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23A-205 67 BEACON ST BP-2016-1200 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A-205 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit# BP-2016-1200 Project# JS-2016-002064 Est. Cost: $975.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: LOWE'S 049918 Lot Size(sq. ft.): 10018.80 Owner: GALUSZA BERTHA V Zoning: URB(100)/ Applicant: LOWE'S AT. 67 BEACON ST Applicant Address: Phone: Insurance: 282 RUSSELL ST (413) 588-0270 WC HADLEYMA01035 ISSUED ON:4/13/2016 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL BASEMENT 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 4/13/2016 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only ji City of Northampton Status of Permit: t 3Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic AvailabilityRoom 100 Water/Well Availability rthampton, MA 01060 Two Sets of Structural Plans " 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 Map Lot Unit (� Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: F-' -1C SPCANtfrel_ ��7 �8ENgCC J ST, 1�7La?-GhjC.-E N14 DI Name(Print) Current Mailing Address: I'�,-S7S-LI iac1 J EE :tJ F 1q t'1' Telephone Signature 2.2 Authorized Agent: It+DNr-_- <_r~ -e:7P-S �� (��SSF_(_t H(4 010- - Name(Print) Current Mailing Address: y I S- _. CE-7 0 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building r; – ov (a)Building Permit Fee 2. Electrical ` I (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = 0 +2 +3+4 +5) —T 7 S G6 Check Number 007;9 9 WD This Section For Official Use Only Building Permit Number: DateIssued: Signature: Building Commissioner/Inspector of Buildings 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: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (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 0 DONT KNOW 0 YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document # 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 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO Q 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 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) —ffNew House F-1Addition F-1Replacementndows Alteration(s) Roofing Or Doorsin I Accessory Bldg. ❑ Demolition ❑ New Signs [[--3] Decks [M Siding[0] Other[0] Brief Description of Proposed Work: F—C"Wr OLD AINQ KBE\ill BVIS=M 1JT NO S ��<:(t '►�(_ C_tt-vrt\1(,F_ 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 existina 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. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, eLas Owner of the subject property hereby authorize LC\,vES "t-(E C iN'�11ZS r_C to act on my behalf, in all matters relative to work authorized by this building permit application. SE e- -oWAe_T Ilr� Signature of Owner bate r I, as Owner/Authorized Agent hereby declare that the statements and i5�0 n on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. s Print Nar. at ner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: (1 A93(, }t<DOI10 C.S -0H qq i j License Number 15 J NES Ev�ST-tfom ipw mss =2:7 12/2g 2016 Addres _ Expiration Date Lt i'?j- nature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number 282 'R Ed— S MA © ,!;� t 1%2017 Addr Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.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 permit. Signed Affidavit Attached Yes....... No...... ❑ 11. - Home Owner Exemptlon 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 The Commonwealth of Massachusetts Department o f Industrial Accidents Office of Investigations I Congress Street, Suite 100 �= Boston, MA 02114-2017 �M www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): -�QIDC1 ,i tAL1-Ac 1�-APP_0vUt--(E1, �..) Address: 15 D Z EVT T 4t-- MN 6102.7 City/State/Zip: Elly Tl'MIA FTS' M r- (310-2--7 Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.05 I am a employer with 1 4. ❑ I am a general contractor and I employees (full and/or part-time). + have hired the sub-contractors 6. F] New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.F] 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.] ' c. 152, §1(4),and we have no employees. [No workers' 13.® Other j/1NDO WS comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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: �J V�V T'1 L011J�V 'SS C co Policy#or Self-ins. Lic. #: AV�-1 C• y 00-7 Q LCI C 1?J Z-OLS✓� Expiration Date: Job Site Address: L1 `�C1�f b� <91 VLPV-C-1 C ��k City/State/Zip: rLOLC-N �`'� ok����� 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 he violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA fo nsurance yoverage verification. I do hereby certify nde a pains a d pendlties of perjury that the information provided abov is ta ad correct. Si natu . Date.4 --� 75 1 1 ln 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es)and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP) with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy infonnation (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE Revised 7-2013 Fax # 617-727-7749 www.mass.gov/dia City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: G-7 PEvA-CU�J s Z.OP-SNC. 61A The debris will be transported by: The debris will be received by: � Building permit number: Name of Permit Applicant Date Signature of Permit Applicant r, • a r- cr �k Massachusetts-Department of Public Safety 4 Standards Board of Building Regulations and Sta co _ to Construction Supervisor I --� License: CS-049998 MARKS JODOIN, 137 PORTER LASE D ,"W.*- •., Lvngmeadew MAF 01106-Z.,:,W. A A00f. sem- ,,�y� » ++� `~ 'expiration C) commissioner 92129!2098 N . M 00 m cn �a +J W w N ' r ti O q Ln r , C) N C��e tpdnvma�2usea�o�C%liGar�lacl2u/,�a ice of Consumer Affairs&Business Regulation License or registration valid for individul use only IN ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration: 148688 Type: 10 Park Plaza-Suite 5170 Expiration: 10/18/2017 Supplement Card Boston,MA 02116 LOWE'S HOMES CENTERS LLC. �----� JAMIE SPOFFORD 1000 LOWES BLVD s --- MOORESVILLE, NC 28117 Undersecretary valid without signature JODOHOM-01 MPROULX ACORO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/4/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 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 SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Insurance Center of New England,Inc PHONE 800 243-8134 FAX 413 731-9539 1070 Suffield Street (AIC,No,Ext):( ) (A/C,No):( ) Agawam,MA 01001 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Nautilus Insurance Co INSURED INSURER B:Commerce Insurance Company 34754 Jodoin Home Improvement INSURER C:Aim Mutual Ins Co-Assigned Risk C/o Mark S Jodoin 137 Porter Lake Drive INSURER D Longmeadow,MA 01106-1246 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000 CLAIMS-MADE X OCCUR X NN569610 06/26/2015 06/26/2016 DAMAGEPREMISES TO (Ea D occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 500,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 500,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) B ANY AUTO X RPJ989 03/26/2016 03/26/2017 BODILY INJURY(Per person) $ 100,00 ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ 300 000 AUTOS AUTOS � X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ 100,00 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY X STATUTE EERH C ANY PROPRIETOR/PARTNER/EXECUTIVE Y� NIA AWC40070296132015A 08/31/2015 08/31/2016 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? F (Mandatory in N yes,describe under E.L.DISEASE-EA EMPLOYEE $ 100,00 nd DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Vendor#16930 Lowe's Companies Inc.and any and all subsidiaries are named as additional insured as respects to General Liability and Auto Liability per Mass Business Auto Forms CA0001 and MM9911 an applicable Mass.State Laws as per written contract only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Lowe's Companies Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: I S Insurance(Metz) ACCORDANCE WITH THE POLICY PROVISIONS. Vendor Compliance/Risk Mgmt,Lowes Companies Inc. Post Office Box 1111 AUTHORIZED REPRESENTATIVE North Wilkesboro,NC 28656-0001 a, 0 arc ©1988-`+20014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ./'..o N ' RE0CERTIFICATE OF LIABILITY INSURANCE °�1)20;�°""Y"' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 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 SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Marsh USA Inc. NAME: 100 North Tryon Street,Suite 3600 PHONrE FAX Exth Charlotte,NC 28202 E-MAIL ac No ADDRESS: INSURERS AFFORDING COVERAGE NAIC► 47095-CASUA-ONLY-15-16 INSURER A:National Union Fire Ins Co Pittsburgh PA 19445 INSURED Lowe's Companies,Inc. INSURER 8: New Hampshire Insurance Company 23841 and Subsidiaries INSURER C:Steadfast Insurance Company 26387 1000 Lowe's Blvd. Mooresville,NC 28117 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: ATL-002938178-28 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. LTR TYPE OF INSURANCE A BR POLICY NUMBER POLICY EFF MMM/DCDM�YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY Self Insured See Below L' -" MA PREMISES Ea occurrence $ CLAIMS-MADE 0 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN1 AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY JECT PRO LOC $ A AUTOMOBILE LIABILITY CA5260749(AOS) 04/01/2015 04/01/2016 COMBINED SINGLE LIMIT B X Ea acddent 5.000,001 ANY AUTO CA5260748 (MA) 04/01/2015 04/01/2016 BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED CA5260760(VA) 04/01/2015 04/01/2016 AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS AUTOS NED APROPERTY DAMAGE AUTOS Per accident $ $ C X UMBRELLA UAB X OCCUR IPR3792301-01 04/01/2014 04/01/2017 EACH OCCURRENCE $ 5,000,OOC EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I I RETENTIONS B I WORKERS COMPENSATION WC017731584 (AOS) 04/01/2015 04/01/2016 XWC STATu- OTH- $ AND EMPLOYERS'LIABILITY y B ANY PROPRIErOR/PARTNER/EXECUnVE Y/N WC039901583 (WI) 04/01/2015 04/01/2016 2.000,000 B OFFICER/MEMBER EXCLUDED? ❑N N/A E.L.EACH ACCIDENT $ (Mandatory in NH) WOOIT731585 (MN) 04/01/2015 04/0i/2016 EL.DISEASE-EA EMPLOYEE $ 2,000,000 If y B DESCRIPTION OF below WC39901584 (AK.AZ. NH,VT) 04/01/2015 04/01/2016 2,000,000 E.L.DISEASE-POLICY LIMIT $ AExcess WC XWC9889959 (AOS) 04/01/2015 04/01/2016 WC:StaVEL:$3mit;xs$2mil SIR A F�ccess WC XWC9883960(FL) 04/01/2015 04/01/2016 WC:StaVEL:$3mil;xs$2mil SIR DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insured is self insured for General Liability for the period of 4/01/2015 to 4/012016. Evidence of coverage. Lowe's sell insures for physical damage coverage to rented and leased vehides. CERTIFICATE HOLDER CANCELLATION Lowe's Companies,Inc. and SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE subsidiaries THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Mooresville,NC 28115 BoxX 1 1000 es 000 ACCORDANCE WITH THE POLICY PROVISIONS. Mo AUTHORIZED REPRESENTATIVE of Marsh USA Inc- Paula Stapleton job-.. . ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD i 1 CONTRACT# 0006429 i MASSACHUSETTS S VICE OLUTIONS INSTALUE- SALES CONTRACT LOwFF'S AUTHORIZED REPRESENTATIVE NUMBER CUSTOMER -i I-//- 2% Sr?F i ic>rA, r t STORE NO. STREET ADDRES j STREET ADDRESS 2 _ / % �� �!>S L> �! ( 7 �; 11l o l 5/ CITVl STATE ZIPCITY S,/TATE ZIP TELEPHONE / / ty, ✓ 'I TELEPHO E GATE LO E'S HOME CENTERflR1 .:t 88 CASH CARD BANKLCD CHREG ARGE FEIN:56-0748358 This is only a quoteforthe merchandise and services pco an agreement upon payment.Upon payment the entire agreement,including the specifically completed pages of this document,the Terms and Cond'dions included with this der da and attachments hereto,shall be referred herein as this"Contre L" PLEASE READ ALL TERMS AND CONDITIONS ON THF PAGE AND FOLLOWING PAGES BEFORE SINING. INSTALLATION STREET ADDRESS�` CITY STATE ZIP // ( rA 0/0 01 PHOTO RELEASE:Customer grants to Lowe's at J Lowe's em oyees and independent contractors the right to take photographs of the Premises where Installation Services will be performed and all woj i performed the Premises related to this Contract,and irrevocably grants to Lowe's all right,title and interest in and to the photographs for use in all me Rets and m a,worldwide,in perpetuity.Customer authorizes Lowe's to copyright,use and publish the photographs in print and/or electronically,and agre Is that Lowe' may use such photographs for any lawful purpose,including,but not limited to,marketing, advertising,publicity,illustration,training and Web ntent.By i ialing here,Customer agrees to the foregoing. [Customer to initial to the left].,. :i Contract Total Are permits required for this installation? [ Yes ]No *applicable tax included NOTICE TO CUSTOMER: Federal law require Lowe's to irovide you with the pamplet Renovate Right.By signing this Contract,Customer acknowledges having received a copy of this amphlet bell re work began informing Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Ct tomer's dw, Iling unit. NOTE:If rotted wood is discovered duri installati additional charges will may.You will be given a quote and a change order must be completed and signed by the c tomer for ny additional charges. _Customer must initial. 'Any work or material not specified is not included in is contract. y changes or additions will be a�-art'additional charge for the material and labor.` WAIVERIF LIEN and 0 YEAR WARRANTY(TO BE SIGNED BY INSTALLER) I,the undersigned Installerlindependent Contractor,havi been employ 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 an the Custom 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 relin ish all liens an 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 ma rials furnished any,by any other party or parties upon the order of the unoerslgned,have been fully paid for.Further,I the undersigned,agree to cause the prompt release of any m nic's lien(s) may be filed against the Customers,prergises by any subcontractor,laborer,mechanic or material supplier claiming the right to file such a118n through work related to a Customers ntrail with Lowes.In addition to any warranties-provided by law or specified elsewhere,including the Customers Contrail with Lowe's,the undersigned,further warrants that II work furnish 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 m tectal used du, 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 all expense t Lowe's and the Customer in a manner satisfactory to the Customer. I further represent that I have given Customer the option of taining some 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 thisproject,I,the u ersigned Installer/Independent Contractor,do hereby certify that I have complied with all requirements of the Lead Renovation,Repair,and Painting Program Rule("LRR P Rule"),40 C .R.sec.745.80 at seq.,or any applicable state laws or program regulating lead-based paint safe work practices, including compliance with all information distribution,notice uirements an rk 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 un r the LRRPP le 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 a plicable state p gram. Signed and delivered this day of (seal) Installer Print Name CERTIFICATE OF COMPLETION 1.I,the Customer,certify that the Installers/independent or tile' dors,he"furnished all Goods a or services,that installation,repairs and alterations or improvements ('the installation servitcee)have'been completed as set forth -,mylour con Lowe's,and that I have been offered a opportunity to request that Lowe's allow me to retain some or all of any unused,receipted surplus materials rather than have su us rrrsteri Ute property of Lore's. 2.Buyees in'Itials(BuyerlINITIAL ONE only) There wee no such surplus materials. I accepted all suhAus materials I wanted. 1 declined to rel any surplus ma$erdls Die: j G Ovmers Ptirtted Name 1 2t 55102 REV. 12113 INSTALLER COPY ®2004 b9 Lowe's.®Lowe's and the gable design are registered trademarks of LF Corporation.