31B-312 (5) 26 CRESCENT ST BP-2017-0414
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:31 B-3 12 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 if BP-2017-0414
Project# JS-2017-000688
Est.Cost: $3175.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grouo: HOME DEPOT AT HOME SERVICES 99209
Lot Size(sp.ft.): Owner: DURANE WALKER
Zonino:URC(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 26 CRESCENT ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCERI02908 ISSUED ON:9/28/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 3 DOUBLE HUNG WINDOWS ON 2ND
FLOOR BEDROOM
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 9/28/2016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
—_•_--t, Department use only
_"D City of Northampton Status of Permit: •
I „'- -" Building Department Curb Cut/Driveway Permit
1 Zits 212 Main Street Sewer/Septic Availability
5�t' 2 Room 100 Water/Well Availability
's, noas
N q �:"'
Ni rthampton, MA 01060 Two Sets of Structural Plans
Deo.O(sintn" -587-1240 Fax 413-587-1272 Plot/Site Plans
NOAT'ANPrnN
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
n -/-- Map Lot Unit
7/ //s/yam��,U/ T Zone Overlay District
v� G�L!{�4�/�W' Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
tv tw /k4 -.
Name(Print) Cunen i- rims
t wn7t7� 1 M� �s�g8
ele e
Signature
2.2 Auth• ' ed •ent: " q
1! /.01 - ar AS/11m If 4 .Atem .4
At
Name Pnn� Current Mailing Address: / r
,400,
/ /0.0—196.2-- G/
Sign. re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building .?17 -,op/^ (a)Building Permit Fee
2. Electrical �rJJ
(b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
•
4. Mechanical(HVAC)
5.Fire Protection UV
'/ ///
6. Total=(1 +2+3+4+5) 9/�� f�r� Check Number /f 4 70 �O
This Section For Official Use Only
Building Permit Number: Date
Issued: Jam/
Signature: 17�,/ .�� 1 In-.;ai`
Building C missioner pector of Buildings
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 he filled in by
Building Depanment
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(kat arca 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 DONT KNOW 0 YES 0
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#
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(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition El New Signs [CI Decks [C] Siding[p] Other[CO
Brief Descriptio P •p.:-. /�J
Work: ltih n 44 tompa, /L y T Na
Alteration of existing bedroom Yes No Adding new bedroom Yes No �1r % 5
Attached Narrative Renovating unfinished basement Yes No �9/"VV'•
Plans Attached Roll -Sheet 2nd F/o0'v- /3/Inns-z.‘
5a.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
I. D✓C.Pr�C �'rc— ,as Owner of the subject
property �/� �7'�W
hereby authorize •///"t 1f l n
to act on my behalf,in all matters relative to authorized by this building permit application.
115( et-AT/7 q —27-/i
Signature of Owner /I�' � Date
I. /y�/12- J�ir Jqas Owner/Authorized
Agent hereby declar that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed undert ain- :nd penaldry.
4LQj '
',7201
Print Name 1-Z 711
Signatureof w Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction/Suppervisor: '� ,f Not Applicable 0
Name of License Holder V/454,71/4e ✓ ��✓C /l��.. �—� ! 71P
License Number r� X /�� - -12
17
Address Expiration Date
t ! `2/4 , v�
of 3�
Signature Telephone
923 136 -
9.Registered Home •roveme Contractor: Not Applicable 0
) �$ 1 a $ �
Company Name / _ tar. RegistrationNumber
Addres
�/��� ,�/�1 ,r Deft)
-3r-^�, Expiration Date
fery �i•iszi Art- Deft) Telephone/ ✓�/ 7.---
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6))
Workers Compensation Insurance a vit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuan ildin permit.
Signed Affidavit Alt d Yes No ❑
11. - Home Owner Exemption
The current exemption for"homeowners'was extended to include Owner-occupied Dwellings of one(l) 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 andi or farm
structures.A person who constructs more than one home in a two-tear 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 mat 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
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: 2e ClEktAir 4/
The debris will be transported by: MM/4/6,0-C1Zr
The debris will be received by: IL4u1ZeMA
Building permit number:
Name of Permit Applicant Chtil5
q z)- d i1 it ,
Date Signature of Permit Applicant
. JoS1:.ontacts
Friday,September 23,2016
Comments Lead: 19565350 Go I Advanced Search �I 1:46 PM
Info/Updates Homeowner Information Job Information
Homeowner Dr.Durane Walker Sale Amount $3,175.00 Balance Due: $2,175.00
Commissions Homeowner2 Product Andersen Windows(8%)
Documents Job Site Address 26 Crescent Street Status Sale/Material Ordered
203 Branch Boston North
Job Issues NORTHAMPTON,MA 01060 Measure# 78412330
Order Detail County HAMPSHIRE Sales
Billing Address 26 Crescent Street Commission Rate
Payments 203 Consultant Name Term Date SOIIt Como Plan
Permits NORTHAMPTON,MA 01060 Timothy Drost 100.00%Straight Commission
PO Primary Phone (347)295-8488
Work Phone Ext. B-Back: No Cross Regi 1-8356041722 Siebel Ord... 115985
Result Combo Cell Phone Key Dates
Work Phone 2 Sale Date 9/11/2016 FUP Date
Services Cell Phone 2 Credit Date 9/11/2016 FPD-Customer
Show Map Email dkpwalker@hotmail.com RTP Date 9/12/2016 Post Install Date
TouchPoints Cross Street Start Date 11/4/2016 FPD-Home Depot
Marketing Inspection
Update Job Referral Store 8452-HADLEY Job Indicators
Work Orders Base Store 8452-HADLEY Lead Paint: Purchase/No Test-LSW
Lead Source 0205 SC Working Store
User Date Time Status Corr. Appt.Date Kppt.Time Consultant I
Erikka M Lewis 9/17/2016. 9:44 AM Material Ordered No 9/11/2016 3:00 PMITimothy Drost
Erikka M Lewis 9/15/2016 628 AM Order Received-PSG No 9/11/20161 3:00 PMITimothy Drost
David Richter 9/12/2016 9:10 PM Measure Complete No 9/11/20161 3:00 PM Timothy Drost
Cymina Raglin 9/12/2016, 4:23 PM Released to Production No 9/11/20161 3:00 PMITimothy Drost
Cythina Raglin 9/12/2016 4:21 PM Order Entry No 9/11/2016 3:00 PMITimothy Drost
Timothy Drost 9/11/2016, 3:24 PM Credit Pending No 9/11/20161 3:00 PM Timothy Drost
Timothy Drost 9/11/2016 3:24 PM Sale Pending No 9/11/20161 3:00 PuTimothy Drost
KIMBERLY COOK 9/11/2016 3:13 PM Sent to the Field No 9/11/2016! 3.00 PM'Timothy Drost
KIMBERLY COOK 9/11/2016 3:12 PM Confirmed-Customer No 9/11/20161 3:00 PM Timothy Drost
KIMBERLY COOK 9/11/2016. 312 PM Pre-Book -..No 9/11/20161 3:00 PMITimothy Drost
KIMBERLY GOOK 9111120161 311 PM Lead Entered No I 1
Close Print
,
ft.
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:
Durane Walker 9565350
First Name Last Name Branch Name Lead rt
26 Crescent Street 203 NORTHAMPTON MA [01060
Customer Address Cly State Zlp
(347) 295-8488
Home Phone# Work Phoned II Phoned
dkpwalker@hotmail.com
Customer E-mail 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 City State Zip
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
DEPOT'S 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 DEPOT'S 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 09/11/2016
Customer.Signature Dale
1
Distribution:White-Home Depot Yellow-Customer Copy
•
Andersen Wood SPEC SHEET SC: Timothy Most Measure Tech: INSTALLER:
branch Name Reston NOM boa a. 0566050 Prepares ER' ISM:
Ship To twnprc BustomerNarne. Dunne Walker Dale O9/11/2016 SHEET 1 of 1
NEW WINDOW TWIT
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Lwm FRAIN Sean nuns Eiden Fen WTI (WIDTH RO et Oen
Window Typo Style Oder Coke Liner Tin WALL SILL Sean nage Tenn lwmew.a Type Penh (per wet Location alma° Finish FliniSh Lan/Item
Roam Flew Coale CODE CODE COM CODE Color Meth Heigh HEIGHT Wish Height TIP? DEPTH ANGLE Spa Vevey/Handing Style CODE coin CODE CODE sash/ seem CODE CODE CODE Type FinishCODES
1 BED grici OH 400 OH-I TR Wil 4,00 45 00 05 new Wil STD WH STD WH
2 BED 20T DH 400 DH-I TR WE 41 00 IP IN SE none TM STD Rh STD wii
3 BED Wal OH 4011 OH pi TR mi 41 Do 45 00 as none WIT STO WH STD RH
MAYr MxrIWW I kwNe Neteenneen r>un.wr as Nem.ams neat...rimer anneewnocenee4 ANALIINCTIMR.Nr.uNtry TRi.iwa keel ,
Go knew FR/weigh ecesenne win sionnernene
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IMAI Anderson ewes Eden /tot muaismcx
a ease maim! ors ME ME SOLO Iter TM MEASURE TECH SIZE FULL FRILME ONLY ame(yaw IPEW WH PRICING( Onvr/. o(tlm Cµm Hnnn MtlwIA OV Opna Wnk” MiaC LABOR ORTIWS
Location ant% gongs g,dgnor Finn TOTAL 1/1 Eiti Extension Gild HO. Wiac Dow Dow Look wok Opwnn
Dew Type „le Ryer [Wet (WIDTH• so/Tip wate Jen Type Finn mei on per obene sweet, IN ei Venice: Venice 0 PL) HROWR IIRDWR Keyed mein/ Special
ROOM riti.Or CM!, COOF. CODE CODE CODE Wet Height HEIGHT) Won Height le TIP Use Lunn CODE CODE Sash) San CODE CODE OUT II Rawls Handing Handing Annitly Type r inn ink Stacked Notes RISC Leber Hem CODE s
Ann rv..N... Durane Walker In Home Owner
41
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ac Ro €�e CERTIFICATE OF LIABILITY INSURANCE �1612016oc rvq
4.....----
THIS
iTHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed It SUBROGATION IS WAIVED,subject to
the terms and conditions of me 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).
WNTACT
PRODUCER RAC:
MARSH USA.INC. PHONE FAX No:
TWO ALLIANCE CENTER LAIC No No.EC ![MOT
3560 LENOX ROAD.SUITE 24C0 E.MA4
ATNTA.GA 30326 ADDRESS:
INSURERISI AFFORDING COVERAGE I BRIG
10C492HonMDGAWV-I-17 INSURER A:Beadil InsUIanca CmnpMY 126381
2unen Amer Lan lnsurapre CD 115535
INSURED INSURER B:
DBATH-EHOMSDEPA.INC
. 1y3R4l
DBA THE HOME DEPOT OTAT-HOME SERVCES WSURE0.e:NEW HWnpol'ue Ins Co
2690 CUMBERLAND PARKWAY.SUITE 300 WSURER 0:IFmis National Insurance Company I23M7
ATUNTA.GA 30339
INSURER E:
INSURER?:
COVERAGES CERTIFICATE NUMBER: A11a03746B46-14 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. NOTNATHSTANDING ANY REQUIREMENT.TERM OR CONDTNON OF ANY CONTRACT OR OTHER DOCUMENT MATH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR NIAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.WAITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
SR TYPE OF INSURANCE -Plan VVAEIM POUCY EFF I POLICY EXP I
LTR INRI WPOLICY NUMBER WWMIDO
IMOdY91 IIMMIYYI' LIMITS
A X COMMERCIAL GENERAL GASIUTY '•GLGIBB/1146 0310112016 03112017 -i,FACXOCCURRENCE !S 9.000.000
!DAMAGE TO RENTEOI.WOAW
• CLAIMS-MAGE X OCCUR 'PREMISES Ma occurrence) S _
LIMITS OF POLICY XS •
MED E-eP!Any one pesanl I- ExCLUDED
-OF SIR:SIM PER DCC PERSONAL&ADV INJURY 15 9,0.00.
TERM AGGREGATE LIMIT TPOUES PER ". 'GENERAL AGGREGATE IS 9,000,000
FOLK'_ MCI LCC i PRODUCTS-COMPIOPAGG i 5 9,003,003
s
OTHER: •
B AUTOMOBILE LIABILITY BAP aV11:1-13 .,0310112016 103101201] .!IEOMBIN2. OEDESMGLE UNIT 's 1,000.000
•
BODILY INJURY(Per peOn)
X ANY. AUTOnIa
—AUTOWNED SCHEDULED SELF INSURED AUTO PH?DMG i ROMS INJURY(Per acdilen S
_
AUTOS --AUTOS i
NON.OVANEO - i PROPERTY DAMAGE
HIRED AUTOS .AUTOS '(Per accdeml
1 $
• UMBRELLA CAB OCCUR I ' . I EACH OCCURRENCE Is
-EXCES$t1AB COMAS-MACE I AGGREGATE iS
DEO RETENTIONS IS
C .WORKERS COMPENSATOR iwC015519215(AOS) 1031012016 -03X111201] 1 X !PTATurE 1 1 ETH- I
!AND EMPLOYERS LIABILITY NH,NJ, 103012016 '0381201] 1.000,000
C :ANY PROPRIETOWPARTNERFXECUTIVE YIN IWC01551921T(AK,X{, Vln LEL EACH ACGOEM i5
D OFFlCENMEMeER EzcwoEw N x1A. ':yyC015519216 FL '03rot2m6 103A1t2m1 I EL DISEASE-EA EMPLOVEST t000.W0
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lyes Eeviba omen iCoopinuedon AdCNnn'RP P 1,134330,000
'DESCRIPTION OF OPERATIONS EeImv I E9 LEL DISEASE-POLICY LIMIT IS
. i 1
DESCRIPTION OF OPERATORS I LOCATIONS I VEHICLES IACORD 101.ACEItional Remits Schedule.may be amcned IinnR space is required)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT-HOME SERVICES.INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA,GA 30339
AUmORI2O REPRESENTATIVE
of Marsh USA Inc
Manashi Mukherjee Setn,.sAoa.- �.aiOsa tL-
m 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
i -
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 126893
Type: Supplement Card
THD AT HOME SERVICES, INC. Expiration: 8/3/2018
RICHARD TROIA
2455 PACES FERRY ROAD, HSC C-11
ATLANTA, GA 30339
Update Address and return card. Made reason for change.
Address Renewal - I Employment J I Lost Card
Office of Consumer Affairs& Business Regulation License or registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR Delon:the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Registration: 126893 Type: lip Park Plaza -Suite 5170
Expiration: 8/3/2018 Supplement Card p;ostiaa;. MA 12116
THD AT HOME SERVICES, INC.
THE HOME DEPOT AT HOME SERVICES
RICHARD TROIA
ATLANTA, GA 30339
' ---��
2455 PACES FERRY ROAD, HSC — - - y
211/11: 1uN6.-�2i
3.'rdcs.ccrePvry ' F ok valid without signature
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, Mn 021l4_79 77
www.mass.gov/dia
\Yorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
Please Print
t se" Legibly
Name(Baamessrorgannadonnnaiwieaap: 1liYDF% )T }{,, Y
C' .S
�. C, �,� n via" -'f)Address:
City/State/Zip:, r.YGv%'7-'L ij M/;'6''r 94hone#: YlG�'-'/tz L)2.
Are you an employer?Check the appropriate box: Type of project(required):
❑1 am a employer with employees(full and/or pan-tinre)'
am a sole . Ill New Remodelingnruction
"-'.❑ proNocmrkepannmp uranceeegemdloyees working for me in 8. ❑
any capacity (No workers'comp insurance repulredl
1❑I am a homeowner doing all work nnyselr INo workers required.):comp insurance r d 9 ❑Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ID Building addition
ensure that all contractors either have workers'compensation insurance or are sole II.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.l am a general contractor and l have hired the sub-contractors listed on the anached sheet
These subconaaetors have employees and have woRea'comp insurance: 13.�r�nR,�O'Of repairs
j��`
b.❑We are a corporation and its ollicers have exercised their right of exemption per MGL c. 14.InLtdther �y�Y��®(/
152.51(4),and we have no employees.[No workers comp insurance required.]
'Any applicant hat checks box MI must also fill out section below showing their workers'compensation policy Inti rmauon.
'Homeowners who submit Nis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1Comractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not Most entities have
employees. If the sub-contractors have employees,they must provide their workers comppolicy number
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. Aft/Insurance Company Name:_ LkfYiN1 ���'-rrrra I r))7. j Ct3 _ I
Policy q or Self-ins. Tic.g: �,(,,(�"jtj" ry�'� Expiration Date: �� � 17
Job Site Address: //� tent City/State/Zip- - fiti)
Attach a copy of the workers'compensation policy declaration page(showing the policy num er and exp alma date). op,i0
Failure to secure coverage as required under MGL e. 152,§25A is a criminal violation punishable by a fine up to$1.500.00 (� Cl
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 Once of Investigations of the DIA for insurance
coverage verification.
I da h, eby certif ti,de II .. �p-ena tiesieof�perjury that the information provided above is true and correct.
Signature: I^ U^
� �'ltt/" Date: (?,),0-14
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Phone Al: .,-(4b2-664/1—"
Official use only. Da not write in this area,to be completed by city or town official.
City or Town: Permit/License#
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Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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