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23A-119 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations r 600 Washington Street Boston, MA 02111 www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors ifiectricians/Plumbers A. ,licant Information Please Print Le.ib1 Name (Business/Organization/Individual): 3/4404F T101 _ '/ �7 Address: Ole g Y t City/State/Zip: �r hone#: tar ./► fi Are you an employer? Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. El New constnnction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling These sub-contractors have e e 9 1-1 r molition '.ip ., working for me in any capacity. employees and nave workers 9. 11 Building addition [No workers' comp. insurance comp.insurance.t required.] 5. ❑ We are a corporation and its 1 o.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL l 2.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.11 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. .r 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: 14't,t1 vn 4.4 t'_. ►t: (L7 Policy#or Self-ins.Lic.#: /t Expiration Date: - Job Site Address: City/State/Zip: / 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 ' sur., ce cov age veriv ation. I do hereby certify u ,der e p I an' ' o'perjury t a e information provided ab ve is true and correct. Signature: ,,.' Date: 9 3- Phone#: 11W- 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#: HOAR IMPROVEMD l'CONTRACT PLEASE READ THIS � /�� Sold,Furnished and Installed by Branch Name:Boston Kerb&Swam Date:LV jt i THD At-Home Services,Inc. d/b/a The Home Depot At-Houma Services Branch Number.31 sad 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 • Toll Free 877-903-3768 Federal 0)#75-2698460;ME Lae#C 02439;RI Cont.Lictl 16427 ( (4 CT Lie#HIC.0565522;MA Home Impro ment Contractor Reg#126893 C InstagateonAddress: este-x.1k Fbrot)t (L- 0(662_, City State Zip • Purchaser(s): • Work Phone: Home Phone: Celi Phone:. Ike re r t l [ [ 11111111111111 [ Home Address: (If different front installation Address) City State Zip E-mail Address(to rive project communications and Home Depot updates).- ❑I DO NOT wish to receive any marketing entails from The Horne Depot Pi lest Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and TI-iD At-Home Services,Inc.("I'be Home Depot")agrees to fitraish,deliver and arrange for the installation(`Tttsfatlatiou")of all materials described on the blow and an 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 attached hereto and any Change Orders(collectively, "Contract"): Job tt turewem P ucts: S ac Sb s tk Pro ect Amount 1 � III Mutters II Siding t'Windows MI Insulation)] (f ' 1 Mutters 1 Covets OSntry Doors 13 7 7 ,r` q 1/01if —s�sitiag 3 Windows p ntsntation Daum/ 21 try Doors n b i 3 I Roofing IR idiwg•Windows •halation 0t3 !hers DEntty Doors o_.. 11RooTms using p windows rrinsutation EIGatuis/Covees°EntyDoors❑ 2n Deposit otComaset Amouetdus span execution seats contract. Total Contract Amount S Maine Punhasas may eat deposit more than one thins of the Contract Amount Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate tone fn each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each 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 Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural • problem with the home,environmOnlal hazards such as mold,asbestos or lead paint,other safety concerns,pricing eeors or because work required to complete the job was not inducted in the Contract. Payment g tomes : The Payment Summary# k 177 , 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 completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual 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-e date of termination,plus any other amounts set torch 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. gg ptsnee mud Authoritatio$: Customer agrees and understands that this Amman= '.the entire agreement between Customer e Home Depot with regard to the Products and Installation services and sup-:-'-_ •'or discussions and agreements,either oral or writes,relating to said Products and Installation.This Agreement cannot be .. •1 ., or amended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agrees that C : ,t cad,tmderatands,voluntarily accepts the terms of and has received a copy of this Agreement. Acre : r Submi • •y: ±... r , a , • e Date Sales Con v tgnature Date Telephone • Customer's Signature Daft Sales Consultant License No CANCELLATION: CUSTOMER MAY CANCEL THIS (uappl+cahr.) AGREEMENT WITHOUT PENALTY OR OBLIGATION (4 t -5,3a/ BY BY DELIVERING WRITTEN NOTICE 1O THE HOME °+- DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AF'T'ER SIGNING THIS AGREEMENT- THE STATE ' SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOT E:ADDITIONALTennis AN DCONDITIONSARE SfA'rgDONTHEREVERSESIDEANDAREPARTOFT HISCONTRACT 98-19.15 WNtt-araisoNFite renew-Customer CERTIFICATE OF LIABILITY I SU 0 NCE j 302/27/2 3°'Y ` THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 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 INSURER(S), AUTHORIZED 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 CONTACT MARSH USA,INC. NAME: TWO ALLIANCE CENTER (NC,No,Ext): I FAX C No 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL S 100492-HomeD-GAW-13-14 INSURER A:Steadfast Insurance Company 26387 INSURED INSURER B:Zurich American Insurance 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 INSURER D:Illinois National Ins Co 23817 BUILDING C-20 ATLANTA,GA 30339 INSURER E: INSURER F: . COVERAGES CERTIFICATE NUMBER: ATL-003159545-04 REVISION NUMBER:7 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.. (LT I TYPE OF INSURANCE ELI POLICY NUMBER I(MMIDDY/Y YY1 i(MMMUUD/YYYYYD I LIMITS 1NSR A GENERAL LIABILITY GL04887714-03 103/01)2013 103101/2014 EACH OCCURRENCE S 9'000.000 X DAMAGE TO RENTED 1,(100,000 X LIMITS OF POLICY XS {COMMERCIAL GENERAL LIABILITY PREMISESLEa occurrence) $ EXCLUDED C ( CLAIMS-MADE OCCUR MED EXP(Any one person) $ OF SIR:$1 M PER OCC 9,000,000 PERSONAL&ADV INJURY S I GENERAL AGGREGATE S 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: LPRODUCTS-COMP(OPAGG S 9,000,000 X POLICY PRO-- E LOC S B AUTOMOBILE UABIUTY BAP 2938863-10 03/31/2013 03/01/2014 COMBINED SINGLE LIMIT 1,000,000 (Ea accident) s X ANY AUTO BODILY INJURY(Per person) S— ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) S AUTOS NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LLAB I T 1 Ik OCCUR _EACH OCCURRENCE S EXCESS UAB 1 I CLAIMS-MADE AGGREGATE S I DED I RETENTION S ' S C I WORKERS COMPENSATION WC033575314(AOS) 03/0112013 03101/2014 X I WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER 0 ANY PROPRIETOR/PARTNER/EXECUTIVE(YIN WC033575315(AK,AZ) 03101/2013 103101/2014 E.L.EACH ACCIDENT S 1,000'000( D 'OFFICER/MEMBER EXCLUDED? ( N 1 N/A WC033575316 FL 03/01/2013 03/01/2014 1,000,000 (Mandatory In NH) ( ) E.L.DISEASE-EA EMPLOYEE S Eyes,deaaibe under 1,000,000 I DESCRIPTION OF OPERATIONS below i E.L.DISEASE-POLICY LIMIT S C WORKERS COMPENSATION WC033575317(KY,NC,NH,VT) 03101/2013 03/01/2014 (EL)LIMIT 1,000,000 C WC033575318(NJ) 03/01/2013 03/01/2014 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION THE HOME DEPOT INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HOME DEPOT USA,INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING C.20 ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. I Manashi Mukherjee .Mctuoot 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD , SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su rvviisor: Not Applica le £ Name of License Holder: / �" J /i " / Cam' ..-�V,/� 712/ License Number -724 101/0--kiVpsie/2 /4/9-Ai ......,...3 49 ,—/y1 Address Y �� Expiratlo Date U ( J 412 d/0�� Signature Telephone 9.Re•istered 'e m•rovenie"t Contractor •' Not Applicable £ Com an Name I Registration Number , i , P141 r s / / ,j J Expiration Date � - 0" pp", D/ ✓�elephon ©/'ill 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 buildi ermit. 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 ❑ Addition ❑ Replacement W' ows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding [C:1] Other[D] Brief Description of Proposed (2t/ u/)IJ Work: UUU OPP.' ,l a, Oh i �/ OF Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 4-it New house acid or'addition to erstinq fiousnq;`compfete-the10 lowing: 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, 0r? t/1 4/ 2 0#4' f/Z ---- , as Owner of the subject property / 7 hereby authorize / Are—j) i Y to act on my behalf, in all • ers r • e to work authorized by this building permit application. �� r7�e /D --J 0-"-‘1 Signature of Owner Date I ��f)0 J19-- ,as Owner/Authorized Agent hereby declare hat the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under t ins a d penalties of perjury. Print Name Signat e of Owner/Agent 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 1 i ` 1 [ i Frontage I._-__.__ ________...-1 ....___-_ — __I 1 1 __.._.__. _ _ Setbacks Front = I Side L= R:t I L:I J R:1._t r -- =Rear 1.____..__I -- l Building Height r----1 L I ! Bldg.Square Footage 1`--- i--"-'-1 % 1--" 1 I Open Space Footage r'--�'--� % € (Lot area minus bldg&paved L.___ J T L-1 I ___wj t parking) #of Parking Spaces = ____._,. I I Fill: I 5 E_._.._ _........_.... _.._.,__. 3 (volume&Location) I 11 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:1 IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES 0 IF YES: enter Book 1 Pagel and/or Document#1 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 Q Obtained 0 , Date Issued: r------- C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: 1 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: i s 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. • ,e , ju _,. ' ;Y"Y3�' Deparfinent use only �3.: z.. s r 1 x ' ,:\i, �- �'Fp ,� 4 ''4 ti p� 40-14:W1�i ,I�4. a."� 1 1 : ��-� ' C= ity of Northampton $fatus ofPerm)t , y 6 -d ri-�i k 8 h�'£y.41 e rf Iii �;. D �� J' l ..�yr '�M,�-`�? � 4 rr+ r iiu r""L ,+#� > 4 C_ �1 L� 4•t f m� eS ka :e n e i s 1�' �,ullding Department CurFa�CUt/DxirtewayFerrrtit �, , � 212 Main Street Sey+�er/6eptle Awail"a'` Illty r i' 1�z ` OCT I 0 2013 �� ' � r Room 100 Water�kltfeliAvail'ablllty`� 4 �� ' 'tr�'' �'� ' No hampton MA 01060 Two Sefs of Struct„rat°Piar's .:,.: :f t E � d 7r,, S��, ,� - a, t Electric,Plumbing&�ab�tml�l� �ht35 87-1240 Fax 413-587-1272 Piof/SiteiPlans �'° 'o v i, k `5 , t 4 Northampton, A 01060 Dther Spec�f�f� i ti!..,,,,:..:,,,,,,,,,,,,k_,,,,,' �s 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 ZMap s Lot t� Overlay Distric oe r CB Dlstn cf EIm.St Ditrc Unit SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT r—� 2.1 Owner of Record: ^r�7----;11;;)_1 r �� „mac- 1 0/a6 2- (Print) Current Mailing Address: ( Telephone Signature 2.2 Au�tl sr ed ent: ^ _--- C— /A/12--194 : / Name(' A.:0 ,94:::4");v0,. . 9.0 i 49 -----. te'-'2.-3 Current Mailing •f dress: Si•T-tore llj/ Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS. Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building ‘,7 h 7 J') , I 0 (a)Building Permit Fee 2. Electrical (�`�! (b)Estimated Total'Cost of Construction from(ti) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) / /� ) r � � ' V Check Number (Yr���j .1 This Section For OfficialUse Only . Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 11 CHESTNUT ST BP-2014-0433 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A- 119 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-2014-0433 Project# JS-2014-000756 Est.Cost: $6020.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 67121 Lot Size(sq. ft.): 6141.96 Owner: LASELLE JOHN J&MARGARET D Zoning:URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 11 CHESTNUT ST Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCERI02908 ISSUED ON:10/11/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS/ENTRY 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 10/11/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner