18-002 (23) 84 PINES EDGE DR BP-2017-0338
cis#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18-002 CITY OF NORTHAMPTON
Lot:-090 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Door Replacement BUILDING PERMIT
Permit# BP-2017-0338
Project# JS-2017-000552
Est.Cost: $2157.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(se.&.): Owner: ANDREWS ADRIANNE R
Toning: Applicant: HOME DEPOT AT HOME SERVICES
AT: 84 PINES EDGE DR
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCERI02908 ISSUED ON:911312016 0:00:00
TO PERFORM THE FOLLOWING WORKGINSTALL 1 PATIO DOOR FOR REPLACEMENT,
NO STRUCTUAL CHANGES
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 MAYBE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeTvpe: Date Paid: Amount:
Building 9/13/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
Rif C�� City of Northampton Status of Permit
VL Building Department Curb Cut/Driveway Permit
CCs p 1 i L 2�t��i 212 Main Street Sewer/Septic Availability
as Room 100 Water/Wen Availability
orthampton, MA 01060 Two Sets of Structural Plans
Pro or BUILDINelr4 lain 41c-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
r APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
I SECTION 1 -SITE INFORMATION
iii t.t Property Address: ���^^^ pg.. , This section to be completed by office
42/
fig* F))/J Map Lot Unit
K/ j' Z. Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
A .4'
' .2 , , .l �6;h �
%i✓c
g/2- AlIj '
r
Nome(Print)
6r�' t ysy /a
t `L C- tiTr iephone
Signature
..2Auth ,•enl. �
S'
Name P t /I/f/ , :, - 0-, /1: /...7)il fa, — _ i
i } Current Matng Address: , / ,r,�'11T
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
I, Building '}h7 ,Z7 (a)Building Permit Fee
2. Etectricai ' / (J (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection ' /2YJ
S. Total=(1 + 2+3+q+5) 9I 6x77 '720 Check Number / gra 4/cin
y This Section For Official Use Only
Building Permit Number: Date
Issued-
''
Signature:
Binding Gomrmssionerfinspector or Buildings Date
Section 4. ZONING Alt Information Must Be Completed,Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
lhB c,l mn to Se idled in h}
e mltlin5 Oepanment
Lot Size
Frontage
Setbacks Front
Side C: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
Dc
Hot area minus M1ldgWg V paved
catkins)
4 of Parking Spaces
Fill:
(equine&Location) ..........
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW 0 YES O
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 DONT KNOW O YES 0
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 a 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, xcavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION Si DESCRIPTION OF PROPOSED WORK(Check all applicable)
New House ❑ Addition ❑ Replacemedows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [CI Decks (q Siding[Cl Other(p)
Wet
Wo kOescnplf✓ Y174- 1;e ,1 B/3970 %6"nL it:1 - /2(/ l C- rl l,.J V,) ,'":174--
f/✓ d7/Zc..-
Alteration of existing bedroom Yes No Adding new bedroom Yes No / �
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roti -Sheet
Ga.If New house and or addition to existing housing, complete the following:
a. Use of budding;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 Ta•OWNER AUTHORIZATION•TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES
FOR
BBUILDING PERMIT
✓ " fLIy " ( ' 2i.
.as-Owner of the subject
property � /y♦ _
hereby authorize ,1,A�,,,d / J
to act on my behalf, all matters relative to work authorized by this building permit application.
/e-7%_ ia % � .61-772
�1 l
Signature of OwnerDate
e� ((
(. .4 1-' r - ,,,, ,as OwnerJAuthorized
Agent hereb declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed u e the ins and enalties rtury '�
li
Pint Na e
, �-� r"ad .
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction,Suuypp�e/rv�isorr ,., ) {/)�}yy��//.,/� Not Applicable 0 / J
Name of License Holder: 4ls)r'1/t/ er r(J kr 'Li �-&~967/ 2
G4�� lo7 / r/ / License Number
Address ��4114‘,3-/f/ i int 0//t/s6'17'7
�� Expiration Mate
Signature Telephone
Q.Registered Home Impre Co tractor Not A is ❑
-i---'lkir
w`r''Yl tQ�LFr: �s^" -
Iom an mr Registration Number
AAdddresiifi M // �''" E .iration Dale
^". LY� 1��iv ,_...2 / Telephone P _h,d ? . .-
SECTION 10-WORKERS COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c, 152,§25C(6l
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
M the denial of the issuance of the building permit.
Signed Affidavit Allactivi'Yds. ❑ No 0
I I. — Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(11 or two(21 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 ISO, Sisth Edition Section IOS.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 font acceptable to the Building Official that beishe shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will he 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
Empioyees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,von 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
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 cc 111 , S 150A.
<37Address of the work: � 17/1/12:," t P72- •
The debris will be transported by: I I,2 /Y `7Lr�
The debris will be received by: /4/2al<>2
Building permit number:
Name of Permit Applicant i ✓�I 2L> //2'74—
q— . IL, r L�✓ 7/4
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
t Department of Industrial Accidents
r-31W10=' Office of Investigations
5rig 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/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer? Check the appropriate box: 'Type of project(required):
1.0 am a employer with 4. ❑ lam a general contractor and I
employees(full and'or part-time).* have hired the sub-contractors 6, ❑New construction
2.❑ I am a sok proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8, ❑ Demolition
working for ine in any capacity. employees and have workers' t
[No workers' comp. insurance comp. insurance.* 7. ❑Building addition
required.] 5. ❑ We arc a corporation and its 100 Electrical repairs or additions
_l.❑ tam a homeowner doing all work officers have exercised their I l.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.)' C. 152.§1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Airy applicant that checks box al must also fill out the section below showing their workers'compensation policy information,
t Homeowner wbo submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indication such.
1Contraetors that check this box must attachedan additional shah showing the name of thesub-contrnaats and state whether or not those entities have
employees. If the nub-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:
Policy or Self-ins. Lic. #: Expiration Date:
Job Site Address: City'Statc/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 e. 152 can lead to the imposition of criminal penalties of a
tine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: _ Date:
Phone#:
Official use only. Do not write in this area,to be completed by do'or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"._every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual, partnership,association. corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of deceased employer. or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGC chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work-until acceptable evidun.e of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
industrial Accidents. Should you have any questions regarding the law or if you arc required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line_
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Rob Site Address"the applicant should write ''all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must he filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves chid said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel, # 617-7274900 ext 7406 or 1-877-MASSAFE
Revised 7-2013 Fax#617-727-7749
www_mass.gov/dia
City of Northampton
t« -�
if\4
artt t Massachusetts
4T OF BUILDING INSPECTIONS
A
+rr uz Main Street • Municipal 0v31d3ng
th
Norampton, MA 01010 60 1y„ t_res
tRSPECTJR
Louis Hasbrouck Chuck Miller
Buffing Commissioner Assistant Commissioner
UQjdE OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor.The state defines "Homeowner as, " Person(s) who owns a parcel on which
he/she resides or intends to be, a one or two family dwelling, attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in a two-
year period shall not be considered a home owner?
The building department for the City of Northampton wants any person(s) who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages,which include
foundation/footings (before backfill), sonotube holes Ibeforr.pour). a rough building inspection
!before work is concealed), Insulation inspection (if mature...) and a final building inspection.
The building department requires these inspections before the work is concealed,failure to secures
these inspections can result in failure to obtain a certificate of occupancy until the Work can be
inspected.
If the homeowner hires other trades to perform work(electrical, plumbing & gas)the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections- Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
Home Depot Contractor License Numbers:
MA Home Improvement Contractor Req. # 126894
Salesperson Name and Registration Number:
Timothy Drost: HIS 0553710, R-R-073-15-00005
Home Improvement Agreement
The Home Depot ("Home Depot") or Service Provider named below will furnish, install and/or service the
equipment listed below at the price, terms and conditions as outlined on this form.
customer information:
Adrianne Andrews 19537468
First Name Last Name Branch Name Lead#
184 Pines Edge Drive 1 ',NORTHAMPTON [MIA ... 01060 I
Customer Address City State Zip
(413)586-1643 rf--
Home Phone# Work Phone# Cell Phone#
arandrews90r@ilgmail.com
Customer E-mail Address - - -
NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR
OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT:
BOB Boston Turnpike Unit1 Shrewsbury MA 01545
or Email CustomerCancellationNorthEast{ahomedeoot.com
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME
DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME
CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU.
OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT
HOME DEPOTS EXPENSE.
THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL.
Acknowledged by:
X 08/31/2016
Contract Price and Payment Schedule: Payment of the Contract Price is due upon completion unless
a different payment schedule is specified in the State Supplement.
Includes all applicable discounts, rebates, and , taxes.
Contract Price $ 2157.00 Excludes finance charges?
Minimum e!deposit$ Due Immediately
Remaining balance $ Due upon completion C /'7,)
1
Finance Charges
*Any interest payments or other finance charges will be determined by Customer's separate cardholder
or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's
payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or
loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service
Provider may collect Customer's payment(s) made payable to The Home Depot.
insurance proceeds will _will not . be used to pay some or all of the total amount of sale.
Description of Work to be Performed:
Installation of Windows
A more detailed description of the work to be performed is included in the section entitled Scope of Work
which appears on page a of this Agreement.
Anticipated Delivery Date I Installation Schedule
Approximate Start Date: 10/26/2016 Approximate Finish Date: /1/2312016
All dates are approximate and subject to change based on unforeseen events including inclement
weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if
applicable.
Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you
consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and
written communications related to this agreement. By contacting your Service Provider, you may update
your email address, withdraw your consent, or obtain a paper copy of the Agreement or related documents
at no charge. By providing your consent and verifying your email address above, you confirm that you
have access to a computer that can receive and open emails and PDF documents.
By initialing this paragraph, I consent to receive only electronic records related to this transaction.
- -__
I Initial
Acceptance and Authorization:, By signing below, you authorize Home Depot to (a) arrange for Service
Provider to perform Installation and/or(b)order and arrange for the delivery of special order merchandise,
including special order merchandise that may be custom made, as specified in this Agreement. Do not sign
if blank or incomplete. (Service Providerts/permitting information may need to be provided to You later.)
By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety,
including the General Terms and Conditions and State Supplement, if any. You further acknowledge
receiving a complete copy of this Agreement. Keep it to protect your legal rights.
X E 108/31/2016
Cuttmat''s Signature. L Date
x
co—. aagucawa) Date �t
X 08/31/2016
Sales Coneulta.*,Si9Muta OW
License number(s) held by or on behalf of the Home Depot:
POA Home Improvement Contractor Req.# 126894
License numbers are subject to change in accordance with local or state government processes.
For the most current listing of license numbers held by or on behalf of the Home Depot, please visit
www.homedepot.com/licensenumbers.
2
Scope of Work
Job#: °n.n+teaerence) Products: Spec Shee s ft: Project Amount
9537468 $ Roofing 9 Siding i• Windows Insulation ""
gi Gutters/Covers 0 Entry Doors 9537468 $2157.00
Roofing 0-Siding 0—Windows Insulation
Gutters/Covers ❑ Entry Doors $
ng ❑ Siding .
� RaofiU Windows Insulation $
I Gutters/Covers En Doors L
• Roofing 9 Skiing ❑ Windows Insulation
• Gutters/Covers ❑ Entry Doors 0 $
SubTotal $2157.00
Sales Tax --
$0.00
Total Contract $2157.00
Amount
Warranty_
The warranty on the work identified above is listed in the General Terms and Conditions,or if applicable, specified in
the following documents:
VantagePointe 6500-6100-6060 Warranty,VantagePointe 6500-6100-6060 Warranty,VantagePointe 6500-6100-6060
Warranty,VantagePointe 6500-6100-6060 Warranty
Warranty Name(s)
3
WINDOW SPECIFICATION SHEET Spec.Sheet 4: 9537469 Sheet: t of 1 ci
Customer', Adrienne Andrews Joh p', 9537468 Consultant Timothy Drost Date: DB/31/2016
New Window
Hinge Lonatione
Existing Window routside.measurements Grids Product Options OplioaEor OptionsFrom ore osipe,
I
Len to Rigbl
• Bays,Bowls
Location Color Rough Opening a of bars p mbar, Camnls,1 Pnl,
use L,R or
•
Glass Use Items
natware Code
Screens For doors use
TS Mull "GA Flannery or
ir
Style Wraps g 5 _ — _ y B_ _ — _ .K,y opereMg
Room Floor Code COON) Style Cow Series Code _ y Lin 3 x n r m O ¢ yi > x I
Ft„ letPo Pbos erbo WI- win eau Ts sa nsI STO,TWA up F
SPECIAL CONSIDERATIONS'.
Wrap Color MISC1:Lots al rot
interior Casing Type 1 Gabriel
Bay or Bow window:
SeatbmN„atonal(vinyl onlybprh or Oak) —
Bay Project Angle(3DorJS)
Bay Flanker Typo(DH,SH or Comnt)
Toy of window to sofa(inches)
If tied la soak,color of soft material I neve reviewed and agree with all lob specifications above ono the
Construct Pool No or NO)' Special Terms and Conditions on the following page
•
Garden Window.
-
Sealboerd Material(vinyl only-While Ranim,Bich or Daq
Wall Thickness(inches) Customer Signature
Additional shelf(Yes or Not t
'There is no guarantee that new amnglas will match existing intoe.
BRIAN C THOMPSON
38 WILLOWBROOK LANE
v trIF r, pt , 010 8 5
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 126893
Type: Supplement Card
THD AT HOME SERVICES, INC. Expiration: 8/3/2918
RICHARD TROIA
2455 PACES FERRY ROAD, HSC C-11
ATLANTA, GA 30339
Update Address and return card. Mark reason for change.
Address - Renewal - -� Employment Lost Card
Office of Consumer Affairs & Business Regulation License or registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Registration: 126893 Type: 10 Park Plaza -Suite 5170
Expiration: 8/3/2018 Supplement Card Boston. MA 02116
THD AT HOME SERVICES, INC.
THE HOME DEPOT AT HOME SERVICES
RICHARD TROIA - // (Tr
2455 PACES FERRY ROAD, HSC - • -- — -)1" .ATl'ANTA, GA 30339 , �� f l � ��
Undersecretary of valid without signature
The Commonwealth of Massachusetts
i°-1'— Department of Industrial Accidents
C'.,—� I'e 1 Congress Street,Suite 100
// Rosfan,MA 112.1t d-201 7
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Ruiiders/CantractorslElectricia,\Plumbers.
TO HE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information �,r' p'}�' yy, Please PrintrinLegibly
Name (Business/Organization/Individual): I112]pry DP-1U J3T' �mf t gc2V)C
Address: V
� � 7� ViiT12), 2 —
City/StateIZip( ...:'' 11 . Pj5l4hone#: 9/115 ,P/ �'dJ`�2i2-- _
Aro you an employer?Check the appropriate box: Type of project(required):
hp I am a employer with empioyecs(fatl and/or pan-dine)? 7. I]New Construction
2❑Iamasole proprietor orpannersltipmid have noemployees working fpr me in 8. Li Remodeling
arty capacity (No workers'comp.insurance required I 9, ['DemolitionJi f�i I am a homeowner doing all work myself(No workers'comp Insurance.required I'
A.01 am a homeowner and will be hang nouracias to conduct all work on my prolnv I will 10 Building addition
ensure that an contractors either have workers compensation insurance or are sole I LQ Electrical repairs or additions
proprietors with no employees.
12.0Piumbing reparrs or additions
Xi am a general contractor and have hired the subcontractors lined on he attached sheet 13.❑Roof repairs
These sub-contractors have employees and have workers cump.Insurance: I
6.0 W ate a corpormion and its oltccrshaveexercised their nght ofexemption per MG(.c. 14.f.�r Other l �p"di't��"�
152.§I(4).and we have no employees [No workers'camp insurance inquired.I ���, bbb
*Any applicant hat checks hoe el most also fill out Qe section below showing,their workers compensation policy information.
r 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 sate whether or not hose cmiues have
employees if the sub-contractors have employees,they must prov,'de their workers'eontppolicy number
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. Al
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Insurance Company Name:_Alt& ai - - }7 )4 3-k-7. ' 4- ' _.
Policy#or Self-ins. Lib #:(W Q 11',55167..-h. 15 :1-7_ Expiration Date: /� ..' ) r 1 7' Pie:*Job Site Address: Lf lSi,rei 2 CJ� 1�.. ° ' City/StatetZ,ip'/ Xr1d .4 j t!(r ,�/�rl)d�1/, /''
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expirA{ion date). (l�UQ'2t�
failure to secure coverage as required under MOL c. 152,§25A is a criminal violation punishable by a One 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$250.00 a
day against the violator_A copy of this statement may be forwarded to the Office of investigations of the DIA far insurance
coverage verification.
I do h. eby certi v u de t , an hes of perjury that the information provided above Is true and correct.
r `? JVSl
Signature: �/ �./ Date:
4.
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Phone#: t...41ay-y"bg ._
1 Official use only. Do not write in this area,to be completed by rity or town official.
City or Town:_ Permit/License#_
Issuing Authority(circle one):
I.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
b.Other,,,,,
Contact Person: Phoned:_,
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ACC)120 CERTIFICATE OF LIABILITY INSURANCE DATE )
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
MASSE USA.IND PHONE
TWO.11LwaCECEHiFR _Eat ___ __...... _._...___ LNS�°I:
3.50 LENOX ROADSWrE 2400 ILP PILL.
ATLANTA,GA 30325 —.
INSURERISI AFFORDINGCOVERAGE NRICX
..........
lD 4YLY.OmBCGAW'-IB.IY INSURER A_3Bdtl1a5tN5u211re('.empd(Ly u<Q.TB]
MURREE.DA iN$VAER B Lett AnlntiCSn IPSW_ ° t'NS.Y.,
THAT EHO a DEPOTAT-O.
MADi CUMOME BERLAND
PA AT-HOME SIE'300 rIINSURER Cx New HNalion B Ins Co '23841
ATLANTA,GA 3033 PARKWAY SUITE'63U INSURER0:Illir.Cis NaUCntl Insurance Company 121917
ATLANTA GA 30379 '—
INSURER E:
INSURERF:
COVERAGES CERTIFICATE NUMBER: A13:014-"£45-14 REVISION NUMBER:8
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.
IttSR_.... —._..�_ .—•..• AODiRYOp POLICY EFF 'I POLICY SIP`"
PIPE OF INSURANCE POLICY NUMBER (MWDOtYWY) LM Q9tYYTY) I141T5
A :f GENERAL COMMERCNL LIABILITY 61CA OAM ...,812018 I3B'2.J
_ Edo/GETPENTR, S SMOGS
DAMAGE TO
RENr`cYl
,,..11M$JHAOE X CCL'bfl PUN/ISAR Ea Decease/ a 1000,003
LIMITS OF POLICY XS UND EYP(Any one vwsom S EXCLUDED
OF SIR:SW PER CCC oBRSONAL&ADV INJURY - 9,003,000
Dew_?DO EQx..DMIT APPLES PER ^GENERALw6REGatr 9000,000
XAGCcar „E , '.LC PEgOUCTS.COmPKW AGG:i 9.006.100
OTHER
B AUTOMOBILE LIAenm BAP 293885313 CO:- O. CO01.2017PIMNEED SINGLE Dor 's 1,000,00
Ljr,oX ANY AUTO I BODILY INJURY(Pea P c$r 4 'i S
SEL INSURED AUTO AHY CMG BODILY RuJeY[cur sunder.) s �.
NAOS sou S
U S AUTOS 5O PROPERTY DAMAGE Is
HIRED
-_.,00105 �.1k'.aLamom �..._. —�...
a
UMBRELLA UPS OCCUR I EACH OCCURRENCE m IS
_.._ _ ...�
EXCESS MS ,NM5N.tn- ' AGGREGATE
DE.^. REiENTbNi —..
WORKERS COMPENSATION ;WCO15519215(AOS) 1281: rn, 1,117 X' ) 'Eft i I /1
AND EMPLOYERS LIABILITY
C EATVTE '
'aur vsovRETORmARrNEwFxecurlPE YNN.,xIA.. IWD815$19217IAN.XY NHNd,VI) ] 15 OYOIRUT7
P. EACH ACCIDENT R '.s 1,OW,WO
CPFCERIMEMBEREACLu0E0i `NC91551921”(FL) 03.0:.29:= CA01/2017
D ManEatory in NXl a `" E L.DISEASE-EA£MPLOTE2 a 1 �
11 es S95REe NiGOr ._ - � ....
O�SCAu�i IX:9F OvrR.aTIOrvS Dear COOifiV¢C W NkkNnal P� I g.L.DISEASE-POUCH t14rt I S tOrad00
•
•
OESCRIPNON OF OPENATONS/LOCATORS I VEHICLES IACORD 101.Additions)RYmahs Scxeame,may be aNened Mmnre space n required)
EVk?LNC£OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THU AT-HOME SERVICES.INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
:)EA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
AAA.PACESFERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS,
ATLANTA,GA 30334
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Marlaahi Mukheljee
C 1988-2014 ACORD CORPORATION. AB rights reserved.
ACORD 25(2014100) The ACORD name and logo are registered marks of ACORD