29-467 (5) A) )/
H 0141 E IMPROVEMENT CONTRACT Sold,Furnished and Installed by:
PLEASE READ THIS CONTRACT THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
908 Boston Turnpike Unit l,Shrewsbury,MA 01545
Branch Name: Boston North Date:9/21/2014 Toll Free 8779033768;Fax 8009863610
ME Lic#C 02439 RI Cont.Lic#16427 CT Lic#
HIC.0565522 MA Home Improvement Contractor
Branch No: 33 Reg.# 126893 Federal ID#75-2698460
Installation Address: 9 crestview dr FLORENCE MA 01062
City State Zip
Purchaser(s): Work Phone: Home Phone: Cell Phone:
M/M rosemarie kilbride 413)259-7313 413)584-2146
Home Address: 9 crestview dr FLORENCE MA 01062
(If different from Installation Address) City State Zip
E-mail Address (to receive project communications and Home Depot updates):mannyl2780(a hotmail.com
Marketing emails will not be sent from The Home Depot.
Project Information: 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("Installati
on")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(where applicable)attached hereto and any
Change Orders(collectively,"Contract"):
Job#:(Internal Reference) Products: Spec Sheet(s): Project Amount
7812759 Windows 7812759 $1,529.61
Minimum 25% Deposit of Contract Amount Total Contract Amount $1,529.61
due upon execution of this contract
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 Summary
. The Payment Summary# 7812759 ,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).
07109/14-SA / Page 1 of 10
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Boston 2114 2017
Massgov/dia
Workers' Compensation'iD� anceAuidavit: Builders/Contractors/EIectticians/Plumbers
AD-D licant rnformat-ori' Please Print L'eg'ibly,
�:s.,Ior �tionlmdividual):
d ess:
City/State/Zip: 7Ph0 ne `
11 Are you an'employer? Check the appropriate bo . • Type of project(required}:
1.❑ I ant a employer with ' 4. I am a general contracior and I
employee's (full and/or part-tin--).`
have hired the'sub-contractors 6 New construction
2.❑ I am a sole'proprietor or pay- °r- listed on the attached sheet. 7. []Remoasling
ship and'nave no employees r These sub-contractors have g, Demolition
worl;ng for me in any capacity, znployees and have workers'
9, [] building addition '
[No workers' comp:insurance comp. insurance,t ;
requir°d.]' D. Q «'e are a corporation and its . 110 Elect it'zl--Dairs or additions
3.❑ 1 am avhomeow•der doing all wort: o5cers have exercised their. 11:17 Plulnbi:.;repair or additions
myself. [No wor}•°rs'.comp,••; • : n°ht of exe Tttition per MGL 12.❑ Rooi r°pzirs' I
insurance required.] t c. 132, �1(4)'; and we have no
employees. [No workers'' 13. Other (ice
comp. insurance required.]
'p.ny box=!rc;:st al- till out the sr_•tion below shoN^ing their workers'"eo npersatioa poiicy info.iation.
Homcowa:z who submit t is a:fidati�t indi-a 3ng h_y z -doing zll work and th-n hi r_outsid-con=dors must submit? - such.
'Contractors that check this box must atachcd an adai6onal shc:t showing the carne of the and'stat:whc
mployr_s. If the sub-contrzctors have cmployr_s;they must provide their wor}tors' comp,pohcy number.
I am,a;i employer that is providing tvorf:ers' COfrtDel2Satlon i12S11ra11Ce fOr!ny enlpl0yees. Below is theRoliey and job site'
Irsura*tce Company Name:
Policy T or Self-ins. Lic. I/lJ� =xpi anon Date:
� -� �,
Job Site Adaress:_ � ' City/StatelZip ���'
Attach a copy of the)Yorkers' compensation policy declaration page(showing the policy number and eipiration date).
Failure to s-cure coverage as required under Section 25.4 of h/,GL c. 152 can I-ad to th- imposition of criminal penalties of a
nne'up to S1,500.00 and/or one-year impr'so'rLment, as well as civil p-nalo-s in the form of a STOP WORK ORDER and a Em:
Of up to S25D.00 a day against-the violator. Be advised that a copy of thls stater :rtt may bt;forwarded to the OIPCe of
Investigations of the DL4 for insurance,covcrag--,veri5cauon — .
I do heraby card, u pa'. and oI al. f ^rjury that the information provided above is true altd correct
��a --/
Siznature i Dot.
Phon-r
Of::ial use only. Do not write in ibis area, to be con>_Dlcted by city or town offai�. 1
Ciry or T01"'n• Perr-tit/License
ls;uinc,Authority (circle one): y
1.Board of Health 3 Build=Depa.-4:eat � cti —
3. City(I'o«•a Clerk -+,�L .,real�spector, S.Plumbi..,Inspector
6.Other
Contact Person: phone„:
City of Northampton 212 Main Street, Northampton, MA 01 060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: `�/ C � � / JPII T
by:
It ' fir
The debris will be transport ed
The debris will be received by: `` `�
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
Uity or Northampton
r` Massachusetts
E .
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DEPARTMENT OP BUILDING INSPECTIONS
1 212 Main Street • Municipal Building 11
Northampton, MA 01060 srW ,y�til "
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
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 C'ommonwealtn ojlvrassacnuseus
�r
Department of Industrial Accidents
Office of Investigations
600 Washington Street
- Boston, MA 02111
4 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an 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
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.$ g• ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. o workers comp. right of exemption per MGL
y � ' P 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Sue isor: j Not Ap/plliica le £
Name of License Holder
License Number
Ad�r' /,y Expiration Date
ignature Telephone
.•. ��/fir/✓
,. m �:.... . Applicable £
9. Re istered Home Im r v ment Contractor Not A i
Com an Name � Redistrajion Number
A r s Ex *ration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure'to provide this affidavit will result
in the denial of the issuance of the building per
Signed Affidavit Attached Yes....... No...... £
11. - Home Owner.Exe — ion,
The current exemption for"homeowners"was extended to include Owner-occupied DwellinE$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 Addition ❑ Replacement Wi Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [O] Other[EI]
Brief Descriptio f P Al2—
Work: / /
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
11'''1.1...use and or'addiiion 6 exisiinq housing, complete tiie following:
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 BUN DING PERMIT
, as Owner of the subject
property
hereby authorize a'.01Zw',
to act on m behalf, i II tte a ive to wo orize y this building permit/aplication.
Signature of Owner Date
l ,as Owner/Authorized
Agent hereby declare that the statements and informs i on the foregoing application are true and accurate,to the best of my knowledge
and belief.
1
Signed nd the ns and pp na lti per' . /
Print Nam /� 2:4
Si n re of Ow a/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Irrfvr1M4hrrt -
,y
Existing Proposed Required by 4oning �a
This column to be filled in by
Building Department
Lot Size ! t - 3 -----'------
Frontage _.-_-_.------ .___...._ _.
Setbacks Front
Side L:' i R:= L:r__..; R:=
Rear
Building Height
Bldg. Square Footage -_-._.... %
Open Space Footage % -
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill: 1
(volume&Location) 1 — - --- --- --
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW YES Q
f._......._....._... -------
IF YES, date issued:;
......._.._.._.._._.._—.:._..._._._.._
IF YES: Was the permit recorded at the Registry of Deeds?
NO C) DONT KNOW�0 YES
IF YES: enter Book i Page' j 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 Q , Date Issued:
C. Do any signs exist on the property? YES 0 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 O NO Q
IF YES, describe size, type and location: i
—._._ _.. ---..........................
.._
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 Q NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required,
' �� � Department use only h, ;
ity of Northampton Status of Permit 1 �' s
LOF ED ien ir�} it't
uilding Department Ctrrla cur/DnrrewayPerni#
nis
212 Main Street Sewer/SepticA`vaitabllrty r
rim
Room 100 VVater/Vli`e11A�atlabtlity
J
No hampton MA 01060 f
l'wa Se#s o S#ructural Plalts �
Fit
IN
13 87-1240 Fax 413-587-1272 PloWite Pians r "
NoRrtlaMFrON MA 01060
Qtherz5necify y
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This.section to be completed by office 1.
1.1 Property Address:
Rj
Map. Lot VK Unit
' ��✓1 �
Zone Overlay D�strtct
Elm St DiStnct CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: '
Nannel rii t) Current
Ma ilinTcL2�j;e ss:iW 2131b
41
Telephone
—z
Signature
2.2 Autbevized ent: 'J'� eljv'oev);;g'� -A/v
Nam P' t) Current Mailing Address:
nature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed b permit a licant
1. Building � / (a) Building Permit Feb
2. Electrical / / (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature: _
Building Commissioner/In.spector'of Buildings Date
9 CRESTVIEW DR BP-2015-0489
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-467 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit# BP-2015-0489
Project# JS-2015-000923
Est. Cost: $1529.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 104327
Lot Size(sq. ft.): 12240.36 Owner: KILBRIDE ROSEMARY&MICHELLE M
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT. 9 CRESTVIEW DR
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON.1012812014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 3 REPLACEMENT WINDOWS
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 10/28/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner