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29 • i a • • • .. • Cro �. a • I CJ C v o t a CD II. Oil reee CD e---8 r -1 47" a N a7 f l E c " 0 04 c `' a a 0.0 � c cu ' tee,. C CI) •.-a ' -, 1.- c` . .'z' F/ g 'b 'LO '� .. ,� � 4-••. _ 31 x1 Q E u) r te+ • N illi I j n a F+ • " .. . 10 0 • 1L �, . • 4e X 4` rn i ltil lat I le . 1 i , v e ce • ri) . rr5. a-.4 .' LWs_PEf ` H. 0 < 1" _ . - `E c 0 c , U U T. 1b ` ` a+ • a j 0 . 4 ry .. 1` � .. . �' . F �f Lit- t' =� ,,: t 1 - ' Z C) < , G it o ' :� :` • ` v . - z Q, L r�. U U C?? , E �) `) 6, .. - :.;� ".`r `' o m I - - 'I °I ,-7-, -c-, ti, 11111'.) . B11id F ��� - t ` a 1 a .s e - 5 7EIA Ifui7rl r{ .. ` 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONIFERS NO RIGHTS 1PON THE T,FlC _ ,CL ER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES , ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. I IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policyd`Nes) must be endorsed If SUBROGATION IS WA1�NED suh)ect tee 11 the terms and conditions of the policy, certain policies may require an endorsement. A state,ment on this certificate :Ir)on root c nfer riOrits W the 1I 6 3arsh Inc, l�lreu' 17N Ii4N Gti such �➢L �6 C,S��G;n'Cy S)'. - . ...__... __-___ __d._._., __ 1 1 - 866 - 96 -?' 664 CONTACT 1 PRODUCER I NAME: - --- ; PHONE i FAA _jMA% Ettt --- -- -- --. _ -- — --- --- -- -- -- (AIC, Nfn): _ at homedepot. certrequest @ arsh.co:u ADDRESS: _ :Two Alliance Center, 3560 Lenox Road, Suite 2400 Atlanta, GA 30326 INSURER(S) AFFORDING COVERAGE NAIC it Fax (212) 948 -0902 INSURER A: Steadfast Ins Co 26387 INSURED INSURERS: Zurich American Ins Co 16535 The Home Depot, Inc. Home Depot U.S.A., Inc. INSURERC: New Hampshire Ins Co 23841 2455 Paces Ferry Road NW INSURER D: 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: 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. INSR ADDL SUBR I POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVD • POLICY NUMBER ■ (MM /DDIYYYY) MMIDD A GENERAL LIABILITY GL04887714 -02 03/01/12 03/01/13 EACH OCCURRENCE $ 9,000,000 X . ._ —__. _ _.. DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $1,000,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ EXCLUDED X LIMITS OF POLICY XS PERSONAL &ADVINJURY $ 9,000,000 X OF SIR: $124 PER OCC GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 9,000,000 POLICY PRO LOC $ FCT B AUTOMOBILEUABILITY BAP 2938863 - 09 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 INSUR D 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 W CYUMRS OT ER AND EMPLOYERS' UABIUTV D ANY PROPRIETOR/PARTNER /EXECUTIVE II /N N/A E (Mandatory ory in NH) WC019736917 (FL) 03/01/12 03/01/13 E.L. EACH ACCIDENT $ 1,000,000 OFFIda ER EXCLUDED? I WC019736916 (CA) 03/01/12 03/01/13 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 • in If 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 (ADS) /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 INSURANCE CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME 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 -20 C �( � ATLANTA, GA 30339 ,S a ti�v'> A.L UIL ha 0« USA ©1988 -2010 ACORD CORPORATION. All rights reserved. 1 ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Jthornton_hd ]nnanC09 HOME IMPROVEMENT•CON'TRACT PLEASE READ THIS Sold, Furnished and Installed by Branch Hamm H stns 'Dine: • THD At -Home Services. Inc. d/b/a The Home Depot At- Horne Services 908 Boston Turnpike, Unit 1, Shrewsbtny, MA 01545 Tall Free (800) 657 -5182; Pax (508) 845-6017 Branch Number: M Pl dram ID # 75- 2698460; ME Tic# C 02439; RI Cont. lice 16427 G� t CT L is # RWC.0565522; MA Home, Improvement Cooattri ctor Reg. *1261193 Installation Address: i.52 C� � r i L'>+l�lt eT I 1 City State Tip Pttirehaser(s): Work Phew: 80111b Phone: Cell Phone: C l O i E 1 E l E l Home Address: _ (If different from Installation Address) City State Zip E-noall Address (to rwrive project communications mad Home uqx t updates)_ 0 I DO NOT wish to receive any marketing entails from The Home Depot Information: Undersigned ("Customer"), the owners of the property lowed at the above installation address, agrees to buy, At-ktorne Services, Inc. ( "171e Home Depot") agrees to furnish. deliver and arrange for the installation rinallation ") of all materials described on the below and on the referenced Spec Sheet(s), all of which ate in into this Contract by this reference, along with oily applicable State Supplanted and Payment Summery attached hereto any Change Orders (collectively. +#' menet Predawn Spec Sheel(s) P Protest Amount 41V t.._/ 0Rooting USidng U windows 0 Insulation , t ') 432 Damns � 5'1 Damns / C peaty DOOM ❑ s t s L 7t{ 3 ,..��� f 0 ❑S•idmg U Windows 0 Insulation DGutters / Cavan Dewy Doors n ❑Roofing U$idulg 1--1 Windows Icsulatim $ 7— rJ DGuttcrs / Coves [Wray Doan E _ ORoo ing USiding ❑ windows 0 Insulation DGuttas/ Covers ❑ley Doors f l Mhemve2Sei Deposit (iceman*antauntteee meacatianc d*orneram. Total Contract Anima $ (�,7 Maine Purr sm ynotdeposit msetlenonNhirdsowCamactA alt C Customer agrees that, immediately upon completion of the work for each Product, Customer will execute a Completion Certificate (one for rach Product as defined by an individual Spec Sheet) and pay any balance due. As applicable. cads Customer under this Cataract agrees to be jantly and severally obligated and linable hereunder. The He Depot reserves the right to issue a Change Order or terminate this Contract or ally individual Ptoduct(s) included herein, at its discretion, if The Horne Depot or its authorized service provider determines that it carnat perform its obligations clue to a structural L 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. # Pay out Sntttgm The Payment Summary t tn'l r q . included as part of this Contract, sets 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 clot;{ Me -1n copy of the Contract at the time yea sign. Do not sign a Completion Certificate (note: there i$ one Completion Ceslitiate for each listed Prodnet as defned by indllvidnal Spec Sheets) before work on that Product is complete. In the erect 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 OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Atxxthtsanee Autborizalfian. Customer agrees and understands that this Agreement is the entire agreement between Customer an Home pot m regard to the Products and Installation services and - - all prior discussions and agreements. either oral or written. relating to said Products and Installation. This Agreement .- of . - assigned or amended except by a writing signed by Customer and The Horne Depot. Customer acknowledges and agrees .. - o er has read, understands, voluntarily accepts the tams of and has received a copy of this Agreement. X ._ _' / X �. "1- he, Cu- , s . ' • Dade S- VT' tare's Signature Date ,A ' . N u - a - Customer's Signature Date Sales Consultant License No. CANC7 TI Qtr CUSTOMER MAY CANCEL THIS (et apps ahhe ACRE ]T WITHOUT PENALTY OR OBLIGATION BY DELIVERING WR111EN NOTICE TO TEE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING TIES AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO . CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE: AterflONee TERMS AND CONDITIONS ARE STATED ON TER REVERSE SIDE AND ARE PART OF TH(S CONTRACT 03 -30.12 C-$C White - branch File YNtan - Cui%>tner t,, a i h e i ,. l)t / 7i 1 Df % ^>, : i t 0 1 : 4 1 0 ' 0''`_ » !,1 ,,,,,, ..� Department o ch Inzstria Acc �""" - a . ,,, ,...t4.-a: ... O ce r f Investigations w _. 600 Washington .Sr /e.e i Y : ` a ,. =`- . Boston, MA 02111 wwwomass.gov/dia Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers A 6 ,lican1 Information Please Print Legibly Name ( Business /Organization/Individual): � ` Address: a Jri l ,�t :i - t I � . . . City/State/Zip: milli. A i 1 Phone #: . g w I' Are yo, . n employer? Check the appropriate box: Type of project (required): 1. .15 I am a employer with L ) 4. 0 I am a general contractor and I 6. 0 New construction employees (full and/or part- time).* - hav -fiired the sub contractors 2. 0 I am a sole proprietor or partner listed on the attached sheet. 7. 0 Remodeling — —__. __.. These sub- contractors. have 8. 0 Demolition ship and have no employees . _.._ . working for me in capacity. employees and have workers' . g any P ac ty 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$. . required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 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 R repairs insurance required.] t c. 152, § 1(4), and we have no - employees: [No workers' . 13• Other comp. insurance required.] ' *Any applicant that checks box #1 must also fill out the section below showing then workers' compensation policy information.. . I 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." Cam' ,,.1 Insurance Company Name: l i)' e7 1 I r-e --�-u t °J (. Policy # or Self -ins. Lic. #: if/d /I lExpiration Date: s . ,_ .__Job Site Address: ..__.._ -- 54 .. -- - 3 4 .glii.e_37r City/State/Zip: k 6.14, a AS , —.a Attach a copy of the workers' compensation policy declaration page (showing the policy number and expi ation 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 thgr insuranc overage verification. I hereby ce - y • under t i. . , in s "d pe lties of perjury that the information provided above is true and correct. S a , 4,-,et - - Date: Phone #: D `7tro .. =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 nepartment 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector b. Other • _ _ Contact Person: Phone #: SECTION 8 CONSTRUCT1ON SERVICES + x a.. al Licensed Construction Sioervisor: Not Applicable Name of License Holder: 1 License Number . V C)I .r --- le) I�/ Address Expiration Date Sign./ . ! / ' . Telephone �� li; sT oriole ornetlm•coveme >GontEac or rt E „z # F �Zi t ry; +k4.` `� 4 i 7 Y pp �, - , ,,,; Not Applicable ❑ • 5 Company Name Registration Number - - 1111 L__ -Trtgi _ .14)1 E1dd[ess -. - Expiration Date 1 b ithadi/liJh, i// elephone x,47.14745.2 y�' 9 ,d..n h i T�i•ky`ItaG4 4, h 4 FOi 4 +ki^ -akt , :ii ' t ig.- r..,( `'NEbila *✓. ad.4 7. SECTIQN,d0 WORKERS "COMPENSATIOI INSURANCE AFFIDAVIT (M G! 'S2 § 25C(6))� ��. :Workers Compensation Insurance affidavit m 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 ❑ 1r : 1 1 Intw :, Wife Ia 11U011 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 two -year period shall not be considered a homeowner. Such "homeowner " submit 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 refeieii a to Chapter-f 52 (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 'Wide? 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 ofMassachusetts'General`Laws Annotated. Homeowner Signature • . , CJ: l Park St 1 Boston_ ..\\,lasachusetts 02116 Home imr)ro% ement Contractor Re2istration 150517 T pe: Individuai Expirati.on: 4/6/201 Tr # 2278z VLADIMIR SHEVCHUK, VLADIMIR SHEVCHUK 5 OGDEN ST CHICOPEE, MA 01013 'Update Address and return card. Mark reason for change. Address Renewal Employment Lost Card License or registration valid for Milk idol use only • = Office of Consumer Affairs & Business Regulation IMPROVEMENT CONTRACTOR before the expiration date. If found return to: (50517 Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 3170 Expiration: 4.'6 Ind.%0dua! Boston. MA 02116 'ILA0;1 .R SHEVCHUK SHEVCHUK 5 OGDEN ST CHCOPEE. MA 01C13 Undersecretary Not salid without signature • PTH-dic ,! 4 Rui,t1 Co7struct Superrisor Sp,Pcia'ty 99209 Restricted tc: WS VLADIMIR SHEVCHUK 5 OGDEN STREET CHICOPEE. MA 01013 101112013 7572 SECTION 5- DESCRIPTION OF PROPOSED WORK check all a.•Iicable) New House [ Addition_ Re •.ows Alt eration(s) n Roofing oors P. Accessory Bldg. El Demoii iorz fl New Signs [0] Decks [C9 Siding [0] Other [01 1 Brief Description of Propo - • • Work: s 111 . � ��. AI / ' f t. • C•Elp Alteration of existing bedroom Yes No Adding new bedroom Yes No 0 D l Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to 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. 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 // _0 , . , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit applicati n. Signature of Owner Date I, I( .V G�� , as Owner /Authorized Agent hereby declare that the s tements a in o rmation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains - penaltie • - - ' ry. Ilk t A i I) ‘"------- Print Name iray / / Air , 4 4 ■ 142//c247 Signature • • er Age ' Date 28 BEATTIE DR BP- 2013 -0652 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 219 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 -0652 Project # JS- 2013- 001074 Est. Cost: $4748.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 99209 Lot Size(sq. ft.): 15333.12 Owner: VITO MICHAEL J Zoning: Applicant: HOME DEPOT AT HOME SERVICES AT: 28 BEATTIE DR Applicant Address: Phone: Insurance: 345 GREENWOOD ST (401) 935 -2633 () Workers Compensation WORCESTERMA01607 ISSUED ON:12/12/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS & PATIO DOOR 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