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HOME IMPROVEMENT CONTRACT � UJ
PLEASE READ THIS
Sold,Furnished and Installed by:
Branch Name:Boston Nordi&South Date:q_/4/� THD At-Home Services,Inc.
d(b!a The biome Depot At-Home Services
Branch Number 31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toli Free 877-903.3768
Federal ID#75-2695460:ME lie#C 02439:RI Cont.Li.#16427
Q CT Lie# G0565521_-,_W Homc Imp semen Contractor Reg.1t 126893
,
Installation Address: t 1 At,301Jt Ph C-l�,'�F2ZA �iM_-A `�,t►/1tr�
City State Zip
Pnrchascrts): Work Phone: Nome Phme: Cell Phone:
Home Address:
(If different from Installation Address) City State Zip
E-mail Address(to receive project communications and Homc Depot updatesi:
C I DO NOT wish to receive any marketing emails 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-CThe Horne Depot")agrees to furnish.deliver and arrange for the installation(-Installation")of
all materials described on the below and on the referenced Spec Shecl(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"):
.lob 4. um., Products-. SpLy Sheens)# Project Mmunt
4 RaoTng ElSiding 0 Windows Insulation
L ❑Gutters/Covers []Entry Doors ❑ 3 W
Rooting Siding 0 Windows Ll Insulation
❑Coders/Covers ❑EntryDcors ❑
Roofing E]Sidin7gD Windows U Insulation
❑Gutters I Covers ❑Entry Doors Q S
Roofing 03iding Windows Insulation
❑Gutters/Covers ❑EntryDcxn:c ❑
Misnrtun 25%Deposit of Contract Amount due upon execution orthis contract
Mahe than Purchasers may not deposit mo than unc-third ordw Contract Amaatt Total Contract Amount
I
Customer wets 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 appliwblc,each Customer ander this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depot rescaves the right to issue a Change Order or terminate this Contract or any individual Produet(s)included herein,at
irs 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 saPcty concerns,pricing errors or because
work required to complete the job was not included in the Conu'acL
Payment Summary: The Payment Summary # 11 W16 2--- , included arc 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 ftlled4n copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there is one ConVietion 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 Home Depot the costs or materials,lalwr,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 PAYMEM'S MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
AcceMnce and Authorization: Customer itgrce-s and understand+that this Agreement is the entire agrecnrenl between Customer
and The Home Depot with regard to the Products and hnstaliation services and supersedes all price discussions and agreements,either
oral or writton,relating to said Products and Installat ion.This Agreement cannot be assigned or amended except by a writing signed
by Customer and The Home Depot.Customer acknowledges and agrees that Customer ha%read,Understands,voluntarily accepts the
terms of and has received a copy of this Agreement.
Accept Sub y: _ f
X / x {)16Z� J
Cult s Signtx c Date Sal- ultimt'+5ignatnre Date
X Telepho a No.
Customer's Signature Dale
Sales Consultant Licc.ase Va.
CANCELLATION: CUSTOMER MAY CANCEL THIS 0111 a"'°t"et
iGREEMENT WMIOUT PENAL'T`Y OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS , L
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
.,r ec.r��.mn•n a+m.mr
City of Northampton 212 Main Street, Northampton, Na 01060
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: � �����
G- � 4t?z-
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant s )12-OM-
V
Date Sign-ature of Permit Applicant
The Commonwealth of hllassachusett5
Department oflndustrialAccidents
i 1 Congress Street,Suite 100
Boston,KA 02114_2017
wmgp.mass.govldia
Norkers' Compensation insurance Affidavit:builders/Contractors/Electricians/plumbers,
TO BE FILED WITII TPR PERIVIITTIItC AUTHORITY.
nolicantinformadon Please Print Legibly
!Manic(BtSLries=,'Organization(Iridividual): �� ✓ � s��- t'
VaAddress: (� s"� / '`p
Cif-',/State/ZTp: Phone, :
:S-re ou an employer?Check the appropriate box_ Type of project(required):
1.(�t as a e�alo;;r.'xith employees full ardor �m_
i ( per`-u °)- 7. ❑New construction
2.;�lam a sole nronactor or partnership and have no empioyccS wci in= forme in
S. Remodeling
(—� •;ceaacit:.[No w'orf cr'comp.iasurmcc rca mod.]
.I �,...3 i1:LP.?pw'^'r,_ _�1•'•G:�:�75°!r.f\a t -. ,t t; °• ❑Demolition
l !
IQ ❑Building addition
1 am a homeowma-aad%-.-:11 be hiring eunL-aetwS to conduct all work oa my pion:::j. I will
.._.ac LIME all con=tois eidicrhave worker' insurapce or are sole I I.❑Electrical repairs or additions
with no employees.
l' 12.n Plumbing repairs or additions
5.! 1 as a cncral contractor and i have hi.cd the sub-coanctor_listed on the attached sheet. j3.❑Ro epairs
Te•_se sue-con z ctor have employee;and nave::oa ers'cor_;u.i surnce �� n 14. ther
6.F—',. `.�e are a corpontioa and its a-�tcer have excrescd their right of exemption per MGL c.
152,F 114),and vie have ao camloyces.[No~workers'comp. umace squired.]
". ny avDUcant that check:boa:=i mtut also all out the secdca be1o::shoerin_a their Nvorkcer'compensation policy information. —
Homeora airs who sub=;'&-,is a Tda;it iadicatLng they arc doing,ir::'ors and then htr_outside contractors must submit a new afndat•ii indicating such.
:Co-mraaor that ch_cl:t-us pox must abaci°d an additional sheet showing the name of the sub-contractors and state tebether or nott-ese ndties have
employees. Ir ti:. e:at.oy=:s,they Dust provide ci .workers'came.policy number.
.�ain all employer that is providarg)vorkers'compensation lnsltr'ariCE far rnJ'errlplo i'CES_ 3elow is tine policy hard job site
inforrnetion. •--;^y�
Insurance Company'-dame: ��l'j� tf `/ ✓ �/ � ?�� s I/
an '
r ` Ll G/i —h6
Polio -or Self-ins.L ic.-: L`t�( - /� U Expiration Date: -�
Job Site Address: 'v State/Zi
Cllr/ p
4ttach a cope of the workers'compensation policy declaration paL: (shorvind the policy n-imber anqcxpira date).
Failure to secure coverage as required under h'iGL c. lit,525A is a criminal violation punishable by a f_ne up to 51,500.00
and/or one-year'i.upriso^r en z,as:'.'_il as_ivi 1 pen a'_ties in the form of a S-1-OP WORK ORDER and a fine of up to S250_00 a
day against the violator._h cop;of this sta_ement may be for warded to the Orrice of Investigations of the DLk for insurance
coverage verification.
1 do hereby ce/r ti rns n�=nrtdger:aItiec erjury that the information provided above is 1true and correct
Si-anattisc / Date:
Phone T-*:
Official use only. Do not)vrite in this area,to be completed by city or toivn official.
City or Torn: PermitfLicense r
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cit r/ToNNan Cleric a.Electrical inspector S.Plumbing Inspector
6.Other
Contact Person: Phone r:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: l Not Applicable £ ✓j
Name of License Holder:
License Number
Address 1� ;�" Expiration Date
Signature Telephone 2 ��
T _ .
9 Re isfered_H'ame lm rov`ment.Cor ti for k_. __. '_ . __ Not Applicable £
Company N arrig � Registration Number
Add r s, Expiration Date
Ale Telephone
SECTION 10-WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.O.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 buildin
Signed Affidavit Attached Yes...-:I No...... £
11 Home QWU6Xgeinption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinzs 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 Mo-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,
i
SECTION 5-DESCRIPTION OF PROPOSED WORK check all applicable)
New House ❑ Addition ❑ Replacement Wi s Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [M Siding [❑] Other[Ell
Brief Description o P s djG h, �� ¢-y�C' �J�
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
?—
sa `I:f New,house and ohadtlI id to exlsfi`nd.houslng,:comi4lete the:foll q:
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 A PIP PLIES"FOR.BUILDING PERMIT
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
as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under t ins an penalties of pe ' l
Print Name
Signature f ner/Agent Date /
I
I
Section 4. ZONING AU Information Must Be Compteted. Permik 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 L
Side L:= R:?—I L:I R:� J {
r--'_
Rear
Building Height —� f
Bldg. Square Footage i % �J
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location) — I
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q 'YES Q
IF YES, date issued:)
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q_
IF YES: enter Book Pagel and/or Document#1
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location: f
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO 0
IF YES, describe size, type and location: j t
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 Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only i
it
City of Northampton Sta��us'ofPermrt I 4' ^g 4t g.1
♦ � ,1!r F ; ,P t-
�"� ° = uilding Department Ct7rh Cur�Dri+tenray P�rml# ___
z ,
212 Main Street SewerlS _ ^
eptic Avall"a611rty , ,k = ,, �;
Q Room 100 aiVater/Vel�Aualla6tltty�' ;' ! '
0 ZQ�� ` No hampton, MA 01060 TwoiSetsrafStrcrcteJFal
v
phone 413- 87-1240 Fax 413-587-1272 Pfot/site Plans C, ! 4 r ''
DEPT. �,DEPT. �.F _ •.,
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
__,._ectl_orr,fo_;be.com leted,b.:_office'-:.-=_ -
Property Address:
}�
n
���'� / Zone I Overlay Dlsfrtcf '
EIm St Dlstrlct t- j e KGB District
SECTION 2.:-PROPERTY OWNERSHIP/AUTHORIZED:AGENT-
2.1 Owner of Record: /
Name(Print) _ 6-2, Current Mailing Address: ,
Z�' Telephone
Signature
2.2 Au ized ent: A/P _
Name(Print) � Cu(rret Mailing Address:
Sign e Telephone
S CTION 3.ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building /' P (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 lip
This-Section For Oft iciaf Use'Onl
Date
'11jilding Permit Number: Issued:
�mmissioner/Inspector'of 8ui(dings: Date
23 RANDOLPH PL 201 BP-2016-0766
Gas 9: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 163 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate<�or,r: windows replaced BUILDING PERMIT
Permit 4 BP-2016-0766
Project# JS-2016-001281
Est. Cost: $1150.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 92937
Lot size(sd. ft.): Owner: PREDMORE JOYCE R
Zoning,: URC(105)/WP(53)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 23 RANDOLPH PL 201
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401) 935-2633 O Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON.121712015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 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:
Rou<-h: 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
, I )' OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
B1111din-, 12/7/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner