
�,,�l.. ; _"'� ,.0 pj �
New House ❑ Addition ❑ Replacement Wi • • ows Alteration(s) n Roofing n
Or Doors in
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [D] Other [D]
Brief Description of Proposed 4 },
Work: _.Iii L 1 ' ►, Ala 11, 'O. (�J� G 1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
a: i
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
a 0. t u
...
I, pc , 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
I. L�II I A. 1 loe.. , as Owner /Authorized
Agent hereby declare tha the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
_Signesl_under_th and pe Rica . perjury. _._..- _ -_...
J.. . L b1
Print Name ow II
divot, 144
Signature of s'r er/ 'ent Date
.4
Section 4. ZONING, Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplet- . . . ..
11. "
Existing . Proposed Require, by 'L. . id g
This col .., to b 'Ned in by
Building D ..artm.. t
, .
Lot Size I I I II \ I
1...
Frontage 1 1 I
Setbacks Front 1 1 1 1 1 1
Side L:1 I R:i 1 L:1 I R:1 i I I I I
• • 1 1
I I
Rear 1 1
1 1 1
• Bldg. Square Footage 1 I I I % 1 I 1 1 I. I
----- -- - - - -- 0Sfla - CiFootage --
(Lot area minus bldg & paved r ---- 1 1 I I I I
parking)
- - # of Parking Spaces 1 I 1 =
- - Fill:
(volume & Location)
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
IF YES: enter Book • Page 1 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 Obtained
0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO C)
. _
IF YES, describe size, type.and location:
-- — D. Are there any proposed changes to or additions of signs-intended for the property? YES
C) NO
IF YES, describe size, type and location: 0
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 Q - •
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
----- -
47 WINTERBERRY LN BP- 2012 -0630
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 203 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit # BP- 2012 -0630
Project # JS- 2012- 001086
Est. Cost: $2228.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 100962
Lot Size(sq. ft.): 86248.80 Owner: WENTZEL RICHARD & KATHLEEN
Zoning: SR(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 47 WINTERBERRY LN
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers
Compensation
WORCESTERMA01607 ISSUED ON :•1/5/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE FRONT ENTRY 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 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 1/5/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner