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22D-087 30 SCANLON AVE BP-2017-0550 GN COMMONWEALTH OF MASSACHUSETTS Map:Block: 220-087 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: _...Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit 4 BP-2017-0550 Project JS-2017-000890 Est.Cost S5734.00 Fee: S40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License; Use Group: HOME DEPOT AT HOME SERVICES 67121 Len Sizen. ft.Y 75794.40 Owner: FIERST BEN Zoning.: LiRA(l00)WSP(100)r Applicant: HOME DEPOT AT HOME SERVICES AT: 30 SCANLON AVE Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCERI02908 ISSUED OaN:10121/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 10 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: Finuh Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Anal: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeTvpe: Date Paid: Amount: Building 10/2112016 0:00:00 S40.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner � Department use only ' = City of Northampton Status of Permit: °CI ! 9 F Building Department Curb Cut/Driveway Perms 212 Main Street Sewer/Septic Availability 'DEPT-or auxot Room 100 Water/Well Availability _ Nam prouiNsPecnovs Northampton,ton, MA 01060 Two Sets of Structural Plans "MA Oita? o 4 13-587-1240 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 L 6,- J ',"SOV 1.7 Property Address: `ddm�sfs /�L�-., j/p, This section to be completed by office /U .L;r/• 'LY' n /i Map —,.._ LotO Unit ..,_.` !f!Av!(- Zone Overlay District ____ Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Re ord: ....--" q /p Name(Pent) 77 .--„i- current Marling tit a. .. AMial y 7:4,77L u 2!1 r 'Signature Telephoneti t2I /14€9f 2. A.th.dzed A.• t ! 4 ale- .qa _X _. Name(Print) if Current Mailing Add s' Signatur= i TeiephonejiN'—/24Z --1--f52-- SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to he Official Use Only completed by hermit applicant 1. Building 47791/- Ob (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of _. _... Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 6.Fire Protection c. ? d (1 6. Total=(1 +2+3+4+5) �U Check Number/ 70 �' Tf/ This Section For Official Use Only Date Building Permit Number:_ /,��� ,,Jl� -411111,4 Signature: /!i// _7 —; �/ " .—.— allir ,00- Car - IIIII Build . mmissiener/lnspecior of Buildings Date Section 4, ZONING AU information Must Be Completed.Permit Can Be Denied Due To Incomplete information Existing Proposed Required by Zoning Thin column robe filled in by Bulging uepenmem Lot Size Frontage Setbacks Front Skis L: R' C,.._....—R: Rear Building Height Bldg Square Footage ,n Open Space Footage to arta mimes Dtdg&pared T of Parking Spaces Fill: (otiose&Location) _J A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © 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 a IF YES: enter Book Page and/or Document it B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW Q 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 oris it part of a common pian that will disturb over 1 acre? YES © NO 0 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 0 Addition 0 Reptacement Wkttlows Alteration(s) [3 Roofing Or Doors Accessory Bldg.rg [ID Demolittiioonn y,�0 ,r y�Neew,Siigns [D) Decks (a/ Siding D) Other ICZ ,,..JJ�� BnerfDey iPlltio JD OG-ioptile(/ e"at/ w9✓pt1U5 * 44' ,„,...$7-2,4,g-).„„" G£f Work; � :/ V Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roil -Sheet 6a.If New house and or addition to existing housing, complete the following: a. Use of building i One Family Two Family Other b. Number of moms 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 ORRCryOONN,T/RACTO�Ry-APPPLIIEE/yS-F—OR BUILDING PERMIT I, r ---,,, gez!JlQy/,,�/�/ /4'}/'' yam..- , as Owner of the subject propertyeryg[a`J/"rl /i rJ hereby authorize to act on my behalf,in all matters relati ork authorized by this building permit application. 6tE.. r_' Tiiv -t4-i6 Signature of Owner Date I. f( PIT,/ 'Tin- ,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 i nd penalties of'pg' �}blI Alf A ' 1 l j Print Name � e. ` �.t-i%' AO -I4 -11 Signature of a e&Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction$$upeeivisoor,:r ) J Not Appplicca�ble ❑ Name of License Holder: Pr`ZI i 9, r'Lr1 /,$i� t_,J p47/2/ ;4' M ,y7 —'�Y`fe'� / . w License Number /7r Address�� j /��';" ff�!//_/�� � jlY' `JYrAYj Expiration Date {v VM ° °lam • F/'"�._. Signature Telephone —, .5.--2- 9, 2- 9,Registered Home Improvement Contractor. Not Applicable eijiti-Lmv Y /i i2b4423 Company Name f Registration Number -0 .lag? /mak' , --3/14/ Address, r /( /,� Stpiration Date / r //��„/i ;ft (( —A Telephone 0/5:191.9 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 th-_:,..�.:.r permit. Signed Affidavit Mae( • -es ❑ No 0 II. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one{I t or two(2)families and to allow such homeowner m engage an individual ter 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-year period shell not be considered a homeowner. Such"homeowner shall submit to the Building Official,on a form acceptable to the Building Official that be/she shall be respousBde for all sack work performed under the buildinv 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 157(Workers' Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may he liable for person(s) you hire to perform work for you under this permit. The undersigned'homeowner Gentiles and assumes responsibility for compliance with the State Budding 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. Nonhampton, 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: '770 't,47i �c- k kip-61i The debris will be transported by: 61h4-77,-- The y The debris will be received by: k ertet- nib' Building permit number: Name of Permit Applicant "1-) /8- Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents „ t t Office of Investigations 1 Congress Street, Suite 100 e Boston, MA 02114-2017 �vo. ' wwwanass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ l am a general contractor and] 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sok proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have S. []Demolition workingfor me in anycapacity. employees and have workers' an9. 0 Building addition [No workers comp. insurance comp. insurances required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] f c. 152,§1(4),and we have no employees. [No workers' 130 Other comp. insurance required.] *Any applicant that chxks box 41 must alio fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating Ihty axe doing all work and then hire outside contractors must submit a new affidavi indicating such. Conuaciors that check this box must attached an additional sheet showing the name of tin subcontractors and state whether or not those entities have employees. if the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy fl or Self-ins. Lie. S: Expiration Date: Job Site Address: City/StateiZip:, 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 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 imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification_ Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date:, Phone#: 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 r fi.Other Contact Person: Phone#: __, • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein-or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MCGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers" compensation affidavit completely, by checking the boxes that apply to your situation and.if necessary, supply sub-contractor(s)4101410s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. Ilan LLC or LLP does have employees, a policy is required. Bc advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Depat meet at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year. need only submit one affidavit indicating current policy information (if necessary)and under"Job Site Address"the applicant should write"ail locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit, The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Fax #617-727-7749 Revised 77-2013 www.mass.gov/dia City of Northampton Na.Hnp s i U'•' Massachusetts ,r Ir ,a DEPARTMENT OF BUILDING INSPECTIONS fit+ ` 212 Main Street • Municipal Building Northampton, MA 01060 rl i INt PE TOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines"Homeowner as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundationffootinas (before backfillt son• b: ha- . :f. • . r.u. .u' d' • n.pection (before work is conceaiedj,l"i isolation inspection (if,requketU and a final building insoection The building department requires these inspections before the work is concealed, failure to se&gre_ these insoec 'o . r .i f-'iu e p obtain a certificate of occupancy.until the work can be„ inspected If the homeowner hires other trades to perform work(electrical, plumbing&gas)the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections, Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location Job Contacts 7/r�"li `2%/`� y ! Thursday,October 13,2016 Go Comments Lead: 9612977 1 Advanced Search 5:08 PM Info/Updates Homeowner Information Job Information Commissions Homeowner M/M Ben fierst Sale Amount $5,734.00 Balance Due: $4,000.00 Homeowner2 Product 6500/6100 Sones Windows B l) Costs Job Site Address 30 scanlon ave. Status Sale/Material Ordered Documents FLORENCE,MA 01062 Branch Boston North Measure k 78187784 Schad Measure County HAMPSHIRE Sales Homeowner Bitting Address 1253 westhampton Commission Rate FLORENCE, MA 01062 Consultant Name Term Date Split Comp Plan Job Issues Timothy Drost 100.001 Straight Commission Labor Update Primary Phone (413)320-1894 Work Phone Ext. B-Back: No Cross Ref# 1-8939201642 SiebsI Ord... 117579 Order Detail Cell Phone Key Dates Older Entry Work Phone 2 Sate Date 10/3/2016 FUP Date Cell Phone 2 Credit Date 10/3/2016 FPD-Customer Payments Email six.ten.ben@@gmail.com RTP Date 10/4/2016 Post Install Date permits Cross Street Start Date FPD-Home Depot Marketing Inspection ED Referral Store 8452.HADLEV Job Indicators Result Combo Base Store 8452-HADLEV Lead Paint: No Test-LSWP Not Req Lead Source 0080 Store Associate-OLS 15ervloe@ Show Map 1Xigyt oints Update Job User_ Data Time Statin __Cort. Appt Dao Appt Time Consultant 1 Ashley S Asigbey 10/11/20161 10:41 AM Material Ordered No 10/3/2016 6:00 PM Timothy Drost Work Orders 'PETER TALBOT 101812016 9:11 AM Order Received-PSG No 10/3/20161 6:00 PM.Timothy Drost PETER TALBOT 10/8/20161 9:11 AM Measure Complete _ No 1013/2016. 6:00 PM Timothy Drost Cythlna Raglin 1014/201e 4:06 PM Released to ProductionNp 101372016'x. 6:00 PM;TimoGhy Durst Cythina Raglin 10/4/20161 4:03 PM Order Entry No 10/3/2016, 6:00 PMiTimothy Drost .Timothy Drost 10/3/20161 7:10 PM Credit Pending No 1013/20161 6:00 PM Timothy Drost 1 __ .—. .. Timothy Durst 10/3/2016, 7:10 PM Sale Pending No 10/3/2016 6:00 PM Timothy Drost Dayend Dayend 10/2/20161 9:08 PM Sent to the Field No 10/3/2016: 6:00 PM:Timothy Drost Da end Dayend 10/212016 9:05 PM Confined-No Contact No 10/312016i 6:00 PM Internet Lead 10/2/20161 4:25 PM Pre-Book No 10/3/2016. 6:00 PMITimothy Drost • — —_ Internet Lead 10/2/201$ 4:25 PM Lead Entered No Close I Print '. Home Depot Contractor License Numbers: MA Home Improvement Contractor Reg. # 126893 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: Ben fierst 9612977 ,rst N Last Name Branch Name lead# 30 scanlon ave. I FLORENCE MA 01062 tustwier Address... cry State Zip (413)320-1894 Home°none# work Phone# —.... Cell Phone# six.ten.ben@gmail.com Customer email 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 __ §aro i 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 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. PLEASH.SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL ANDWRITTEN NOTICE OF YOUR RIGHT TO CANCEL. aF9ea bY: 10/03/2016 cnucosse.efv#m,re Date 1 Distribution:White-Home Depot Yellow-Customer Copy WINDOW SPECIFICATION SHEET - Spes.Sheet it 9612977 Sheet: l of 2 Customer'. Ben Iierst Job#: 9612977 Consultant: Timothy Prost Date: 10/03/2016 New Window ATIMS Evsling Window Measurements Grids Product Options Labor Options HingeFoLmuslte, — _ _ _ Left lo Right Bays. Location Cobr Rough Opening re of Rcf Oars Bs1 is ne. Pnl. W6 use L.R«s Glass Misc Items Hardware Code Screens For doors use S = c d Mull $'_ Gonaryor 2 Style Wraps = _ o £ _ co$ VD g e p 1 _B .K.5'oporating id Room Floor Code (CMM Style Code Series Code to E 3 0 O _i Id > SRO GlansPtlek Standard WRAP 1 LIV 101 OH X ON eloo WH WH 31 00 53 00 84 3 Liv Isi OH y DH earo WH vdd et 00 53 00 84 STD Drexel:Rol, Standard .WRAP 3 LIV 191 OH A OH idea WH WH 3,on 53 05 oi STD alasaPack Standard WRAP 4 Lig tat OH y Dil 6100 WH WH 31 00 53 00 84 STD.GlansPaCk Pandora WRAP 5 Lig lat ORI 15 OH 0100 RH WM 31 0° SA 00 PI 1 RIO GlassPade thaddard WRAP 6 Liv art Ott y Die 6100 WH WH 31 00 53 00 34 cry GiaxsPack sowers WRAP 7 oo IP 011 A OH ergo WH W11 31 00 53 00 ea S10 Glaxxidack Stwareard Wear. re LIV 1st Oar l' OH 6100 vett wet 31 00 53 00 84 SPECIAL CONSIDERATIONS'. Wrap Color ntencr Casing Type Bay or Bow window. Sealhoard mater ml(vinyl(1111Y-Sioh or Oak) Bay Rigout Angle(9O or SS) Bay Flanker Type(DH,SR.or Gaunt} Top of window to soffit(inches) I hod to soHX,color of sone material I nave reviewed and agree with all the loo sooc?capons above and the idonslrucl Pool(Yes Or NO)' Spepal Terms and Conditions on tie Following page Garden Window Bealboard Material(vinyl onlywhile Pionite,Birch or Oak) Wall Thickness{inches/ Customer Sl0nature Admlbnal shelf ryes Or There 6 no guarantee that new shingles will match existing color WINDOW SPECIFICATION SHEET - Spec,Sheet f'. 9612977 Sheet'. 2 of 2 Customer: Ben liars) Job p: 9612977 Consultant: Timothy Drost Dale. 10/03/2016 New Window Hinge Locations Edsling WindowMeasurements Grids Product Otions Labor Options From outside, Left to Right Bays,Bowls Location Cola Rough Opening a of bars a of bars Csmnls,1 Pnl, use LA or S Glass Misc Items Hardware Code Screens For doors use S c _ 4 c o Mull "S Stationery Or style Wraps b W ` f _ gip S` E R 9 Pt - p = S 'operating Boom Floor Code (MBI) Style Code Series Cine B 3 I m U 6 > I STD Masse/my Serowe WRAP S UV Ist OH St DH moo WH !NH 31 00 53 00 ea SPECIAL CONSIDERATIONS. wrap Color MISC10 Ropers and wrap garage Windows rneror Casing Type Bay or Bow window. Seatboaro materiel(vinyl onlyBnoh or Oak) Say Project Angle 130 or 45) lay flanker Type tOH,SH,or Cemml Top of window lo solm(Inches) need to sdln,odor N add malaria I have reviewed and agree with MI the job sgplicatmns agave and Ina Construct Roof(Yes or No)' Special erms and Conditions on the Allowing page GoNen'window Sealboard Material(vinyl only-White tonne,Birch or oak) Wall Thickness(Inches) Customer Signature Additional Shell(Yes or NO) •There is no guarantee that new shingles will match existing color. 11 =nac . ft sa-;r_ si1.a4=s'k_.+33`.•-._du:-_c �.vnzsva i, 1. `."s"7?, 0.va/WE`.+-x S9s9L<ftI3;i7-iz .( dz"��:yg+z_4�c^a�:r is 1; -- 11 ' =D.e� s^fix _- Zbd hii _ - 1 - i- a7fi%..Ei,' S-arae 1_._i`_-�•t*_ ,� t- C _ �.,. - ` ki- 7,: wF Rula1Fs3 isi s-vima, -:- om - ;ms?i�c�D-�+1Ei03R �- .a xr,_ Q t -,-- _ _5 `1`,U i • L-1'c� OLFaRIMMI9k1'I z'Ik-xrl:wlr:f k03::•1-11•1'-'t+^ _ t' ^„ C=AI-4'> • ( aJiSa':%`a°: w'+`,e-AJQiEti RuasTflVE —.--- Plan=l- Cv.? �__y--:p- rr_' :4 h . ri II W:QY{' �.�• 'i --`_. L `1 li i _ Kti�^ = ii_ -v io4 1 `— -i! �y�JS ii ati oto- y>:�.].fig I3 _; `".F -r 6 The Commonwealth of Massachusetts -��`�• � Department of Industrial Accidents -^4' _ I Congress Street,Suite /00 na noytanMs p>,reQ_a;7j7 ' www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information r s7 Please Print g Le wily ,r Name (Business/Organization/Individual: li /.j')i 7)9 al '� ' . `t/-_ ��F�f2V)C_Yf? Address: ‘ ' }� n=� ' (1l.—' t _. �e�` . / -moi,,�,,,/ r, City/Slate!/,iP L� +�yCi�-"tr'U • 7 J l Is 0ig'`JAfhone II: �"il9"lr 1 . 2-31`)2_ Are you in employer"Check the appropriate box: Type of project(required): !CI I am a employer with_ ,,,_employees(full and/or pan-time}' 7. O New construction 2.0 I am a sole proprietor or pannership and have no employees work mg sot me in 8. J Remodeling any capacity (No workers'compinsurance required.) 9 El Demolition }0I am a homeowner doing all work mysel 11No workers romp.insurance required f' 4.11am homeowner and will be h rin,y contractors to conduct all work on myIO Q Building addition 1 property will ensure that all ctm:actors either have workers compeaanon insurance or are sole I I.Q Electrical repairs or additions ��.�{ 12.Q Plumbing repairs or additions proprietors with no employees '.�{.i alp a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These subeonnnema have employees and have workers comp ins1mM'e: 15.1 6.❑We are a corporation and its officers have exercised their right of exemption per MOL r. I4.L�s'ther�rJ)/vr��{v ! 152,§N¢}.and we have lN no employees. o workers re romp insurance uired.] L`Any applicant hat checks box dl mint also fill out the seerion belovshowing their workers'compensation policy intrmstion. s Homeowners who submit this affidavit indicating they are doing all work and then hire outride contractor:must submit a new affidavit indicating such. Conveyors that check thz box mast attaciedan aPditional sheet showing the name of the sub-contsaefors and stmt whether or not those entities have employees. If the sub-contractors have employees,they finest provide their workers'comp.policy number. /run an employer that is providing workers'compensation insurance for my employees. Below Is the policy airsjob site information. ,( / r� 7/'� Insurance Company Name: ' yf I g___,z�r":,,^L?/4/! l/..� s-+--�L-� ' CO " .. Policy#or Self-ins_Lie_#: jy„s[.'/QJ j4$.44—�ki5, /� Expiration Date:,,, -.L� I �Mil Job Site Address: t! /l a ✓ " 7Jk 4- City/State/Zi . '/ te/ Attach a copy of the workers' compensation policy declaration page(showing the policy number and cap tion dale). 49,002_, Failure to secure coverage as required under MGI.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 of a STOP WORK ORDER and a line 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 DR for insurance coverage verification. 7 do It, eby certi fir;de h .:R�pend ties of perjuryy that fie information provided above is true and correct. Signature: ' ti 6r .1fl fres../' Date: t 01 fd Phone p' 124 - ec -- 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): I.Board of Health 2.Building Deportment 3.City/Town Clerk C.Electrical Inspector 5.Plumbing inspector 6.Other Contact Person: Phone#:__ 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-11 ATLANTA, GA 30339 Update Address and return card.Mark reason for change. Address - Renewal Employment I I Lost Card Office of Consumer Affairs& Rosiness Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration: 126893 Type: 10 Park Plana -Suite 5170 Expiration: 8/3/2018 Supplement Card Boston. MA 02116 THD AT HOME SERVICES, INC. THE HOME DEPOT AT HOME SERVICES 1 RICHARD TROIA - 2455 PACES FERRY ROAD, HSC - - - - ATtP.NTA, GA 30339 t Undersecretary I id without signature Po- s? CERTIFICATE OFLW�ILYY INSURANCE DATEMMdDetivrh 020016 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, csitND OR ALTER THE COVERAGE AFFORDED EN THE POLICIES BELOW. THIS CERTIFICATE OF rtLSURANCE DOES NOT CONSTITUTE A CONTRACT SE'IWWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATEHOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policyQes)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 conferignta W the certificate holder in lieu of such endorsement(s). -. FReaucER co A2r . MARSH MARSHUSA.WC_ TWO AWRNCE SSEER MWCNN,WI' i FAX TWO 3EVIENOX ROAD.SUITE 2400 Eness: —� AilANTA,GA 30326 INSUREAISJAFFOROMO COVERAGE I NAI 1CC492NnmeD-GAWM.1OhiTr mdUR£RR:SNatlstinMdCCmpsP _.... w5URE0 116515 THDAT-tDdEaERUt(r.S.THC. watReRe:LeenN MINIMA MAINE HOME DEPOT AT-HOME SERVICE, inmost C:Nov MdmpNke km Co 12380 2B90CUMREP.LLIO PAAICNAY.SJTIF3Mrummy D:IYnDiSNa§Oml Inbra eCompany 2iB11 ATLANTA.GA 30339 INSUReR E: I INSURER P: I COVERAGES CERTIFICATE NUMBER: ARYAd614 REVISION NUMBERS THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE Lit I Lu BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT WDf 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 CONOFDONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. INSALTR TYPE OP INSURANCE - �y-c polCY NUMBER ( ftrbe T`WI UWTS A X waits lemtOENERALDaeanY ac4esm4-c 103101010 '03101iz0t7 1 EACS DCcume ce i s9.003.020M AUE CL IUS.aAOE OCGJR PDREM15FITTOFaREosNR9mdMal I s memUNITSCi POUCY X$ ':JED 666(Any �, EXCHIDED OF SIR SIM PER OCC i vcntorw.a Aw IHJURY I3 9 ,ODO,LTU _ . _ v'-ENLAG6NE ,MT APPuES?x R: - E .GENERAL AGM/MATE. IS BAR= X PDCC._!2G :CC '.I PRODUCTS-COMP/OP AGO 13 9�� GmER: i,E a AuWMoecE OARUfT • a.P2P3P.EB1tl .. .O3At12015 QM/20H I CGONBItet HGLE LIMIT •3 1,000M0 4A% %�Any AUTO - 1 WM,i10196r(Per pnavn) ALLOYMEN MSIESMNI Isar 9ISnREo AUTO PAY DM I:901)1LY RIStMrtPsettMA)!3 AUTOS .AVMS NON{MNEB pAfTGsr-"OMIAGE 'a s HIRED OS , R1TOS ,MOT SMMnIl , I UMBRELLA LIAR _accui '.. .y EACH On"RAENC 13 _ $,,EXCESS MAD LtAUSSMOE I AGGREGATE i S '-Oat - TNonNs - • I IS C •WORKERSCOMPENSAtON FNC015519215(AOS) 03.101,2016 ;OLbIMI] I x Ifee lois- I imp EMPLOYERS41ABILltt 4 STATUTE I MI C Ion(PROPRE OaiARTNEaeeECVn+E VfN NC0155192111AK,KY,NH,NJVI) 0310112016 A3M112011 I- OPFlChT/ResieexCWDaG I R/A DSEAsCCNENr .3 i.OW.000 O 'AMAndmon M Nm U: 4VC01551921ff 1 03101IZDt5 103'O1R01) .. LOOO,WO : 040 .Mei dEmR4oMT I Es_QiSEASE.ES 6MPLOVT3 ..RL'UO OP OP?3ATIO'SYmm !Comb/Mon FCdYanN Pap r IEL DISEASE-PRICY LRAIT I3 t.0�. • i I oeselNPnaNOFOPERGTIONSI LWeanOnSrvtlUCLEZ IACONO 101,AdLIbn.iWNaYa schedule.may tm IIME➢edU mit 9pxeek,gmnd) EADMICEOF MIMI:ANSE CERTIFICATE HOLDER CANCELLATION TND AT-NOME SERVICES INC. SHOMI°ANY OF THE.ABOVE DESCRIBED POLICIES BE CANCEL I CO BEFORE DBA THE HOME DEPOT AT-HOME EUMEES THE EXPIRATION PATE THEREOF. NOTICE WEL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDAHPEW{MTHE POUCY PROVISIONS. ATLANTA,GA 30339 AUTNORRED REPRESENTATIVE of Mesh USA Inc. Manashi Mukhenee ka ..r .54..,4cnun C .. 0 i 9884014 ACORD CORPORATION- Al rights reserved_ ACORD 25(2014101) The ACORD name and logo are registered maths of ACORD g: { 3R!AN C THOMPSON 38 WILLOWBROOK LANE ',`FSTF E ) r1085