Loading...
22D-084 (2) A� CERTIFICATE OF LIABILITY INSURANCE _ °0 t0"1 ) r THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSH USA INC. NAME* PHONE I INC.TWO ALLIANCE CENTER PAIL.No.Ezt1: tA/C Not: 3560 LENOX ROAD,SUITE 2400 E-MAIL_ ATLANTA,GA 30326 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL S 100492-HomeD-GAW-13.14 INSURER A;Steadfast Insurance Company 26387 INSURED INSURER B:Zurich American Insurance Co 16535 THE HOME DEPOT,INC. ' New Ins 23841 HOME DEPOT U.S).,INC. INSURER C: Hampshire 2455 PACES FERRY ROAD,NW Illinois National Ins Co 23817 BUILDING C-20 ,INSURER D ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003159545-04 REVISION NUMBER:7 THIS • CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTA4THSTANDING 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 • NDmONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE ANpRIS two I POLICY NUMBER I DD I M (MMDrYYYYI LIMITS A GENERAL LIABILITY GL04887714-03 03101/2013 03)01/2014 EACH OCCURRENCE 5 9,000,000 X AMAGE TO RENTED S 1,006000 I 71 co COMMERCIALGENER�ALUABIUTY PREMISES(Eaocaerencel I "' I LIMITS OF POUCY X5 MED EXP(Any one person) $ EXCLUDED CLAIMS-MADE OCCUR OF SIR SIMPER OCC PERSONAL&ADV INJURY 5 9,000 003 —..._ ., • GENERAL AGGREGATE S 9,000.000 GEM.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 5 9,000,00 1 POLICY n ma n LOC S B AUTOMOBILE LIABILITY I BAP 293896310 0310112013 0310112014 fEREc MenSINGLE LIMIT _ 1,000,000 ---1,, ANY AUTO BODILY INJURY(Per person) S ALL OWNED -SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) 5 AUTOS _ AUTOS PROPERTY DAMAGE s I — HIRED AUTOS = AUTOSS EO _ (per eni1 S HUMBRELLA UAB OCCUR - EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE s I OED I I RETENTION 5 S C WORKERS COMPENSATION WC033575314(AOS) 03/01/2011 03/01!2014 X I WC STATU- I IDTH- AND EMPLOYERS'LU1BIUTY TORY LIMITS 1_ ER C ANY PROPRIETOR/PARTNER/EXECUTIVE Y i N WC033575315(AK,AZ) 03)0112013 0310112014 EL EACH ACCIDENT S 1,000,000 D (Mandatory In NH)EXCLUDED? © NIA WC033575316(FL) 03101/2013 03/0112014 EL DISEASE-EA EMPLOYEE S 1,000,030 (Mandatory In NH} u yes.dasdibe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UNIT.S C WORKERS COMPENSATION WC033575317(KY,NC,NH,VT) 0310112013 03/0112014 (EL)UNIT 1,000,000 C WC033575318(NJ) 03/01/2013 03/0112014 DESCRIPTION OF OPERATIONS I LOCATIONS U VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is rsqulrsa) EVIDENCE OF COVERAGE •. \ • CERTIFICATE HOLDER CANCELLATION • THE HOME DEPOT INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HOME DEPOT USA,INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD,NW ACCORDANCE WITH THE POUCY PROVISIONS. 'BUIDING C-20 ATLANTA GA 30339 AUTHORIZED REPRESENTATIVE or Marsh USA Inc. Manashi MukherjeeAUDc - 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 04/24/201,1 03:50 FROM 4546822 TO P.01 office of Consumer Affairs&Business Regulation i '..License or registration valid for individul.nse only before.the expiration date. If.found return to: '-7'1 2_yOME IMPROVE ENTCON RACTOR Office of Consumer Affairs and Busmess,Regulation T-' -Registrattofr.',� TYPe= .10 Park Plaza-Su ite�5170 ^ ..:: t'Y Supplement Ord Boston MA 02116 r.•• . The Home Depot ►'heir`; • .\ i .k't4 'N . ORHARD TROIA +::'` l w 2690 CUMBERLAND p 3 r— � A A' rA,.GA30339 Undersecretary ' Not valid without signature • a -7 - 1 I°1)11-1 / \ • \ \-/ , ) - t \r\ • 1Th A \ }. /;? --•°" • Massachusetts - Department of Public Safety Board of Building Regulations and Standards C:unszruction Supen.iwr License:CS-067121 .4.93°41i • . , •.,.1:-""*.s BRIAN C TFICAPSO- N • 3 WILLOW/11;100K LANZ WESTFEELfMA 01a85 • E;:piration Commissioner 04/3012014 • PLEASE READ TUB _ Sold,Furnished and Installed by: / V �, Daum THD At-Home Services,Inc. r' I �I drbfa The Home Depot At-Home Services ��JJ 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free(800)657-5182;Fax(508)545-6017 Branch Number:31 Federal ID*75-2698460:MS uric*C 02439:RI Cont.talk 16427 ' ape#HIC.4012.21 MA Home ven �Rag.#126$93 Installation Address: 5 e�t /L�a,/'']►��a2, City State Zp a Work Phone: Home Phrase: Cell:Phone: 11E*31 ' iii r [ ] [ ] I J [ .] I ) I l Home Address: (If different From Installation Address) City State Zap E-mail Address(to receive project communications and Home Depot updates): E]I DO NOT wish to receive any marketing einaiis from The Home Depot project R: Undersigned("Customer"),the owners of the property located at the above installation address.agrees to buy. and THU.At-H Services,Inc.("The Home Depot")agrees to furnish.deliver and arrange for the installation("Installation")of all materials described on the below and on the referenced Spec Shect(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): Job*: ihiental a"6mie) Sherds ls: Pro' Amount •Roofing "ding Windows •Insulation $ rr .i, Dona p '. Doors O --yy+ •Roofing aSkiiag at Windows U insulation ❑Gutters i Covers DFney Doors 1] $ _ QRoofing OSiding ❑Windows ( Insulation DGuttera/Covers 4intty Doors❑ •Roofing ■Siding R Windows •Insulation D[huters t covers [Wary Doors rl llTnbruem�YeAgpae•tiContredAworeadneupon erecodoa older contract. Total Contr'actMnount '$ Mane Aude®ax.0 yratdepositmoredmoneehirdoftheCommaAAtounn. Customer agrees that,immediately upon completion of the work for each Product.Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Home Depot or its authorized service provider determines that it cannot pesfotm its obligations due ton structural problem with the borne,envirotw ental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because work required to complete the job was not included in the Contact. Pay.mget,,jelmeEei The Payment Summary# -.31101""„ . included as part of this Contract,sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-in copy;Odle Contract at tie time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. IA the event of termination of this Contract'Customer agrees to pay The Home Depot the costs of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE ROME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Aceeotaace and a1 thttrization: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. A — ;0:4' Submitted by:.ds■• D Customer's Signature Date Sales Consultant's Signature Date Telephone N . Customer's Signature Dare Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS tin arel'icable) AGREE1VIENT VER WITHOUT PENALTY OR OBLIGATION E HOME i HY DELIVERING WRITTEN NOTICE TO THE HOME -1,( 66---g349 DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE;ADDITIONAL TERMS AND Cc/NAIM14NS ARE STATED ON TILE:REVEUSE SIDE AND AXE PART OF THIS CONTRACT 104142 When-Branch File Yellow Customer • The Commonwealth of Massachusetts = Department of Industrial Accidents I ' 'ii Et Office of Investigations �C= • 600 Washington Street .:.._ 7 Boston,MA 02111 2r..�4� • www.rnass.gov/ditz Workers'Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Piumbers Applicant Information _ Please Print Le.ibi Name(.business/Organizntion/Individual): R, f � f •Address: , ` t t7 City/State/Zip: i 1%A i ... - 1 w Phone.#: al a 1, ,, Are yon an employer?Check the appropriate b• : Type of project(required): • 1.0 I am a employer with - 4. f, I am a general contractor and 1 ❑New construction • 6.employees(full and/orpelt-time).* have hired the sub-contractors 2.0 I am a'Sole proprietor or partner- listed on the'attached sheet. 7. 0 Remodeling • ship and have no employees These sub-contractors have 8. 0 Demolition . working for me in any capacity. employees and have workers' 9. 0 Building addition co insurance.'[No workers'comp..insuuance required.] • 5. 0 We are-a-corporation and its 10.0 Electrical repairs or additions •3.0 I am a homeowner doing all work officers have exercised their . 11.0 Plumbing repairs or additions - myself[No workers'comp. right Of exemption per MGL []12. Roof repairs I insurance required.]t c. 152,§1(4),and we grave no employees.[No workers' 13:0 Utlier s comp.insurance required.] I *Any applicant that checks box#1 must also fill out the section below showing their victims?ci napensaaon policy information. t No.• eowners who submit this affidavit Indicating they are doing all work and then hire outside contractors must submit anew 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'camp,poi cy number.. - - Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site i information. ----� Insurance Company Name: i, � 'ji ,- . V `. Policy#or Self-ins.Lic.#: ' 75i--)7,5-3.1/ Expiration Date: l i t Job Site Address: City/State/Zip: $ b Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure-to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised .•t a copy-of this statement may be forwarded to the Office of Investigations of the D • . 3'r'' s _ .verage v.-'..cation. -I do hereby certify the ,a and : . • , a erjury that the information provided abo is true and correcat Signature: L,,:7►�'" pate: 1 _ Phone#: 5---d& Official use only. Do not write In this area,tai be completed by city or town official }City or Town: - Permit/License# t Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector b.Other . _ i Contact Person: Phone#: { E z i SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: ,I ,gg' gillfiliW �ilr/� C�J -D6712-/ ., i'l j License N ber ----"3Z)____// Address Expiration Date Sign tune Telephone 9.Registered Home m roveme Contractor: ,...7,- Not Applicable ❑ ' / 4...: t- )....rer 0 egp Com..n N- e r- Registration Num e A. f' Expiration Date J/6 gl' a G�' Telephone �1 G SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building/permit. Signed Affidavit Attached Yes r f�" No ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Vyind'ows Alteration(s) n Roofing n Or Doors Accessory Bldg. El Demolition El New Signs [D] Decks [C] Siding[0] Other[D] Brief Description of Proposed 4 g e}X F 3 W/A/D $ f� -7�6/ Work: �' °J� /'� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building: One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING . P/ERRMIT I, - t _ 'Jr d2 ✓ L/ as Owner of the subject property hereby authorize / a %4 ' Jej9- to act on eh If, in a�ttteerss relative to!pork authorized by this building permit application. // Si gnature of Owner Date "22- —t I, r T / , as Owner/Authorized information hereby declare the statements and nformation on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under. ains nd penal of p= ' . i ' * 1" i/P Print Name //74 4-22-13 Signature of Owner Age t Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 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 DON'T 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 0 , 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 the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ,r \/ Department use only City of Northampton Status of Permit: i G 2 2 zoo \ Building Department Curb Cut/Driveway Permit Gvw 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability DEfNi 41i,APTON isAA 01060 orthampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot Unit ?;216 Zone Overlay District 434 77 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: f,.�'� ✓7r Aini,141 Name Prin / Current Mailin Addr s: '' 471.- 491 Telephone // _ Signature 2.2 Auth tar,.d A •nt: Name("rintt) AITAIWV Current Mailing Addrress: _ _�U ! 523 )�3 � Signat '� Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 1 f � (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Pfotection �/ 6. Total=(142+3+4+5) k,4, - Check Number /607 3 1 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 55 BLISS ST BP-2014-0231 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 22D-084 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit# BP-2014-0231 Project# JS-2014-000383 Est. Cost: $1636.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 67121 Lot Size(sq. ft.): 74487.60 Owner: BAUMER DONALD C&POLLY S Zoning:URA(100)/WSP(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 55 BLISS ST Applicant Address: Phone: Insurance: 908 BOSTON TPK Workers Compensation SHREWSBURYMA01545 ISSUED ON:8/27/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 3 REPLACEMENT WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 8/27/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner