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12C-091 (5) 5 RICK DR BP-2017-0903 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12C-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: window replaced BUILDING PERMIT Permit# BP-2017-0903 Project# JS-2017-001534 Est.Cost: $6981.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 99209 Lot Size(sq. ft.): 10585.08 Owner: MISTERKA KENNETH& LINDA M zoning: RI(l 00)/URA( 00)/WSPU 00 Applicant: HOME DEPOT AT HOME SERVICES AT. 5 RICK DR ApplicantAddress: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCER102908 ISSUED ON.112712017 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: 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 1/2720170:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner C Department use only 'City of Northampton Status of Permit: ,,, Building Department Curb CutlDmerway Perms RI 212 Main Street Sewer/Septic Availability �� Room 100 WaterrWell Availability Northampton, MA 01060 Two Sets of Structural Plans \� phone 413-587-1240 Fax 413-587-1272 PlottSde Pians Other Spectly,_ APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR A ONE OR TWO FAMILY DWELLING SECTION t -S1TE INFORMATION - 9/�^JpJ17- q6 ,33 t.i Property Address: ` This section to be completed by office Map - Lot—Unit--.— Zone olUnit__.ZoneOverlay District,_,_____, Elm Sc District Ce District SECTION 2-PROPERTY OWNERSHIPtAUTHORiZED AGENT 2,1 Owrter of Record' Name(�P.�enit)� Cuoe _ LLTL-. ✓/�l— —Y it Telepfion ��_ (sL � G/ _ S:pnahre 23�ri. dAgent' .,� ��-- Nam Current Mailing Address Signatre SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost{Doiiars)w be Official Use Only completed b emifl apPlcant _ _ f. S.4dmg (a)Builten t Permit Fee 2. Electrical (b)Estimated Total Cost of Construction From 8 3. Plumbing Building Permit Fee 4, Mechanical(HVAC) 5.Fire Protection 6. Total= (1 +2+3+4+5) Check Number (Jy, This Section For Official Use Only ate Building Permit Number: ssv Signature'. 7 Budding CommissionedInspeet e at Redrings Cats �a*�e.CeeK �T�ct.zi�e � Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column no be filled in by Building Detriment Lot SIZe Frontage Setbacks Front Side L: RL: R: Rear Building Height Bldg. Squire Footage Open Space Footage (Lot rrca minuF bldg&retire ,king) of Parking Sp.... Fil6 (volume&Lawtinn) 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 N 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 obtafned 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 II applicable) New House ❑ Addition ❑ Replacement IgIi. Alteration(s) ❑ Roofing ❑ er Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[0] Brief Descriptio�n sort 15" work: l/Y%7//TL CI K./ @oLY✓L/RY/T6 r 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 Fari 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 constmcton. Dimensions e. Number of stories? L Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction 1. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain_Yes No I, 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRRA�{-C-�TOR APPLIES FOR BUILDING PERMIT I. as Owner of the subject property hereby authorize to act on my behalf, in a matt/e�rs relative to work authorized by this building permit ap I' attii-o7n. �f l Q71�/W l ' ✓ Slgnalure of Owner Dale � �, as OwnerlAuthonzed 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 and pain and penalties of perjury. I }zo one Name Signature of VwKinrA6ent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Sucervi - Not Applica le ❑ Name of License Holder. �/'r �� � —'4��///� License Number Adtlres Expiration Date Signature Telephone 8.Re is[t Home Im rovement Contractor: Not Applicable ❑ Com Mame c Registration Number e Add si{-'�/ �/,��� /� ) Expiration Dale "r?//75 A/ U � 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 th permit. Signed Affidavit Ada es_..... ❑ No...... ❑ 11. - Home Owner Exemption The current exemption for 'homeowners"was extended to include Owner-occupied Dwellings of one(I I or nroi families and to allow such homeowner to engage an individual f)r hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Seefion 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which helsbe resides or intends to reside,on which there s.or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use amb or farm strictures.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 Conn acceptable to the Building Official,that he/she shall be responsible far all such work perfprmed under the building permit. As acting Construction Supervisor your presence on thejob site will be required from time to time,during and upon Complefimt oflhe work for Which thispermit is issued- Also be advised that with reference to Chapter 152(M orkers Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)ofthe Massachusetts General Laws Annotated. on may he liable for person(s) you hire to perform work for you under this panni[ The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and I oval Zoning Laws and State of Massachusetts General Law,Annotated. Homeowner Signature City of Northampton 212 Main Street, Northampton, MAO 1060 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 , Sy150A. Address of the work: �&I Dy/XL ��1�i2�n/�j /�/� 6))N 2, The debris will be transported by: 1 7 - The debris will be received by: Building permit number: Name of Permit Applicant 124-- Date Signature of Permit Applicant 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 lnfermm ien: _ rKenneth Misterka �] Boston North 9-P91443 F,{,Nam. last me Bramh Nam. Lead# 5 Rick DtSve �� FLORENCE MA ] 01062 Cuirxme,Md,.. C'iy bite zip __—._ I ` o ea}x584-4514 M -.._ _.._ ...... _ fnn_kir n@gmait.corn UaWme, aruu 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 --- ary rete zin or Email CustomerCanoellationNorthEast@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 _ 01/11/2017 cewomx"sie •mre om. 1 Distribution:White-Home Depot Yellow-Customer Copy Contract Price and Payment Schedule: Payment of the Contract Price is due upon completion unless a different payment schedule is specified in the State Supplement. 1392.00 Includes all applicable discounts, rebates, and , taxes. Contract Price $ Excludes finance charges.* Minimum _ %deposit$ Due Immediately Remaining balance $ Due upon completion Finance Charges *Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customers payment(s) made payable to The Home Depot. Insurance proceeds will J will not I be used to pay some or all of the total amount of sale. Description of Work to be Performed: Installation of Windows A more detailed description of the work to be performed is included in the section entitled Scope of Work which appears on page 3 of this Agreement. Anticipated_Delivery Date / Installation Schedule Approximate Start Date: 03/08/2017 Approximate Finish Date: 04/05/2017 All dates are approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if applicable. Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written communications related to this agreement. By contacting your Service Provider, you may update your email address,withdraw your consent, or obtain a paper copy of the Agreement or related documents at no charge. By providing your consent and verifying your email address above, you confirm that you have access to a computer that can receive and open emails and PDF documents. By initialing this paragraph, I consent to receive only electronic records related to this transaction. ! - _']Initial Acceptance and Authorizatiorc By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation and/or(b) order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this Agreement. Do not sign if blank or incomplete. (Service Providers/permitting information may need to be provided to You later.) By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety, including the General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a complete copyof this Agreement. Keep it to protect your legal rights. X= ` 101/11/2017 c.mo,aars siynamm Dm x�^4 01/11/2017 s,i c �.mum.agnw• D. 2 Distribution: White- Home Depot Yellow-Customer Copy WINDOW SPECIFICATION SHEET - Spec.Sheer#: 9791003 Sheaf 1 at 1 Customer Kenneth Mlsterke Jab W'. 9791003 Consultant'. Timothy Drost Date'. 011111201) Each wlhurw Evbimg Wmrow Hot,Lamtlnn¢ m.a,llramem, Gra, Oems,Gvnons L.hor of h,eFrem outside, Tell to Right Bays,BmW Lamtlan Color Rough Openly pot 0s,r¢ pIt— Camnt9.1 Pnl, ee Le.rS - - Glees, Mnc he.a Hereware Cora xreens For a."1. MA 'S=e.t.we ar f I 6Me Wrap, _ c 5 — e'.�� a 0_ `y Q x=upereny Roo Floc Coae YM) Style Coa ben Loa, 3vi all lald 444 -LLL I SPECIAL CONSIOER 10NS. rev Colw WMIe Inbnor Ca,ing Type Bey or Box wlnaow'. eatboeM—elel(vinyl only Srch or Oak) s P--- 11.,., mietl Angle(SO or ifi) ay Fl a nkat iy(re(DH,6H,or C¢mnB .P.1 ten.b '30 —heel an Moe) "- an.d.ennu.cnlnrefern —�nal mavens, e-1¢na eg tae wer.IHna ns, __ w.alea.uone atone alu the as utl P..l(Ye er No)' fipaeel Dean.and C..It.n,en the mabwlne Pete Garden Window. ealnoaM Mele(el(,.,,I oh,Ws.Feel.,Eleh er 0ak) ell The nea.MMe,f Gatcarer SgneWn Oltbnel 6helt(Ye¢or No) There m no quare...not a—tr ngle,.11 mal@ enlatinA color. + 11 .u' 4iJ a' 1� 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: _ Kenneth Misterka Boston North 9784601 Fitt Name -. Lash—� anM Name L p 5 Rick Drive A 0 FLORENCE M1062 WW _ zip —_.. (413) 584-4514 Hume Ph.,e# Work PM1one# (Yell PM1a 9 linnkinn@gmaii.com 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 .� O W� IF — Or Email CustomerCanceliationNorthEast@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. A k..Wrtge by: x 01/07/2017 a.w,oer.s'e .rv.. Dara 1 Distribution:White-Home Depot Yellow-Customer Copy Contract Price and Payment Schedule: Payment of the Contract Price is due upon completion unless a different payment schedule is specified in the State Supplement. 558300 Includes all applicable discounts, rebates,and ,taxes. . Contract Price $ Excludes finance charges' Minimum %deposit$ Due immediately Remaining balance $ Due upon completion Finance Cheraea "Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customers payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payment(s) made payable to The Home Depot Insurance proceeds will ❑will not I be used to pay some or all of the total amount of sale. Description of Work to be Performed: Installation of Windows A more detailed description of the work to be performed is included in the section entitled Scope of Work which appears on page 3 of this Agreement. Anticipated Delivery Date I Installation Schedule Approximate Start Date: 03/0412017 Approximate Finish Date: 04/01/2017 All dates are approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if applicable. Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written communications related to this agreement. By contacting your Service Provider, you may update your email address,withdraw your consent,or obtain a paper copy of the Agreement or related documents at no charge. By providing your consent and verifying your email address above, you confirm that you have access to a computer that can receive and open emaiis and PDF documents. By initialing this paragraph, I consent to receive only electronic records related to this transaction. [- �Initial Acceptance and Authorization: By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation and/or(b)order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made,as specified in this Agreement. Do not sign if blank or incomplete. (Service Providers/permitting information may need to be provided to You later.) By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety, including the General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a complete copy of this Agreement. Keep it to protect your legal rights. XC _ _� 01/07/2017 =asq.pm.w�*�i X=. 01/07/2017 ss:.oor,.,mmragnxu,. awe'— 2 Distribution: White- Home Depot Yellow-Customer Copy WINDOW SPECIFICATION SHEET - Sore, Street p: 9784601 Sheet 1 of 1 Customer: Kenneth Mistretta Job#: 9784601 Consultant. Timothy Drost Data: 0110712017 New window Ewining..Is. --_ Fln,Loretlone Meieremev, Goes Pmtluct opliom LaOor Opticns From ouleltle, Lee to Right Bays,B. Lorstlon Color Rough Opening pM pets pot an Oemnt., Pnl, use L K Hardware Miss Ilem9 same cpm -goore _ F e c 9g Mull s 'S=51e4onaryor �j 91Y1e Wraps g 5 Rcc Fmo coos (ym) stria Cme Genes Or. — AOn d �j I 'no plaral ernos, L1. STD Gni glen rd 4 OED on ED 'no ey se I On Col I All IIH 11 re Or 12 am Geleelk all worker LrR I Do I DH EH Opt On 4rol k ED SPECIAL CONSIDERATIONS: 11 On rep OolOr 'Welk MIS CB Out Inredor Cesmg Type Bay Or re.einacw: eatMeM mOleml on,tyl oeyERM or Oak) ay PrOl dot Anple(90 or 45) an,Flankm Type me,on .nano on of set e to.1(In�oes) Il Oso to wak.mint of knight makdal I new reHewetl end agree MN eII the pro apetiRreticna above end the aneWtl ROCI(Yea or No Speclsl Tem-ono Omtlltlonkon the lollowing Pepe gal Window'. eeOceM Mebnal wall only WMR Planik,Blmb or Oak) _. .....- —..._ Oumomor Bl Th son eee(incoek grelu re Tpnal Snell(V es or to Toar Is n0gone...teat new strl veil match edsfing aolcr. C� a Y." g V, V1 AnJ ROIL CU=l/f`l�iUW i,.r%lofeBER i'a 6 40— # %0`4 V 6A $00 BURLINGTON L A 14 a � vv srr i > s ' l The Conm:onweahh ofMassrec/rusetts Department of Industrial Accidents 1 I Congress Street,Smile 100 ... r-'� Rae/..q_ 114{4 127/4/-2117 �Z www.tnass.gov/dier Rockers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO RE FILED WITH THE PERMITTING ALITHORITV. ;applicant Information Please Priest lae'blV Namecenam¢a organiadnnnnaiwianaD: ��—Y ,v/ 77)^17 Address: City/State/ZIP L- 4?1''--A;A'' h'' '?phone#:_ Are yon::n employer?Clmd:n..appropn:ne mesa. Type of project(required): L❑I am a employanwth employees(m1l and/nrpnn-Inne).* 7. ❑Nlew construction am a sole propnddr or pannzrship antl love no employees wmkine (or me In -❑ B. ❑Remodeling any capacity (No n'ortnrs'cpmp.Insurance rcguirzdl 3 71 am a hommoamilang all work myself [No waiters'comp.Insurance required It 9. El Demolition 4.❑lama bonsrand willbe MilnemmratocoMuaall sudon my progeny. n'ill 10❑ Building addition 1ensuremaulln cocm reitherha.e.worterso'cmpeauon.nxdmna or are sole IL❑Electrical repairs or additions propm orselthmucand yeez. n ns12. Plumbing repairs or additions Xlamagenzral comrvcmrandlhose hned lnesnb-cpm:atton-Iisled on Nc artacbetl sheer 13 ❑Rofrepairs These can conmmeard have cmployia add have workers'rump.inm amm: to 6.7We all e conductance and.',.1111.have ammeed[beirrighrdfesempdpn per MGL, 14. Olh¢r 5 193.;I(4),and we have no employes IN.wit cam,.ioundear required) 'Any applimnt[hat checks box-I must also Fill out the section belmv shoving their uvrkzrs'compensation poli'arrom linin. 'Homeowners who submit Nis amdava inditatine they arc doing all work and then hire outside contractors must submit a new a(lidavit indicating such. ;(dommdg rs and check this Ms mon muchad an additional sheet shoving the name of the suLcommetors antl sutc wM1mber ar ma theme calleas have employees. If the sub<onsmctors have employees,lM1ey must protide.IM1eir 'utters'comp.policy number. 1 urn nn ernptaper that is providing workers'compensation iusnralce for my emplayees. Belmv is the policy and jobsite infornmtio n AA I J r r��� }� /2 Insurance Company Name: 6 Vo'61) vv+r^ /� ,7 j7,k? 60 Policy#or Self-ins.Lie.N: �,�I- ytj (�7/,I J < J Expiration Date:- Job Site Address l L� r City/State/Zip Attach a copy of the workers'compensation policy declaration page(shoving the policy mot and expiration date). Failure insecure coverage as required under MGL c. 152,625A is a criminal violation punishable by a fine up to 51,500.00 and/or one-year imprisonment,as well res civil penalties in the form ofa STOP WORK ORDER and a fine of up to 8250.00 a day against the violator.A copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification, do lr74eby cert If,it de t ri 14p�erm Cres of pe Jury that tire information provided above is true and correct. Signature: .l ?7^ �7�p '7 Date' Phone#: _ f/ �U J �j' ,//- Official ase only. Do not write in this area,to he completed by city or torn 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 6.Other Contact Person: Phone#: �� IMWoo+rrvl ACORO� CERTIFICATE OF LIABILITY INSURANCE onTE62J11y20,5 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(les)must be endorsed. V 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 cooler rights to the Certificate holder in lieu Of such endomemenns). PRODUCER CONTACT MARSH HOC NO NAME. PHONE - - FAX IN'AILANCE CENTERINCNP Ni _ No, .--. 35bO LENOXRGAO_SUITE 24CC RMAIL AT,VTA GA M326 ADDRESS ---' NEDRERIs1 AFFORDING COVERAGE NAICM 100J921011ie13 GAN-111-_ _ __ _ _ _ __ INSURER ABlind M InD,ance(Ji ripen, 261g! xsHE;TLOME ERVOES PC INSURER A.Tuncn American Insurance Co -06535 OBI THE HOME ODELL,I TOME SETO ICES _INSUR EN G_New Hampshire Ins CD 1-1. 269)CC SPREADS PARKWAY.SHITE 300 INSURER D.11I,Ux National HUNAOe Company �2301J ATLANTA CA 00339 —-- IxsuREaE: INSURER F; COVERAGES CERTIFICATE NUMBER: ATLL037466W14 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. EXCLUSIONS AND CONDITION$OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID DIOXINS XNA - -- -- --- Abp-�eR - PoLICY EFF POLICY EXP LAR TYPEOFINSURANCERED REUCYRUMBER INNID NWOdYYYYLIMITS A X COMMERCIAL GENERAL LIABILITY GUCAR71106 0310101E '.0310112017 EACH OCCURRENCE s Bxy�W�p / OAMO FEMED _CLaIMCNTC1 _X- CCCUR oREM15E5Ea0(Gllm I 5 _ 1OCQW3 LIMITS OF POLICY X$ ' MEOEXPIAn�Feemn S EXCLUDED OG SIR:q1M PER OCC 'i PERSONAL SADV IrvJuny '' S 9000,fA0 9Eti'_> 6 _INI':P As PEP 'GENERAL AGGREGATE :s 9000,000 HE h pGr_iC JECT LCC PRODVCTS-COMPIOP AGG :s 90m.0m CiYr_4 : '.5 _ _ B AUTOMOBILE LIABILITY BAP29DRO-13 030112016 031012DI COM BINEO GANGUE LIM IT 3 1,0N1,m3 V V, X ANY AIPO a00RY INJURY(Per por— jf A' 1,NIIIC —BOHEOULEO SELF INSURED AUTO PH'VMG ODDLY INJURY PeracuJRUC S 10ID5 _ 0.1TLG HIRED iViy` VCWOVNJED PROPERTY DAMAGE AUTCS L non!__ UMBRELLA LIAO GCCLR EACH OCCURRENCE _ EXCESS LAO CGIMSMADE AGGREGATE s OEn R •crv➢ON' .S C AND WORKERS COMPENSATION WC6155192o51A0S) '031011201( ',01pV2017 '�i % .PER IOTN- ANOEMPLOYER$LIABILnY $TAH AC ER vPRDPP ETDemaarNEwSxecunve YIN WCO165192D AKEY,NH NJ CID 03NiQ018 03101I201T ELEACH ACCIDENT Is L000,1100 C CFFCERIMEMBER FICLUDEa i� (Manaaory n N.) xIn µg01$519216 FLI 00112116 031 ' E L DISEASE FA EMPLOYEPX S t.000'Dry Ives '—f—Par Pgniinuen on AEtliEAnal Pa9 _. -. p REICH"ON OF OP5RVIOOD LAN- A EL DISEASE-POLICY LIMIT I$ 1000,IX1 DESCRIPTION OF OPERAIHONS I LOCAT INS I VEHICLES (gCORD 10,,gOOMonN RemaMs SGeXule,may M a14cxM amore spa[e Is rcyulrt0l EVIDEW E OF INSJPANCE CERTIFICATE HOLDER CANCELLATION THC ALHOME 3ER'v ICES.INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE OBd THE HOME DEPOT AT,HOME a"ERMCES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2465 PA SFSRPY POA0 ACCORDANCE WITH THE POLICY PROVISIONS. ,71NFA.GA 30339 AURICRUSED REPRESENTATIVE of Manh USA Inc. Manachi Mukhe9c, ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD ;FUC00eo !_2ac'i 4 `^>'r. 2E£^_e �:fi1DE13_E'c it P `..'SJ.`ti?AG�lrli�'�`1��a'"Y4C4".�fceeliv"!�?crrl'aivY �� II II it li .i _cJl'IiP=P9o!o sa;J'CO ueo`Jnl — li. =LIQ (slu—g- 1 j� ii m�:imnasne ao sac!xs_�s�i:oi_x'rn;n> ' i; ��i!�N^al'L3 CSn'aallCi•!3'd?c ri9i.'?C i:�n�`.__ i },;:'v'-srls i— i -.aJCa qJ �_'Ji\'�=`50"V L•S':`v S�:J n`L'i'iS•v'il _:1�=:�Q::- 'i =_'_�i._ JGS3 i� Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 51.70 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.Nark Mason for change, Address Renewal - 't Employment 1 Lost Card Office of Consumer Affairs& Sugmess 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 Plata -Suite 5170 Expiration: 6/3/2018 Supplement Card Boston, NIA 021I6 THD AT HOME SERVICES, INC. THE HOME DEPOT AT HOME SERVICES I RICHARD TROIA r,� -✓� 2455 PACES PERRY ROAD,HSC ATLANTA,GA 30339 - w IIudcrsecretary r l of va u1 without st�mture