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17C-299 (7) BP-P 022-1373 131 CHESTNUT ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 17C-299-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-1373 PERMISSION IS HEREBY GRANT AD TO: Project# DOOR Contractor: License: Est. Cost: 1168 LOWES HOME CENTERS INC 117055 Const.Class: Exp.Date: 08/02/2025 Use Group: Owner: S SASS JONATHAN R&CHRISTINE Lot Size (sq.ft.) Zoning: URB Applicant: LOWES HOME CENTERS INC Applicant Address Phone: Insurance: 1000 LOWES BLVD (413)272-8931 0 WC016393105 MOORESVILLE, NC 28117 ISSUED ON: 10/26/2022 TO PERFORM THE FOLLOWING WORK: REPLACEMENT DOOR 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIO ATION OF ANY OF ITS RULES AND REGULATIONS. Signature: '• �,.11 yg . I)1 • � I , Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner r---. li' Emu► ) V / L V alety O CI 2 4 2422 he C mmonwealth of Massachusetts Y of building Regulations and Standards FOR • rani n1Nc ir�sP Ns MUNICIPALITY �ti „Oh.�Aschusetts State Building Code, 780 CMR USE Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building ermitNum �ber: ' -' 1 " /3 73 Date Applied: E�i►-)<1Co� �� /6-2 -7 iz Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1,1 Pr77 ddress• 1.2 Assessors Map&Parcel Numbers 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: Zone: Outside Flood Zone? Public 0 Private 0 Check if yes❑ Municipal 0 On site disposal system !:l SECTION 2: PROPERTY OWNERSHIP' 2.1 Own �l�1Ra07!!r) c �ld S ��{zip�(► �l f��V�Y N);(1 " (13)4 51) 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 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': ellt)Ni4 Js ui' K4r8k 'L dintr SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ /// , 9 9 1. Building Permit Fee:$ Indicate how fee is determ4ted: Cl2.Electrical $ / Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ r1 Check No. 4 heck Amount: v Cash Amount: 6.Total Project Cost: $ ilk/ 49 9 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Constructi Supervisor License(CSL) i i�D�� kj.// ' 14 Li/tense Number Ex 'ra on Date Name of CSL Holder / 7 `�,/yy ,L 6tfrititi e4ist CSL Type(see below) No.and Stree ` JCG((i�) �""�' Type Description U Unrestricted(Buildings up to 35,000 Cu.ft.) ,� ��/4 R Restricted l&2 Family Dwelling City/Town,State,GZIP i M Mas onry RC Roofing Covering WS Window and Siding (26 30,60_0 ,7 i, / SFISolidFuelInsulationBurning Appliances �� G, ^� 1 TelephonEmail address /'1/, tv r' /D Demolition 5.2 Registered He Improvemen ContraMHI49. /�� F 1yG,�,/IEri / / HIC Registration Number Expiration to HIC palirorli ran .r2e_73,5- 1 `do.SM`^/alio ,4 Non� r Yo0 /Y2 �7//7s9� Email address/ 1 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 V No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize bQ � j to act on my behalf,in all matters relative to work authorized by this building permit application. jaa s10( ` cO - /1c� f1)/-*/1 Print Ow me(Electronic Signature) Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained' is application is true and accurate to the best of my knowledge and understanding. ./14/ ge0 /oJ1) 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 HIC 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 half/baths 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" STORE COPY MiINSTALLATION SERVICES CUSTOMER CONTRACT- MWORK - INT/EXT/PATIO DOOR LOWE'S OF HADLEY. MA, STORE # 1916 STORE PHONE: (413)588-0270 282 RUSSELL STREET SALESPERSON: CHASE FORBUSH HADLEY, MA 01035-0000 SALESPERSON ID:2195341 Document Print Date : 10/10/2022 s only a Quote for the merchandise and services printed below. This becomes an agreement upon payment and issuance of a Lowe's receipt, upon which the entire agree- including the specifically completed pages of this document, the Terms and Conditions included with this document, the applicable portion(s) of Lowe's receipt, and any addenda or attachments hereto, shall be referred to herein as this"Contract." SE READ THIS ENTIRE DOCUMENT.INCLUDING THE "TERMS AND CONDITIONS:' BEFORE SIGNING. 's Registration or Contractor License Number/Lowe's Contractor Name 's Home Centers, LLC's MA HIC NO.: 148688 Lowe's Home Centers. LLC's FEIN: 56-0748358 Customer Name Home Phone JON SASS 413-588-8857 Customer Address Other Phone 131 CHESTNUT ST City State/Province Zip/Postal Code BAY STATE VILLAGE MA 01062 Installation Address 131 CHESTNUT ST Installation City Installation State/Province Installation Zip/Postal Code FLORENCE MA 01062 MERCHANDISE AND INSTALLATION SUMMARY MERCHANDISE SUMMARY : FB50N V GEO 619 : STK : SCH SN COMBO SGL GEORGIAN : SCH SN COMBO SGL GEORGIAN : SCHLAGE LOCK - QTY 1 0 : 2829 : STK : 1INX1OINX8FT PVC BOARD : 1INX1OINX8FT PVC BOARD : METRIE INDUSTRIES INC - QTY 1 3 : 2866 : STK : 1INX3.51NX10-FT PVC TRIM BO : 1INX3.51NX10-FT PVC TRIM BO : METRIE INDUSTRIES INC - QTY 3 9 : SSCD4E28LB : STK : 32 TTBM FG 9LITE EXT GRL SMTH LH : 32 TTBM FG 9LITE EXT GRL SMTH LH : TRU LOGISTICS INCORPORATED - QTY 6 : ART10002096 : STK : 1-2-8 AZEK TRADIT PVC BOARD : 1-2-8 AZEK TRADIT PVC BOARD : PARKSITE INC - QTY 3 76 : 99108862 : STK : SMART WINDOW AND DOOR 12-OZ : SMART WINDOW AND DOOR 12-OZ : DDP SPECLTY ELECT MATERIALS US - QTY 1 Materials Price $ 627.09 6 Project No. 752368877 for JON SASS Page 1 of 8 STORE COPY INSTALLATION DESCRIPTION Der.type: Exterior_ Location of new door(s) : Back Door Select new door : Single Pre-Hung Hardwood door : No Sidelights or transoms : No Number of additional holes bored for accessories : None Install specialized mortise hardware : No Install storm door : No Lead safe practices : No Total linear feet of custom trim to be Installed : 0 Deliver door : Yes Customer understands scope of the project : Yes Permit Fee : Yes Additional Mileage : 0 Access fee : None Dump entry Fee : Yes Additional Work : Jamb ext. Sill support trimwork Additional Work Charge : Yes Comments : No Comment Labor Charges S 594.90 Detail Deduction -S 35.00 Additional Specifications: Notation.Lowe's will not make structural modifications.remove cabinetry to accommodate new appliance.or upgrade electrical service. Additional Specifications: 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 Families. 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 to be performed in Your dwelling unit or facility.A copy of the pamphlet is also available at the following website: httos://www.e a.gov/sites'productionifites/documents/renovaterightbrochure.pdf. For more information see:httos://www.eoa.govllead/lead•renovation•reoair-and•Qainting-program. PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photograghs of the Premises where Installation Services will be performed and all work performed at the Premises related to this Contract. and irrevocably grants to Lowe's all right, title. interest in and to the photographs for use in all markets and media.worldwide,in perpetuity. Customer authorizes Lowe's to copyright, use and publish the photographs in print and/or electronically,and agrees that Lowe's may use such photographs for any lawful purpose. including, but not limited to.marketing,advertising,publicity,illustration,training and Web content.By initialing here.Customer agrees to the foregoing. 4V/4 [Customer to initial to the left]. NOTICE TO CUSTOMER-PRICE CALCULATIONS: In order to properly perform the installation of certain Goods,the Contract Price may include more Goods than actually will be installed based on the measured square footage of the Project Area.As a result.the parties agree that the lump-sum Price stated in this Contract is calculated upon both the value of the estimated Goods required to ful- fill the Contract(including waste),which may exceed the actual square footage of the Project Area,and the labor which may be estimated based on the amount of Goods required to fulfill the contract (including waste). By signing this Contract below, Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may not be refunded once the Installation Services are performed.. 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 or- der 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. Store 1916 Project No. 752368877 for JON SASS Page 2 of 8 STORE COPY TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES •whereapplicable SUB-TOTAL S 1186.99 'TAX $ 0.00 DELIVERY --- - - $ ---0.00 ORDER TOTAL $1186.99 BALANCE DUE Work is to commence upon reasonable availablity of Contractor which is anticipated to be I /1 V/ ZO LL [fill in date). Estimated completion date is !VI 0/24' ZZ [fill in date]. f f NOTICE TO CUSTOMER QQ 11 All items listed in this contract and specification sheet(s) are to be installed under conditions agreed upon at time of purchase and at the price appearing on this contract form. This assumes sound existing substructures, superstructure and points of attachments. Extra labor or material incident to installation necessitated by defective substructures. superstructure. points of attachment, or the moving of fixtures or appliances to be billed at extra cost to custom- er. IF THE CONTRACT TOTAL IS S1.000.00 OR LESS. Customer must pay in full. COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS $1,000.00: [ ) Customer to use the following payment schedule: (1) Deposit of $ to be paid upon signing contract. Any deposit collected at the time this Contract is signed will not exceed one-third (1/3) of the contract price; and (2) Payment of S _ to be collected upon or after the commencement of work. I/We authorize Lowe's to do one of the following (check ap- propriate box below): ( ) Charge my/our credit card for the amount of the payment indicated above upon or after the commencement of work; or Deposit my/our check for the amount of the payment indicated above anytime upon or after the commencement of work: and (3) Final payment of $100.00, to be paid upon completion of the installation to both parties' satisfaction. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CON- TAINED IN THIS CONTRACT AND WHICH FOLLOW THE SIGNATURE PAGE(s). BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU HAVE READ. UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH IN THIS CONTRACT. YOU ARE ENTITLED TO A COPY Store 1916 Project No. 752368877 for JON SASS Page 3 of 8 STORE COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. 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 CON- TRACT. THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRET- ARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUB- MIT TO SU H ARBI ATION AS PROVIDED IN M.G.L. c.142A. By: Date: 1O//O/ZdL Lowe's Home Centers. LLC r By: Date: ( \ . Owner By: _ Date: Co-owner or Witness THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWE'S PURSUANT TO M.G.L. c.142A. THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES. WITNESS OUR HAND(S)AND SEAL(S) BELOW THIS I O4k DAY OF 0Gf013Gr , Lowe's Home Centers, LLC By: C/2�L (Seal) Print Name: 67 f C F r6r--S "� I (Seal) Address Owner 'kW( f}' Orb 3 -Top.) City State/Province Zip/Postal Code Print Name Co.Owner or Witness (Seal) Store 1916 Project No. 752368877 for JON SASS Page 4 of 8 The Commonwealth of Massachusetts Department of Industrial Accidents !r. -' Office of Investigations -It--; Lafayette City Center ��.�-, ' & .. . ' 2 Avenue de Lafayette. Boston,MA 02111-1750 ";-i• 5=,' www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): LOWES HOME CENTERS Address: 1000 LOWES BLVD City/State/Zip: MOORESVILLE,NC 28117 Phone #: 860-505-9314 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ® I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.ElI am a sole proprietor or partner- listed on the attached sheet. 7. IDRemodeling r ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9[No workers' comp. insurance comp. insurance.t ❑Building additio required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself No workers' right of exemption per MCIL ys [ comp. 12.❑Roof repairs insurance required.]t C. 152,§1(4),and we have no employees. [No workers' 13. x❑Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. !Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the cub-contradors 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: AIU INSURANCE COMPANY Policy#or Self-ins. Lic. #: WC035901712 AOS �.� Expiration Date: 4/1/2023 Job Site Address: 2/ ( 1/ Xa? £ City/State/Zip:461Y17ww i D1l/ c 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 c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Ofir e of Investigations of the DIA for insurance coverage verification. I do hereby a '(v under the pains and pe perjury that the information provided above is true and correct: Signature: Date: 11)112 Phone#: 860-505-9314 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 50Pluetbing Inspector 6.0Other Contact Person: Phone#: THE COMMONWEALTH(3F MASSACHUSETTS Home kuffnialLiffitrabon = r.= ==`_-r. 4, ::ter__ =- :< ,? ,.: Cad LOWE'S HOME Chu.L LC A .�. 10/17121123 SERVICES COMPLIANCE ` .- t-,-' ,__& Mt30I�SilILLE NC Z8ii7L. i--...._1 ' E UMW Address and RIM ttCard. THE COMMONMEMLIM MASSNAIRINECIS olllosolGasss wirMIr11sieaslsws-i/rrllvA IkJJ UMandbdarwwt_rM.sakjrdMbwsme BONE T ___cupd_ asioginEssrrrla lftsysdsellmO e airo.dCammlllsisai Brims wioraaian -iIIa- i.tisrs-SOO* La s HOME CENTERS.t - - , - fzt Es SOTOL " i'E .rp.,FAd.' cte WOO LOWES t�.w -r:, -` -, = �;;�-,.,,�%,��- SERVICES COMPUNNCE - th acy Not valid without�t�ttEt�ICC UM - A`oRD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDrrryy) 03/23/2022 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 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 CONTACT Marsh USA Inc. NAME: 100 North Tryon Street,Suite 3600 ((AA/�C�.PHONE No.Ex FAX No/: Charlotte,NC 28202 �DDRE ADDRESS: INSURER(S)AFFORDMG COVERAGE NA/CC CN102776519 LowesSl-22 23 INSURER A:National Union Fire Ins Co.d Pilsburgh PA 19445 Casually Co INSURED INSURER B:Interstate Fire& 22829 Lowe's Companies,Inc. and subsidiaries INSURER C:AIU Insurance Co 19399 1000 Lowe's Boulevard INSURER D Mooresvile,NC 28117 _INSURER E: ,INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-004976909-11 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 POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSD WVD POLICY NUMBER 011WDp yyYY) (NNIDD(YyYy) UNITS DNSR TYPE OF INSURANCE ADOLISUBR POLICY EFF POLICY EXP COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS�IADE OCCUR Self Insured-See below DAMAGE TO-RENTED PREMSES(Ea occurrence) _ $ MED EXP(My one person) _$ PERSONAL&ADV INJURY $ GEAR AGGREGATE LIMIT APPLES PER GEKEtAL AGGREGATE $ PRO- POLICY jEcT LOC PRODUCTS-COMP/OP AGO $ OTHER: $ A AUTOMOBLE amour( CA7030892 (AOS) 04/01/2022 04/01/2023 C BM SINGLE LSAT $ 5.000,000 C X ANY AUTO CA7030891 (MA) 04/01/2022 04/01/2023 BODILY INJURY(Per person) $ A AOVVNED UTOS ONLY AUTOS CA7030893 (VA) 04/01/2022 04/01/2023 BODILY INJURY(Peracciden() $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) B X UMBRELLA LIAR X OCCUR )USZ00024220 04/01/2022 04/01/2023 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED RETENTION S $ C WORKERS COMPENSATION WC035901712 (AOS) 04/01/2022 04/0112023 x PER OTH. ER C AND EMPLOYERS'LIABILITY Y/N WC035901713 (ND.WA,WI,WY) 04/01/2022 041b1/2002;i 5TATl1TE ANYPROPRIETORPARTNER/EXECUTNEEl.EACH ACCIDENT $ �'��� OFFICER/MEMBEREXCLUDED? N N/A I (Mandatory In NH) EL DISEASE-EA EMPLO $ 2,000,000 It yes.describe under 2,000,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY UM $ A Excess Workers'Compensation XWC1647325 (FL) 04/01/2022 04/01/2023 (WC per statute) 3,000,000 A Excess Workers'Compensation XWC1647324 (AOS) 04/01/2022 04/01/2023 (WC per statute) 3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Connreraal General Liabiity policy is Self-Insured,effective 4/1/2022 to 4/112023. CERTIFICATE HOLDER CANCELLATION Lowe's Companies,Inc.and Subsidiaries 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 yi- -/ '2 ©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 AOREP ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA hc. Lowe's Companies.Inc. and subsidiaries POLICY NUMBER 1000 Lowe's Boulevard MooresviNe,NC 28117 CARRIER NAIL CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers'Compensation and Excess Workers'Compensation policies induce a se8-insured retention at$2.000.000. General L abity.Tie insured is self insured for$10.000.000 each occurrence for the period of 4/1/2022 to 4c 1 r2023. The Automobile Liability poky ev:encad above is suoject to adds onal self-insured retentions excess of limas shown for various perils covered. ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD City of Northampton S Massachusetts ,��`�`~t" 'c4C� (4 it I. ;`d�lifir) • T '` DEPARTMENT OF BUILDING INSPECTIONS S `' �^..- 212 Main Street • Municipal Building V,i, aa� �. Northampton, MA 01060 r 0C amp SN„, 10%1 1 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: Ho re A //7ic NI aeyimid•‘L bbv'i4 Nwe? The debris will be transported by: Name of Hauler: 62dAilionde--/ Signature of Applicant: Date: I D,7412 ACORD CERTIFICATE OF LIABILITY INSURANCE DA'o; "" 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 POiJCES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S:.AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: V the certificate holder is an ADDITIONAL INSURED,the polley(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 than of such endorsement(s). PRODUCER CO4TACT Diane General,CISR Nicholso^Associates,Inc. PHONE e�i. 1203)877-2741 .FA. ,, t203)877.8004 395 New Haven Ave. r4UdL d.gendreau4nichoMonassoc.com P.O.Box 5169 INtURplle)AFFORDING OOVSRAGE rsaw. Milord CT 06460 ruLaER A; Selective Insurance Co of S.C. 19259 waune, PRIMERS: EAST COAST FLOORING AND WINDOW TREATMENT INC. POURER C: 14R PEACH ORCHARD RD aNIlRell o NEWER E PROSPECT CT 08712-8001 ,"Run P COVERAGES CERTIFICATE NUMBER: 921,22 GL Aulo Limb REVISION NUMBER: 1 THIS IS TO CERTFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PEPJOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT TERN OR COMMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT T.DISCO THIS tilt I IFICATE MAY BE ISSUED OR MAY PERTAN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB.,ECT TO ALL'YE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS. POLICY EFT POLICY EXIT LTR ADOLMOINTYPE OF INSURANCE POLICY NUMBER p INDEP YYY) ( Y) LIMITS X COBERCML GENERAL WaalTY FACT occ RRFA'c { 1.000.000 L D I CLAMS4IADE ®OCCUR ANA aA rO neN: S XI t10D ABIAGE3 f5euu.Yoon' I ,-'., LED EYE,My one Leman. s 15000 A — Y S 2040386 09/2212021 09122/2022 PERSONAL 41 AD,o..;,Rt $ 1.000,000 BENI AGGREGATE LNNAWES PER GENERAL AGGREGATE f 3.000,003 RPOLICY El,TO' ED LOC PROOLCTB-CWNPOPAGG {3.000,000 OTHER. f AUTOMOBILE LIARLT' CIVESPED SING-E JMT { 1,000.000 IFs ace oeHIl _X'k'r'µ0 BOOLY WARY IPa'pe'wr' { A OWNED ^SCYEDULED Y S 2E40386 0922/2021 09222022 BODILY tamer IPe coc.r,• { AJTos PH,' AUTOS NEED a AUTOS:;H_ AUTOS O I Pf1 DAMAGE Y AUTOS ONLYLY (Per=Wenn Medical payments {5.000 X uEERELLA LIAR _OCCUR EACH OcomRREH-.: a 2.000,000 A EXCESS L•LB clNMesA•ADE S 2049.386 09f222021 09222022 A.,,,,,,„ $2,000.000 LED I I RETENTION S a WORKERS COMPOISATEII PER OTH'. EMP LOYERS PLOYER'U INLITY Y1le sTANII I I TR A ANY PROPRETOR RI PARTIEEXECUTIVE El NIA WC 9084546 BBID42D22 081041202J F I.FACE ACCOE,:- {500,000 OFFIERIEMBER EXCLUDED, (MeadMRy•r ens F.L.OFRAAVF.FA OUP i O rF 1500,000 e yes,oeepe.under DESCRPmEN OF DPERATo.s e.U-. E.:.psnASE- Tim0.000 Pt J�`LIMIT { DESCllPf oll OF OPERATIONS/LOCATIONSf VEHICLES(ACORD T01,AddttNnel Rants Schedule.may be aMnchhed a nom spare is required) Vendor Number 1'878 Region 18 Lowe"s Companies.Inc.and Lowes Home Centers.LLC are named as add'Nonal novas as respects general Sabikty and auto Parsley primary over any other available insurance coverage.IC Day Nonce of Calcel m. ,aalftY TOEs i-sL*ance is aion for Nor-Payment of Premium CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Bc CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED le Lowe's COI,OSPeS.IM.and any and as subsd:anes ACCORDANCE WITH THE POLICY PROVISIONS. 1300 Lowe's Bend AUTHORIZED REPRESENTATIVE Mooresville 'NC Litt; AfLeA.5 ,_ I "`1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2018103) The ACORD name and logo are registered marks of ACORD The Official Websrte of the Executive Office of EOHED the Drvsion of Professional Lrcensure. and the Division of Standards Now Public Safety ;• / I _a �6 MassMass. Gov State Agencies r fx Licensee Details Demographic Information Full Name KYLE R SEARLES Owner Name: License Address Information City: PROSPECT State CT Zipcode 06712 ,Country: United States License Information License No: CS-117055 License Type Construction Supervisor Profession: Building Licenses Date of Last Renev al Issue Date: 6/27/2022 Expiration Date- 8 2 2025 License Status. Active Today's Date: 823,2022 Secondary License Type Doing Business As Status Change Reason License Issuance