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17C-091 (6) 120 CHESTNUT ST BP-2017-0842 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C-091 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Door Replacement BUILDING PERMIT Permit# BP-2017-0842 Project# JS-2017-000018 Est. Cost:$2588.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 092937 Lot Size(sq.ft): 7187.40 Owner: STEPHENS MICHAEL Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 120 CHESTNUT ST Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCERI02908 ISSUED ON:1/10/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 1 ENTRY DOOR 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 1/10/2017 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only 1,City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit '\ 6, ' 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability • I, __j N rthampton, MA 01060 Two Sets of Structural Plans phone 41 587-1240 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 IV ! 7 - Xya 1.1 Property Address: This section to be completed by office ^^77 //� �jh 1/ Map Lot Unit 1 O LJ�v r-�� Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: N') m6)174- l I $ 1' 46 IaUGhvvT � Name(Print) �ip�� pay A Cure attralle 1114-, 19 7 Z- CiF1//�/%/�i/ Tele onegn..'7 r/'/!/ // l/(pG� Signature 2.2 Authorized ent: A r�11+-- 4ak T q Irk- 7, /� Current Milling ddress: ` n' _,r4 9/ Signature Telephone IU-r/L--..5 ,,>"--'—o// S�//-- J[7L� SECTION 3-ESTIMATED CONSTRUCTION COSTS 7�� 7 Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building G/-7/ y0 (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 '/,l 6. Total=(1 +2+3+4+5) //51.[/(/ Check Number aO0� elD 6 This Section For Official Use Only Date Building Permit Number: — Issued: sr- Signature'. // � 6 /- / Building Commissioner/Inspector of Buildings Date Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Thi.column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg_Square Footage °o Open Space Footage (Lot area minus bldg&paved parking) of Parking Spaces Fill: (volume&4satian) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES 0 IF YES: enter Book Page and/or Document# 6. 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 El Addition ❑ Replacement W' ows Alterations) ❑ Roofing ❑ Or Doors Accessory Bldg. El Demolition ❑ New Signs [M] Decks_I Siding[p] Other Ip] Work: escdplion of Prof JEeyf T��� /!] YN�� Jam, )(2a -1. �T Aid ���G /�, Alteration of existing bedroom Yes iy No Adding new bedroom ''Ly YesY / ' 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 FORK BUILDING PERMIT tY)iebril J7Z (� ,as Owner of the subject propertypropertyhereby authorize 9i)(� rl#94 Vx2 �y) —Prnie to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner TIy��J Date C')`' Mt) P-172-‘2)4— ,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 ..• pen/es of perj j y. i t at G Pant Name 1 Air. l 17 Signature of Own- /Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: G61)3-Yq// 4:76 -937 License Number -74. Pea 4 hz< wXt L`✓ c -241 ) 7 Address Expiration Date i2hT Mfr. i,w � Signature Telephone iti9H-7? 7442-- 9.Registered Home Im rovemen Contractor: Not Applicable ❑ Company Name Registration Number T' Y' Add ess //'qq�//-- Expiration Date r - .fy ��///JJJi�,�n,��r 1,0 01.9A P 9Df.�* Z— / Tele hone 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 buildin permit. Signed Affidavit Attached 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 108.3.5.1. Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is.or is intended to be,a one or two family dwelling attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will he 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 he 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: //( �`'41t'r� �/ e,�' O4)42_ The debris will be transported by: /1,1/4,47eP1/0/2.( -2 )472- ,� // 11 The debris will be received by: M 0/2.( /�/ Building permit number: Name of Permit Applicant /9-0//)-- Date Signature of Permit Applicant Job Contacts Link Leads \- I ti _ \/' I Friday,December 16,2016 Comments Lead: 19735835 Go j Advanced Search 1:56 PM Info/Updates Homeowner Information Job Information Homeowner M/M Michael Stephens Sale Amount $2,588.00 Balance Due: $1,726.00 Commissions Homeowner2 Product Wincore Entry Doors(8%) Costs Job Site Address 120 Chestnut Street Status Sale/Order Received-PSG Documents FLORENCE, MA 01062 Branch Boston North Measure# 79847135 Sched Measure County HAMPSHIRE Salsal . Billing Address 120 Chestnut Street 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 (908)256-3920 Work Phone Ext. B-Back: No Cross Refit 1-9287364583 Siebel Ord... 122185 Order Entry Cell Phone Key Dates - - Work Phone 2 Sale Date 12/72016 FUP Date Payments Cell Phone 2 Credit Date 12/7/2016 FPD-Customer Permits Email MJstephens22Qgmail.com RTP Date 12/14/2016 Post Install Date PO Cross Street Start Date FPO-Home Depot MarketingInspection Result Combo Referral Store 8452-HADLEY Job Indicate., Services Base Store 8452-HADLEY Lead Paint:Assumed-LSWP Requir Show Map Lead Source 0080 Store Associate-OLS f (.).Y‘.____.) \\ Y Touch Points `N. w �� Update Job Work OrdersUser ',Dale Time 1StatusjCorrlAppt Date .: Time Consultant1 _',. Erikka M Lewis 12/16/2016 8:11 AM Order Received-PSG No j 12/7/2016 8:00 AM Timothy Drost Cythina Raglin 12/14/20161 3:18 PM Released to Production No 12/7/2016 8:00 AM Timothy Drost __— i Cythina Raglin 12/142016 3:11 PM Order Entry No 1 12/7/2016 8:00 AM Timothy Drost _-_ ')Timothy Drost 12/82016 5:06 AM Credit Pending No 1 12/7/2016 8:00 AM Timothy Drost 'Timothy Drost 12/8/2016 5:06 AM Sale Pending No 12/7/2016 - 8:00 AM Timothy Drost Dayentl Dayend 12/6/2016] 9:15 PM Sent to the Field No 12/7/2016 8:00 AM Timothy Drost Tiffany R Samuels 121520161 8:02 PM Confirmed-Leff Message No 12!7/2016 8:00 AM Timothy Drost !Internet Lead 12/12016', 9:34 AM Pre-Book No 12)7/2016 8:00 AM Timothy Drost !Internet Lead 12/12016 9:34 AM Lead Entered No Close I Print I HOME IMPROVEMENT CONTRACT PLEASE READ THIS II -- Sold,Furnished am Installed by-. Branch Name;New England Date:I 7/ [V TED Al-Home Services,Inc. d'Nn The Home Depot At-Home Services Branch Number.33 908 Boston Turnpike,Unit 1,Shrewsbury.MA 0.545 Toll Free Sr-903-17S Fede.ID a 75.289146 9;ME Lie C 02439;RI Con:._ie.ltior Cr Lie tl HIC0565322:MA Home Improvermat Con ator Reg 0 126493 Installation Adana: 171 , (TH€f-T�k\t t'{' S� Eft &D N,Csheri Cary Stam Zip Purchasrlai: Work Mom: Home Phone: Cell Phone: 11 1 .l -kG I I [ 1 II I Hume Address: (If different thorn Installation Address) City State Zip E-mail Address(:0 receive project communications and Home Depen iodates Pi _ I DO NOT wish to receive ray marketing ecm'Js Prem The Home Depot - -- - - Project infnrmarian: Undersigned("Customer"h the owners otthe property located at the above inzmllmion address ages td buy, and THD At-Home Serrfcs Inc.("The Home Depot")ogees to furnish,deriver and arrange for the institution('lnstalim 'ioncf n aU nmrials Jest ihd one below and on the referenced Spec Shect(sl,all of which are o:pnmmd into drs Contracr by alis reference.along wit any epplieable State Supplement and Payment Summary eta ed Lento and any Change Ordets(collie:ively, "Contract'): Job Y', oarrnaw...., Products: Spec Sheets)M: _ PrejectAmount , • ■Reounp SINrt ■willows[3,Insulation - I Demers/Covers,' aryDoors 7SFL Rooting ❑Siding ■Windows trisection 0Cuttert(Covers ❑Etary Rao"' 0 _ Rmtiag ■S:diag ❑Windows IS[osu:Rion - -- D€wtem/Coven DEotry Doors Fl -_ S ■Roofing •Siding ■Wincows ■Insulmin 1 ❑Lunen/Covers DatilDoors ❑ - S magnum 25%Deposit of ContactAmountdoe upon enwdonefte contract I Maiaepssn unbaAmy natdepmilmcee than oupTirdoftt ContraciAmaunt ' Tolal CourrM.4mouot $ Ste., C_ Customer(-gmes that, immediately'uporcompletion of the work for each?roduct Customer will execute a Cetrplcion Certificate Cone for each Product as defined by an individual Spec Sheet)and pay an> balance due_ As applicable,each Customer under this Contact agars to bejaitaly and severally obligated and Boole hereunder. The,gone Depot reserves the right to issue a Change Order orteem inme this Contact or any individual Products"included besia at its discretion.if The Home Depot or its whetted service provider determines that is cannot pettorm Es obligations clue to a structural trot lem with the home,environmental hazards such as meld,asoctos or lead paint,other safety consras,pricing errors or base work required to complete the job was not included in the Contract. "�� Payment Summary: The Payment Summary# I-33 r SOC mcludcd as part of this Contract, sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER Yon are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign n Completion Certificate(note: there is one Completion Certileote for retch listed Products defined by indisidual Spec Sheen)before work on that Product .s 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 dale of termination,plus ally other amounts set forth in this Agreement or allowed under applicable Ian. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE. WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SLCH AMOUNTS. A race and Aum n - Customer Junderstands thatthis A. entire g betweenCustomer and The Home Depot with regard the Products and Ins tatoand supersedes aII prior and agra. sinter servicesrcended es oral carcn,e, eg[oseiD pt.Cusamtr anog :13grhennaPc oerhase cad nderttexceptbyn lyaccros the by Cu eine iner and The Home p> o'_ is Aomtt acknowledges antl agrees that Customer has rend.understands.tdnnwrily:teems the terms o-:rad Its received a cavy of this Agreement. A by: Submitted by: ` Customer's Signature Date Sales Consallant's Signature Date X TelephoneNo. -. Customer's Siennure Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS Ia ePpt ablel AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME ` ci DEPOT BY MIDNIGHT ON THE THIRD BUSINESS `��) / DAY AFI ER SIGNING THIS AGREEMENT. THE J STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE if ONE IS , SPECIFICALLY PRESCRIBED BY LAW----ttti— CI ISTOMER'S STATE. lid d17Z:80 9 U Z L Pea .a ry -Yv%ec y c d'ds+5t L%# 9 Massachusetts - Department of Public Safety Board of Building Regulations and Stan.. dards License: CS-092937 i -,t ! e4 F \14 s SLAV MOICAN El 43 SAA BR s t _.. WESTFIELD M* #I , f �9 et r 4 9t. .�•....�" i+ )l ifs Expiration Conwntsswner Ac0 CERTIFICATE OF LIABILITY INSURANCE DATE(Mals 9 1/44.--r° 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(SI, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policyfies)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 endorsementls). PRODUCER CONTACT MARSH USA INC. NAME: TWO ALLIANCE CENTER -I44644Pk�d __ .. —E FAX Mol 3E% LE1106 ROAD SUITE 24% EMAIL ATLANTA GA 35325 AOGRESS INSURERMI AFFORDING COVERAGE NAIL N_ 100492-HOmeCGAW5I6-17 INSURER A:SIeaJ(di1Insurance Cgmplly 26351 INSURED INSURER B'ZUKA American InsUrence Co 116535 HD4 -NOME SERVICES INC New Hampshire Co123841 OSATHE HOMI DE0 AT-HOME SERVICES INSURER C' ps _ __ _ 2690 CUMBERLAND PARKWAY SUITE 365 INSURER D:Illinois National Insurance Company 23817 ATLANTA GA 30339 — -_ INSURERE:INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003746€48-14 REVISION NUMBER:8 THIS 15 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. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ /NSR ADDLBR' I POLICY EFF I POLICY UPi )ND POLICY NUMBER 1IMMIDDNY05 IMMWYYI' TYYLIMITS LTR TYPE OF INSURANCE SD WV A X COMMERCIAL GENERAL LIABILITY GL04BB111496 .0310112016 0310112117 ',_EACH OCCURRENCE IS 9,1.00,00 ,DAMAGE TO RENTED G•AMSMAOE X OCCUR PREMISES LEawTegel 5 11�" ,000 _. _ LIMITS CF POLICY XSMED EXP(Any one perwm S EXCLUDED OF SIR SIM PER OCC PERSONAL&ACV INJURY 'S _ 9,%8080 E1/! aC _LIMIT AP ES PER ' GENERAL AGGREGATE 1 s 9,000.030 X PGI R... _ Loc PRODUCTS S 9000,500 _.HER. s B AUTOMOBILE LIABILITY BAP 2938%3-13 ,03/01/2716 0310112017 'cGMemeD SNGLE LIMIT s 1,900.505 lga awdRnn X -NY-AUTO e001Lv INJURY(Per person _ u DWE� SCHEDULEDc -_ L INSUREDAUTOn INJURY(Per euulm p S -_ ,U DS _.AUTJWn2] PROPERTY DAMAGE HIRER.AUTOS AUTOS • I 1P?r acaccident) IS UMBRELLA LIAR OCCUR. 'EACH OCCURRErv_CE S EXCESS LIAR CLMMSMACE AGGREGATE IS DED RETENTION H o WORKERS cOMPExsanONax IwC015519215(A05) 'p310112016 :0319112011 X iSSTATUTE3 ERH I AND EMPLOYERS' PRIETORiPA alum IWC01551921] AK,KY,NHNJ I03NV2016 ''.0.3101/211) C ANY RO REroR'EXCLUDED, JT./ VIN ( VC 'EL EACH ACCIDENT 'S 1,099,990 D OFFICER/MEMBER Fn NE E wmo N I'xlA %5015519218 FL 103101/2016 1030112017 000 (Mandatory nNH) ( 1 E.L.1__ DISEASE-EA EMPLOVEq.S 1,500, Ii yea.aesanoe under Comleued on Addannal Pa I1090,030 'DESCRIPTION OF OPERATIONS oelow 9E , I E L DISEASE.POLICY LIMIT is DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remelts Sceaaue.may he attached Ft more space Is required) VIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION T'^D A:-HOME SERVICES.INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DEA THE LOME DEPOT A`-HOME SERVICES THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN 2415 PACES FERRY?EAD ACCORDANCE WITH THE POLICY PROVISIONS. AT_NTA,GA 30339 AUTHOR2ED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee 23341345%..aov 551,&s2cw4w41e/- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD �.. The Commonwealth of Massachusetts t• � = Department of Industrial Accidents • I Congress Street,Suite 100 ea Rncrn.r, "492114-2017 '-�-- www.nmss.gov/dice Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information -� �J i1. Please Print Legibly y` Name Business/Oreanization/lndiv�iduuap:�J 'Qjfj"1� tlE fIL-'�� ;43--T t l_J ;f2tV)a:_ • Address: ( t-/ r/ l'Z/ 2 I�l / till •'d J � City/Slate/Zip:. tai ,7 Are you on employer?Check the appropriate box: Type of project(required): LQ [am a employer with employees(full and/or pan-time)` 7. ❑New construction LEI I am a sole propnelor or pannership and have no employees workingfor any capacity [No workers coma insurance required] me in 8. El Remodeling 9- ❑Demolition 3 I am a homeowner doing all work;nysdf No workers'compinsurancealui cdl' A.❑I am a homeowner and wprsoe ill be hiring contractors to conduct all work on myn . I will 100 Building addition ensure mat all contractors either have workers'compensation r penzauoninsurance or are sole 11.0 Electrical repairs or additions P iotas with no e;nPlowees. roar 1?. Plumbing repairs or additions i .lam a general contractor and I have hued the sub-contractors listed on the attached sheet. These subconnactors have employees and have workers'comp. insurance.: 13.�/ROo(repairs lJ 6❑Wcorporation and its oil Odle kers hove exercised maty ri ht of exemption MGL c 14.2 they 9 (O.andwe haven0 employees 1 .[No workers'comps insurance required.] . I� 'Any applicant dim checks box 41 must also tin out the section below showing their workers'compensation policy information. r Homeowners who submit this affidavit indicating they are doing all work and then hire ouaide contractors must submit a new aff tdavit indicating such. :Contactors that check this box must attached an additional sheet showing the name or the sub-contractors 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. A y r Insurance Company Nine: f V�ik 1+1^ 7 _1/v1-7 (�y Policy ti or Self-ins.Lic.#: f f&^ i�7!J n / -. ) r 1 - � � �r� --l'J -(� Expiration Dale: ��/� 01202- Attach She Address: ) 20 L�'J / s//✓t'✓� '/ City/State/Zip:.gd�`Ynei � - 17&b2i Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hqt certif a de tGe�g�e/rs an' penalties of perjury that the information provided above is true and correect.t. Signature'. �f Date: 12-- r /"� Phoned: . I2_-b"j'/,!/ Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone ft: 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 i Employment I 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 02116 _ THO AT HOME SERVICES. INC. THE HOME DEPOT AT HOME SERVICES RICHARD TROIA 2455 PACES FERRY ROAD, HSC - -- , j �i ATL ANTA, GA 30339 ° �T r '°" ` --- undersecretary of valid without signature 'i 4 ai ioasn`A.4add,as II ti I Ii /-2-i'-; A II o5- C V ��?taint=_ i _ -=171. a iiz:_- _ , -1::"G'es_ - -Lo, c.No La...,,ze G't= I 7, 7t�; „ = it Wine I • =sa`, ii -•--ry_e&isle euikene-Wilo-:'f8 mrmn5d:io-keen-Lost-Si= - e -_Gess ir Vorc_.irrsdo-Gan C'Ses i CPG.S3P-.. 21:342-0:30C2 07-75 GI-III 1 ENERGYA iQ 0F9aPMENTQ RATING-; !I 1fvuta�bfi LIZG1`it71ii11Gi.11 E'�Ll,-'EI��iQ !� il 1170'._l 4: .5 .. 0:24 :I a pL7ii[(}~t_i LR:F��RP.4R1�C-"GRf--.��IGw . E MWJtClaili ESLesmereee.GE RENOW IEIffia T. 045 i • 1 v = -s" .-,f."" .2e.e ei .S=monis) il�serr - ;I `^Y`-z1"�z `--,- u Mom Cons*South Cenral 1l :� r1 .g' Seven e'�iY,' rC�e Inl e:?tele 061Gass o,-oSe)srM-LGSE Testae SY2:48"h ail" il Il Ii i II !':;fids Pruducb'eeprav'ei:FLS iEY iI I', 11 ii ._ IIi i 4 aeanraaeTzmtS�tcerjsi- mNaliA-a1N,.it. :OAWflS2---r iiPdWDn?JCS.", it 1 naSJk=-B05.Ak0iKIRDS/INCS.M4e1S3A441-06. II A!GS1.0e.G_n_cer:Sup I 11 i III 835E720101 ;03333 HS Hoearii 6400324A 1I II