12 HARTFORD ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
4 Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SdMar Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For O ial Use Only
Building Permit Number: 96c Applied:
74� ,s 7, S>iP.� lam n � l7
Building Official(Print Name) - Signatu Date
SECTION 1: SITE TivK
1. 2 /-�Progeny Addre� 7�/ f C�/e 1.2 Assessors Map&Parcel Numbers
A('
1.is Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(fit)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided r
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
'Lone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes[] Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 Ownert of Record:
fhA r C q v fI •� S9 le rt• M a r219 7 �
Name(Print) City,State,ZIP
i �, H M4 For rr _ l
No.and Street elepbone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKZ (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s),C Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work: d-- in,--
aG
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SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building $ 3 3, at 0 1 Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee -
D Total Project Costa(Item 6)x multiplier _.. x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ /�3�, w ❑Paid in Full ❑Outstanding Balance Due:
97� 9 -�" �
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Dale
Name of CSL Holder I /
/ 2 Y 4/ �, S�/ List CSL Type(see,below) v
No.and
Street t Type Description
is7/?/1 f/(Tf ®� �Z U Unrestricted(Buildings u to 35,000 cu.ft.)
^'7 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
O b - SF Solid Fuel Burning Appliances
( /(� ''1
/ C�— I Insulation
Telephone Email address D Demolition
5.2 Registered
Home Improvement Contractor(HIC) /V D 6 P1
IVY v M�1 L �'t�. _ HIC Registration Number Expiration Date
HI Com pazt Na rHIC Reg trant7Aame
- � �
No. d Street Email address
-n11L qr
Ci V/fown, State, ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit most 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........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTO�R,APPLIES FOR BUILDING PERMIT
yt I,as Owner of the subject properly,hereby authorize ' " rC �,q Ce-
to act on my behalf,in all matters relative to work authorized by this building permit application.
p
kri erne(Electronic Signature) 15atc
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
cont• ned this li tion is true and accurate to the best of my knowledge and understanding.
to 'e"s r uihorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at
LA .mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.sov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
SPECIAL SERVICES CUSTOMER INVOICE Page 1 of 7 No. 3409-73107
Store 3409 PORTSMOUTH Phone: (603)431-0517 a
a 100 ARTHUR BRADY DRIVE Salesperson: RP85AV
�. PORTSMOUTH, NH 03801 Reviewer:
This is only a QUOTE for the merchandise and services printed below. This becomes an
oAgreement upon payment and an endorsement by a Home Depot register validation.
N Nme Wre f.
L 10 JAVERY MARC (781>608-7368
m Atl m- 12 HARTFORD ST voaw°"° (603) 431-0517
01
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o" SALEM ooOw n'bn 0015 AWM ENTRY, STORM
A MA Lp 01970-1034 cwm ESSEX QUOTE is valid for this date:03/05/2012
s
Nto I1�5TfAL4ER ELF�i FiY#1` MERCHANDISE AND SERVICE SUMMARY erese"�the Ant to limit the4ua " o Eire
o REF# 101
STOCK MERCHANDISE TO BE DELIVERED: o
REE # : S1YU :..' QTY UM DESCRIWTION'' -
:, '.. CYi .,EXTENSION:.....
R02 163-613 1.00 EAJ 1X8-8 PT APPEAR WEATHERSHIELD $6.97 $6.97
R03 715-499 2.00 RL E!O 2"X16"X48" M/P INSUL RL 5.33SQFT N $3.94 $7.88
B04 560-638 1.00 EA 10LB.QUICK SETTING CEMENT-QUIKRETE N $6.95 $6.95"
R05 677-038 3.00 EA 3/4X3-1/2X8 AZEK S2S N $0.31 $0.93'
ti R06 914.835 1.00 EA 1X8-8 NO.2 PREMIUM PINE N $8.17 $8.17
z1 R07 489-467 2.00 EA 1X8X8 DBTR S4S WHITE PINE N $18.98 $37.96
x S/O- MDSE TO BE DELIVERED: REFAAMJ ESTIMATED ARRIVAL DATE: 03/1&2012
a
PTION i TAX PRIL` `E AC H'. . EXTENSION
o S0801 261-009 1.00 EA CONTOUR/CONTOUR S GLASS'STEEL ENTRY-10 DA/ref quote N $408.77 $408.77`
a 477160-03 sM9.81x2l.
d me, contour,sgl door unit, LH, is,2-8, reduce door hgt.
x please cut fo9", reduce frame hgt to r.o. hgt 69", reduce hgt 6"8 over,
, ct100, It cl 'cut a 'eldwen panel for,sal
01
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O www.homedepoLcondorderetatus
rV (98)1) 0100108129
' Indicates Item markdown
N Page 1 of 7 No. 3409-73107 Customer Copy
SPECIAL SERVICES CUSTOMER INVOICE-Continued Last Name:JAVERY Page 2 of 7 NO. 3409-731 07
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`INstALlLtA DELIVERY #1
(00"nusd),':: REF#101
oS0802 688-212 1.00 EA NS30419376I NS30419376 S/O ALL OTHR SECTIONS/ref quote 477160-03 N $285.27 $285.27
ns30419376 278-ss 32"x67-1/2"wht for larson storm door
N I 762.90
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~ DELIVERY INFORMATION: DELIVERY DATE: INSTALLER WILL SCHEDULE
m INSTALLER WILL DELIVER MOSE TO: SITE OF INSTALLATION 0101 AT TIME OF INSTALLATION.
o. NOTE:UPON RECEIPT OF ALL SIO MERCHANDISE-INSTALLER WILL CALL CUSTOMER TO SCHEDULE INSTALL
DATE.
ors::,:":�
2 ::INTLLATION #y
REF# 101
ti
ESTIMATED INSTALL BEGIN DATE: 03/WOI2 ESTIMATED INSTALL END DATE: 04/04/2012
N MERCHANDISE TO BE INSTALLED:
s
c 1. .A F#:: iKll : QTY: UM. i" . ::DESCRIPTIONiz
R02 163-613 1.00 EAl 1XB-8 PT APPEAR WEATHERSHIELD
R03 715-499 2.00 RL E/O 2'Xl6"X48" M/P INSUL RL 5.33SQFT
R04 560-638 1.00 EA 10LB.QUICK SETTING CEMENT-QUIKRETE
R05 677-038 3.00 EA 3/4X3.1/2X8 AZEK S2S
R06 914-835 1.00 EA 1X8-8 NO.2 PREMIUM PINE
R07 489-467 2.00 EA 1XSX8 D/BTR S4S WHITE PINE
S0801 261-009 1.00 EA CONTOUR S/O FI BERG LASSISTEEL ENTRY-10 DA
yl S0802 688-212 1.00 EA NS30419376 Sr0 ALL OTHR SECTIONS
x BASIC INSTALLATION LABOR:
QL
SKU:. DESCRtF?TIpN. 0. ITAXP f'..Rot6iC: =�ScTEhiSION
0
898-501 EXTERIOR DOO R-NAT/PRE-HUNG DOOR UP TO 36X96 1.00 EA N 379.00 379.00
X OPTIONAL LABOR SELECTED INCLUDES:
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SPECIAL SERVICES CUSTOMER INVOICE-Continued Last Name:JAVERY Page 3 of 7 NO. 3409-73107
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a INSTALLATION #1.
'.(CorlNn!ledl REF 9101
0 1 HAUL AWAY OF EXISTING DOOR/ 1.00 EA N $25.00 S25.00
3 INSTALLATION BETWEEN 31-50 MILES FROM STORE/ 1.00 EA IN0.00 $50.00
cm
23 INSTALL NEW STORM/SECURITY DOD"
(APPLICABLE ONLY DURING INSTALLATION AT 1.00 EA N $97.00 $97.00
THE SAME ADDRESS AT THE SAME TIME/
ti CUSTOM LABOR SELECTED INCLUDES:
Ok
(..N: DESCRIPTION C]TY .:..c UM . : TAX .PRICE EACH EXTENSION
.1 DISPOSAL OF STORM DOOR 1.D0 CT N 20.00 $20.00
t AL LAnbliq,5ITFHAME9?JAVERY, MARC INSTALL LABOR CHARGE: $571.00
n ADDRESS: 12 HARTFORD ST TRIP CHARGE: $0.00
s CITY: SALEM STATE: MA ZIP: 01970-1034 CREDIT FOR DEPOSIT/MEASURE: 50.00
s COUNTY: ESSEX SALES TAX RATE: 6.250 TAX: Merchandise- N LABOR- N INSTALL TOTALr $571.00
cmPHONE: 81 608.7368 ALTERNATE PHONE: 603 431-0517
It
M BASIC INSTALLATION LABOR INCLUDES:
C) 'PRE-INSTALLATION AND JOBSITE MEASURE FEE APPLIED TO EXISTING DOOR
PURCHASED INSTALL •INSTALL NEW INTERIOR CASING AND EXTERIOR TRIM)BRICKMOLD
'DELIVERY OF DOOR AND ALL JOB RELATED MATERIALS BY OF THE NEW DOOR WHEN THE CASING TRIM IS THE SAME SIZE OR
INSTALLER(UP TO 30 MILES FROM STORE) WIDER(CUSTOMER PROVIDES)
'REMOVAL OF DUSTING DOOR UNIT 'INCLUDE NON-COLORED STUCCO PATCH UP TO 4'FROM JAMB AFTER
'INSTALL NEW SLAB OR PRE-HUNG EXTERIOR DOOR UNIT EXTERIOR MOULDING IS INSTALLED.WHEN APPLICABLE
'INSTALLER TO PROVIDE NECESSARY FASTENERS,SHIMS AND •PRE-HUNG DOOR UP TO 7ZX96 INCLUDES DOUBLE DOORS AND DOORS
N CAULKING WITH SIDELIGHTS(FACTORY MULLED)
N
'INSTALL NEW OR EXISTING LOCKSET AND KICK PLATE(IF 'FINAL CLEAN UP OF ALL DEBRIS RELATED TO INSTALLATION
ZI APPLICABLE)ON NEW DOOR(CUSTOMER PROVIDES) 'FINAL INSPECTION WITH CUSTOMER INCLUDING INSTRUCTIONS ON
d 'ADJUST DOOR TO ENSURE PROPER OPERATION CARE
'DRILL HOLE IN JAMB FOR ALARM WIRING IN SAME LOCATION AS
Q'
~
0 UNLESS STATED ABOVE THIS INSTALLATION DOES NOT INCLUDE:
X INSTALL DOORS OVER 72X96 STUCCO PATCH GREATER THAN 4',PAINT AND STAINING
Lu INSTALL FIXED ARCH TRANSOM LITE IN EXISTING OPENING DISCONNECT AND RECONNECT OF SECURITY SYSTEMSIWIRING
p• REPAIR CARPENTRY TO EXISTING OPENING
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SPECIAL SERVICES CUSTOMER INVOICE- Continued Last Name:JAVERY Page 4 of 7 NO. 3409-73107
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INSTALLATION #1
(Candweo REF f101
PLASTER, DRYWALL OR SIDING WORK
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N SPECIAL NOTES:
AN ADULT OVER 18 YEARS OF AGE WITH THE AUTHORITY TO MAKE BEFORE COMPLETING THE INSTALLATION.AIRBORNE DUST IN OTHER
DECISIONS ABOUT YOUR INSTALLATION MUST BE PRESENT DURING THE PARTS OF THE HOME IS A NATURAL OCCURRENCE AND IS THE
QINSPECTION(WHEN APPLICABLE),DELIVERY AND INSTALLATION RESPONSIBILITY OF THE CUSTOMER.
'CHILDREN AND PETS MUST BE KEPT AWAY FROMTHE WORK AREA 'THE INSTALLER WILL PROVIDE THE MANUFACTURER'S PRODUCT
'ELECTRICITY MUST BE ACCESSIBLE TO THE WORK AREA MANUAL AND WARRANTY CARD TO THE CUSTOMER.PLEASE REFER
'IT MAY BE NOISY DURING YOUR INSTALLATION TO THIS FOR WARRANTY REOUIREMENTS AND MAINTENANCE
A 'CANCELLING APPOINTMENTS WITH INSTALLERSOR MISSING RECOMMENDATIONS,
A SCHEDULED APPOINTMENTS WILL LEAD TO ADDITIONAL CHARGES 'NO WORK TO BE DONEON SUNDAYS OR HOLIDAYS
'THE INSTALLER WILL BROOM CLEAN THE IMMEDIATE WORK AREA
j :.FEND OF'IN:
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o TOTAL CHARGES OF ALL MERCHANDISE & SERVICES
`o • $1,333.90
SALES TAXI $0.00
TOTALI $1,333.90
BALANCE g)iiF!l $1.333.90
END OF ORDER.No. 340373tOT
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Page 5 of 7 No. 3409-73107
Home Improvement Agreement
PLEASE READ THIS
Important additional information regarding Customer's rights may be contained in an attached State Supplement.
Scope: This "Agreement" consists of this page, the following General Terms and Conditions, the Invoice, the State
Supplement if applicable, and any drawings or Change Orders expressly made a part of this Agreement. The Agreement is
between the Customer identified on the Invoice and The Home Depot. Any installation services provided under this
Agreement shall be performed by a licensed and insured third party Authorized Service Provider. The Home Depot does not
perform architectural or engineering services, nor does it make structural changes to dwellings or other structures. The Home
Depot and its Authorized Service Provider will perform installation services in accordance with applicable law.
Payment Schedule: Payment is required immediately as follows: -
Payment: S 111.1 An Due In full immediately.
Sales Tax: S n.nn If applicable.
Total Amount of Sale: S 1 S3S_90 Includes all applicable discounts, rebates,and
taxes.Excludes finance charges.'
'Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement,to which The
Home Depot is NOT a party,and will be In addition to Customer's payment under this Agreement. Customer is subject to the terms and
conditions of the cardholder or loan agreement.as applicable. No funds should be made payable to Authorized Service Provider;
however.Authorized Service Provider may collect Customer's payment(s)made payable to The Home Depot.
Anticipated Delivery/Installation Schedule
Deliver Date: TBD Start Date: 03/05/2012 Finish Date: 04/04/2012
Acceptance and Authorization: Customer authorizes The Home Depot to order and arrange for the delivery of all goods
and services included on the Invoice. Customer further agrees and understands that this Agreement is the entire
agreement between Customer and The Home Depot with regard to said goods and services and supersedes all prior
discussions and agreements, either oral or written relating to said goods and services. This Agreement can not be
assigned or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and agrees
that Customer has read, understands, voluntarily accepts the terms of and is entitled to and has received a complete copy
of this Agreement at the time Customer signs the Agreement. Installation Professional's license number and permitting
information may need to be provided later and as such this information may he omitted at the time this Agreement is
signed.
Electronic Signature: The parties to the Agreement agree that the digital signatures of the parties included in this
Agreement are Intended to authenticate this writing and to have the same force and effect as the use of manual signatures.
Customer acknowledges that he or she is the person named on The Home Depot contract number identified on the point of
sale device. �l
CANCELLATION: CUSTOMER MAY CANCEL THIS 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 HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY
LAW IN CUSTOMER'S STATE. Under such circumstances. Customers payment(s)will be returned within ten (10)
business days after The Home Depot's receipt of Customer's notice.
Accepted by:
x 03/05/2012
Customer's Signature Date
Authorized Service,Provider's Full Business/Trade Name,Addraea and x _
License No. or Nets).,as applicable: Associate'srAuthorizad Service Provider's Full Signature
Date
Associate: Please print your salesperson's license number,9 applicable.
License No(s).
Authorized Service Providers Tel.No.
Home Depot U.B.A.Inc.,2455 Paces Ferry Roed.N.w.,Bldg 13.3.Aborts.Georgia 10,V9
312aN
Page 5 of 7 No. 3409-73107 Customer Copy
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Page 6 of 7 No. 3409-73107
Home Improvement Agreement
General Terms and Conditlons
Questions? If The Home Depot store and Authorized Service Provider are unable to answer Customer's questions,
Customer may contact The Home Depot Customer Care Department at 1-800-553-3199 or use the address below.
Resoonsibilitiss:
The Home Depot:will provide the products identified on the Invoice and make arrangements to have the Authorized Service
Provider perform the installation services in a professional and workmanlike manner. Unless otherwise expressly provided for
herein, Authorized Service Provider will obtain required permits and provide permit numbers if required.
Customer: will identify any property lines,easements, covenants, underground or overhead utility lines, pre-existing physical
or environmental hazards, building code violations or other legal encumbrances that could affect the installation services prior
to the installation. Customer shall keep posted permits on display at all times. Customer is responsible for any delays or
interference caused to installation by Customer or third party under Customer's direction or control.
Changes and Change Orders: Any changes to the installation, including but not limited to Changes necessitated by
undisclosed, unidentified or unforeseen conditions on the site,are subject to a written Change Order signed by Customer and
The Home Depot and any additional products or services included in such Change Order will be paid for in full before any
such change is made. The Home Depot or Authorized Service Provider has no obligation to attempt to remediate any such
conditions and may immediately discontinue the installation or ask for a Change Order. Please note, The Home Depot or
Authorized Service Provider will not remediate any mold, asbestos and lead-based paint. Neither The Home Depot nor the
Authorized Service Provider is responsible for delays caused by events beyond either party's control including but not limited
to acts of nature, governmental actions, delivery delays or damages caused by thins parties, labor strikes, Customer's credit
or financing,or any incorrect information or non-compliance with this Agreement by Customer.
Liens: Security Interests: If Customer makes all payments as required under this Agreement, no security interest will be
placed against Customer's property by The Home Depot. After paying on any completed distinct phase of the installation,
Customer may request from Authorized Service Provider a signed lien release and waiver of any right to place any claim
against Customer's property applicable to the work then completed. Customer should also refer to the State Supplement for
specific State requirements, if any.
LIMITED WARRANTY: TO THE EXTENT PERMISSIBLE UNDER APPLICABLE LAW, THE HOME DEPOT WARRANTS
THE WORKMANSHIP OF THE INSTALLATION FOR ONE (1) YEAR FROM ITS COMPLETION DATE. PROVIDED
CUSTOMER NOTIFIES THE HOME DEPOT DURING THE WARRANTY PERIOD, THE HOME DEPOT WILL ARRANGE
FOR REPAIR AT NO CHARGE TO CUSTOMER FOR ANY DEFECTS DUE TO FAULTY WORKMANSHIP. THE HOME
DEPOTS WARRANTY DOES NOT COVER DAMAGE CAUSED BY ACTS OF GOD. INSTALLATION OR REPAIRS MADE
BY PERSONS OTHER THAN THE HOME DEPOT OR AUTHORIZED SERVICE PROVIDER,ABUSE, MISUSE. NEGLECT,
OR NORMAL WEAR AND TEAR. MERCHANDISE AND MATERIALS ARE COVERED EXCLUSIVELY BY THE
MANUFACTURER'S WARRANTY, IF ANY. THIS LIMITED WARRANTY GIVES CUSTOMER SPECIFIC LEGAL RIGHTS
AND CUSTOMER MAY ALSO HAVE OTHER RIGHTS THAT MAY VARY FROM STATE TO STATE.
WAIVER OF CERTAIN DAMAGES: EACH OF CUSTOMER AND THE HOME DEPOT HEREBY WAIVES ANY CLAIMS
AGAINST THE OTHER FOR LOST USE, LOST PROFIT, LOST REVENUE, INDIRECT, INCIDENTAL OR
CONSEQUENTIAL DAMAGES RELATING TO THE INSTALLATION, THE MATERIALS OR SERVICES OF THE HOME
DEPOT OR OF AUTHORIZED SERVICE PROVIDER OR THIS AGREEMENT. TO THE EXTENT CUSTOMER'S STATE
DOES NOT ALLOW THE EXCLUSION OR LIMITATION OF INCIDENTAL OR CONSEQUENTIAL DAMAGES, THIS
SECTION MAY NOT APPLY.
Termination: If Customer breaches this Agreement or declines a reasonable Change Order request, The Home Depot may
immediately terminate the Agreement without further obligation. In the event of such termination, Customer agrees to pay
The Home Depot the Costs of materials, labor, 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 DOWN PAYMENT OR
OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOTS OTHER REMEDIES FOR RECOVERY OF SUCH
AMOUNTS.
Acknowledgment: If Customer's purchase Includes Countertop installation, Customer acknowledges and agrees that
Customer has received and understands the following additional documentation: (a)Countertop installation: What to Expect;
and(b) Product Specification Sheet. The Home Depot,via third party,offers Extended Protection Plans on some products.
Customer may receive marketing materials on The Home Depot's behalf concerning such Extended Protection Plans.
Home Depcl U.S.A.Inc..2455 Pecee Feny Road.N.W.,Bldg 131.3,Atlanta.Georgie 30339
&2011
Page 6 of 7 No. 3409-73107 Customer Copy
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Page 7 of 7 No. 3409-73107
The Home Depot Special Services
Will Call/Direct Ship/Delivery
Returns: Except where prohibited by law, all returned Special Order Merchandise is subject to
a fifteen percent (15%) restocking fee. Custom made goods are not returnable.
Will Call: The Home Depot Store will call the number provided on the Invoice when Order is
available. A Will Call held at the Store for over thirty (30) days shall be subject to the
abandoned property laws in your state.
Direct Ship: Direct Ship merchandise will be sent by the vendor and/or manufacturer to the
address on the Invoice.
Delivery: Home Depot shall arrange for its Delivery Agent to deliver the Order to the address
identified on the Invoice pursuant to the following terms and conditions:
Roads Notice: The delivery address must be accessible by vehicle over roads and bridges rated
to handle up to and including (40)forty ton loads. If any portion of Delivery Agent's route must
traverse a section of road that is not rated to handle a forty ton load or heavier, Customer will be
responsible for seeking a waiver, at Customer's expense, from the appropriate governmental
authority. If Customer is unable to obtain a waiver, delivery service will not be available to the
delivery address.
Unattended Droo: If Customer will not be present to accept the delivery, and the delivery
can be left unattended, Please indicate by Initialing below:
_ By initialing here, I authorize Delivery Agent to leave the merchandise
unattended following delivery and accept full responsibility for any resulting loss of, or damage to,
the merchandise.
Curbside Deliveries Only: You are purchasing merchandise that has been designated by Home
Depot for curbside delivery only. Your purchase does not include delivery beyond curbside, on-
premise or in-house ("Additional Services") or the installation/hook-up of merchandise ("Non-
included Installation Services"), and Home Depot has not authorized its Home Depot Delivery
Agent ("Delivery Agent") to perform such Additional Services or Non-included Installation
Services. In the event you request, and Delivery Agent agrees to perform, Additional Services
and/or Non-included Installation Services, YOU ASSUME THE RISK OF, AND FULL LIABILITY
FOR, ANY RESULTING PERSONAL INJURY, DAMAGE TO PROPERTY, OR DAMAGE TO
MERCHANDISE. Also, any Non-included Installation Services shall void any express or implied
warranty provided by Home Depot and may void the manufacturer's warranty on the merchandise
so installed. By signing below, you acknowledge that you have read and fully understand
the terms of this waiver and release, and you intend it to be a complete and unconditional
release of all liability in regard to any requested Additional Services and/or Non-included
Installation Services.
Accepted by:
X nzmFnnig
Customer's Signature Date
Page 7 of 7 No. 3409-73107 Customer Copy
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I
The Commonwealth of Massachusetts
Department of Industrial Accidents
lr Office of investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plulnbers
Applicant Information Pleas/e�Print LeZilbly
pa
Name (Businessiornization/lndividual): / 'I F7L}.1/�I 50A S �c��} / '{/�L�.L�H t/• �/��
Address: 180 DAr9-m ST
City/State/Zip: IIAmVIRS 2.3- Phone#: q1S - 77 y- 63P0
Are
you an employer? Check the appropriate box: Type of project(required):
1" !� I am a employer with 10 4. ❑ I am a general contractor and I 6. El New construction
employees (full and/or part-time).* have hired the sub-contractors Remodeling Do
2.El am a sole proprietor or partner-
listed on the attached sheet t
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10-❑ Electrical repairs or additions
required.] officers have exercised their
3-❑ I am a homeowner doing all work
right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12"❑Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
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
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy inforrnation-
I am an employer that is providing workers'compensation insurance for my employees. Below is the.policy and job site
information-
Insurance
Insurance Company Name: 1 n v et eh S p
Policy#or Self-ins.Lic. #: 1�1 UA r 40 X3 3 g .a Expiration Date:
Job Site Address: I Z I7�17 Ga�'D- ST City/State/Zip: r9le*7 /h4
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 againit 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 cent' under Ire a and penalties ofperjury that the information provided above is true and correct
Stplratur
.� Date- �' r 'L
Phone#7 L / 77[ G 3 80
O
fficialonly. Do not write in this area,to be completed by city or town official.
n: Permit/License#
hority (circle one):
Health 2.Building Department 3_City/1'owu Clerk 4. Electrical Inspector 5.Plumbing Inspector
son: Phone#:
1
Wassachusetts - Department or Public Safety
Bu;u•d or Buildin_ Re_t lations and Standards
Construction Supervisor License
License: CS 20014
IRA G MALKIN
180 DAYTON ST
DANVERS, MA 01923
oiL- may fj� Expiration: 7/31/2013
( mull .inner TrK: 17976
Office of Consumer Affairs and Business Regulation
. = 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 100654
-- - Type: Individual
Expiration: 612212012 Tr# 298948
IRA G. MALKIN ---
Ira Malkin —
180 Dayton St
Danvers. MA 01923 _
Update Address and return card.Mark reason for chanEe.
Address Rene,at - Emp!o ment _ Last Card