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29-395 (4) AGENCY CUSTOMER ID: 570000034159 LOC#: A�ORO® ADDITIONAL REMARKS SCHEDULE Page _ of _ AGENCY NAMEDINSURED Aon Risk services central, Inc. Sears Holdings Corporation POLICY NUMBER See Certificate Number: 570058793162 CARRIER NAIC CODE See Certificate Number: 570058793162 EFFECTIVE DATE ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER INSURER INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information,refer to the corresponding policy on the ACORD certificate form for policy limits. POLICY POLICY INSR .ADDL SUBR EFFECTIVE EXPIRATION 1'rR TYPE OF INSURANCE INSD WVD POLICY NUMBER DATE DATE LIMITS MM/DD/YYYY MM/DD/YYYY WORKERS COMPENSATION B N/A SCFc48589674 08/01/2015 08/01/2016 WI ACORD 101(2008101) ©2008 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD DATE(MM/DD/YYYY) A�coRO CERTIFICATE OF LIABILITY INSURANCE 07/252015 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 d NAME: AOn Risk services Central, Inc. PHONE Chicago IL office (A/C.No.Ext): (866) 283-7122 ac.No.: (800) 363-0105 v 200 East Randolph E-MAIL p Chicago IL 60601 USA ADDRESS: _ INSURERS)AFFORDING COVERAGE NAIC b INSURED INSURER A: ACE American Insurance Company 22667 Sears Holdinqs Corporation INSURER B: ACE Fire Underwriters Insurance Co. 20702 dba Sears Home Improvement Products, Inc INSURER C: Attn: Risk Management E3-219A 3333 Beverly Road INSURER D: Hoffman Estates IL 60179 USA INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:570058793162 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. Limits shown are as requested SUBRI LT R TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDM/YY MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY HDOG 0 Ol 1 EACH OCCURRENCE $5,000,000 CLAIMS-MADE — OCCUR DAMAGE O RENTED $5,000,000 PREMISES Ea occurrence MED EXP(Any one person) Excluded PERSONAL B ADV INJURY $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $5'000'000 M X POLICY ❑PE COT- ❑LOC PRODUCTS-COMP/OP AGG $5,000,000 u OTHER o A AUTOMOBILE LIABILITY ISAH08859000 08/01/2015 08/01/2016 COMBINED SINGLE LIMIT Ea accident) $5,000,000 A ISAH08859012 08/01/2015 08/01/2016 — •• A ANY AUTO ISAH08859024 08/01/2015 08/01/2016 BODILY INJURY(Per person) O ALL OWNED SCHEDULED Z X AUTOS AUTOS BODILY INJURY(Per accident) N NON-OWNED PROPERTY DAMAGE U X HIRED AUTOS X AUTOS Per accident t d UMBRELLA LIAR HOCCUR EACH OCCURRENCE U EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION • WORKERS A COMPEEL Y YIN OH COMPENSATION AND Uc418589662 08/01/2015 08/01/2016 X STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $2,000,000 • OFFICER/MEMBER EXCLUDED? N N/A WLRC48589650 08/01/2015 08/01/2016 (Mandatory in NH) All other States E.L.DISEASE-EA EMPLOYEE $2,000,000 If yes,describe under — DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $2,000,000— M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ~ EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Sears Home Improvement Products, Inc. AUTHORIZED REPRESENTATIVE -� 1024 Florida Central Parkway Longwood FL 32750 USA ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 11")J?d{ l: Office of C:onsumei ,A f 1�t rs and I3rtsu�I 5s R��f tlicrt t� I36ston., Massachusetts 02 l 16 1lolne I:mprovernent Contractor Ref,istratiorr RCIIStr<atiota: 148607 _I,Vpe. Public Corporation Expiration: 10/1112017 Tr# 270727 SE'ARS FiOME IMf' ROVEMEFNT PRODIJ T ALERFD NYMAN - - 1024 FLORIDA CENTRAL PKWY i LONGWOOD, FL 32750 Update Address and return card.Murk reason For change, °ac address Kenewai v nipioyme7i# Lost{`str<I rte, f4fice ofConsumer A1(sirs lSustness Ret.utat:on t..acensc or reoistration valid for individul use only i (,'ftC3ME IMPROVEMENT CO'NTRAC1OR before the expiration date. tf found return to: t a "� ° ecdistration '%4800-f Type 0ffir-e of Consumer=Affairs and KneinrsN Rogulzation Expiration. ja 11112017 Public Cotporatlon LO Park Plaza Suite 51-0 Hos€on,MA 02110 St.tiRS N(;MF IMt"'RCIVE�Mkii1 C OFZ0, UC S INC. J' £ I C ' )A CE:N1PAI PKVVf. • _�� thratrrsFCretr2ri tint .alad+4iitto si}narure CS-097519 LUBOS SVF.0 827 THOMPSON ROAD r z•�. "Thompson CT 06277 J "I r° �...E ..�>.��• u 08/31/2016 Job Number: 19832362 NOTICE TO BUYER 1. DO NOT SIGN THE AGREEMENT IF ANY OF THE SPACES INTENDED FOR THE AGREED TERMS TO THE EXTENT OF THE AVAILABLE INFORMATION ARE LEFT BLANK. 2. YOU ARE ENTITLED TO A COPY OF THIS AGREEMENT AT THE TIME YOU SIGN IT.KEEP IT TO PROTECT YOUR LEGAL RIGHTS. 3. YOU MAY PAY OFF THE FULL UNPAID BALANCE DUE UNDER THE AGREEMENT AT ANY TIME,AND IN SO DOING YOU SHALL BE ENTITLED TO A FULL REBATE OF THE UNEARNED FINANCE AND INSURANCE CHARGES. 4. YOU MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY[FIFTH BUSINESS DAY IN ALASKA, FIFTEENTH BUSINESS DAY IN NORTH DAKOTA IF YOU ARE AGE 65 OR OLDER]AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. FAILURE TO EXERCISE THIS OPTION, HOWEVER, WILL NOT INTERFERE WITH ANY OTHER REMEDIES AGAINST THE RETAIL SELLER YOU MAY POSSESS. IF YOU WISH, YOU MAY USE THIS PAGE AS NOTIFICATION BY WRITING"I HEREBY RESCIND"AND ADDING YOUR NAME AND ADDRESS.A DUPLICATE OF THIS RECEIPT IS PROVIDED BY THE SELLER FOR YOUR RECORDS. 5. IT SHALL NOT BE LEGAL FOR THE SELLER TO ENTER YOUR PREMISES UNLAWFULLY OR COMMIT ANY BREACH OF THE PEACE TO REPOSSESS GOODS PURCHASED UNDER THIS AGREEMENT. NOTICE TO MASSACHUSETTS RESIDENTS ONLY In addition to the Notice to Buyer shown above, Massachusetts law requires that contracts for home improvement work state that all home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration P.O.Box 871 Taunton,MA 02780-0871 Telephone:(508)821-9375 Please note that owners who secure their own construction-related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund. Notwithstanding any other language in the contract or associated documents, Sears will not remove, replace, or install any heating or air conditioning system, or any portion thereof, if asbestos or asbestos-containing material is known or likely to be present in that heating or air conditioning system, or any portion thereof. If it is determined or reasonably suspected that asbestos is present, either before commencement or during performance of the work, it shall be the customer's responsibility to select, retain and pay all costs of a Division of Occupational Safety ("DOS") licensed Asbestos Contractor to remove all asbestos or verify that none is present in the components involved in the job. If the determination or reasonable suspicion of the presence of asbestos arises after Sears has started the work, Sears will immediately cease performing the work until a DOS licensed Asbestos Contractor, hired by the customer, removes all asbestos from the components scheduled for repair or replacement in accordance with 310 C.M.R. 7.00 and 453 C.M.R. 6.00 or verifies that none is present. By signing the contract the customer agrees that it understands the above. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES 01/27/2016 01/27/2016 Customer's signature Date Customer's signature �Qj� Date Accepted by Sears Home Improvement Products, Inc.("Sears")on 01/27/2016 by '44 Date Management Representative SS]. MA (Dig.) Rev 08/01/12 Page 3 of 3 Job Number: 19832362 APPROXIMATE START DATE and APPROXIMATE COMPLETION DATE: The work will start approximately 1-2 WEEKS (Approximate Start Date) It will be substantially completed by approximately 3-4 WEEKS (Approximate Completion Date) These dates are subject to change at the time the contract is accepted by Sears Home Improvement Products, Inc. ("Sears")or at any other time by mutual written agreement. Customer understands that the Approximate Start Date is only an estimated date and the Customer will be contacted prior to this date to schedule the actual start date. ASBESTOS ABATEMENT: This Estimate and Proposal assumes that there are no asbestos containing materials ("ACMs") that would be disturbed in the performance of the installation work. If upon further inspection by the contractor or others it is learned that ACMs have to be disturbed to perform work, then Customer must arrange and pay for abatement of asbestos by a qualified person prior to the start or continuation of work. If Customer fails to arrange for necessary asbestos abatement within thirty (30) days, Sears may cancel this contract upon Customer(s)initials written notice to Customer. I cikix-' IF The TOTAL PRICE including all labor,material,taxes and any applicable discount is$ 13,563.70 Contract Price $13,S63.70 Initial Payment(not to exceed 30%of Total Price unless Special Order)$ 4,069.11 State Sales Tax( 0.00 %) $ 0.00 Final Payment(balance payable upon completion of job)$ 9,494.59 Local Sales Tax( 0.00 %) $ 0.00 Total Amount Due $13,563.70 The form and method by which the Customer(s)will pay is described in a separate Cash/Credit Customer(s)initials Card Payment Addendum made a part of and incorporated into this contract by reference. NOTICE TO BUYER: YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY (FIFTH BUSINESS DAY IN ALASKA, FIFTEENTH BUSINESS DAY IN NORTH DAKOTA IF YOU ARE AGE 65 OR OLDER)AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. ADDITIONAL PROVISIONS Proposal and Approval.Sears offers to furnish the materials and arrange for their delivery and installation as specified on the first page and/or the attached sketches and specification sheets for the TOTAL PRICE shown.This offer must be approved by the Installation Department. If this is a credit sale or a payment on completion sale,it must be approved by the Credit Sales Department. If this proposal is not approved or the installation cannot be made in accordance with the law,this offer will be withdrawn and any payments you have made will be refunded to you.Any materials left over after the installation has been completed are Sears property and will be removed by Sears. Installation. I understand that Sears will not install the materials but will arrange for the installation. Sears is not responsible for materials or installation NOT furnished or arranged by Sears. Sears'installation contractor(s)will obtain all building permits required by local law. For homes located in historic or landmark zoning districts,Customer will be responsible for obtaining required approvals and related permits prior to the commencement of work on this contract. Authorization. I authorize Sears to: (1)arrange for a contractor(licensed where required by law)to make the installation of materials; (2)issue a work order for this installation to a contractor; (3)inspect the installation; and (4)pay the contractor when the installation is complete if I have signed a certificate that the installation has been completed to my satisfaction. Delays in Installation.I agree that Sears is not responsible for delays in delivery or installation due to weather,fire,strikes,war,government regulations or any causes beyond Sears'control. Oral Agreements and Changes in Contract.I understand that there are no oral agreements between Sears and me.Everything I expect Sears to do has been included in writing in this contract. Nothing can be changed in this contract unless it is in writing on a separate form accepted by me and Sears. Responsibility of Buyer. I agree that any information or measurements that I give to Sears are correct and complete. I am responsible for any special work described in this contract. Electrical& Plumbing Service. I will provide adequate electrical and/or plumbing service(s)to run any newly installed appliances or other furnishings. If the electrical and/or plumbing service(s)do not meet the standards of the utility company or electrical and/or plumbing codes, I will make the necessary changes at my expense unless Sears has agreed in this contract to make the changes. Payment.I will pay Sears the cash price that covers the price of material and installation as shown on the first page. Warranty Information.Appropriate product warranty documents will be given to me by Sears.Sears'Warranty on Installation is: SEARS'LIMITED WARRANTY ON INSTALLATION In addition to any manufacturer warranty extended to you on the product(s) used (which warranty becomes effective the date the merchandise is installed), if the workmanship (or application) of any Sears' arranged installation proves faulty within (i) one year for Weatherbeater or other brand, (ii) two years for Weatherbeater Plus,or(iii)three years for Weatherbeater Max,then upon notice from you Sears will cause such faults to be corrected by repair at no additional cost to you. If Sears determines that repair is not commercially practicable or cannot be timely made,then,at Sears'sole discretion,Sears may elect to provide replacement or refund.Service under this Limited Warranty is available by calling Sears Home Improvement Products at 1.800-222-5030,Option 4.This warranty gives you specific legal rights,and you may also have other rights that vary from State to State. SS1 MA (Dig.) Rev 08/01/12 Page 2 of 3 IIIII I II II III III Office Location: HARTFORD Proposal Date 01/27/2016 Job Number 19832362 Sears Home Improvement Products,Inc. Customer Name ( arrsP.O. Box 522290 MILTON ROSS 1024 Florida Central Parkway Customer's Home Phone Customer's Work Phone Longwood, FL 32750-7579 (413) 559-8444 Home Improvement Products Phone(800)469-4663 Street Address ESTIMATE AND PROPOSAL Contractor License/Registration Number 116 SANDY HILL RD MA(148607) City State J/Jp Code Siding All plumbing and electrical services performed by NORTHAMPTON MA 01062 Is installation within city limits? licensed subcontractors Installation Address County HAMPSHIRE (Yes/No): YES FEIN 25-1698591 E3illing Address(if different from above) City State lip Code ['reject Consultant Name&License No.(if applicable) MATTHEW GELINAS Description of the Project and Description of the Significant Materials to be Used and Equipment to be installed The work to be done under this contract includes the following(where checked): Specifications(Z =Included ❑=Not Included) Preparation: 1. Z Obtain all necessary permits and insurance. 2. ❑ Inspect surfaces in work area,re-nail loose wood,and replace rotten surface wood where necessary in work area(excluding roof,decking,rafters,and structural members). 3. 0 Remove existing siding. Type: VYNLE AND SHAKES UNDERNEATH 4. ❑ Fir out walls on brick, block,metal,or stucco areas. Location: 5. © Caulk and seal around all windows and doors in the work area as necessary. 6. ZI Install approved non-corrosive starter strip. Insulation: 7. 21 Install insulation of flatwall areas that are to be sided with (3/4"or 1/4"): 3/4" extruded polystyrene insulation. Custom Trim: 8. ❑ Install custom Vyna-Klad aluminum fascia system. Color: 9. ® Remove existing guttering.After removal,existing guttering will be: (re-attached 1 disposed of): DISPOSED OF 10. 2 Install new guttering and downspouts. 11. ❑ Cover soffit areas of home with vinyl soffit system(except where noted below in"Work NOT to be done")using: (WB Max/WB Plus/Weatherbeater/Value Line/Other): Color: Pattern: 12. El Install custom Vyna-Klad aluminum frieze boards. Size: Location: Color: 13. © Window trim: (jump/butt): BUTT Location: ALL COIOr: GLACIER WHITE 14. ❑ Custom wrap windows,sills,mulls,headers with Vyna-Klad aluminum. Color: GLACIER WHITE 15. ® Remove and re-install existing: (storm windows/awnings/shutters): SHUTTERS 16. ❑ Install new shutters: (Panel/Louver): Color: 17. Z! Custom wrap door facings with Vyna-Klad aluminum. Color: GLACIER WHITE 18. ❑ Custom wrap garage door facings with Vyna-Klad aluminum (single/double): Color: 19. ❑ Remove and re-install storm doors. 20. ❑ Install deluxe corner posts. Color: Siding: 21. FZ Install: (WB Max/WB Plus/Weatherbeater/Value Line/Other): WB PLUS Solid vinyl siding. TYPE:(Horizontal/Vertical): HORIZONTAL _ Color: COASTAL SAGE Porch Systems: 22. ❑ Porch ceilings: Location: Color: _ 23. ❑ Porch posts: Color: 24. ❑ Porch beams: Color: Clean up: 25. 0 Clean up and removal cf all job-related debris. 26. Z Remove excess materials and re-stock(each job is over-shipped to avoid delays). Additional work to be done: Work NOT to be done: No drip edge covered;no paint applied. DO NOT TOUCH THE HOZIONTAL WHITE SIDING IN THE GABLES OR THE FACIA , CUSTOMER KEEPING THAT SPECIAL INSTRUCTIONS: All of the above check boxes, "Work NOT to be done," "Additional work to be done," and Customer(s)initials "Special Instructions"sections have been reviewed and explained to me. SSl MA (Dig.) Rev 08/01/12 Page 1 of 3 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: 6 / The debris will be transported by: 3 S hive ; � venues The debris will be received by: es 07-40 Building permit number: Name of Permit Applicant S ec� rs klowie car )129401lig Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.govldia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/lndividual):Sears Home Improvement Products Incorporated Address: 1024 Florida Central Parkway City/State/Zip: Longwood, FL 32750 Phone #: 860-753-0452 Are you an employer?Check the appropriate box: Type of project(required): 1.[]I ant a employer with employees(full and/or part-tune)* 7. New construction 2.E]I ant a sole proprietor or partnership and have no employees working forme in 8. Remodeling any capacity.[No workers'comp insurance required] 9. El Demolition 3.]1 am a homeowner doing all work myself.[No workers'comp.insurance required-I' 10 ❑ Building addition 4.C]1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I.E] Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurances IF 14 ✓ Other 6 E✓ We are a corporation and its officers have exercised their right ofexemption per MGt,c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 1/16-1 z 2– S *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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. am an emplover that is providing workers'compensation insurance for my employees. Below is the policv and job site information. Insurance Company Name: Ace American Insurance Company / Phone : 866-283-7122 Policy 4 or Self-ins.Lic. #: WLRC48589650 Expiration Date:__08/01/2016 Job Site Address: City/State/Li P A Attach a copy of the workers' compensate n policy declaration page(showing the policy number and Mtn? 0106?, Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif un r the pains d penalties of perjury that the information provi ed above is true and correct. Si)nature: Date: 860-753-0452 Phone#: Official use only. Do 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#:__ IRESET FORM ` SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Suvervisor: Not Applicable 0 Name of License Hold., 4U6C�S SVICC- so A Add . ear5 ate Telephone 9, Registered Home Improvement Contractor: Not Applicable El - Sect _11 CornpanV Name Registration Number 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. ` 11. - Home Owner Exemdon The Current exemption for^honeownmn''was extended minclude one(I) or xvo(2) fani|icx and to allow such homeowner to crigage an individual for hire who does not possess a license,Vrovided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s)who own a parcel ofland on which he/she resides i'rt_,�ndt,reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structur ccessory to such Use and/or farin structures. A person who constructs more than one home in a two-year od shall not be considered a homeowner. Such"homeowner"shail submit to the Building Official,on a form a, table to the Building Official,that he/she shall be responsible for all such work performe un(JertbKbuildin rmit. As acting Construction Superviso your p, 1,on th ' site will be required from time to tirne,during and upon is completion of the work for which this Pen ",I Also be advised that with reference to Chapte (Workers' Compensation) and Chapter 153 (Liability of Employers to ction ef ry or th BeIrlod shall not Ernployces for injuries not resul ing in Q i)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perfonn work for YOU U r this permit. The undersigned"homeowner" rtifies and assU111CS responsibility for compliance with the State Building Code,City of Northampton Ordinances, e and Local Zoning Laws and State ofMassachusetts General Laws Annotated. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors r--1 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E:J Siding[X Other[01 _ --------- ---------------_-_- -------- ------ -----.__._-._.- Brief D iption f Pr s�.�� i " 2 m;� Work: h 5 Q V 1/ 1 V)q O V1 Ol S, �� e 1/ W 1 Alteration of existing bedroom Y No Adding new bedroom_-___ Yes _ No Attached Narrative Renovating unfinished basemen 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_____ b. Number of rooms in each family unit:__ _ or 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__. umber of each ! ' g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction_r i. Is construction within 100 ft.of wetlands? Yes No. Is construction wit 0-gr--fl6Udplain 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 _ Citv Se e ity water Supply SECTION 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT --_- 1?! I Q�___ S- ._ . -_-- ---_.___ as Owner of the subject property �� ,.� �,dT hereby authorizes ��I S L W _-��V Sr to act on my behalf, in all matt rs rel ive to w rk authorized this building permit application. Signature of Owner Date as Owner uthorize_` en ere y declare that the statements and information on the foregoing application re true and accurate,to the best of;L n w e and belief. Signed he pains and enalties of perjury. 4'ao-5 -- ue'-c- - -Sc-Cw5– - Print me AA -- - --- --- �f Z 9 - 1 ----- ----- --- Signature of Own gen 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 tilled i y Building Dcpartmci Lot Size Frontage Setbacks Front Side L_ R: L: Rear Building Height Z 01 Bldg. Square Footage 01/o Open Space Footage % (Lot area minus bldg&paved parking) #of Parkin(,,Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW � YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW YES 0 IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO � DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained t Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES NO 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 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only C ty of Northampton Status of Permit: .IAN 3 Q 20(6 B ilding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability CEPT Room 100 Water/Well Availability OF DUIL^ut'.,r,INSP_ NORTh'h,n,•F��v NsP osooNs N hampton, MA 01060 Two Sets of Structural Plans p 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 11100 Q 1 s �,aY iA ` 1 ROD a Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _M----1 ffi—Oy-) Ross Name(Print)(Print) Curr nt Mailing Address: -t- 5�-- ' $444-- ---------- A�- /���0 (� Telephone �k���+..�—sue l��-L-�-'-'�='y-� ----- -- ----- Signature O 2.2 Authorized Agent: dZ� oyk7pson Hbocl 777h_o n -R_'Q�►__�-- __ _c__T_i%z7 Nam rint Current Mai ling'Address: 3 gnature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only complete by ermit applicant 1. Building eft 1 �1 n �— (a)Building Permit Fee 2. Electrical 1�7 `v (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total = (1 +2+ 3 +4+5) ZU 12 gG ''-- Check Number .' This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 116 SANDY HILL RD BP-2016-0955 GIS #: COMMONWEALTH OF MASSACHUSETTS MU-Block: 29-395 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: vinyl BUILDING PERMIT Permit 9 BP-2016-0955 Project# JS-2016-001621 Est. Cost: $13563.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEARS HOME IMPROVEMENT PRODUCT 097519 Lot Size(sq. ft.): 12196.80 Owner: ROSS MILTON R zoning: Applicant: SEARS HOME IMPROVEMENT PRODUCT AT. 116 SANDY HILL RD Applicant Address: Phone: Insurance: 51 BELAMOSE AVE (860) 620-9036 WC ROCKY HILLCT06067 ISSUED ON.•112 912 01 6 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL VINYL SIDING 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 1/29/2016 0:00:00 $60.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner