35-097 (2) BP-2024-1450
89 DREWSEN DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
35-097-001 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-2024-1450 PERMISSION IS HEREBY GRANTED TO:
Project# WINDOW 2024 Contractor: License:
Est.Cost: 3143 HOME DEPOT USA INC CSSL098785
Const.Class: Exp.Date: 04/27/2026
Use Group: Owner: BOMBARD LISA M
Lot Size(sq.ft.)
Zoning: WSP Applicant: BOMBARD LISA M
Applicant Address phone: Insurance:
89 DREWSEN DR
FLORENCE, MA 01062
ISSUED ON: 10/31/2024
TO PERFORM THE FOLLOWING WORK:
1 REPLACEMENT WINDOW
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:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. !�
Signature: !�/�C:.--
Fees Paid: $60.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
ifiECE
0Cr 30 2024
The Commonwealth of. •• IMsett t'!t n,.v�rNc
fit, Board of Building Regulations and Stai ar r70N.r�q Ot r1 NS FOR
j Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
' A1 . /b on For Official Use.Only
Building Permit Number: 4? Date Applied:
Building Official(Paint Name) • Si Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
89 Drewsen urlve, Florence MA
1.la 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 tt) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required i Provided
I
I
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
l'uhlic 0 Private 0 Zone: Outside Flood Zone?
— Municipal 0 On site disposal system 0
Cheek if yes❑
SECTION 2: PROPERTY OWNERSHIPt
2.1 Owner'of Record:
Lisa Bombard Florence MA
Name(Print) City,State,ZIP
89 Drewsen Drive (413)336-6842 lis91m@aol.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building is Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units. Other 0 Specify:WINDOW REPLACEMENT
Brief Description of Proposed Work`:
REMOVE AND REPLACE 1 WINDOW,LIKE FOR LIKE,SAME SIZE, NO STRUCTURAL CHANGES
PLEASE EMAIL APPROVED PERMIT TO PERMITS@GOPERMITS.ORG
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $3143.00 1: Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ 0 Standard City/Town Application Fee
0 Total Project Cost3(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire
Suppression; $ Total All F p i
Check NO—Clolti Check Amowit: 0 Cash Amount:
6.Total Project Cost: $ Paid t tanBalance Due:
3143.00Idid 0 in Full 0 Ou s dig
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CSSL-096785 4/27/2026
IVAN KOSOBUTSKYY License Number Expiration Date
Name of CSC Holder
List CSL Type(see below) WS
72 STAFFORD RD
No.and Street Type Description
MONSON, MA 01057 t: Unrestricted(Buildings up to 35,000 Cu.ft.)
R Restricted 1&2 Family Dwellin
City/Town.State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
860-952-4112 dkosobutskyyagmail.com I Insulation
Telephone Email address I) Demolition
5.2 Registered Home Improvement Contractor(HIC) 112785 04/22/2025
HOME DEPOT USA HIC Registration Number Expiration Date
H1C Company Name or HIC Registrant Name
2455 PACES FERRY RD PERMITS@GOPERMITS.ORG
No.and Street F.mail address
ATLANTA,GA 30339 860-952-4112
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 0 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 SCOTT DOUGHMAN
to act on my behalf.in all matters relative to work authorized by this building permit application.
SEE ATTACHED CONTRACT 10/24/24
Print Owner's Name(Electronic Signature) Date
SECTION 7h:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 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.
.'ca t Tali y .� 10/24/24
Print O.+tter's or tut urized Aeeut.6 Name(Electronic Signature) Date
NOTES:
I. 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 gpl have access to the arbitration
program or guaranty fund under I.G.L.c. 142A.Other important information on the HIC Program can be found at
www.rnass.govtoca Information on the Construction Supervisor License can be found at www.mass.govfdps
2. When substantial work is planned.provide the information below:
Total floor area(sq.ti.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.11.) 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"
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 . '`�i
DEPARTMENT OF BUILDING INSPECTIONS i
212 Main Street • Municipal Building
<< '^ Northampton. MA 01060
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: 12 LINSCOTT RD, WOBURN, MA
The debris will be transported by:
Name of Hauler: TRUCK
Signature of Applicant: a'ce Pau/tfrma..v Date: 10/24124
CUSTOMER TOTALS COPY Date C.ntercd: 10/18/2024
Date Printed: 10/18/2024
QUOTATION #3017775 Printed 13y: Daphnee
S 1 MONTON` SOLD TO: SHIP TO:
W I N I) 0 W S The Home Depot Tlil)/NEW t NGLANI)W Enfield
Accounts Payable B-I2 THD/Enfield,CT Warehouse
2455 Paces Fcny Road NW 72 Shaker Road Unit it2
Atlanta,GA 30339-4024 Enfield,CT 06082
Phone:508-736-6320 Phone:508-736-6320
Fax: Fax:
PO \t %1BF,R Q1 (1I I \1111: PRO,11-1.1 N>\11,
53965494 BOMBARD Unassigned
I.ineltent 1i Qt,. I)c crilttiun
100-I 1 6100 Double Hung 34.5"X 50.75" Operation=
RO: Operating, Frame=Replacement Frame(2R),Ext.
34.75 x 51.25 Color—White,Int.Color—White,Glass Package—
EnergiSaver,ProSolar Shade Low E,Argon,
Room ID: Supercept,3/4"IGU, Glass Thickness= 1/8 in- 1/8
Bedroom out DS,Upper=Annealed,Lower=Annealed, 1=4*
Locks=2,White,Cam,Air Latches=2,Sill _
Extender,Head Expander,Screen Coverage=Half, to
Fiberglass,Extruded,U-Factor=0.29,SHGC= .
0.21,VT=0.49,STC=0,CPD Number=SBP-A-
1 12-10689-00001,Meets Energy Star Zones=
Southern,DP=30,AAMA,TDI=WIN-1601, 11 •r
Florida Approval Code=5167 s4.
i+.s r—t -.
.— as- -.
Initials:
1 Total Qty Units sI i>-ro 111 : $231.92
101 11 1 1\: $0.00
Comment:
TOTAL LABOR: $0.00
TOTAL.FREIGHT: $0.00
DIST/DLR DISC: $0.1111
TOT: I.: $231.92
DEPOSIT PAID: ($0.00)
:1MOE N 1 Dl F:: $231.92
Submitted by: Accepted by: Date
Page 1 Of 1 Quote#: 3017775
`1' Home Improvement Agreement: Page 1
Home Depot License#'s-For the most current listing visit www.Homedepot.com/LicenseNumbers
MA: 107774, 112785
Ronald Engelbrecht
Salesperson Name Registration#-CA,CT,ME,MD, MI,NJ,DC only
Home Depot U.S.A.,Inc. ("Home Depot")or its Authorized Service Provider named below will furnish, install, or
service the equipment listed below at the price,terms,and conditions set forth in this Agreement.
I.Service Provider Contact Information
The Home Depot The Home Depot
Service Provider Contact Name Service Provider Company Name
(203) 265-7037 customercancellationnortheast@homedepot.com
Phone# Service Provider Email Address
j 2.Customer Information
Bombard Lisa New England West F46301699
Customer Last Name Customer First Name Store#/Branch Name Customer Lead/PO#
89 Drewsen Drive Florence MA 01062
Customer Address City State Zip
(413) 336-6842 lis91m@aol.com
Home Phone# Work Phone# Cell Phone# Customer Email Address
3.NOTICE OF RIGHT TO CANCEL
YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY CONTACTING
THE SERVICE PROVIDER OR STORE DIRECTLY; EMAILING SERVICE PROVIDER AT:
customercancellationnortheast@homedepot.com
OR DELIVERING WRITTEN NOTICE TO HOME DEPOT AT:
200 Elm Street Unit 3 NORTH HAVEN I CT 06473
Address City Statc Zip
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME
DEPOT'S RECEIPT OF YOUR NOTICE. ANY MERCHANDISE OR MATERIALS DELIVERED TO
YOU MUST BE MADE AVAILABLE FOR PICKUP BY HOME DEPOT OR SERVICE PROVIDER
AT YOUR ADDRESS LISTED ABOVE AND IN SUBSTANTIALLY THE SAME CONDITION AS
WHEN DELIVERED.YOU MAY ALSO CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING
RETURN SHIPMENT AT HOME DEPOT'S EXPENSE.
THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL.
Acknowledged by: 4,, 4670471,4te
09/30/2024
Cus +mer's Signature Date
460 Standard Form H1A(13 Aug.24)(E) Generated Date 09/30/2024 l cadieoa F46301699 v 4.0.0
Zys Home Improvement Agreement: Page 2
4.Description of Work to be Performed
A detailed description of the work to be performed is included in the paragraph or document entitled Scope of
Work, Specification, Customer Summary Sheet, Quote Form, Estimate, Invoice, or Measure which is included in
this Agreement.
5.Anticipated Delivery Date/Installation Schedule
Approximate Start Date: 01/28/2025 Approximate Finish Date: 02/27/2025
All dates are approximate and subject to change due to various circumstances such as weather,manufacturing delays,
obtaining permits or HOA approvals.
6. Electronic Records Authorization
You are entitled to a paper and electronic copy of this Agreement if You choose. If You consent to an e-mailed
copy,Your consent applies to this Agreement and all subsequent documents and written communications related to
this Agreement. Contact your Service Provider to update Your email address, withdraw Your consent to electronic
records, or obtain a paper copy of the Agreement or related documents at no charge. By providing Your consent
and verifying Your email address above,You confirm that You have access to a computer that can receive and open
emails and PDF documents.
7.Contract Price and Payment Schedule
Payment of the Contract Price is due upon signing unless a different payment schedule is required by law,is specified
below,or is in a payment addendum.
Contract Price: $ 3143.97 Includes all applicable taxes.Excludes finance charges.*
Sales Tax: $ 0.00 (If applicable,total amount of taxes included in Contract Price)
*Maximum deposit ONLY applicable in MD,MA,ME(33%),NJ, WI(99%)
Deposit% 125.0 J Deposit Amount$ 1786.00 ..._._.._.__I Remaining Balance$ [235797 ........_._I
8.Finance Charges
Any interest payments or other finance charges will be determined by Your cardholder or loan agreement,to which
Home Depot is NOT a party,and will not affect the payment due under this Agreement. You are subject to the terms
and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service
Provider; however, Service Provider may collect Your payments made payable to Home Depot.
9.Acceptance and Authorization
By signing below,You authorize Home Depot to:(a)arrange for Service Provider to perform the Services;or(b)order
and arrange for the delivery of special order merchandise,including any custom made special order merchandise,as
specified in this Agreement. Further,You acknowledge: (i) You have read and understand this Agreement;(ii)You
have accepted this Agreement in its entirety, including the General Conditions and State Supplement(if any); (iii)
You are receiving a complete copy of this Agreement;(iv) all rights and interests under this Agreement, including
interest in the property where Services are performed, are solely vested in the person listed as "Customer" above;
and(v) electronic signatures will be deemed originals for all purposes. Do not sign if blank or incomplete. Service
Provider's or permitting information may need to be provided to You in writing at a later date.
X ."444vjl 09/30/2024
Customer's Signature Date
X Is/The Home Depot 09/30/2024
The Home Depot Digital Signature Date
For questions related to your installation,contact Service Provider at (203)
For any other concerns, contact The Home Depot at 1-800-466-3337 26r—,031
460 Standard Fonn HIA(I3 Aug.24)(El Generated Date 09/30/2024 Lcad'PON F46301699 v 4.0 0
WINDOW SPECIFICATION SHEET - Spec.Sheet k: F46301699 Sheet: 1 of 1
Customer: Lisa Bombard Job 1t:F46301599 Consultant: Ronald Engetbrecht Date: 09/30/2024
New Window
Ftinge LOCations
Exist window
Measurements Grids Product Options Labor Options nrom outside.
Lett le Right
Bays.Bows
Location Color Rough Opening I of bars a or bars Camnts,1 Pnl,
use L,RorS
Glass Mist hems
Hardware
Screens Code For doors use
Q 3 c 9 Mull "S"=stationery or
a Style "' . '
5 b 'X"=operating
Wraps a
t Room Floor Code (Y/N) Style Code Series Code w 5 I--y 8 a > 2
STD,White, OlasmPack: METAL,F,
1 BED 1st SH- Y OH 6100 WH WH 36 50 i86 5100-Prosolar Snade WRAP.LSR
Pv
SPECIAL CONSIDERATIONS:
1:While Line Level Notes:
1.MISC(1):(null/
2.Extensive rot.May Include siding wood repair
Wrap Color Permit Processing
Interior Casing Type
Bay or Bow window
Seatboard matorlal(vlrlyt only-Bkch or Oak)
Bay Project Angle(30 or 45)
Bay Flanker Type(OH.SH,or Csmnt)
Top of window to soffit(inches)
B led to soffit color of soffit material I have reviewed and agree with al the job specifications above and the
Construct Roof(Yos or No)'
Spada)Terns and Conditions on the following page
Garden Window.
Seatboard Material(vinyl only-White Pionite.Bkch or Oak)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofa•e of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston.MA 02111-1750
wwiitmass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print ',glibly
Name it;ttAit si tanyinshvittuat): HOME DEPOT USA
Address:2455 PACES FERRY RD
City/State.Zip: ATLANTA,GA 30339 Phone#:860-952-4112
Are you an employer"Check the appropriate box: Type of project(required):
I.D 1 am a employer with 4-X I am a general contractor and I 6. ,construction
employees(full andlor part-time).* have hired the subcontractors
2.Li I am a sole proprietor or partner- listed on the attached sheet. 7. El Remodeling
ship and have no employees These sub-contractors have .8, Q Demolition
working for me in any capacity. employees and have workers'
jNo workers' comp.insurance comp. insurance. 9. 0Building addition
required.] 5. LiWe are a corporation and its 10,0 Electrical repairs or additions
3.. I I am a homeowner doing all work officers have exercised their ILO Plumbing repairs or additions
myself[No workers' comp. right of exemption per MGL 12. Roof repairs
insurance required.] t c. 152,§+I(4),and we have no I3 Othrt�(�f IndoW replacement
employees.[No workers' p
comp. insurance required.]
'Any applicant that checks box It l must also fill eat the section below showing then workers'compensation policy information_
t Homeowners who submit this affidavit indicating they arc doing all wink and then hire outside contractors must subtntt a new affidavit tndicatiet such.
:Contractors thin check this box nest attached an additional sheet showing the name of the sub-contractors and date whether or not thaw entities have
employees lithe sub-contractors have employees.they must provide their workers'comp.pokey number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name: AGE.-Araericanin u[ ce--- - -- ----------
Policy a or Self-ins. Lie.i:_Policy jNLLRC506681_5JO-_4MT)--_- Expiration Date: /2025
lob Site Address:89 Drewsen Drive cityistatezip:Florence MA
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data
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 S1,500.00 and:or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fore
of up to$250_00 a day against the violator. Be advised that a copy of this stawnx.ttt"nay be forwarded to the Office of
Investigations of the DIA for insurance coverage verification,
I da hereby eertify under the rains and penalties of perjury that the information provided above is true and correct
. .
Signature; _._....._.___._..... ...._.........�____.._-..__ Dtttc: 10/24/2024
Phone#: 860-952-4112
Official use oak Do not white in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(check one):
IDBoard of Health 20 Building Department 31:1CityITown Clerk 4E1 Electrical Inspector 50Plumbing
Inspector ti.D()ther
Contract Person: Phone#:
Go Permits, LLC
105 Buttonball Lane
1111 Glastonbury, CT 06033
PERMITS Scott Doughman
Phone: 860-952-46112
Fax: 860-430-6719
scottdoughman@gopermits.org
—
Re: Building Permit Application - Licenses
Good day,
Please find attached permit application, licenses and supporting documents.
Home Depot USA, Inc. sold the job and is the G.C. HIC 112785 Exp. 4/22/2025
Workers Comp — Indemnity Insurance Company of North America
Policy WLRC50670284 Exp. 3/1/25
Ivan Kosobutskyy, D/B/A I & I Remodeling is the sub-contractor.
#CSSL-098785 Exp. 4/27/2026 / HIC#152379 Exp. 8/22/2024
Workers Comp. —Atlantic Charter Insurance Company#WCV01468904 Exp. 11/13/2024
All licenses and insurances are attached.
Once the permit is ready:
• Please fax or e-mail a copy of the permit and receipt to the below address and mail
the original to the homeowner:
Fax: 860-430-6719
Email: permits(a.gopermits.orq
• If you unable to mail the permit to the homeowner please send to the below address
and we will ensure the permit is at the home posted at the time of installation:
Go Permits, LLC
105 Buttonball Lane
Glastonbury, CT 06033
If we are required to pick up the permit in at the building department, please call
860-952-4112 once it's ready and we will come to get it.
Thank you,
Go Permits
ACo oR , CERTIFICATE OF LIABILITY INSURANCE DATE ISAIWOOWYY'q
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 OW certificate holder is an ADDITIONAL INSURED,the policy(ies)must twve 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 ondorseitnei*(s).
PROOUCER corlACT
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COVERAGES CERTIFICATE NUMBER: AT 005072225.21 REVISION NUMBER: s4
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,TERN OR CONDITION OF AMY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH tHIS
CERI IFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
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DESCRIPTION Or OPERATIONS)LOCATIONS I VEHICLE 5(ACORD 101,AdAr onal Ramada Schedule,may be reached II mare spice es«pattey
EV1)EACE OF MIA AVRCE
CERTIFICATE HOLDER CANCELLATION
HOE DEPOT mt.F4 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
2455 PACES L'ERRY ROAD-.. THE EXPIRATION DATE THEREOF, NOTICE WILL RE DELIVERED IN
BULLING C-20C ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA GA 10335
AUTHORIZED REPRESENTATIVE
ODEr-est...4 s.-e'.c..cr�
®1988.2016 ACORD CORPORATION. All rights reserved.
ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: CN101642069
LOC f: Atlanta
A R® ADDITIONAL REMARKS SCHEDULE Page 2 of 3
AGENCY NAMED ROMEO
MARSH USA LLC: THE HQIIE DEPOT,AC
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POLICY rAIMER 2455 PACES FERRY R OAtk
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EFRCTWE DATE:
ADDITIONAL REMARKS
THIS ADOITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
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ACORD 101(2008/01) C 2008 ACORD CORPORATION. AM tights reserved.
The ACORD name and logo aro registered marks of ACORD
AGENCY CUSTOMER m: CN101642069
LOC R: Atlanta
A o' ADDITIONAL REMARKS SCHEDULE Page 3 01 3
AGENCY NAND INSt1RED
MARSH USA LLC: NE HOME DEPOT.INC.
___...._.___ HOME DEPOT USA,PC:
POLICY N[NlER 205 PACES FERRY ROAM
BULLING C 20:
ATLANTA,GA X339
CARRNA NMC COOS
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM.
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
^'HOIEDEPOT NSURBRS.":
The Hated Gigot Inc:
Horne Depot USA Ix:
lone DepE USA s e d5O The MOTE Oepo:
Home Depth O P E,floe tar:
4ome Noce Radjd Alfieri/;LC
Home Depo Stair&rapt,Inc:
Red Beim,LLC
H DV I Hoiden Company,taps
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Nome?teal It ageeeerrlCkmpDlT,LL.CF
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ACORD 101(2008/01) t 2008 ACORD CORPORATION Al fights reserved.
The ACORD name and logo are registered marks of ACORD
THE COMMONWEALTH OF MASSACHUSETTS
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Office of Consumer Affairs and Business Regulation
1000 Washing141;4FAK.- Suite 710
BostoMassachttnett7_,___ 2118
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HOME DEPOT USA INC
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P 0 BOX 105451 0.
ATTN: LICENSE MGMT TEAM , :7,-3 .4*; 04/
ATLANTA, GA 30348 t:‘ - 17::"---"i„24:_.------ 1;
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Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affaa%&Business Regulation Registration valid for individual use only before the
HOME IMPROVEfilENT,CONTFtACTOR expiration date Pt found return to:
TY_f*,:,tr;iniirat;nri Office of Consumer Affairs and Business Regulation
: . •# •'.•-,-._ Eapitittion 1000 Washington Street -Suite 710
11 04/22,2025 Boston,MA 02118
HOME DEPOT USA I
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ATLANTA GA 30339
Undersecretary Not valid without signature
A RLP CERTIFICATE OF LIABILITY INSURANCE DER 3"`i
THIS CERTIFICATE IS ISSUED AS A MATTER OF 1IFORMATION 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 cerUwcate holder is an ADDITIONAL INSURED,the poHcy(les)must haw ADDITIONAL INSURED provtslons or be endorsed.
if SUBROGATION IS WAIVED,subject to the terms and conditions of the po icy,certeln policies may rsquIre an endorsement A statement on
this certificate does not confer rights to the certificate holder In Neu of such endorsement(s).
PRODUCER CiAr►ACT Mary""T -%
GREYLOCK MISI.W4N4CE AGENCY tM,M�E dal: (413)729-6090 IfAx
INC,rhr
AOOREis: mbeniermuckrerocitorg
5 Court St SAUK RFC a/FORM°COVERAGE NAIL
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INSURED *WadRS
IVAN KOS G8UTSKYY IMRERC.
INSURER
72 ST.AF FORD ROAD
MONSON MA 01057 utou eRr-
_COVERAGES CERTIFICATE NUMBER:948979 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LASTED BELOW HAVE BEEN ISSLIED TO THE INSURED NAMED ABOVE FOR THE POtICY 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.
EXGLUSlO NSANDC.ONOITIONS OF SUCH POLICES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES SE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE MU_ RE DELIVERED IN
THE)At-Horne Services IncACCORDANCE WITH THE POLICY P*OMStONS
2500 Cunil,emland Patkwsylf300 AUrigRti®IIRMIIMiIITATNE
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C 1988.2016 ACORD CORPORATION AN rights reserved.
ACORD 25(2018103) The ACORD name and logo are registered marks of ACORD
HIC Registration Complaints
Registration# 152379
Registrant Ivan Kosobutskyy
DBA I & I Remodeling
Name IVAN KOSOBUTSHYY
Address 72 STAFFORD ROAD
City, State Zip MONSON, MA 01057
Expiration Date 08/22/2024
Complaints Details .-
No complaints found for this registrant.
Office of Consumer Affairs&Business Regulation
Division of Standards and
Division of Occupational Licensure,Office of Public Safety and Inspections
Licensee Details
Demographic Information
(Fall Name: IVAN KOSOBOTSKYY
!Owner Name.
License Address Information
City: Monson
State: MA
Zipcode: 01057
Country: United StateS
License Information
License No. ............ .- CSSL-098785 License Type: constructiOn supemsorSpeck*___W_.
Profession: Building Licenses Date of Last Renewal: 3/24/2024
issue Date: 4110i2008 Expiration Date: 4/27/2026
License Status: Active Today's Date: 4/15/2024
Secondary License Type:
Doing Business As: I&I Remodeling
Status(mantle Reason: License Renewal
rreregnistte Information
Licensee: KOSOBUTSKYY,IVAN
Relationship: Attribute Of
License No: CSSL-098785
1 1"van._.._-1 osA b►k 4_k
authorize Go Permits LLt to pull prm�its uniiK my
CS License 4 -p°-1-574 __ _ and
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er
Installer Signature g_+ :.' , ._
R Y Name $_x-'�_.: a i. '
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Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Regulations and Standards
Cll is
Construct Specialty
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Go Permits, LLC
' 105 Buttonball Lane
Glastonbury, CT 06033
PERMITS Scott Doughman
Phone: 860-952-4112
Fax: 860-430-6719
scottdoughman@gopermits.org
Re: Massachusetts Solid Waste Affidavit
Good day,
Please find attached locations where the installers can bring their debris from the jobs. These
are all Home Depot USA, Inc. locations. Contact is Jason Timm 203-265-7037
• 72 Shaker Road, Unit 2 Enfield, CT 06082 (USA Hauling)
• 32 Scotland Boulevard Bridgewater, MA 02324 (South Shore Disposal)
• 12 Linscott Road Woburn, MA 01801 (ACME Waste Systems)
• 535 Grand Army of the Republic Hwy, Somerset, MA 02726(EZ Disposal)
When filling out any solid waste affidavit, it's the installer whom will be removing the
garbage and dumping the trash at one of the above Home Depot dumpster locations
closest to that job.
Thank you,
Go Permits
GU: Get The
PERMITS Jennifer Winke<
Permit! 1 t�gopermits.org>
Purchase Confirmation
1 message
Stamps Account Support<no-reply@stamps.com> Thu, Oct 24, 2024 at 12:13 PM
To:Jennifer<jenniferwinke@gopermits.org>
CI Stamps.com'
Dear Jennifer,
Thank you for your recent purchase.The following transaction has been
successfully posted to your account.
Transaction Details
Date: 10-24-2024 09:13 PDT
Description: Purchase
Payment Method: Visa
Amount: $50.00
Your current available account balance is: $50.63
Your username is:jenwinkel.
Sincerely,
The Stamps Customer Care Team
Go Permits,LLC
0 0 105 Buttonball Lane
_ Glastonbury,CT 06033
\\saiiiiimilasupois)
PEIIM11 Glynn Norgnn
Phone: 734-395-3663
Fax:860-430-6719
glynnnorgan@gopermits.org
To Whom It May Concern,
Enclosed is application and documents with a check for the permit fee. If you have any questions,
require any further information or need additional payment for this building permit application, feel
free to call us at your convenience and we would be happy to assist you.
Once the permit is ready please fax or e-mail a copy of the permit and receipt to:
Fax: 860-430-6719 (Attn: Scott Doughman)
Email: permits@gopermits.org/rachelpatterson@gopermits.org
If fax or e-mail is not an option,please mail a copy of the permit and receipt to 105 Buttonball Lane,
Glastonbury,CT 06033.
If you have any questions or require any further information for this building permit application, feel
free to call us at your convenience and we would be happy to assist you.
Thank you,
Rachel Patterson, Permit Specialist
Go Permits LLC
Mobile: 772-501-0377
rachelpatterson@gopermits.org
Go Permits, LLC 105 Buttonball Lane, Glastonbury CT 06033 www.gopermits.org