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29-119 (8) BP-2023-1238 76 FOREST GLEN bR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-119-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2023-1238 PERMISSION IS HEREBY GRANTED TO: Project# DOOR 2023 Contractor: License: Est. Cost: 1800 LOWES HOME CENTERS INC 117055 Const.Class: Exp.Date: 08/02/2025 Use Group: Owner: MARTIN JEAN M TRUST Lot Size (sq.ft.) Zoning: WSP Applicant: LOWES HOME CENTERS INC Applicant Address phone: Insurance: 282 RUSSELL ST (413)588-0270 WA565D294595013 (AOS) HADLEY, MA 01035 ISSUED ON: 09/11/2023 TO PERFORM THE FOLLOWING WORK:. DOOR REPLACEMENT 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: O 7-) b • wi - ApiT Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner CtegOLtrata‘ pintii / k i i . • ni y&,;,.. 647,c......... S ., The Commonwealth of Massac s etts .C� „ Board of Building Regulations and .tanrdds V . FOR ./. Massachusetts State Building Cod: 780/ M . SE IPALITY Building Permit Application To Construct,Repa r,Re ovate Or Deeoljjpa evis d Mar 2011 One-or Two-Family Dw•1lin�F� C This Section ForOfficia O® 8U1th g st 3� ���O pp N�MnTp`'i;Sa Building Number: Q• � Date Applied: N,�,A�bo,� 1; ti ! 2 . q-11.2 Z Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Prope Ad i.S ..6bA, Si/. 1.2 Assessors Map&Parcel Numbers 1.1a 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(II) 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'ofnord: or),,ad1417 /iW 42 2th 2- Name(Print) (� Ci ,State,ZIP 170*e "-99r /J✓. 21131_5 //6' 1)j jrrlei f eeme W No.and Street Telephone Cl EmailAddress SECTION 3:DESCRIPTION OF PROPOSED WORK2(check an that apply) New Construction❑ Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work'. k ip J(q)11uAft. L/L4WLi no V i'c/(yu✓ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ j g 00.(flD 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: S 4, 'L Check No..)40 eck Amount: `7 O Cash Amount: 6.Total Project Cost: % /(04 0 Paid in Full 0 Outstanding Balance Due: , SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License CSL)) 1/I i7 �-' �� e. 4Sei License Number Expiration Date Name of CSL Holder ✓ _Dtt( n/e� x e / List CSL Type(see below) No.wile.t T� (/ ( :(/` Type Description " 'v n,� Cr /5/, /�/ ^ U Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,���///lStatev�[.�� lA V(�/ / oL� R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering WS Window and Siding P14\ �1 SF Solid Fuel Burning Appliances J9eT• 79 jekifyii,le4rC�t " we//e. Insulation Telephone 'Email address lifyik,., D Demolition 5.2 Registe5ed Home Improvement ontract (HIC) AIS4dr �/C! HIC Registration NumberExpiration Date MC Co a e or Re • va a4C . `�/L4' .ie No.a isid 1 6 c, /7 C U O 6 C / Email address City/Town,State,ZIP Telephone SECTION 6: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 V No .❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize/ t 2 ,rat) `) to act on behalf,in all matters relative to work authorized by this building permit application. t d yk.iiii4ix.) /i4o Print '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. ,Mello SrV q/�/ Print Own 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(MC)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.govioca 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. II.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfibaths 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" i Store 1916 LOWE'S OF HADLEY, MA 282 RUSSELL STREET HADLEY, Massachusetts 01035 LowEls® Contract Prepared for: Jean Martin 76 forest glan drive florence, Massachusetts 01062 (413)586-1105 Prepared by: Steven Lockwood (413)588-0270 steven.lockwood@lowes.com Store 1916 LOWE_S OF HADLEY_MA-Contract-1205347-Page 1 of 29 LOWE'S MASSACHUSETTS SERVICES SOLUTIONS INSTALLED SALES CONTRACT LOWE'S AUTHORIZED REPRESENTATIVE SALES ID DATE CUSTOMER NAME Steven Lockwood 3070929 08/30/2023 Jean Martin STORE NO. STREET ADDRESS SI REE I ADDRESS 1916 282 RUSSELL STREET 76 forest glan drive CITY STATE ZIP CITY STATE ZIP HADLEY MASSACHUSETTS 01035 fiorence Massachusetts 01062 TELEPHONE TELEPHONE (413)588-0270 (413)586-1105 EMAIL EMAIL steven.lockwood@lowes.com jlipmart@ comcast.net LOWE'S CONTRACTOR LICENSE n LOWE'S REPRESENTATIVE LICENSE S CREDIT/DEBIT CHECK LCC CARD GIFT CARD 4CSL-081810;HIC#148688; 3070929 This is only a quote for the merchandise and services printed below.Lowe's does not offer services to paint,seal or stain fences. This becomes an agreement upon payment and issuance of a Lowe's receipt, upon pay-ment,the entire agreement,including the specifically completed pages of this document,the Terms and Conditions included with this document and any other addenda and attachments hereto,shall be referred to herein as this"Contract."PLEASE READ THIS ENTIRE DOCUMENT, INCLUDING THE "NOTICES,""TERMS AND CONDITIONS,"AND"ADDENDUM"CONTAINED WITHIN THIS CONTRACT ON THE FOLLOWING PAGES BEFORE SIGNING. INSTALLATION STREET ADDRESS CITY STATE ZIP 76 forest glan drive florence Massachusetts 01062 MERCHANDISE AND INSTALLATION SUMMARY:(I.E. ITEM NUMBERS,COLORS,DIMENSIONS,CONSIDERATIONS): Entry Doors Product Entry Doors Project Installation of steel exterior door. Masonite 36-in x 80-in Steel Half Lite Right-Hand Inswing Primed Prehung Single Front Door with Brickmould Insulating Core Item#740744 Model#740744 Proposal and pricing dependent on installer second measure to ensure suitability, sizing, and estimated installation costs. 2nd measure results: Threshold support needed, door frame/building exterior needs to be aluminium coils rapped, custom labor and one roll of trim coil. 3 1x4x8 primed pine trim boards increasing cost$449 which brings proposal up to 1799.43 Store 1916 LOWE_S OF HADLEY_MA-Contract-1205347-Page 2 of 29 Project Preparation Process o Dedicated project support staff keeps you up-to-date through every process o Installer conducts Pre-Installation Inspection o Provides appropriate protection to home during installation o Obtain &post any necessary permits o Perform Lead Assessment (if applicable) Installation Process o Remove&haul away existing doors o Check existing door(s)for leaks and evidence of pest infestation o Install new doors&accessories, including handle set, caulk, stops, and fasteners o Follow Lead Safe Practices (if required) o Follow Health and Safety Guidelines Clean-up/Final Inspection o Complete final clean-up and haul away all job-related debris o Test product&perform complete inspection with customer o Review warranty information Work is to commence upon reasonable availability of Contractor and/or any special order or customer made Good(s)which is anticipated to be 09/25/23 . Estimated completion date is 10/27/23 CONTRACT TOTAL $1,799.43 Paid upon signature of Installed Sales Contract(33%) $560.81 Paid upon or after commencement of work(67%) $1,138.62 Paid upon completion of Installed Services to both parties satisfaction $100.00 Store 1916 LOWE_S OF HADLEY_MA-Contract-1205347-Page 3 of 29 NOTICES LEAD SAFE INFORMATION. Federal and applicable state laws require that You be provided with a lead hazard information pamphlet such as the Renovate Right: Important Lead Hazard Information for Families, Child Care Providers and Schools. By signing this Contract, You acknowledge having received a copy of this information pamphlet before work began informing You of the potential risk of the lead hazard exposure from renovation activity performed in Your dwelling unit or facility. A copy of the pamphlet is available at the following website: www.lowes.com/EPARRP. For more information see: https://www.epa.gov/lead/lead-renovation-repair-and-painting-program. NOTICE OF ARBITRATION AGREEMENT: This Contract provides that all claims by Customer or Lowe's will be resolved by BINDING ARBITRATION. Customer and Lowe's GIVE UP THE RIGHT TO GO TO COURT to enforce this Contract (EXCEPT for matters that may be taken to SMALL CLAIMS COURT). Lowe's and Customer's rights will be determined by a NEUTRAL ARBITRATOR and NOT a judge or jury. Lowe's and Customer are entitled to a FAIR HEARING. But the arbitration procedures are SIMPLER AND MORE LIMITED THAN RULES APPLICABLE IN COURT. Arbitrator decisions are as enforceable as any court order and are subject to VERY LIMITED REVIEW BY A COURT. FOR MORE DETAILS: Review the section titled ARBITRATION AGREEMENT, WAIVER OF JURY TRIAL AND WAIVER OF CLASS ACTION ADJUDICATION found in the Terms and Conditions of this Contract. NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L. c. 142A: LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S 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. THE SIGNATURES OF THE PARTIES BELOW APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWES, PURSUANT TO M.G.L. c. 142A. THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. If customer has a complaint which cannot be resolved informally, the home Improvement Contractor Law(M.G.L. c. 142A) may provide Customer with the right to request arbitration through a private arbitration program approved by the Director of the Office of Consumer Affairs and Business Regulation, as an alternative to court action. The same right is not afforded to Lowe's unless this Notice is signed and dated by Lowe's and Customer. All claims by Customer or Lowe's concerning this Contract which cannot be resolved informally, and which are not covered by M.G.L. c142A or subject to the jurisdiction of a small claims court, shall be resolved by binding arbitration as set forth in the Terms and Conditions. By: ,&}Linn, pro-c4L,v-o-ad Date: Lowe's Authorized Representative By: 6Ic"11 Date: 08/31/23 Customer PRICE CALCULATIONS. If this Contract includes Goods and related Installation Services sold by unit of measurement, such as per square foot, the Price may include more Goods than the actual measurements of Your project area. The Price includes the total amount of Goods required by Lowe's to fulfill the Contract (including surplus materials and overages) (together the "Estimated Product")and the Installation Services required based upon this total amount of Goods. For instance, a 120 square foot room may require 140 square feet of carpet to properly match the carpet seams, pattern, or unique room characteristics, and the Price would include Installation Services based upon the 140 square feet of carpet. The total amount of Estimated Product is based upon the total Goods recommended by the Installer, based on the Installer's assessment of unique characteristics of Your project. If any usable Goods are left over, Lowe's may, at its discretion, initiate a Price adjustment. Lowe's will not adjust the Contract Price for the related Installation Services. By signing this Contract, You acknowledge You are aware of Your project area measurements and the amount of Estimated Product, and that the Estimated Product may exceed Your actual project area. If Your project includes the installation of flooring materials, by signing this Contract You further acknowledge having received a completed Flooring Detail Diagram (the "Diagram") prior to execution of this Contract. Upon request, Lowe's can provide You with additional copies of the Diagram, which identifies the square footage of Your project area and the square footage of the Estimated Goods. PHOTO RELEASE. By signing this Contract, You grant to Lowe's, its representatives, and Installer the right to take and use photographs, videos, or other representations of the Premises before and after the Installation Services and all work performed at the Premises related to this Contract (the "Content'). Lowe's irrevocably keeps all rights (including the copyright), title, and interest in the Content for use in all markets and media, worldwide, in perpetuity. Lowe's can use the Content, in any form or medium, internally for any purpose (e.g., customer service, planning, and claims. NOTICE REGARDING PAYMENT SCHEDULE. If the Contract Price is$1,000 or less, payment of the Price by Customer to Lowe's is due in full upon execution of this Contract. If the Contract Price exceeds $1,000, Customer shall use the following payment schedule: (1) Deposit of $ 560.81 [enter 1/3 of the contract Price] to be paid upon signing this Contact. Any deposit collected at the time this Contract is signed will not exceed one-third(1/3)of the Contract Price; Store 1916 LOWE_S OF HADLEY_MA-Contract-1205347-Page 4 of 29 Rev.03/02/2021 (2) Payment of $ 1138.62 [enter 2/3 of the contract Price minus $1001 to be collected upon or after the commencement of work. Customer authorizes Lowe's to charge Customer's credit card. or deposit Customer's check, for the amount of the payment indicated in this section anytime upon or after the commencement of the work; and (3) Final payment of$100 to be paid upon completion of the Installation Services to both parties' satisfaction. NOTICE OF CUSTOMER'S RIGHT TO CANCEL. If this is a "door-to-door sale" as defined by 16 C.F.R. §429.0(a), or if this Contract is signed by Customer at a place other than the address of the seller as set forth in M.G.L. c. 93 § 48, You, the Customer, may cancel this Contract at any time prior to midnight of the third business day after the date of this transaction. See the notice of cancellation form sent as an attachment to this Contract for an explanation of this right. By executing this Contract, Customer acknowledges receipt of two(2) completed copies of the Notice of Right to Cancel form and certifies Lowe's has informed Customer orally of his or her right to cancel. NOTICE TO CUSTOMER. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Lowe's Home Centers, LLC EXECUTION DATE: 08/30/23 LOWE'S AUTHORIZED REPRESENTATIVE SI RREPRESENTATIIVE SIGNATURE OWNER'S SIGNATURE�/ CO-OWNER SIGNATURE Q tculfw Customer acknowledges receipt of a true copy of this contract which was completely filled in prior to Customer's execution hereof. Store 1916 LOWE_S OF HADLEY_MA-Contract-1205347-Page 5 of 29 Rev.03/02/2021 City of Northampton •'' Massachusetts �,,� A• '.� DEPARTMENT OF BUILDING INSPECTIONS . -v >. 212 !lain Street • Municipal Building yJti jai \: Northampton, MA 01060 ss'N ,• 0� 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: �� e .�`'l �/(�V`� /i/ A o /,,,te__,- Y D4t e (,7�02� The debris will be transported by: Name of Hauler: L—P,Vefd:./6//gat/)R__-/ /� /e le: Signature of Applicant: Date: 0.2,5 ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) o3r,72023 • 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 CONTACT Marsh USA Inc NAME: PHONE FAX 100 North Tryon Street,Suite 3600 (NC.No.Ext): (A/C,No): Charlotte,NC 28202 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC x CN102776519-LowesSl-23-24 Y INSURERA:Liberty Mutual Fre Insurance Company 23035 INSURED INSURER B:Interstate Fre&Casualty Co 22829 Lowe's Companies,Inc. and subsidiaries INSURER C:LM Insurance Corporation 33600 1000 Lowe's Boulevard Mooresville,NC 28117 INSURERD: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: ATL-004934190-29 REVISION NUMBER: 27 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 TYPE OF INSURANCE ADDL.SUBR EFF POIJCY EXP LIMITS LTR INSD WVD POLICY NUMBER (MMIDD/YYYY) (MMDI IDYYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS-MADE OCCUR Self Insured-See below REM SaGE TO E NTED PR ES(Eoccurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JERCTT LOC PRODUCTS-COMP/OP AGG $ OTHER $ A AUTOMOBILE LIABILITY AS2651294595103 04/012023 04/012024 COMBINED SINGLE UNIT $ 5,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) B X UMBRELLA LIAB X OCCUR USZ000210200 04/01/2023 04/01/2024 EACH OCCURRENCE $ 10.000.000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED RETENTION$ _ C WORKERS COMPENSATION WA565D294595013(AOS) 04/01/2023 04/01/2024 X PER OTH- C AND EMPLOYERS'LIABILITY y/N WC5651294595023(WI,MN) 04/01/20232•�•� 04/01/2024 STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT : OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 2•000•000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 2•�•� C Excess Workers'Compensation EW565N294595063(FL) 04/012023 04/01/2024 (WC per statute) 3,0001300 A Excess Workers'Compensation EW265N294595033(AOS) 04/01/2023 04/01/2024 (WC per statute) 3,000,000 DESCRIPTION OF OPERATIONS(LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Commercial General Liability policy is Set(-Insured,effective 4/1/2023 to 4/1/2024 SEE SECOND PAGE FOR ADDITIONAL WORDING CERTIFICATE HOLDER CANCELLATION Lowe's Companies,Inc- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE and its subsidiaries THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1000 Lowes Boulevard ACCORDANCE WITH THE POLICY PROVISIONS. Mooresville,NC 28117 AUTHORIZED REPRESENTATIVE /era.,? Zl.Srf Tic. ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN102776519 LOC#: Charlotte ACO ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA Inc. Lowe's Companies,Inc. and subsidiaries POLICY NUMBER 1000 Lowe's Boulevard Mooresville,NC 28117 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance EXCESS WORKERS COMPENSATION(MO) Camer.Liberty Mutual Fire Insurance Co. Policy Number EW265N294595053 Effective/Expiration dates 04/01/2023-04/012024 Limit(Per Statute)_$3,000,000 EXCESS WORKERS COMPENSATION(MA) Carrier Liberty Mutual Fire Insurance Co. Policy Number EW265N294595043 Effective/Expiration dates 04/0 1/2023-04/01/2024 Limit(Per Statute):$3,000,000 Workers'Compensation and Excess Workers'Compensation pokes include a self-insured retention of$2,000,000. General Liability:The insured is sett insured for$10,000,000 each occurrence fix the period of 4/12023 to 4/1/2024. The Automobile Liability poky evidenced above is subject to additional self-insured retentions excess of limits shown for various perils covered. Regarding Auto Liability and Umbrella Liabiity Any party with which the Named Insured has a contractual agreement to include as additional insured is included as such under the poicies if required by written contract with the named insured,subject to the poky terms and conditions.Coverage under the policies only apples to the extent of the coverage required by such contractual requirement and for the limits specified in such contractual requirement,but in no event for coverage not afforded by the policies nor for limits in excess of the appicable limit of the poldes. Insured is self-insured for Automobile Physical Damage for the period of 4/1/2023 to 4/1/2024. Regarding Workers Compensation,Excess Workers Compensation,and Umbrella Liability: Any party with which the named insured has a contractual agreement to provide Waiver of Subrogation is inckrded as such under the poicies if required by written contract with the named insured,subject to the policy terms and conditions Coverage under the policies only apples to the extent of the coverage required by such contractual requirement and for the limits specified in such contractual requirement,but in no event for coverage not afforded by the potties nor for imits in excess of the applicable knit of the polcies. Additional Information- The Named Insured includes Lowe's Companies,Inc.and its subsidiaries,including but not imited to Lowe's Home Centers,LLC,Orchard Supply Company,LLC,Alied Trade Group,LLC,and Maintenance Supply Headquarters,LP. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Reguiation 1000 Washingto . t-Suite 710 Boston,Massachusetts 02118 Home hnpro gent ctOr ,Registrati on Type: Supplement Card 688 LOWE'S HOME CENTERS.LLC =_4 11 1712 1000 LOWES BLVD Qi712023 SERVICES COMPLIANCE MOORESVILLE,NC 28117 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. tf found return to: TYPE:Su3pierr it Card Office of Consume-Affairs and Business Regulation Rai Expiration 1000 Washington Street -Sine 710 148688 10;1712023 Boston,MA 02118 LOWE'S HOME CENTERS.LLC NEXEDES SOTO 100 LOWES BLVD s i sl % •�! s� /f/('e 56` SERVICES COMPLIANCE . MOORESVILLE.NC 28117 Undersecretary Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents y Office of Investigutions Lafayette City Center 1,777 2 Avenue de Lafayette. Boston,MA 02111-1750 .`- www.mass.gov/tdi.a Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizationMdivithral): LOWES HOME CENTERS Address: 1000 LOWES BLVD City/State/Zip: MOORESVILLE,NC 28117 Phone#: 860-505-9314 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with 4. ❑x I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity_ employees and have workers' [No workers' comp. insurance comp. insurance. t 9. ❑Building addition required.] 5. El We are a corporation and its 10.0 Electrical repairs or additions ] officers have exercised their 11. Plumbingrepairs or additions 3.❑I am a homeowner doing all work ❑ Pa 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 fin out the section below showing their workers'compensation policy information. I 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: LM INSURANCE CORPORATION Policy#or Self-ins T,ic. #- WA565Q2945955001/3n(AOS) Expiration Date: 4/2/2024 Job Site Address: �(, * �J (1/yr) City/State/Zip`-���te/W �/-// 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$?50.00 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 I do h y certify under the pain penalties of perjury that the information provided above is true and correct Signature: L7 ��f Date: 9/( / Phone#: 860-505-9314 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/IAcense# Issuing Authority(check one): l❑Board of Health 20 Building Department 311City/Town Clerk 4.0 Electrical Inspector 5E'lumbing Inspector 6.0Other Contact Person: Phone#: Commonwealth of Massachusetts Division of Occupational Licensure �f Board of Building Regulations and Standards Constl -11' t tSiervisor CS-117055 pires: 08/02/2025 KYLE R SEARLES 14R PEACH ORCHARD ROAD _ PROSPECT Cj 06712 Commissioner lieu (6,6474,11..) DATE(MMIDDIYYYY) ACRL CERTIFICATE OF LIABILITY INSURANCE 06/16/2023 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 CONTACT Nancy Lewis NAME Abbate Insurance Associates,Inc. PHONE (203)777-7229 AXX �) (203)865-7593 671 State Street E-MAIL nlewis@abbateins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL• New Haven CT 06511 Acadia Insurance Company INSURER A: � y INSURED INSURER B East Coast Millwork,LLC INSURER C: 14R Peach Orchard Rd. INSURER D: INSURER E: Prospect CT 06712 INSURER F: COVERAGES CERTIFICATE NUMBER: 23-24 All lines 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) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCEDAMAGE T $ 1,000,000 RE 500 CLAIMS-MADE XI OCCUR PREMISESO(Ea occurrence) $ '000 MED EXP(Any one person) $ 15.000 A CPA5549377-10 06/04/2023 06/04/2024 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2000'000 POLICY JEQ LOC PRODUCTS-COMP/OPAGG $ 2'000.000 OTHER- AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A - OWNED SCHEDULED CAA5549378-10 06/04/2023 06/04/2024 BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 A - EXCESS UAB CLAIMS-MADE CUA5549379-10 06/04/2023 06/04/2024 AGGREGATE $ 3,000�, DED RETENTION$ $ WORKERS COMPENSATION XI PER OTH- AND EMPLOYERS'LIABILITY Y I N 500STATUTE ER A OFFICER/MEMBER EXCLUDED?ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A WCA5549380-10 06/04/2023 06/04/2024500 EL EACH ACCIDENT $ '� (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ '000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Vendor 11878 Region 18 The General Liability And Auto Liability policy include Lowe's Companies,Inc.a nd Lowe's Home Centers,LLC as additional Insureds as required by written contract. This insurance is primary and non-contributory over any other available insurance coverage. 10 Day notice of cancellation for non-payment of premium. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Lowe's Companies,Inc.and any and all subsidiaries ACCORDANCE WITH THE POLICY PROVISIONS. 1000 Lowe's Blvd. AUTHORIZED REPRESENTATIVE Mooresville NC 28117 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD