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PIYASE READ THIS
l Sold,Furnished and Installed by:
Breach Name-,Boston North&South Dete:S THD At-Rome Services.Inc.
d/Wa The home Depot At Home Services
Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Sbrewsbury,MA 01545
Toll Free 877-903-3768
Federal W A 75-2698460;ME l is#C 02494;Rr font 11co 164-27
Cr Ue*kW.055655 ;MA Bone Improyarem Contractor Reg#126843
Installation Address: X'1 a dLg-to Cz— -5 4- [.-ALN;A ti}. 3
City State Tip
Yuxctswer(s): work Phoua: Home Phone Cell Elton:
Hoare Add,1W
(If different from installation s) City State Zip
E-mail Address(to receive project communications and home Depot updates)_
❑I DO NOT wish to receive any marketing ema0s from The Home Depot
Pmiect Intbrroation: Undersigned('Customer"),the owners of the property loeated at the above installation addrtss,agrees to buy,
and TIID At-Home Services,Inc.("The Home Depot")agrees to famish,deliver and arrange for the installation("Installation")of
all materials described on the below and on the referenced Spec Sbeet(s), all of which are incorporated into this Gourmet by this
refane m along with any applicable State Supplement and Payment Summary altached hereto and any Change Orders(collectively,
Contract"):
Job#: o�w a"m-m� Products: S ec Sbeet(s #: Project Amount ,j 7
]tooting Siding Windows dtrsutar]on
Sol ❑Gutters!Covers ❑Entryl7oaxs ❑ ,,,
Rooflng 3idin�- El Windows 0 tnsvlwivn $
❑putters/Covers ❑Entry Doors ❑
Rootlrg LJSKng U Windows 0 Insulatloo
❑Gutters J Covers D&L ry Doors El $
Roofing Siding LJ%iD4ows LJ Imulation $
❑Guttcn I Covets ❑rmtry DoQn ❑
iVllsdan m 25%rl"'t of[outset Amount due upon a cotim of toil coub mil'
moble Pur dams may not depusk twice Own one-third ofihe Counted Amount Total Contract 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 itereundet.
The Hume Depot reserves the right to issue a Charge Order m terminate this Contract or any individual Product(s)included herein,st
its discretion,if The Home Depot or its authorized service provider dt:terminek that it cannot perform its obligations due to a structural
problem with the home,environmental hay=Ls such as mold,asbestos or lead pain(.other safety concerns,pricing emus or because
work required to complete the job was not included in the Contract.
Payment Summary: The Payment Summary#_-,A t60-) (�7
, included as part of this Contract,sets forth the tots]
Contract atneunt and payments required for the deposits and final Payments by Product(as applicable).
NOTICaE TO CUSTOMER
You are entitled to a completely f0led.(u copy of the Contract at tote 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 coinpletc.
In the event of terwJnation of this Contract,Customer agrees to pry The Home Depot the costs of materials,labor,ettpetuies
and aer vises prov'tied by The Home Depot or Authorized Service Provider through the date ut termination,plus any other
amounts set f rrt h in this Agreement or allowed tinder applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT 1;`1gOM THE DEPOSIT PAYMLNT OR OTHER PAYMENTS MADE, WITHOUT
]TOOTING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
A utanee and Authorization, Customer agrees and understands that this Agreement is the entire agreement between Customer
ail The Home 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 Wtallation.This AgreemeSn�� igned or amended erupt by a writing signed
by customer and T$a Flame Depot Customer acknowledges)tad agrees read understands,voluntarily acce pt�thc
tetras of and has received a copy of this Agreement.
Aare b : Subm 11Customer's Si re D e Sales nature Date
Teleph+oate No,
Customer's Signature Date
Sales Consultant LiCeatse No,
CANCELLA 3ON: CUSTOMER MAY CANCEL THIS (n applicable)
AGREEMENT WMIOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME J
DEPOT BY MIDNMGM ON THE THIRD BUSINESS
DAY A>(rl')ER SIGNING THIS AGREEMENT. THE
STATE SVPMEMENT ATTACHED REMO
CONTAINS A, FORM TO USE IF ONE IS
SPEC11zIC ALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE,
NO'ME!AO01T1ONAI,TERMS AND CONtyMONS ARE ST ATF0 ON TITS REWRSE WE AND AM PART OF TM8 CONnACr
11-00.13 White-Branch File Yellow-Customer
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,.MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):,
Address: S /1'�LC�S ��P��� Kp 14--1)
City/State/Zip: y bfi, -3C3 V Phone#: 7
Are you an employer? Check the appropriate�'°x: Type of project(required):
1.F-1 I am a employer with 4. E— 1 am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' q ❑Building addition
[No workers' comp. insurance comp.insurance.$
required.] 5. E] We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself o workers' co right of exemption per MGL
y t c. 152 12.E]Roof repairs
insurance required.] ' §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. /y
Insurance Company Name: / v /7 i 5�?�I-� .L N-5 . 10 ,
Policy#or Self-ins. Lic.#: V1 Cl 10 g g v2 Expiration Date: 3 j `J
Job Site Address: r City/State/Zip 9
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 e. 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 the DIA for insurance cove rage verification.
I do hereby cert' der a pain a s of perjury that the information provided above is true and correct.
Signature: f Date:
Phone#:
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 Su ervisor: Not/Applicable E
Name of License Holder:
License N mber
Address /G �� / t� ))w_
� Expiration Date
Signattuurree/ %%%%,/// Telephone
9.Re 'istered Ho a Im rovement Contractor .,_, , Not Applicab ^�
Com an 6m e �c Registra'on N�r
ss xpiration Date
r
TelephonVO-6
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8))
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...... £
11 'Home Owner Exemption
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 buildine 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 ❑ Addition ❑ Replacement Wi ws Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other[[3]
Brief Description o
Work:
Alteration of existing bedroom Yes No Adding new bedro Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.If New house and or addition to ezistinq`housing, complete the#aowinc
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
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR.BUILDING PERMIT
as Owner of the subject
F M-6— ),�)r
property
hereby authorize /
to act behalf��tters rel to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Agent hereby decla a that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under a ins nd penalties of perju �
VtN Z2
f Owner/Agent Date /(/
+
^
Section 4. ZONING AR Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
11is column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front -il
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&pav d
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Vahance/Rmding ever been issued for/on the site?
x�� �-�
NO �v-�_/ DON7KNO�/ �_/ YES �~�
|F YES, date issued:/ �
IF YES: Was the permit recorded at the Registry ofDeeds?
NO � ) DONTKMOYY ,ES
~~
IF YES: enter Book Page and/or Dncument#
B. Does the site contain a brook' body of water orwetlands? NO 0 DONT KNOW 0 ES
IF YES, has a permit been or need tobe obtained from the Conservation Commission?
Needstobeubtained �-
\ Obtained �~\ Date Issued:
�-� »+� '
��
C. Do any dgnsexist on the property? YES ��. NO ����
,
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 �ypean� inca1ion�
' ' ______-_-_____-__-__-�
E. Will the construction activity disturb(clearing. grading,excavation,or filling)over 1 acre oriait part ofa common plan
'
that will disturb over 1acre? YES NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
^ -
�, �� 5 z Deparfineht use ortlx
CI of Northampton Status ofPermrt " ,� "'A "r
Iding Department Gtir6 CtitDrl�euvay Perrrsl# 1 ;
kmec l lJ Ir'.� 12 Main Street Seyver/SeptlGAvalra6tllty k 1 Room 100 y N.JUN I 0 2014 ampton, MA 01060 Tfuphone 41 -5 7-1240 Fax 413-587-1272 lof/SltPlumbing&Gas Inspectlona �
PLICATION TO CONSTRUCT,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
- Lot Unit
Zone Overlay D�sfr�cf
Elm St p......
SECTION District
SECTION 2. PROPERTY OWNERSHIP/AUTHORIZED AGENT.
2.1 Owner of Res cord:
-- � � z/ ate
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 AgWi9rizei Agent:
r
Name(Pi Current Mailing Address:
ature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building /J)/ }� (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number 3 5
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector'of Buildings Date
83 FLORENCE ST BP-2014-1321
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I IC-066 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-2014-1321
Project# JS-2014-002223
Est. Cost: $4104.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(ss . 1): 20865.24 Owner: KOLODZIEJ PETER J&MARILYN J
Zoning. URA(100)/ Applicant. HOME DEPOT AT HOME SERVICES
AT. 83 FLORENCE ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.611012014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT PATIO 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 6/10/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner