18C-049 (5) 67 HATFIELD ST BP-2017-0412
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I8C-049 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit# BP-2017-0412
Project JS-2017-000686
Est. Cost: $1302.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(su.ft.): 40685.04 Owner: HEBERT LOUIS 0&JOAN J
Zoning:URB(1001/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 67 HATFIELD ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCERI02908 ISSUED ON:9/27/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 3 DOUBLE HUNG WINDOWS FOR
REPLACEMENT ALL ON 1ST FLOOR DINING ROOM
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: OI: 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 9/27/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
I
Department use only
nit:r. - City of Northampton Status of Permit:
i - Building Department Curb Cut/Driveway Permit
ICY 2.1 %'U(° 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
coma
oceuun�^'tio1^p0'V,o Northampton, MA 01060 Two Sets of Structural Plans
t pion° phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
• APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit
Zone Overlay District
ILS Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
To4sory dl- L' 7 ,7/' / �� -" ' .
Name(Print) �j /'7/� Current Mailing ddress: '
5 -✓ f4-A717.4-(--
Signature Telephone /113
—L/y� g� �p10L6
Signature V /�
2.2 Auth•_ed ent:
'I/ - ' 1 T / 9N �, T '-
Name(Print) _ _kid:L._ Current Mailing Address: Rt I
Signature ' Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 092 . 00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection /9�� '
6. Total=(1 +2+3+4+5) 170.. ✓ / Check Number ,s75179 i TO
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: / f- 22- ;,0`(/
Build Commi oner/Inspector, of Buildings 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 nepanmmt
•
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
h of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O 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 tt
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it pad of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors pi...
Accessory Bldg. �❑ De{moolliitionn /❑ New Signsr [p] l Decks� [1:1 J Sidingdigm] Other[DI
BrietD7 li nri✓"L F4' I M4 v �O a asi rCp'ft 0
Work: prove/
Alteration of existing bedroom Yes No Adding new bedroom Yes No _ An
Attached Narrative Renovating unfinished basement Yes No ( 9/]/de
Plans Attached Roll -Sheet
Sa.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 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR' APPLIES� FOR BUILDING PERMIT
I. 37747411-1-€F -47-7- ,as Owner of the subject
property �j y� (�� yy
hereby authorize F-/C 2/„� 7720169
to act on my behalf, in all matters rel to work a zed by this building permit application.
� 1 4-Z7�6
h gllSignature of y,,p'//yl�� Date
aM ] r ”' 11204---- 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 .. ns am .enalties of perj. i.
it AIL. :�' -I
Pant N.
7112-4--4 9 -27
. .
SIurea Owner/Agent Date
•
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su•- :isor: y�/ Not Applicable Elsr
'7
Name of License Nobler: / 'yj(//v � 1 y/� r m)I7/2/
�j /-� /„ 4! ' License Number 10
Address Expiration Date
Signature Telephone
Vityrc523
9.Re•istered ome lm•rovement C•ntractor: Not Applicable 0
X26.19_
Comoan Name Registration Number
24
Add - s Expiration Date
43467 ina � lephone 0/T3 )3S2
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 • i permit.
Signed Affidavit Attac d Yes No ❑
11. - Home Owner Exemption
The current exemption for•'homeonners'•was extended to include Owner-occupied Dwellings of one(I) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,presided that the owner acts
as supervisor.CMR 780. Sixth Edition Section 108.3.5.1.
Defmition 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
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: le 7 , /i /
! ' 77{7
The debris will be transported by: /4,
The debris will be received by: itineC )V I
Building permit number: 9/� �/ , f� /� ✓1�
Name of Permit Applicant ) 1 o `/� Zb 7741/
G_ 4
Date Signature of Permit Applicant
•
• JotsContacts A ✓1c (I (.V"
�� Friday,September 23,2016
Comments Lead: 19538765 Go I Advanced Search 12:59 PM
Info/Updates Homeowner Information Job Information
Homeowner Ms.Joan Hebert Sale Amount $1,302.00 Balance Due: $868.00
Commissions Homeowner2 Product AC12(4%)
Documents Job Site Address 67 Hatfield Street Status Sale/Material Ordered
NORTHAMPTON,MA 01060 Branch Boston North
Job Issues
Measure ft ]822233]
Order Detail County HAMPSHIRE Sales
Billing Address 67 Hatfield Street Commission Rate
Payments NORTHAMPTON,MA 01060 Consultant Name Term Date Split Comp Plan
Permits Timothy Drost 100.00%Straight Commission
PO Primary Phone (413)4]4-8986
Work Phone Ext. B-Back: No Cross Ref* 1-8185175092 Siebel Ord... 115198
Result Combo Cell Phone Key Dates
Work Phone 2 Sale Date 8/31/2016 FUP Date
Services
Cell Phone 2 Credit Date 8/31/2016 FPD-Customer
Show Map Email limothy_drost@homedepotcom RTP Date 9/1/2016 Post Install Date
Cross Street Start Date 10/12/2016 FPD-Horne Depot
TouchPoints
Marketing Inspection
Update Job Referral Store 8452-HADLEY Job Indicators
Work Orders Base Store 8452-HADLEY Lead Paint:Assumed-LSWP Requir
Lead Source 0205 SC Working Stare w
User Date Time Status Corr. Appt.Date Appt Time Consultant i
_ . _ . PMd _.. 0163 m _..
Brittany Johnson 9I19I2016 3:37 PM Material Ordered No 8/31/2016 11:00 AM�Tlmothy Drost
01 1_ 011d_P Timothy
6101._.
PETER TALBOT 9/18/2016 10:57 AM Order Received-PSG No 8I31I2016 11:00 AMTiDrost
PETER TALBOT 9/18I2016 10:57 AM Measure Complete No 8I31I2016 11:00 AM'Tlmothy Drost
Gylhlna Raglin 9/112016 8:17 AM Released to Production No 8/31/2016 11:00 AM Timothy Drost
0101_-__ 1013__. 1611
Cylh na Raglin 9/1/2016 8:16 AM Order Entry No 8/31/2016 11:00 AM Timothy Drost
Timothy Drost 8/31/2016 11:29 AM Credit Pending No 8/31/2016 11:00 AM Timothy Drost
Timothy Drost 8/31/2016 11:29 AM Sale Pending No 8/31/2016 11:00 AM Timothy Drost
Dayend Dayend 8/31/2016 11:10 AM Sent to the Field No 8/31/2016 11:00 AM Timothy Drost
Martecia Williams 8/31/2016. 11:07 AM Confirmed-Customer No 8/31/2016 11:00 AM,Timothy Orost
Martecia Williams 8/31/2016 11:07 AM Pre-Book No 8/31/2016 11:00 AMITimothy Drost
1101._—
Martecia Williams 813112016l 11:06 AM Lead Entered No
Claw Print
S�
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: _
Joan Hebert 9538765
First Name Last Name Branch Name Lead #
67 Hatfield Street NORTHAMPTON MA 01060
Customer Address City State Zip
(413)474-8988
Home Phone# Work Phone# Cell Phone#
timothy_drost@homedepot.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:
908 Boston Turnpike Unit 1 Shrewsbury MA 04545
or Email CustomerCancellationNorthEast(o homedepot.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
Custcm.rsse �w
Date
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 $ 1302.00 Excludes finance charges.*
Minimum _ %deposit$ Due Immediately
Remaining balance $ Due upon completion
1
WINDOW SPECIFICATION SHEET - Spec.Sheet p'. 9538765 Sheet: I of 1
pc
Customer. Joan Hebert Job p'. 9538765 Consultant Timothy Drost Date: 08/31/2016
New Window
Hinge Locations Window Meuremiens Grids Product°pions Labor
Options From
L eft to Right
Bays.Bowls
Luton Color Rough Gpeaing y M bars P of bars Csinnts,l Pnl.
use 1.R or S
Glass Mlsc Items
Hardware
Sure
e Code For d
Mull 'S stationary or
StyleWraps a .- =nrc g1 _ 3 3 -operating
Room Fluor Code (YIN) Style Code Series Code w 3 z o m C d > x > x
STD Gossaaus styntsd SR
I OINE Isi OH ON 1200 28 OE 49 00 77
2 HNC 1st on Hug 28E0 79 all 7E
ETD GlassPeak Standard LEP
3 DINE Ism EH ON 1200 28 00 43 023 77
•
SPECIAL CU'NSIDERAT IONS'.
Wrap Color
Metter Casing Type
Bay or Bow window
Seatboard material(vinyl only-Birch or Oak)
3ay PreyedAngle 00 Or 051
3ay Flanker Type IDH.SH,or Cemml
Top of window to sone(inches)
I tied to soled color of soffit material I hive reviewed dad agree with all the ph specifications above and the
Construct Roof{Yes or NutSpecial Terms and Conditions on the following page
Garden Window:
Seatboard Material(vinyl only-While Plcnlle.Si M or Oak)
Wall Thick/lege onehesi CUSamer Slgn spore
Additional Shell(Yes or No)
'There is no guarantee that new shingles will match existing color.
.d-S" 67 7,d:
BRIAN C THOMPSON
38 WILLOWBROOK LANE
WESTFIELD Ma 01085
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ac Ro ae CERTIFICATE OF LIABILITY INSURANCE DATE
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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. It SUBROGATION IS WANED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on Ibis certificate does not confer rights to the
certificate holder in lieu of such endorsement(s). -
-
PRODUCER CONTACT
MARSH USA,INC. PHONE I I BICC noY
PNO ALLIANCE CENTER we No FOR
3560 LENOX ROAD,SUITE 2400 EMAIL
ADDRESS:
.ATLANTA,GA 30326
INSURER(S)AFFIXtgNG COVERAGE i NAIL P
100492-HomeT-GA'M-I -i7 NSURERA:Steadfast Insurance Company 1�1 __
_-- Zorn'Alrelan Insutalrs Co 16535
INSURED INSURER B:
THA THE HOM5DDEPOEA,INC. !23641
OSA THE HOME DEPOT KW YMS SERVICES INSURER c:NET/samponae TS CO
2690 CUMBERLAND PARNW.AY.'SUTE3N INSURER D:IIfuWS National Insurance Company ZDIT
ATLANTA,GA 30339
INSURER E:
• INSURER F:
COVERAGES CERTIFICATE NUMBER: AR-00374654614 REVISION NUMBER8
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 NIAY 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 :A6f'U POLICY FFF POLICY SCP GLUTS
TYPE OF INSURANCE • PoJCY NUMBER MMRP MWD'
A X _COMMERCIALGENERAL LIABILITY -GLD46RTT14- 10&0114616 103101112017 .i EACH OCCURRENCE 1s 9.000.003
-- IDM4AUE TO REM U I.000A03
'CLAIMS-MAGE • X OCCUR •I PREMISES(Eaosurenml S
LIMITS OF POLICY XS MED EXPIAm^ Rom-0M,epu �s IXCLU D
GESR:SIM PER OCC PERSONAL&ADV INJURY !S 9'001)"0130
GEN" AGGREGATE AGGREGATE LIMIT APPLIES PER. ".• " GENERAL AGGREGATE '�3 9000000
X POLICY _ Act LCC • 'PRODUCTS-COMPIOP AGO TI 5 9003,000
CT IS
OTHER:
B AUTOMOBILE UAMDTV 'BAP 293080113 .03/0112016 '03)012017 IOMUIIeEDISINGLE UMIT s TLg0.000
X ANY AUTO • !BODILY INJURY LPs person)
ALL MATED e'CHECUL-D SELF INSURED AUTO PRY DMG j• BODILY INJURY(Per MdO&Y1:S
_ AUTOS —'AUTOS
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HIRED AUTOS AUTOS • '(Per aNJdenO
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•
UMBRELLA LAB OCCUR I EACH OCCURRENCE 15
•
• EXCESS GAB CLAIMS.'IADE ' - I AGGREGATE i5 -.
'DEO RETENTION ' I 1I 5
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!ANDEMPLOTERSLNBIU1Y B31D112%6 �OLp17N1T i 1000.60.3
D ANY PROPRIETORNARTNERFJCECUTNE YJN �!WC015519217(AK,K1',NRN,Vf) I EL EACH ACCIDENT IS
D FFlCcaIMEMBEREXCWOEOT n:.NIA. WC015519216R03/0111016 !0311)2017 i EL DISEASE-EA EMPLOVEFS 1,810,000
IMan4tlory in NHI I I
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•DESCRIPTION OF OPERATIONS oekm Page EL 06EABE-POLICY LIMn $
•
T I
OESCRIPTON OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,AIOYCI,a1 Remarks scheat ,may be'Tacna]If Mose Spate is required)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT-HOME SERVICE&.INC. SHOULD ANY OF THE ABOVE DESCRIBED POL)CIES BE CANCELLED BEFORE
DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA.GA 30379
AUTHORIZED REPRESENTATIVE
of Marsh LISA Inc.
Manashi Mukherjee SXa+..00b- ,pd"fe^•'}..•
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
r
Office of Oon_su.ne r Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improver ent Contractor Registration
Registration: 126893
Type: Supplement Card
THD AT HOME SERVICES, INC. Expiration: 8/3/2018
RICHARD TROIA
2455 PACES FERRY ROAD, HSC C-1 1
ATLANTA, GA 30339
Update Address and return card.Marl;reason for change.
I Address Renewal Employment I Lost Card
Office of ConsumerAffairs e, ltnshress 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: 9 ';'a•k HIM] -Suite 5170
Expiration: 8/3/2018 Supplement Card BO:110m. MA£82116
THD AT HOME SERVICES, INC.
THE HOME DEPOT AT HOME SERVICES �I
RICHARD TROIA
2455 PACES FERRY ROAD, HSC - . - - `` n�,,,
gTL'ANTA, GA 30339 th;de secrct:uyalyd x'trout signature �/
The Commonwealth of Massachuselt-v
/- Department of Industrial Accidents
1 Congress Street, Suite 100
Bey# - l?;trtnn, nod 02114-2017
`rte' www.mass.gov/dia
1lorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information ���'f' Please Print Legibly�
Name (Business/Organization/Individual): lig% Y^, }aY/.f f l'? f,�yl�l- _J
�4
Address:............. t��;/ .tl d UgAi ] a
City/State/Lip: S k k L �LL� (. [_hone#: 4 — 162—N'Z7 '-„�
Are you an employer?Check the appropriate bex:
Type of project(required):
L❑I am a employer with employees(NU actor pert-rmc).' 7. ❑New construction
2.9 1 am a solo proprietor or partnership and have no employees working for me in 8. 9 Remodeling
any capacity [No workers'compinsurance required.I 9.
3 l am a homeowner doing all work myself No workers comp.insurance re ❑Demolition
❑ g' > ( gnop rty 109 Building addition
4.❑inm a homeowner mid win he hinngco,1&rrors le conduct all fork on my p sole . twin
ensure that all contemn either have workers'compensation insurance or are sole 11.9 Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5X1 amgeneral contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Rauf repairs
Thesee sub contractors have employees and have workers comp.insurance {� ` /�}j/
2.
6 9W arc a comoafiooand its o0%ees lave exercised emir right ter emotes per MGI c 140 Cher ke
l5aOak and we have no employees.{No workers'comp msmance required.l
'Any applicant that checks box ei mast also fill out section below showing their workers'compensation Nl icy information.
6 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 anachedan additional sheet showing the name or the subcontractorand suite whether or not those entities have
employe¢ lithesutrarntractors have employees,theymost provide their workers'comppolicy cumber.
l am an employer that is providing workers'compensation insurancefar my employees. Below is the policy and job site
information- it h
Insurance Company Name: Ssptti` �v 11.4J1ba�^yy . 7 '_ i
Policy#or Self-ins.Lie..#l:'7 y"' y 1 ,ra:.-YJ _ Expiration Date — 1 )- 1 (/�n ,�)¢—
lob Site Address:_ 18 ! • _City state/ZIP ♦ I'i y.,,,b 4 * / r Y//
Attach a copy of the workers'corn nation policy declaration page(showing the policy number an expir'in date)-OG/ ,p
Failure to secure coverage as required under MOL c. 152,62.54X 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 ofa STOP WORK.ORDER and a fine of up to 5250.00 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 h ehy cerrtif a.de 1 au peno)ties of perjury That the information provided Botts and cytreat
Signature: 2t's th"^r�'�'"t�' Date: t(!_--,____-
Phone ft: - " . .....C.
Official use only Do not write in this area,to S completed by city 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#: