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32A-085 (2)
35 GRAVES AVE BP-2022-0142 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:32A-085 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-2022-0142 Project# JS-2022-000249 Est.Cost: $1 5000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: LOWES HOME CENTERS INC 049918 Lot Size(sq. ft.): 4051.08 Owner: PARKER SUSAN A Zoning: URC(100)/ Applicant: LOWES HOME CENTERS INC AT: 35 GRAVES AVE Applicant Address: Phone: Insurance: 1000 LOWES BLVD (413) 272-8931 O WC MOORESVI LLENC28117 ISSUED ON:8/5/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:STRI P & 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: � , ' ' an, , 1 FeeType: Date Paid: Amount: Building 8/5/2021 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner r I The Commonwealth of Massa 4 used' G' /� �,Q41i Board of Building Regulations and .n•: . • ` \ 40.;R j Massachusetts State Building Code, 780 _' 4;.G S�O� ITY �: q NCO I IJS. Building Permit Application To Construct,Repair, Renovate �'- } ilish a 'evised ar2011 One-or Two-Family Dwelling • SAFE This Section For Official Use Only o'�?'ol, Building Permit Number: (6/0^d.]-1y2i Date Applied: Lt�1iV l�Q�g i' 22' 9'5-ZoZ' Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1. Property Address: 1.2 Assessors Map& Parcel Nu d g�s� ' S G+rotVPS Au e a 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property, Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Lone: — Outside Flood Zone' Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of R ord: 5"56.r► Vc1rK.ere" /1/ur4-119m P4cio, /I h O I 3 Name(Print) City,State,ZIP -3 5 6-htei..S A../.e 413-6(9-04i 4n,,,,Ker yq0 ► ei thr.44.1.Cc," No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': 14..i,Q Gj n d \ (Wf .tit, 61kC)wra I Chin y o SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ l S r d vv 1. Building Permit Fee: $ Indicate how fee is determined: '.Electrical $ ' ❑Standard City/Town Application Fee ❑Total Project Cost(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (11VAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Feq,jd,, Check No. Ol 'heck Amount: ill Cash Amount: 6.Total Project Cost: $ 1 Ci( 00 J 0 Paid in Full 0 Outstanding Balance Due: • SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor LIcense(CSL) d 1-1 c (c I r.4 'aft_2 4 �A(\� Sv pa I n) License Number 1 Expiration Date Name of CSL Ilolder List CSL Type(see below) S Zbh P4 \)f& No.and Streetf�`` Type Description e g �N� AM p-tUti 0 � A �`� U Unrestricted(Buildings up to 35,000 Cu.ft.) / Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding y'l-ieS-V� SF Solid Fuel Burning Appliances to V �S S�ot��wvhe�t+tprovfQh�S,Q//►w�•� 1 Insulation Telephone Email address rar D Demolition 5.2 rRegistered Home Improvement Contractor(H1C) f p to_() `G(N e 45 "{ (-en S HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name I cw 4 t 4,v-es I tr,v i) L t►A;S P1,42e e (a CA-40S. u No.and Street Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached'? Yes . No........... ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTIIORIZEU AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and ac ate to the best of my knowledge and understanding. GRk t� �r sg' - l Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the IBC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfbaths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD SIDE YARD ' SIDE YARD FRONT SETBACK FRONTAGE City of Northampton ' Massachusetts t -A'/1 :''' we , DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building r'r *; Northampton, MA 01060 r'Ey -t~" CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: /1-t- 071A( (7 I -,Po. ta,o-P/6-c4 fii,d_ The debris will be transported by: C ,07(.4 :(d,45 (.yG r o ci---vC Name of Hauler: A-44 e Signature of Applicant: Date: e ___)._ a I The Commonwealth of Massachusetts Department of industrial Accidents I Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.goP/dia 11 orkers ll'ompensation Insurance Affidavit:Builders/ContractorsiElectricians/Pluinhers. Fri Vit 1111 T11E.PLRSIITTING AtiTii()RITY. lit Information Please Print teihh Name taustnes%Iirgan1Andividuall: L 'ei i1/4c ( )- Address: C.2&() C.,,) City/State/Zip: 1^'‘u ( 1,1 it1-) Phone (t -(-)7 — S-5 Art 141t1 iii rrzijk ii k the appropriate h*t: Fype 01 project Irrtlaired I I Ea I an a employer with employ-can(fa and,or pan-tn .• 7. New construction 20 I am a sok:proprietor or partnership and have nu erlipkty•Xl*Inking for nve tt. 0 Remodeling any cruelty [Nu*otters'camp,insurance required 1 9. E] Demolititm ani a homeouliCt Joins all kkoft ItIFICIf.(No walkers'enim,.imaranor retina-M.1' 4,M 10 0 Building addition I am a hansoms Ilea and*it! hirtng ountraeturs to eundnet all work un my roperty, I will a-Aire that all i.untractors eithet liaYe iviatcrs'compensation ennianince WV WIC 1 a Electrical repairs or additions ptupnetters, nth ra,onpluyees, 12.0 Plumbing repairs or additions ‘a general eontractur ant 1 lir,e had the sub-contractor*listed an the attached stied_ 1311 Roof repairs sob-emu-scans st employees and hat e workers'eump..unturance.: 14_in Other n.1:1 We are a corpuration and its oilmen hare exercmcd then nem or rxemption per 4401. 152,§1011).and we have no eTriployees.[No workers'comp.insurance required.) 'Any applicatt that checks bus moot aims rill out the wetiott below bowing their*orkt-ri'evmpensation psticy inIcarmatioct *Hotrattatmers*Pao submit this affidavit ay.heating they an dc....ng Nit .ork and then hue outside emit-actors mint ubout n 11Cw atIidai it mil ii.nting such aeten,that ehea this box must attached an additional sheet showing the name of the suts-contraelor,and state lied=or nut[how enttnes cc, If tls: 1 I ir ir. r r has,rinpi sOTC!, i imrcnrWoikers' NiiCy ratitibet OM an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ikA-RcF/ (AC/9- Policy#or Self ins Lie.#: (/"((,) (0.174f 171(/ Expiration Date: Job Site Address: 3; C-Atve A-. ' C city,state:zip: 4kc 01 Q3 Attach a copy of the workers'compensation policydrrla,jtnrii pni.t (slo, .ing the policy number and r‘piration date). Failure to secure coverage as required unalerMGL c. 152,IPS A is a criminal solation punishable by a tine up to S1,500.00 andior 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage i ification. / lo hereby eerti tilts tire puiasand penalties rt.,perm u the inforrnaniut provreted above P true will eurreet. n.iiurc: I 4 -ot Plsonc q(-3- -T91 Official use only. Do not write in this area.to be completed by city or town official City or Town: Permiiiiicense 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: Phony#: City of Northampton t? n.,4-, '.,< ,�,i ;, Massachusetts 4 1 '"''F'? t,,,, .: A DEPARTMENT OF BUILDING INSPECTIONS Si it =r 212 Main Street • Municipal Building Jos fib,' , 7 Northampton, MA 01060 4.40 HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, (insert flu legal name), born _ (insert month, day,year),hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. 1 qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s)who owns 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 home owner. 4. 1 do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of , 20 . (Signature) l .® DATE(MM/DD/YYYY) ACOR© CERTIFICATE OF LIABILITY INSURANCE 03/29/2021 THISCERTIFICATE 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 have ADDITIONAL INSURED provisions or 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 CONTACTNAME: Marsh USA Inc. PHONE FAX 100 North Tryon Street Suite 3600 (A/C.No.Eat): (A/C,No): Charlotte,INC 28202 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# CN102776519-Loaves-SI-21-22 INSURER A:National Union Fire Ins Co.of Pittsburgh PA 19445 INSURED INSURER B:Interstate Fire&Casualty Co 22829 Lowe's Companies,Inc. and subsidiaries INSURER C:AIU Insurance Co 19399 1000 Lowe's Boulevard INSURER D:New Hampshire Insurance Company 23841 Mooresville,NC 28117 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-004976909-08 REVISION NUMBER: 10 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL.SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD INVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ Self Insured-See below DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ $ OTHER: A AUTOMOBILE LIABILITY CA7030892 (AOS) 04/01/2021 04/01/2022 COMBINED SINGLE LIMIT $ 5,000,000 (Ea accident) A X ANY AUTO CA7030891 (MA) 04/01/2021 04/01/2022 BODILY INJURY(Per person) $ A OWNED - SCHEDULED CA7030893 (VA) 04/01/2021 04/01/2022 BODILY INJURY(Per accident) $ - AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ B X UMBRELLA LIAB X OCCUR USZ00024220 04/01/2021 04/01/2022 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION$ $ C WORKERS COMPENSATION WC016393105(AOS) 04/01/2021 04/01/2022 x PER OTH- STATUTE ER AND EMPLOYERS'LIABILITY D Y/N WC016393104(ND,WA,WI,WY) 04/01/2021 04/01/2022 2,000,000 ANYPROPRI ETORIPARTNERILXEGUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? N NIA 2,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 2,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Excess Workers'Compensation XWC1647266 (FL) 04/01/2021 04/01/2022 (WC per statute) 3,000,000 A Excess Workers'Compensation XWC1647265 (AOS) 04/01/2021 04/01/2022 (WC per statute) 3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Commercial General Liability policy is Self-Insured,effective 4/1/2021 to 4/1/2022. CERTIFICATE HOLDER CANCELLATION Lowe's Companies,Inc.and Subsidaries SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1000 Lowe's Blvd. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Mooresville,NC 28117 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee -ate - .-- -...^+?-...- I ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN102776519 Loc#: Charlotte A C—CoRL ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA Inc. Lowe's Companies,Inc. and subsidiaries POLICY NUMBER 1000 Lowe's Boulevard Mooresville,NC 28117 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance TX Employers XS Indemnity Policy Number EPG000016700 Carrier:North American Specialty Policy Effective Date:01-Apr-2021 Policy Expiration Date:01-Apr-2022 Limits:$8,000,000 Each Occurrence I$35,000,000 Aggregate XS TX Employers XS Indemnity(Excess) Policy Number XCB3095 Carrier:Evanston Insurance Company Policy Effective Date:01-Apr-2021 Policy Expiration Date:01-Apr-2022 Limits:$15,000,000 Each Occurrence/$35,000,000 Aggregate XS Workers'Compensation and Excess Workers'Compensation policies indude a self-insured retention of$2,000,000. General Liability:The insured is self insured for$10,000,000 each occurrence for the period of 4/1/2021 to 411/2022. The Automobile Liability policy evidenced above is subject to adrilional sdfinsured retentions excess of limits shown for various perils covered. ACORD 101 (2008/01) C 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC� DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 07/27/2020 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 NAME: Marie Proulx HUB INTERNATIONAL NEW ENGLAND LLC IN No.Extl: (413)750-7106 /c,No): E-MAIL ADDRESS: marie.proulx@hubintemational.com 600 LONGWATER DRIVE INSURER(S)AFFORDING COVERAGE NAIC# NORWELL MA 02061 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER 8: MARK JODOIN INSURER C JODOIN HOME IMPROVEMENT INSURERD: 15 JONES DRIVE INSURER E: EASTHAMPTON MA 01027 INSURER F: COVERAGES CERTIFICATE NUMBER: 557741 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD W VD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DDI W YYI IMM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL BADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY PET LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION X PE OTH ATUTE ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A AWC40070296132020A 08/31/2020 08/31/2021 (Mandatory In NH) E L DISEASE-EA EMPLOYEE $ 500,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govilwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Lowes Companies Inc and any and all subsidiaries ACCORDANCE WITH THE POLICY PROVISIONS. Mail Code A3ESS 1000 Lowes Blvd AUTHORIZED REPRESENTATIVE Mooresville NC 28117 Daniel M.Crowky,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 33UO1SSEib.a tic,a 4,1 "< 2T,Ot O SVCtk 4UOIcii+ltlH1S!#3 ' i#£ S3NOf 96 141-oaof S AK AN spoepkir,.S r.rc swolleisafi,)-b 64411rEi dry p..,rogl a.r1<taa.sr .i c30r45«3°),,i in a cxcf q; Sb;3Sr l aessL"i^ i u.pat/woulwwo,z k s 3 apu t a3i1 S3NOr mock r NHVi; • i 0 It arc01.:1 S I 1 •N'•;;,,V1::"3.t.te.el N-4,6*4t 1,2iV*141PP: 4t? • - • 'Z''•Verr • 3:,!, , • 1, • • 4V•c ' ,',"A•S' ••• .4 • a ice of Consumer Affairs&Su.ineen rieguiatien HOME. IMPROVEMENT CONTRACTOR , , , TYPE; Individual 'tt400P4OVV.,,044t.**V,40,410:: Expirajign 159137 04 032022 MAfik 401DOIN JDDOIN HOME IMPROVCMNT = 44, , kV '44.°4:,44:1,11","!•!°›- MA C)RK 3,JODOIN /, EASTHAMPTON, MA 01027 , Undersecretary •. — 0 X Search... (f* i ncs;n*iei sic_ I'ehtvsu#s Uatai.> file £dit View t' :;t;tes ck ye1,� i,lerox N..Bttiie i/ON Ex\vNl 4Yvz w f HF;sn. >tr w Ame Itt, i Avviw...eitst1M1r T.xian i..ta+}an!c. '111t7!' t Puhbc Safety a+ Mass. Licence Details D moar,i.hk t,ao s1 ttnn teARt(S IOIX%N_.._.. Name 1 AJd E Mraut cta, MA stp-ose: 0102T i.v m[!)_,__ Unsed Staten 14 It>r� License N0. G3 04391a LItense Type CollsauCt:On supestisnt Protesslen: DulOinqO LY.Mses Date of Last Renewal. 12162020 1<sae Dale 1229fZ010 Eselra'irn:Darn t2 i2022 License Status Actt e -1day's Dal 1'1912021 Secxaan License Type: DU-vy SaltlSs As' _LI t c GnlS9e 1Ca100' LRlein$e RenPk21 _.. II engnbflh.lsE nvnankm No Prerequase Inttani000n .... ......... No Acaaaele Du tnnelltS Mnf ai1Qtl�watHi t4 h#n.:aiue:elk; ;,xe Pat�tes i i[xtl:vl�h j (i/z. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Sucolernent Card aggIO.Tatign PApitali-gn 148888 10i1712021 LOWE'S HOME CENTERS,LL CHRISTOPHER MINE 1000 LOW ES BLVD • SERVICES COMPLIANCE Undersecretary MOOP.ESVILLE,NC 28117 • FUSE IMS — Sold Job Cover Sheet LOwE's SERVICES Directions: Fill out the below form completely and upload with all required documents(outlined below). Store Number: 197 Customer Name: 7�7 4 ricers' PROvider Company Name: �I-VC/ J c'41 �Prole.7 Required Documents for Sold Job Below documents must be included for Installer to begin customer project installation. Failure to provide all required documents may result in rejections. �✓ Sold Job Cover Sheet(this document) ! Signed Customer Contract • Includes all pages from the state-specific contract in Adobe Sign • Uploading partial Contracts will result in a rejection OSold Material List • For SOS Product Only—M20/Paradigm or appropriate Vendor order sheet If applicable: Contract Change Order Engineered Drawings for Decking Projects E Required Actions: I have confirmed with the PROvider if a permit is a required,and if so,was sold on invoice: �r I have c firmed ' PROvider if Lead Safe Practices will be required on the job,and if so,were sold on invoice: By signing this document, I am confirming I have taken all required actions and uploaded the necessary documents to the IMS Detail for thi customer's pr ' ( A __--.-,_L„..._-k___ ___ 1 i , 1 • . , • !AWES MASSACHUSETTS SERVICES SOLUTIONS INSTALLED SALES CONTRACT LOWE'S A THORIZED REPRESENTA I iV E SALES ID LATE CJSTCIVELI N'%1: f Dan Flaherty 2054066 7/20/202 Susan Parker STORE NO. STREET ADDRESS STREET ADDRESS 1916 282 russell rd 35 Graves ave CITY STATE Z., C T4 SATE 2IP Hadley MA 10135 Northampton rtna 01035 TH.I-Pii'N, 413-325-3625 (413 584-0689 [daniel.flaherty@storeiowes.com spad<er4901@gmall.com LOWE'S CONTRACTOR LICENSE# LOWE'S REPRESENTATIVE LICENSE it CREDIT ERI- CHECK LCC CARD #24688(home miproventent cortractotl,035194 NA it ApplIcable) ......* i This is only a quote for the merchandise and services printed below; Lowa's does not offer sorvicos to paint, sial or stain fences. This becomes an agreement upon payment and issuance of a Lowe's receipt,upon payment,the entire agreement,including the specifically completed pages of this document, the Terms and Conditions included with this document and any other addenda and attachments hereto,shall be referred to herein as this'Contract.'PLEASE READ THIS ENTIRE DOCUMENT, INCLUDING THE 'NOTICES," "TERMS AND CONDITIONS," AND "ADDENDUM" CONTAINED WITHIN THIS CONTRACT ON THE FOLLOWING PAGES BEFORE SIGNING. INSTALLATION STREET ADDRESS 35 Graves ave Northampton ma i 01035 ! MERCHANDISE AND INSTALLATION SUMMARY(i.E.ITEM NUMBERS,COLORS,DI • NSIONS,CONSIDERATIONS): Removal of single layer of roofing, Not to install flat rolled roofing. , Installation of full Owns Corning roofing system, 6' of Ice and water, pro armor, Owens Corning starter stripes, New f8 drip edge, white, Owens Corning Duration singles Brownwood, matching hip and ridge, sure vent, permits and delivery, dumpster included. [ , CONTRACT TOTAL INCLUDING TAX) $14888.00, Work is to commence upon reasonable availability of Contractor and/or any special order or customer made Good(s) which is anticipated to be 09/20/2021 [fill in date]. Estimated completion date is 10/20/2021 [fill in date]. COVIO-19 has affected manufacturers and labor markets, with the production of fence, deck and generator material experiencing significant delays and installation start dates that are at least four(4)months away in most cases. Please also note that weather can delay start dates for these and other exterior categories,particularly in colder climates. , Rev.03/02/2021 ii • LOWE'S SERVICES CONTINUATION OF MATERIALS AND WORK TO BE PERFORMED LE. ITEM NUMBERS,COLORS, DIMENSIONS, CONSIDERATIONS): 1 • 1 • 1 Rev.03/02/2021 2 LEAD SAFE INFORMATION. Federal and applicable state laws require that You be provided with a lead hazard information pamphlet such as the Renovate Right: Important Lead Hazard Information for Famines, Child Care Providers and Schools. By signing this Contract, You acknowledge having received a copy of this information pamphlet before work began informing You of the potential risk of the lead hazard exposure from renovation activity performed in Your dwell ng unit or facility. A copy of the pamphlet is available at the following website: www.lowes.comJEPARRP. For more information see: https/lwww.epa.gov/lead/lead-renovation-repair-and-panting-program. NOTICE OF ARBITRATION AGREEMENT: This Contract provides that all claims by Customer or Lowe's will be resolved by BINDING ARBITRATION. Customer and Lowe's GIVE UP THE RIGHT TO GO TO COURT to enforce this Contract (EXCEPT for matters that may be taken to SMALL CLAIMS COURT). Lowe's and Customer's rights will be determined by a NEUTRAL ARBITRATOR and NOT a judge or jury. Lowe's and Customer are entitled to a FAIR HEARING. But the arbitration procedures are SIMPLER AND MORE LIMITED THAN RULES APPLICABLE IN COURT. Arbitrator decisions are as enforceable as any court order and are subject to VERY LIMITED REVIEW BY A COURT. FOR MORE DETAILS: Review the section titled ARBITRATION AGREEMENT, WAIVER OF JURY TRIAL AND WAIVER OF CLASS ACTION ADJUDICATION found in the Terms and Conditions of this Contract. NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L. c. 142A: LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT, THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L. c.142A. THE SIGNATURES OF THE PARTIES BELOW APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWES, PURSUANT TO M.G.L. c. 142A. THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. If customer has a complaint which cannot be resolved informally, the home Improvement Cont-actor Law(M.G.L, c. 142A)may provide Customer with the right to request arbitration through a private arbitration program approved by the Director of the Office of Consumer Affairs and Business Regulation, as an alternative to court action. The same right is not afforded to Lowe's unless this Notice is signed and dated by Lowe's and Customer. All claims by Customer or Lowe's concerning this Contract which cannot be resolved informally, and which are not covered by M.G.L. c142A or subject to the jurisdiction of a small claims court, shall be resolved by binding arbitration as set forth in the Terms and Conditions. 07/20/2021 By D ate: Lowe's Authorized Representative By: 4-1"1Date: 07/20/2021 Customer PRICE CALCULATIONS. If this Contract includes Goods and related Installation Services sold by unit of measurement,such as per square foot, the Price may include more Goods than the actual measurements of Your project area. The Price includes the total amount of Goods required by Lowe's to fulfill the Contract (including surplus materials and overages) (together the "Estimated Product")and the Installation Services required based upon this total amount of Goods. For instance, a 120 square foot room may require 140 square feet of carpet to properly match the carpet seams, pattern, or unique room characteristics, and the Price would include Installation Services based upon the 140 square feet of carpet.The tctal amount of Estimated Product is based upon the total Goods recommended by the Installer, based on the Installer's assessment of unique characteristics of Your project, If any usable Goods are left over, Lowe's may,at its discretion, initiate a Price adjustment. Lowe's will not adjust the Contract Price for the related Installation Services. By signing this Contract, You acknowledge You are aware of Your project area measurements and the amount of Estimated Product,and that the Estimated Product may exceed Your actual project area.If Your,project includes the installation of flooring materials, by signing this Contract You further acknowledge having received a completed Flooring Detail Diagram (the "Diagram")prior to execution of this Contract. Upon request, Lowe's can provide You with additional copies of the Diagram, which identifies the square footage of Your project area and the square footage of tie Estimated Goods. PHOTO RELEASE. By signing this Contract, You grant to Lowe's, its representatives, and Installer the right to take and use photographs, videos,or other representations of the Premises before and after the Installation Services and all work performed at the Premises related to this Contract(the"Content"). Lowe's irrevocably keeps aNI rights(including the copyright),title,and interest in the Content for use in all markets and media,worldwide, in perpetuity.Lowe's can use the Content, in any form or medium, internally for any purpose(e.g., customer service, planning, and claims. NOTICE REGARDING PAYMENT SCHEDULE. If the Contract Price is$1,000 or less, payment of the Price by Customer to Lowe's is due in full upon execution of this Contract. If the Contract Price exceeds $1,000, Customer shall use the following payment schedule: (1) Deposit of $ $5,000.00 [enter 1/3 of the contract Price] to be paid upon signing this Contact. Any deposit collected at the time this Contract is signed will not exceed one-third(1/3)of the Contract Price; Rev.03/02/2021 ' (2) Payment of $ $9,788.00 [enter 2/3 of the contract Price minus $1001 to be collected upon or after the commencement of work. Customer authorizes Lowe's to charge Customer's credit card, or deposit Customer's check, for the amount of the payment indicated in this section anytime upon or after the commencement of the work; and (3) Final payment of$100 to be paid upon completion of the Installation Services to both parties' satisfaction. NOTICE OF CUSTOMER'S RIGHT TO CANCEL. If this is a "door-to-door sale" as defined by 16 C.F.R. §429.0(a), or if this Contract is signed by Customer at a place other than the address of the seller as set forth in M.G.L. c. 93 § 48, You, the Customer, may cancel this Contract at any time prior to midnight of the third business day after the date of this transaction. See the notice of cancellation form sent as an attachment to this Contract for an explanation of this right. By executing this Contract,Customer acknowledges receipt of two(2) completed copies of the Notice of Right to Cancel form and certifies Lowe's has informed Customer orally of his or her right to cancel. NOTICE TO CUSTOMER. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Lowe's Home Centers, LLC EXECUTED ON 20 , DAY OF July 2021 .OWE-'S AUTHORIZED REPRESENTATIVE SIGNATURE CAVNFR'S SIGNATURE CO-OWNER SIGNATURE Customer acknowledges receipt of a true copy of this contract which was completely filled in prior to Customer's execution hereof. Rev.03/02/2021 4