17A-092 (2) HOW 9V.0 0VENWM CONTRACT
I'I..EASE READ TW.S
�q r Sold,Furnishod and Installed by. ;
Brantb Name: Boetost Date:�i—1 �.�1"] THD At-Home$0rvvica,lad.
` d/b/a The Home OcW AI-110m Servi-
Branrh Number: 345A Greenwood Stnect,Unit 2,Woteeater,MA 01607
❑North 33 [ nth 31 Toll Free(SM)657-5182; Fax($OS)756-8823
Fed*W M#75-2698460;NE tae#C 02439;PA Cont I ic#16421
CT Ik#565522;UA Rmue Eoupmveoftrk Conuactor Reg,#126893
Installation Address. 'S-)- MO&ZL ..3c M 0lC] C
City State zip
Porohiser(s): 'W"Pheae: Reese Phe"; Cell Phsne:
fu Z 7
Rome Addresie:
(1f different from Tnstallation Address) City stator Zip
R-mall Addtera(to receive project eoAmMunkmiun and Rome Depot Updates):
Q 100 NOT wiob to receive say marketing emaila from The Home r"ot
Pro�o Undersigned("Costumer"),the owners of the property bear at the above installation address.agrees to buy,
and 1 At- onx Tic.('The Route Depot-)agrees to fetmtsh,deliver and arrange for the installation QnstalUtti011 of
all materials described on the below and an the referenced Spa Sheet(s),all of which are incorporated into this Contract by this
refnranr*,along with any applicable Sure Supplement and Paynleot Summary attached herds and any Change Orders(collectively,
"Contraex");
Job#;tr ONA RA-4 e # Yro"eat Amount
xloofiag 1]9id1n}t Wmdows l
L t ao ❑Gurt!ers I Covets 01210y Doors-❑
�g oswi g masses o liwilation
'�a! b�3 parutxaea/cn�sra k r n — + '-► {ca iL4 0- -
�{ phi fmy D�.n
Unbafing s Wohrsumon
[]Cutlers f Caves OEMy Doons 1]
Mtaimemzs'.DepositofCoa%*AAM tduoIM--t- meftLh-O nit. Total Contract Amount S malty Aa Down may not depook mmo three aa*4b&4 of the CoauaaAneam
Customer agreee dust,immediately upon completion of the work for each Product,Customer will execute a Completion CettiPCate
(one for each Product as defined by an individual Spec Shact)sad pay any balance duo, As applicable,each Cwtorner nmfot @lis
Contract agrees w be jointly and severally obligated and liable hereunder.
Tt a Rune Depot taeervee the right to issue a Chww Order or uamivacte this Contra"or&ay inividual Produces(s)laotudod limci n,at
is discretion,if The Rome Depot or its aalthmized service provider determines that it cannot perform its Obligations due to a stns hgzl
problem with tho home.environmc W hazaala such as mold,subestos or kad pamt,other safety concerns,pricing errors or berauso
wotk roquired to complete the job was not included in the Contract.
Payment,ti5:lam The Payment Summary# r�7 � 5b ,included as part of this Contract,seta forth the total
Cot3trsct amount and psyments required for*c deposits and fiat paylments by Prndurt(as applicable).
NOTICE TO CUST MER
you are entitled to a completely filled-la Copy of die Coetsaet at the time you sigiL Do not sip a Completion Certificate(cote:
there is one Completion Cerdifeate for each listed Product as delflaed by Individual"Shecb)before work op that rMilact
is complete.
In the event of tersalmn"of this Contract'Costumer agrees to pay The Rome Depot the cants of materials,labor,expenses
and services provided by The Home Depot or Authorised 5ervlee Provider throto the date of termination,elms BUY other
amounts art forth is this Agroomeot or 611dWed under ap ble law. T 60MM DEPOT MAY W1TfWOLD AMOUNTS
OWED TO THE ROME DEPOT FROM THE DEPOSIT �PAYMENT OR OTHER PAYMT'NTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDM]FOR UECOVERY OF SCtCH AMOUN1'S-
te and AuMgdagoa_: Customer agrees and wu ers;Wit s that this Agreement is$re entn-c agreement between Customer
an a Otne US10 w1g,rt gard to the Products and installation services and suprr=ks,all prior diactiWons and agmernents,either
oral or wriim n,relating to said products and Installation.This Aueement cannot be aniped or amended except by a writing armed
by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,tmderstamds,voluntarily accepts tits
terms of and has received a copy of this Agrvcment.
Customer's Signature Dale sales resultant's S' Nero elate
x Telephone loo.
C ustoma's Signature, Date Sales Consulisot License No.
CAN t rri ti TTON: GUSTONM 'A"Y CANCEL 'fIITT S (d5�1iv�`T
At 11ENT WITROCIT PENALTY O$t OIILIGATTON
BY DF:IJVVA NG WRITTEN NOTICE TO THE How
DEPOT BY MIDNIGHT ON THE TMRD BUSINESS
DAY AFTER SIGNING THIS At :EN"T. THE
STATE SUPPLEMM A'rTACmfb HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCAU" BY LAW IN
CUSTOMER'S STATE.
NanCB;aGt?1TTt)NAr.TERM AND CUNDffKM ARK STATW ON THE SEVEASR 8 @E AND Altlt PART OF TNt$CONTRACT
4.05411 G- Whits-Branch File Yelhw--evzomer Plnk-s*ho Conaukant
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 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
� = Office bf Investig,ations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): _
Address:
City/State/Zip: P one#:
Are n emp loyer?Check the appropriate box: Type of project(required):
a employer with IW .. 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 g. ❑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.F-1 Electrical repairs or additions
3.❑ I am a homeowner doing all work
officers have exercised their 11.0 Plumbing repairs or additions
myself. ' . right of exemption per MGL
Y [N o workers comp. 12.❑Roo pairs
insurance required.] c. 152, §1(4),and we have no
employees. [No workers' 13. ther 1,0 )41 '),OA�IL
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. e -
--Insurance Company Name: Oe A 5� G
Policy#or Self-ins.Lic.#: I t Expiration Date:
Job Site Address: C:2c,.- 1�� �I 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
Investi-ations of the D insurance coverage verification.
I do hereby certify nder ai and enalties of perjury that the information provided above 's true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town offtciaL
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
b. Other
Contact Person: Phone#:
0
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervis r: Not Applicable
Name of License Holder: 9" IJL6 �/0
License Number
L
Address Expiration Date
Signat re Telephone
9.Re isteedHornefmovement�Contractor ...., �' „.., _..,.. .. ... .,. ,� Not Applicable ❑
142(
Company Name Registration uumber
_;��1 ,1-1-vapV1 i kJ r 1,o ;7
Address Expiration Date
Telephon
SECTIO 0-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§26C(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 9wrrlit.
Signed Affidavit Attached Yes....... No...... ❑
11. - Home-OwnerEgemptlon
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 ❑ Addition ❑ Replacement Wi ows Alterations) Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [C] Siding[O] Other[I]]
Brief Description of Proposed-
Work:.
dyl 0
Alteration of existing bedroom Yes No Adding new bedroo Yes No rL�h
'
Attached Narrative Renovating unfinished basement Yes NNo Y r--
Plans Attached Roll -Sheet
6a. If New house and or addition t existinct hou sina, com lete.the fol(owin :
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 Wcodstoves 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
I, 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, as Owner/Authorized
Agent hereby declare tha a statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed undeefTeyains and 'es of perjury.
P me
i
Sig atu f wnerAgent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L._._._,....__ R.._---'_ L: .,__,...'+ R r
Rear
Building Height
Bldg.Square Footage _.. .� % ,.,_,,..; _....
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 DONT KNOW 0 YES
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 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 0 , 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 0 NO
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Depal�e t use only
City of Northampton tas of F�arxrt r �
Building Department it r x
212 Main Street Sevice6sepfcAvaitabt y
Room 100 Watet/,WeIIAuaifab '
Northampton, MA 01060riSets o€StructuraTPlarts
phone 413-587-1240 Fax 413-587-1272 PloSlte Plans
Qt�er Specify � �
APPLICATION 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
I Map Lot Unit
v` 1 Gt Vjj )1 1 e Go � Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner e
Name(Print) , Current ailing Address.
A _ Telephone T
Signature
2.2 Authorize nt: �/�+,,
n4��"I CJ
Name(Print) Current Mai ing Address:
!3 ;
Signature Telephone
SECTION 3-dTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (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 =(1 +2+3+4+5) {-- Check Number S
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/inspector of Buildings Date
s Gi�DVIEWST BP-2009-0649
GIs#: COMMONWEALTH OF MASSACHUSETTS
�i: h ck. t7A:p92 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0649
Project# JS-2009-000946
Est.Cost: $7220.00
Fee:$105.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 126893
Lot Size(sq. ft.): 11630.52 Owner: DOBROW MARTIN&CATHERINE L DIMMITT
Zoning_URA(100)//RI/WSP Applicant: HOME DEPOT AT HOME SERVICES
AT. 22 GRANDVIEW ST
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935-2633 O Workers
Compensation
WORCESTERMA01607 ISSUED ON:112012009 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 1/20/2009 0:00:00 $105.0025334
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo