32C-265 (2) Dec 01 1504:57a P
HOME IMPROV Evl ENT CONTRACT
PLEASE:READ THIS
• Sold,Furnished and Installed by.
Branch Name:Boston North&South Date:,1/13L THD At-Home Services,Inc.
dibfa The Hontc Depot At-Horne Services
Branch Number.31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,NIA 01545
Toll Free 877-903-3765
Federal ID 9 75.2698460;ME Lic h CO2439;RI Cont.Lie#16127
�,/� CT Lc 0 HiC.0565522;MA H the Intprovemrnt Contra�c:o]r Reg.k 126893
Installation Address: _ --5_S �� 4)V-Q- M "`" '
City state Zip
Purehaser(s): Work Phone: Hmnt Phone: Cell Phouc:
Horne Address:
.ilfdiffcrent from Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑1 DO NOT wish to receive any marketing mails from 7hc Home Depot
Pr-ooiect 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 famish,deliver and arrange for the installation("Installation")of
all materials described on the below and on the referenced Spec Sheet(s), ail 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#: it--o r,n a Products: S Sheets #: Pro'ectAmount
Roofing Siding Windows Insulation
65A 9a3 L [)Gutters f Covers ❑Entry Doors ❑ C{ k �0
Roofing SidinS Windows Insulation $
❑Gurers r Covers ❑Entry Doors ❑
Roofing Sid ng Windows Insulation
S
❑Guuars i Covers ❑Entry Dears❑_ __ _
RcofinJ Siding Windaus Insulation
❑Gutters:CCVCM❑EntryWors C1 $
Mirimum25%Deposit of Contract Amount due uponexwdionofthiscontract. Total Contract Amount S
1=I'urxkwsenmayuddgtositmmthanu"4iirdeftheCostraetAmoont. ` vf°
Customer agrees that,im ncatiately upon completion of the work for each Product,Customer will execute a Completion Certificate
(one for each Product as dafmcd by an individual Spec Sheet)and pay any balance due. As applicable.cacti Customer under this
Canimet agrees to be jointly and severally obligated and liable hereundc7.
The Home Depot reserves the right to issue a Ci,.ange Order•or terminate this Contract or any individual Product(s)included herein.ai
its discretion,ifThe(ionic Depot or its authorized service provider determines thtt it cannot perform its obligations due to a Strucrura
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 Contr�act.
Pavment Summary: The Payment Summary t< «J t/D(=A!6 , 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 filled4n 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 evvat of termination of this Contract,Customer agrees to pay The Horne Depot the costs of materials,labor,expenses
aed 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 alMwed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceistance and Authorization: Customer agrees and understands that this Agrement is the entire agreement hctween Customer
and The Home Dcoot with regard to ate Products and Installation services and -des all prior discussions and agreements,either
oral or t+.Tiucn,rclatiag to said Products and Installation.This Agreement can o a signed or amended except by a writing si�med
by Customer and The Home Depot.Customer acknowledges and agrees that u trlmc has read,understands,voluntarily accepts the
terms of and has receivot!a copy of this A6ncement. j
i
Acce ted by: Submit b
Y X
Custo 's Si cure D tc Sales on is Signature Date
X Telephone No.
Customer's Signature Date
Sala Cansullant License No.
CANCELLATION: CUSTOMER IMAY CANCEL THiS tualt(thi bI6
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED RERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW 1N
CUSTOMER'S STATE.
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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:
The debris will be transported by:
The debris will be received by:
Building permit number:
r
of Permit A jl '
Name Applicant
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of I'ndustrialAccidents
t 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE Fl-LED WITH THE PERNff=G AUTHORITY.
Annlicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: 4 Phone!::
Are you an employer?Check the appropriate box: Type of project(required):
l.�I am a employer with cmployecs(full andior pa..-time).' 7. ❑
New Construction
2.7[am a sole proprietor or pa:-merhip and have no employees working for me in g. �Remodeling
any capacity.[No workers'comp,insurance required.]
3.❑last a homeowner doing all worw mysc:f.(10 xorkcrs'Como.insurance required.]t
9. ❑Demolition
10 Q Building addition
4.F-1 I am a homeowner and will be hiring contractors to conduct all work on my propurty. I will
ensure that alt coa actors either have wotkcrs'comoematron insurance or are sole 11.0 Electrical repairs or additions
z am netor•a;th no employees. 12.F]Plumbing repairs or additions
a grncrzl contractor and I have hired the sub-coo-ctors listed on the attached sheet r
T ncse sub -ctors have employees and have workers'comp.insurance.: 14,[]Roo.repairs
6.Q I've are a corporation and its off-jccrs have exercised their right of exemption per'MGL c. 14.F-1 Other
152,§1(4),and we have no employees.[No worker'comp.is urmce eouced.l
-Any appucaut tlrat cbecls box#I must also fill out the section below showing sec w•o.-:- rs'compensation policy information.
t Ho=av,-ncrs who submit this affidavit indicating they are doing all wort:and,-1-en hire outside con-ctors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sbect showin=_the..a.-:e of tht sup,-Can-.actor and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their won:e..'comp.policy number.
I an an employer that isproviding workers'compensation insur-ancJe for my employees.
Below is the policy and job site
information.
insurance Company NN ame:
Policy or Self-ins.Lie. M/1- Q 10h?92— Expiration Date: �'6 ^/�✓
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 MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00
nad/or one-year imprisonment,as Well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certi and naltie erjury that the information:provided above is true and correct.
Sigrtatu / "/— Date: �
v ^ �^
Phone r• -
Official use only. Do not write in this area,to be completed by city or town officiaL
j City or Town: Permit/Ucense
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Citv/Tovrm Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone R:
i
'It
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Sue isor: Not Applicable £
APName of License Holder: yi`T�
n License Number
Address /--- Expiration Date
Signature Telephone
9_Re i5.fered'Home Uri.rovem nt Conf"ractor Not Applicable £
Com a;nv Nam Registration Number
Add e s Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.W.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 =Hoe Owner.Egeinpt><on
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. CNM 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.
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SECTION 5-DESCRIPTION OF PROPOSED WORK'(check all apolicable)
New House ❑] Addition ❑ Replacement W' ws Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [C]] Other[IZ3]
� .� /o Des e� j W k / A .d a'
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:and_or:adtllfron.to'exlsflng-:housi'ng,..corns�fete fhe#ollowrnc�:
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.
1. 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
property
hereby authorize
to act on my behalf, in all rhatters relative to work authorized by this building permit application. _
7
Signature of Owner Date
r t
I, 1 / 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 the pa' nd p alties of erju f
Print Name )�
Signature caner gent Date // /
Section 4. ZONING Alt 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:`i L:! 3 R:1
Rear ' 1 �---
Building Height (-
Bldg. Square Footage
Open Space Footage %
t l
(Lot area minus bldg&paved w i
parking)
#of Parking Spaces 1—_--1
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES Q
IF YES, date issued:; }
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
I—�
IF YES: enter Book Page and/or Document#f
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained , Date Issued:
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location: I
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, excavat8on, or filling)over 4 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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Wm-
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Crty of Northampton °Stat`us,ofPerrn�t �l partment
( B ildli Department c�;�CurlDrl eway Perrntt �
' 12 Main Street SewerLSeptic,4uairaT�ltty "
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DEC 4 2015 Room 100 a Nater/i/�fe7�Avatlabllity
t
�r
ort ampton, MA 01060 Twa,Sets ofS#rt adral Pta[ts � '
ti A'1`3-5 7-1240 Fax 413-587-1272 PIof/Slte Plans`a T j irk
_r.
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
_....__..__..___.__—�This_sectw.�rfo:;be c.omplee d b:Y o_ff_ic..e'-; --_;
:�:v_+rye:==iv' r:—=_=c_J's.—:r—¢_'—_7-!e_a-_ �_.,_:1_ „ '•.r:�:' tai '''-.' ':rv_..._:
1.1 PropertyAddress.
q �
Ali -p _ _ --
Zone >: .. ._.- Overlay Disfr►ct :� _
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED.AGENT:'.
2.1 Owner of cord:
�vr l �
Name(Print) 1 Current Mailing Address:
"'5 f & ��,�y Telephone
Signature
2.2 Auth ed A nt:
Aot V/
Name( nn ` Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS. . .
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building .(a) Building'P.ermit Fee
2. Electrical (b)'Estimated Total'Cost of
Construction from fi
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'Onl
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/In Buildin
spector.of wings , Date
43 EASTERN AVE BP-2016-0810
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-265 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-2016-0810
Project# JS-2016-001363
Est. Cost: $1620.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin HOME DEPOT AT HOME SERVICES 92937
Lot Size(sa. ft.): 5619.24 Owner: HURLEY WILLIAM P JR
Zoning. URC(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT. 43 EASTERN AVE
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 () Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON:1211712015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 4 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 12/17/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner