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18D-053 (15) March 24, 2014 Ms. Linda Lapointe Principal Clerk for Building Inspectors 212 Main Street, #100 Northampton, MA 01060 Dear Ms. Lapointe, This letter is to confirm that I have hired Lowes to install replacement windows and doors at our condo located at 80 Damon Road, #5306. If you have any questions, I can be reached at 202.441.7713. Thank you. Sincerely, Jennifer Cook Johnson i CONTRACT# 00(1 4) :1 MASSACHUSETTS.SERVICES SOLUTIONS INSTALLED SALES CONTRACT LOV'` IZED REPAQS6NTATWE NUMB/ERr CUSTOMER 1 AUTHOR�f if C 1 J ZL l !rte•! ~\L A Y� ST9RE NO. L STREET ADDRSS STREET ADDRESS I CITY STATE ZIP CITY STATE TELEPHONE _ TELEPHONE o DAT5"74M C Cv CFEI ` This Is only a qwt.for the man9mndba and san4oes PMmd below.This be mas an aIpaemant upon Payment Upw payment the entire agreement Induding the spvAcall•/wrnplated pages of this dorumem,the Tenor and ConAons Included Ath elu dowmanl and any other addenda and aeadmenle hereto,shall be referred to Ih herein as a Tumt-V PLEASE READ ALL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING. INSTALLATION STREET ADDRESS CITY STATE ZIP j l � `h r I NOTICE TO CUSTOMER—PRICE CALCULATIONS:In order to properly perform the installation of certain Goods,the Contract Price may include more Goods man actually will be installed based on the measured square footage of the Project Area.As a result,the parties agree that the lump-sum Price stated in this Contract is calculated upon both the value of estimated Goods required to fulfill the Contract(including waste),which may exceed the actual square footage of the Project Area,and the labor which may be estimated based on the amount of Goods required to fulfill the Contract(including waste). By signing this Contract below,Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may not be refunded once the installation Services are performed. Contract Total ] Are permits required for this installation?:[ Yes [ ]NO *applicable tax included NOTICE TO CUSTOMER:Federal law requires Laws's to provide you with the pamplet Renovate Right By signing this Contract,Customer acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure from renovation activity to be performed In Customer's dwelling unit. NOTE:If rotted wood is discovered during installation additional charges will apply.You will be given a quote and a change order must be completed and signed by the'customer for any additional charges. / —Customer must initial. 'Any work or material not specified Is not included in this contract.Any changes or additions will be at an additional charge for the material and labor. PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photographs of the Premises where Installation Services will be performed and all work performed at the Premises related to this Contract,and irrevocably grants to Lowe's all right,title and interest in and to the photographs for use in all markets and media,worldwide,in perpetuity.Customer authorizes Lowe's to copyright,use and publish the photographs in print and/or electronically,and agrees that Lowe's may use such photographs for any lawful purpose,including,but not limited to,marketing, advertising,publicity,Illustration,training and Web content.By initialing here,Customer agrees to the foregoing. ]Customer to initial to the left]. Work is to commence upon reasonable availability of Contractor and/or any special order or custo�e r made Goods)which is anticipated to be 4l !�/y ]fill in date].Estimated completion date is �-!f�- /rf [fill in date]. Said estimated substantial completion date is not of the essenccq�,,.A statement of any contingencies that would materially change Said estimated substantial completion date is as follows: °'t'•f� CEG rC'6T 6+ (f applicable,insert a statement of such contingencies). IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full j COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00: J Customer to Pay in Full; OR [ ]Customer to use the following payment schedule: (1)Deposit$ to be paid upon signing contract.Deposit should be 15 the total contract price;and (2)Payment of$ to be paid anytime after this Contract is signed and before commencement of installation,I/We authorize Lowe's to do one of the following(check appropriate box below): [ ]Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or [ ]Deposit mylour check for the amount of the payment indicated above anytime after the date this Contract is signed;and (3)Final payment of$100.00 to be paid upon completion of the installation and both parties'satisfaction. NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L.c.14 LOWE'S A DIOWAt�: EREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT LOWE'SYAY POBMIT PUOH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BYTHE SECRETARYOF THE EXECUT- IVE OFBICE, C N R AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED I .,C.142A. By: Date: Landis Home Centers,LL C.,' By: ",. k�—..; Date: Owner Signature THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWE'S PURSUANT TO M.G.L.c.142A.THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE SECTION ABOVE IS NOT SEPARATELY SIGNED BY THE PARTIES. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT. BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ,UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS j CONTIj/CCT.Y rl ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. I WITNESS OUjt'0A4(S)AND SEAL($)BELOW THIS �� DAY OF ; ! ' LOW16 s;4111 Centers,LLC _ :.r---�- LowIpXAutWbflzeV Representative Owrfer Co-owner or Witness Customer acknowledges receipt of a true copy of this contract which was completely filled in prior to Customer's execution hereof.You,the buyer,m: cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See the attached notice of cancellation form for an explanation of this right. pip p r-npV 02004 by.Lowe'&*Lowe's amp.the gobte dosbn LA d ZLZLI8SEM « 800*`LLHLt` WEE# sales 11a1SuI SZ-E0-tiL0Z 1 CONTRACT# MASSACHUSETTS SERVICES SOLUTIONS INSTALLED SALES CONTRACT LOWE'S AUTHORIZED REPAF_SENTATIVE NUMBER CUSTOMER - r STORE NO STREET ADDRESS ,y STREET ADDRESS j p CITY STATE ZIP CI7V STATE ZIP e TELEPHONE TELEPHONE DATE J LOWE'S HOME CENTERS,LLC'S MA HIC NO.:148688 CASH BANK F Lcc REG CARD CHARGE j � t FEIN:56-0748358 This is only a quote for the merchandise and services printed below.This becomes an agreement upon payment.upon payment,the entire agreement,including the specifically completed pages of this document,the Terms and Conditions included with this document and any other addenda and attachments hereto,shall be referred to herein as this"Contract." PLEASE READ ALL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING. INSTALLATION STREET ADDRESS CITY STATE ZIP C G^-1,... i PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photographs of the Premises where Installation Services will be performed and all work performed at the Premises related to this Contract,and irrevocably grants to Lowe's all right,title and interest in and to the photographs for use in all markets and media,worldwide,in perpetuity.Customer authorizes Lowe's to copyright,use and publish the photographs in print and/or electronically,and agrees that Lowe's may use such photographs for any lawful purpose,including,but not limited to,marketing, advertising,publicity,illustration,training and Web content.By initialing here,Customer agrees to the foregoing. [Customer to initial to the left]. I Contract Total Are permits required for this installation?:[)&Yes [ ]NO "applicable tax included �� 1 NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right.By signing this Contract,Customer acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit. NOTE:If rotted wood is discovered during installation additional charges will apply.You will be given a quote and a change order j must be completed and signed by the customer for any additional charges. _ Customer must initial. 'Any work or material not specked is not included in this contract.Any changes or additions will be at an additional charge for the material and labor. WAIVER OF LIEN and ONE YEAR WARRANTY(TO BE SIGNED BY INSTALLER) I,the undersigned Installer/Independent Contractor,having been employed by the Customer who signed the Certificate of Completion below do hereby certify that the work for this project will be or has been completed in a workmanlike manner and to the Customer's satisfaction.In consideration of the receipt of one dollar and other good and valuable consideration,and to the extent permitted by applicable law,I hereby waive and relinquish all liens and all rights and claims of liens which I,the undersigned,now have or may hereafter have for labor or materials furnished,and further certify that all work performed and materials furnished,if any,by any other parry or parties upon the order of the undersigned,have been fully paid for.Further,I the i undersigned,agree to cause the prompt release of any mechanic's lien(s)which may be filed against the Customer's premises by any subcontractor,laborer,mechanic or material supplier claiming the right to file such a lien through work related to the Customer's Contract with Lowe's.In addition to any warranties provided by law or specified elsewhere,including the Customer's Contract with Lowe's,the undersigned,further warrants that all work furnished for this project shall be free from defects either in material or workmanship.If any defects in material or workmanship shall be discovered in the work furnished or material used during the course of the work or within one year from the date of the Certificate of Completion,the undersigned agrees i to replace or correct such defective work or material,free from all expense to Lowe's and the Customer in a manner satisfactory to the Customer. I further represent that I have given Customer the option of retaining some or all of the surplus materials or having some or all of such surplus materials removed from the Customer's premises. If applicable to the performance of the work required for this project,I,the undersigned Installer/Independent Contractor,do hereby certify that I have complied with all requirements of the i Lead Renovation,Repair,and Painting Program Rule("LRRPP Rule"),40 C.F.R.sec.745.80 at seq.,or any applicable state laws or program regulating lead-based paint safe work practices, including compliance with all information distribution,notice requirements and work practice standards in performing the work required for this project.I certify that I have provided the Customer with all documentation required to be supplied under the LRRPP Rule or state program,shall retain all records required by law,and have attached to this document copies of all of i the records required to be retained by the LRRPP Rule or applicable state program. I Signed and delivered this day of I (seal) Installer Print Name CERTIFICATE OF COMPLETION 1.1,the Customer,certify that the Installers/Independent Contractors or their sub-contractors,have furnished all Goods and/or services,that installation,repairs and alterations or improvements j ("the installation services")have been completed as set forth in mylour contract with Lowe's,and that I have been offered the opportunity to request that Lowe's allow me to retain some or all of I any unused,receipted surplus materials rather than have such surplus(materials remain the property of Lowds, 2.Buyers initials(Buyer INITIAL ONE only) There were no such surplus materials. 1 accepted all surplus materials I wanted. I 1 declined to receive any surplus materials. Date: Owmers Signattue, Owners Printed Name j i I I ®2004 by Lowe's.®Lowe's and the gable design 55102 REV. 12/13 INSTALLER COPY are registered trademarks of LF Corporation. 1V/G1/LV1J 10.11 rAA 10002 10/17/2013 9939 AM FROM: Fax Hewlett-Packard Company TO: 1-413-692-9483 PAGE: 001 OF 001 �YJ CERMFICATE OF LIABILITY INSURANCE 0/3. "I2013' �..--- �oi�7izozs THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONF*RS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE APPORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(SI AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. MPORTANT: If the certMes&holder Is an ADDITIONAL INSURED,the pollcypes)must be endorsed. K SUBROGATION 18 WAIVED, sA*&to the terms and condlUons of the polley,certain policies may requlre an endorsement. A statement on this certificate does not comer rights to the ceKNlcate holder in lieu of such endomemen s. RODWOR WKFAVT Becks Serra sat-S IrUllam Insurance agency, Inc PHO . (413)737-3339 (+19)731-seas 175 Zlm Street baerraQbatesfullam.con INSURE s AFFORDING COVErt11QG NAIL e rest Springfield ma 01089 IAA W"t0vn I+Wrld Ole NFOR M I <7aamelrae Xnausanoe Compow3r, 4754 !aradize Builders, LLC INSLetER c: :18 Hampden Street I :hi M& 02..013 I :OVERAGES CERTIFICATE NUMBER-4 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTE=D BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDI Q 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 HERl=1N IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMEYS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF MV9~cE am 110M I LIMITS Grdi-RAL LIAeIUN EACH OCCURRENCE f 1,000,000. X COMMERCIAL GENERAL L"ILMY Z 50,000; E► CMMSMADE ®OCCUR rB1 0/17/2073 0/17/2014 MEOExa oft eryon 1,000 PERSONA.a ADV INJURY 1,000,000 GENERAL AGGREGATE s 2,000,000 GENt AGGREGATE.1.11Mn APPUES PER: PRODUCTS-COMP/OP AGG f 1,000,000 X1 POLICY LOC AUTOMONA LIABILm 0 B ANY AUTO BODILY INJURY(Per person) i �9VGMIED X WOEDULED X LASUAW3403 /3/2013 /3/2014 QODILY NJURY(Per axdent) t X FARED AUT03 X /�O VMED Mwfal ens i UMBRELLA LIAa HQrWR EACH OCCURRENCE i rm=M UAS CLAIMS-MADE AGGREGATE t RETENTION WOplCouCOMPENSATION b be sent directly A OTH- AND EMPLOYOW UAOLr(Y ANY PROPRIETORIPARTNERIKxrCUTIVE^ NIA �� E.L.EACH ACCIDENT i QFF1cEwMEMat=R E)C,LUDED? u ; ,,P.Jry w NH} E.L.DOEASE••FA EMPLOYEE S W dounbe under RIPTION OF OPERATIONS hdow E L.DISEASE-POLICY L MR S Wenp TION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(ASaaIIACOR0101.Addtliend FA"wka Sdudulo,If more#pace I*r* Wred) tesidential Carpentry s Pkocfing Contractor �oweIx CcWanies Tna and a=y and all their subsidiaries are named as additional insured With respects to :he Comercial General Liability j=cluding Prod=t9/ Completed Ope=ationx aaverage and the Autoaapbile ;.lability policy caused by the operatiCinS pe:Gtommed by the named insured. 'ERTIFICATE HOLDER CANCELLATION eHouLD ANY OF THE ABOVE DESCRIBED POLICM BE CANCSE MM BEFORE THE EXPIRATION PAIN THEERNM NDTIIx WELL BE DELIVERED IN ACCofWANCE WITH THR POLICY PROVISIONS_ Loin@'s Cdtlpa>yfes Iht� l9 Eaauraaee ALITMFUM RWRESEWAT1VE PC }cox 1111 N 9Qilkexb=6, HIC 26656 E Bates, Jr. Acc Eace/ N_WRD 26(2010103) M 1898-2010 ACORD CORPORATION. All rIgWs reserved. N8025(201005)01 The ACORD name and logo are ragietsred marks of ACORO 12/23/2013 13:_30 FAX Q001 —I , n (t AAA OA 1 U >-A rNn iiln c CERTIFICATE OF LIABILITY INSURANCE DAT!(MMIDp/YYyy) 12123!,2013 THIS CER'T'IFICATE l$ISSUED AS A MATTER OF IN ORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NE 71VOLY AMtsND, !EXTEND, OR ALM THE COVERAGE AFFORDED BY THE POLICIES 4 VV. \1{aV {�la. rn\r. MI IIFHv,Ir•a�,r•r yr. {•N{ ✓\ray 111M 1a, •, ♦ava�a,al ay.. ya...V.•.•r.a• „ar a�ruu„�.' a,�,..arl�r.a,r�, .•.4,\!wa\,w.ry RIPRLSt:NTA11Yri QR F+ROpUCER,ANO THE GERT7 !GATE HOLDER. IMPORTANT: If the certlllcate holder Is an ADDITIO14AL INSURED,the pollcy(les)must be endorsed. IT SUBROGATION IS WAIVED subject to the terms and conditions of the policy,certaln pollcle i may require an andorsement. A ttatement on this certificate does not confer rights to the Certlllcats holder In lieu of such endamement(s). PRODUc" 01097-001 W—d"f V/IMII,tl/r{N N114r ,'F IMIi wl•.r.+�/ w v �r,.rf.v!'VhvY 875 Elm Street Went Springf old,MA 01089.2743 ee: A.I.M. CIS ImungA Mutual Insurance Company 33758 INSURED Paradlw tlullders,LLC - - 218 Hampden Street Chloopoe,MA 01013 COVERAGES CERTIFICATE NU BER: REVISION NUMBI=R: THIS IS YO CERTIFY THAT THE POLICIES OF IN&URANCE[ LISTED BELOW HAVE BEEN ISSUED TO THE INSURE[) NAMRD ABOVE FOR THE POLICY PERM CGRTIFICATIE MAY BE ISSUED OR MAY-PEiRTAIN,,7HE *]• RANCE,AE'FgRl76D By THE POLICIES DESCRIBED^HEREIN IS{SUBJECT TO ALL THE"yTERMS, EXCLUSION3 AND CONDITION$OF SUCK POLICIES.LIMITS OWN MAY HAVE SEEM REAUCED BY PAID CLAIMS. I[ TYPE OF INSURANCE POLICY NUMaIiR LIMITS GENI.RAL LIABILITY EACH OCCURREIyGE S COMMERCIAL:CF_NERAL LIABILITY -MI L_J _ PERSONAL&ADV INJURY S GENSFkAL AGGREGATE I; EN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGG t OLICY 0- OC AUTOMOPILOL1AP&ITY on T,rtnrltl S ANY AUTO BODILY INJURY[Perpnsonl S ALL OWNED SCHEDULED BODILY INJURY(Per eccldent) S AUTOS AUTOS HIREOAUIUB AUTOS NEO 7017 _ S UMISRELLA LIAB OCCUR EACH OCCURRENCE S tA4C"a�141A{0 44l47y1•�M14d: IlbISITCb/\IL ^ • .-_.�. _+. - .- DED RETENTION S y s MWE&MMM A 8r�IE1RM5RKM CECUTIVE E.L.EACH ACCIr�NT 6 500,000.00 xt�� N NIA A -400.7020370.,2013A 17!7312013 12123/2014 (Yendetorc II)NMI ( C.L.O;JCACE..C-A 0.'"L94E II-.88,8S8.$6 Fl. M�ACP P01ICY l IM1T 4 RIU)Ann nn DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Athah ACOR13 101,Additlonel Remrks Schedule,H morn spec@ Is required) Worker's Compensation aoverolp oppNRs<to MA emplo ews only CEICTIFICATF,HOLDER CANC GN Lowa's Campenles Inc Attention:IS Insurance SHOULD ANY OF THE ABOVE 0118CRII8 O POUClB BE CAMCR LF4 BEFORE P O Box 1111 THE EXPIRATION DATE THIiRROF NOTICE WILL bR fIRLNlRSO IN North Wilkesboro,NC 28858 ACCORDANCE WITH THE POLICY PRbWOONs. 0 1088-2010 AC ORD M R PO RA 11 OX-All AUTHpRt2ED RFPRf9PNTATIVR g s reserVP ACORD 25(201005) The ACORD narns and logo are registered marks of ACORD 3950 05/16/2013 17:28 FAX U001 ?013-05-15 08:59 >a P 1/1 PROVIDE A SKMQa=NEW PROJECT INCLUDE HOUSE LOCATION AND Mi.0(L4MN,$SET-BACKS EXISTING STRUCTURES SHOULD BE SHOWN IN!SOLID PROPOSED PROJECT SHOULD BE SHOWN AS DASHED------- INCLUDE 1 DIMENSIONS AND SET-BACKS FROM ALL PROPERTY LINES i R PROPERTY LINE LEFT RIGHT RI SIDE SIDE IiOP12RTY PROPERTY LINE LINE NUMBER Anw nARM vr o i rcpt I: 780 CKR BOARD OF BUILDING REGULATIONS AND STANDARDS AI UMM-RATION SITE" A Site pion shall be filed tsbowing,to s"Ja,tie she and location of all new conem000n wxd all crlsanF Jrrucrums on the site,dimtoncoe f- m lot Unes,the established atrm grades and the proposed finished grades,and it WW be drawct in wxordance widl an iwourate boundary line survoy. In the caw of demolition, tite site plan shalt show all construction to be domollshed and the location and size of ail w(Wing sk,ceturet aid coomuction that arc to renuin oil the site or plot, (Ret uh*d for all bemoHtlon and Renovation world In accordance with the provisions of MGR Chapter 40 $S4, a condition of demolitionjrenovation permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MC,L Chapter 1211 1SDA. ADDRESS OF PROJECT (if the debris will not be disposed as indicated,the holder of the permit shall notify the building official in writing,as to the location where the debris will be disposed) .� 'X The debris will be transported by: t � .�J" [ a=4 lc� 10- NAME OF HAULER �1 X 'rho debris will be disposed at what fedllty: w►a rvt�!__ SIGNATURE Or PERMIT APPLICANT �. DAN Oct 0412 08:08a Randy LaSante 14135929483 p.1 2012-10-04 06:42 Lowes 1916 ISO 413 588 0278 >> 14135929483 P 2/2 The Commonwealth of t1Jl4&ca mietta Departlneut of lndnaWAce denir Office of Invesfigatiom .` .,-j 600 Washington Stater! Saston,MA 02111 Jam' www.mass.gavldia Workers'Campensatton li=ra nm Aff davit:Bw'lder-J Contractors/ElectriciansMumbers Apiplic mt b ormation ' ' w _i Please Prutt Legibly Name(Ba,c3ncsx/t7r�ar►i�otionitndiyiduuJl:���{t r�t Sf �[�_C�1•'...__� Addrus: C�1 t� �-�a ate,© eat . City/State/Zi ` G 4F-G Phone / J (dam 9 Arc you an anployer"t Check the appropriate box: of project( red}: 1.❑ 1 am a cinployer with 4. ❑ 1 ain a general contractor ad 1 f. [ Kew jpmplayims ifv1 atdfvr pat-umcw havc hired the sub- muziaurs 2.Nr 1 am a sole propriclor or Parq»- Boxed an the auUhcd sheet. 7. ❑Rcamlcling ship and have noetnployces Thek sub-cotttr=wn have 8. C] Dciuolition working for me in ally mpacity. evaployees and have aotiuxs 9. Q Building aitiat (Nu wofkac'co ap.insurance corp.insurtnx mquired,j 5. ❑ W4 area ctlrpmlion and its 1011 Elcurit:al re pairs or addiliow 3.❑ 1 am a hoincowtter duing all work officers have cxcruisw their 11.0 Pluinbing repairs or addilioac tlt se1C tNo workers*comp, right of exemption per MGL y t p c. 152.§t 14X!tact we ltrive no 12.[]Roof repair: intiutaarc rcrlwirCil.) 1311 Other cntploycas.(Noworkos' comp.insvtnantxr rcyaired.) 11 1 "Atty aMkwt that cheeixl+M 01 fair!also rill ova 4k-waiun Mow Anwiay thei'worsts'compcewden"ey intarmntien. I Ioutem"I.M wha afltmit shit a1,151avit indhcuier;they are dninr all work void thra hire nuclide eaatraelwc►oust U*J1U►a new 4 adavii indtcaliagsuch. k,Q11t 1vMM than ertwc k the larnt must alu died uo add16n A sWct showing the time egtrtiex have employe". lr the sail-enetIOMn how employem dtry must pmvtec their work",camp.pal icy unnbrr. I am a r omplaryer that&prwwidiag w urkeo'compenratien inormtee formy awplayem Below is tlrc policy seed jub sires urfermation. - lasurancc Company Name: Policy#or Sclf-ins.Lic.4t: Expimdon Dare: Job Site Addreac: CitylSMWzig: Anacit a copy of the workers'compensation policy dwlsndilin page(diewimg the policy awnber and expiration daft). Failure to secure coveragc as required carer Section 2SA of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S 1.5W.00 and/or ooc-year imluisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine or up to S250.ou G clay*gaunt the violator. 8c advised that a colpy of iW statement may be fotw;tr*X to the Office Of InmIst'tplioas of t D1A for insuratl= gr;vctyft ation. 144 hereby ee Cr undr pains tti 'of per' ry time the WarotWun proYded re s•tree and comeerr i at r Dale' b � e18_5 art 3 Alua Official& e only, Do not write in tki5 area,to be eompleied by d*or rewit offrriaL City or't own: Imming Authority: Contact Person- Plttxui4. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: 0A 0 J n 7 of \F License Number R " 1 ao i Lo dress i t f� Expiration Date S gnatur Telephone 9.Registered Home Imorovement Contractor: Not Applicable ❑ Company Name Registration Number _ Address , Expiration Date Ci(71% h 6O f C, L)04 Telephone J77-x"(00 0 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 bu'ding permit. Signed Affidavit Attached Yes....... iiI No...... ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellinps 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 Windows Alteration(s) Roofing ❑ Or Doors n Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [0] Other[d] Brief Description of Proposed Work: 11 L101 CIA, 1/ " ``ty) "' 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 ~-J �(/) (! { i2 C^>�0 in \ as Owner of the subject property hereby authorize ( VU `� 7 IDrw 7 f' f 7 to act on my behalf, in all matters relative to work authorized by this building permit application. au cam,Q cJ Signature of Owner Date l 0,QAA<-A � C 'o( I A as Owner/Authorized Agent hereby beclare that thi-stateVnents and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ' t_QA'!!��& Q C P fie , r 81tyn-ature of caner/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 _ 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 DON'T KNOW 0 YES F YES, date issued: IF YES Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES enter Book . Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0 IF YES has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 Date Issued: C. Do any signsexist on the property? YES NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 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 Department Curb Cut/Driveway Permit LEIel��-R 2 4 ?ui4 212 Main Street Sewer/Septic Availability� Room 100 WaterNVell Availability rthampton, MA 01060 Two Sets of Structural Plans u Ir pection1 1.44666 41 -587-1240 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 - - Al /2 b V/ Map Lot Unit (y) ICS /V ✓� Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: rjoj±jl o Telephone Signature 2.2 Authorized Agent: Name Knt) Current Mailing Address: p i 7 Signature 97 Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit 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) 36 .06 5. Fire Protection 6. Total = 0 +2 +3+4+ 5) q0 , 40 Check Number i This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner/Inspector of Buildings Date 80 DAMON RD#5306 BP-2014-0974 GIS#: COMMONWEALTH OF MASSACHUSETTS Map.Block: 18D-053 CITY OF NORTHAMPTON Lot: -000 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-2014-0974 Project# JS-2014-001696 Est. Cost: $2390.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: LOW E'S 089613 Lot Size sq. ft.): Owner: JOHNSON JENNIFER Zoning: GI(88)/SC(12)/WP(12) Applicant: LOWE'S AT. 80 DAMON RD #5306 Applicant Address: Phone: Insurance: 282 RUSSELL ST (413) 588-0270 WC HADLEYMA01035 ISSUED ON:312512014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 2 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 3/25/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner