25C-133 (2) 2011 -08 -01 15:18 2610 - EXPDTR /PHN SLS 4135937016 » Home Depot AHS P 1/6
HOME 1MPROV.EMENT CONTRACT
PLEASE REAL) THIS
Sold, Furnished and Installed by
Branch Name: Ruston Date: 7/.).q f THD At -Home Services, Inc.
— / d/h /a The Home Depot At -Home Services
345A Greenwood Street, Unit 2, Worcester, MA 01607
Toll Free (800) 657 -5182; Pax (508) 756 -$823
Branch Number: 31 Federal ID # 75- 2698460; MP l .+c # C 02439; RI Cont. Licit 16427
� f t 1 CT Lie ti HIC.U565522; MA Home improvement Contractor Reg, # 126893
Installation Address: [Tee i l T �i �j -a &44,-ta30- Vl • t 0 c!7
City State Zip
Purchaser(s): Work Phone: Home Phone: Cell Phone:
%Jurrct/lC:2.. C—q i [ 1 31 3t kff31 .3aD-
,ate if 1 If ] f 1
HomeAddre s :_ ,`a'" V;F +� 4k aet 4 __ tN Ct� 39U _
�J
(If different from Installation Address) City Stair Zip �,
E-mail Address (to receive project communications and Home Depot updates):
0 t DO NOT with to reuave any nunketing cmails from The Ilome Depot
Proiect Information: Undo rsigned ("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 a the below and on the Spec t Su all which incorporated into this er (coil by y
reference, alongwith with th any applicable ble State Supplement and and Payment Summary attached Change hereto and any Change Orden (collectively,
"Contract "):
Job #: ,l.inaYelkroe.i Products: Spec Sheet(s) #: Project Amount
IRtwrmg Owing ❑ Windows [' insulation Q
/ , 54 e DS ['cutter! Gagers ['Entry Doors ❑ . _ 1 "t 2 n $ I 3 3'46
URoo(ing USiding 0 Vriadows C( Insulation
❑ Gutters / Cover ['Fairy Doors ❑ _ $
❑Roofing ❑Solna 0 Windows ❑ Insulation
❑[Antos / Covers r]Enuy Doors ❑ $
❑Roofing ❑Siding ❑ Windows ❑ Insulation
❑Gutters t Covers ❑hntry Doors n $
Weimar 25%DepuritdOontrad AMMO* doerpm emama= dthismiact Total Contract
Maine i sarynotdere&mo eman.oeiheddthe(ntractAmount. 1 3 , 3
Customer agrees that, immediately upon completion of the work for each Pr duct Customer will execute a•Complction Certificate
(one for each Product as defined by an individual Spa: Sheet) and pay any balance due. As applicable, each Customer under this
Contract agrees to be jointly and severally obligated and liable herenndrr
The Hone Depot resc`rves the right to issue a (flange Order or terminate this Contract or any individual Product(s) included herein, at
its discretion, if The Ilomc Depot or its authorizes! 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 Ctmtravtt.
Payment Snmmarr : The Payment Summary # r l included ax 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
Yon are entitled to a completely filed -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 defmcd by individuni.Spec Sheets) before work on that Product
is complete.
in the event of termination of this Contract, Customer agrees to pay The Hume Depot the costs of materials, labor, expenses
and services provided 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 DEPOT'S OTHER REMEDIES NOR RECOVERY OF SUCH AMOUNTS.
A tpnce and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Flame Depot with regard to the Products and Installation services alai 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. C xr acknowledges and agrees that Customer has mad, understands, voluntarily accepts the
terms of and has received a copy of this Agreement
Accepted by: Submit t
._77 x
Customers Signature Date Sa C tent's "immure Dale
Customer's Signature Date
. ales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THiS lea applicable)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MiDNICIIT ON THE THIRD BUSINESS
DAY AFTER SIGNING THiS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE iF ONE IS
SPECIFICALLY PRESCRIBED BY i.AW IN
CUSTOMER'S STATE.
NOTICE: ADDMONAL TERMS AND CONDITIONS AAF. STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT
10.18.112 CSC White - Branch Filo Yellow - Customer
• City of Northampton
Massachusetts
flitT;; ti
r
4 DEPARTMENT OF BUILDING INSPECTIONS tot
212 Main Street • Municipal Building t
ys.v Northampton, MA 01060 41.4. `''
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
- Iiershe resides or intends to be, a one ortwo familydwell ng, 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
1 Department of Industrial Accidents
__....A17- Office of Investigations
s
' . =a 600 Washington Street
` Boston, MA 02111
_ e' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): F Y L - ' t _
Address: A I A'�'.i % , .A
City /State /Zip: Aral E .4 • . A ,.r ® / ' Phone #: g ` O / 7 s I' ?
Are o an employer? Check the appropriate box:
YJ� Type of project (required):
1. I am a employer with RD
4 0 I am a general contractor and I 6. 0 New construction
employees (full and/or part-time).* have hired the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees - - These sub- contractors have 8. 0 Demolition
for me in any capacity. employees and have workers'
working Y P ty 9. 0 Building addition
$
[No workers' comp. insurance, comp. insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 P1 mg repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. oof repairs
insurance required.] t c. 152, § 1(4), and we have no
13.0 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.
tContractors 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. \°1,3 Insurance Company Name: t 1 WV1 )1 -_( - 6 Co
z
Policy # or Self -ins. Lic. #: C .q9f-735 Expiration Date: .�
- - Job Site Address: __ L-1,7. - i 7,6 ' lt, 5 ( City /State /Zip: i',.lt or 4i it i ti---
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expi ation 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 - ' . ' st the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of th kr insurance, overage verification.
--- rd e under t 4 hies o perjury that the in information provided above is true and correct.
y V ms d pe f f P
Si ro / Date: � —4 Pli //
Phone #: L-1.014 .:
-- - - Official- use only. Do not write-in this -area, to be completed by city ortown-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 #:
SEC.TIO 8 CONSTRUCTION SER CES r
Y
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder : ',A/Fr -y /f. (9 (r/
License Number
,
Ilk a Aid • w.
Address Expiration Date
at _ . �' " I �
Signat t - " Telephone
?=t nt? ∎is erae ,. inn. , o. .emea' - f Not Applicable ❑
Company Name n 0 Registration Number
0 1 g 9//2---
_• -z= Address i Expiration Date
`N / `.0 r'4 00)l(elephone 1 !��C1j
ECTION $ O RKERS'� OMPOISX OWN RAN T "� �A0 .27,..,-"4,7,4q7, 3
,.. � C am,
Workers Compensation Insurance affidav m be completed and subm w th appl Failure to provide this affidavit will result
in the denial of the issuance of the buildin ermit.
Signed Affidavit Attached Yes No ❑
tr 1 E .1.7 1 .Vi s a i 0 F ,La, IT
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 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 Cliapter - 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, von may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibilty 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 "may it ' o A w yx ,,v s ' � `ma`i i u — • " � i d* S •
SECTION 5" DESCRIPTION WORK e c `alI able ' a
New House [J Addition [❑ Replacement Wi, • ows Alteration(s) ❑ Roofing
Or Doors In
Accessory Bldg. ❑ Demolition ❑ New Signs [ID] Decks [ 0 Siding [O] Other [0]
Brief Description of Proposed r� ,.
Work: I 1 \w4Nrla (
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
. w i ^ - 0 q. , Y. .11' 4. Pti I=-Y ,' WO ii 4 " ■1 ' 1 0. i; -® a il -I t' l rol VoT, ',,:
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
tOWN k AGE ttt 7 ® -e LIES OR; s ® 4 Af3 ; .
C o 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
1, 1• Al O 4 , 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.
Signed _under . and pe • perjury .
ict it
Print Name 0/Siff - r
Signature ofsvv er /' tent Date
Section 4. ZONING • Ali Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information,
Existing Proposed Required b 'Zoning
This column t be n ed in by
Building Dep en
Lot Size 1 1 1 1
Frontage ■ 1 1 1 1 1
Setbacks Front 1 1 1 1 1 1
Side L:1 R:) 1 L:1 • 1 R:1 1 1 1 1 1
Rear , 1 1 1 1 1 1
Building Height 1_ .. I 1 1 1 1
Bldg. Square Footage I 1 1 1 1 1 1 1 1
Open Space Footage -- - -
� � /O 1 1 1 1
(Lot area minus bldg & paved 1 [ I
pig)
# of Parking Spaces 1 1 1 1
Fill: i
(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 0
IF YES: enter Book Pag and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF_YES,_has a permit been or need_ to be_ob-tained.from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES Q NO 0
-
IF YES, describe size, type and location:
•
— 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:
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.
44 ELIZABETH ST BP- 2012 -0151
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 133 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -0151
Project # JS- 2012- 000217
Est. Cost: $13340.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 96194
Lot Size(sq. ft.): 7056.72 Owner: LEE TERRENCE J
Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 44 ELIZABETH ST
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (508) 341 -9401 Workers
Compensation
WORCESTERMA01607 ISSUED ON:8/5/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP, PLY & SHINGLE ROOF
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 8/5/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner