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17D-023 (3) , - -- . - — THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ; C E R 7 r lC TE HCi D!ER. TX!,F.° i CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED IEY THE POLICIES ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITWE A COT CT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If StU ROGATION IS WANED, stthject to the terms and conditions of the policy, certain policies may require an endorse er t. A statement on this certificate_ sAoss rint confer r igl t to the, - ( Lrti'ficate I in fled of such endorse.menx(s). �_n - w�__ne PRODUCER 1- 866 - 966- 46F-:t CONTACT I NAME: -- - - -- - - -j Marsh USA Inc. 1 PHONE -, _IAIC No Ett1J� — _-------- .-------- _ - -_ -- (A/C, No): __ _ homedepot.certrequest@marsh.com ----- E DSS: Two Alliance Center, 3560 Lenox Road, Suite 2400 Atlanta, GA 30326 INSURER(S) AFFORDING COVERAGE NAIC# Fax (212) 948 -0902 _ INSURER A: Steadfast Ins Co 26387 INSURED INSURERS: Zurich American Ins Co 16535 The Home Depot, Inc. New Hampshire Ins Co 23841 Home Depot U.S.A., Inc. INSURERC: P 2455 Paces Ferry Road NW INSURER D: Illinois Natl Ins Co J 23817 Building C -20 INSURERS: NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURERF: Illinois Union Ins Co 27960 COVERAGES CERTIFICATE NUMBER: 30289573 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE INSR SUER POLICY NUMBER IMM /DDIIYYYY1 (MM/DDIYYYY) LIMITS LTR INSR 1/16/D A GENERAL LIABILITY 0L04887714 -02 03/01/12 03/01/13 EACH OCCURRENCE $9,000,000 .__._.. _ DAMAGE TO RENTED 1, 000, 000 COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) CLAIMS -MADE X OCCUR MED EXP (Any one person) $ EXCLUDED X LIMITS OF POLICY XS PERSONAL BADVINJURY $ 9,000,000 X OF SIR: $1M PER OCC GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 9,000,000 X POLICY PRO- LOC $ IECT B AUTOMOBILELJABILITY BAP 2938863 - 03/01/12 03/01/13 COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS NON -OWNED - PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) R SELF INSUR D PHY DMG $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ C WORKERS COMPENSATION WC019736915 (ADS) 03/01/12 03/01/13 X TORYIIMITS ° R AND EMPLOYERS' UABILnY D ANYPROPRIETOR/PARTNER/EXECUTIVE YIN N/A E (Mandatory in WC019736917 (FL) 03/01/12 03/01/13 E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER in NH) EREXCLUDED7 I WC019736916 (CA) 03/01/12 03/01/13 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 I( ye describe ON unde PERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DCRIPTI O F O E Workers Compensation WC1192494 (QSI) 03/01/12 03/01/13 SIR (AOS) /SIR (GA) 1M /750,000 C Workers Compensation WC019736918 (WI) 03/01/12 03/01/13 F TX Employers XS Indemnity TNSC46566397 (TX) 03/01/12 03/01/13 Occurrence /SIR 30M /1M DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. HOME DEPOT U.S.A., INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C -20 �,( ATLANTA, GA 30339 jut a L J ha...,).Ct USA 0 © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ', Jthornton_hd • IN F, NV' 11, I\IPSI 1 I RI' r ith (WI. RA (UK • i I 1 % 1 Ys�r 5w �wWY 1 3 Massachusetts - Department i? t of Pu SS1i °tY 'Board of Building Regulations and Standards Cuusti Supervisor License: CS - 081458 • > • PAULL ANTOS {• 46 NEW ROAD SALISBUR 03268 Expiration COMMIS sioner 11106/2013 4901/11t0?aCr1F v 1tCCttubela Office of Consumer Affairs & Business Regulation :i ? £ 3 , 1 1..17 HOME IMPROVEMENT CONTRACTOR Registration; 170622 Type: Expiration:, .11/22/2013 Individual PAUL ANTOS PAUL ANTOS • 46 NEW RD SALISBURY, NH 03268 . ; ~'. t • • • t 'J II ` i 0 , , ,C, 1 •.• -• I I 1 �l � ._t _t.. Q �II, 0.157.;z;77 _' R cS � . c 1 —• co O ' CCD -, ° I _ ,re H 1 i ' 44 .41;:a 4, TI W� kolo C • • 2) 3. • T °.c > 0 • Ca �� • 3f h13 F-; • • ' I t �t 0 . o . I 'Virgil' k � I� yam, fi ecn N . - • • . P'\\ 4 , .. , litifiti 1 w �a a m �• w G C nC a CD • • • G • 0 `CCU .. .a i-3 k • .. . w pa F 1. C.) w ® ' • • •. o • ' • r .n • • • • • • • • • . 1` '% ri• k j ° . YJ Dl t C- T ra , L1i_, 1 1 L ml lti va L11� ',l_ 1 .■,,' t. ' t r t i s, °'iti., I i <\ IM I l T' Tit 'i ' n rn!:) i- i n n `.11 'ri fa ..r ' 1 % I r 1_ i 1 1 I 1CSS /t IF ` 7 .i.0 r 1 .il•1. /, 3,. 3 , -1 JJ ? ]] 4 a 1 1 ...' it - 4 4 3 ilfri,b/ 7 Cit .. . '''9Zip: � - {, -- -9d • -, - , 4' ene #: j �J (/! y. Are yo, .: employer? Check the appropriate box: Type of project (required): 1. �'/ I am a employer with 4. 0 I am a general contractor and 1 employees (full and/or part-time).* have hired the sub - contractors 6. 0 New construction 2.0 I am a sole proprietorDr partner- listed on the attached sheet. 7. 0 Remodeling ship and have do employees These sub - contractors have `i 8. 0 Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance. required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 PI ing repairs or additions myself. [No workers' comp. right of exemption per MGL y p 12. oof epairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. er u1/49 deriti 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. -)— __ �-" Insurance Company Name: __ �,,,R __.4,.. Policy # or Self -ins. Lie, #: ao Expiration Date: Allri . Job Site Address: 40 -414 . • City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expirati i n 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 da against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations oft' - 1 IA for insur. ce coverage verification. I do hereby ce der d a pa and / enalties of perjury that the information provided abo e is tr ' and correct Si t ature: ,d► i / .... - Date: p ia s Phone #: Li Di ` 72 4 0 5 Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit /License # Issuing Author (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other _ Contact Person: Phone #: 1, > 01/01/2010 17;12 PAX ®col HOMI:.IMPKOVEMENT CONTRACT • • PLEASE READ THIS sold, Furnished and.lnaalled by Brooch Name: Heaton .Daat 0/134 . TIT At -Bone Servlu4 Ina, • I J . . • • dtbfa The ILomcT)epotAtHoars'3ervioee. . • . Teunpike, Unit 1. Shrewebeuy, .01545 . Toll Prtie1000)`657 -5182: Fax (SOB) MS6017 Br.,wL Nurtiitir:, 31 ' •' .. ' 'Federal 1f1'1 71.2696460; HE Lk C 02439; RI Co, t. Ltd 16427 ' : ^ • • • ' 'CI Lie II RTC.D565522; MA Hems linproVaNOlint Contactor keg % 12699!' IrsgTlaties Addraut f5 ✓I� Q�l� : : ar = = = L� :: i r , • . ity . .... . Stone .. - Zip .. Peweluser(sy Work phasic • Haile PMra Cefl POWs ... . • . � . • [ 1; • 1 foot] • Hattie AddreM: ' .. .. . (Ifdiffblent from lasti 111011 Achim) C ity .. Sate Zip • E-ma11 AddreN•(to receive projectcontmuntcations eid.Hofne Depot-updana); , .. - - Q I DO. NOT wish to receive any marketing malls from The Home Depot . . _ . • • [4orpottigr Undersigned " attic "); the owners p braced at t above installation iridium. aerate to buy, D At -Homo services, In ( Home Depot ") ages to. Amish, deliver and anangu ibrthe. installation (IRaallatkr") of all materiels dea oribed on the below end on the.refureoced Spec Shoot(s), All of which ire into horat.d into chi) Contract hy, din refet+O�nc.. eking with arty applicable State Supplement and Payment Summery attached hereto and any Change [7rdere (colleonvely, "Contract "): Jab a :- e.e.warhr.e/ Priam • SemSamtltiee' • • Prate' Am.ttrt fing Oaten* D Windows Olinulrdon. � f r111► 6 ,5 - 731.1. :Moons / Covers 06nuy mere D C_ l5 4Q .� • �... • : . Dneofma patinae L I Window: 13 tniulanon Deutt«s r Covets Oltmry floors El ." -.. • / • DRoofirtg) f4Yhg Wiaaorfa� Insulation . . . ;� ` DGunts' l Coven Bewona f1 Oy D . S h naming a smug • We • s • Insuladon . ` _ . DGUueti I Corm pf>atr7 Doors fl �,p. Mtdmute2S1I Depict of C*oa a iet An ias dere ei«aden MAY eoimriecj a amnia Anaemia � - G J9s,,...9' M.Mw Perehasere may not deposit ores th.a .do -third Maw donne Amount. • . C ueloeaor agrees that, immediately upon oomplation albs work for melt' Produm,• Customer will exegete . Completion. C.ertifimfe (one fur Mach Product -as defined by an t spec Shea)' ..d pay ahy balance duo. Ai applicable, soh Cuttoiner wider this Coietc:et agrees to'brjointly and severally•obNgrtod and liable bereander. • • The Hong Depot recarves MI right to issue i Change Order -oi tarminate'thie Contractor any. individual Product(a) imuluded heroin, at its discretion, if The Home Depot or Its au thorized'service provider determines that it cannot perform in obligations due to a smuttiest problem with the home, environmental haaids ruch an mold, asbestos or lead paint, other ufoty conger(, prleing errors or because 5 I f W work required to complete to job was not Included in the Contract pavme[. Sim *nary: The Payment Summary, 0 , inctudad as part of this. Contact, seta forth tha. toW Coon amount and paynlcnterequired far the deposit and Mai paymend by Product (a applicable). .. • • NOTICE TO CUSTOMER • Yar..ra **titled to a -completely fdl.d -in nopr of the Contract at the time you sign..De notat`a a Compietktn CartifieateOnata there is Inc Compl.tloa Ccrtifitate for each listed Product ..s defined by Jodlvklu.l Spec Sheets) before work on that Pr.d■ot Is townie& In the event of termination of this Contract, Customer agrees to pay The Home Do 1 the Colts of m.teriah, labor, expenses and services provided by The Home Depot or Authorized Service Provider *rem die date if armin.tlon, phi a other mottoes set forth in Ms Agreement or allowed under applicable law. THE NOM 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. 1 01tance and Arthoria*u.a: GNtomer (gees and understands that this Agreement is the entire agreement between Commit the Home Depot with regard to the Prudtwta and lnatallation services and supersedes all prior discuaaluna•end agreements, either oral or written. rulatIng to said Produeb and Instillation. This Agreement cannot be aarigned or alnenied except by a writing signed by Customer and The Homo Depot. Customer acknowledges and agrees that Customer bas rant, understands, voluntarily accepts the tetras of and has received a copy o(thia Agreement Ant �f" _ i 0 °1 — X 1 1 /°Air stoma's Silloatur Date / 7$/ Salta�I► . am 's _, , . urn Data X _.. To -3'! No. #75 " d .� Customer's Sinecure Drte Sales Conaultant Livorno No, A Cli. A.ATION: CUSTOMER MAY CANCEL THIS . or *ONION) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DRLIYERING wRITTEN NOTICE TO TNR NOME DEPOT RY MIDNIGHT ON THE THIRD BUSINESS • DAV AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE lP ONE IS SPECIFICALLY PRESCRtaaa RY LAW IN CUSTOMER'S STATE. NOTJCEt ADDITIONAL TERM ANY CUNDmTIOtra ARa STATaD ON TI16 R6V:AM SIDS API) ARE PART Of MS CONTRACT 05.10.17 White - Swan HIe yellow —Customer • LT /L 'afVd OLOT8T9998 Z33MS Mo2IUNY old EV :Z0 ZTOZ'LT'AON HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold. Furnished end Iu mDal by ratacb Nnmx Bowen Date: 1140 AI -Home Services, hie. !xi \ 4-•. Mf/s The Hann Depot AI - pone Services 90d Roston Turnpike, Unit 1, Shrewsbury. MA 01545 drank Number': 31 PeduaI ID I - Toil (BOO) MLitt. C 0174 Rt Cmi Lied 6427 �[]] 1 CT Lit a MIC,O566ST2S: MA Boma ` tt Connecter Rug. it 12dg91 InotsllsdesAddress; -(� S+�th�e.) AYQ-- NOJ1t� f)tM City State Zip P.rtteter(e): Work Mew 111 etwor Ceti 'Wu: 1 &CAAq }► I}1v 1 1 [331170]-311 ?[ 1 I t l [] t 1 A)141 Herne Address: (If difMent from Installation Address) City Stem Zip �nsil Addron (to receive project antunu icattoia and Hose Depot updates): [J 1 Op NOT what to receive any marketing mails font The Home Depot Protect Information: Under.tgned ( "Custoe er"), the owners of the property located et the above instillation address. apace to buy, and THD At -Home Sarvlom, Ina. ( "The Herne Depot") agraea to famish. deliver and aminee for the installation (`hstaIsBN ") of j .11 materials described on the below anti on the referenced Spot Wogs), III of which are ineemoreled into this Contact by this reference. along with an applicable State Supplement and Payment Summery attached boreto end tiny Champ Otdare (oollootwoly. "Contritet "): Jet. e+ awe ade...r, ��/jeaoud Spec 51 WII Ar Proton Amara( U Rteree US.ding aindowe O Insulation r � � a sS �7 I OOemas /Corers OLnary poets ❑ (.� 3 D 3 ��' , 1411 `1./ 111::r Dui*, ❑ Winnow. ❑ htuatletioa 00vnere / Coven °Easy Doors fl 43/41P4 ❑Reonng ❑SWfng ❑ Wierlesa ❑ tnwt.rlen OGusere / Coven Maury Doan ❑, • ` ,eg Is • rag / "Ie U alien 0Gtnars / Covers °Entry Doors f l s6.hewm 2SY. Deposit gamma Amami due upon etreneses ar tau carman. Teta Contract Amuust S 1 _ Q ( mom rwa..■ra wry as depot moo month= woothird of law Canonici Aat0W . 1�7 ` Customer agrees dal immediately upon completion of the work fbr each Product. Customer will exams a Cem platioa Certificate (one for each Product as defined by an individual Spec Sheer) and pay any balance due. AS applkabk. each Customer under this Contract agrees to be jointly and severally ablierted and liable her. voder. The Name f)epie Menial the right to issue a Chan;e Oidcr or terminate this COM:Wi or any individual Product(s) Included herein, al ks diacrdkon. It The Hone Depot or its authorized service provider determines deaf it cannot perform its obliSat(une due to. etnuotural problem with the tome, environmental hsuirds such at mold, albums er lead paint, other safety concerns. pricing error. nr beotuee work required to complete the job was not included In die Contract. Pamela Suanasryt The Payment Summary # 7 162 , included as pact of this Contract, seta foetlt die 10151 Contract nnount and payments reeuirtd for the deposits and fins) payments by Product (Is applicable). NOTICE TO CUSTOMER You are tattled to • eampletely flNedrn eery of the Coretru$ et the time you flits. Do not gip a Completive (srtltkste (sore: there to dre Cem plasIeo Certificate for etch listed ?redact ea donned by Mdividaai Sono Shads) Wore work on that Product is complete. In rte event of termiealien of this Contract. Customer Agrees to pay The Home Depot eke Costs of tmateriak. lobar. enpe*tes cod services provided by The Horne Depot or Asd%Or*06 Service Provider two Hit tit dere if terasfaatloi, plus any otter In ettnta set Oros* le cult Agreement or allowed ender applkabk law. THE HOM DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT PROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME Dltr0rs OTHER REMEDIES I+OR RECOVERY OP SUCH AMOUNTS. Aeeeptanee and Autbariza$Mar Customer soma and understands that this Agreement is the entire /agreement between Customer and The /tabs Depot with nerd m duo Products and loaulletion services end aupal*rrta all prior discussions and sgeoa+onrs, either Ots1 or Wrk1Cn, relating to said Products and Installation. This Agreement stoner be eeaignal er amended except by a writing awned by Custbmor and The Home Depot. Cuomo( aaanowledges and agrees dr ^ er has road, undesatanda, voluntarily accepts the terms and has received a copy 0f this Aggreerna't. Acr /t ' �� ( //2 x ,. LL -W'< gunner's Sitnuurc bare Ss l Ham's Signature Mire X Te one Nix. Customer's Signature Date Solos Consultant License No. CANC FLLATMON: CUSTOMER MAY CANCEL THIS for yg$tebk) AGREEMENT WITHOUT T PENALTY OR OM qt 3 6� / -53=.1 BV DELIVERING Wkl'f"i'RN NOTICE TO THE THE HOOME E Cl`.) _ t DEPOT EY MIDNIGHT ON THE THIRD BUSINESS DAY AF*'ER SIGNING THIS AGREEMENT. THE STATE BUPPLEMtom ATTACHED HERETO CONTAINS A FORM TO USE 11 ONE IS SPECIFICALLY PRESCRIBED RY LAW IN CUSTOMER'S STATE. NOTICE: ADDITIONA1. TOWS AND CONDITIONS ARE SUMO ON Y246 REVRRSE SIDE AND AM PART Of TNIS CONTRACT 00.10.19 woke -IOWA Pio VMaw - fyatareer Lt /5 "aDVd 0LOT819998 z23MS Nd ZV: ZO ZTOZ' LT -AON HOME iMPROVEMtNT CONTRACT PLEASE READ THIS Sold. Punished and Inmeltad by rot ink t ea: Menem Meter THD At -Home Services, Inc. .ho I drVs The Hone DepotANiame Senvic a 908 Hoalon TUmplke, Unit 1, Shrewsbury, MA 01545 Toll Free (100) 657 -1182: fax (508) 845 -6017 Smack Number: 31 Federal ID M 73. 3691460: ME Lie 8 C 02439; 111 Cont Lill 1642? C l, Cr Lk 0 HlC.056SS22: MA (Improvement Contractor Reg. # 126893 Inu wa altatten Addv. Cl ''t y 1 � ' p 1tJ2 Fl UwrvCQ m6 �.. Cit Saw Zip turebaser(sh IU Work best: Mew Mean CA P40MI MIMI C 11101111111 I. 3 [ ] 1 l Home Address: ( tfdiffrent from Installation Address) City . State Zip TS,jnail Address (10 receive protect communications and Homo Depot updates): p I 00140T wish to receive any marketing entails from The Hon* Depot prelim b Underslgaed (Ywtsmef'). the owners of the pommy located at the above inesslletion addreat, agrees to buy. THD AMtlom6 S vice, Inc. ("The Home Depot") awes 40 furnish, deliver end wimp for the installation (Weataltedan ") or , all materiels deaonbed on the below and on the referenced Spot Skaa1(s), all et which are ineotpor1Mtt into this CalUTE by thb ? i n refcrenee, along with any Applicable State Supplement and payment Summery attached hereto and any Choose Orden (eolleoi.vely, "Contract"): Jae an o..r•a ew ..y its: _ SON SerVsl gL rimiest *maser ,- i OSidinge a lac laden - �(' — (`f]I 3' Covets Olney Deed ❑ ` ` _ ! w , a / e 4 Moak; DSId1M SWlndows 0 II6UIMIOA +1 p 39 Q� Q OOtwen / Cw «a 0E.°'y Dears o Lk ` t 31 9 S r 9 1 R � M Wi adowc inwg tiw� $ ,,'' 11 �Ourun 1 Cavan Dray Desert ❑ W - �i+oobaq LISIdint U Windows U In4htion t QGuntn i Covers QEauy Doan ❑ Waimea ea 25 % Oapat* etteetrut Amount do ups* maze* al >w narrate Total Contract Ameoat $ e a e l 3 Mahe Parebatere way net aped+ nuts ban engNMS N ow Commaamecum Customer agrees that, inemedemeiy upon completion Of the work for each Product. Customer will execute s Completion Certifier (one for mai Product as Wined by an individual Spec Shoot) and pay any balance due. As appliaeblt. each Customer under this Contract sgru_a to be jointly end teetotally obligated and liable baxe*rder. The Home Depot reams the right to issue a Change Order or terminate this Contract or any individual Produot(s) included herein, et its discretion, if The Home Depot or its authorized service provider determines tluu it cannot perform iu obligations due to a touches' problem with the home. envitonmental hazards such as mold. asbestos or wad paint. other safety concerns, pticing effort or bususe work required to complete Oro job was not inelutled in be Contras, pmvatent Sammeaev; The Payment Summtuy # 1 11 Z . included a part of thin Coatmet, eau torah the total Contract amount and payment* required for the deposits and Gail payees* by Product Oa applicable). NOTICE TO CUSTOMER You are entitled le a cempklely filled -in copy albs CeaIraes at me dm* you alga. Do not sign a Completion CernNkate (nab: • Mere is eau Completion Certificate fir eNb listed Product al dented by Iddlviduai Spec Wets) Were work an (bat Product is eamtilefe. le the mime el termiaati.a of this Centric*. Customer agrees to pay The Moore Depot foe 6plt1 of materials, labor, expenses and Isrvleas provided by The Hems Depot or Autbetleed SWAN Prevl6er throw the date et ttrmminati0a. phis any ether memo me remit le We Agreement or slowed coder aptllatble i w. THE HOME DEPOT MAY WITHHOLD AMOUNTS Ow;b TO THE HOME DEPOT PROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE. WITHOUT LIMITING THE HOME DEPOT•8 OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. peftptaace and Atdberisatietl: Cestomar egress and untkretande Met thlt - •rat is the entire agreement between Customer Ind The Home Depot with regard to the Prnduou and Instell$h0I services • • s all prior ascensions sod agreements, either oral or written, reudn$ a mid Products and Installation. This Agreement k geed or Wended =CM by a writing Signed by Customer and The Home Depot. Customer acknowledges and agrees tic Ms toed. understands. voluntarily accepts the terms of and has received a copy of this Agreement. t frall if ei i 1 Customers Signature Data Sales . Date � Tatap .�. of Customer's Signature Due Sales Conaultent Lunn No. CANCELLAV1N: CUSTOMER MAY CANCEL THIS occeptksble AGREEMENT WttR OUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME - DEPOT PY Mt)DNIGHT 019 THE THIRD BUSINESS DAY AFTCR SlGNdNG THIS AGREEMENT, TMc STATE SUPPLEMENT ATTACMED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE: ADDITIONAL 7'MMMS AND CONDrrron6 Alit RTATEDON 1118 SWIM SIDS AND ARE tARY or Inns c0NTR*Cr 05-41-12 Vise. -Doman Pee YelOw - Custom, LT /9 '3EWa 0L0T8T9998 wants M3iiaNK tea Eb ;ZO ZTOZ'LT -Aom City of Northampton s Massachusetts * c V4 " DEPARTMENT OF BUILDING INSPECTIONS w. ' 212 Main Street • Municipal Building ��. a1 ;0:� Northampton, MA 01060 h3 INSPECTOR Louis Hasbrouck Chuck Miller ' Building Commissioner Assistant Commissioner 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 any 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 1, 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 . � s Office of Investigations 600 Washington Street "" Boston, MA 02111 _ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Address: City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. j I am a general contractor and I employees (full and /or part- time).* have hired the sub - contractors 6 El New construction 2. ❑ I am a sale proprietor or partner- listed on the attached sheet.. 7. fl Remodeling ship and have no employees These sub - contractors have p 8. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance. required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 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. $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. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: 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 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 Investigations of the DIA for insurance coverage verification. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official 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 6. Other Contact Person: Phone #: 9 SECTION 8 - CONSTRUCTION SERVICES g 8.1 Licensed Construction S'��,'sor: Not Applic Name of License Holder : 1111P: 1 * Number S ' License I. ° � ,,,• c, ����i Address / A Expiration f}at 4f» hi/ '-- Signal, Telephone 9T Ragisfered,Home Improvement Contractor ,q ..., z, Z M7 ;: Not Applicable El YI k 1P Company Name Registration Nu ber Address C Expiration Dat c i • ► f u JY� 1 ._, Telephone ) /1�t 73 _ Y SECTION 1 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G L c.µ1,52, § 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 ❑ No ❑ 1 1 ,�x. , ;llo:e.Qwner , Xxemptian 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 • J SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) r New House ❑ Addition ❑ Replacement Wi ows Alteration(s) pi Roofing Or Doors Accessory Bldg. n Demolition ❑ New Signs [0] Decks [CJ Siding [p] Other [p] . 9 4 M Brief Description of Pr ^� Work: _c o d ) l + / �,� .,m4to 4N sei t Alteration of existing bedroom Yes s No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet =± �i."F, u =., 7 "'.'G"^'42 :=°n.: 9' ,.c."�,f' : -- fi! £�s"i'-�,'."'A t . ? "". Fr *`e' ills .New,hous -and or addition,. existinc #: »housing,:comp[etethe.follow ng: a. Use of building : One Family Tw 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 5i3 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 :OWN AUTHORIZATION, TO BE COMPLETED WHEN .. t „ _; OWNERS AGENT OR CONTRACTOR; ■APPLIES FOR BUILDING PERMIT f: : 1, I o ■ , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit ap icatio . 6 i P. IQt 1., Signature of Owner Date i� I . � , 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 pain iik, penalti- • -- AiII • 41 _--- -- Print Name , /F �i Jr Signature of 0 ner /Ag: t r Date i J Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by'Goning This column to be filled in by Building Department Lot Size — i ' i ., Frontage Setbacks Front f Side L: R:- . _a L R: 1 Rear l Building Height i Bldg. Square Footage % # t 6 t Open Space Footage (Lot area minus bldg & paved i ■ parking) i i I i i I # of Parking Spaces Fill: i , v i (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW 0 YES 0 IF YES: enter Book Page; I and /or Document #1 B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES I IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO Q IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q 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 Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. r s d� Departmea Uelgr3� ` x - w* S'+. .s; app, ws '' a$" City of Northampton Statusof Perrait� { Building Department N'''''''-`41#4-201; u phwa erm t : "� .4- y t..51 212 Main Street Se e rlee p tic A � � _� t- _ Room 100 water ellArratiabirn � 0 �° .. 0 14 Northampton, MA 01060 oSeiuctulPahs w, au "_0TONS �a ray -----0---J,,. TN Q1o N M6�me • 5 87 -1240 Fax 413-587-1272 te cans r �: 44. x - 4 Oth 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 Map Lot I Unit 4 95 ki ,,,,,,,,,..„..,,,...,,,„„,,„,„,„,,,,„, k : r:Zone M , . ,, p "`z Ov .w. } M ,.s sou. fi � _ - Elm St_Df '. C B District . - , SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Rec 6 \� . fl ' ° Name (Print) Current Mailing Addres � , t ae -_ lift. Telephone Signature 2.2 Authorized A. ff I r r (Print) � . C urren t M ing Name Address: Signat F Telephone SECTION 3-- STIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use.Only , completed by permit applicant . - 1. Building 1 4 9 1 4 (a)'Building P ermitF'ee 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 C t%' 40i, .�.. 0,'i - ' , - - This:. Secfion For Official. Use Only_- Date - Building Permit Number:--',' Issued: - - Signature. Building Commissioner /inspector of Buildings Date 95 STRAW AVE BP- 2013 -0649 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D - 023 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- 2013 -0649 Project # JS- 2013- 001071 Est. Cost: $16400.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 81458 Lot Size(sq. ft.): 9583.20 Owner: BOUGHAN PATRICK Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 95 STRAW AVE Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 () Workers Compensation WORCESTERMA01607 ISSUED ON:12/12/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS & ROOF 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 12/12/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner