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11A-021 (9) BP-2024-0992 58 UPLAND RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 11A-021-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREG1ST[RED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2024-0992 PERMISSION IS HEREBY GRANTED TO: Project# WINDOWS 2024 Contractor: License: Est.Cost: 2109 LOWES HOME CENTERS INC 117055 Const.Class: Exp.Date: 08/02/2025 SKANTZ-HODGSON LESLIE C&KEVIN J Use Group: Owner: HODGSON Lot Size(sq.ft.) SKANTZ-HODGSON LESLIE C& KEVIN J Zoning: URA Applicant: HODGSON Applicant Address Phone: Insurance: 58 UPLAND RD LEEDS, MA 01053 ISSUED ON: 08/08/2024 TO PERFORM THE FOLLOWING WORK: 2 REPLACEMENT WINDOWS 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 VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 7/7" Fees Paid: $60.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner IIP \i '() C1(k*:)TifYk:nlIS epuvr,/ S, The Commonwealth of Massachusetts .0): Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR MUNIUSE 1`f' US E Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised At SOH- z One-or Two-Family Dwelling iW o u This Section For Official Use Only otr,a Building Permit Number: 60- -2'Y.. g4'7/ Date Applied: _ N z z 1 W zo J Building Official(Print Name) ature = a- SECTION G SECTION 1:SITE INFORMATION CCCC o 2 1.1 Pr ope A s • . i 1.2 Assessors Map&Parcel Numbers o � � �/� � Q`�___ 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 II) Frontage(II) 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 Zone: Outside Flood Zone? — Municipal 0 On site disposal system 0 Check if yes❑ )J SECTION' 2: PROPERTY OWNERSHIP' 2.1 Owner of n t, i Q �/( ez71.9� l "e� Jig/g 01668 Name(Print �u t,SS,taatte,Zff `J i /JUt 6 1tryt eat-- 13)37�6701 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 44 1 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Proposed Work'-: layoy-41ripae i .02 idii-vioias- rm 3/rii e ,e (9?& `e SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ op/l)9 42., 1. Building Permit Fee: $ Indicate how fee is determined: 2.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: Check No.),AXA Check Amount:0 ldl Cash Amount: 6.Total Project Cost: $ �ld9, 7,,,, , 0 Paid in Full 0 Outstanding Balance Due: *e SECTION 5: CONSTRUCTION SERVICES 5.1 Construed dpervisor Lice (CSL) I /7�� -s- ��`� k �) License Nuumber piration Date Name of CSL I old 114 o. fila, dr`„ e/ List CSL Type(see below) No.and St "� Lam•- Type Description j1 11 n ; /0 : OG 7i,„ U Unrestricted(Buildings up to 35.000 Cu.ft.) U V� e. / R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding a_ __ 9zpc idA/21K6kil,fir—yA,--- SIF InsulationSolidFuel Burning AppliancesTelephone Email addresse Ai . D Demolition 5.2 R stored Horn mprovem t Contractor(HIC) l 971. Pope joiiim---- _ --rKL_____ iIICReegistration Number Expiration Date IIIC Na�d��/ nt/veit..0• 1CC / . -8 No.an 46)6 Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit mutt 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 W 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 " 2( '—) -C-070 to act onLifit.che ,_ takt- #'7211my behalf,in all matters relativeto work authorized by this building permit application.Print Owner's Name(Electronic Signature) 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 in this application is true and accurate to the best of my knowledge and understanding. c----'' KI)[-AdkJ--Gir6 Print Owner's or Authorized Agent's Name(Electronic Signature) e7)..?)/ 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.govioca Information on the Construction Supervisor License can be found at www.mass.govldps 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" A LowE's MASSACHUSETTS SERVICES SOLUTIONS INSTALLED SALES CONTRACT LOWE'S AUTHORIZED REPRESENTATIVE SALES ID DATE CUSTOMER NAME Steven Lockwood 3070929 07/26/2024 Leslie Skantz-Hodgson STORE NO. STREET ADDRESS STREET ADDRESS 1916 1000 Lowes Blvd Attn: ISI-26 58 Upland Rd CITY STATE ZIP CITY STATE ZIP Mooresville, NC 28117 Leeds MA 01053 TELEPHONE .I PnC^,. 888-516-1010 413-374-6701 EMAIL EMAIL kteven.Iockwood@Iowes.com lcskantz@gmail.com LOWE'S CONTRACTOR LICENSE N LOWE'S REPRESENTATIVE LICENSE# CREDIT/DEBIT CHECK LCC CARD GIFT CARD See MA Addendum (If Applicable) This is only a quote for the merchandise and services printed below. This becomes an agreement upon payment and issuance of a Lowe's receipt,upon pay-ment,the entire agreement,induding 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 CITY STATE ZIP 58 Upland Rd Leeds MA 01053 Lowe's does not offer services to paint,seal or stain fences. MERCHANDISE AND INSTALLATION SUMMARY(I.E.ITEM NUMBERS,COLORS,DIMENSIONS,CONSIDERATIONS): CONTRACT TOTAL $2,109.12 (INCLUDING TAX) Work is to commence upon reasonable availability of Contractor and/or any special order or custom made Good(s) which is anticipated to be 09/02/2024 [fill in date]. Estimated completion date is 10/04/2024 [fill in date]. Rev.05/01/2024 1 LOWE'S SERVICES CONTINUATION OF MERCHANDISE AND INSTALLATION SUMMARY (I.E. ITEM NUMBERS, COLORS, DIMENSIONS, CONSIDERATIONS): 1-1;o-cket installation of two windows. 3201's full screen white vinyl. I Rev.05/01/2024 2 Window 1 Quantity 2 Options Description: Atrium RB Series 3201 Best Buy IHC Double Hung Unit Type: Complete Unit Energy Star Climate Zone: Energy Star Northern IECC Climate Zone: Zone 5 Nailing Fin: No iWidth: 37 i Height 60 Sash Configuration: Equal Operation/Venting: Double Hung 1 Exterior Color: White 1 Multi-Cavity Foam Filled Frame: Yes Glass Energy Efficiency: Low-E w/Argon(Northern Fnergy Star) Exterior Glass Color. Clear Glass Strength&Safety Double Strength Grille Location: Grille Type: No Grids Grille Pattern: No Grids Hardware: Color Matched Double Sash Lock Yes WOCD Sash Limiter/Night Latch: Standard Night Latch Screen: Full Screen Screen Mesh Type: Standard Charcoal Fiberglass Mesh Screen Shipping Option: Installed in Window Foam Wrap: Not Applied Head Expander No Extended Warranty: Lifetime Glass Breakage Only Remake: No CPD Number: A• .-M-409-03995-00007 Interior U-Factor: 026 SHGC: 0.48 Satisfied Energy Star Zone(s): Northern DP Rating: DP35.:Size Tested 36-in x 74-in SOS: 1097957 SOS Description: WTS IHCATR RB3201 BESTBUY Labor SKU: 1166040 LCZ: NP-07 Production Time(does not indude transit time): 15 Customer Service Number: 800-672-5828 Comment/Room: Window 7 Delivery Method: In-Store Pick-Up Catalog Version Date: 07/10/2024 Additional Project Details permit: permit Quantity 1 Package Price: $1,988.58 Tax: $12054 Your Price: $2,109.12 NOTICES LEAD SAFE INFORMATION. Federal and applicable state laws require that You be provided with a lead hazard information pamphlet such as The Lead-Safe Certified Guide to 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 performed in Your dwelling unit or facility. A copy of the pamphlet is available at the following website: www.lowes.com/EPARRP. For more information see: https://www.epa.gov/lead _ad-renovation-repair-and-painting-, am. 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 Contractor 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. By: Date: Signed at 07/26/2024 03:39 PM -- Lowe's Authorized Representative Signed at 07/27/2024 09:40 AM By: Date: 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 total 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 the 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 all 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. CONSENT TO COMMUNICATION. By signing below, You consent to Lowe's and its authorized Installers contacting You through automated means or system at the email address and phone number provided regarding the product and/or Installation Services You requested. You understand Your consent is not required as a condition of purchasing Goods or Installation Services. Privacy Statement, SMS Terms Rev.05/01/2024 3 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 $ 663.00 [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; 1346.12 (2) Payment of $ [enter 2/3 of the contract Price minus 51001 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 attached notice of cancellation form 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 EXECUTION DATE: Signed at 07/27/2024 09:40 AM LOWE'S AUTHORIZED REPRESENTATIVE SIGNATURE OWNER'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.05/01/2024 City of Northampton atr "7P ,i , 04. SAS •• S,C Massachusetts ti ( ��� • 4 DEPARTMENT OF BUILDING INSPECTIONSeft 212 Main Street • Municipal Building 0h cam Northampton, MA 01060 J'sy ., `d 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: C t l e(" l/l,()&2/0 Jz/, Afp<Ag ���C-�(.�-t ia240 ' l&hJJ The debris will be transported by: Name of Hauler: kiik7 Siae,o) pP Signature of Applicant: ) Date: '0%1 g THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs"and Business Regulation 1000 Washingtgtrt- Suite 710 Boston,_Massachusetts— :02118 Home lmpro _ ;. i «,' Registration r F-( i� --.-. "' . Type: Supplement Card '"� _.-;... e+gisl Lion. 148688 LOWE'S HOME CENTERS,LLC V- Et iration. 10/17/2025 n 1000 LOWES BLVD ''"��t =- ... SERVICES COMPLIANCE s,.P2°' ,.. ..,:p: �--- MOORESVILLE, NC 28117 " ,,' 7-- ' K::^ :: '-i \�,` k tip, - Mom: . , Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENTCONTRACTOR expiration date_ tf found return to: TYPE 340e/bentCard Office of Consumer Affairs and Business Regulation Restistrafion " Expiration 1000 Washington Street -Suite 710 140888 10/'17i202Z Boston.MA 02118 LOWE'S HOME CENTERS.LiC . NEXEDES SOTO 1000 LOWES BLVD �.,,,, ; x//,eli' AP..„),.°.-4 `�SERVICES COMPLIANCE ~ MOORESVILLE.NC 28117 Undersecretary of val d wit •ut signature HCORO® CERTIFICATE OF LIABILITY INSURANCE D�(MM/ODIYYYY) 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 Use Beam MARSH USA LLC. NAME` 100 North Tryon Steel,Suite 3600 (n/c PHONE,Exit: 1-704-374-8365 FAX No): Charlotte,NC 28202 E-MAIL ADDRESS: Ltsa.beam9marsh coo INSURER(S)AFFORDING COVERAGE NAIC S CN102776519-Loaves-Front-24-25 INSURER A: Liberty Mutual Fire Insuance Company 23036 INSURED INSURER B: Fireman's Fund Indemnity Corp 11380 Lowe's Companies,Inc. and subsidanes INSURER C: LM Insurance Corporation 33600 1000 Lowe's Boulevard INSURER D Mooresville,NC 28117 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-005147621-21 REVISION NUMBER: 2 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS ----- LTR INSD 1wD POLICY NUMBER (MM/DD/YYYY) (MYIDD/YYYY) A X COMMERCIAL GENERAL LIABILITY TB2651294595074 04/012024 04/05t2025 EACH OCCURRENCE $ 3,003,000 GE To CLAIMS-MADE X OCCUR PRREMISES(EaENTED occurrrence) S 3,000,000 MED EXP(Any one person) S PERSONAL&ADV INJURY S 3,003,000 GENT AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE S 3.000,000 E0X POLICY LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: S A AUTOMOBILE LIABILITY AS2651294595104 04/01/2024 04/01/2025 COMBINED SINGLE LIMIT $ 5,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per acc dent) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) S B x UMBRELLA LIAB X OCCUR USZ00094624 04/01/2024 04/012025 EACH OCCURRENCE $ 10,000,003 EXCESS LAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED RETENTION$ $ C WORKERS COMPENSATION WA565D294595014(AOS) 04/01/20 X 24 04/01/2025 PER EOTH- R AND EMPLOYERS'LIABIUTY STATUTE ER C ANYPROPRIETORIPARTNERIEXECUTNE Y/N WCJ 51294595024(WI,MN) 04/01/2024 04/01/2025 E.L.EACH ACCIDENT $ 2,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) El_DISEASE-EA EMPLOYEES 2,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 2,000,000 C Excess Workers'Compensation EW565N294595064(FL) 04/012024 04/01/2025 (WC per statute) 3,000,000 A Excess Workers'Compensation EW265N294595034(AOS) 04/012024 04/012025 (WC per statute) 3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION Lowe's Home Center,LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1000 Loaves Blvd THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Mooresville,NC 28117 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE we.....( 1e5�4,_ f_ 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 AC€Ro ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA LLC Lowe's Convenes.Inc and subsiclanes POLICY NUMBER 1000 LONB's Boulevard Mooresville.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 EXCESS WORKERS COMPENSATION(MO) Carrier Liberty Mutual Fee Insurance Co Pdicy Number:EW265N294595054 Effective/Expirabon dates:04/01/2024-04/01/2025 Unit(Per Statute)$3.000,000 EXCESS WORKERS COMPENSATION(MA) Caner Liberty Mutual Fee Insurance Co. Pdicy Number.EW265N294595044 Effective/Expiration dates:04/01/2924-04/01/2925 Limit(Per Statute):$3,000,000 Workers'Compensation and Excess Workers Compensation pdiaes include a self-insured retention of$2.000000. The Automobile Liability policy evidenced above is subject to additional self-insured retentions excess of limits shown for various pens covered ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD P� The Commonwealth of Massachusetts Department of Industrial Accidenxc IIII 9=7.---9 (mice of Investigations 7. =ail= 1 Lafayette City Center " - F 2Avenue de Lafayette, Boston, MA 02111-1750 "• � www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizationMdividual): Lowe's Companies, Inc. Address: 1000 Lowes Blvd City/State/Zip: Mooresville, NC 28117 Phone #:860-505-9314 Are you an employer?Check the appropriate box: I am ageneral contractor and 1 Type of project(required): 4. 1.❑ 1 am a employer with ® 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in capacity. employees and have workers' x 9. ❑ Building addition ]No workers' comp. insurance comp. insurance. 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' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Ilomeownexs 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 sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: LM INSURANCE CORPORATION _ Policy#or Self-ins. Lic. #: / WA565D294595014(AOS) //95014(AOS) Expiration Date:4/1/2025 // S Job Site Address: g 1L7 -7t4._ City/State/Zip: - 40bA ,9- D/a TC 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 Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: /f/Z ' 7 5'BZ Date: 3/7/ Phone#: 8605059314 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): 1❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: AC CERTIFICATE CERTIFICATE OF LIABILITY INSURANCE DATE I D""" 05/23/2024 THIS CERTFICATE 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 POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER. IMPORTANT: tf 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 Alexis Gerzabek NAME, Abbate Insurance Associates,Inc. PHONE (Y03)777-7229 I No): (203)B65-7593 �(EA/C.No,Eefl: 671 Stale Street ADRIESS: agerzabek@abbateins.com INSURER(s)AFFORDING COV ERACE NAIC a New Haven CT 06511 INSURER A: Acadia Insurance Company INSURED INSURER B East Coast Mihvork.LLC INSURER C 14R Peach Orchard Rd. INSURER 0 INSURER E: Prospect CT 06712 INSURER F: COVERAGES CERTIFICATE NUMBER: 24-25 COI 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.UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Nip TYPE OF NSURANCE ADOUSURR POOCYEFF POLICYEXP UNITS INS0 WV0 POLICY NUMBER (YMIDDn'YYY) (MWODr'/Y1r) . X COMMERCIAL GENERAL UABILITY EAGIOCCURRENCE s 1.000.000 CLAIMSADE ®OCCUR PREMISES EatNTE uccura ncel S 500CLAIMS-MADE — WO EW CM'?one one person, S 15, A Y CPA5549377 06:04/2024 06/04/2025 PERSONAL&AOV INJURY S 1•CM•0 GOA- AGGREGATE UNIT APPLIES PER: GENERAL AGGREGATE s 2.000,000 POLICY❑jECT LOC PRODUCTS-COMP/OPAGG S 2,000,000 S ,R OTl COMBINED SINGLE OMIT s 1,000,000 AUTOMOBILE LNBIUTY (Es ac6MM1 X ANYAUTO BODILY INJURY(Per person) S A — OWNED —SCHEDULED Y CAA5549378 06/04/2024 06/04/2025 BODILY INJURY(PeracOceaU S AUTOS ONLY �_ AUTOS CEO NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY (Per a rodent I S X UMBRELLA LIAR 1 OCCUR EACH OCCURRENCE s 3.000.000 A EXCESS LIAR C A MADE CUA5549379 06/04/2024 OG/04/2025 AGGREGATE S 3.000.000 DED I I RETENTION S S WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE I I ERl4. ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N EI.EACH ACGOENR s 500.000 A OFFICER/NELIMER EXCLUDED? D N l A WCA5549380 06/04/2024 06/04/2025 (Mandatary in NH) El.DISEASE-EA EMPLOYEE S '000 I yes,dewiM under DESCRIPTION OF OPERATIONS bob* EL.DISEASE-POLICY UNIT $ 500. DESCRIPTION OF OPERATIONS r LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Vendor Number 11878 Region 18 The General Liabil(ty(Inclucin9 Products Liability)and Auto Liability include Lowe's Companies,Inc.and Lowe's Home Centers,LLC as additional Insureds as required by wrinen contract. This insurance is Ornery and noncontributory over any other available insurance coverage.A Waiver of subrogation applies in favor of the additional insured in respect to General&Auto Liability policies. 10 Days notice of cancellabaon for non-payment of premium. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Lowe s Companies,Inc.and any and all subsidiaries ACCORDANCE WITH THE POLICY PROVISIONS. 'OCO Lcwe's Blvd. AUTHORIZED REPRESENTATIVE I400resv Ile NC 28117 ,k'4'-,—{� i M ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Constt ott$visor CS-117055 c411"111124pires: 08102/2025 KYLE R SEApLES Yr n 14R PEACH fiRCHARD ROAD (gib/ PROSPECT t`J 06712 Commissioner Construction Supervisor Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code Is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpi