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31A-117 (5) ___ _ CERTIFICATE OF I 1LIT ._. HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERMCATE H',` LUEIi. 1.115' CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING' INSURER(S), AUTHORIZE REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 certificate holder in lieu of such endorsement(s). — . PRODUCER 1 -866- 966 -4664 CONTACT Marsh USA Inc. PHON: PHONE JA/C, No. Ext); (A /SA No): ------ -- --._ _ _ ot.certre est@marsh.com E-MAIL homede P 9u ADDRESS: Two Alliance Center, 3560 Lenox Road, Suite 2400 Atlanta, GA 30326 INSURER(S) AFFORDING COVERAGE NAIC# Fax (212) 948 -0902 INSURER Steadfast Ins Co 26387 INSURED INSURERS: Zurich American Ins Co 16535 • The Home Depot, Inc. New Hampshire Ins Co 23841 Home Depot U.S.A., Inc. INSURER C: P 2455 Paces Ferry Road NW INSURERD: Illinois Natl Ins Co 23817 Building C -20 NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURER E: - -__ INSURERF: 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 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 INSR SUER POLICY NUMBER (MM /DD (MM DD/YYYY) LIMITS — EFF POLICY EXP LTR INSR 11)/VD A GENERAL LIABILITY GL04887714 - 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 PERSONALBADVINJURY $ 9,000,000 X OF SIR: $1M PER OCC GENERAL AGGREGATE $ 9,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 9,000,000 X POLICY , C LOC $ B AUTOMOBILE LIABILITY BAP 2938863 -09 03 /01 /12 03/01/13 COMBINED SINGLE LIMIT (Ea accident) j 1,000,000 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 T TS V ANE) EMPLOYERS' LIABILITY D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN NIA WC0197 3 6 917 (FL) 03/01/12 03/01/13 E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? l 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) 03/01/1; 03/01/13 SIR (AOS) /SIR (GA) 1M /750,000 C Workers Compensation WC019736918 (WI) 03 /01 /1; 03/01/13 F TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1: 03/01/13 Occurrence /SIR 30M /1M DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 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 / / • r —^ ATLANTA, GA 303 C ._ l 2,-4 USA ©198 -`2010 Ac RD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Jthornton hd 1 ..t,: .+. iir ff 6190 J as iii c t or i St J -i M4 021.17 Workers' COMp :3 AtiC 1 ' `r1rs,,.,; Affi'dav'it ' uil td" 3, __.*..s Z :' . ,.x;:.,. .i: art #r3AI131 . .g llcant In Qr a on ,_ —— __ ��._ _ ,__ .4 Please Frint 1 ,� Name (BusinesstOrganizas onrin dividua ); 1 0 i'f's e.-.: k • ; j Address: L { ce 5 • f.t"r ...0, City /StateiZip: f ti.. 4-ec, 6 A - - 5 Phone #: 76 ' 6 51- 5 / gr-- Are you an employer? Check the = pprapriate box: Type of project (required): L I. I am a employer with d- 0 4. 0 I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ❑ New construction. 2. Q I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub- contractors have 8. ❑ Demolition working for me in an capacity. employees and have workers' g y p tY• t 9. ❑ Building addition [No workers' comp. insurance comp. insurance. 10.0 Electrical repairs or additions required.] - 5. 0 WiVe are a corporation and its 3.0 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 ltJt( employees. [No workers' 13 . Other • comp. insurance required.] /QAg 1''C� -A -- *Any applicant that checks box #I roust also fill out the section below showing their workers' compensation policy information. t Homedwners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name 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. T am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. r - Insurance Company Name: Gt .,0 II /.. ,, • r " . --/ 0 5 ® j+ • ,t p j Policy # or Self -ins. Lic. #: W o 1 3 6 ! f 6 Expiration Date: -- / Job Site Address: 3 �/ `T . City / State/Zip: dr dim 0Y06O 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 D for insurance coverage verification. 1 do hereby certify f ' the pains and penaldes of perjury that the information provided above if true and correct. Signature: �''� Date: 4/0-0 : . - Phone #: r 0) 9 T5 3' 'Official use only. Do not write in this area, to be completed by ay or town official City or Town: - • Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4.-Electrical,Inspector 5. Plumbing Inspector If i ./ ./ g / / 4'/4 _ `� 0 ' ice o onsumer • ai and : usiness Regulation 10 Park Plaza - Suite 5170 % 77- • :t i Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 126893 Type: Supplement Card Expiration: 8/3/2014 The Home Depot At -Home Services ANDREW SWEET 2690 CUMBERLAND PARKWAY SUITE 300 ATLANTA, GA 30339 _ Update Address and return card. Mark reason for change. Address Renewal Employment LI Lost Card DPS -CA1 0 50M-04/04-G101216 /�� Office otionsfine A"�fa rsi'li°use stio License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: _�— Office of Consumer Affairs and Business Regulation Registration: 126893 Type: 10 Park Plaza - Suite 5170 Expiration: ( 8/3/2014 Supplement Card Boston, MA 02116 T - Home Depot At -Home Services .1-21 ANDREW SWEET ' 2690 CUMBERLAND PARKWAY S A'I'�I , GA 30339 , '� A � Undersecretary ■ • i 'thou signature • PIOVLZIPO LOO 1,4114.03NOW. fiV0116.11WAVIS /VAT V.C1r.prhi3 - • L.- HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold, Furnished and Installed by: Boston Date: THD At -Home Services, Inc. d/b/e The Home Depot At-Home Services 908 Boston Turnpike, Unit 1, Shrewsbury, MA 01545 Toll Free (800) 657-5182; Fax (508) 845 -6017 Branch Number: 31 Federal ID # 75- 2698460; ME Lic # C 02439: RI Cont. Lie# 16427 �j � ` Cr Lie # 6551 ?: MA Home �or Rag. # 126893 Installation Address:: Aci (42, {� f�!y Ild 1 City State Ziip Pa )= Work Phone: Rome Phame Cell Phan= JweR� [ ] [ Horne Address: (If different from Installation _ Addre es) City State Zip E-mail Address (to receive project communications and Home Depot updates): 0 I DO NOT wish conceive any marketing emails from The Home Depot t • Undersigned ("Customer"), the owners of the located at the above installation address, agrees to buy, and T ProjJr HD AServic s, Inc. ("The Home Depot") agrees to fu and arrange for the installation C LnetteAiatton") of all mareriais described on the below and on the referenced Spec Sheet(s), all of which are iNcorporated into this Contract by this reference, along with any applicable State Supplement and Payment Swatmary attached hereto and any Change Orders (collectively. "Contract "); jab #: a.k.sr am, store Sheet= # Peeled Amman URoefipag USirrmg LJ insulation . . + pantos I Comas OF.narr boors 0 . + - $ in Rooting ■ siel+lut la Windows H Insulation OOunaecs / Covers OIE,ary Doors 0 URooting US1 g U l ndows D Insulation $ Doom= / Covers OEmuy Doors f uRoofng L s�zding QWIndoes O Insulation OG,thers / covers OEntry Doors (1 MIn1inamMi Deposit efCe traetimeeredr :eu;ponentenlonoftbrsemends. Tali contract Amount 6 lJ MalasPyedasets soy mat deposit zstett6 noinAird theCtnn=Armuat. Customer agrees that, immediately igloo cornpleticxr of the 'work for each Product, Customer will execute a Completion Certificate (one for each Product as deed by an individual Sp= Sheet) and pay any balance due. • As applicable, each Customs under this Contract agrees to be jointly and severally obligated and liable he:sunder. The Hoare Depot reserves the right to issue a Change Order or terminate this Contract or any individual Ptndutx(s) included herein, at its discretion, if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem With the home, etvbwurtaatat hazards such as mold, asbestos or lead paint, other safety concerns, pricing errors or because work required to complere the job was not included to the Contract Payment Summon: The Payment Summary # - 1 l Cei . included as part of this Contract. sets forth the total Contract amount and payueents required for the deposits and final payments by Product (as applicable). NOTICE TO CUSTOMER You are entitled to a filled-in ropey of the Contract at the time Do not sign a Campletlion Certificate (note: a there is we Coupled each ch listed Product as defined by Spec Sheets) before wok on that Product is complete In the event of termination of this Contract, Customer agrees to pay The Horne Dot the coats of materiak, labor, eapetases and services provided by The Home Depot or Authorized Sere Provider tbrop ep igh the date of terminadon, pmts any other amounts set forth In this Agreement or allowed under applicable law. THE HOME DEPOT MA l wratnoLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR (YfIIER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDDIS FOR RECOVERY OF SUCK AMOUNTS. a and Atet Customer agrees and understands that this Agreement is the entire a pee nent hamlet) Customer an d t11 a � Hone Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements, either oral or written, relating to said Products and Installation. This Agreement can o • assigned or amended except by a writing signed by Customer and The Home Depot. t titstomer err lrnovrle es and agrees that ; t .. , has [raid, understands, voluntarily accepts the terms of an received a of this Agreement. bubmF X ' 4 ,4 O gz--,zy —72 e, " ` . s gesture Date Sales -o► tant's Si tame Date X Telephone ` . • s.I♦ Customer's Signature Date Sales Consultant License No_ • CANc LLA'TION: cUW3MER MAY CANCEL THIS taeiestiatio AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN leOTICE TO THE HOME DEPOT LtY At ioNN;wF ON THE THIRD BUSINESS DAY AFTER SIGHING 'TINS AGRZEM ENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE 1B SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. - NOTmCB. Am moe4ALTERMS AND COttDttlONS ARE STATED ON 171E REVERSE SIDE AND ARK PART OF THIS CONTRACT 03 - 1042 C-SC Where - Branch Fife Mow .- Customer SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : J.4 ,4N 18 (�1� 6 e7 / / License Num er 72- S/A , M 7 , /1 o,t/SwN ,'M o/o -i/ ? 7. /1 Add " Expiration ate �.�1� 4o / — fir 6 3 Sign - Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ )/n a ,4 l vi /abet' 3 Company Name - Registration umber 8/3 26/ Address i Expiration Date , Ii li r 7 Telephone 0 7 � I�I — 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 ❑ 11. - Home Owner Exemption 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 n Addition ❑ Replacement Wjndows Alteration(s) n Roofing fl Or Doors ✓`�\ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [O] Other [0] Brief Description of Proposed Work: ` . �` Q7 a. rii • � � n�- 1�w�1� ILt�� � /lV 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 . 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 , 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 4 / 4)4 kr31k ) , 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 der the pains and p- alties of perjury. Ali 11 Print Name -�— Signature of S -nt 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 Q DON'T KNOW Q YES Q 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 Q DON'T KNOW Q 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 Q 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 Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Cit . f Northampton Status of Permit: Department use only Bulldl g Department Curb Cut/Driveway Permit t,u1 1 2 2012 21 . Main Street Sewer /Septic Availability "OOn1 100 WaterlWell Availability LEp OF BUILDING INSPE vial" ha pton, MA 01060 Two Sets of Structural Plans NoRTHAM?J. - = 240 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 U Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: S ax � — 3 iltajpc s� ,� ithethilia7Au/ ifl,f 0/40 Name (Print) Current Mailing Address: -44 A / its! i` Telephone Signa ure 2.2 Authorized Agent: 77 r rv�/` Oar R-T -ht art c S P(V!ncS 9t r ,ash ur Name Print J Current Mailing Address: Qj /s, .411401101Mg 10E-7/1148 Signatu ,• r 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 (HVAC) 5. Fire Protection \ 6. Total = (1 + 2 + 3 + 4 + 5) g- ,3 /� �' Check Number 3 3�� 'F1 S This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 32 VERNON ST BP- 2013 -0437 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 117 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 -0437 Project # JS- 2013- 000699 Est. Cost: $8340.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sq. ft.): 7274.52 Owner: DEAL SHARON H Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 32 VERNON ST Applicant Address: Phone: Insurance: 908 BOSTON TPK Workers Compensation SHREWSBURYMA01545 ISSUED ON:10/15/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 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 10/15/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner