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29-554 (10) 385 RYAN RD BP-2018-1173 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-554 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category- ROOF BUILDING PERMIT Permit# BP-2018-1173 Proiect# JS-2018-002103 Est.Cost: $4455.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group HOME DEPOT AT HOME SERVICES 088261 Lot Size(so. ft.): 19994.04 Owner: CHAN WILLIAM T&HIGY WAN Zoning, Aonlicant. HOME DEPOT AT HOME SERVICES AT. 385 RYAN RD AanlicantAddress: Phone: Insurance: 5 RIVERVIEW DR (401)935-2633 O Workers Compensation NORTH PROVIDENCER102904 ISSUED ON.5/9/2018 0:00.00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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: FeeTvoe: Date Paid: Amount: Building 5/9/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner RECEIVED (2"r- Departmenteseonly, Ci[8o he pt Status of Permit: MAY Building Depa me t Curb CuaprbgweyPeimlt / 212 M eel SeweNSeptleAvalbla y III\ DFT OF SUILDINGr WaterNsfAvailiel i NOnT MPtON. A T 60 TVq$ate of StNaaltal Plana phone 413-587-1240 Fax 413-587-1272 PloVsite Plena Other 3pecdy APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH ON OR/TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION B p" — t!9-/173 1.1 Property Address. This section to be completed by office Map, Lot 55 Unit Zone Owflay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORRED AGENT 2.1 Owner of Record: Name(Print) N try, Cur, ailingnas � Signature 2.2 Authorized Austrit: 9 �e � Name(Print) �l� Cure t Mailing AM Signatur Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Oficial Use Only completed bpermit applicant 1. Building (a)/� (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 6. Total= (1 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signatu r . Building Commi ainspector of Buildings pate EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 fi11W in by Building Depanment Lot Size _. Frontage Setbacks Front Side L: R: — L_ . R . . Rear Building Height Bldg. Square Footage - % Open Space Footage (Lm arca mi nus bldg&paved ""king) #of Parking Spaces Fill: (volume&Lncelio") 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#' 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 S-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterallon(s) ❑ Rooling or Doo s 3 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (p Siding[C3] Other[[31 Brief Descr' tion f P posod.0 gyggip lT/ /���/ /y h9 d✓�ir. / Work �/ L/ i/ 7�Y ✓ `7�`i Alteration of existing bedroom_yes No Adding new be&mVous' yy o6� Attached Narrative Renovating unfinished basement Yes No Plans Attached Rall -Sheet Ga.If Now 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? J. 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? In. 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? Ves No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION•TO BE COMPLETED WHEN OWNERS AGENT OR C/ONNTRACC-TOO,R, APPLIES FOR B/(UILDING PERMIT I, �AJ�I/(��,[[ /�'l�////�a• .as Owner of the subject property hereby authorize to act on my behalf,in all me ours relative to work authorized by this building permit application. Signature of Owner Date as Owner/Authonzed Agent herdby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed and he ins and penalties f perjury. Pont Nam Signature of Ownerokgenl Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su rvisor: / �p Not Applicable ❑yn�y��, 1 Name of License Holds r ` �L/�^ &�-,—� "✓ / 7� ��/v% A / W License Number-4 –,?d Address Expiration Date SignatureVblephi 9.Re istered Home IMM me CoNot Applicable El Company Name Registration Number Ad dr Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit at be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi permit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton / Massachusetts I ' DEPARTMENT OF BUILDING INSPECTIONS 212 Nein Street a Municipal Building Northampton, !A 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC"). M.C.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owneroccupted building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building'be done by registered contractors. Note:/f the homeowner has contra red with a corporation or LLC,that entity must be registered Type of Work: L�.(� n�'�T /c- ZV I Est. Cost: Address of Work: a r Date of Permit Application: ✓ ����� I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): Job under$1,000.00 _Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: / I hereby apply for a building pe it as the agent of the owner ' Date Contractor Name I I IIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts F C 3 DEPARTMENT OF BUILDING INSPECTIONS L 212 Main Street * Municipal Building �p moi/ pT No[tEampton. MA 01060 'r lyP'yj�6 Massachusetts Residential Building Code Section I10.R5.1.2 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. Section 110.85.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 790 CMR 1 I O.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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. City of Northampton s ` ;. Massachusetts Ao � s DEPANTNBNT OF aOLLDLNG INSPECTIONS 212 Nein Street •emicipal Building Northampton, M 01060 Y� Debris Disposal Affidavit In accordance of the provisions of MGL c 40, $54, 1 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. The debris from construction work being performed at: �3� Ai gyp' z � 41 (Please print house n mbar and street name) ~ 0196 Z Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) ` 711�/ d-lf Si nature of Permit Ar5plicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. he Home Depot Contractor License Numbers: MA: 107774, 112785 Salesperson Name and Registration Number: Kyle Harmon Home Improvement Agreement Home Depot U.S.A., Inc. ("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. WILLIAM Information: (WILLIAM CHAN New England South 1-SWJOAJR Flno N ma a Last Name B,anrb Name � Lead# 385 Ryan Road Florence L� 01062 comer Aeeress_ Ciry stale zip (413) 326-1684-� Home Phone# WaA PM1one Cell PM1one# hchan522@gmaiLcom CuslomerEmail Atltlress 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 01545 AWEr ilc y Slate Zip or Email customercancellationnortheast@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 DEPOT'S 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. ACWtow ged by X "��/�1 �OM 04/27/2018 cuno�.e slye.rv� "�T oe,e 1 rice and Payment S 'ayment schedule is epee fled(ip the$at of thPp Contract Price is due m State Su upon completion unless ice � `css oo Includes all . ap lrc ble giscountsrebates,fnanehagesand, fazes,3 %deposit$ 147015 balance $ 298485_ �- Due Immediately herpes Due upon completion est payments or other finance charges will be determined by Customer's separate cardholder ireement, to which The Home Depot is NOT a party, and will be in addition to Customer's under this Agreement. Customer is subject to the terms and conditions of the cardholder or ement, as applicable. No funds should be made payable to Service Provider; however, Service may collect Customer's payments) made payable to The Home Depot, e proceeds will will not -' be used to pay some or all of the total amount of sale, tion of Work to_be Performed: ion of Roofing detailed description of the work to be performed is included in the section entitled Scope of Work appears on page a of this Agreement. pate- Delivery Dam!Instailatio» ctteduie ximate Start Date: 06/2212018 Approximate Finish Date: 07/20/2018 tes are approximate and subject to change based on unforeseen events including inclement ier, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if cable, tronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. if you sent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and ten communications related to this agreement. By contacting your Service Provider, you may update r email address,withdraw your consent, or obtain a paper copy of the Agreement or related documents io charge. By providing your consent and verifying your email address above, you confirm that you ✓e access to a computer that can receive and open emails and PDF documents. initialing this paragraph, I consent to receive only electronic records related to this transaction. ) Initial cceptance 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, nciuding special order merchandise that may be custom made, as specified in this Agreement. Do not sign f blank or incomplete. (Service Provider's/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 i to protect your legal rights. xa.e e---- v x� --- im 04/27(2018 Sale ,9J1 SaaWre� � p License number(s) held by or on behalf of the Home Depot: 2 5#'o , 'r1, r4 77 -,o ty 31 Wk 6 A Branch New England SouthLabor 1-5WJOAJR Branch a 31 77 �77777 7 Culdourear Nam: —Liol—'How Job Address 385 Ryan Road Nam Phone I Cell Phone#: Work Ph..# (413) 326-1684 Email Address: TThan522@gma I cum — Drop Location: compiler Location Roofing 1 Labor: Additional, Garage only Noted, 5 Assails it 7 "'177 1 1 Roofing#1 2 13874 800 Square Landmark Certrunced 10 year Colonial Slate 55800 446400 3 6173 1000 Lin,Ft Rigid Ridge Vent 0.00 000 4 13742 14HO Piece Drip Edge While 12,00 168.00 5 22457 100 Job Duni Fee(THD) Up to 10 SO 57000 57000 6 15948 700 Square Deduct for Ranch Two Plane -3600 252,00 Job Total $49500 0 Percent Off Ptarmigan Tape Sales Tan, IPramotlon Amount Carlo.Total 114411,11 The Home Depot-2455 Paces Ferry Road,N.W. Bldg.B3,Atlanta,Georgia 30339-Customer Care:1.800-466-3337 116 HOE Call Som Draw(E)(01 Fee,18) � 118 ✓ J 601ki?IVI?Cn�Oc(IIM c ��ai �cc�tt3elfy Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Supplement Card HOME DEPOT USA INC Registration: 112765 2455 PACES FERRY RD C-11 HSC _- - - �_: ,,.:� Expiration: 04/22/2019 ATLANTA,GA 30339 Update Address and return card. Mark reason for change. O Address O Renewal O Employment O Lost Card /..f,......u...oe../i/f .,/...M6 office of consumer amara 6 BuNneet aeeula0on .; HOME IMPROVEMENT CONTRACTOR Registration valet for individual use only ��-- TYPE:Suoolement Card before the expiration date. Iffound return to: -_ Reaistre[ion fsalragQp Office of Consumer Affairs end Rust....Regulation -- 11065 04/222019 10 Park Plaza-Suke 5170 -HDME DEPOT USA INC -- Boston,MA 02116 RICHARD TRDIA... 2455 PACES FERRY RD C-11 HSC r ATLANTA,GA 30339 undersecretary Not valid wlihou signature A`ORo® CERTIFICATE OF LIABILITY INSURANCE mu mTMeDIYYYYI 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, MEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTRUTE A CONTRACT BETWEEN THE ISSUING INSURERIS), ADiHORQED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certiff to holder Is an ADDITIONAL INSURED,the policy(iss)must have ADDITIONAL INSURED provisions or 1W endorsed. IT SUBROGATION IS WANED,subject he the terms and mndMons of me policy,cardio policies may require an endorsement. A statement on this certificate does net roofer rights to the certificate holder in lieu.f such end.rsement(s). PRODUCER MARSH USA.INC. = AGT FAX TWOAWANCECENTER MAP Etl: x.: 35W LENOX ROAD,SUITE 2400 ATLANTA.GA 302M RAITUAIL INSURINDID AFFORDING COVERAGE NAIG6 CNIDIM3069-HeneDOAW-18-192414) MSURERA:OB RE Ik 116WdM2 GY INBUREO 114L HOME INSURER.:NCM4:I N51u¢MICD HOME DEPOT IL238dr TTS INC.A. IRSURERC:H9mxRisk Cd IIVC Inswarce Csm ROA 2455 PACES FERRY ROAD BUILDING INSURER D: PT1gNTA,NiA,GA GA 30139 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-0043530916 REVISION NUMBER: 3 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOPNITHSTANDING 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 EeT SHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ,NSR .......BURARCEAWL LTR BU VWD POUCYNUUMER Pp . PMp E� Lame A X coMMERc1ALGBNERALUA1ILm RRIDY 312712 (V19111018 03101,2019 FACNOCCVRRENCE E 9.0.V OW CfAIMS.CE OOCCUR PREM 5 r0W.m0 LIMITS OF POLICY XS NEDEXP(ARymece..a) S EXCLUDED OF SIR:SIN.PER DEC PENSD ILAw,NJUW E 9,0000w GEN'L AGGREGATE UNIT APPLES PER: 9.000DD) GENERALAGGREGATE S X POUCv� 0 D[DC PRODUCTS-CIXAPNPAGG S 9,000.000 OTHER: E A AUTOMOBILE UAamTT MWTB312318 0301,2018 03MI12019 [)EOaaWNEDSINGLFUmT S 1.000.0w X ANY AUTO BODILY MJVRY IPV pcaon) E MO SCHEDULED SELF INSUREDAUTO PHI'U`IC RODILY AUTOS ONLY AUTOS PUUM Ihamtivl rl S HIRED NON-0WNED pROPERIY ppMAGE AUTOS ONLY .05 ONLY P r S E UMBRELLAUAB OCCUR FACN OCCURRENCE S EXCESS ME CWNSMME AGGREGATE S DEO RETENTIONS s B WORRERECONPENEATON WC 014122511 AX,WAJVN 03MI12018 030112019 X PER OIH. Q AANOEMPLOYERB'WBnTrY YIN ANTE ER NTYPROPRIEIOWPARTNERAX1UTNE WC01411111. R ONOI12018 OM112019 EL EACH ACCmEM 5 5.m0,m0 +NEMBCRCXCLVOEDi O NIA IMaMao, I.END EL DISEASE-EA EMPLOYEE S .5.000JIM rims.Nem mx Crenreue mA]Oilirral Page 100,1.000 DESCRIPTION OF OPERATgNS M E.L.DISEACE-FULLY DMn C Ercccss AUln 292-i-10011002018 0310112018 030111019 Um!: 4.000.000 EB DEC PION OF OPERATONBILOCAIbNBILUDEN (pCORO1M.AtlElWtul Ra,nvr4SCLaW,le,mayheaXavi,vtlBmpvyvm kmRdM1 EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEITED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED M 6UILDING 020 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANI A.GA 30339 AUMMUTDREPREBERRATVE dMarm USAN, Manashi MAN". _SKuunlow: .]4.wtc.aa4ro<.L 0 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2015103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 LOU:all. Atlanta ACO ADDITIONAL REMARKS SCHEDULE Page 2 of 3 ABENCY NAMED INSURED MARSH USA.INC. THE HOME DEPOT,INC. HOME DEPOT LLS A.INC POLICY NUMBER 1455 FACES FERRY ROAD BUILDING CEO AILAN IA,GP 30339 C4RRIER NONE COUE EREEcmE mre� ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACCORD FORM, FORM NUMBER: 26 FORM TITLE: Certificate of Liability Insurance WMers Carte lfm Carl. 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All rights reserved. The ACORD name and logo are registered marks of ACORD The Connromt:enith pfhlassacltlrsetts - Department of fndnsn•rnlAecidil I Congress Street,Able 100 _ P Poston:ATA 02114-2017 u Il,1v:..massooP/din {-orkers'Compensation Insurance s Miidavit(tnilderslContnctars/IIledricians/1'tumbers. '1'0 8r.FILED RRTTITR$PERai1TrING A0'i'IIORIT)'. AonOrn [fnfm-nold. Please Print Legibl• (�Ianie(Dusin�>OrBamzalicMl��nJiw�yySJoap: '—�—�' F)xC Address: goo /1/�-N�f �) C--7� City/StaterZi ' �V7 D� Phone+'!: 277 Are r:m an unn!vyc!:dmtlr nn:apprvprink ha' Type of project(required): l O l sen a PntvlPyanvhh_cmP:o)ca((ull er.:b'ur'n.url rr''��I am.sol: 7. 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All JobSireAddles: CitylsualtZip:Atmch a cop} n'the wflursr campenntio policy deciarafihn page(shmring the policy number. dev, Failureto secure coverage as required under'adGL c. l�,a25P.isacriminal violation ptmistubie lryaiine up to$I,SOB.W and/er ane-year imprisonment,as well as civil pernities in[he forth of is STOP NOM ORDER and a fine of up to$250.00 a on,,,againsr the violator-A copy of this statement may be fare arded to the Office of investigations of the DIA for insurance csvl:rage vetlEcatiom i da herebp ccrafj•un the in r fper' r tbnt lir/e/r/9jvrmnlinn prmildcd ubmie&ern rindrject. S gnnnNr, Due- Phan • -he le Dffcinl rrse mrlJ'. Dom#wile 1n this area,;o be cmaplelett by env or tool,qciai. Cly or Town: PFrmil/License y tssmng Authority(circle seep [. t.Board of health L Building Department 3.CiryA'mvn Clerlt 3.Eleetrieni Inspector S.Piambing Inspector (.Other jl Contact Person; Phone.5': l Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor :;S -088261 Expires : 03/19/2020 THOMAS M KELUHER 25 BEAUDRY PkVENUE CHICOPEE MA 0:1020 Commissioner