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29-160 (3) 91 BRIERWOOD DR BP-2017-0103 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29- 160 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:windows replaced BUILDING PERMIT Permit# BP-2017-0103 Project# JS-2017-000174 Est. Cost:$3050.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: LOWE'S 049918 Lot Size(sq. ft.): 10497.96 Owner: ZADWORMY GLORIA TRUSTEE Zoning: Applicant: LOWE'S AT: 91 BRIERWOOD DR Applicant Address: Phone: Insurance: 282 RUSSELL ST (413) 588-0270 HADLEYMA01035 ISSUED ON:7/26/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 6 REPLACEMENT WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy sienature: FeeType: Date Paid: Amount: Building 7/26/2016 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner ;1.4x s 1541- ' Department use only City of Northampton Status of Permit: rr� z 6 2016 Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 WaterANeli Availability r Northampton, MA 01060 Two Sets of Structural Plans_„ phone 413-587-1240 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 Q� sgAnAmoot) DQ Map Lot_.._ Unit .. cLoteTJCE 010‘01- Zone Overlay District Elm St.District C6 District SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: LwN(E %rSTpt1 q{ gf lRWOOO DR Name(Print) .p Curren(Mllnr .9Qdfyss^ Telephone 'S��' L Signature 2.2 Authorized Agent: J 1E ••r'' R • IS (owesoC-rEtJT) net gQ LLit -V , FhWLEy MW_ Name(PcApir Current Habig Address: s` qIS -SW-02-70 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS 7 Item Esii eeted Cost(Dollars)to be Official Use Only completed by permit applicant 1_ Building it6OSID (a)Building Permit Fee 2 Electrical (b)Estimated Total Cost of Construction from(hp 3 Plumbing Building Permit Fee 4 Mechanical(HVAC) 5. Fire Protection 6. Total= * $ (1 +2+3+4 5) Check Number This Section For Official Use Onl Building Permit Number: Date issuu ed Signature: _ Building Commissioner/Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information _...._ _ Existing. Proposed Required by Zoning wlmne to be tilled in by Nodding Ucpamnani Lot Sine Frankton Setbacks Front Side L: R: L: R: Rear Building Hcig,hl Bldg.Squats Portage n. .o Open Space Footage —. °o 01 diva mime bldg&Pied 1irkingl of Parking Spaces Pill: olumc& ncanonl A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document Ft B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and tocationc D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 0 IF YES, describe size, type and location: E, Will the construction activity disturb toIeanng,grading, ernavation,or filling)over 1 acre or is it pail of a common plan that will disturb over 1 acre? YES O NO j'C4�Jt IF YES.then a Northampton Storm Water Management Permit from the DPW is required. SECTION Si DESCRIPTION OF PROPOSED WORK(check all applicable) New House 0 Addition ❑ RepIacement_Wjjndows Alteration(s) U I Roofing t Or Doors 121 Accessory Bldg. ❑ Demolition ❑ New Signs I0] Decks IC Siding ID] Other]D] Brief Description of Proposed � Work: hat*i citta of t,'QJ NEW VN M- wtNcowS - No tneu'i1 tot CNWN6E, Alteration of existing bedroom _ Yes )C No Adding new bedroom _Yes X No Attached Narrative Renovating unfinished basement Yes y4 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 m 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 ftof wetlands' Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade It 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 l, LbTDN _ as Owner of the subject property hereby authorize LOUJES 1AES (,,,,f"tJr g'p LLC. _ to act on my behalf, in all matters relative to work authorized by this building permit application. SEE C61.7112YiC1' el4 WIC° Signature of Owner r-y pie\ o (LovJES '{ry[s Grp t L ,as Owner/Authorized J��t E S �PFteR Agent hereby declare that the statements and information on the foregoing appticatkon are true and accurate,to the best of my knpwiedge and oefieF. Signed under the pains and penalties of perjury. J- pr _ Print � - - on 201 « Sig, re Owner/Agent ... to - .__ SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed ConstructIQf Superviso(: ''yy Not Applicable ted Name or License HolgerM{}Q, S e Qfl4 _ C" S ' Oticleitg license Number 4441 i ES IR, Deist ftflHerm 141%4 t0"2.7 AWA/2.o16 Andres:, Exultation Oat 413 -2,25-- 7SCA tenature Telephone 9.Registered Home improvement Contractor, Not Applicable El OW ' _HOMES CEA7TERS LLC 1 �18fo88 Company Name Registration Number 282 RVSSEt ST HWDLEY MA 0t03S • _ to (t4/2at� Aggro: ---/orExpiration Date Telephone KI g. 588.027o SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.c. 152,§25C(8)) 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 building permit. Signed Allidavit Attached Yes dlQ No___ 11. - Home Owner Exemption the current exenption for"homeowners' was extended to include Owner-occupied Dwellings of one(1) or tw fl2) 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(iomeowner_Person ts)who own a parcel of and on which he/she resides or intends to reside,on which there is.or is intended to he,a one or Iwo family duel ling,attached or detached structures accessory to such use and/or term structures.A person who constructs more than one home in a two-veer 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 he responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the Job she wig he 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 cork foe you under this permit. The undersigned"homeowner certifies and assumes responsibility for compliance with the State Building Code.City of Northampton Ordinances,Stale and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature see coMILACC. City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150k Address of the work: 0(1 1112-1ERV.)000 DR The debris will be transported by: t-409-1c. ACYCZIN The debris will be received by: 41-1 RoSC ST 3P21NSFIELD Mf Building permit number: Name of Permit Applicant tA ' • J• %DIN S110j201fo Date Signature of'''ermit Applicant The Commonwealth of Massachusetts a= Department of Industrial Ace/dents l ,gth tyke of Investigations i;l .� I= :v a 1 Congress Street,Suite 100 Boston, MA 01114-2017 __ \7\-.7"-;c7/ www matis.gov/die Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business Organization Indisiduab: GDOf1.j SME MP2oVe-AFNt _ Address: 15 JONES "pe. Coy/State/Zip: E1As'CPI-Amy-RAJ Phone#: 4%' -fl& - 73GpI Are you an employer?Check the appropriate box: Type of project (required): I.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full anor part-time). < have lured the sub-contractors ❑Nen:ern:aructton d: 2.al I am a cote proprietor or partner- listed on the attached sheet. 7. L Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition ur',trking for me in an capacity. employees and have workers' Y p' y- 9. 0 Building addition (Nb workers-comp. insurance comp. insurance. required.] 5_ 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ pm a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions myself. [No workers' comp, right of'exemption per Mfil_ 12.0 Roof repairs insurance required.] c I5p2. k I(4) and we have no com insurance em loyees. /No workers" 13.®Odtcr E?L4q(ETI}BF7T_. required.( ttaDou7s� *Any applicant that check.:hos el must also ill he section hank shaming their workers' ropy -r policy la eorniation Hoinechffices who submit hs affidavit indicating thee air doiriall wt 'k and then hire outsidecontractors must submit new alidaeit indicating ctich. onnaictora dial cheek this hx must attached aadditional suet showing l tic manic White sub-contractorssub-contractors and state whether Or not those entities have employees lithe sub-e. t hake empkycca.they mint prtividethcir sserk ,ntv policyumber_ am an employer that is providing bunkers'compensation insurance for any employees. Below iv the policy and jolt site infirnmdon. q Insurance Company Name: NA- V.) Oil LOS I NI Q14NCE Co _ 1 Polus 0 or Self-in, tie, It: �1V,lC4 OC1 Q'L ,� t`01% -015 Expiration Date: !.LZ 1 j 2Q%YQ lob Site Address: all ea et'QOD t _ City:State.zip: FLOReNc-E MW01062 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 25 of A c. 153 can lead to the imposition of criminal penalties ofa fine up to$1.500.00 andor one-year in,arisonmentyd� M'ell as civil penalties in the form of a STOP WORK ORDER and a fine of up to 9250.00 a day agains c v;.•(for. Office Bc ed that a copy of this statement may he forwarded to the of Im ncations of the DIA -ins ce cove gc e.dtication. I do hereby cernijr u teed wins to en* ties of, j , &-that the information provided above„_ is true and correct. Signature: I Date: I �f?.OI4 Phone : ' V5 .SSS— 7 '^ Official ase only, Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): I. Board of Health 2. Building Department E.CihTCawn Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: -",."1 JODDHOM-07 MPROULX ` CORD CERTIFICATE OF LIABILITY INSURANCE °FTE(MMIDDIYWY;� 6421f2015 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 MOLDER. 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 ICONTACT NAME: Insurance insurance Center of New England,Inc (ArP"i Ho EMI(800)243-8134 (Alt.No(413)731-9539 1070 Suffield Street EMAIL Agawam,MA 01001 ACIDNESS: INSURER(S)AFFORDING COVERAGE HAICF INSURER A'.Nautilus Insurance Co INSURED INSURER a:Commerce Insurance Company 34754 Jodoin Home Improvement INSURERC Aim Mutual Ins Co-Assigned Risk cb Mark S Jodoin INSURER o 137 Porter Lake Drive Longmeadow,MA 01106-1246 INSURER E: INSURER F: COVERAGES 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 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. INSRP POOL SUNK POLICY EFFPOLICY EXP LTTYPE OF INSURANCE POLICY NUMBER LIMITS 0 IMM@OMYYI... M(M loD/YYYY) A X COMMERCIAL GENERAL EACH OCCURRENCE s 500,00 CLAIMSMADE X OCCUR X NN678226 06/26/2016 0612612017 DAMAGETORFrvTEo 50,000 PREMISES(@u oc..unoncel & MED EXP/Any one re.acn; S 5.0001 PERSONAL E ADV INJURY a 500,0000 eErL AG(REGATf LIMIT APPLIES PER GENERALAOOREGATE S 1,000,000 POUCY 7a LOC PRODUCTS.COMP-P AGG s 500,000 OTHER: $ BND AUTOMORLLE LwaIUTY CEa Acoaerci LIMP D B ANY AUTO X RPJ989 03/26/2016 03)2612011 BODILY INJURY.Per person) $ 100,000' ALL OWNED x SCHEDULED BODILY INJURY meracwenu S 300,000 AUTOS tUvOO4YNEp PROPERTY DAMAGE $ 1nD,000, X HIRED AUTOS X AUTOS IPer acadere S UMBRELLA LIAS OCCUR EACH OCCURRENCE a EXCESS LIAR CLAIMS'MADE AGGREGATE DEO RETENTIONS WORKERS COMPENSATION _ —... ANO EMPLOYERS'LIABILITY X PERTNYr ER L C o E o P rye CU1IVP. YYx NrA AWC40070296132016A 08/31/2015 08131/2016 EL. EACHACCIDENTs 100,004 OTF ME WO O (Man ,YI NN).. FL DISEASE.EA EMPLOYEE s 100,00 If yes deemlbe under GESCRICPON OF OPERATIONS'belo'.a _ _.. EL DISEASE.POLICY LIMIT S 500,0001 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional RemaMs Schedure,m y Pe alto deed K more space Is maimed) Vendor X16930 Lowe's Companies Inc,and any and all subsidiaries are named as additional Insured as respects to General Liability and Auto Liability per Mass Business Auto Forms CA0001 and MM9911 an applicable Mass.State Laws as per written contract only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Lowe's Companies Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN p ACCORDANCE WITH THE POLICY PROVISIONS. Attn: I S Insurance(Men) Vendor CompilancetRisk MSPM,Lowes Companies Inc. Post Office Box 1111 AUTHORIZED REPRESENTATIVE North Wilkesboro,NC 28656-0001 y. 0- ere 7 . O 19884014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD LOWES [CONTRACT4 00116611 MASSACHUSETTS SERVICES SOLUTIONS INSTALLED SALES CONTRACT Innis hlef mEPt/AI 11835/9<A "PeiMcu^J ha_(LSI_10..QP-n4-(1O4s 'a 4r Latd-tfr's rat 26547 rte . 282 kusserfst 8'~.2_`3"4- asp St 1 qj 136-ehwoot7Jr`ve f�AA�/t /e 0/De i !Crr`PlaMee ?k_ X)Y trOb/// Ftoraca./c.A [nf -Jan —i � fizyq - —i q13- 5`88- 02.7o N1 1) I [aril ilii t'Y a.—,.e I ; L _a,� , U . rMnrx%- 'mmgo%0� �aS(C0 UT a5"tG ,Can„��vEK,mtO-vs. . at O tE 'E f. H e.nae„ a, an .t z 'I/a. ---...- 91 jre.rwaac( L7! ADrenci MA 0104 a� . a{f3� 3''1-( -3Ca`J' rterni5h f,his/Li, ( _tlew Abad, 1 1.4,,y/ i'oylau..,eti. (nit,ldr,.d'._ �.a+h 5*T1t��.-op c ..c r=: 7i. ur�d.,. �s /174...t3e<a brs/m± ,r- L, T74nvt4h _1.7, . a>t'C. e vfr It it IAhfd'” cid,✓ { are- I',._-. � NOTICE TO CUSTOMER-PRICE CALCULATINS&In wire properly pFXIXm the,nsallatavi of cortmnGoods.mo Contract Pries may include mare I Coa Man adtSly MVI Ln.melted haunt on Use Aria^u,ed square tu%go m the FngW Area Asa resat the panne agree:that 4te Uryunum Pnvf O#M m tm s CAMmY v tte 1 uxst tat:Iv 304,0o1 esloglwd 6w3s tectimel R fitlt too COMract 10&Iedm9 waelet..sltt may nrtgpq the aHnai sewn 1mlYdn of Me Pmjtq Area,are the boor wticn may ba rehmaletl TVI ed on The aFinanl of rmt5 re fledd to NthPI'he CntlracI Illv:nldNG wa.lel By egning T6 Conrad below.Cugomer acANM ooem incept at mm nowt and agrees and undorstanad Taal the Poem Trichites Inav cnMs wnrh may ;m21)e refunded mw leo 1nsttalun Services are tedOnnJ I Contract Total IOy__.—_ Ata 'a perm'IU cede red fur IFis IYStallalion?.I Yes No ( pplicable tax included I _I'1 Sc NOTICE TO CUSTOMERh Feder*Lw mashers towe'a to proelde you%KM the pampa. Renoearo Right.BY signing this Contract Gugpnor a*MowIsegirs having MeelVed d copy of ISM pamphlet beam sore began IMomting Customer of the potential risk of the lead haa.d exposure Irani renovation wavily to be performed in Customers dwelling unit/ i NOTE:It rolled wood is&scanted during inmtallati n addltionat harges wrist(*PPM von will be Hirers a stlydtf.aE(4a,vhenge order MOM be completed and signed by Ma customer for any additional charges.___—F.......omet must Inih. .sty sort ne matenai *molted a no incidtieil L.,trus tont/act ehanges a addrhea ptdl tse at an addsonel*MNn .{ PNOTO RELEASE CuslOrnerq ts tt rd Lown emPSaYees and'ntlepend CosaW't3m t^tke tMvWepha a the PremmeswNwe 7Msar3 Sconces wat be pMpmen and ea tvttk Igebnxd in The P tleyinti G ..ul Y b to ll 9M.i ntfttl- d to Me photographs for en d Marry. M y. oviM, neraef rm y toe L b c pyt t as an' and nsn me 1 Walyraph5 onn and/or aloe vary antiagrees thatmay Lee win photgrep lotany 1.1,310 p sulea.M.dg butnot N tomonkey - aawnm o Iwo, to ar 3twlon l coo Iv w Icay po r Ig Viae t r baMVN °6 , hl is xaekr II upon res eWavailability' fCmlnompbOa v PFt mad...Comas)winch anticipated to be Ill ..... — TNI (Wel Estimated AomtYgan mm - .(Ea,a date]. '.y\ a c/1 Bion*aid tubstantgil WO comp 1 n dale a5 notof the A statement nl any r:Ma9rge as Ina k matena.ty Cturge, q . �m"Itp sub.larllaa tr wmAYNm deS rsmkoobs: ___ l 1,appl pawn,i�-t OL sed BOM npue'ppY` 1F THE TRACT TOTAL IS$1,0D0,00 OR LESSGamnmer mol pay in EXCEEDS `4l G ETE THIS SECTION ONLY WHEN ThE CONTRACT TOTALEXCEEDSS 0WAe '33 I ;ASbne.to Pay,n Fur. OR F p irbupe Tab Ergs paymenttabe1 I. l Payment 5 ..__..... beW upon 9 Mcontractnope i he l b N HI HIPa f5 _ to paid artytmr.Mai 93s Contrbel 45 agnadand halm w romm of ytylaltybon,Me ae.MNS L owe Y\ t UMWbhrp(rhea aopronnate roe boowS W 1 tow;gemy'ootwu cam Rewtar3.maal am parten.wu ad asw 3yame ado,the dwtMscomao is'sired. j Uep,u yNu at the of ymonl nd ate aMve an-nmo alterh dateNa a, i3t1FilslW of 4100 Wm o upm pawn of the W( dM tulawf'ao �_ NDIGEAEfl >Pv_MENIEFOAESSWERER MS.4Fu j. Z,ILOWES AND OWNERHEREBY MUTUALLY AGREE INADVANCE THAT IN THE EVENT LOWES HAS A DISPUTECONCERNNG SCONTRACT.THAT LOWES MATSUBM SUCH DISUTP TOA PRIVATE ARBTRATINSERNCE WHICH HAS HUN APPROVED BT THE SECRETARY OF THEC (CVT AS OFFICE ONS RAFFAIRS D eusiE5$ ESULAT10N5 NOTHEOWJER SHALL EE REQUIRED TOSUHNT OS G RBRPA 10 [[[yyy qqq ASVi� AV E�HM to i]. / yd/ aY (�.r e,•„ OA.. r; S.p(ZSry��IDS{{ I / E fin r . gTla La+tt�-60n �/�$�1�i �pf-a� .'). �HESIGNAUNE50 HEPARTIESABOVE A PLYT)NLY TO TIE AGREEMENT OF THE P TO ARENTVELSPL EH CLLFION Ib! to >I BY LOWE B PURSUANT TO M.G L c H21.THE OWNER MAY bEPERMITIEO TO INITIATE ALiERN TVF CSPUTE RESOLUTION E3IFN WHENr THE A.l 6EC`TIMMOVE ISNOT SEPARATELY SteNED BY THE PARTE S. //yy�EO@@@ ccs DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND L•�y CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT y BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ.UNDERSTAND AND AGREE TO THE �+. TERMS AND CONDEMNS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS R' CONTRACT.• YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. _y b } 'INE o eD;Aro SP1CSt NE:aim: JD t. TmsQer<Al golf C . C emmat ackfaMertiptelaceipt Of a Nue copy of MI. olqMf h completely Riled inp W cal ^n1 You.tb y ,may nett a ranlMtak n at any thee prior to amgh W Neea third business dy nt date oF rt I)/ aenn Soo the11 bh ad no/Ica of cancodatIon torn'for an explanation el this ngnt y'l02 REV 1Z`15 733',3,33. -;3:3.3,3r173`3`1;;3.,:' 4CORci CERTIFICATE OF LIABILITY INSURANCE DATE""81201G Y" oMM/D0ie 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 policypes)must have ADDITIONAL INSURED provisions or 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 c` certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT y A.On eu oServices south, Inc. _ (856J 283-0172 FA (ROO) 363-4105 Charlotte NC Office 140.Ne.Erp. (4C.xo 1. — '0 1111 Metropolitan Avenue. Suite 400 IDE IMFss_ Charlotte C 28204 USA = INSURERS)AFFORDING COVERAGE NAI II INSURED aSraERAsteadfast Insurance Company 26387 Lowe's Companies. Inc. INSURER B: National Union Fire Ins Co of Pittsburgh 19445 and its subsidiaries 1000 Lowe'S soul evard assoNE4C New .mmpshire Ins Co 23841 Mooresville NC 28117 USA wsVflExR — ----- -_ INSURER E: ai51RERF. COVERAGES CERTIFICATE NUMBER:570061530649 REVISION NUMBER: THIS 5 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTW RH$YANDING 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 9V 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. Limits shown are as requested zsap TRE OF INSURANCE a.sD 1000 POLKyNUMBV2 POLICY 3 IMLICYEKP ',mks y D m COMMERC141GExERAt LIABILITY EACH OCCURRENCE Y Y sem Insured 04/01/7016 04/0I/3017 WMpdE TO RENYED CLaMGMAOE X OCCUR FP—`.-PIELP EEXP WY 0"Person! --. _ PERWONAL&AOV INJURY 15 GENT AGGREGATE L�UUTAPPLIES PER- GENERAL-AGGREGATE POIC+' ❑.EQ fLOC PRODUCTS-COMP/OP Ao0 resro — OTHER S S xnO*WaelifinTY V V CA 1861270 041012016 04/01/Z017 co wNSINGLE Lr 11.000,000 h AOS (fa acenU c —ANY Y Y CA 1X61269 04/01/2016 04/01/1017 cooed ' nl 0 Flx II INJURY Vv —.OwNE Q a SCPEOUIPO MMA EOOe.YIN1uRVIPe avY.nV Ps �.. PATO YTOS CA 1661271 04/01/2016 04/01/2017 PppFEkrvAO Mnr� -OWNEDYbyWNLYVA 'er ar.�a }OxLv060NLv °"C9A UMBRELAS BOCCUR Y TPR3P19230101 04/01/014 04/O1/2cifl EACH OCCURRENCE 110,000.000 0 eXCESS UAaPALLS-MADE AGGREGATE SID,000.000 bEn/ rRrTrl11xa C WORKERS COIIMENSAMIN WO Y WC015519214 04/00016 64/01/]ot7R STATUTE H EMPLOYERS'LIABILITY YlE ADS "Y PEER ANY PROPRETOP r PARTNER'EXECUTIVE per HC ter us & condi ions Ec.EACNUPCEM S2,000,0000 GEPICERPAREVERExc SOUP N 'inn SIR appliespolicy .. (Mandpbry m NIS E L DISEASE-EA EMR L OYEE 12,000.000 ner DESCRIPTION mba OF OPERATIONS[Maw E L DISEASE-POLICY LIMit 12,000,000 a Excess WC Y )C.C61X13043 04/01/2016 04!01/2617 a Each ACC'Ident 51.000.000 ai mos EL Disease i. Policy 13,000,00 SIR applies per policy terns & condi ions EL Disease - Ea Emp 13,000,000 DESCRIPTIP OF OPERfTIOY4i LOCAS:ONsivENCLES(+CORD leF,A4rtit4e.H ReaterireSCMMer may be attacMEH more Apace Is es@rireEl Commercial 'u nnral Liability is self-Insured. S 4� CERTIFICATE HOLDER CANCELLATION (1Y UL SHOD MT OF ME ABOVE DESCRIBED POLIES SE DAMMED BEFORE THE pfae EXPIRATION DATE THEREOF. NOME WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY 000,4511A Lowe'S timpani e5, InC. AMOR/ZED RGPRESEXTATYc and its subsidiaries 1.000 Love's Boulevard MOOresville NC 28117-8520 OMA r./I dam 9LO �P a,kYpp J Jwi6b itaiN ©19884015 ACORD CORPORATION.ANI rights reserved, AGGRO 25(2016103) The ACORD name and logo are registered marks of ACORD