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24A-114 (3) ' . • . Office of Consumer Affair and Business Regulation . 10 Park Plaza - Suite 5170 ----- ,' 7'' 'bjj", j • Boston p rssachusetts. 02116 Home Hoe Tniprove 'eatcontractor Registration • — Registration: 128893 1 =.........._. — Type: Supplement Card a tu Expiration: 8/3/2014 The Home Depot At-Home Servi RICI • FALLONE r— , ,...,T. , ..=== ,,,:„ • . . 2690 CUMBERLAND PARKWAY ATLANTA, GA 30339 = . . • .. ..:.- • . . - . -- lA r ...41• Update Address and return card. Murk renson for change. 0 Address • 0 Renewal •0 Employment j Lost Cnrd PM_ CAI ,' 50M.o4104-0101218 . gAr3 '63 Of ...1;634dack.a.ge41 •-• , Office of Consumer A ffnirs & Business Regulation License or registration valid for lndlvidul use only • IMPROVEMENT CONTRACTOR before the expiration dnte. If found return to: , IA' :li ' OME 11. 1 -11 . :_1 : e;`r'''• Office of Consumer Affairs and Business Reguintion Rogistratlom,j.26893 . :Typo: 10 Park Plaza - Suite 5170 • • . ExpirefftiKanytl Supplement Card Boston, MA 02116 ' . • . ' • No Homo Depc45Vekiriling1100s . . • :•:/. 'i.!,,,&,, js) ,-; ICHARD FALLONE41:igita-Tif,:,a / A g . . 2690 CUMBERLAICOAiRKWA5 `a TI 7\N9\ GA 30339 ... Undersecretnry ot valid with tit sl • • . . . • . . • . • , . • * • • - i7S , v0I l.rI!y'„ _ _ IG ',,SUED A . . ' , ; ' ' � ' MATTER OF IN p s i ONLY >11 L. Pte, i , e,, .,r i w _ , :RIG, CIS I.IFCiN _ i_.. , a 'n' - +,,1.__ _ - CERTIFICATE !DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENO, FX T ENO u? Ai-::ER ICHE COVERAGE A 8 i ' caEL'OW. THIS CERTIFICATE OF INSURANCE DOES .1OT CONSTITUTE A CON.rR?:C, EET:PIEEN THE ISSIIINC I).$URE^,' ,!J HI r?I REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate hoider is an ADDITIONAL INSURED. t policY,l s) must Ioa endorsed. If SUEROCATION IS IANFj, ,LIMP t the tennis and conditions of the ).acy, Certain policies may require an endorsement A at.r7't:err' . t 7fl '':nla .er'tifica:, d_..,-, i 7cinfer i "0.i.., to tn.= certificate hold-9.r in lieu of such $nd'I)S'30fYH2J')2(5). 466 CONTA:,T ,...- _,.....- .._.,.._____.__...._.. ODUCER ^.y, .L -So;, .Nam _ NAME: AME: -- - - — - - - -- �„ --- ----- .._..— r 3 USA LAIC. No, -:(t): i U-)( E -MAIL Dme.clepot,certr ciueet @i^a rS'_7,c.,c ADDRESS: vo Alliance Center, 3560 Lenox Road, Sui'ta 2400 ;lenta, GA 30326 INSURER(S) AFFORDING COVERAGE I NAIL 4 3x (212) 948 -0902 INSURERA: Steadfast Ins Co 26387 SURED INSURER B: Zurich American Ins Co 116535 1e Home Depot, Inc. - - - Dme Depot U.S.A., Inc. INSURER C: New Hampshire In3 Co 23841 155 Paces Ferry Road NW INSURER D: Illinois Nati Ins Co 23817 gilding C -20 NATIONAL UNION FIRE INS CO OF PITTS 194.45 INSURERS: tlanta, GA 30339 INSURER F: Illinois Union Ins Co 27960 'OVERAGES CERTIFICATE NUMBER: 25776028 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. SR TYPE O F INSURANCE ADOL WV0 POLICY NUMBER POLICY EFF POLICY EXP LIMITS rR ([VSR WYD (MMlDDIYYYY) (MM /DDIYYYY) 1. GENERAL LIABILITY GL04887714 -02 03/01/12 03/01/13 EACH OCCURRENCE $9,000,000 X DAMAGETO 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ CLAIMS -MADE X OCCUR MED EXP (Any one person) $ EXCLUDED X LIMITS OF POLICY XS PERSONAL & ADV INJURY $ 9 , 000 , 000 X OF SIR: $1M PER OCC GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 9,000,000 X POLICY PF O LOC $ B AUTOMOBILE LIABILITY BAP 2938863 -09 03[01/12 03/01/13 COMBINEDSINGLELIMIT (Ea accident) _51,000,000 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS _. NON - OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) - X SELF INSURED PHY DMG $ UMBRELLA LIAB OCCUR EACH OCCURRENCE _ $ ` EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ • $ C WORKERS COMPENSATION WC019736915 (AOS) 03/01/12 03/01/13 X WCSTATU- OTH- AND EMPLOYERS' LIABILITY / _.^ TORY i IMITS ,__ D ANY PROPRIETOR/PARTNER /EXECUTIVE YIN N IA WC0197 3 6 917 (FL) 03/01/12 03/01/13 E.L.EACHACCIDENT $ 1,000,000 OFFICER /MEMBER EXCLUDED? N -- - E (Mandatory lnNH) WC019736916 (CA) 03/01/12 03/01/13 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 It yes, describe under 1, 000, 000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ E Workers Compensation WC1192494 (QSI) 03/01/12 03/01/13 SIR (AOS) /SIR (GA) 1M /750,000 C Workers Compensation WC019736918 (WI) 03/01/12 03/01/13 F TX Employers XS Indemnity TNSC46566397 (TX) 03/01/12 03/01/13 Occurrence /SIR 30M /1M )ESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, 3 more space is required) tE: EVIDENCE OF COVERAGE :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN [ONE DEPOT U. S.A. , INC. ACCORDANCE WITH THE POLICY PROVISIONS. ;455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C -20 LTLANTA, GA 30339 r-0,--- Cum I USA © 198$'2010 ACRD CORPORATION. All rights reserved. 1 ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD :< The Commonwealth of Massachusetb -- Department y of Industrial Accident's nycci n 4'�a_t� ate. � p. Office of Lstzgazbiln qi i. i� alig. �r t E:2, :� �, 600 Washington ,Street L, >� ,> www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A lica.nt Infor ation Please Pr I.�e2°hl Nanie (Business/organization/individual): 1 i " ,), g Address: , 1 1 ' %' ,' City /S e /Zip: - - - -L /1 ' Phone #: y t-'57 7 e -)14�,_ r 2. re an employer? Check the appropriate box: Are of project (required): I am a employer with . 4. r: I am a genes a� contractor aid I employees (full and/or part - time). have hired the sub- contractors ❑ I am a sole proprietor or partner- listed on the attached sheet. E] New construction 7. ❑ Remodeling 6. ship and have no employees These sub - contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t 9. 0 Building addition required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 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 81 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: hk 0 14 a% j_ j-r5 ( s Policy # or Self-ins. Lic. #: 1 `-) Expiration Date: jib Job Site Address: Al City/State/Zipti (b ..1_,PECIS 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 u der pairs ' d nalties of perjury that the information provided above true d correct / 9 Signature: t ...t 1, 't' Date : C . a, Phone #: / `tr' j. ., t .: - T3 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 #: 19 f � 'Massachusetts - De.pattrnent of Rutaiic Sa!ety \\` Board of Building Regulations and Standards Consza action Sup rii ur - License: GS-067121 38 WILLOW 21100K LANE .; WESTFQE . 1A 010:5 • f r ispt1 7 }tol Commissioner 04/3 W2014 • • • HOME IMPROVEMENT CONTRACT SASE READ THIS • eater N Boston D' TRD At -Home Services Inc. del dRrla The Home Depot At -Home Services 908 Btu Turnpike, tJmt 1, may, MA 01545 Toll Fate (800) 657- -3182; Fax (S08) 845.6017 Brandt Number.: 31 . Federal ID # 75 269846th I L#e ABC 02439:xi Cent Lid! 1607 CT Lie #BIC.0565 hammiest* Canty tit Eeg.# 126193' lrretallatton Address: f a.+ r " ,;,,, a _..! ftl• • INa • City • t Tip Pareabee te); • Work 1 Hesse Pular, Ce4 Phew IIIIIKAMIIM7 1 [ .Its + wr•.C.r1.1111 Herat Address: Of dl ffrient from Installation Adtheee) City T State Zip Email Address (to receive roject communications and Haase Depot updates): w DO NOT wish to inceivo say marketing amok from The Hone Depot tlndessiped (°CCestomer"), the owners of the property located at the aberve inetalledon addrc5s, agrees to buy and At-Homer 3ervicci, Ice. (The Hahn Depot') agrees to furnish, deliver and arrange for the installation ("IretauI lkn") of all materials described on the below and on the teed Spec Sheet(s), all of which are a into this Contract this rel�ncc, along with any applicable State Supplement and Payout Snam y attached hereto a Omura (colW y, nom lob r# wires ._ ■� :. a :',;. L'. W N indows • munition fJ Aassaat 6544 log 1 emsiCovers ' DEaayDoors ❑ ► S 340 * ■ • , ;,,_ A Windows • In*Watwn Doaaass/ Covers DEntry Doors n ■ w H windows ere Insulation 414 M u t t e r s r! • • OS d ng U Windows U Int►aatloa UG.reus f coven DEmry Doom la Moan= 29% DepsherCooaaetASmeat due upon e>seeatlon adds reuer rota ammo Amount Mem Purchasers way sotderadtmeretlene aarmeCenuaQAreomte 340 Customer agrees that, immediately upon completion of the work for each Product, Customer wllt execute a Completion Certificate (one for each Product as +harmed by an individual Spec Shea) and pay any balance due. As applicable, each Customer under this Contract agrees to be jointly and severally obligated and liable her+armler. The Hot,u Depot test rves the right to issue a Change Order or terminate this Contract or may individual Product(s) included hot*, at its diacietion, if The Hearne Depot or its authorized service pnavider determines that it cannot perform itz obligations doe to a structural problem with the home, environmental hamids such as mold. asbes or lead paint, other salty eweerns, pricptg mugs or because work requited to oom a the job wan Dot included in ih I �� C7 Bari Satnin ran The Payment Summery # included as part of this Contract, sett forth the total Contract amount and payments required for the deposits and final pa tents by Product (as applicable). NOTICE TO Yea a to a Ca an ett* Uad nepdst 1 kdin� et contrast t CUSTOMER ebae a there is one Completion Cart ate for Pradaet as defined le dual Tha Ant a compel** afoe twit on that Product o d u c: is oobtptale. by Spec-Shuts) before tootle eu that Product In the event of termination of this Contract, Customer agrees to pay The Home : the costs of aatuitds, labor, expenses and services provided by The Home Depot or Authorized Service Provider the date of airma'natioa, plus any otter amounts sat forth in this Agreement or allowed under a law. THE IC a , I' DEPOT MAY WITHHOLD AMOUNPS OWED TO THE >OME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. an e �eg Customer agrees and understands that this Agreement 1S the entire agreement between customer ome epos wtth towed to the Products and Installation services and supersedes an prior discusaiona and agreements, either Mt or Written, relating t0 said Products and Installation. This Agreement cannot be assigned or amended except by a writing signed by Customer and The Roue Depot. Customer acknowledges and agrees that Customer has read, underbtuada, voluntarily accepts the trans astir! has received a copy of this Agreement. Submitted bv' IN)0 • r ' s Signature + hate Sales Comultanr's Stream bate X Talopboee No. ;3 E+.^ * 3 J* Customer's Signature Date Sales Consultant Licence No_ CANCELLATION: C)JSTOMZR MAY CANCEL MS Ica appliathk) AGREEMNT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DET'OT BY MIDNIGHT ON THE THIRD BUSINESS DAV AFTER SIGNING TIM AGREEMENT, THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE 13 SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE IsroTtath ADDITIONAL TIRMS AND CONDITIONS An! SEATED art THE REV*ks6 SIDE AND Alt4>t Peter or THB CONTIMET 05.10.12 White- Branch Flu Yeaow- Cusromar SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors , ® Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [p] Other 1E1 Drip�io�7 P pL ) /Ct� m) p...0 ID,i w s '- sllut i l>( __— Work: Brief esc / /��t// Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. 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 . I. 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 I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work aauthori by this building permit application. 7<- Mri9a/A6 � Signature of Owner Date I, WOO S '/ wit r r r , as Owner /Authorized Agent hereby declare that the statements a d information on the foreg ng application are true and accurate, to the best of my knowledge and belief. Signed un 21 the pains and penalties of perjury. Print Name / ��Ii /Z Signatur of V? nt Date Section 4. ZONING AU 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 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 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 Q 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. EIVE p Department use only Cit of Northampton Status of Permit: SEP 2 Bu ding Department Curb Cut/Driveway Permit 6 toe '12 Main Street Sewer /Septic Availability DE Room 100 WaterNVell Availability NORTHAMPTON G Two Sets of Structural Plans -y No ham ton MA 01 060 HAMPTON M CTIONg hampton, • - 13 87 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify 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 Map Lot Unit I I D o Zone Overlay District tio��rn,� , lnPr I 1 l 0 Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: .Su s / � u s4,iJ 7f( Progpe — AVM NdriAtu AL- y /060 Name (Print) ra Current Mailing Address �i T L( Et j 7 k 1 4 a TelepIfn _sQ _$ 0 L,! Z. — e Signature 2.2 Authorized Agent: 4 !u AY/ r co( ? oN�P/l 97 SZlR ,r7 o /syr Name (Print) Current Mailing Address: e_I�IA#0 10F7/5 3'r Signatur i Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only mpleted by permit applicant 1. Building $ 34#8 (a) Building Permit Fee 2. Electrical 11 (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 0,3 yLt Check Number c/ / This Section For Official Use Only Building Permit Number: Date g Issued: Signature: Building Commissioner /Inspector of Buildings Date 78 PROSPECT AVE BP- 2013 -0355 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24A - 114 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit # BP- 2013 -0355 Project # JS- 2013- 000565 Est. Cost: $3408.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 67121 Lot Size(sq. ft.): 20995.92 Owner: CHILDS SUSAN F Zoning: URA(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 78 PROSPECT AVE Applicant Address: Phone: Insurance: 908 BOSTON TPK Workers Compensation SHREWSBURYMA01545 ISSUED ON:9/26/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL(4)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: 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 9/26/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner