44-080 CONTRACT# 00 0 443C3
MASSACHUSETTS SERVICES SOLUTIONS.INSUL L,ED SALES CONTRACT
LOWE'S AUTHORIZED REPRESENTATIVE INUMBER CUST MER
STORE NO. STREET ADDRESS STREET ADDRESS
CITY STATE ZIP- CITY STATE ZIP
TELEPHONE - TELEPHONE
5 S 06170 Li' -7 �
DATE LOWE'S HOMECENTERS,LLC'SMA HIC NO.:148688 - CASH - BA�NKD "" ACC CHMGE
FEIN:56-0748358
This Is only a quote for the merchandise and services printed helm.This becomes an agreement upon payment Upon payment,the entire agreement,inducting the sperAmIly completed pages of this
document.the Terms and Conditions mctuded with this document and any other addenda.and affaduronts hereto,shalt 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
�C'V+"\` iC: C�.7C„�y\�r�C "gc�.., �-; Cat' .�+"` �.•-L=``C ��1C1 )=�
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NOTICE TO CUSTOMER-PRICE CALCULATIONS:In order to properly perform the installation of certain Goods,the Contract Price may include more
Goods than 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?:[XYes ( ]No *applicable tax included 4J- >
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 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 ad 'tonal 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 usto er made Good(s)which is anticipated to be
j-/.c-/�f [fill in date].Estimated completion date is FZ"f T-j4 [fill in date].
Said estimated substantial completion date is not of the essence.A statement of any contingencies that would materially change said estimated substantial
completion date is as follows:
(H applicable,insert a statement of such contingencies).
IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full.
COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00:
[,.f)5Customer to Pay in Full; OR [ ]Customer to use the following payment schedule:
(1)Deposit $ to be paid upon signing contract.Deposit should be 113 the total contract price;and
(2)Payment of$ to be paid anytime after this Contract is signed and before commencement of installation,1/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 my/our 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.142
LOWE'S AN9 OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT
LOWE'S Y SUBMIT SUCtH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT-
IVE OFFt E OF EONS fVYR AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION
AS PROV,IDED'7 M- b.142A. 1
By E s lJ✓y l Date:
Lo Hom r
r✓c� `�.... Date: ~
By: a
ner 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
CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE.
WITNESS'OUR H4,ND(S)AND SEAL(S)BELOW THIS :; DAY OF t)l` t- -' 'r`
Lowe's Homeif,"nters,LLC c f
Lowe'�,Aut orized Representative Owner 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.
n Inns N.,I nwe'c A I nwn's no the oable design
.��—ter ry �. wuiP«'�O ,r O11L0t pI N. ):i. �yyLlyyl
JODOHOM-01 CKASKI
ACR°� CERTIFICATE OF LIABILITY INSURANCE 74114120`14(MMIDDNYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS
CERTIFICATE 0069 NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OP 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 pollcy(lea)must be endorsed, It 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 andomme a).
PRODUCER CONTACT
Insurance Center of New England,Inc PHONE FAX
1070 Suffield Street � �, �en:1600)243-8134 413 731-9639
Agawam,MA 01001
INGURER131 APPOMNGCOVRRAGP NAICS
INSURER A:NBuUlud insurance Co
INSURED INSURER 0:COMInOrC$Insurance Company 34734
Jodoln Home Improvement INSURER C:Aim Mutual Ins Co-Assigned Risk
clo Mark 8 Jodoln IroauReR D
137 Porter Lake Drive
Longmeadow,MA 011061246 INSURER E:
IN$uRr�R F:
COVERAOES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR TYPE O P F INSURANCE POLICY NUMBER MMIDDI'MY LmrrA
A X COMMERCIAL GENERAL LIAa1LnY EACH OCCURRENCE ' 60 0,0 lox
CLAIMS-MADE 1 -- I OCCUR NN360424 08/2612013 06/26/2014 pREMI$E$ Ea ox i $0.0
ME EXP(Arty one peron) S 6,00
PERSONAL&ADV INJURY ® 60010
GIEWL AGGREGATE LINT APPLIES PER' GENERAL AGGREGATE $ 11000100
POLICY a JEC F�LOC PRODUCTS•COMPIOP AGO $ 600,00
OTHER: a
AUTOMOBILE LIABILITY OM6INED SINGLE LMIT S
f6 a;s�e!I
ANY AUTO RPJ989 03/2012014 03/2612019 90DILY INJURY(Per person) s 100,00
ALL OWNED X SCHEDULED SCDILY INJURY Per ecCidenl S
AUTOS AUTOS ( ) 300,00
NON-OWNED PROPFATY DA s 100,00
X HIRED AUTOS X AUTOS
a
UMBRELI.ALIAR OCCUR EACH OCCURRENCE $
EXCEGGLIAB HOLA046-MAOE AGGREGATE 5
DED RETENr" a
WORKER$COMPENSATION X $ATUTE R
AND EMPLOYERS'LIABILITY
C ANY PROPRIETORraARTNERIkXFCUTIVE YIN AWC40070296132013A 08/3112013 08/31/2014 91,EACH ACCIDENT ; 100,00
OFFICEMMEMBER EXCLU0E0? NIA
(Mandatory In NN) F.L.DISEASE-EA EMPLOYEO 6 100,00
"43",rtaealba uno
RIP OF OPERATION$below E.L.DI$EA$E.POLICY LIMB I a 500,00
DESC RIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddMonel RMeree Schedub,nary be aNached If more epees Is mplredl
Carpentry
tx 413-686-0278
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE 010CRIMED POLICIES BE CANCELLED BEFORE
Lbws'$Companies Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Hadley,MA ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIXED REPRESENTATIVE
0 1988.220.14 ACORD CORPORATION. All rights reserved.
ACORD 28(2014101) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts Print For
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mavv.gov/dia
Workers' Compensati, n Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ) / p Please Print Legibly
Name (13usiness/organizattioii/tndi .dual):_ JU1�L�J ffIM
Address: 132
City/State/Zip:_%/ mgt s 6 Z o t Phone #: x{13 e_Y;�'S 73,(; j
Are you an employer? Check the ltppropriate box: Type of project(required):
1. 1 aln a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-ti ►e).
have hired the sub-contractors 6 F1 New construction
'
2.❑ t am a sole proprietor or part► .r- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capac y. employees and have workers'
fNo workers' comp- insurano comp. insurance. 9. F1 Building addition
❑ We are a corporation required.] 5. oration and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all v ►rk officers have exercised their 1 I.El Plumbing repairs or additions
myself. No workers' com right of exemption per MGL
y f P� 12.n Rtwf repairs
insurance required.] t c. 152,§1(4),and we have no
employees. f No workers' 13.❑Other
comp.insurance required.]
'Any applicant that checks box#1 must also fi out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indict ng they are doing all work and then hire outside conuactots must submit a new affidavit indicating such.
tContractors that check this txrx trust attached t additional sheet showing the name of the sub-contractors and state whether of not those entities have
employees. If the sub-contractors have employ -s.they must provide their workers comp.policy number.
1 ant an employer that is providing w rkers'compensation insurance for my employees. Below is the policy and job site
information. _
Insuranec Company Name:_ ��`'� � >r U -
Policy #or Self-ins. Lie.#: iration Date: `
Job Site Address: City/State/Zip:
Attach a copy of the workers' compe ksation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required nder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year it inwntnent,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 viol or. Be advised that a copy of this statement lnay be forwarded to the Office of
Investigations of the DIA for i,>lsuranet: ;overage verification.
1 do herehy certif pfidep&e pains qn4 C=lties of perjur that the information provided above is true and correct.
Signature: Date• l
Phone#:
Official use only. Do not write in to :area,to be completed by city or tows:official.
City or Town: Permit/License:#
Issuing Authority (circle one);
1. Board of Health 2.Building Dep rtment 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Super visor: � Not Applicable ❑
Name of License Holder: Lme� Jp4)01711- r s-Q 4t-�9 C/
F
License Number
L-37 G� �2 (�3.t,�Gr�El�aw 4 v l a l 49 moo/
Address 7v ion Da(e
- s- 7�3�/
Signat a Telephone
9.Realistered Home improvement Contractor: Not Applicable ❑
Company Name Registratio Num er
Address J -,5V- Expiration Date
C11.3
0r77 Telephone Od70
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 builclin 2 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 ❑ Addition ❑ Replacement Wirydows Alteration(s) Roofing
Or Doors (�
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding [p] Other[d]
Brief Description of Proposed ��G� 11
Work: &���'ly r7/J� T /r
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 existina 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
I, 2 6-1p as Owner of the subject
property
hereby authorize C d /E /5
to act on my behalf, in all matters relative to work authorized by this building permit applica'on.
Signature of Owner Date
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 under the pains and penalties of perjury.
Print rName
Signature of Owner/Agent Date
Section 4. ZONING All Information Whist 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:—
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 U DONT KNOW 0 YES 0
IF YES, date issued:'`
IF YES Was the permit recorded at the Registry of Deeds?
NO U 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 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 0 Obtained Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IFYE� describe size, type and Iocation:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
j Department use only
City of Northampton Status of Permit:
iL (____. Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
r, 2 Room 100 Water/ ell Avallablli
orthampton, MA 01060 Two Sets of Structural Plans
Electric,North mP3-587-1240 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 Prouertv Address:
This section to be completed by office
✓d /�/J-C/ 7,., vn4 /v J �,/� Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
4- A 1 e,-b Jw6'� _3o Wcl/-y,*iit/ dam' ��,
Name(Print) Current Mailing Address:
e, Telephone
Signature
2.2 Authorized Agent:
w� 5 � �o sSE cG ,57' jpL �l '/r�ova;
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ��/ �—� 671 (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) o 6'zj Check Number
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
30 AUTUMN DR BP-2014-1375
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 44-080 CITY OF NORTHAMPTON
Lot:-00 1 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-2014-1375
Project# JS-2014-002325
Est. Cost: $5100.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: LOWE'S 49918
Lot Size(sg. ft.): 10018.80 Owner: JUDGE EDWARD O JR&KRYSTYNA E&EDWARD O JUDGE JR
TRUSTEE
Zoning: Applicant. LOWE'S
AT: 30 AUTUMN DR
Applicant Address: Phone: Insurance:
282 RUSSELL ST (413) 588-0270 WC
HADLEYMA01035 ISSUED ON.612312014 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE BAY WINDOW
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 6/23/2014 0:00:00 $50.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner