36-043 �.8/11/201I 14.01 I.CN1 GroupICNE GroUp Marne Proulx -►LOWE'S COMPANIES INC 2/3
ACORD DATE (MMlDDMYYY}
.P.1 CERTIFICATE OF LIABILITY INSURANCE 06/24/2011
I'1''.(x)1.1:2=r PYIt r4)3) 7e1 - :416 Fb 413.73'1'359'] THIS CERTIFICATE IS ISSUED AS A MATTER Of INFORMATION
INSURANCE CENTER OF NEW ENGLAND ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1070 SUFFIELD STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P 0 BOX 1230 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
AGAWAM MA 01001
INSURERS AFFORDING COVERAGE NAIC
—
INSURED INSURER A: Connecticut Underwriters
MARK S JODOIN INSURER B: Commerce Insurance Company 34754
❑BA JODOIN HOME IMPROVEMENT INSURER C
137 PORTER LAKE DRIVE
LONGMEADOW MA 01106 INSURER D:
INSURER E:
ter+ W...
COVERAGES
THE r :A .IE' 1 e F -1;;LI2ANi .E LuL 1 ED BELOW I LAVE BEEN ISSUC■ Ti l Tl r IN:>U RIT) NAMFF) AR! ivr FOR TI IF Poi icy PMC.C Mr:A.TM. rIOTWM ISTOIDING
.ANY Idtultll'tMENT , TERM OR CONGITII)N OF Ahrr' CONTRACT OR C'TI P DNc.uMPnrr VAN kFSP'r .. 1rrvr* 'H THls CFRTIFIC:ATF MAY nr IS,UTT OR
MAY rE =TAIU THE IIdS'.1RAPii:r AFFORrrrri no T! IF PC1I CES DESt,1IIBLL Htl /EIN I5 `:IJe...1:I IIi ALL IHt I El EM 1 IX.CLIJ'SIUN`. ANi, I,ON iii()N" OF f'JC
P ' r. F> l 4..T I IP: *T:; ';HOWN MAY HA VI NEI IIy.E . EN I - AIU r LAIME,
II i' '•n0'_ T YPE OF INSURANCE POI. ICY NUMBER POLICY EFFECTIVE POLIC'fEXPIRATION LIMITS
DATL' /MU;DICIr DAT IIM'(UDQn■
GENERAL LIABILITY NNO31125 06/26/11 G6/26/12 r/rHFNf - 500,000
X :OMI.IFRCIA l CN.MAII. TO F.LNI L 5
HNU,IISUS iLe acwencr)
CI. AIMS MADE , X U'J:Uh w',tu. EX'' (Am cne I:•r,or,) ; 5,000
A PERSONAL . ADV 1 1 500,000
•
ENEI2AL dE. A1 f 1,000,000
Galt A f F'rCSATF I 00II ii LIES I'El FROCI T, Mrlr l' AC.r_,, t 1,000,000
! FPO_ - _._.....
X PC,I. JEI :I I LOC
AUTOMOBILE LIABILITY RP-1989 03/26/11 03/26/12 . sua:;I F L MT
T:, :K.Iracldl _f
AIa r AUTO ,
A1,I. ,rN JED AUTOi EriDU_Y PJ.M.IRY -.. _. -...
Per ;Pe) i.11 100,000
X ''�HEDLILtU AU I; S
B X HIRED ALIT; r-- __.....
13 xILY I u I *r 300,000
X bIC4J.C, /Vt [DAIJTC :Frr.v He-,no
PRCrprPTY •C,r T 100,000
(Pgr
GARAGE LIABILITY �g
AI, !TO C)IJI,Y - FA i 1C.IF..IFNT
AUTO
01HtII. I HAN LA ACC 'f
AUTO ONLY AGO
EXCESS 'UMBRELLA LIABILITY i rAITI I TA LRkr - Nt:r tF
l :.•..'..,le•. ri CLAIM'S MArir AGi,R'r! ?A.Tr 'l
r..I._O•JCIMPI P F
lit I LN:ION $ 1
WORKERS COMPENSATION ANC Ax ,TAM. HRH,:
EMPLOYERS' LIABILITY TONY I IMIT° l_.._.._
ANY PROPRIETOR/PARTNER/EXECUTIVE EL,tAC:H .AL- LILrtNt
OF I ERMEMBER EXCLUDED? r I r'r.•:r iC:YTF re5 l i EF
H yea, cmccrfbe undo
9PECVIL PROVI9ION9 Nom./
t L. LrIStASE PULPY 0111 1 3
1 -
OTHER: I 1
DESCRIPTION OF OPERATIONS/ LOCATIONSNEHICLESIEXCLUSIONSADDED BY ENDORSEMENT! SPECIAL PROVISIONS
LOWE'S COMPANIES INC. AND ANY AND ALL SUBSIDIARIES ARE NAMED AS ADDITIONAL INSURED AS RESPECTS TO GENERAL LIABILITY AND
AUTO LIABILITY
F #231.5562
CERTIFICATE HOLDER CANCELLATION
•
i1 0 AN OF TIIF ABOVE CE2(,.N EU I'ULIQE6 EL (..ANLELLELI YE/ -O IHt Er -IF'A.iIL/NI
DATE 11- IEPLOI- I HE s' ;INC; IPJ:d IRrB YIAI F RJDEAJC'R TO MAIL 20 DAYS; ,omrEN NCI)cE TO
THE E'-EPTIr /, H'OLLV.P.. NAMED TC.'• TI Irr77 NIT rAIl n rr TC:, ri[l IDi, 74w
LOWE'S COMPANIES INC. OBI I ,ATIi:r, )P LIAC!IUTr OF ANY KINU IHt M Ieul?tu ll A.ctrn :i, I .'EI rnAr':
ATTN: I S INSURANCE (MEZZ)
POST OFFICE BOX 1111 nl. m InRI rn RrPPFErJT,ATIVE
NORTH WILKESBORO NC 286560001 1404,
Attention; ' II
_ tep en Gallagher
ACORD 25 (2001/09) Certificate # 56718 ACORD CORPORATION 1988
£/Z d S31VS 03llVJSNI 0990 47 Z9SS LE? EL, VO: LL- 80 -L1.0Z
LOWES x x CONTRACT# 0000221
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CUSTOMER
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/94 alK frNiS54 es F'. CITY STATE ZIP CITY STATE f�.....,._.�*LP:r.:�,FZ L `'
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2 .. . DA , LOWE'S HOME CENTERS. INC. 'S MA HIC NO 148688 ' CASH I BANK / 1
- i' FEIN: 58 -0748358 p Y d ® g j
t t i t 7 i r ' , i t �; r ttia
i INSTALLATION STREET ADDRESS CITY STATE ZIP
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Contract in c r f
Are permits; required for this installation ?: [ Les [ j No *applicable e tax included DC(pt
NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pampiet Renovate Right. By signing this Contract, Customer
acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure
from renovation activity to be performed In Customer's dwelling unit.
WAIVER OF LIEN and ONE YEAR WARRANTY (TO BE SIGNED BY INSTALLER)
I, the undersigned Installer /Independent Contractor, having been employed by the Customer who signed the Certificate of Completion below do hereby certify that the work for this project
will be or has been completed in a workmanlike manner and to the Customer's satisfaction. In consideration of the receipt of one dollar and other good and valuable consideration, and to the
extent permitted by applicable law, I hereby waive and relinquish all liens and all rights and claims of liens which I, the undersigned, now have or may hereafter have for labor or materials
furnished, and further certify that all work performed and materials fumished, if any, by any other party or parties upon the order of the undersigned, have been fully paid for. Further, I the
undersigned, agree to cause the prompt release of any mechanic's lien(s) which may be filed against the Customer's premises by any subcontractor, laborer, mechanic or material supplier
claiming the right to file such a lien through work related to the Customer's Contract with Lowe's. In addition to any warranties provided by law or specified elsewhere, Including the Customer's
Contract With' Lowe's, the undersigned, further warrants that all work fumished for this project shall be free from defects either In material or workmanship. If any defects in material or
workmanship shall be discovered in the work furnished or material used during the course of the work or within one year from the date of the Certificate of Completion, the undersigned agrees
to replace or correct such defective work or material, free from allexpense to.Lowe's and the Customer in a. manner satisfactory to the Customer .
1 further represent that I have given Customer the option of retaining some or all of the surplus materials or having some or all of such surplus materials removed from the Customer's
premises.
If applicable to the performance of the work required for this project, I, the undersigned Installer /Independent Contractor; do hereby certify that I have complied with all requirements of the
Lead Renovation, Repair, and Painting Program Rule ( LRRPP Rule), 40 C.F.R. sec. 745.80 et seq., or any applicable state laws or program regulating lead -based paint safe work practices,
including compliance with all Information distribution, notice requirements and work practice standards in performing the work required for this project I certify that I have provided the
Customer with all documentation required to be supplied under the LRRPP Rule or state program, shall retain all records required by law, and have attached to this document copies of all of
\the records required to be retained by the LRRPP Rule or applicable state program.
Signed and delivered this ot; a day of .
Installer Print Name
: .
► t°c �(rr JGe r c ?i I
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e 2004 by Lowe'S.®LaA+erd Me 9 ante design
#90981 (Rev. 12/10) INSTALLER COPY Bre registered traaem bf LF Cbrpora0on.
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! 1 /110'2012 21:46 #4651 P. 001 /005
2012- 01-10 14:51 lowes 1916 ISO 413 588 0278 s» Jia
SZ1 The
p �Commonwealth
� ) of . Massachusetts
Department M.hw.rrN�.1WYw of Industrial Accidents
I '' Of of Investigations
68O Washington Street
Roston, MA 02.111
www.mass.goOdia
A �y
Workers' Compensation Insurance Affidavit; Build/Co ntractors /EI cttriivitu t�Illig s./`■Pnl bet
A M t t ii lr =�.. i � .1�F��� w il•nu +.�� • base , ■ b�
Name fgusnresblpTfptlaizattaxt /ttrdividuat): L1J3�:i y�M�,��
Address: L4 UNION ;�T• -- ,! ��
CityIState/Z
Are you an employer:' Check the appropriate box: Type of project (required):
1 D I atn a employer wit 4. 0 am a general conmwtor a nd f
6. New eonst action
employees (full andlor pett:.titria) * have hired the subcontractors
2.0 t am a sole proprietor or partner. listed on the attached shoes. 7. d Remodeling
ship and have no employees These strb•contractors have B. Demolition
working for me its Any capacity employees and have workers' 9. C Building addition
No workers' comp. insurance comp. insurance.;
required.) 5. 0 We are a corporation and its 10.0 Electrical repuits or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. (No workers' comp. tight of exemption per MM. 12.
t c. 152,$1 an d we have no Q Hoof repairs
insurance required.]
e 15,0 Other
mplayesCS. Flo workers'
corn . insurance utrccL]
+ appltennt that checks boa #1 waist also fir oni the 'Action Wow showing their wo cs' compoai ul m pntiCy tafarmatlon.
T Homoownets who Dibrell this affidavit indicating they tiro toinp aft *wend thot+ hies onside camattatu mutt snbptir a Am affidavit iedkatins Est ch.
4 Contnatars ihal aback this but roust attaINed as addlgoaai shoed sbowipa the nape of the s ab.aulracte s a d stela whether at ear these entities ball.
cropioycaa. if the sob. otttt<aetorz havo emptayces, they into providm their workers` coop. policy number,
I am an employer that is ,providing workers' compensation insurance for my employees. Below is the policy and job sir
information.
rnsumrce Company Name: ift ta_Cba eQ tleik I. aND-
Policy fl or Self L.ic, #: 1 l 7 S Repieation Data O(o • Z(o . ( 2- —
Job Site Address: 2:1 WttkCHEStIEiR_. TErtr�.p.NC,e CiryiStaterzip :E Etvc.E Mf} OfO(o2
Attach a copy or the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section of MG!_. c. In can lead to the imposition of criminal penalties of a
Ina up to $1,500.00 anal /or one -year imprisonment, as well a s 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 DM for insurance coverage verification.
Y elo hereby certify r penalties of pcdury that the in onnattntt provided above it trite and correct.
'RS . #:
Offidial use onlly. Do not write in tIos area, to be completed by cL(p or town official
City or Town .. Ft r#talt/li,icctuse # .
baling Authority (circle one):
1. Board or Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
m e .- a.
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t)1I1(i; r.)12 21:48 #4E;51 P.002/005
2012 - 01-10 14:51 loges 1916 ISO 413 5$8 027$ >
I' 4/
SECTION 8 - CONSTRUCTION SERVICES
g.1 _l.lren�od AanatS,etion s visors Not p ppliea l
Nart[t Lk fSo Holdor' M�} l S. . ILJ .. L4 L f'
Lloonse Number
P.• - � - - . L.ON yN E • • v m - 0 !0(o 12.21./2.
A47.110011111r. expiration Date
9nature Telephone
9. Re, is e Ome Inndrove ant C..on kaAm Not Applicable C1
SopotpLHt mt. ImPt2_t�ttfrvl4 �, -- 1 Q� �
COmpathy Meals Registration Number
• 1 •. ..• U i DI 0 �. x•12.
Address AF' Expiration Dale
7elo hone J.
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. 0.152, §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 permit.
Signed Affidavit Attached Yes...,,., ■ f No 0
11. -Home U'V{r11e>r xem� tion
The current exemption for "homeowners" was extended to inelude C)wn r-r cc u,pled w illngt of one (I) or two(2) families
and to allow such hgmeowncr to engage an individual for hire who does not possess a license. =Aim . th tt)y`r+v ttctA
iLS 4npervit:ng , CMJ2 7t{t?�ttr clitirw �fiectiou t(t$.3.5.i
aonirimar Hoaterlwner: Perron (s) who own a parcel at' hind on which he /she resides or intends to reside, on which therc
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 er. who en S. tic s mor t , e o i e , • ear , e •io . n I nn I c S i t e _ ■ ; , „eow • ,
Such "homeowner shall submit to the Building Official, On a form acceptable to the Building Officialah at be /she hn J he
resEnn>vibte for at! !'ch nrk potter d isigr t t tt il„� d ue it
As acting rnnF froctinn supery_k% 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 I$2 (Workers' Compensation) and Chapter 153 (Liability of Employers to
.Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, t ila baiabte for person(s)
y ou hire to pertbrtn work for you under this penult,
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 ot'Massachusetts General Laws Annotated,
Homeowner Signature _. -- _ - -
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition ❑ Replacemen indows Alteration(s) Roofing n
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [D Siding [0] Other [D]
Brief Description of Proposed
Work: Ia. vtto*,m FWD tERA - CF WItv001 11b -A flcucrUw.h4L C`H14TlC�E.
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the 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.
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 BUILDING PERMIT
I, TESSteA LMW -01',/ , as Owner of the subject
property
hereby authorize Lrowea Rome- CGntTeIC I'/ •
to act on my behalf, in all matters relative to work authorized by this building permit application.
So eCMrTtel eLT 1. 11. 12-
Signature of Owner Date
I, L.mfvse-y Zkos.&t , 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 pains and penalties of perjury.
but? Pi 2(14.04
Print N_/ e
/• f/• /2—
Sig . at re of Ow er /A -e t 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:_
Rear
Building Height
Bldg. Square Footage %
_
Open Space Footage 'Y�
(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 C DON'T KNOW C YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO C DON'T KNOW 0 YES C
IF YES enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained I Obtained 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 0
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 t
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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City of Northampton Status of Permit:
a t Building Department Curb Cut /Driveway Permit
` 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
10 Northampton, Northampton, MA 01060 Two Sets of Structural Plans
d F � "' phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
Other 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
T 11 WtNCNE5TE1. TE.i XFINCE Map Lot Unit
TLUt26NCE, RYA 010 ( Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
5Essi L ndoom 2.1 wwemt-vreae Ter.seratitvet. 4ov*Amo,tf-ro otoraz
Name (Print) Current Mailing Address:
y/,5- 5
.5j�r.E _CDAMPrieT Telephone
Signature
2.2 Authorized Agent: � r �
er_ _ z. J 282 12USStc c 8n. 1- More -y /y� /9 o rd 35
Na:(P j Current Mailing Address:
g ra re Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 2 -1(4(0. 4)2- (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 r` i
6. Total = (1 + 2 + 3 + 4 + 5) G. qZ Check Number J t "
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
27 WINCHESTER TER BP- 2012 -0650
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 043 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2012 -0650
Project # JS- 2012- 001120
Est. Cost: $2617.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK JODOIN 49918
Lot Size(sq. ft.): 10018.80 Owner: LACROIX STEVEN E & JESSICA S
Zoning: URA(100) //WSP II Applicant: MARK JODOIN
AT: 27 WINCHESTER TER
Applicant Address: Phone: Insurance:
137 PORTER LAKE DR (413) 885 -7361
LONGMEADOWMA01106 ISSUED ON:1/11/2012 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:
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 1/11/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
_ a