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29-392 - INSULATION INS N REPORT TRUt �#�E'11 This analysis is the first step in yourTruGreensM Insulation Service. The observations below are used to evaluate what measures can be taken to make your home more energy efficient This assessment can help calculate your INSULATION SERVICE home's need for new insulation "and recommend the exact right amount necessary to maximize the efficiency of your home's heating and cooling systems, which may save you significant amounts of money over time. OWNER'S NAME / ,-? C7 /::,: `,© e - / ! ACCOUNT # 2 4/ DATE • TREATING ADDRESS / 7 /3 (2C A/ t C I TY r '(1r� /z p STATE 77.- ZIP HOME PHONE 9/ 3 c s O / CC C 7 s3 c ALT PHONE EMAIL INSPECTED BY J J GJ `� home interior assessment STRUCTURE AGE f 1 / [ / IS EVERY ROOM IN THE HOME UTILIZED? YES DESCRIBE ,:i' -/- - 7-F / "" ^l AVERAGE THERM t AT SETTING (/ � NO SUMMER WINTER / ARE THERE ANY DRAFTY UNCOMFORTABLE ROOMS? ISTH R MOSTAT PROGRAMMABLE? ' C" t i , / ,, r v YES DESCRIBE /, {. ,- /i r� - /-/x, ES NO NO V AVERAGE MONTHLY ENERGY EXPENSE /[' <j-' r ,. r 17 4- g- /^/((( i 7,O . V t .✓ attic assessment ATTIC/ACCESSIBLE / / ' ACCE,Q�1 SULATED V YES HEIGHT I �' / J ( YES NO (suggest attic tent) . NO (� IS MOISTURE PRESENT IN INSPECTED AREAS? 4( \ ( DIMENSIONS OF ATTIC OPENING 72—> ,- ¥.6S Describe C , NO LADDER NEEDEDTO ACCESS ATTIC? YES NO LIVETUBE & KNOEf1NIRING PRESENT YES NO RECESSED LIGHTS ISTHE HVAC LOCATED IN? (Check all that apply, ■ YES OTY /NO ,,/ <,,,,, ATTIC OPEN TOP CHASE WALLS y, RAFTER DIMENSIONS P.E , /�' ,,( ;C -7 I " . 6 J CAVITIES OTHER VOIDS Describe + ' /��' � 24" O.0 16" 0.0 ARE THERE ITEMS STORED IN THE ATTICTHAT MUST BE MOVED ATTIC VENTILATION OR COVERED BY OONER? GABLE RIDGE YES ✓ NO • §OX TURBINE 3 COMMENTS S FFIT Continuous? __ Spaced? Number? / r� ,, Cv C A 7 r J current insulation assessment 7 ! ' ( ? TOTAL SQ. EXISTING INSULATION AVG. DEPTH R -VALUE CURRENT R -VALUE FINAL CELLULOSE INCHES FOOTAGE (inches) INCH R -VALUE ADDED R•VALUE TO BE APPLIED tic o° / 1 Aj � FIBERGLASS LOOSE•F0. / L F fry 3,5 R - VALUE FIBERGLASS BATES 3,2 GOAL CELLULOSE LOOSE -FILL 3.5 6 0 ROCKWOOL 2.8 OVER L R -VALUE GRADE LOW - INSULATION SERVICE STRONGLY MODERATE - INSULATION SERVICE RECOMMENDED HIGH - CONSIDER INSULATION SERVICE RECOMMENDED IN THE FUTURE Areen Insulation Service uses a premium cellulose insulation product. ENERGY STAR and the ENERGY STAR mark are registered U.S . marks. © 2012TruGreen Limited Partnership. All rights reserved. (I Charter #448, #439, #185, #422, #443, #3883. In CT, B -0153, B- 3 -0 -0 00, B -0151, CT #HIC. 0544505. In PA, #HIC. 092436. MI - 2101202938. Key# 10253 NEW 08/12 Tr 0 6, P BRANCH COPY 1 855 - 207 - 5223 A e #: T \ TRUG REEN. Insulation Service Agreement INSULATION SERVICE TruGreen.com 1- 855 - 207 -5223 ner Name: ! j (V /9 P4 f E -mail: ervice Address: 77 (3( / L,,,o2,a 0 g City: )v 0(�v State:41/ / County: ZIP Code: Gle% Billing Address: 5 ( , City: State: County: ZIP Code: ,1 - ipma Phone: Work Phone: Cell Phone: I n YES, I am interested in your insulation service but not ready to purchase today. You have my permission to cat me at any of the above numbers at a later date to discuss further. Customer's Signature Date TruGreen Rep's Name Date TruGreen Insulation Service: Date of Installation: (or as otherwise agreed) TruGreen will install insulation in accessible open /uncovered designated spaces (Service Areas) of Property as described below. Total Sq. Avg. Depth R -Value Current R -Value Final Cellulose Footage Existing Insulation (Inches) Inch R -Value Added R -Value Inches Applied TOTAL SW Fiberglass Loose -Fill O 2.5 / c %1 Co 12 /1,610 Fiberglass Batts 3.2 R -Value Goal Cellulose Loose -Fill 3.5 Rockwool 2.8 CUSTOMER AGREES TO SUPPLY TRUGREEN WITH ACCESS TO GROUNDED OUTLET(S) AND POWER AND TO SHUT DOWN THE PROPERTY'S HEATING /COOLING SYSTEM(S). CUSTOMER UNDERSTANDS THAT INSTALLATION OF INSULATION MAY GENERATE DUST AND OTHER AIRBORNE IRRITANTS IN THE SERVICE AREA AND THROUGHOUT THE PROPERTY. TRUGREEN RECOMMENDS CLOSING ALL WINDOWS AND INTERIOR DOORS DURING INSTALLATION. CUSTOMER MAY WISH TO COVER OR REMOVE PERSONAL PROPERTY AND TAKE OTHER PRECAUTIONS CUSTOMER DEEMS NECESSARY TO AVOID DUST /IRRITANT EXPOSURE. SU ,: •:'`�4, CHARGES AND PAYMENT OPTIONS SUMMARY OF CHARGES AND PAYMENTS !L' r option: See TruGreen Retail Installment Agreement INSULATION SERVICES / �/'� it Down Payment Option: Initial 20% down - payment of Total Investment ( #1) INSTALLATION _11.0 by check or credit card due upon execution of Agreement. Remaining Balance , ( #3) due upon completion of installation. ATTIC TENT INVESTMENT O Pre- Payment Option: Payment in full of Total Investment ( #1) by check or �� � /s�Gf / v credit card due upon execution of Agreement. OTHER O Payment On Completion: A one -time check or credi': card payment of Total TAX = Investment ( #1) due upon completion of installatior. If paying by credit card, Customer authorizes TruGreen to process credit card 1. TOTAL INVESTMENT = ! 3S' payments in accordance with the above payment option selected by Customer without further signature or authorization. 2. LESS $ / 7 DOWN PAYMENT.... - ` O G 7 Customer Signature: - -L_�� 3. REMAINING BALANCE Best Number to Reac ustom r to Obtain Credit Card Number: d ES h ee-/ A e' e /fr , I would I+ke to purchase the services set forth in the Total Investment ( #1). My agreement is subject to the terms and conditions on the reverse side. Customer's Signature r.L-..' ( 1 1_ .11.i t > ate 0 l ` t / luGreen Rep's Name /C..-ho e / Jul r‘S Sales Rep # 7602_ YOU, TIi(: BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. PLEASE SEE NOTICE OF CANCELLATION PROVIDED FOR MORE EXPLANATION OF THIS RIGHT. The Terms and Conditions on the reverse side, including the mandatory arbitration provision, are part of this agreement. :ey #10248 New 6/12 > 2012 TruGreen Limited Partnership. All rights reserved. ��— License # °� / N Charter #448, #439, #185, #422, #443, #3883. See Reverse for Additional Terms and Conditions 1 CT B -0153, 5 -1380, B -0127, B -0200, B -0151 A - #H IC 11074,q6 CT - #Nir ARA4Fnc n 4 a ,n, onn„-,,, C HOW L0 M1': UP TO THE tlfzi-`, TO VIEW TRUE WAIEHMAJK " HOLD 1'iOGY,MIENT UP TO THE LIGHT TO ViEW TRUE :N'ATEHMARK . S ` y=_ 511721749 -6 I a o Citizens Bank 0115 ALiqt1E _ 09 , 2 01 t 'i PAY 4 $ "> a &:': a o7 * * :1OL. 17, To THE ds'a ° t' : }Y'e 104'' �_'�:. $ "9 < rt k:..2�k ORDER OF Drawer: RBS Citizens. N. A. �y ' 33 MEMO k is a vision =S ens, N . L'.1 Sat: o + I I A • a IUD SIGNATURE • 1040)_, ue u' i t �r • t f Sit ?21749 .Oi150t7120. 207521,64 co Cr) n 0 X 4 w H a w P. P. '-1 N �-i 0 • • THE COMMONWEALTH OF MASSACHUSETTS For OCABR Use Only. OFFICE OF CONSUMER AFFAIRS AND le _ BUSINESS REGULATION Registration No: 10 Park Plaza, Suite 5170 � s Boston, MA 02116 Effective Date: Aopltcatdon for Registration as a Rome Improvement • Contractor or dab- Contractor Rtpiration Date: '10:‘ (MGL c. 142A; 201 CMR 18.00) 1. NAME OF APPLICANT: i 1 At t 111 a s (MUST BE F17HBRANINDWIDOAI., CORPORATION, LLC, UP, TEMOROIHSRLEGA .IMI TY) 2. NUMBER OF EMPLOYEES: ) Ltw ;4ed 3. APPLICANT TYPE: INDIVIDUAL CORPORATION A, PARTNERSHIP TRUST (CHECK ONE -- MUST BE sAME LEGAL ENTITY AS THE ENTITY IDENTIFIED IN PI) 4. SociALSEcuurryth 001 s v 5 I ( _ FEDERAL TAX m th ,'� 3 ?S L/ L. 4 5. APPLICANT PHONE #: J. 2.. 3 'I SS gr' I -1 APPLICANT EMAIL ADDRESS: } t'v6. t e •••. < 1 • f 6. MAILING ADDRESS: �; r w� Or 5 Li it e )v i p l/ 1 C.i3 a 7 STREET CITY STATE ZIP 7. PERMANENT ADDRESS: S 6riA r u f c v Or S k t A/4 4 - 0 . k 0 ' STREET CITY STATE ZIP PLEASE NOTE THAT APO. BOX iS lisirAccerrasis FOR "PERMANENT ADDRESS. YOU MUST LIST A STREET ADDRESS. 8. ]F THE APPPLICANT LS A CORPORATION OR A PARTNF.RSIIIP, PLEASE PROVIDE THE NAME, ADDRESS, SOCIAL SECURITY # AND TITLE OF'TH8„ NDIVmUAL WHO WILL BE RESPONSIBLE PORT= CORPORATION'S THE TRUST'S OR THE PARTNERSHIP'S WORK (Please review the Instructions before answering this question): /144f1/10 Ert . LAST FIRST SOCIAL SECURITY # TITLE 9. IF APPLICANT IS DOING BUSINESS UNDER A D/B/A, PLEASE STATE TRAT D/BIA, AND ATTACH A COPY OF THE FICFICIOUS NAME CERTIFICATE FILED WI'T'H THE CITY OR TOWN CLERK: DBA NAME: 10. (a) DOES THE APPLTCANT.OR RESPONSIBLE INDIVIDUAL HOLD ANY OTHER CONSTRUCTION - RELATED STATE, CITY OR TOWN LICENSES OR REGISTRATIONS? YES NO (b) IF YES, PLEASE FILL IN INFORMATION BELOW. ATTACH ADDITIONAL SHEETS IF NECESSARY. LICENSE TYPE ISSUED BY LICENSE/REG. # EXP. DATE LICENSEE NAME _ C- SL. ii\Oqj Id c 4 01/0146 frurmcl5 TO'd 8L89b£6£09 XVI L3PIi3SVZ dH IddLO:ZT ZT/S0/60 ( THE COMMONWEALTH OFMASSACHUSETI'S Far OCABR Use Only. OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATION Registration No. I* 7 10 Park Plaza, Suite 5170 e n ! ', Boston, MA 02116 Effective Datr. �� 1 t'' �' . licatl. i for R , !.L In . , a : 'me Ln ,rovein . t ;n114 ��` � - ,� ontractor or Sub - Contractor Expiration Date: ( ;. (MGL c. 142A; 201 CMR 18.00) \\ C Of C ry '944 �'. CANT: IA ert ..Itm1 +ed PA (+ie nr . k N A l 6 rw l ► p /be AN SUAL,C IAA I�,r,,R .ORO RL EGAI.>PI ) 0 � 44% j y / � 2. UMBER OF EMPLOYEES: o i Ceo <20? LI.�►:- ec &-' , 3. APPLICANT TYPE: INDIVIDUAL CORPORATION PARTNERSHIP .pi A,,,, J (CHECK ONE --- MUST BE SAME LEGAL ENTITY AS TIC ENTITY IDENTIFIED Di Fl) '74%9 4,4 4. SOCIAL SECCR T1Y ii: 0 D i $ Y S i I ( FEDERAL TAX ID #: .16 - 3 '3.3 t/ / (s q ,7c� 5. APPLICANT PHONE #: ) cCI 2Y( "1 '1 APPLICANT EMAIL ADDRESS: E „•t- )ridocr..Ihh11. ( 6y,, 6. MAILING ADDRESS: 7Z $1i•,1wp 0r ' /A ,i Yv.- /U 1+ 03 d 7 ' STRI7ET CITY STATE ZIP 7. PERMANENT NT ADDREtSS: 3 Z 6 f' r .—m Or S it I tti A' t J- 030'7 4 1 STREET CITY STATE ZIP PLEASE NOTE THAT A. P.O. BOX IS 1' ACCEFFABLE FOR PERMANENT ADDRESS. YOU MUST LIST A STREET ADDRESS. 8. IT THE APPPLICANT IS A CORPORATION OR A PARTNERSHIP, PLEASE PROVIDE THE NAME, ADDRESS, SOCIAL SECURITY # AND TIME OFTHE INDIVIDUAL WHO WILL BE RESPONSIBLE FOR THE CORPORATION'S THE TRUST'S OR THE PARTNERSHIP'S WORK (Please review the Instructions before answering this question): M ari /It) try 0 (7 1 SY 5 i 1 ‘ Q.e «. - ' ' - LAST FIRST SOCIAL SECURITY # TITLE 9. II' APPLICANT IS DOING BUSINESS UNDER A D/EVA, PLEASE STATE THAT D/B/A, AND ATTACH A COPY OF THE FICTICIOUS NAME CERTIFICATE FILED WITH THE CITY OR TOWN CLERK: ruts NAM2_ ..., ■ i. -' HOLD U MENT UP T Tf HT TO VIEW TRUE WATERMARK NOLC DOCUMENT UP TO THE L vNT TO VIEW T RUE WATERMARK , kv, .. �.. �.4 °.,'T `ui1 .G f w lb ATERMARK VA Citizens Bank 95 -0 511721750-4 p rUguc,t. 09, 201,2 a PAY 11 :1... '5, 0 .,. I) 0 Yit : ** DOC.LARS TO THE 44 t`. <.:od'ra flu n:'::ari gw6otl?.c•L .1 fit c:::>11' 11. '• a .+.::: t co 5,ex.! . =} :o: ORDER OF s . wer: RBS Ciuzens, N.A. ,„,. Y MEMO Cit' B s a divisiun'bt. e' CiUz .A. W 0.0, 1 & A 1 . A Itie . 4 ( �._.. ...__.___... _..._. .. ......__..____...__. _..... ....__._.. .._.._._ .__...... . .` ~ ... S "'" . ELM ATURE � _. . _.._. _. ...... J ii' L L? 2 L ?SOII' 1:0 L5001201: 20752 L6411 G T0'd 8L9917£6£09 XV.i I3PUHsv'l dH HdOT :ZT ZT /S0 /60 AGENCY CUSTOMER ID: 570000023893 LOC #: ACORD ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Aon Risk Services Central, Inc. TruGreen Limited Partnership POLICY NUMBER See Certificate Number: 570045720663 CARRIER NAIC CODE see Certificate Number: 570045720663 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Additional Description of Operations/Locations / Vehicles: TruGreen Limited Partnership dba Safeguard Pest Control FEIN #36- 3734669 TruGreen Limited Partnership dba TruGreen Chemlawn FEIN #36- 3734669 TruGreen Limited Partnership dba Heritage Lawns FEIN #36- 3734669 Additional insured applies to the General Liability and Automobile Liability policies if required by written contract. waiver of subrogation applies to the General Liability, Automobile Liability and workers Compensation policies if required by written contract. Any party with which the named insured is contractually required to include as additional insured, loss payee or mortgagee, is automatically granted such status; mortgagees of property leased by the named insured are also automatically granted such status where required. However, coverage under the policy only applies to the extent of the coverage required by such contractual requirement and for the limits of liability specified in such contractual requirement, but in no event for insurance not afforded by the policy nor for limits of liability in excess of the applicable limits of liability of the policy. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD '' ° s CERTIFICATE OF LIABILITY INSURANCE DATE(MWU1 03/30/2020 2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS w 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. a IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) 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 c certificate holder in lieu of such endorsement(s). c PRODUCER CONTACT NAME. 'O Aon Risk Services Central , Inc. PHONE (866) 283 - 7122 FAX (847) 953 - 5390 `y • Chicago IL Office (A/C. No. Eat): (A/C. No.): . 200 East Randolph E 5 Chicago IL 60601 USA ADDRESS: _ INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER k. Zurich American Ins Co 16535 TruGreen Limited Partnership INSURER B: American Zurich Ins Co 40142 860 Ridge Lake Soulevard Memphis TN 38120 -9434 USA INSURER C: INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570045720663 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. Limits shown are as requested INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD ((AM/DD LIMITS A GENERAL LIABILITY GL0293865605 01/01/101 01/01/2015 EACH OCCURRENCE 53,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE( O REN rh6 51,000,000 --� PREMISES (Ea occurrence) _ CLAIMS -MADE X 1 OCCUR MED EXP (Any one person) 510,000 X Pesticide or Herbicide Applicator Coy PERSONAL 8 ADV INJURY 53 , 000 , 0 co GENERAL AGGREGATE 45,000,000 t° X Contractual Liability N GENII AGGREGATE LIMIT APPLIES PER: PRODUCTS • COMP /OP AGG Included N I POLICY n PR- n LOC O A AUTOMOBILE LIABILITY BAP 2938657 -05 01/01/2012 01/01/2015 COMBINED SINGLE LIMIT m (Ea accIdentl $5000000 , , X ANY AUTC BODILY INJURY ( Per person) 0 — ALL OWNEL — SCHEDULED BODILY INJURY (Per accident) y AUTOS AUTOS X HIRED AUTOS X NON -OWNED PROPERTY DAMAGE V -_ AUTOS (Per accident) 4:. 1_ m UMBRELLALIAB OCCUR EACH OCCURRENCE V EXCESS LIAR 1 CLAIMS -MADE AGGREGATE DED) (RETENTION +...m B WORKERS COMPENSATION AND wc293865405 01/01/2012 01/01/2015 X WC STATU- OT EMPLOYERS' LIABILITY TORY LIMITS ER ANY PROPRIETOR / PARTNER / EITCUTIVE YIN A05 E.L. EACH ACCIDENT 51,000,000 A OFFICER/MEMBEREXCLUDED? I N I NIA wC293865505 01/01/2012 01/01/2015 (Mandatory In NH) WI E.L. DISEASE -EA EMPLOYEE 51, 000, 000 If yes, describe under DESCRIPTION O OPERATIONS bek,N E. DISEASE-POLICY LIMIT S1,000,000 �_ n DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) j„� Additional Information *The named insured includes (tl.t is not limited to): TruGreen Limited Partnership dta Barefoot Grass FEIN #36- 3734669 TruGreen Limited Partnership dba EPM Lawn care FEIN #36 3734669 TruGreen Limited Partnership dha AgroLawn FEIN #36- 3734669 TruGreen Limited Partnership dta Bay Country FEIN #36 3734669 CERTIFICATE HOLDER CANCELLATION 6 4 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE '� POLICY PROVISIONS. _te -` TruGreen Limited Partnership AUTHORIZED REPRESENTATIVE 860 Ridge Lake Boulevard Memphis TN 38120 USA %lam. W> eXPe i ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD �. i w r IL. !• 41 • cxs 5 , mow x a '''' ,,„,-, -, '..::''''''''''''' l',,'' '' '-'-' ,:''''' ''' -',,,:',.,:::'''' . -,,,L, ,,t,,',As' '* -- ,-, '-,''''',"'• ' ' ' ',E ' X'' '- ' 't' ' ' ' t e*'4'' ' I g . :' - ,,tf#, --till'" 4" x a .. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, 1. express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self- insured companies should enter their self - insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit /license number which will be used as a reference number. In addition, an applicant that must submit multiple permit /license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114 -2017 Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Fax # 617 -727 -7749 Revised 7-2010 www.mass.gov /dia The Commonwealth of Massachusetts Print Form Department of Industrial Accidents f e 41RJ � r _ Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114 -2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information (� Please Print Legibly Name ( Business /Organization/Individual): 1 �C�+Crl�u� �..., _ �( v .A. — �1. -� Address: ;k l.. Att City /State /Zip:A....4\:,\ �,, , ��)t� Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. E I am a employer with y v 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub contractors 6. 1 New construction listed on the attached sheet. 7. n Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub contractors have g. Demolition working for me in capacity. employees and have workers' g any p y 9. n Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. n We are a corporation and its 10. ri 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. n Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.F1 Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t 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 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: Z..f.aA. t �, Z ti ,r Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /State /Zip: 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 faun 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 der the pain cu penalties of pedury that the information provided above is true and correct. Signature: ' Date: C L° (1-- Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit /License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : ( L" , PI , , ( 3 ( 1 .51 1 License Number } ') Address Expiration Date Signature Telephone 9. Registered Home ImprovementContractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10- 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 ❑ 1 . Jame Owner Exeam ition The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [D] Other [D] B ' Description of Prop hs1 /� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes __No Plans Attached Roll - Sheet sa If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . 1. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , 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. Signature of Owner Date 1, , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ( 6._ Print Na r1) �,-— �( 1 -- Signature of Owner /Agent Date tz' Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L. R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES Q IF YES, date issued: YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES Q IF YES: enter Book Page j: and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. RECEIVED 1 f Northampton o rtham ton ED p Department ....................... ............................................................... ............................... ....................................................................................... ............................... SE P!9 P 12 Main Street Room 100 ampton, MA 01 060 Flo F I O BUILDING � r (DEFT OF . '� 0 Fax 413-587-1272 NORTHAM � • ► ,�, >, 3 7 124 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORMATION 1.1 Property Address: This section to be completed by office vr Map Lot Unit %, V I< h Zone Overlay Di ∎ strict Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: _)s --- S. Telephone Signature 2.2 Authorized Agent: Name (Pri t Current Mailing Address: t "- ""'"-- cc3 °3za Li • Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building'; Permit Fee 2. Electrical (b) (Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVA�,l `w 61-C p 5. Fire Protection � ��� 6. Total = (1 + 2 + 3 + 4 + 5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building! Commissioner /Inspector of Buildings ,'Date File # BP- 2013 -0317 APPLICANT /CONTACT PERSON FRANCIS LATHAM JR ADDRESS/PHONE 170 WEARE ST LAWRENCE (413) 593 -3204 PROPERTY LOCATION 77 BROOKWOOD DR MAP 29 PARCEL 392 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT 756 Fee Paid Building Permit Filled out 9 717 6 Fee Paid Typeof Construction: ADD ATTIC INSULATION p New Construction ., Non Structural interior renovations • r ♦ Addition to Existin Accessory Structure Building Plans Included: Owner/ Statement or License 065519 3 sets of Plans / Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER: § Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission _ Permit DPW Storm Water Management ''�De,y dri 71= Signature o : uildi : b fficial Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. 77 BROOKWOOD DR BP- 2013 -0317 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 392 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2013 -0317 Project # JS- 2013- 000514 Est. Cost: $935.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: FRANCIS LATHAM JR 065519 Lot Size(sq. ft.): 11020.68 Owner: DAWSON CARL E & TINA M Zoning: Applicant: FRANCIS LATHAM JR AT: 77 BROOKWOOD DR Applicant Address: Phone: Insurance: 170 WEARS ST (413) 593 -3204 WC LAW RENCEMA01243 ISSUED ON:9/24/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:ADD ATTIC INSULATION - IN PROGRESS INSPECTION REQUIRED 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: FeeType: Date Paid: Amount: Building 9/24/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner