17A-046 HOME IMPROVEMENT CONTRACT
PLEASE READ TAGS
Sold, Furnished and installed by
Branch Name: Boston Date: THD At -Home Services, Inc.
/,___J__3,__ dlb/a The Home Depot At-Horne Services
908 Boston Turnpike, Unit 1, Shrewsbury, MA 01545
Toll Free (800) 6575182; Fax (508) 845 -6017
Branch Number: 31 Federal ID # 7$.269$460; MS Lie e C 01439; RI Cont. Lice 1647
CT Lie* HMC..O5 710A04302.. 65522; MA $'tome Tmpro A nt Contractor Reg. # 126893
Installation Address: ( 9 62.t4Q Q R () A et c*
City Stare Zip
Purthaser(3): Work Phone: Home Phone: Cell Phone:
11 • , [ 1
Home Address_
(If different from Installation Address) City State Zip
E-mail Address (to receive project communications and Home Depot updates):
❑ 100 NOT wish to receive any marketing entails from The Home Depot
Protect Infort uatlog: Undersigned ("Customer"). the owners of the property located at the above installation address. agrees to buy.
and THD At-Home Services. Inc. ('"Phu Home Depot - ) agrees to famish, deliver and arrange for the installation ("lustallation ") of
all materials described on the below and on the referenced Spec Sheet(s), 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"):
Job (lemmtRdhnm) nets: Sheet(st #: Prolcet Amount �� Irt
- ❑Roofing ❑Siding ndows ❑ Insulation ,tt7 ea� • t ( '
v
"7 (.4 ❑Gutters !Covers ❑Entry Doors ❑ W 46-7 646-7 C ` $ 6437 -}_
.6, ry L� �{ { ❑ROOfu'8 ❑siding ❑ Windows ❑ 1n5u1Atioa 1 I
Ko ❑Cotner: /Cavers,tcy Doors K06 t )- $ 3 b
oo:s ❑ a n h t i
A Rooting U Siding ■ Windows A Insulation - - $
❑ Guttus / Covers ❑Entry Doors ❑
- DRoofing ❑Siding ❑ Windows ❑ Insulation $
❑Gutter;/Covers Entry Doors El
Mlnhnum 25% Deposit of Contract Amount due upon execution offish contract. Total Con trac t Amount — 5 j t� t
Maine Purchasers may not deposit more than one -third :tithe Contrast Amount ` (/
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 Horne 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 read paint, other safety concerns, pricing errors or because
work required to complete the job was not included in the Contract.
Payment Summary: The Payment Summary # .7 O 7(( e... , 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 filkdao 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 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 Horne 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 thi$ Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED T() THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Aeceutnnce and Authorization- Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Horne bepta 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 : ' _ned or amended except by a writing signed
by Customer and The Home Depot. Customer acknowledges and agrees that C read. understands, voluntarily accepts the
terms of and has received a • a • cis Agreement.
Sub ' tied j
-- b .: 1 _ J . A .4S
- gun L Date Sal - a. Pl Signature Date
ye An, a..' • Y' i /_ -AT Teleph• - o. - - --
C 4 er Signature Date Sales Consultant License No.
CANCELLATION: CUSTOMER hIAY CANCEL THIS ( appleobte)
AGREEMENT WITHOUT PENALTY OR OBLIGATION qt BY DELIVERING WRITTEN NOTICE TO THE HOME 3 3 f 4 ,,,/ 3ca i?
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS C7 I
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICE: ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT
46.10.12 White - Branch Flle Yellow - Customer
City of Northampton
� w
,, 7•-:,.;;, fi ,0,,,..=•41'
` Massachusetts ' 4, a f4
„ .g '° s;
z ` ° DEPARTMENT ■ OF BUILDING INSPECTIONS � "
4 .4i1.-11,5, 212 Main Street • Municipal Building t
M Northampton, MA 01060 s ").
s r
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner 4
k. 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
he /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
* — n
Office of Investigations •
TOW it 600 Washington Street
'` ' Boston, MA 02111
0
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): -- h, 1, t - _ L
Address: 0 6,4reirl4d .4
City /Sta - Zip: W_ ∎ _4 ta Phone #:
Are , • an employer? Check t he a propriate box: Type of project (required):
1. 2 I am a employer with �[ a
4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6 El New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub contractors have
p 8. 1:1 Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.
9. El Building addition
required.] 5• Fi 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 12.0 Roo epairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13 Other , )0, ,.,rp
comp. insurance required.] 1 w S
*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.
1 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: /,6'" ✓
��
Policy # or Self-ins. Lic. #: " W Expiration Date: /7
Job Site Address: r d City/State /Zip:
Attach a copy of the workers' compensation p 1 cy 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 a:. ' . t the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D. • fo insurance coverage verification.
I do hereby certify nde th ai an penalties of perjuty that the information provided above is tr e and correct
-
Signature: Date:
Phone #: 49 l qa (c
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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction S rvisor: Not Applicable ❑
Name of License Holder :nD _ 1
License Number •
Address " Expiration Date (((
/
411S6,, 10
Signature Telephone
9:wRegisteed liome=lm roem= a Contr= ctor ., , „7,'i r,. ,µ Not Applicable ❑
Company Name Registration Num er
fag, vaZa my.
�_ _
Address ` Expiration Date
9 1.)& Telephon
SECTION 10 WORKERS' COMPENSATION INSU NCE AFFIDAVIT (M.G L. c. 152, § 25C(6))
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 build' permit.
Signed Affidavit Attached Yes No ❑
1 :1 -; IomeOwner.. xe option
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
•
..
SECTION 5- 'DESCRIPTION OF PROPOSED WORK ?(check `all applicable) ,
New House n Addition ❑ Replacement Wi dows Alteration(s) n Roofing r
�
Or Doors 1 '
Accessory Bldg. El Demolition ❑ . New Signs [D] Decks [IJ Siding [p] Other [O]
A tl M
Brief Description of Proposed----- Al �" !
' ' MC r
Work: A. I i!� �► � . i
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa If >New house andZr3addition to e sting housi
a. Use of building : One Family Two Family Other
b. Number of room's 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 5b
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 - - OTO BE COMPLETED WHEN
OWNERS AGENT ORCONTRACTOR APPLIES. PERMIT ,, ,
, 'E a CO , 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.
.../i, /''''
Signature of Owner Date
I I CVY% l (� / , as Owner /Authorized
Agent hereby declare that the s ments and in Irmation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the -, d pe • ' of .erjury.
At to1 _ a —
Print Name Eripir -
Si Wit' e ' . ' '.- r ania■
Date
„ •
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by 'oning
This column to be filled in by
Building Department
, , ?
..2 '
Lot Size 1 . . ; _ —
II -
Frontage —
Setbacks Front
.. , . .
Side L: R: — L:.,, , ,' R: * :
1 i '
Rear
Building Height ,
, ' , i
Bldg. Square Footage ' , %
, 1
, --
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T 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 . , Page. i and/or Document #1
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T 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
, Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: i f
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. VVIII 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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
`> Ks;pe•artmemt_use3onlyy m1 ,,k --
City of Northampton Sta F� � x „ m '. ��
L,
Building Department C : C u f D� e wO„y`P rmi . ��` 4
iii' zar���
RECEIVED 212 Main Street SewerlSeptic ~Ayallabili ,, i
Room 100 Wa ell AVaila b�ility -1 ` . t:
3 201 p ¢ n k� " '''''Ill-4::' i
ortham ton, MA 01060 TowSe o actur� an _�
h e 4 3- 587 -1240 Fax 413 - 587 -1272 plo S,l e e ta�'.
I _ _ . __.. d Oth Specif •„ - ,
• ' • : STRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
'`Mats Lot U
FS
L brt6P y _ , / / � ;Zone � t ` �' " Overlay District s> �
µElm St.. Distric _ CB District _ , ... , ' '
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: f TAVItd(A;711 Pubitf P 0 % . _� _ / Il X11"
Name (Print) Current Nailing Addre •..--
`De�C.� 11- Telephone
5 ? ?)e, J'
Signature
2.2 Authoris Agent:
n
Nam. (Prin / / Curren Mailing Address: Z-r--,___-&13,..2
C ------ 'ature Telephone
SECTIO 3;. ESTIMATED CONSTRUCTION COSTS -!
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant ,
1. Building
1D-701 ( a) Buildin P ermit Fee
2. Electrical (b) Estimated Total Cost -
Construction from (6) >.
3. Plumbing Building` Permit Fee ,
4. Mechanical (HVAC) =
5. Fire Protection -
6. Total= (1 +2 +3 +4 +5) Check Number
C This Section For Official Oniy
Building Permit Number ''
Date •
•Issued:- .
Signature.
Building Commissioner /Inspector of Buildings Date
•
174 BRIDGE RD BP- 2013 -0819
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 046 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2013 -0819
Project # JS- 2013 - 001409
Est. Cost: $10781.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 11238.48 Owner: POKLEWSKI MILDRED M & KATHLEEN POKLEWSKI
Zoning: RI(100)/URA(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 174 BRIDGE RD
Applicant Address: Phone: Insurance:
908 BOSTON TPK Workers Compensation
SHREWSBURYMA01545 ISSUED ON:3/13/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS /DOORS
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 3/13/2013 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner