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38B-229 (9) CONTRACT# 0 MASSACHUSETTS SERVICES SOLUTIONS INSTALLED SALES CONTRACT LOWE'S AUTHORIZED ,9B REPRESENTATIVE U N CUSTOM ER STORE NO:w STREET ADDRESS STREET ADDRESS CITY STATE ZIP CITY STATE ZIP TELEPHONE TELEPHONE < DATE_ LOWE'S HOME CENTERS,LLC'S MA HIC NO.:148689 CASH eANK Lcc REG-- [FEIN:11-11413111 F CARD CHARGE This is only a quote for the merchandise and services printed below.This becomes an agreement upon payment.Upon payment,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 Warned to herein as this"Contract." PLEASE READ ALL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING. INSTALLATION STREET ADDRESS CITY, STATE ZIP 7— NOTICE To CUSTOMER—PRICE CALCULATIONS:In order to properly perform the installation of certain Goods,the Contract Price may include more Goods than t actually will be installed based on the measured square footage of the Project Area.As a result,the parties agree that the lump-sum Price stated in h is Contract is calculated upon both the value of estimated Goods required to fulfill the Contract(including waste),which may exceed the actual square footage of the Project Area,and the labor which may be estimated based on the amount of Goods required to fulfill the Contract(including waste). By signing this Contract below,Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may not be refunded once the Installation Services are performed. Contract Total Are permits required for this installation?:[ 'r]Yes No licable tax included T.-pp NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right. By signing this Contract,Customer acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit. NOTE:If rotted wood is discovered during installation additional 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. r -�A�" Customer must initial. *Any work or material not specified is not included in this contract.Any changes or additions will be at an additional charge for the material and labor. PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photographs of the Premises where Installation Services will be performed and all work performed at the Premises related to this Contract,and irrevocably grants to Lowe's all right,title and interest in and to the photographs for use in all markets and media,worldwide,in perpetuity.Customer authorizes Lowe's to copyright,use and publish the photographs in print and/or electronically,and agrees that Lowe's may use such photographs for any lawful purpose,including,but not limited to,marketing advertising,publicity,illustration,training and Web content.By initialing here,Customer agrees to the foregoing: '—­ , [Customer to initial to the left]' ;;L Work is to commence upon reasonable availability of Contractor and/or any special order or customer made Good(s)which is anticipated to be [fill in date].Estimated completion date is -7,=",r [fill in date]. Said estimated substantial completion date is not of the essence.A statement of any contingencies that would materially change said estimated substantial completion date is as follows: (if applicable,insert a statement of such contingencies). IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full. COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00: [ ]Customer to Pay in Full; OR [ ]Customer to use the following payment schedule: (1)Deposit $ to be paid upon signing contract.Deposit should be 1/3 the total contract price;and (2)Payment of$ to be paid anytime after this Contract is signed and before commencement of installation,I/We authorize Lowe's to do one of the following(check appropriate box below): Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed;and (3)Final payment of$100.00 to be paid upon completion of the installation and both parties'satisfaction. NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L.c 142 LOWE'S AND OWNER HEREBY MUTUALLYAGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT LOWE'S MAY SUBMIT,9UCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT- IVE OFFICE OKCONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDECIN M G­ ­c'142A By: ­' ' Date: ; ate: —' Lo e's-Home Centers,LLr, ate: (­OWner'8i6nature THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWE's PURSUANT TO M.G.L.c.142A.THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE SECTION ABOVE IS NOT SEPARATELY SIGNED BY THE PARTIES. 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 SIQNAT $E. WITNESS OUR HAND(S)AND SEAL(S)BELOW THIS DAY OF Ill Hbirne'denters;LLC Lowe's-Authorized-Representative "Owner Co-owner or Witness Customer acknowledges receipt of a true copy of this contract which was completely filled in prior to Customer's execution hereof.You,the buyer,may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See the attached notice of cancellation form for an explanation of this right. 55102 REV. 12/13 FILE COPY 0 2004 by Lowe's.0 Lowe's and the gable design are registered trademarks of Up Corporation. 3 Top Unit Lite Pattern: 3W2H 1 Bottom Lite Pattern: 3W3H Hardware Finish:White Sash Lock: Standard Sash Lifts: No Screen: Half Screen Screen Color: White Screen Mesh:InView ttachment Method: Nail Fin Attachment Method Application: Factory Applied Actual Wall Depth:4 15/16-in Wall Depth Application: Factory Applied eries: 750 Series d Will This Product Be Installed By Lowe's(R)?:Installed By owe's(R) Is This A Remake'?: No Lead Time:45 tem Number: 286319 ***This price reflects a 15%Off Promotion on SOS Pella(R) Windows&Patio Doors-05/13/15 to 05/28/15*** 1 his quote is good 05/13/15 to 05/28/15. Project Total: $2,623.04 Salesperson: CHRIS CAMERLIN(S 1916CC2) Accepted by: Date: 06/02/2015 Print this Page This Millwork Quote is valid until 5/26/2015. This is an estimate only.This estimate does not include tax or delivery charges. Delivery of all materials contained in this estimate are subject to availability from the manufacturer or supplier. All the above quantities, dimensions,specifications and accessories have been verified and accepted. Attachment Method: Nail Fin Attachment Method Application:Factory Applied Actual Wall Depth: 4 15/16-in Wall Depth Application: Factory Applied Series: Support Will This Product Be Installed By Lowe's(R)?:Installed By owe's(R) Is This A Remake?:No Lead Time: 45 Item Number: 89144 ***This price reflects a 15%Off Promotion on SOS Pella(R) # Windows&Patio Doors-05/13/15 to 05/28/15*** his quote is good 05/13/15 to 05/28/15. 0002 Manufacturer:Pella Windows&Patio Doors with Window i, Size=32 3/4-in W x 66 1/2-in Fashions H Division: Millwork Product: Windows + ype: Double Hungs i u _ Manufacturer:Pella Windows&Patio Doors with Window ashions Material: Aluminum Clad Wood Frame:Aluminum Clad Wood Frame Energy Star(R)Qualified Products Only:Yes-I would like to view only the units that are qualified for Energy Star(R). Energy Star(R)Zone: Northern Product Family: Full Frame Pella Products with Window ashions Configuration: Single Unit i Room Location:Other 1 Opening Type: Exact Actual Exact Width: 32 3/4-in Actual Exact Height: 66 1/2-in its Opening Width: 33 1/2-in Fits Opening Height: 67 1/4-in Overall Unit Height:Not Applicable Exterior Color: White Exterior Paint Grade: Standard EnduraClad i Interior Finish:Prefinished White Sash Configuration: Cottage 40:60 sash split Glass Type: Triple Glazed(IG w/third pane) Actual Glass Thickness: 5/8-in IG Tempered Glass: No Glazing: Advanced Low E Glass Hinged Glazing Panel Glazing:Clear 4 High Altitude: No Gas Filled: Argon Shade Type: None Actual Grid Type: 3/4-in Removable Between Glass Grille Exterior Grid Color: White nterior Grid Color: Prefinished White rid Style: Traditional 9 rid Location: Top and Bottom Sash $964.80 2 $1,929.60 Back to Quote LOWE'S HOME CENTERS,LLC#1916 282 RUSSELL STREET . • HADLEY,MA 01035-0000 USA Date: 06/02/2015 (413)588-0270 Project#: 441027452 Description: Pella 750 windows Customer Name: ELLY LASH Customer Phone: (202)531-9045 Customer Address: 65 FAIRVIEW AVE N.HAMPTON,MA 01060 USA Line Item Product Code Unit Price Quantity Total Price Frame Size Description 0001 Manufacturer:Pella Windows&Patio Doors { Rectangle Division:Millwork Product: Windows Type: Fixed Frames/Special Shapes Manufacturer: Pella Windows&Patio Doors Material: Aluminum Clad Wood Frame: Aluminum Clad Wood Frame Energy Star(R) Qualified Products Only:Yes-I would like to view only the units that are qualified for Energy Star(R). nergy Star(R)Zone:Northern Product Style: Custom Product Configuration:Rectangle Room Location: Other 1 Opening Type: Exact Actual Frame Size Width: 52 3/4-in Actual Frame Size Height: 66 1/2-in Fits Opening Width: 53 1/2-in Fits Opening Height: 67 1/4-in Exterior Color: White Exterior Paint Grade: Standard EnduraClad Wood Type: Pine- Standard nterior Finish: Prefinished White Glazing: Advanced Low E Glass Tempered Glass:No High Altitude: No Gas Filled: Argon Actual Grid Type: 3/4-in Wood Removable Interior Grid Color:Prefinished White Exterior Grid Color:White Grid Style: Traditional q Lite Pattern: 6w5h 4 $693.44 1 $693.441 - ��ur, mw4k - a., '�� .u�:3r a«.^ffiaw3++���YKt ahxidyY�a' rc�a= s �. � asea�ea�rtna€�s�ras��aa��aeaam ,- _ ,�-- ,` - »�af.,�aw ae s�ew:5ss.;ar xa'��Pi va�a"dAe¢�arhaaw a - k E k m fi. I ® DATE(MWDD/YYYY) ACORN CERTIFICATE OF LIABILITY INSURANCE 03/31/2015 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 FAX 100 North Tryon Street,Suite 3600 No Ext: A/C No): Charlotte,NC 28202 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# 47095-CASUA-ONLY-15-16 INSURER A: National Union Fire Ins Co Pittsburgh PA 19445 INSURED New Hampshire Insurance Company 23841 Lowers Companies,Inc. INSURER B and Subsidiaries INSURER C: Steadfast Insurance Company 26387 1000 Lowe's Blvd. INSURER D: Mooresville,NC 28117 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-002938178-28 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY TYPE OF INSURANCE POLICY NUMBER MM DD/YYYV MM LTR /DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ Self Insured-See Below DAMAGE T RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE F1 OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ F_1POLICYF_1JPRO- ECT r7 LOC $ A AUTOMOBILE LIABILITY CA5260749 (AOS) 04/01/2015 04/01/2016 COMBINED SINGLE LIMIT 5,000,000 Ea accident B X ANY AUTO CA5260748 (MA) 04/01/2015 04/01/2016 BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED CA5260760 (VA) 04/01/2015 04/01/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY NON-OWNED ED per.ccident DAMAGE $ HIRED AUTOS AUTOS C X UMBRELLA LIAB X OCCUR IPR3792301-01 04/01/2014 04/01/2017 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I RETENTION$ $ B WORKERS COMPENSATION WC017731584 (AOS) 04/01/2015 04/01/2016 X I WC NC OTH- AND EMPLOYERS'LIABILITY T ,$Y_ I IT B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WC039901583 (WI) 04/01/2015 04/01/2016 2,000,000 E.L.EACH ACCIDENT $ _ B (Mandatory in ER EXCLUDED? N/A WC017731585 MN 04/01/2015 04/OT/2016 2,000,000 (Mandatory in NH) ( ) E.L.DISEASE-EA EMPLOYE $ B DESCRIPTION OF OPERATIONS below WC039901584 AK,AZ, NH, 04/01/2015 04/01/2016 2,000,000 ( V E.L.DISEASE-POLICY LIMIT $ A Excess WC XWC9883959 (ADS) 04/01/2015 04/01/2016 WC:Stat/EL:$3mil;xs$2mil SIR A Excess WC XWC9883960(FL) 04/01/2015 04/01/2016 WC:Stat/EL:$3mil;xs$2mil SIR DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insured is self insured for General Liability for the period of 4/01/2015 to 4/0112016. Evidence of coverage. Lowe's self insures for physical damage coverage to rented and leased vehides. CERTIFICATE HOLDER CANCELLATION Lowe's Companies,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE and subsidiaries THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 1000 ACCORDANCE WITH THE POLICY PROVISIONS. Mooresville,NC 28115 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Paula Stapleton Pn../.. Ip/��are►� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 7 4b t I AI* Wultrb tal e!� 7' a"t, A-� u OVITAIS w to r tri Ii, jt,1j has ibifilizd tibe based paint rtiCn, low 3n It r I' ;-1 (1 4 PR6W, All -PPA Adrnif.:sl redState:37T3jh,:q-L, ;44ti NAT-11 04022-1 txl*,�7- Certification Michelle Pr;c�, ,-, February 22, 2011 AM Lead, Heavy vv%,als, and I rE.- Issues On PR Q -f- �e�ornmo�ncrreal�i o�C%l�GataacficarP,Cfa ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration: 148688 Type: 10 Park Plaza-Suite 5170 Expiration: 10/18/2015 Supplement Gard Boston,MA 02116_ LOWE'S HOMES CENTERS INC JAMIE SPOFFORD 136 TURNPIKE RD.SUITE 100 SOUTHBOROUGH, MA 01772 Undersecretary of valid without signature a �o o• ' r- U Massachusetts-Department of'Public Safety f Board of Building Regulations and Standards Construction Supervixnr License: ES-049915 MARK S JOD 1 oix-A` 137 PORTER LAfi A y. A Lengmeadow MA?Q1106` 00 C) r` Commissioner 121219MIS N i M %O 00 M N U N , J N J J N V r 0 r C N JODOHOM-01 MPROULX A�OROF CERTIFICATE OF LIABILITY INSURANCE 7/30/2015 D/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HI ILDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY T 1E POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),A UTHORIZED 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 WAIVE�,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Insurance Center of New England,Inc PHONE FAX 1070 Suffield Street A/C No Ext:(800)243-8134 A/c No; (413 731-9539 Agawam,MA 01001 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Nautilus Insurance Co INSURED INSURER B:Commerce Insurance Company 34754 Jodoin Home Improvement INSURER C:Aim Mutual Ins Co-Assigned Risk c/o Mark S Jodoin 137 Porter Lake Drive INSURER D: Longmeadow,MA 01106-1246 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE P(-LICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT T(I 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 I TYPE OF INSURANCE POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,00 CLAIMS-MADE OCCUR X NN432991 06/26/2014 06/26/2015 PREMISES Ea occurrence $ 50,00 MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 500,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,00 POLICY❑ PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 500,00( OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident B ANY AUTO X RPJ989 03/26/2015 03/26/2016 BODILY INJURY(Per person) $ 100,00 ALL OWNED X AUTOS SCHEDULED AUTOS BODILY INJURY(Per accident) $ 300,0 X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ 100,0U $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE YIN N/A AWC40070296132014A 08/31/2014 08/31/2015 E.L.EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? - -- (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 100,00 u If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Vendor#16930 Lowe's Companies Inc.and any and all subsidiaries are named as additional insured as respects to General Liability and Auto Liability per Mas: Business Auto Forms CA0001 and MM9911 an applicable Mass.State Laws as per written contract only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEL.ED BEFORE Lowe's Companies Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: I S Insurance(Mezz) ACCORDANCE WITH THE POLICY PROVISIONS. Vendor Compliance/Risk Mgmt,Lowes Companies Inc. Post Office Box 1111 AUTHORIZED REPRESENTATIVE North Wilkesboro,NC 28656-0001 a, M, 0 ere- ©1988-2`014 ACORD CORPORATION. All right! reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: 'Z �� The debris will be transported by: 7)00<10� i The debris will be received by: 1I.�aw `� l fS ` �c�+•-� Building permit number: �- o t16L- Name of Permit Applicant _ Date Signature of Permit Applicant The Commonwealth of Massachusetts Pant Form Department of Industrial Accidents Office of Investigations ': 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/t)rganizutic,n/Individual): Address: 175:4- DOOK-M- L l': 'Q Levi i(rfA 64 14 �O City/State/Zip: �� Phone#: L41-s t Are you an employer? Check the appropriate box: Type of project red): 1. I am a employer with i_ 4. [] I am a general contractor and 1 employees(toll 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. ?. ❑ Remodeling ship and have no employees These sub-contractors have $, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 9. F-1 Building addition required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions 3.❑ 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 insurance required.] t c. 152, §1(4),and we have no employees. (No workers' 13X Other W�+'-)>-J'j comp.insurance required.) -r '� -�l'\ ")t�•c� "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside co�ntiactors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing die name of the sub-contractors and state whether tx not those entities have employees. If the sub-contractors have employees.they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance:Company Name: Policy#or Self-ins. Lie.#: 9_Lf QQ �{A — Expiration Date: f Job Site Address: City/State/Zip: ��� 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 S 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 that a copy of this statement tray be forwarded to the Office of Investigations of the D1A for insurance coverage verification. I do hereby certify de a pains gad penalties of per'ur that the information provided abov is true pnd correct. Si nature: ° /( Date Phone#: Official use only. Igo not write in this area,to be completed by city or town official. City or Town: Permit/License# issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: ,. -y 7 Not ApplicableG❑ Name of License Holder: NVL S �05_P,-� C�_u-A 1 x\`K License Nu ber Address r Expiration u to ignature Telephone 9.Reciisterreed, Home``Imo�rrovement Contractor: Not Applicable ❑j / Company Name Registrati n N ber aI 0_5 C, '�c1 15 Addre Expirati n Dat Telephone ql'S SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152, §25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... No...... ❑ 11. - Home Owner 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 indows Alteration(s) ❑ Roofing Or Doors MI Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[0] Other[pJ Brief D c ipp�io�n�)f Proposed Work: 0✓��2_ 060 1 ����/tt:iL ��� F, CJAI- - a+ZN I "iz 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 PERMIT as Owner of the subject property hereby authorize l 1 )( ��� �J/-'� �� to act on my behalf, in aTI matters relative to work authorized by this building per it app f ation. Signature of Owner Date I, 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 es oTp rjury. Print Name Sig ure of_D " r/Agent 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 pat-king) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW 0 YES Q IF YES date issued: IF YES Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW YES Q IF YES enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES Q IF YESt has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IFYESs describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q IFYE$ describe size, type and location: E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 WatedWell Availability Northampton, MA 01060 Two Sets of Structural Plans w hone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify TI ON TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTIOAV SITE INFORMATION 1.1 Property Address: (.5 T� b'�M G, This section to be completed by office KW-z-v/�v&P �j �. A ` Map Lot Unit �1 o (Z'C) Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: AAJL Name(Print) ,, Current Mailing Address: �� - U 10(DC) _ A � k ' ill r ` Telephone Signature �1 J 2.2 Authorized Agent: Nam int) Current Mailing Address: �na Telephone bt SECTION 3- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building ( �i (a) Building Permit Fee 2. Electrical I �j (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = 0 +2 +3+4+ 5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 65 FAIRVIEW AVE BP-2015-1192 GIS#: COMMONWEALTH OF MASSACHUSETTS MU:Block: 38B-229 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categoa: window replaced BUILDING PERMIT Permit# BP-2015-1192 Project# JS-2015-002258 Est.Cost: $9869.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Grogg. LOWE'S 049918 Lot Size(sq. ft.): 20952.36 Owner: LASH ELEANOR Zoning:URB(100)/ Applicant: LOWE'S AT. 65 FAI RVI EW AVE Applicant Address: Phone: Insurance: 282 RUSSELL ST (413) 588-0270 WC HADLEYMA01035 ISSUED ON.61212015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOW & STORM DOOR 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 6/2/2015 0:00:00 $35.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner