29-302 (8) 422 ACREBROOK DR BP-2017-0404
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-302 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Door Replacement BUILDING PERMIT
Permit# BP-2017-0404
Project# JS-2017-000671
Est.Cost:$2133.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq.ft.): 10497.96 Owner: VIRKS DARA
Zoning: Applicant: HOME DEPOT AT HOME SERVICES
AT: 422 ACREBROOK DR
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCERI02908 ISSUED ON:9/26/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 1 PATIO DOOR FOR REPLACEMENT -
NO STRUCTUAL CHANGES
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 ft 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 9/26/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File If BP-2017-0404
APPLICANT/CONTACT PERSON HOME DEPOT AT HOME SERVICES
ADDRESS/PHONE 24 SUNRISE DR PROVIDENCE
PROPERTY LOCATION 422 ACREBROOK DR.
MAP 29 PARCEL 309 001 ZONE
THIS SECTION FOR OFFICIAL USE QNLY::
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid permit FilY]/f/ fJ�
Bnlidinged out („)�'(�
Fee Paid
Typeof Construction:_1NSTALL 1 PATIO DOOR FOR REPLACEMENT-NO STRUCTUAL CHANGES
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 47121
3 sets of Plans/Plot Plan
THE OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN RMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:,§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability _ Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolitio,.elay
• . . .i "" 9 aG c9070.
Signature of luildi;_Offici f Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
'� —... Depmbient use only
City of Northampton Status of Permit:
:uiiding Department Curb Cut/Driveway Permit
` ca5 212 Math Street Sewer/Septic Availability
Room 100 WaterfWeft Aweilab ty
Northampton, MA 01060 Two Sets of Structural Plans
Fett4t one 413-587-1240 Fax 413-587-1272 Plot/Site Plans
orfi`cc Other Specify
" CATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address,
77ddrass yJ� / �p�f,/�� /T�� This section to be completed by office
y22_ IiV'4N"�-d1 fir""' / ' G' Map - Lot Unit
Zone Overlay District
Eim St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
121424 Vi tIZ4v Q22 S %f ,',; �?: I*(
Name(Print) 42.
p.�, /v/�../,. Curre(n�t M/�a�il „,."a : ,f._ 0/
bh� -0T Telegne /✓�iJ�
Sgnature
2.2 Authonz A t: /}� y�, /�/� '�/j,+'"^'��� 4r41,
Name(Pin urrent Mailing Address: 7.+--
$Igna /' Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building )33
(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
ti. Total=(1 +2+3+4+5) �' • Check Number 'S7
This Section For Official Use Only
Building Permit Number: Date
Issued'
Signature:
Budding Commissioner/inspector of RuiMings Date
Section 4. ZONING All Information Must Be Completed, Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning—I
this cotama robe filled hi by
wilding Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height — _
Bldg.Square Footage u
Open Space Footage
Min area minus bldg&paved
_parking)
hof Parking Spaces
Fill:
itnlume&L.,raion)
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 0
IF YES: enter Book Page and/or Document P
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C, Do any signs exist on the property? YES O NO O
IF YES, describe size, type and Location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(el aring,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO a
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ j Addition ❑ Replacement V/Indows Alteration(s) ❑ Roofing ❑
Or Doors 1.
Accessory Bldg.
�.l Demolition r� ❑ New Signs [D] Decks [C7 Siding
'[CH Other[Di
Brief
Descnpt: Poi7/F>'Ggo !fTh Loth "�""G�" 2 � ✓fI � eWor
Alteration of existing bedroom Yes No Adding new bedroom Yes Na
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa,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?
I. 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
I. 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
.} 91Q u.) z7-4 _as Owner of the subject
property /.)()�
hereby authorize jJ�J+'�'--t' —rev
to act on my behalf, in all matters re ' e to wgrk-authorized by this building permit applicatio
tC a 4_2.3 /b
Signature of Owner Date
.�y�rpp
� /j
i !' Ierip �'-OI ' 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 p.! s am, penalties of perjury.
t • Al L?1?
Print Name
401..„.... tam 76
Signature r•wner/Agent �� Date
•
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ,/- yam `rn� Not Applicableppb ❑'7J"�
Name q(LfGensa Holder #0/21 0 Air f '�S7/ f` '- .4 /2/
License Number
Address Expiration Date
W15T tb )/ . 0io4C
Signature Telephone
in—c:3 1af2---
9,Registered Home hmtr)wment Cuss :otor: Nol Applicable 0
me , e ; C ► /26 e93 . .
Company NA0)4 jti/')�P fr fiT'y� 1 Pi:
I Expi ars Region Number
Date
I Da ' h ' - p Telephone )/.9.3- ,
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.n. 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 issuangiseMiltizaking permit.
Signed Affidavit Atta Yes No 0
11. — Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(II 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 MI such work performed under the buntline permit.
As acting Construction Supervisor your presence on the job site will be required Goin 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(sl
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
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 150A.
Address of the work: 4 22- //x)/; ®/- gr*vcf mii
The debris will be transported by: w Tf
The debris will be received by: UVra
Building permit number:
Name of Permit Applicant ' J Y t I6 -
Date Signature of Permit Applicant
•
•Job Cvtact% Link Leads NAAR] ,1, tm Tuesday,September 20,2016
Comment% Lead: 19545814 Go I Advanced Search 12:45 PM
Info/Updates Homeowner Information Job Information
Commission% Homeowner M/M dare Mrks Sale Amount $2,133.00 Balance Due: $1,533.00
Homeowner2 Product 6500/6100 Series Windows(8%)
Costs Job Site Address 422 acrebrook dr Status Sale/Material Ordered
FLORENCE,MA 01062 Branch Boston North
Document%
Measured 78437062
Schad Measure County HAMPSHIRE Saks
Biking Address 422 abrebrook dr Commission Rate
Homeowner FLORENCE,MA 01062 Consultant Name Term Date Split COMP Plait
Job lssul% Timothy Droit 100.00%Straight Commission
Labor Update Primary Phone (603)731-5101
Work Phone Ext. B-Back: No Cross Rata 1-8202006411 Siebel Ord--. 116109
Order Detail Cell Phone Key Dates
Work Phone 2 Sale Date 9/13/2016 FUP Date
Order Entity Cell Phone 2 Credit Date 9/13/2016 FPD-Customer
Payments Email dare vonberQhotmait.com RTP Date 9/14/2016 Post Install Data
Permits Cross Street Start Date 10/12(2016 FPO-Home Depot
Marketing Inspection
Referral Store 8452-HADLEY Job Indicators
Result Combe Base Store 84524IADLEY Lead Paint:Purchase/No Test-LSW
Lead Source 0080 Store Associate-OLS I(( +"'pr y
Service% ll
Show Map
TouchPoint%
Update.106User Date Time Status Con. AppL Date Appt.Time .Consultant t
Brittany Johnson 9/16/2016 12:59 PM Material Ordered No 9/13/2016 4:00 PM'Timothy Drost
Work Orders David Richter 9/14/20161 2:37 PM Order Received-PSG No 9/13/20161 4:00 PM Timothy Drost
David Richter 9/14/20161, 2:37 PM Measure Complete No 9/13/2016 4:00 PM Timothy Drost
_ - — _ _.
--Frederena Campbe 9/1412016 12:43 PM Released to Production No 9!(3(2016 4:00 PM TimoMY Brost
Frederena Campbe 9(14/2016 12:41 PM Order Entry No 9/13/2016 4.00 PM:Timothy Drost
Timothy Drost 9/13/2016 4:51 PM Credit Pending No 9/13/2016 4:00 PMITimothy Crest
Timothy Drost 9/13/2010 4:51 PM Sale Pending No 9/13/2016 4:00 PM Timothy Drost
,Dayend Dayend 9/12/2016 9:06 PM Sent to the Field No 9)13/2016 4:00 PM Timothy Drost
':AUBREY MITCHE 9/12/2016 2:13 PM Confirmed-Customer No 9/13/2016 4:00 PM Timothy Drost
Internet Lead 9/3/2016, 12:01 PM Pre Book No 9/13/2016 4:00 PMTTimothy Drost
Internal Lead 9/3/20161i 12:01 PM Lead Entered No
Clam I Prier I
•
Home Depot Contractor License Numbers:
MA Home Improvement Contractor Reg. # 126894
Salesperson Name and Registration Number:
Timothy Drost : HIS 0553710, R-R-073-15-00005
Home Improvement Agreement
THD AT- HOME SERVICES, INC ("Home Depot") or Service Provider named below will furnish, install
and/or service the equipment listed below at the price, terms and conditions as outlined on this form.
Customer Information:
dara virks 9545814
IFame Last Name Branch Name Lead
422 acrebrook dr FLORENCE MA 101062
Customer Address SLY State Zip
(603) 731.5101
Home Phoned Work Phone Cell Phones
dara_vernier@hotmail.com
Customer E.mad Address
NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR
OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT:
908 Boston Turnpike Unit 1 Shrewsbury MA 01545
Address bay State Pip
or Email CustomerCancellationNorthEast@homedepot.com
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME
DEPOTS RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR PROFESSIONAL,AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME
CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU.
OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT
HOME DEPOTS EXPENSE.
THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL.
Acknowledged by:
X 09)13/2016
n tomerrs eymee Date
1
Distribution:White-Home Depot Yellow-Customer Copy
WINDOW SPECIFICATION SHEET - Spec.Sheet# 9545814 Sheett. 1 of 1
Customer. dam virks Job 9.. 9545614 Consultant: Timothy Droet Dale. 09/13/2016
New Window
L
ationsom outside,
Es cling Window Measu remenl5 Gads product Opkons Labor Options From Loc
Leo to Right
Bays.Bowls
Locabn Cdor Roush Opening p of Lars *I oars Csmnts.1 Pnl,
use L.R or S
Glass Mix Items
Hardware Code
Screens For doore use
— _ Mull "5'=stat nary or
m 88a Wraps Rg 2 R % —o r ring
g g
LOP Room Floor Coe (YIN) Style Code Sanas Code _ u5 3 x 3 t.m U 0 > x > x
910,IMP RAI F TS°
•
SPECIAL CONSIDERATIONS.
byran Color MISCI'.Primed clamshell
IMUIw Casing Type Clamshell
Bay or Bow window
Gealbmnl material(vinyl only-Birch or Oak)
Bay Project Angle 130 or 45)
Bay Flanker Type(DH.SR.or Csmnp
Top or window 10 SCR(inches)
alae to somL color of soffit natena I I have reviewed a io agree with all the lob skecnsahank a dove aria the
acnslm or Roof nes or Not' S pedal Terme and Conditions 0n the following page
Garden Window
Bealboard Material(vinyl only-White Poeta.Birch or Oaf
Wall Thickness(inches) Customer Signa re
Addibonal Shan nes or No)
•There is no guarantee that new shingles will malch existing color
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 126893
Type: Supplement Card
Expiration: 8/3/2018
THD AT HOME SERVICES, INC.
RICHARD TROIA
2455 PACES FERRY ROAD, HSC C- 17
ATLANTA, GA 30339
Update Address and return card.Mark reason for change.
I Address Renewal ...I Employment I I Lost Card
Office of Consumer Affairs Si Business Regulation License or registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
(Mice of Consumer Affairs and Business Regulation
Registration: 128893 Type: ID Park Plaza -Suite 5170
Expiration: 8/3/2018 Supplement Card Boston, MA 02116
THD AT HOME SERVICES, INC.
THE HOME DEPOT AT HOME SERVICES
RICHARD TROIA
2455 PACES FERRY ROAD, HSC - - 9
ATl;4NTA. QA 30339 A/ al Ili
Undersecretary :x'ot valid without signature
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° CERTIFICATE OF LIABILITY INSURANCE 020E122016�Tm
ACORIO
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 POLJCIES
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. N SUBROGATION IS WANED.subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not corder rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
MARSH USA,INC. NAME: FAX
PRO ALLIANCE CENTER vHONE, Fna _ I(A/C,No):
35E0 LENOX ROAD.SUITE 24C0 EMAIL
ATLANTA,GA 30326 ADDRESS:
INSURERIS)AFFORDING COVERAGE I NAIL
100492-HOmeD.GA'N'-I61T NSIRER A:SIeaOla1 Insurance Company ;2682
INSURED mum(0:LAIN Amecan Insurance Co ''16535
THD AT-HOME SERVICES,INC. 11
DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:Nen/Hamp9160IR CO
2660 CUMBERLAND PARKWAY.SUITE 300 SURER D:MOMNatofM Ilcurarcecompany 123817
ATLANTA.GA 30339
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-003741E46-15 REVISION NUMBER:8
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 CONDO1ON 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ,-
ISR TYPE OF INSURANCE Ai5D D POLICY NUMBER I(WDCMW
DNII I IM eF ROUES'
DDIYWYI I
LTWard
A X •COMMERCIALGENERAL LIABILITY •CiLC•IBBRIAIA 0310112016 0310112017 I E• ACH OCCURRENCE I S 9.I300.030
• 1 DAMAGE TO RENTED i
CLAIMS-MADE Y` OCCUR I PREMISES MaWiulmxl 1.0 000
'OMITS OF POLICY XS - MED EXP wny m111/5N' - EXCLUDED
-OF SIR:SIM PER CCC •
"P• ERSONAL a ADV INJURY 15 9'01101300
_GEN'L AGGREGATE LIMIT pROAPPLIES PER-- I ;G• ENERAL AGGREGATE IS 9m0.000
X POuCY .moy LOC - PRODUCTS-COMP/OP EGG 15 9•�•�
OTHER-._ • !5
B AUTOMOBILE LIABILITY BAP 29368613-13 :030112016 :03101,201J 1 rameDnSINGLE LIMIT '5 1000.00I
X YAUTO •
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L OWNED OCHECULEO SELF INSURED AUTO PHY CMG j-BOLRLV INJWtt(Per aCidem);5
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—AAUT05
NON-OWNED I PROPERTY DAMAGE -
HIRED AUTOS , __AUTOS I .IPer accident)
S
UMBRELLA UAB OCCUR EACH OCCURRENCE IS
EXCESS MB CLAIMS-MADE - i 1 AGGREGATE IS
I
DED RETENTIONS I5
C ;WORMERS COMPENSATOR IWC015519215(AOS) 1030113016 :03012017 I X PER STATS I VER '
AND EMPLOYERS'RWBILITY I
C -ANT PROPRIETOR EXCLUDE1ExECUTINE N IWC015519217 VicKY,NH,W,VO I031012D16 '�D3N112pt1 I EL EACH ACCIDENT :5 1,000.000
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'DESCRIPTION OF OPERATIONS SNOW COnimued On AddkmM Page I EL DISEASE.POLICY LIMITI S 1•
DESCRIPTIO!OF OPERATONSI LOCATIONS I VEHICLES tACORD 101,Additional Remarks Schedule.May be Mashed It more Space is required)
EVIDENCE OF INSLR?ICE
CERTIFICATE HOLDER CANCELLATION
THO ATNOME SERVICES.INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
GCA THE HOME DEPOT ATHOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA.GA 30339
AUTHORIZED REPRESENTATNE
or Marsh USA inc.
Manashi Mukhedee _ 4a...ml.A ...34...f#a a.f.e
D1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
�(y Department of IndustrialAccidents
_ = {:J 1 Congress Street,Suite 100
HaStOn;f4 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO RE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information r� 0Please Print LeRibly
Name(Business/Organization/Individual): Itp y.re/ M Y HWyjy, ljgf'_2V)C“.7
Address: ( ci ..g, '?��
City/State/Zip IQ C-"' /f. I' - 4j 6d 14hone#: Z j442_
Are you an employer?Check the appropriate box:
Type of project(required):
9 I am a employer with employees(full and/or pan-time), 7. ❑New construction
2 I am a sole propnetor or pannership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'compinsurance required.]
9.
1❑I am a homeowner doing all work myself [No workers comp insurance required.]' 111 Demolition
4.91 am a homeowner and will be hirin 0 Building addition
g conuadorsmconduct all work on my properly (will
ensure that all contractors either have workers compensation insurance or are sole I I Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5l am a general contractor and l have hired the subcontractors listed on the attached sheer13 Roof ors
These sub-contractors have employees and have workers'comp.insurance: oorepairs
"�q�
6 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. they Yr/�/�"'
152.§I(4),and we have no employees.[No workers'comp insurance required.)
'Any applicant that checks box e I must also fill out the section below showing their workers'compensation policy information.
'Homeo'mers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit Indicating such.
(Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not hose entities have
employees. Irthe subcontractors have employees,they must provide their workers'comp.policy number.
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. A •
Insurance Company Name: {s/W11, ))j�L 1, _ j Co
Policy#or Self-ins.Lie.#: a a ¢L...c, j 22- b5 ig 15 Expiration Date: 3 . ' r
Job Site Address: "f / f//(✓ City/State/Zip:'/' t /06
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 doh= eby certif u-de t r pent tiesyie� of perjury that the information provided abov is true and correct
nature: 2^ �At L 21'7 � Date: 61- fp
/
Phone#: ?l-4bl ,�j ,`!/'
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 II:
BRIAN C THOMPSON
32 WILLOWBROOK LANE
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