24A-250 201 NORTH ELM ST BP-2017-0549
GIS E: COMMONWEALTH OF MASSACHUSETTS
Mao:Block 24A-250 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2017-0549
Project# JS-2017-000889
Est. Cost: $4490.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 88261
Lot Size(sq. ft.): 7971.48 Owner: HEBERT MARGUERITE F&JOSEPH 0 HEBERT III
Zoning: URA(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 201 NORTH ELM ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCERI02908 ISSUED ON:10/21/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE GARAGE ROOF ONLY
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 4 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:
FeeTvpe: Date Paid: Amount:
Building 10/21/2016 0:00:00 $40.00
212 Main Street. Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
''0epartmant use only
City of Northampton Status pf Permif _,.u ;
Section 4. ZONING Alt Information Must Be Completed, Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
mu column to be filled in by
Reniding Department
Lot Size 1
I -
Frontage �[ _. I I _-
Setbacks Front 1 __I I 1
Side Bl. 1 R:1. . .. 1 1
Rear 1 --I — _- _.
Building Height i J -.,1 f
Bldg. Square Footage I 1_ _i % I 1 I I i
Open Space Footage __ % -
Bat
tarea minus Bidg&raved I J p I I. I F . I - I
smu)
#of Parking Spaces I 1 -1
Fill. -Cotton) 11 I
(volume -
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO a DON'T KNOW O YES O
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES O
IF YES: enter Book Page I and/or Document 41
B. Does the site contain a brook, body of water or wetlands? NO O DON'T 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: i I
J
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and Location: L
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)aver 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is reguired.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) '` '
•
New House n Addition n Replacement Windows Alteration(s) Roofing }�j
Or Doors 0
Accessory Bldg. El Demolition El New Signs [ci Decks [q Sidi — Other[fl
..-Woelk?eeir1€ AY173 04eter 9 ti/12, fry 7-37-4v a en ;
Alteration of existing bedroom Yes No Adding new bedroom Yes No p. /`�; ' 4ZZee
n+T
Attached Narrative Renovating unfinished basement _Yes No ,.f _ S`
Plans Attached Roll -Sheet � Ff/I
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 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, cJ v'1 Ple9e-fir ,as Owner of the subject
property
hereby authorize cRef -1) :c, e—
to
......
act on my behalf, iry@II matters relative to work authorized by this building permit application. 9
Signature of Owner Dote
I ,as Owner/Authorized
Agent hereby decl re that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed nre- . e pots and penalties of ' .
/d?1 l/iL
Pr• i me
Ae.re�.� .�`� 10 141/J
Signature• •trner Agent ._ Date
•
SECTION 8•CONSTRUCTION SERVICES
8.1 Licensed Construction Supe is r:?y�/ I ) Not
Apppliiccab�lee
Name of License Holder: f 11 - �+'/t C. �" `, S
License Number
Address //�� Expiration Date
_ Lri ee fC X19— • r19)-C9
Signature Telephone
C_it>lar l. '
9. Registered Home Improvement entraeter: - - Not Applicable 0
lf� . c91 —126093 _
Cm an Named Registration Number
iebrT/71 (712
Add •s • Expiration Date
11 ' /�--0+'r' • ' E`. Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152, §25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attache es 0 No ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 108.3.51.
Definition of Homeowner: Person(s)who own a parcel of land on which be/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 fano
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,duringand 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 pork for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with tIE 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 definedlby MGL c 111 , S 150A.
�
Address of the work: 70/ (1/i722�l_ my '7
The debris will be transported by: �21'�/ e., 111 /L=
The debris will be received by: /ivg : 1 m
Building permit number:
Name of Permit Applicant )24/174) (cc f�
/a /—/6
Date Signature of Permit Applicant
The Cmvnnonweahh of Massachusetts
afie
wathirra
Department of Industrial Accidents
ti.
__ d Office of Investigations
I Congress Street,Suite 100
=".4_c .9 Boston,111A 02114-2017
—= www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lceibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:_ Phone #:
Are you an employer?Check the appropriate box: Type of project(required);
LE 11 l am a employer with 4. ❑ I am a general contractor and 1
employees(full andlo'part-tune)."
have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, [] Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers`comp. insurance comp.insurance.:
required] 5. ❑ We are a corporation and its lo.]Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 113 Plumbing repairs or additions
myself. [No workers' comp, right of exemption per MCII.' 12 Roof repairs
insurance required]t c. 152,§1(4),and we have no 13.❑Other
employees. [No workers'
comp.insurance required.]
'Any applicant that checks box al must also 1111 out the section below showing their workers'compensation policy information.
t Homeownwc who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractars that check this box must attached an additional sheet showing the name of du sob-contractors and state whether or not those entities have
wioyees. If the sub-contracton have employees,they mist provide their workxxs'coup_policy number.
7 urn an employer that Is providing workers'compensation insurance for my employees. Below is are policy and job site
infornmton.
Insurance Company Name:
Policy It or Self-ins.Lie, #: Expiration Date:
Job Site Address: City/State/Zip:
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 MCL c. 152 can lead to the imposition of criminal penalties of 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 fine
ofup to$250.00 a day against the violator. Be advised that a copy of this statement may be'jbnvarded to the Office of
Investigations of the DIA for insurance coverage verification,
I do hereby certify under the pout and penalties of perjury that tie 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):
I. Board of Health 2•Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone II:
Information and Instructions
Massachusetts General taws 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,MGL 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)name(s), 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. If an LLC or LLP does have
employees,a policy is required. Be 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
he 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 Department 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 permit/license 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"all 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 tile 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 bum 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
1 Congress Street,Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 7-2013
www.mass.gov/dia
City of Northampton
., a5 I`
Massachusetts w'•
DOF BGIMDING INSPECTIONS
212 Ha
212 HainnStmeet . Municipal Building as tr.'
Northampton, MA OISEDF SOU'
+
�
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWN R EXEM1711Q C �L1OWLEDOEMENT
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 shalt 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 budding department be called to inspect work at various stages, which include
foundation/foottnq (before backfill). sonotube heles (before.pour), a Lough building inspection
(before work is concealed) insulatio s.ectio . 'f re.ui r!. and a al building inspection.
The building department requires these inspections before the work is concealed, failure to secure_
these inspections...an resuin failur o obtain a certificate of occupancy until the work can be
inspecte—d.
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 Contact& Link Leads
•
Monday,October 17,2016
Comments Lead: 19615468 Go I Advanced Search 10:23 AM
Info/Updates Homeowner Information Job Information
Commissions Homeowner Mr.Joe Hebert Sale Amount $4.490.00 Balance Due: $336800
Homeowner2 Product Shingles-Premium 10YR Craftsman Werra
Documents Job Site Address 201 north elm street Status Sale/Measure Complete
Job Issues NORTHAMPTON,MA 01060 Branch Boston North
Measure*/ 78932324
Order Detail County HAMPSHIRE Sates
Payments Billing Address 27 fox glove lane Commission Rate
amheist, MA 01002 Consultant Name Term Date Split Comp Plan
Permits Mark Newhouse 100.00%Straight Commission
PO Primary Phone (413)6995-5950
Work Phone Ext. 13-Back: Yes Cross Relit 1-8945091822 Siebel Ord... 118151
Result Combo Cell Phone Key Dates
Service% Work Phone 2 Sale Date 10/12/2016 FUP Date
Cell Phone 2 Credit Date 10/122016 FPD-Customer
Snow Mao Email )oehebertUCCaoLwm RTP Date 1014/2016 Post Install Date
1'ouchPoin[s Cross Street Start Date FPD-Home Depot
Update Inspection
Job
Referral Store 8452-HAOLEY Job Indicators
Work Orders Base Store 8452-HADLEY Lead Paint: No Test-LSWP Not Reg
Lead Source 0080 Store Associate..OLS �.,1 1/ 5
G 40C /y a0� (Li, tl/ hec
i
User Date Wine Status Corr. Appt.Date Appt.TimeConontaWlxd t
David Richter I 10115/2016. 5:48 PM:Measure Complete No 10/12/2016 1:00 PM'!Mark Newhouse 11
Cylhina Raglan 10/14/20161 1:17 PM Released to Production No 10/12/2016 1'.00 PM Mark Newhouse
_ ... _ 4.00
Cylhlna Raglan 10/14120161 1:14 PM Order Entry No 10/12/2016 1 00 PM Mark Newhouse
PM:
JASMINE FRANKS 1011 2/2016- 1:20 PM.GretlR Pending No 10112J2016 1'.04 PM:Mark Newhouse- r.
JASMINE FRANKS' 10/122016 120 PM11Saie Pending No 10/1212016 1:00 PMMark Newhouse
Dayend Dayend 1 10/12/2016 1200 PMISent to the Field No 10/12/2016 100 PM Mark Newhouse
NINA MCDUFF IE 10/12/2016' 11:55 AMConfrmed-Customer No 10/12/2016 100 PM Mark Newhouse
NINA MCDUFFlE 10/12/2016 1135 AM Pre-Book No 10'1212016 1:00 PAA Mark Newhouse
'Mark
Newhouse ..— ....
1011 412416' 1A9 PMiSlt No Sale No 10!101201@ 9:00 AMiMerk Newhouse
Dayend Dayend 1 10/10/2016 9:11PMISent to the Field No 10/11/2016 9:06 AM Mark Newhouse
es _.
'AOUILLA REED 10/10/20161 9:18 AMConfirmed C ( d-LaR Message No 10/11/2016 9:00 AM Mark Newhouse
CHMPMark
_ ..
'CHARLES WOMA 10/8/20161 4:50 Pre-gook No 10/11/2016 9:00 AM Newhousou e '.
COURTNEY HEtG 1 10/5/2016 7--12 PMileft Message No 1
AUBREY MITCHE 10/312016 750 PMlLeft Message No
Internet Lead '' 1013/20161 4:39 PM Lead Entered No
(lose I Print I
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
1> WlSg Sold.Furnished and Installed by:
Branch Name:New Eagland Date: /_/ TICAt-HomeServices.Inc.
d/b/a The Home Depot Al-Home Services
Branch Num 908 Boston Turnpike,Unit 1.Slums shiny,MA 01545
Toll Free$77-903-3768
Federal IDtl 7.5-269846n ME Lick C 0)439:RI Cont.Lica 16427
`` `` \` CT Tv4 HIC05655222..MA Home lmprovernet Cnntonnor Rag 4 136593
Installation.Address: 11 o1 As+)L -\"'noirMFA pIib is
City 5 to Zip
Pannoner(5): ware Phone: Home Phone: Cell Panne:
•
• 067 0\ 1 [ ] J 7 1 �
[ ] [ L ]
Home Address: � IIra"' NA
ewe �y A MA}, ppIafD
(ifdrtferent from Installation Address) J3 City State Zip
E-mail Address(to receive project communiutlons and Herne Depot update,).
I DO NOT wish to receive any marketing ernails from The Home Depot
Proieat Information: Undersigned(Tuafomer"),the owners of the property located at the abuse installation address,agrees to buy,
and THD At-Home Services.Inc.('The Home Deptsin agrees to furnish,denser and arrange for the installation("Installation")of
all materials described on the below and on the referenced Spec Sheens).all of which are incorporated into this Contract by this
reference.along with ally applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively.
'Contract"):
Job R: risme wn..we vhI Products: Spec Sheena)#: Project Amount
Ranting C]�diog D Windows O Insulation •
,C1.1 bb Donnan/c. DEntry Dean 0_ $ 1-iit
' DRoofing OSidieg 0 Windows D!natation
QGatten'Coma DErmr0.vra 0 R
°RoMng °Siding D Windows D Insulation I S
Demers/Cows DEary Doors D_ _
ORoofing °Siding 0 Windows 0 insulation --
Dower,/Givers DEnny Doors 0
Minimum Dye DepinfContast Amount due upon eanvtieo of fn canna.
Maine PuNmpa may notdmmltmm�tMrou 1Nnl et w CannmtAmapm Trod contract Amens g Litt
Customer epees that,immediately upon completion of the work for each Paduot,Customer will execute a Completion Certificate
(one for each Product as defined by an individual Spec Sheet)and pay any balance due As applicable each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home,Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,if The Home Depot or its authodzed service provider determines that it cannot perform its obligations due to a structural
problem with the home.environmental hazards such as mold,asbestos or lead paint,other safety emmmosz Pd cling errors Or because
work required to complete rine jab was not included in the Contract
Payment Summary: The Payment Summary Y 3 2 21 ° included as part of this Contract, sets forth the Inial
Contract amount and payments required for the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of the Contract at the this you sign- Do not sign a Completion Certificate(note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work nn that Product
is complete.
In the event of termination of this Contract Customer agrees to pay The Home Depot the costs of materials,labor,expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination,pins any other
amounts eel forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
NOTTING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agrees and understands that rhiu Agreement is the entire agreement between Customer
and The Home Dept with(egad to the Products and Installation services and supersedes all prior discussions and agreements.either
ral or written.Mating to said Products and installation.This Agreement cannot be assigned or amended except by a writing signed
by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read.understands)volunnNy accepts the
terms or and has received n copy of this Agreement.
Accepted by: I Submitted /�J��fj/
X .W.'l� °" ix /e"d. Gvs'!/G�- 9012-T-r)I�o
C tt*ner'ss Signanue Date j Sales Consultants Signature Date
X Telephone No. L)13 636 /535_1
Customer's Signature Dam Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS as appNcahla1
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAV AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMERS STATE.
NOTICE:ADDITIONAL TlRMSA,T1 CONDITIONS.ARE OTAIt ON THE REVERSE SIDE.AND ARF PART OF This CONTRACT
W-29.16 white-Branch File Yelow-CusMmet
Ii.
CS-088261
THOMAS M KELUHER
25 BEAUDRY AVE
CHICOPEE MA 01020
03 19 2015 1
The Commonwealth of Massachusetts
ry} Department of JndustrtaLAccidents
!1 E'i` 1 1„� I Congress Street,Suite 100
==r, Sac-m. ,yl.;n2Jad_ynJ7
www.mass.gov/dla
Workers'Compensation Insurance Affidavit:Budders/ContractorsiElectriciansrPlumhers.
TO DE FILED WITH THE PERMrrrrNO AUTHORITY.
Applicant Information i .1. + ��12 Please PrintntLegibly
Name (Business/O ganim )lionilndividual): � '-F ,rr )4J1f 411rif7czvtc€L'
er y
Address: (LC(/_ ''rjf;'? L—� 2? =
City/State/Zip:d /2 j_(A�, •
t''tf'*Phone tt:_...... :YI�I a ct,r-i'72
Are you an employes?Cheek the appropriate box:oType of project(required):
i am a employer with employees(MI and/or pawn-time)? 7. fl New construction
20 I am a sole proprietor or partnership and have no employees working for me in 8, O Remodeling
any capenity I No warkers'compinsurance req n:41
10Iamahomecwrierdoinall work myself No workers'com insuranceDemolition
n lpregnaad.i'
homeowner and will be hiringtoes to conduct as work on m=property [will
10� Building addition
to i am a
w
ensure that all contracture either have workers'
}s”compensauon insurance Cr are sole 11.Q Electrical repairs or additions
proprietors with no employees.
1 7. 0 Plumbing repairs or additions
5X1 am a general contractor and I have hired the submomrectors listed on the attached sheet.
These sub-contractors have employees and have workers comp.insurance. 17 Loof repairs
6.OWe ate a comorationand its oflteers harm exercised thea right of esepitfon per MGLc 14.(]O111er
152.51(4).and we have no employees.[No workers comp insurance required
^Anv applicant that checks tan xi must atm fill out the section below showing then srodiers utmpenrarbn policy information.
1 Homeowners tubo submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that clock Ins box must attached an additional sheet showing the name of the subcontractors and stale nhtthar or not those entities have
employees If the subcontractors have employees,they must provde their Workers'camp pollcy number
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. I ;(n ' i^'^ke
Insurance Company Name:fkeeert7 l A ✓=„`r- J-_.i _2 ' Cor 'policy __ 7
eor rl : r � � fl
Expiration Dale:
lobSite Address: / `Q} /'9gT- - _ CIry5wte/Lip:j}ilf
na1sl
. j./
Attach a py of the wokers'Mnpet policydkdapage(showing the .
policy number and ex f anon date).. e,
Failure to secure coverage as required under MOL 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 fine of up to$250.00 a
day against the violator.A copy ofthis statement may be forwarded to the Office of investigations of the DIA for insurance
coverage verification.
I do h- eby certif u de t --r'f!�,p-ena ties of perjury that the information provided above 's true and correct
l 2^ Jfl trent/� . Date: J k..-.....
SiPntlLure: ) 4122-7
phone#: a �t 2-7btt,
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Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License it
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 IP_
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 H Lost Card
Office of Consumer Affairs& Business 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 Plaza -Suite 5170
Expiration: 8/3/2018 Supplement Card Boston. MA 02 116
THD AT HOME SERVICES, INC.
THE HOME DEPOT AT HOME SERVICES
RICHARD TROIA
2455 PACES FERRY ROAD, HSC - — - - r 7
ATLANTA, GA 30339 Undersecretary \i o d without signature ---/
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A? `✓T? CERTIFICATE OF LIABILITY INSURANCE 1321102016
THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
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BELOW This CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S}, AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
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IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
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PROOUCCR CONTACT
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INDICATED. NOT•lVTHSTANOING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
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