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17D-039 (2) - T�I CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE r- P , � " g rr ?-rho "liEP 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 INSLJRER(S), AUTHORIZED REPRESENTATIVE OR P +- ODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poiicy(ies8 mast roe endorsed If SUBROGATION IS WANED subj tc the terms and conditions of the poky, certain policies may require an endorsement. A statement on this certificate tiDOO a a sat confer ,ightT ua the .-. _ erualaa ate 6aolUer in )ael ezt such endwrelvfenaCs); PRODUCER 1 -866- 966- 4564 'CONTACT Marsh USA Inc, NAME' — -- - -� + PHONE . - -- I F.A, ' _1AIC, Ne. sin_ _ _ — -- - -____ (AIC, No): __ DDR A homedepot .certrequest@marsh.cora E ADDRESS: Two Alliance Center, 3560 Lenox Road, 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 Home Depot, Inc. New Hampshire Ins Co 23841 Home Depot U.S.A., Inc. INSURERC: P 2455 Paces Ferry Road NW INSURERD: Illinois Natl Ins Co 23817 Building C -20 Atlanta, GA 30339 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445 INSURERF: Illinois Union Ins Co 27960 COVERAGES CERTIFICATE'NUMBER: 30289573 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. LTR TYPE OF INSURANCE , �; ,,.�, , POLICY NUMBER POLICY EFF MM EXP LIMITS GENERAL LIABILITY GL04687714 - 02 03/01/1 - 03/01/13 EACH OCCURRENCE $ 9, DOD, 000 r •A' -AGE TO 'E TED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 1, 000, 000 CLAIMS -MADE OCCUR MED EXP (Any one person) $EXCLUDED LIMITS OF POLICY XS PERSONAL &ADVINJURY $ 9.000,000 OF SIR: $1M PER OCC GENERAL AGGREGATE $ 9,000,000 LAGGREGATELIMITAPPLIESPER: PRODUCTS- COMPIOPAGG $ 9. 000,000 POLICY II PRO 111 LOC $ AUTOMOBILEUABIUTY BAP 2938863 -09 - 13 01 1 COMBINED SINGLE LIMIT Ea acdderE 1,000,000 © ANY AUTO BODILY INJURY (Per person) $ I IIII ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS 111 HIRED AUTOS II AUTOS NED PROPERTY eacrident DAMAGE $ SELF INS HIRED PHY DMG ■ $ ■ UMBRELLA LIAB EACH OCCURRENCE $ • EXCESS LIAB CLAIMS -MADE AGGREGATE $ III OED II RETENTION $ ( � y � $ c WORKERS COMPENSATION 1WC019736915 (AOS) 03/01/1. 03/01/13 ©■ ■ AND EMPLOYERS' LIABILITY D ANY PROPRIETOR/PARTNER /EXECUTIVE YIN WC019736917 (FL) 03/01/1- 03/01/13 E.L. EACH ACCIDENT $ 1,000,000 E (Mandatory inNH) EXCLUDED? N WC019736916 (CA) 03/01/1, 03/01/13 E.L. DISEASE - EA EMPLOYE $ 1,000,000 If yes, describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ III Workers Compensation WC1192494 (01) 03/01/1. 03/01/13 SIR (ADS) /SIR (GA) 1M /750,000 Workers Compensation WC019736918 (WI) 03/01/1. 03/01/13 TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1. 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 INSURANCE CERTIFICATE HOLDER CANCELLATION I r SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HQME DEPOT, INC. HOME DEPOT U.S.A., INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C - `,� ATLANTA, GA 30339 ,5n` a1A-Ltla(1,i slkka6 ha�1Lt_ USA 0 - ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010!05) The ACORD name and logo are registered marks of i ACORD Jthornton_hd nn- ,onca.2 • . . DO U U • • _ o • ® m a • ®,� v o \ al • . _.a sn — o . r ) . • - 0 Q.. 5' co o . • • o ii c 2 . � . , m v • m ... b v r - s t fl 1 64 • `� T? Mc, o = � �`v r • V h3i3lAd ❑ c d .o \ ' ? � 31� 1 • U ,. +� a � i ` ` a 1 cd V (� �� ��i d x= N c ' o . [CT • 2 . 1' o = , P . • ` S���Qf - I$7 ' a V.J. I. u , o . C++ �, • • I . a) 0 [lilt( . pt �� . P_ - . • fp! n. • o Z C a c� a. . V r t ^y- ry �.�j LA 4 ,,- A , „.,, .,.., . . < „..„ < • • . ,.,.• P ,,,-, •-•,- - ,- i . _ 6 `IJ . 1• 'Y ° 0-1 " � 2 r • t m ti::FT :i4.1h I y.. 4 U CI • ` 0 ' - t r 1 []' cn I - SJ o .' m 0. _1 a H = C\l <.i: u S 0 ` 11 ' 11 pp __ r c L, i Con.st ruction Super\ istir Speria Ita CSSL-098785 rvAN KOSOBJYKYY daktilktel 72 STAFFORD ROAD MONSON* 01057 • 0412712014 • HOME TREPROVI11t41 NT CONTRACT PLEASE READ Tl1s Sold, Punished and Installed by Inch Namm Boston Dane: nip At -Home Services, Inc. ra54 dMa ThcEiomeDcpot At -Home Services 345A Greenwood Street, Unit 2, Worcester, MA 01607 Toil Free (800) 657 -5182; Fax (508) 756 -8823 Branch Number: 31 Federal 1) * 75- 2698460: ME Lic # C 02439; RI Cont. Lid" 16427 Cr Lic a I 0563522 ; MA Home Improvement Conirxxor Rag. B 126893 installation Address: D-- Kil. 43 4- P td IRl7 ( i c 1 Y / t Isar Qt (6'2. 1, City State Zip • Pur lmiser(a): Work Phone: home Phone: Cell Phone; eti gas 6v7 osic t [ ] . [ J C [ l C Home Address: (If different from Installation Address) City State 7tp E - mail Address (to receive project communications and Home Depot Updates): ❑ I DO NOT wish to receive any marketing errant from The Nome Depot Project Inf ationt Undersigned ( "Customer "), the owners of the property located at the above installation address, agrees to buy. and THD At -Home Services, Inc, ( "'The Home Depot ") agrees to furnish, deliver and arrange for the installation ( "Installation ") of all materials 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 Summary anached hereto and any Change Orders (collectively, "Contract "): Jon#_ cnm.atunn..w p s # 1 ?r• _ Amount • Rooting i Siceng ti • endows ■ Insulation DGutters f Curers DSrury Doors ❑ 55� URoo ing OSlding U Windows ❑ Insulation , `1 DGwaxs / Covers DEatry Doors [] S / ✓/� J 1/ i ■ Roofing Siding ■ Windows ■ Insulation ©outeera / Covert Entry Doors 0 $ - URoo6ng Osidng U Windows ❑ Insulation - $ <— 00../Covers / Covers ©Entry Doors O - 1_ Mtrimm259° Deposit of Cataract Amaemtdueuponeteeioa etdays teati'aes. Total Contract Amount 11 Maine Purehesers may oft deposit mwe than o U <d titre Contract Maim& $ t Customer agrees that, immediately upon completion of the work for each Product. Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable, Celt Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s) included herein, at its discretion. if The Horne Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home, environmental hazards such as mold, asbestos or lead paint. other safety concerns, pricing, errors or because work required to complete the job was not included in the Contract. Pavnrent Summary: y: The Payment Summary # included as part of this Contract. sees forth the total Contract amount and payments required for the deposits and final payments by Product (as applicable). NOTICE TO CUSTOMER You are entitled to a compse �r tiled -9b copy of the Contract at the time you slggpD Do not sign a Compled a Certificate (note: there as one Completion Certificate for each listed Product as defined by individs l Spec Sheets) before work on that Product is complete. In the event of termination of this Contract, Customer agrees to pay The Home Depot the costs of materials, labor, expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTR8R PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot with regard to the Products and Installation services supersedes all prior discussions and agreements, either oral or written, relating to said Products and i istaltarion_ This Agreem- can be assigned or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and a: - -: Cu tomer has read. understands, voluntarily accepts the terms of and has removed a copy of this Agreement. Zet? X ite r 1 " 1 " ! ' 'S Signature DaC � t Si �� • X Telephone r elepone No. t `S t 4 Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS tar apptie bla) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRI'T'TEN NOTICE TO TIIE HOME DEPOT BY MI1DNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTKT. ADDITIONAL TERMS AND CONDITIONS ARE SLATED ON THE REVERSE SIDE AND ARE PART OP THIS CONTRACT 01 -18-12 C-SC White - Branch File Yellow - Customer =PAW, .� Depart entofIndustrial .A:cidents iIiYYWyp � Office o fInvestigations n, 7' ' 600 Washington Street T a Boston MA 02111 www.Mass.gov/dia Workers' Compensation insuraThCe Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leglbll Name ( Business /Organization/Individual): t f Ai Address: cV t � City/State/Zip: in _, A _ 7 Phone #: g �? 1 Are yo . n employer? Check the appropriate box: Type of project (required): 1. I am a employer with a(. 4. ❑ I am a general contractor and I - - - - - - 6. Q New construction employees (full and/or part- time).* have hired - tlie sub contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet.- 7. ❑ Remodeling. — — These sub= contractors have ... 8. Q. Demolition ship and have no- employees working for me in any capacity. employees and have workers' . g Y P h' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$. required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11.0 Plumbing repairs or additions 3. ❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13-1.1 Other employees. [No workers' cornp. insurance required.] *Any applica 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 tContractors 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: - '►rV7 � 1 � g L�� -- Policy # or Self -ins. Lic. #: i _ P _ ���C x iration Date:. 2 -Job Site Address: - City/State/Zip:_, ),I1 44 . i Attach a copy of the workers' compensation licy declaration page (showing the policy number and expi • tion 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 - _ . inst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of th r insuranc - 40 overage verification. --Ti hereby c-' under t ®� �d pe , Ides ofperjury that the info provided above is true and correct: Si• a -�__ _... � . /i �/ .. - , Date: Phone #: l� -- 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other • _ _ Contact Person: Phone #: s ECTT1ON 8 CONSTkRUCT1ON - S ER V C 1 . 8,1 Licensed Construction Supervisoor: Not Applicable 0 !lame ofLacersa Oder: /i - •- ' I.�.e.. . IA- - - License Nu _ mlSer 1 ilk r or...- _ /111 ,r 111 ) g A If 111 411 AP .4. . a /).. Address p , , Expiration Date /< # I , 1 Ali /.i sir . Signatu Telephone e 4 eredi'Orfis4rn•thieme >Gontiiac of V r ..'-? f 1 Wttt c x,MMv yk WR9' I ; - Not Applicable ❑ Company Name Registration Number _Address �< Expiration Date g y)2---- tl �: ����'A � . elephone l ��J �1!7 i C „: i 'ganiY�w ' i ',iigirk ..... .w.� N�k°..'- Ss �'�`t si -akt 44i clei:V 17.c. � a,fa �5rF9t4i. A-- P SECT CON1104NORKERS COM, PENSA11Q l RANGE AFFIDAVIT {M G Ctle- 452,V25G(6)); , Workers Compensation Insurance affidavit in be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin ermit. Signed Affidavit Attached Yes No ❑ '1 ' �` Wills ,�,�.. W ialM ' WIle ' ' ir ;Iii 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. is or is intended to be, a one or two family dwelling, attached or detached structures accessor to such us de, on which there Definition of Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to resi y g ry e 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 ' Building Official; on 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'Cha ter l52 Bikers' Com ensation and Chapter 153 (Liability of Employers y to P � P ) P � tY 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 S tate of Massachusetts General Laws - Annotated Homeowner Signature _ • 1 SECTION 5- DESCRIPTION OF PROPOSED WORK (check ail applicable) i i New House El Addition ED Replacement Wind s Alteration(s) n Roofing in Or Doors Accessory Bidg. 0 Demolition New Signs [0] Decks [CJ Siding [ ®] Other [01 Brief Description of Proposed 1 `d f i _ !�.' /. //. Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No -^ itt t l Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet . °` 6a. If New house and or addition t xistinq 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. 7teg 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 1 O)L YI1._ I, , 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 I, �� 1, - , as Owner /Authorized Agent hereby declare that th- - a =me s -n• i f•rmation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains - • • - nalties of ,• - ' • 4» /Ilk: A_ Print Name a r ' Ili Signatureer /Ag =ir , ' Date 12 HIGH ST BP- 2013 -0650 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D - 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 -0650 Project # JS- 2013 - 001072 Est. Cost: $1344.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sq. ft.): 8755.56 Owner: BRUNSKI CHRISTOPHE D Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 12 HIGH ST Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 0 Workers Compensation WORCESTERMA01607 ISSUED ON:12/12/2012 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 12/12/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner