36-325 (3) 228 CARDINAL WAY BP-2019-1004
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36-325 CITY OF NORTHAMPTON
Lot:-00 1 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category:window replaced BUILDING PERMIT
Permit# BP-2019-1004
Proiect# JS-2019-001657
Est.Cost:$2200.00
Fee:$40.01 PERMISSION IS HEREBY GRANTED TO.
Const.Class: Contractor., License:
Use Group: LOWES HOME CENTERS INC 049918
Lot Size(sa.Rl: 18687.24 Owner: STONE ANDREA B
zoning: Applicant. LOWES HOME CENTERS INC
AT.• 228 CARDINAL WAY
Applicant Address: Phone. Insurance:
282 RUSSELL ST (413) 588-0270 WC
HADLEYMA01035 ISSUED ON:
TO PERFORM THE FOLLOWING WORK INSTALL 3 REPLACEMENT WINDOWS IN
FRONT OF HOUSE
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: Ok 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:
FeeTvpe: Date Paid: Amount:
Building $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northampton
Building Department
212 Main Street Sewer/Septic Availability
ROOM 100 Water/lNell Availability
Northampton, MA 01080 Two Sets of Structural Plans
phone 413587-1240 Fax 413587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1.1 Iiiintoorls,Address: wfl F
17-% 0 Nw^-
VLoNe"Cr r )hA J ) Je'l, no. ..
SECTION 2
2.1 Owner of Record: DSP,OF gUab Ne 1N5PE
NOeTNAMPTON.MA01060
ANOPIA ���Nb 2K CP
Name(Print) II 1 Curets Mailing Adtlma:
>QR SI�nAoc CahJ�IAUA Telephone
Signature
2.2 Authorized Agent
CuAIS)))) M'Ni6 toxo (uwe5 k1k) . pwmrK✓,Its /vc- ZxLs'-
Nems(Prim Garrets Wiling Address:
Signal Telephone
Item Estimated Cost(Dollen)to be Official Use Only
completed by
1. Building 'L �U (e)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee (/�,
4. Mechanical(HVAC) L40. Vo
5. Fire Protection
6. Total=(t +2 +3+4+5) Zi v2 ✓ Check Number
T clot Use Only
Building Pa and Number Date
slued:
Signature: 3- 153- -wig
G�I(tIST�PNER. M1 NIE @ tow eS- Ccn-
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
__
LI 16���„ I _ � -.... __
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(i
j
1 Jtl
Section 4. ZONING All Information Must Be Co npleted.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This Ml M be filled in by
Building Deparr umt
Lot Sim 0 0 0
Frontage 0 0 0
Setbacks Front O O O
Side L:O R:O L= R:O 0
Rear 0 0
Building Height O O O
Bldg.Square Footage O O % O O O
� . dgO %
Iaree hubi@pved Q Q 0
arki
#ol'Parking Spaces O 0
Fill:
wbmuai aim
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#�
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will Bre construction activity disturb(clearing,grading,excavation,or filling)over 1 am or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement WWindows Alteratiori El Roofing 0
Or Doors F�
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks IO Siding 101 Other[C31
Brief Description of Proposed
Work
n<� (Df1ocP.+'>�nl
Alteration of e)asbng bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
a. Use of building:One Family. Two Family Other
It. 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?
I. 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?_Yea _No. Is construction within 100 yr. floodplain_Yes_No
I. Depth of basement or will floor below finished grade
k. Will building conform to the Building and Zoning regulations? Ys _No.
I. Septic Tank_ City Sewar_ Private well_ City water Supply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, r NA ai M l,( F 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.
Gv�15 MIN,C
Prim Name
Signature Data
SECI
8.1 Licensed Construction S.uurvlsor: Not Applicable ❑
Name of License Holder. /,nV\ C 7 — 0L 991$
I-toeras Number
34,1 JP 12 -2y - 2u
�p ess Expiration Date
signature V Telephone
Not Applicable ❑
Lwe,? Fto� r_ eA AV S IYQ 6 k k
Comoanv Name Registration Number
L two l.dwt5 &tUo f comcl.Itc- Ajc
Address Eviration Date
Telephone
SECTION 70. - TION INSURANCE AFFIDAVIT(Y.D.L a 761,S 26031)
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...... ❑
City of Northampton
Massachusetts L.
L A&210=r or aU1WZ= IASFSLTZOa3
112 win atr t •W-1c1W Nil n,
Nemo—ton, M 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c40, 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.
The debris from construction work being performed at:
Z-is4 W 4"en,( Ly A t�
(Please print house number and street name)
Is to he disposed of at:
/ t°5 D (L Erxt 11Rrwt°^ Mq o I�z�
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
SiqhatureXqMit Applicant e
If,for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
/ City of Northampton
e
� MaaaaChusatia L
FL
' DEFAR NQlr or anzzozxc zxssscrzoxs
212 win strove • ld cipal eulldv
anrfd tcn, 101 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the`reconstruction, alteration,renovation,repair,modernization,conversion,
improvement,removal, demolition, or construction of an addition to any pre-existing owneraccupied building containing
at least one but not more than lour dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: Est.Cost:
Address of Work:
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
—Job under$1,000.00
_Owner obtaining own permit(mplaut:
_Building not owner o cupied
_Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSDIMITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of pajury:
I hereby apply for a building permit as the agent of the owner:
- �q �— Inv-est{ hy Console✓ I u 8Co8CC
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property.
Date Owner Name and Signature
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1 Please Print Leaibly
�p�
Name(Business/Organiztion/Individual): .YDOW 4o., (��6 m ENT
Address: 15 -po Ohl vE
City/State/Zip:EA,ir4jfnJ,att, mw 0017 Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
U® 1 am a employer with l 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t ?. ❑ Remodeling
ship and havq no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. q_ ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself [No workers' comp. c. 152, §I(4),and we have no 12.[3 Roof repairs
insurance required.] f employees. [No workers' 13.❑Other
comp. insurance required.]
'Am applicant that checks box#1 mug 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.
tGnnrac ors that check this Inc,must attached an additional sheet showing the name of the subcontractors and th,inankers comppylic,intorrogion.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job.site
information.
Insurance Company Name: I A111%RAIII Gfni1E0. 0P A161✓ e.V(rL.9✓O
Policy#or Self-ins. Lic.#: Aw(_4 OJ7f22 q G(2)ZO % A Expiration Date:
Job Site Address: Z21 Caivolee,( w it —City/State/Zip: rrk-"rdar Ms of rr1Z
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 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 deains and penalties ofperjun•that the information provided above is Ince and correct.
Signature � _ Date: 5
Phone#: 413- SY5 -736 l
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License It
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 ajoint 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 anv contract for the performance of public work until acceptable evidence of compliance rcith the insurance
requirements of this chapter Race been presented to the contracting authoriq:
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),addresses)and phone number(s)along%ith 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 permit/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 information (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
600 Washington Street
Boston,MA 02111
Tel. #617-727.4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax# 617-727-7749
www.mass.gov/dia
,eco vB CERTIFICATE OF LIABILITY INSURANCE aA EMHiadta T
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THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CEWIRCATE HOLDER.THIS
CERTNICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, F IFND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER) AUTHONGED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the Conditions holder is an ADDITIONAL INSURED,the Foliry(Ms)mutt be andoreed. If SUBROGATION IS WAIVED,aublect to
the terns and conditions of the policy,certain policies may reader an endorsement. A atetemant on this cartiFicaN doss rat confer rights to the
c irbf{date holder in Bell of such endorsemen al.
a.1reA CONTACTMare Front,
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INSURANCE CENTER OF NEW ENGLANDI"erMOs" u13)>sa>IDB _ _T,`"x`ll. --
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1670 SUFRED STpt0lrl{ERS)MFGRDMGCGYEMGE � Hill
AGAWAM May 01001 1. A: AIM MUTUAL INS CO _ 33758
MARK JODOIN
JODOIN HOME IMPROVEMENT
atMmPrw ._._—
15 JONES DRIVE Iwumae:
EASTHAMPTON MA 01027 I F:
COVERAGES CERTIFICATE NUMBER: 30578a REVISION NUMBER:
TIM IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE MEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONOfTION 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 HAD CLNMS. _
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANYOF THE ABOVE DESCRIBED FOLILYES 9E CANCELLED BEFORE
THE EXPIRATION DAR THEREOF, NOTICE WILL BE DELIVERED IN
Lowes Companies Inc any and all subsidiaries ACCORDANCE WITH TIE POLJCY PROWSIONS.
Mau Code MESS au CRceorlaaEaaMrArn
Mooresville NC 28117 Daniel M.Crealey,CPCU,Vice PresMenl-Residual Mane-WCRIBMA
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD25(2014101) The ACORD IIBme and logo am migtstend merles of ACORD
---l1 JODONOM-01 FIR ULX
ACRO CERTIFICATE OF LIABILITY INSURANCE Sanusereate l _
THIS CERTIFICATE IS *SUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIRCATE HOLDER.TINS
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 INSUREWB),AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT: N the candficale holder is an ADDITIONAL INSURED,me policy(les)most have ADDITIONAL INSURED provisions or be sitakasa4
X SUBROGATION IS WANED, Subject to the tends and oeedltlonf of the policy,certain policies may require an endorselmld. A slaament on
this certificate does not confer rights To UIe certificate holder In Ilau of auditanndwesment(e).
PMWCER Q1H`T
Inawanu Cards,of New England.ino _ - -
1070 Suffield Street .Luc.is,SMI_(8001243.8134 jam,X.,-(413)731-9539
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Longmeadow,MA 0110&1US NNMIE: _..—
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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 CONDTNJN OF MY 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 WIVE BEEN REDUCED BY PMD CLAIMS.
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CERTIFICATE H
QLDFR CA EL EXPIRATION
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SHOULD as"Of THE ABOVE DESCRIBED FOLICIM BE CANCELLED BEFORE
LWro'S COm nles inc. THE EXPIRATXIN GATE THEREOF, NOTICE WBL BE pEUVEaED IN
IM ACCORDANCE WIrX THE POOCY PROw9pNS.
and any and all subsidiaries
Mail Cods A3ESS
1000 LOwaB Blvd aVINOR@DREPREBEMATIYE
Mooresville,NC 29717
ACORD 25(2016103) 0199&2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks Of ACORD
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MARK JODOIN
O)WAJODOIN HOME UPROVEMENT
MARK S.JODOINCC-
15 JONES DR U
EASTHAMPTON,MA 01027 UndsrsecM2rY
OonsnanweMthof Massachusetts
Division of Professional Lvensum
Board of 13.114 ng Regulations and Standards
ConstrucNun Supervisor
C5-049918 Expires: 121291202
MARK S"DOW
15 JONES DR
EASTHAMPTON NIA 0011027
Commissioner V'^' A'
CONTRACT t V O Cj '1 nl L
1
MASSACHUSETTS SERVICES SOLUTIONS INSTALLED SALES CONTRACT
LONES AUnpILUp"I' ESENT" MM10ER CUSTEA EN
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CITY STATE IV CITY STATE M
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M e n s'v Pcu b N my lural vtl urs Pwaa slew. nr aml�an Vexrlee Wm[eleua wer ament M essis and garArl eelraMa mail
OHM,tlr•i•mwIM falavw rcAIW al awmull arE erM1 Mw tlYlbN WMrhlraMiM 4Mnell bti�uele Ceael'
HFA4E RFb ALL TERMe AHD CDNpipIB OII1Ya REVERSE SDE Ce TM MADE YN FIXLOWIM VAaEB aFFdY 9alAN0.
INSiALUTION STREET AppgESs CnY STATE aP
NOTICE TO CUSTOMER-PRICE CALCULATIONS:to order to property perform the inalallaton of cerain Griddle,the Contract Price may Include more
Goods than actually will be installed based on the measured square footage a The Pup res Area. As a result, the paries agree that the lump-sum Price
stated in this Contract is calculated!noun both the value of estimated Goods required to/infill Ills Contrail(inducting waste) am"may exceed the actual
square footage of the Project Area,and the labor which may be estimated based on Ne amount of Goods required to(utgll the Contract(including waste).
By signing this Contract below.Customer acknoxledges receipt of this notice and agrees and understands that the Price includes these costs which may
not be reh nded Once the Installation Services am parMI1M.
Contract Total
Are permits required for this Installation?: [;�] Yes ( )No •applicable tax included
NOTICE TO CUSTOMER: Federal law reeulres Lam's to Provide you all the pamplet Rarwvam Right. By signing this Contract, Customer
acknowledges having received a Copy of this pamphiat banner work began Informing Customer of the potential That,of five lead haaard institution
from renovation activity to be performed in Customer's divelfing unit.
NOTE: N rotted wood Is discovered during Installation additional charges will aW..-You will be given a quote and a change order
must be completed and signed by the customer for any additional chargee( Customer must initial.
'My work or material not specified Is mt mcluaen in this comrade My Changes or adi Immo w'f De at an additional Charge for tM material and Inbor.
PHOTO RELEASE:Customer grants to Lowe s and Lowe's employees and Independent contractors the right to lake photographs of the Premises where
Instalmtion services will be performed and all work perfumed at the Premises reined to this Contract,and irmwxd aay grants to Lowe s all right,lick antl
Interest In and to the pholographs(or use in all markets and media wlarldwme,in perpetuity.Customer authorizes Lowe s to copyright,use and publish the
photographs in print andlor elttlronically,and agrees that Lowe's may use such photographs for any lawful purpose,.kidding,DW not Indeed b,mFketirg,
achumisin .publiury.Illustration.traveng and Web content.By initialing here,Customer agrees to the foregoing. [Customer m mal m the left.
Work is to commence upon reasonable availability of Contractor andlor any spacial order or customer made Goodi which Is anticipated to be
roll In betel.Estimated completion date Is [fill In danl.
Said estimated substantial completion data Is not of the essence. A steemegt of any contingencies that would materially charge seat estimated Substantial
completion date's"follows: I
(if applicable,Insert a statement of such contingencies).
IF THE CONTRACT TOTAL IS$1,OOD.00 OR LESS Customer must pay m NII.
COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS SL N10.N.
(1)Deposit S r ' z' to be paid upon signing contract.Any deposit collected at the time this Contrail is signed will not exceed olefifgld
(1n)of the contract price;antl _
(21 Payment a $ to be misted open or after the commenammt Of work.100 autlespor Lowe's to as cow of the following(chxk appmpnale box Eeiom
[ (Charge mylour credit card[or the amount of the payment indicated above upon or after the commencement of work:
or
I I Deposit mylour chedt for the amount of the payment indicated above upon crafter the commencemmlt nt coot,;arm
(3)Final payment of 5100.00 to nd paid upon wmpkkm a Ne in"Wtmn and loom padtas sabsfailmn.
NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COWRED BY M.G.L.c.141A
LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT.THAT
LOWES MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE
OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS
PROVIDED IN M G L.c.142A. DISPUTE
RESOLUTION INITIATED BY LOVI PURSUANT TO ll c,142A.THE 03NNER MY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION
EVEN MERE THIS SECTION is NOT SEPARATELY SIGNED BY THE PARTIE .N orslonar has a complaint which cannot be resoi informally. the honor
Improvement Conlrarla taw IM G.L.C 142A)may provide Customer min the di m regNsl arb rat on through a proem arbitration program approved nby me DsaCor
d IM 0?w d Cdnsurner Alfaka and Beaerns Regaaton,as an etlemativa m cvur action.Tho same rgM k ria elladad m Luxe a unkf pis Nelke b silpwo cod
Oalw!by I rnan a and Cndnror Aa clime M fnelmw nr 1 rcue c mncomrv.rlrm r'nm.�n wae.a..nnr rc mc..L.w.n/nn..=u, �m .r.nn /`I
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CONTRuai0 0007402
MASSACHUSETTS SERVICES SOLUTIONS INSTALLED SALES CONTRACT
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nasuM'aT btla mxNstla•atl[xNru a^�0eaw. IN Ware an 9�IrN 4erIW^I�Ir Ora^kw/mea hwinarlawawasAw- MaparhwlraaNslw tgpalria
bacon.l Twmf A ANDCre4bEantab EAeneatlaware tlYW�mML rr P tier b Mnsantram aaw'LNai.'
PLEASE RHD Al rFRMS ant<CNdrp1140.Y THE REVEnaE SIDE OF iH8 PAGE ND rIXLbMHG PµtE9 BEFORE 91fW WO.
INSIALLaolm$TAEIT A00RE55 cry STALE LIP
PHOTO RELEASECustomer thane to Lowe's and Lowe's employees and iadep froxam comrepps the right to take phodogrephs of the Premises where
Installation Belau es will be performed and all work peripheral at the PremL related to Nls Contract,and imevooadly grants M Lowe is al right,Elle and
indlla%l In and to the photographs for use in all markets and mend,woMwide,in perpetuity.Customer authorizes Lowe s to copyright use and publish Ne
photographs in print ander alectronicaly,and agrees(hat Lewis a may use such photographs for any lawful purpose,including,but not landed b,markl
advertising,publicity,illustration,training and Web content.By Initialing here,Customer agrees to the foregoing. [Customer to Inmel to the leal.
Are permits required for this installation?: [ ] Yes [ ] NoContract Total '
'applicable tax Included
NOTICE TO CUSTOMER: Federal few requires Lowe's to provide you with the pa moth Reass a e Right By signing this Consul Customer
ackmwledges having received a copy of this pamphlet before work began informing Customer of the potential nsk of Me load husband!exposure
from renovation activity to be pedoreaed in Customer's dwelling unit
NOTE: If rotted wood is discovered during installation addifional charges will apply. You will be given a quote and a change order
must be completed and signed by the customer for any additional charges. -' Customer must initial.
'Any work or mal l not spenLed is ml mcludrin rn m5 contracl Any changes or wh anuria win he at an admlwnal Charge for the malarial and IoM.
WAIVER OF LIEN and ONE YEAR WARRANTY(TO BE SIGNED BY INSTALLER)
I,the undersigned InslalmalldepeMent Cannctorhaving been employed by the Customer who aired the Ormflowe of Completion peal 0 hereby"rely Nal Me work far gas Final
will M or has been zomptotod in a vmrltmal manner and to the Customers ministrant.In"nsdemllon of the reregt of and dol and dher goad and vebWb personal and to the
extent penned by applkabe law.I hereby waive and reinstall,all liens ad all Its and dakm of liens which I,the umasgned,oow have a nay hMOW have dor hbor or materials
furnished seat M1vber onnify But all aodr yedormed and maerdls furnished.If any,by Any uMa party or partes upon the aver of Me urdengned,hon barn lulhy ped its fuller,I Me
uMwsigled.agree 0"use No pomp rde0ae of any mechenK5 Rents)whits may be Iced against Ile Customers premises by any wbpeaBdp,bborer,mMank or mmenBl suppar
damirg Ne night a Iib such a hen Mraugn aork rdalar b IN OAb s Com-ad wnh .is In addidm to any waren"s pmydtd by Ian or spedfie!saewae,iriCkng the Customers
coni am LOee'a,the Ynda6gMd.bI wJrants sell all RVs flim M V Vas voting"ba hes Iran Cede Cts MYr m,normal or worked".N an,dBNeb In nae 0
wakmaral snN he discovered is ft work klrmhed or mdwla Mad during the coarse of Me wnrk of adm ore year from the date of Ne Cerbfeass of Completed,tie aMesiged agrees
a rade"or coned such Mp a wok a matonal.free hen A Manx to Late s and rhe Custom in a manner Refr ,nary a the Customer.
Pedder we vent Mat I have g.Cos.the dinner of naming acme of M of Ue surplus ma'rsha'l or haying sane or a i of turn surdas maenads emmed from Ne CUNwrers
peroses
If Varesple to the Montreal of the wok required for ails protest.I,de undeeigmal InsmlledlPdeperdenl Contractorco hereby derAN Nat I have"milled All ek regMwrene of NB
Lox!Aaronson,Repair,and Painting Program Rule('Ll Pub},40 C I.All 745:N 0"1 or any applicable slam laps or program regaseng Maar thand pawl safe work pactloas.
inm irg wmpunce with all Information daNbutron tusks nquinelnenls and wars"dim stanheNs In pevamirg Ne work required fa'his real I"niry Nat I hare pmwded Me
Casal wile A documentation required to be suppiwal under Me UUl We in state frogman,shall retain all repad5 required by year,are haw a,hW to INS document miles of all of
Me awards required to ba Wood by the LRRPo We on tropical dant pogrom
Situate and delivered NIs day of
seal)
InNakr print Name
CERTIFICATE OF COMPLEYM
t.I.tte Cvscmer r,sxfy Ihal the'.nsdauers9rgeperdent Conlmdors or iteh subcon!mcarshave f rn'ahed!Goods wd'a Ew4km Mat iaY- nights ad rbrles or k powlnanh
(Vie irstaNto,.seMces)hays been rgmdeted as set IoM m ni cmnh3d war tare's,and that I have[leen offered tin Appekstly'b nQl Md LaMY sloe M b lekyn coma Wal of
any un lab,recorded samus Miami$order Nan have sere it rembals eaaln Na"My Of brans,
2 Buyers mans(Burro INITIAL ONE pay)
Imemal in and Io Ute photographs for use m all markets and mediae warWwide,in Perpetuity.Copartner auuunces Low—
photographs
photographs In print ands electronically,and agrees that Lowe's may use such phoographs for any fill lul purpose. oftedlrlg,but not Ilmited to,markadg,
advertising,publicity,Illustration,tralirg and Web content By initialing here.Customer agrees to me foregoing. ICusto nor m initial to le teal.
Wpk Is to commence upon reasonable availability of Contractor singer any special order or customer made Good(S)vision her antelpated to be
[fill In date].Estimated comptetlon,dete is - [fill in dotal.
Seid estmated substemial comPwdm este is cot d the sexual A slalomed of any cpni,ge that wool materially change said esWreted substantial
completion data is as follows:
fit applicable.Insert a statement d such contingencies).
IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer most pry in NII.
COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS 111.000.00:
(1)Deposit 5 r- to be old upon signing centred.My deposit teaseled at the time this Contract is signed will rot exceed ane-third
(LI)of the conned price;and .
(2)Pareent0 $ r robe colicc[M upon err akd tlw WmmBnt,IlmdwUt LYye wllprl¢Loxe's rode pie of pre h4lowing ldutll dpprppnal¢Mr bebwi.
[ j Charge mylour credit card her Ute amount of the payment indicated above upon or after the commencement of work;
or
I I Deposit all check for the amount of Me payment indicated above upon or after the commencement of werk;and
(0)Final payment of 5100 00 No be field upon completion of the installation and holm partiessatisfaction.
NOTICE REGARDMIG ARBITRATION AGREEMENT FOR CLAIMS COVERED RY IN G I SJ42A
LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWER HAS A DISPUTE CONCERNING THIS CONTRACT,THAT
LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE
OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS
PROVIDED IN M.G.L.c 142A. PARTIES BELOWAPPLY ONLY TOTHE AGREEMENTOF THE PARTIES TO ALTERNATINEI
BESOLUTIO INITIATED BY LOWES.PURSUANT TO Mi it 14M.THE OMER MY BE PERM UTE_RESQLvi
EVEII WHERE THIS SEI 15 NOT SEPARATELY SIGNED BY THE PARTIE . If customer has a complaint which cannot be resolved Informallythe home
Improvement Contractor Law(M.G 1.c, 142A)may provide Customer will Me right to request arbitration Uxough a private alduation program approved by the Drescher
of the Offer of Consumer Affairs and Business Harold.,as an aftemxUve to court action.The same right he rut afforded to Lowe's unless lis flatcars signed and
dated by Lowe s and Customer.All claims by Customer or Lowe s cenceming this Contract which ramal the resolved informally.and which are not covered by M.G.L
e142A or subject for the jurisdretan of a small daims Wed.shall be resolved by dndvg amitration as set form in the Gere al Terms and Conditions
By: Data.
Lowe's Aphorized Repesenlaiive
By; Date'.
Customer
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND
CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT
BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ,UNDERSTAND AND AGREE TO THE
TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS
CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE.
WITNESS OUR HAND(S)AND SEAL(S)BELOW THIS DAY OF _
Lowe's Home Centers,LLC
Lowl Aulorized Remnants" ` — Owner Co-ower or Witness
Customer acknowledges realpt of a ha copy of this contract which sun compMey Beed in prior to Cup es execution honest.You,the buyer,m
canal thus hansaction H any Ume prior to midnight of the third business day~On data of this Irsnssctlon.See the attached nobles of cancellatfor
form for an explanation of this right.
96016 0911] FILE COPY o wee Iys sur®"•""u"•a t`ob xxe'
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