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12C-052 (13) BP-2022-0386 20 CLOVERDALE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 12C-052-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-0386 PERMISSIONIS HEREBY GRANTED TO: Project# basement windows Contractor: License: Est. Cost: 4450 MR HOME CSL103401 Const.Class: Exp.Date:03/19/2023 GRIFFIN ANNETTE &SUSAN D REARDON Use Group: Owner: TRUSTEE Lot Size (sq.ft.) Zoning: RI/WSP Applicant: MR HOME Applicant Address Phone: Insurance: 74 CISLAK DR (413)222-5368 UB003R873577 LUDLOW, MA 01056 ISSUED ON:04/14/2022 TO PERFORM THE FOLLOWING WORK: INSTALL BASEMENT EGRESS WINDOW 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: T1, . • *,k , � Fees Paid: $65.00 212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner The Commonwealth of Massachusetts V Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMRMUNICIPALITY _ USE Building Permit Application To Construct,Repair, Renovate Or Demolish a ' Revised Mar 2011 One- or Two-Family Dwelling This Section For Official Use Only Building Permit Number:, - a a- ` 9 Date Applied: A(M J 7255 Z77 y-N-ZOZZ Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Proper Addr ������� � 1.2 Assessors Map& Parcel Numbers Zi/l1.1 a Is this an accepted street?yes / no_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: -iv //9/J12d/./ / '?f,,tJz°`_ Name(Print) .,2 , Z47,42,49)04 ?tY,St7,47,275) cJ?) No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all t apply) )� New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 A teration(s)�l Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work'-: We/17 ,.r/ 2A/ -s g " /6.0% 1 /e (A/iiiW ' I) tr; /ii , fir✓ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee — ❑Total Project Costa (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ �� 6.r Check No. Check Amount: 6. Total Project Cost: $ ❑Paid in Full 0 Outstanding Balance Due: / City of Northampton s`� � �' � Massachusetts * I a ¢V S .4 4 DEPARTMENT OF BUILDING INSPECTIONS ` APR 13 20?2 212r Main Street • Municipal Building AA. � Northampton, MA 01060 i 1 DEPT.OF BUILDING INSPECTIONS t NORTHAMPTON.MA 01060 PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS, DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR, ETC. 1. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work(Digital and hard copy). 3. Construction Debris Affidavit filled out and signed by applicant. 4. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance. 6. Energy Conservation Compliance Certificate (new I replacement windows). 7. Home owner's License Exemption Form (if applicable). 8. Note any Special Permit requirements (if applicable). 9. Energy Code —all new construction(Gut/Rehab) requires a HERS Rater Affidavit 10. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton. / SECTION 5: CONSTRUCTION SERVICES • 5.1 Construction Supervis r License(CSL) /o 3 L'IO i. A3 � 7 �.11///i'°.A7 License Number Expiration Date Name of SL Holder 7 y jy/ List CSL Type(see below) No.and Street T Description /,�414/ U nestricted(Buildings up to 35,000 Cu.ft.) �/� 6' -it- Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding /j� y��/IV J , ��P�G� SF [ Solid Fuel Burning Appliances (/I/ Insulation Telephone Email address/ D Demolition 5.2 Registered Home Improvement Contractor(HIC) `N47 // y2// ,� 3 fry --- /1 o HIC Registration Number Expiration Date HIC Company Name or C��gisft•an t Name No.and Street 7i41.p /10✓IJ. EiR •z�2 3- aEmail address City/Town, State,ZIP 4` Telephone SECTION 6:WORKE ' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance ffidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the deni o he Issuance of the building permit. Signed Affidavit Attached? Ye . ❑ No .0 SECTION 7a• WNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGE T OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize 72, ,/ '2/11 to act on my behalf,in all matters relative to work authorized by this building permit application. 4112A/ MG/Pi , AJ ji` 2 Print Owner s Name(Electronic Signature) Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. . � '1—/ 0� y Y/S,,. 2 Print Owner s or Authorized Agent's Name(Electronic Signature) Date NOTES: _ 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.uov%oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the.information below: Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) _ Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches _ Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" \ The Commonwealth of Massachusetts '-r Department of Industrial Accidents 1 Congress Street,Suite 100 t, Boston. MA 02114-2017 www.mass.gooldia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricianv Plumbers. It;RE FILED WITH THE PERMITTING AlItt()R1t1. Applicant Information Pie:INe Print Legibly Name i Bus akeOrgantiatiort l rid 1•%ILI:nal): Address: d /./ . City/State/Zip:. .1c1/1 ___________ Phone#: , , Are yen an employer?Cheek the rippisopriate her: I I I ant a employer with .0/6) employees MX amine part-travel.* 5r Ty pe of project(required): 7. 3 New construction 2.0 lam a sole proprietor or ixinnership and base no employee%Woricuis for mc m g. 0 Remodeling any cupacity.[Nu workers'comp.insimullx ft-quit-ed.] 9. [3 Demolition 30 lam a homeowner doing all wort myself.[No workdrs*comp,irtsurancv required] 4.0 1'NW 100 Building addition I ant a homeowner and will be hirmg contractor%to conduct all WINgit Ott My prersty. crburt thud all contractors either have workers coirci:nsotion insurance i.ir are auk 11 a Electrical repairs or additions proprietor%with rio employem., l la Plumbing repairs or additions 5i:3 1 gun a genera]contractor and I hive hired the sob-contractors listed on the attached sheet. These sub-contractors have employees and have workers'cumin,.insurance.: 13.0 Root repairs 1.4_0 Other 6.0 We are a corporation and its officers have exercised their right of exemption per WI.c. 152.§hal,and we have ma employees.[No workers'comp.insurance required.1 *Any appficant that dweeks box al must also till out the section below,Abu*inc their workers'compensation policy information +timoimishers,who submit this affidavit trt..11cutmt.they are doing all work and then hire outside contractor%:Wig 4-Ubnut a new affidas it itiiiii.:.-Aing ',.t..-onr.r.Jetor%that du:Lk lit,NA mina attached an Aidltiorta)%beet ibouing the name of the stcontructers and gate w hobeT or not thus4:,...itmitni,have employees tithe niii-cor .4-.1-...a.,,e employees.111,:, :flul,1 provide ificir 'wort.cr;IN!,my.paii...-,number I am an employer thus IN proidinz workers'compensation insurance for my employees'. Below is are policy and job Nile information. Insurance Company Vain 712-AA' ///6A/ — .e....- ...., Policy#or Self-ins.Lie.#: Expiration Date: , . a' .... eZ *2 Job Site Address: / P),70;4, 1-4 CityrStateZip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152. §23A is a crunitial violation punishable by a fine up to S1.500.00 antkor one-year imprisonment,as well as civil pena •es in the form of a STOP WORK ORDER and a tine of up to S250.00 a day against the violator.A copy of this statement , ..y be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifr under the pli N tli d pen iiif eN ofpefiury that e infar tin n provided oho yr'i.% irue and correct. -----"/ --- Sispiatun:-. Phone#: Official use only. Do not write in this area,to be completed kv city or town official City or Town: PermitiLicense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing In siwc ci 1 r '•- 6.Other Contact Person: Phone#: City of Northampton SH , Massachusetts DEPARTMENT OF BUILDING INSPECTIONS . fly * . ill 212 Main Street • Municipal Building Northampton, MA 01060 Ss {Y `)^`� CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: MIA,�Y✓ /`✓�4 A✓ft✓L°/'.4, The debris will be transported by: �2✓�Vy�!'�/`� Name of Hauler: /1 V✓d' , Signature of Applicant: Date: City of Northampton .1m44 `�� Massachusetts „Ss ^srt DEPARTMENT OF BUILDING INSPECTIONS S; �' 212 Main Street • Municipal Building • ,r ,c. s Northampton, MA 01060 ry 3;j1'1� HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, (insert full legal name), born _ (insert month, day, year), hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners' exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns 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 home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of , 20_. (Signature) HOME-01 OP ID:AC -A CI�RO CERTIFICATE OF LIABILITY INSURANCE DATEIMM/DD/YYYY) 03/1512022 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 have ADDITIONAL INSURED provisions or 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 413-589-0901 CONTACT House NAME: Ideal Insurance Agency,Inc. PHONE 413-589-0901 1 FAX 413-583-6511 187 East St. (A/c,No,Ext): (A/C,No): Ludlow,MA 01056 E-MAIL ADDRESS; House INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Travelers Insurance 19046 INSURED INSURER B: Mr.Home 6 Dumaine Street INSURER C: Wilbraham,MA 01095 INSURER D: INSURER E: I 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 POLICY EXP LTR TYPE OF INSURANCE INSD SUBRD POLICY NUMBER I(MM DD/YYYYI I(MM DD/YYD'I LIMITS I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ee_occurrence) S MED EXP(Any one person) rS IPERSONAL&ADV INJURY I S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I S POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG S OTHER S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) S _ ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED AUTOS ONLY 7 AUTOS BODILY INJURY(Per accident) S HIRED NON-OWNED PROPERTY DAMAGE 1 AUTOS ONLY _ AUTOSONLY (Per accident) S IS I ! UMBRELLA LIAB I OCCUR EACH OCCURRENCE S I-- II EXCESS LIAB I CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS S A WRKAND EMPLOYERS'ERS'LIRS ABILIITY Y I N ATION X I STATUTE I I ER H ANY PROPRIETOR/PARTNER/EXECUTIVE UB003R873577 09/25/2021 09/25/2022 E.L.EACH ACCIDENT S 500,000 OFFICER/MEMBER EXCLUDED? N/AI (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Concrete Services CERTIFICATE HOLDER CANCELLATION INSRECD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN FOR INSURED'S RECORD ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED�pp REPRESENTATIVE (ILL. a- ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • • Commonwealth of fitassachasi 's le; Divrston of Professional Lreens Board of Building Regulations and S ;ndards ConstructionSUp`orvitlo-1 & 2 CSFA-103401 plres:03:19/2023 WILLIAM H SWEENEY 74 CISLAK DRIVE LUDLOW MA 01056 Commissioner 1. e THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration .j LYE 14yh, Type: Corporation ,mot{ . .. Registration: 194368 MR HOME, INC. Expiration: 01/29/2023 74 CISLAK DRIVE - ; LUDLOW, MA 01056 ..rK .,. > � . F. Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 194368 01/29/2023 Boston,MA 02118 MR HOME, INC. WILLIAM H.SWEENEY 6 DUMAINE STREET i , 4.( • WILBRAHAM,MA 01095 Undersecretary Not valid without signature - Form W-9 Request for Taxpayer Give Form to the (fler.October 2oti) identification Number and Certification requester.Do not \\,,.......Detwtrriont of the Treasury _ send to the IRS. Internal Revenue Service ►Go to www.irs,govIFormW9 for instructions and the latest information. _ 1 `le ', „,. arm ur ir.7 tax return).Name- used o/n�this kne;d not leave this line bier. 2 r3tM me/disregard-Cif ent name.it different from above_ /171:4 --/-/- /2.ie-- .14/./z)- _ j ai 3 Check appropr`ate box for federal tax classification of the person vmose name is entered on finer.Check only one of the 4 'Exemptions(codes apply only to CO following seven boxes. certain entities,not Individuals:see a elstnrtiorts on page 31: p ❑ Individual/sole proprietor or 0 C Corporation ;KGorporation Partnership CITn t/eagle >n single rrteenlar tIC `ci C Exempt payee code(If any) ^ o 'j LI Limitod liability company.Enter the tax classification(C--C corporation.S=S corporation,P ►Partnership) - o1. Not=Chock the appropriate box in the tine above for the tax olayitication of the single-member owner. Do not cheek Exemption from FATCA reporting c ;; LLC if the LLC is c aasireed as a single-remember LLC that is disregarded from the owner unless the owner of the LLC"s cotio .4 a'1 ) -4 n another LLC that is not disregarded from the owner for U.S.fcda„l taut purposes.Otherwise.a single-member LLC that ( Y _ is disregarded from the owner should cnock the appropriate box for Ova tax classification of its owner. V 0 Other(see instructions)► Voo.his C,cccavro mv,s.ercot:ao ire u si a 5 Adorsss(number,street,and apt or suite no.)See Intructions, j Requester's name and address(optional) /7ZAr% f 44te 6 City,state,and ZIP code /I/ 7 List account ntmhberts)here(optional) Part I Taxpayer Identification Number(TiN) Enter your TIN in the appropriate box.The TiN provided must match the name given on line 1 to avoid [Soclal security number backup withholding.For individuals,this is generally your social security number(SSN).However.for a _, resident alien,sole proprietor,or disregarded entity,See the instructions for Part I,later.For other entities,it is your employer identification number(ON).tf you do not have a number,see How to gets TIN,later. or Note:If the account is in more than one name,See the instructions for line 1.Also see What Name and (Employer Identification number 1 Number To Give the Requester for guidelines on whose number to enter. Part II- Certification Under penalties of perjury,I certify that: 1.The number shown on this form is my correct taxpayer identification number(or I am wafting for a number to be issued to me);and 2.I am not subject to backup withholding because:(a)I am Exempt from backup withholding,or(b)i have not been notified by the internal Revenue Service(iRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that i am no longer subject to backup withholding;and 3.(am a U.S.citizen or other U.S.person(defined below);and 4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are ctrtrently subject to backup withholding because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid, acquisition or abandonment of secured property,canceltat¢ln of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than interest and dividends.you are not r uir to ign the certification,but you must provide your correct TIN.Sec the instructions for Part II,later. Sign Signature of Here 1 U.S.person► O.- 1.1i4r1 Date' <J l % 4 •Form 1099-DiV(dividends,including those from stocks or mutual General Instructions funds) Section references are to the internal Revenue Code unless otherwise •Form 1099-MISC(various types of income,press,awards,or gross noted. proceeds) Future developments.For the latest information about developments •Fora.1099-B(stock or mutual fund sales and certain other related to Form W-9 and its instructions,such as legislation enacted transactions by brokers) after they were published,go to www.irs.gov/FormW9_ •Form 1099-S(proceeds from real estate transacions) Purpose of Form •Form 1099-K(merchant card and third party network transactions) An individual or entity(Form W-9 requester)who is required to file an •Form 1098(home mortgage interest),1098-E(Student loan interest). information return with the IRS must obtain your correct taxpayer 1098-T(tuition) identification number(TiN)which may be your social security number -Form 1099-C(canceled debt) (SSN),individual taxpayer identification number(iT1N),adoption •Form 1099-A(acquisition or abandonment of secured properly) taxpayer identification number(ATIN),or employer identification number (EIN),to report on an information return the amount paid to you,or other Use Form W-9 only if you are a U.S.person(including a resident amount reportable on an information return.Examples of information alien),to provide your correct TiN. returns include,but are riot limited to,the following. !f you do not return Form W-9 to the requester with a TIN,you might •Form 1099-INT(interest earned or paid) be sibboct to backup withholding.See What is backup withholding, later. Cis.Na.1023/X Form W-9(Rev.10.2018) • PROPOSAL/AGREEMENT 11111111111 MA Lic.#194368 Mr. MICE, in. www.mr-home.net CT Lic.#613751office.mr.home@gmail.com IMIIIIIIIIIIIINIPI 6 Dumaine Street,Wilbraham,MA 01095 (413)222-5368 (860) 627-5610 `fi'+� ; .' Date Proposed To Be nose Windsor Locks,CT `-..-uas+. Submitted To: �7�� Al Phone Numbers: R.,,, 0,.. 3 c Street: f/#FF�'y�PA e /,, Cell: City,State and Zip Code: Email: Notts: WORK TO BE DONE /� COLOR: t " .ji.& UJ' l gs�e GUTTERS: Al,.,, /,j1%9,14 _--Ze /-F �t�-/ DOWNSPOUTS: A�J .4'."1.4 ✓ #/ed.A G/A4 ,Z.. /. /. ° .2 MITERS: ",A _.e .7 ).) /1 "14.(1 ,."�Ji,?(Jyy . " .,a HANDCur MITERS: „ ice 2"..4 ),:kear4.li‹/" , r�9f1°,7,60 1 . RIP/REMOVE: GUTTER GUARD:' jt�/44rJ'//1)f%%-Wy` 'G�'iiod ' . et °4), 12/i'7/ 41,12 2PlA,40. Z, n. IW� to KI ' i'veipiblim/_,,fez, 7.4?"'"" '',/vir/g8f1-7.i f i ' - 1- ' -- 73/S"--61 • : _J t 4 !" : -1:r7-7), -- ,3 9apg, I I ZV i hair 1/40 Please Check Diagram Carefully and Sign Below - Total Cost For Above Specified Work Includes Material And Labor: S 113 Down Required to Book Work and Balance Is Due Upon Completion ili .0 Acceptance of Proposal-The above prices.specifications and conditions arc satisfactory and hereby accepted. 0 You are authorized to do the work as specified. Payment will be made as outline above. Kw may cancel this transaction without penalty or obligation within three business days_ Date of Acceptance I 1 3. Completed By: .-- Customer Signature:......21(111 _. Authorized Signature _dea,.01 — Atide ps: rive.goog e.com I e vom a view.re e ey= - S eg Page 1 of 1