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38C-039 (2) y i s _J ' I ,1 A ,u S v_R 'i =1 ar', TIE IS !,Bl3EL" AS A MATTER OF INFORMATION v i_.' AND COi i, s.i, i'a(', RICr; 'i "S .i Cr' T rTJ% r ti. , •O .. _. _. ri ;::ER T JFICA T = DOES NOT AFFIRMATIVELY CR vEGA T IVEL'f AkiENC, EXTEND OR AL r ER f HE COVERAGE -AF_FO :JED 3 ( l i E cJi_IC i E : BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CCNTR,CT 'EE TJVEEN THE iSSU1t1r J':SIURE..( I . T GRa r REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT' if the certificate holder is an ADDITIONAL INSURED, tr. palicj(ies) must be e:ndorssu. If SUBROGATION IS WANED, sLibleci L the tams and conditions Of the policy, Certain policies may require an enclorsament. A statement on -f;1;3 ei- ificatta d_..5 not ,.n e; t �h.. ;t) h = certificate holder in liau of such andor-sament(s). PFODUCER 1-355-95;i-4.554 ' CONTAT NAME: -- areh US`. Inc, PHONE A: (AJC. No. Exit: I 'A/C N E -MAIL 'ccued.enct,certrecu _ ot@ma ti „r, ADDRESS T wo All Center, 3550 Lenox Roaad, Suite 2400 Atlanta, GA 30326 INSURER(S) AFFORDING COVERAGE NAIC Fax (212) 948 -0902 INSURER A: Steadfast Ins Co 26387 INSURED INSURERS: Zurich American Ins Co 16535 - -__ The Hotne Depot, Inc. New Hampshire Home Deport U.S.A., Inc. INSURERC: p hire InS Co 23841 2455 Paces Ferry Road NW INSURERD: Illinois Natl Ins Co 23817 1 Bu C -20 NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURER E: INSURER F: Illinois Union Ins Co 27960 COVERAGES 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 7 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 III WVD POLICY NUMBER (MM /DDIYYYY) (MM /DD/YYYY) LIMITS A GENERAL LIABILITY GL04887714 - 02 03/01/12 03/01/13 EACH OCCURRENCE $ 9,000,000 X DAMAGE TO RENTED $ 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 &ADVINJURY $ 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 JE LOC $ B AUTOMOBILE LIABILITY BAP 2938863 - 03/01/12 03/01/13 COMBINED SINGLE LIMIT 1,000,000 (Ea accident) 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 INS D PHY DMG $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE . AGGREGATE $ DED RETENTION $ • $ L WORKERS COMPENSATION WC019736915 (AOS) 03/01/12 03/01/13 X TQRYI MIT °R AND EMPLOYERS' LIABILITY "--- " - - --" Y/N D ANY PROPRIETOR/PARTNER /EXECUTIVE N WC0197 3 6 917 (FL) 03/01/12 03/01/13 E.L. EACH ACCIDENT $ 1,000,000 OFFICER /MEMBER EXCLUDED? N E (Mandatory In NH) WC019736916 (CA) 03/01/12 03/01/13 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 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 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C -20 / ATLANTA, GA 30339 f o-__ _ 6,,.it USA ©19B 2 22010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD-.' `i: The Commonwealth ofMas.sachasetts 1 - _ Department of Industrial Accidents "2" `? Office of Investigations -. ix 600 Washington Street Boston M4 02111 `'+t- 1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builder° s /Contractors!ElectriciansfPl _Applicant Information Please Print Legibly Naine ( Business /Organization/Individual ): t < � -1 .I Address: . -11_�' t,, �,i .14A: > ' if1 - . ,i, ; ' City /St e /Zip: _ _ al ; I /,, . ; - 7 --P #: ` . Are y a n employer? Check the appropriate box: Type of project (required): 1. I am a employer with 4. I am a general contractor and I employees (full and/or part-time).* have hired the sub- contractors 6. ❑New construction 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 working for me in any capacity. employees and have workers' Building addition [No workers' comp. insurance comp. Insurance. required.] 5. ❑ We are a corporation and its i0.0 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 I2 [] 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 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 employee& Below is the policy and job site ixformat e' n, , _ ,-% [� _ Insurance Company Name: t L•ij 1 G-1 14 ie) jr- 1 h G Policy # or Self -ins. Lie. #: 0 � `9 1..'-) Expiration Date: /i ) .. Job Site Address &3q •S€Z(!t sr , City/State/ZipkOttiikilfew, /71,4 0060 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 E der pains ' d nalties of perjury that the information provided above true correct Signature: +... .,4t # �. ,, j -- _ _ Date: CI i:,- P h o n e #: 1 ° J f `" M5 2 Official use only. Do not write in this area, to be completed by city or town official I City or Town: Permit/License # It 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 #: l �.\ 9t.--,---z-.3-e• ....--;.--.. 0 fice of Consumer Affair and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts. 02116 • Home Improve . '• ontractor•Registi.ation ' • • _ -= Regiatratlon:..126893 j , ,_ . -_ Type; Supplement Card 1 . The Home Depot t -Home Servi'''' �� Expiration: 8!3/2011 RICHARD .i+ALLQ E , , W • 2690 CUMBERLAND PARKWAY r i o W ATLANTA, GA 30339 — ma ti . • • ....c> ..r- ;y a Update Address and return card. Markrensonfor change. • E Address El Renewal .fl Employment n Lost Cnrd PIT C;'). 1 ,` 50M-04104- G ,g2.4 - 6 :7 0Mt47tMUUB12a CI .../( ad Y,--\ 0 flice of Consumer Affairs & Business Regulation License or registration valid for indh'idui use only • P` j` before the ex iration date. If found returnto: , Dry . OM IMPROVEMENT CONTRACTOR P I i r ^ 4 Office of Consumer Affairs and Business Regulation Registratlon. . Type: 10 Park Plaza - Suite 5170 af I xpiratftini,10:014 Supplement Card Boston, MA 02116 • ' rho Homo Depdt0A1 Hbtne>3'rvfN 2690 CUM BERL4ID PAJ XWAY' S a:"...4----„.61;-.11._____ �,. p ' fI_ 'ARITA, GA 30339 •: -: •• Undersecretary of valid with, tit sl f. nature . • • __________________ 09- 12-'12 06:48 FROM -THD PRODUCTION 5087569009 T-365 P035/035 F • 4 ... • . . -:-.. . • 4 ! . • . . • • j • t • i • . . • . . 4 • 1 1 • I i• • _ I 21 I 2 I • • i I _ - .- LOU 1 NOSNO14 :1 ellON ellOilyttg ti, ... 0}V41 AVIV • „ • 22. ... , 2 lia sansineso iitiliaads .7259+-14tI1 IS Ut9)311,13tUti) : ..2 %,.:7;!.',.3 t!..k 5", ,':T±' 7 ;4 7.,..:.#C.,S, • . . ,.. • Ammw 09- 12 -'12 06.48 FROM -THD PRODUCTION 5087569009 T - 365 P034/035 F - 898 1S*I1ND3 JarYa MtA211 auNQaunt auv am***FetrWextuaav maw 'WWI liatINOVIVI3 i'a ! el AII 611201381141 ArlfrrallIMIS SI IMO AI a:a W. WHOA V SWUM* OJT UH3V,LLY Difiltribillit Zi Sat 11 Y OW. 0$11038 112L4V LYM . 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C :�°�!:t�►i;L i-, as L , thxs. wag • .. . .. is -• -■ , tea , ■ ■ ■ ■ ■ ■ Uteatspegm) *s, kg & S d Fa tddeS a g OW ran tots It e 4 ps0 4 6 2 °3 1 r g P . as Rita• 3 its Nv) a sIS wit psle sashes all) *4 P se ww PaqW � a al 4 al nlwa4 W A S SIR i* rang (juke as ,3 p ,} sops i0iO4MY PR Vxlatt awn pia lino arm Iowan hi OWN= MINA jai OM n `4swePias mow pm imisvapolsosoighef up= aty maw wag dry mos Ail OhlIPPV nopainesui ung suaqug A) WIMPY Mgt IIIMIIMIMIIIIIIIIIIMIIIIIIIIIIIIIUIIIIIIIIIIIIIIIIIIIENIIIIIIPIIII 111.11111 "1-4 111111111111111.1111111ELUZIGIGIF ni■s41 • wimill4 II ;amid sa y► a • MT MS Qc�v Q j, 1p ,) -r 11 =KM ■*wtl l ta9zlptgl ... ...,,� smog - ,,, �r 1HSasida ono Yf'C 'I 11113 wan 906 (' =poi fiamykty yam anon au amp aH RPM Pus Poll 11 �7 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacemen± indows Alteration(s) Roofing Or Doors ' ® C Accessory Bldg. ❑ Demolition ❑ New Signs j0] Decks j(= Siding [0] Other 11=I] Work Descripti on of Proposed 6 _. 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 , 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. 4 rvc a agriMer Signature of Owner Date 1, A&c m ih E , as Owner /Authorized Agent hereby declare that the sta nts and information on the fo going application are true and accurate, to the best of my knowledge and belief. Signed u •er the pains and penalties of perjury. Print Name Signature of Owner / • s n 11 11111 Date 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 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 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained trkD Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 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 (3 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 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit Building Departmen [�• u :* D riveway Permit 212 Main Street !!l eptic vailability Room 100 � » 2 6 Water ell vailability Northampton, MA • 06f e,T !, : • S - is o Structural Plans phone 413 -587 -1240 Fax •c4i, G , Plot/-ite Pans PTO N Sp cify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEM • • H A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office LL ��, ( .Stjie rf S Map Lot Unit Nort ,NA v'po "J/ iA o10to b Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: `` ,, b & }tf W0 jay �c &� A .1 o� �/6h b Name (Print) Current Mailing Add e — 5- 3 / — ff � See etf- 1 f7 ( Tee got Signature 2.2 Authorized Ascent: •, 79 � JDg &s m.() S{, l / 19A- a5 Name (Pri Or Current Mailing Address: �J Sign�tu�!, Telephone 1 SEC 0 - ESTIMATE* CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building c� c /3 (a) Building Permit Fee 2. Electrical I (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) 'c c2/.3 Check Number 7 g This Section For Official Use Only JJ �` Building Permit Number: Date g Issued: Signature: Building Commissionerllnspector of Buildings Date 354 SOUTH ST BP- 2013 -0356 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38C - 039 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 -0356 Project # JS- 2013- 000566 Est. Cost: $2213.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sq. ft.): 4791.60 Owner: WIJNHOVEN DEBORAH K Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 354 SOUTH ST Applicant Address: Phone: Insurance: 908 BOSTON TPK Workers Compensation SHREWSBURYMA01545 ISSUED ON:9/26/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 5 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