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35-157 (8) 824 RYAN RD BP-2017-0605 GIS 4: COMMONWEALTH OF MASSACHUSETTS Map:Block:35 - 157 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:window replaced BUILDING PERMIT Permit BP-2017-0605 Project# JS-2017-000982 Est.Cost: $2644.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 67121 Lot Size(sq. it): 47044.80 Owner: APOLINARIO JILL Zoning: Applicant: HOME DEPOT AT HOME SERVICES AT: 824 RYAN RD Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCERI02908 ISSUED ON:II/I/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 6 REPLACEMENT BASEMENT WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: _ Date Paid: Amount: Building 11/1/20160:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only /'� _ 'r, ) City of Northampton Status of Permit: U�! wilding Department Curb Gut/Driveway Permit i 3 q` .5 212MainStreetSewer/Septic Availability \`\ )' / Room 100 Water/Weil Availability _ orthampton, MA 01060 Two Sets of Structural Plans ` • ne 13-587-1240 Fax 413-587-1272 PloUSite Pians \\.., Other Specify — APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A' ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 6 i�/g' Dto'.7 1.1 Properly Address: This section to be completed by office - ,;q fl [^ Map Lot Unit "/Z% Plc Pb Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: JILL A-22Lm'r-n219 �4/u7..V.$4.0471) �p R0124-41/E4- Name(P � li i '// �y/,/(� telephone Signature • nnn... rIr 2.2 Authodzid ent: / i qo ,/ bee /PX- 94 ��LL//�/14 Current Mailing Address: - 3/3S2- )04-, )mss Sigma[ re ( ypJh�Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed/� 94/ - ' by1permit applicant 1. Building Z(e / 1 J - �Q (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 )/' / ,/ _ 6. Total= (1 +2+3+4+5) Z42 `� - U© /}�Check Number / 7 � 0yf/ / This Section For Official Use Only Date Building Permit Number: Issued: Signature:/j K ./ /G 6 / t+ Building ommissionerllnspector of Buildings Date Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage I Open Space Footage tni area minas bldg&paced ',arising) c of Parking Spaces Fill'. Profane&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document# 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 doves Alteration(s) D Roofing ❑ Dr Doors Accessory Bldg. ❑ Demolition ❑ New Signs [Cl QQ Decks ]lam Siding[Cl Other KM] 4CQi1 m le/ f Brief Descripttn rgp set �/ry,.y�yyr fJ//M / %' 7 OUi rL/ �/ a, Work: //�/VV ��l��J!`` GG��K--`YU-I''�l N U Ill Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a Use of building:One Family Two Family _Other b. Number of rooms 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 BUILDING7PERMIT Jib / 2— x )7oLi /F R)!/ ,as Owner of the subject property hereby authorize to act on my behalf, in all matters re tij0 work authorized by this buildingf permit application. eir-71/ GIM-ei Signature of Owner I\) J ) yD�atte I, 1 c / 7/O/ ,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 pain ,d pena es of per7uty. / A GAJ-\� / Print Name''-- /9 13L /4 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable c❑ Name of License Holder1h/�/' t/ yma / 6.6o—0b7/.2-) License License Number kiiiInt3/2A9X, Li Address Expiration Date w(/,TRR�v Mk. 6 /9 Signature Telephone 1f9) - hZ� y3 ' 9.Registered Home Improvement Con ractor: Not Applicable ❑ ) 493 Company Namey�., Registration Number 90/ )/0,211-rn ' Address yl, �y^7��j)332-- SECTION Dale a� Telephone90323 } Expiration SECTION 10-WORKERSCOMPENSATION 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 issuan ' ing permit. Signed Affidavit At ched Yes ❑ 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 108.33.1. 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 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 may 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, S150A. Address of the work: / 44 V P_,13 C1 b �`� ' The debris will be transported by: W11" E-- o ©leZ The debris will be received by: W ,6��GS1-- in Building permit number: el �� a � Name of Permit Applicant el'f1 `�/ /41 Date Date Signature of Permit Applicant Job Contacts wJ , ...`7i✓L Friday,October 21,2016 Comments Lead: 19628558 Go I Advanced Search 3:10 PM Info/Updates Homeowner Information Job Information Homeowner Ms.Jill apolinaria Sale Amount $2.644.00 Balance Due: $2,000.00 Commissions Homeowner2 Product 6500/6100 Series Windows(8%) Costs Job Site Address 824 Ryan rd. Status Sale/Order Received-PSG FLORENCE.MA 01062 Branch Boston North Documents Measure# 78996280 Sched Measure County HAMPSHIRE Sales Billing Address 824 Ryan rd. Commission Rate Homeowner FLORENCE,MA 01062 Consultant Name Term Date Split Comp Plan Job Issues Timothy Drost 100.00%Straight Commission Order Detail Primary Phone (413)336-5252 Work Phone Ext. B-Back: No Cross Ref# 1-8976767942 Siebel Ord... 118316 Order Entry Cell Phone Key Dates Work Phone 2 Sale Date 10/14/2016 FUP Date Payments Cell Phone 2 Credit Date 10/14/2016 FPD-Customer Permits Email lillapollo@comcastnet RTP Date 10/17/2016 Post Install Date Cross Street Start Date FPD-Home Depot PO Inspection Marketing Result Combo Referral Store 8452-HADLEY Job Indicators Services Base Store 8452-HADLEY Lead Paint:Assumed-LSWP Reguir Lead Source 0080 Store Associate-OLS Show Map 1 \) TouchPoints "`� Update Job User Date Time Status Cort. Appt.Date Appt.Time Consultant 1 Work Orders PETER TALBOT 1012012016 5:42 PM Order Received-PSG No 10/14/2016 12:00 PMiTimcthy Drost PETER TALBOT 10/20/2016 5:42 PM Measure Complete No 10/14/2016 12:00 PMTimothy Drost Mary Harris 10/17/2016. 11:56 AM Released to Production No 10/14/2016 12:00 PMTimothy Drost Mary Harris 10/17/2016. 11:53 AM Order Entry No 10/14/2016. 12:00 PM Timothy Drost Timothy Drost 10/14/2016 1:26 PM Credit Pending No 10/14/2016. 12:00 PM Timothy Drost Timothy Drost 10/14/2016 1:26 PM Sale Pending No 10/14/2016 12:00 PM Timothy Drost Dayend Dayend 10/13/2016 9:08 PM Sent to the Field No 10/14/2016. 12:00 PMFTimothy Drost TYRUS RUSSELL 10/13/2016 10:41 AM Confirmed-Left Message No 10/14/2016 12.00 PM Timothy Drost Internet Lead 10/9/2016 1:20 PM Pre-Book No 10/14/2016 12:00 PM Timothy Drost Internet Lead 10/9/2016 1:20 PM Lead Entered No Close I Print I a 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: Jill apolinario 9628558 First Name Last Name Branch Name Lead s 824 Ryan rd. FLORENCE MA 01062 Customer Address City State Zip _ (413) 336-5252 Home Phones Work Phone# Cell Phone# jillapollo@comcast.net 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 10/14/2016 Customers Signature Otte 1 Distribution: White-Home Depot Yellow-Customer Copy WINDOW SPECIFICATION SHEET - Spea.Sheet tr. 9628558 sheet. 1 of 1 Customer Jill apollnano Job N: 9628558 Consultant. Timothy Drool Date 10/1012016 New Window Hinge LocationsExisting Window MeasrreTens Grids Product ptic a L¢Wr Opilo c 0 fto ide. Le Right Says.Bowls Location Color Rough Opening a of bars p of bars Coons,1 Pnl, use L.R Glass Misc hews Hardware Code Screens For doors we m Mull "S nary or w Style Wraps _ a _ g .15 I= g 'q� z — i �v .x'So aerating Room Floor Code (VTR Code Series Code w R x 5 w > x > > 1 BSMT Pascoe OH RH 6100 'NH 33.00 13 DO 46 3 SWAT Berea> BH BH 6100 33 0° 13 0.0 STD.Gla6aPaa Standard Lsn 4 BSMT Baseme BR BH 6100 Ron In nil 46 s IL} Siondard !SR 5 BSMT Baseme B11 BH 61.00 ere RR 13 00 es nt e Born ElaSeille. 6101) gip 33 00 1.3 00 06 • SPECIAL CONSIDERATIONS'. Wrap Color white Manor Casing Type Bay or Bow window Seatboard material(vinyl only-Birch or Oak) Bay Project Angle OC w15) Bay Flanker Type(DH,SR or event) Top of window to soffit(inches) I bed to wife color of song material I nave reviewed and agree web all the lob speoficauons above and the :Destruct Roof(Yes or Nn)' Special Terms and condemns on the mnawrng page Garden Window Seatboard Material(vinyl only-White Pion,te Birch Of Oak) Nall Thickness(inches) Customer Signature Addreonal Shell(Yes or Not 'There is no guarantee that new shingles will match ea5tlgg color. DA ACORD CERTIFICATE OF LIABILITY INSURANCE 02�118Q0t6 n THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ONTACT MARSH RU$ INCNAME: PHONE ONO ALLIANCE . BL b 14/c,Noll 3 ; ROAD.SUITE 24C2 MIL ADDRESS ATLANTA.CA 32325 _- INSURER(S)AFFORDING COVERAGE NAIL A_ 11] ob40,Frt2G6F 41'='o-1i INSURER A:$IBMIId511n5pldllCe Onmpaly ]EIB] INSURED INSURER B:5001 61111566nlnsuR858 CO 06535 THO E REPLACES.INC DBA THE HOME DEPO-Air-HO ME SERVICES INSURER C:New Hampsldm Ins C0 i23841 2005UMIBERLAND PARNLIAY.SUITE 326 INSURER O:IIIInoIs Normal Insurance Company 123917 TLLATA.2A 3933.E INSURER E: r I INSURER F: F COVERAGES CERTIFICATE NUMBER: ATL-0374664614 REVISION NUMBER:8 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, Lr TYPE OF INSURANCE wso wv0 POLICY NUMBER EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN6R 9999. - I IAMMOCDIYYYN:IMNDDTYYYY1 UNITS A -Y._ COMMERCIAL GENERAL LIABILITY GLO4a8714-05 03101/2019 .0310112017 EACH OCCURRENCE i s 9,900.309 I DAMAGE TO RENTED _ 1.000.000 PREMISES{Ea occurrence) LIMITS CF POLIS%X$ MED=_'cP ucy one;mom EXCLUDED S OFSIR.SIM PER CCC PERSONAL ADP INJURY 9'900.000 GENERAL AGGREGATE S 9880,000 PRODUCTS-COMP/OR AEG I5 - 9.080,000 is G AUTOMOBILE LIABLLITY BAP 293556313 03111112015 010112017 :6EOIJ iNvt51NGLE LIMIT S 1090900 AUTO I BODILY IN URY(Perpe(sonl :3 RIES O ' 2.-Hisousin SELF INSURED AUTO PH?DMG i BOORT INJURY(Per acddet l!,S .. LIENLEVANED PROPERTY DAMAGE HIRED AUTOSU i OP (Per acc em1 UMBRELLA LJAB OCCUR • EACH OCCURRENCE EXCESS LAB CLANS-MADE : AGGREGATE .-• _ 010 RETENTIONS - C WORKERS COMPENSATOR IWC0i5519215(NOS) 103101)2015 10311)112917 j X STATUTE j1 oW(rH- ANO EMPLOYERS'LABILnV I iyC1)15$19$17 AN,H1',RH i1Jr :931012015 103/011201] "'SO RTMERN ECU /E VifN NIA ( .m 'EL EACH ACCIDENT IS 1.000,000 O Imn�a 4/p% 'HO015519216(FL) °31°11221)15 .094/112017 I EL.DISEASE.EA EMPLOYEE S 1000,000 DESCRIPTION OF OPERATIONS o2Cu Canimued On MO16on21 Page I EL.DISEASE-POLICY LIMIT 13 1,0]0'001) DESCRIPTION OF OPERATONS I LOCATONS I VEHICLES IACORD 101,Additional Remaras Schedule.may be attached it more spare is equited) EVIDENCE OP INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES.INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE SEA THE HOME DEPOT ATHCME SERVICES THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. _FAIT CA 30339 AUTHORIZED REPRESENTATVE of Marsh USA Inc. Manashi MUkbe9ee -SlaNnm6.: Nnu-4 F"-icr-F- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts F Department of Industrial Accidents 1 Congress Street, Suite 100 ATA ()I iln_Mly www.mass gov/ilia Workers'Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information 1 Please Print Legibly Name(BusineseOrgan-zaronil di stool): HtJfnC i,/1•- d/) Address: (ig;.fr3/9. /9L /Gift- U -ice— City/StateiZlpL)iyyk2-2,tGnt P)) 'b// hone4: :27,1).4-6/z2._zj� Z- re you anemployer?Check Inc appropriate box: Type of project(required): 1-0 l am a employer with employees(full and/or pan-times.' 7- n New construction 2 I an;a sole proprietor or partnership and have no employees working for me in $. ❑ Remodeling any capacity [No workers)compinsurance required.) 9. 5n am a homeowner dome all work myself[No workers'comp.insurance required.l' Demolition 10 n Building addition a..n l amahomeowncr and will be hiring contractors to condnn all work onmy propeny I will ensure that all contractors either have workers'compensation insurance or are sole II.Q Electrical repairs oradditions proprietors with no employees. 12.❑Plumbing repairs or additions i _. '_ andi t r d hed se.r I iQRoof repairs hese ` employeesor(have p 1I00lherp �2)y''aKK E :mpd d is oil 1 he exercised theirreof exemption MGL e. 52,200.aid wahaveno employees.[No workers'compinsurance required-1 eAne applicant dust checks box=1 must also 011 out the section blow simwine their workers compensation policy information Homeowners whosubmit this affidavit indicating they are doing all work and ben hire outside contractors must submit a new affidavit indicating such. :Contsu ractors that check this box must attached an additional sheet showing the none oldie subcontractors and nate whether or not those entities have If tsub-contractors have employees they must provide their wcomp.policy number. I ane-an enrp/oyer that is providing workers'compensation insurance for nn:employees. Below is the policy and job site information.Insurance Company Name: I I/qq '� C] _ /Policy (if or Self ins. Lia 4: ):(16,—/�,��yr�"�7,��J lye )� _ Expiration Date � )" �)�1�r` Job Site Address: 41574 (F'—Y14 fl Cit)/Stme/Zip:pf�„4jyVr_ Attach a copy or the workers' comae see tion policy declaration page(showing the policy number and expiration date). 9/9 _. Failure to secure coverage as required under MOL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 C� 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 orchis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ,- I do herby ecu /f adae t an''hpe�ndities of perjury Mal the information provided �above is/ruee and correct. Signature: ./ h2--- - / ��jj Date: 1// /:/ 7�i Phone.` .14 6/h2--^dj'C)7Z Official use only. Do rust write in this area,to be completed by city or town official. City or Town: _Permit/License k _ Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 3.Plumbing Inspector 6.Other I Contact Person: Phone#: __. ._I. ,. . . il ;".o0a]ee ear_,. o.. 2220b AIO"c_33E2 •• . II - - tdelSilzure7�� ''c0as7 ' I' '57th,1 511'.01VSC RGATy-,APThr-_13-.1@t:W.eiii0i ;iE�",YSCNl u'Ie�Y-�E"i. . 4@%' tti2i�tr-rte:1�3i . :S_^a•= g-'ia+c2aaeert ii I II !, . lI ii 1', • 'i I, I, L i.. II (�S- ¢—I �T IcariPyro:o2 5 .J(000Pv:VIIV. . _i. L:-. 6Z-I019 :.w ;,tilit v.. 7 -- - k I?-4USO t noS'ter)1401,2 - u - 5-x_v i -~ �r, "w`aw (Slump_J_ is .m -f A iv io m1 nb (1 _ "F _ Aer r zr. - •I II i'( ora'@RsgisikIa Re:Y1='6ii k il6 itlD'f_.fiT'P3 _ 93N1i tuy -,JljiliI'r'Iu_, 1 ='illj1 ;i1iQri l C- 1• D0;!S_:--21'1 v:.N?CiQfl ea-C i;qiO=i:e: .. l s-3NI <s_:::.'..CIW1it,103- =d A£:ca_M ii 1✓G,a' =1o; s o- - iSe.JnEi 1: ___ i _ Il . - v — Office of CO Si:f .eti Affairs and Business Regulation 10 Park ?:azo. - Suite 5170 ':acstcn, Massachusetts 02116 Home lincp o>>e_a eut Contractor Registration Registration: 126893 Type: Supplement Card Expiration: 8/3/2018 THD AT HOME SERVICES, INC. RICHARD TROIA 2455 PACES FERRY ROAD, HSC 0-11 ATLANTA, GA 30339 Update Address and return card.Mark reason for change. Address Renewal - Employment ! Lost Card • • Office of Consumer Affairs& Rosiness Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If t'ound return to: °Mee of Consumer Affairs and Business Regulation Registration: 126893 Type: ;; r]c aPlaza Plat u -Suite 5170 Expiration: 8/3/2018 Supplement Card C3oswa. MA 02(16 THD AT HOME SERVICES, INC. THE HOME DEPOT AT HOME SERVICES RICHARD TROIA '-� 2455 PACES FERRY ROAD, HSC • - - - - • (/!/�/ ATLANTA, GA 30339 lZ 41 T,L-�.%• Undersecretary PTht valid without sgiu duce BRIAN C THOMPSON 38 WILLOWBROOK LANE TSTFtEL[; M 1' 1D8