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142 Hinckley 23D-153 142 HINCKLEY ST MBP-2018-00183 GIS#: COMMONWEALTH OF MASSACHUSETTS 23D-153-001 CITY OF NORTHAMPTON Map:Block:Lot PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit:Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A). BUILDING PERMIT Permit# MBP-2018-00183 Project# Est.Cost:4483 Fee:40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RAY HUNT CSL- 082485 Lot Size(sq. ft.): Owner: WILSON SUZANNE T &GROCCIA LOU Zoning: Applicant: RAY HUNT AT: 142 HINCKLEY ST Applicant Address: Phone: Insurance: 24 SUNRISE DR 401-523-1352 PROVIDENCE,RI 02908 ISSUED ON: 08/22/2017 TO PERFORM THE FOLLOWING WORK: Install 3 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: Check Number: Building 08/17/2017 40 23257 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#MBP-2018-00183 LJ / APPLICANT/CONTACT PERSON: RAY HUNT 24 SUNRISE DR PROVIDENCE,RI 02908 PROPERTY LOCATION 142 HINCKLEY ST MAP:LOT 23D-153-001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE. ZONING FORM FILLED OUT Fee Paid '.40.00 Buildin_Permit Filled out Fee Paid $40.00 Typeof Construction: Install 3 replacement windows New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOfMATION PRESENTED: V'Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission - Permit DPW Storm Water Management Demolition Delay /4_ J 912o', 7 Signature of Building Official Date Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. • *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. i I, x i Departnerit use oily �' f 4 - 4AP41. City of Northampton Status ofPerm�t' -, L4t � � 5,' ,.. Building Department - + 44v .y P-ermit Y • ;, 212 Main Street sewcrr' p ic'Avat i lit'k �1 p' j i iS`` t iI l''''- Room 100 Water/UMi'eltAvaila»Iity 1 F,E;, Northampton, MA 01060 two Sets of Structural Plans `' y �' ' ; phone 413-587-1240 Fax 413-587-1272 PIot/SitePfan ` ' 4' ;x' n ?{ !` Otherpecify y , : ti APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE.INFORMATION,: 1.1 Property Address: This section to be completed bf offices. Map Lot Unit /142- i--)-,) /4/4144/ ,.. ,Zone' Overlay District Elm St;.District CB District SECTION 2-PROPERTY O1IYNERSHIPIAUTIORIZED.AGENT 2.1 Owner of Record: 1q2- 441 �� � L��"1 �^ �.�rh `-- 10 elf- X11 J Name(Print) Current Mar des e?,,z &,-,77-i);9-e/7---- Signature 4'1_3 ��� ���� 2.2 Authorize+:•ent• • 110 04a7;771 /4 Na •: in) ,t---.... - 9 i Current M fling Address: ., . _. b-i,a7_, e---61_,,,p/_‘-- Signature Telephone Z.,0) ---/ -. .-'....2-.— SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use;Only completed by permit applicant 1. Building L//' #49 l 4 . �� (a)Building Permit Eee" 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) Check Number /� Vie'/ � � This Section"For Official Use Only Building.Permit Number: hate" Issued: . . Signature: Building Commissioner/Inspector of Buildings Date a EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING AR 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 ofSize _N....,... �. .. x..,u._ .. u ..._M ._a , Frontage .._ 4. ... Setbacks Front I � Side L i,. a_ R.;, i.__. L t__,._,a1 R"t. .,, i i Rear ° , Building Height Bldg. Square Footage % yT ," I, i Open /o Space Footageo p ._� f �.0 .ti (Lot area minus bldg&paved l rE ' parking) #of Parking Spaces Fill: f r... =.I Rj (volume&Location) i A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: ..»,..�,»...��:..,w,.». IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0' YES 0 N IF YES: enter Book x Page and/or Document#. P..0 B. Does the site contain a brook, bodyof water or NO DON'T KNOW 0 YES 0 wetlands? IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: TyJ i C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 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 0 NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5.DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement W' Bows Alteration(s) ❑ Roofing Or Doors Accessory Bldg. El Demolition ❑ New Signs [Dl Decks [Q Siding[p] Other[p] Brief Description . P .+..- erI Work: A ' it. Lam/ 74611 V / lam`/ ��� HP / W / 0-Alteration of existing bedroom Yes No Adding new bedroom Yes No , ' Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet fa. If N'ewrhouse avid or,,; i1diltionlo.existinq hi;uil nch,Complt.e the allowunci: 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 ) 1, ,' Ili ,as Owner of the subject propertyeryPla,11-724) ��hereby authorize ��=--Co to act on my behalf, in I ma elative to work authorized by this building permit application./tion. 61 Signature of Owner JLC '` J Date /� I, ,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 and penalties of perjury. .ediAY 40'/el Print Name -:-. 11/, ' /1. ,.....1-2 " f., :r..... _ Signature of Ow r/Agen Date SECTION 8'=CONSTRUCTION'SERVICES 8.1 Licensed Construction Supervisor: rNot Applicable ❑ _� Name of License Holder: r-- htTl/f1i ( 4dj�t' License Number 1 �i � r� _ — )._ le Address. , a* .7/ Expiration Date i,th2i '" 016-• 0)U Signature Telephone 4./D/---5'0 ---- i:36-.1 "9.Re=isterad:.Home im•rovemeM C.O:ntractor Not Applicable 0 l0 El 4)ri - VI� �Company Name Registrationmber 9144 M.971mTP1/ q-zo----)9 Address _ Expiration Date �%� j ' elephone 1/0) 523 y .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 ermit. Signed Affidavit Attached Yes No 0 Kir City of Northampton 1(-- \. ,,,3,,,t,,,,1 Massachusetts `" ee :. 1. * :t1 � . DEPARTMENT OF BUILDING INSPECTIONS `^as P ,- \11' ;'.-^-:';1-'L-1;r '`k` '`r 212 Main Street • Municiaffpal Building IA,. ;A, Northampton, MA 01060 '4s . .' AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporationior LLC,that entity must be registered. Type of Work: eftgAaM 110 15...0 Est. Cost: N ri1n Address of Work: t 1-12— k/ i Date of Permit Application: ' --I / 17 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): _Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied _Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as t e agent of the owner: � 117 Ainvk Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton •n �� Massachusetts * DEPARTMENT OF BUILDING INSPECTIONS tw 212 Main Street • Municipal Building Northampton, MA 01060 ss _ Massachusetts Residential Building Code Section 110.R5.1.2 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. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, providedthat if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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. City of Northamptonif: _ ¢rtH >Qy� Massachusettsw?s1$ f� oifK- �, ° xa DEPARTMENT OF BUILDING INSPECTIONS ;= 1,' ,,� �; 212 Main Street •Municipal Building A Northampton, MA 01060 4Y,,,,„ 3N Debris 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. The debris from construction work being performed at: print)L/2- 47)k)C /- 131": house number and street n e (Please ) Is to be disposed of at: 1--6 ak0A-C— - kli* (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) / , 7 tr 4 ('-'0 Signature of Permit pplicant or Owner Date If,for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts romi Department of Industrial Accidents ='v�jl1. t Office of Investigations Q --:-- 1•11111 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I 6. 0 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. + • 7 ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp. insurance. 9. 0 Building addition [No workers' comp.insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] i employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 MGL 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 of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation,for their employees. Pursuant to this statute,an employee is defmed as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defmed as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint 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)alsostates 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 be returned to the city or town that the application for the permit or license is being requested,not the Departuuent 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 andprinted legibly. The Depai tuient 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 file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia 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 Home Depot U.S.A., 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: Louis Groccia Boston North 10235488 First Name Last Name Branch Name Lead# 142 Hinckley FLORENCE MA 01062 Customer Address City tate Zip (413) 586-9523 Home Phone# Work Phone# Cell Phone# Igroccia13@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 Citytate 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 b X T 07/29/2017 fir" Customer's Signature ""' Date, 1 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. 4483.00 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 Customer's payment(s) made payable to The Home Depot. Insurance proceeds will -will not " 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 Dater 09/23/2017 Approximate Finish Date: 10/21/2017 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 i 1itia!Jb g 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 Provider's/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 Agre T ment Cep it to protect your legal rights. X � 07/29/2017 Customer's Signature Date e X Co-Signer(i(p 1 able) °x9�' �1 Date X 07/29/2017 Sales Consultant's Signal e -� _Date License number(s) held by or on behalf of the Home Depot: 2 ttpl; t5 y et - E ' 04 5 gN UEa� U -o3at � � ms$ U � t 2"v1 v .9waa'ge '' m 8 �ik i' a ,t,, X rEN N O S <0. t.&.,';, ° 1'0 1 el ° `�` vzNa�° zz zcow E,%\''t,,','''., wIt e z I. vi m m }° 'i� Ei y11 o\I` t � N OrN O N 5 . EWW 11,„',";, , �1cU r r r 1 '+ O 1 } pt 4+Pt, 411 FQ- ' ii t c;11171.0';'8 f,`t° Ts en 0 N t d . < g NN. jjhxa ;1 o3�F tp ` j Utid9 .CI 'cyti oO va ;� cyJ U i I - - 43 8O 'ice a „, i a.,A, LL 4, w. ,, k,gto, piA4,7; o t0101 g 1,71 ? q '1 _ I o m G 9UUP ---®U -.0 -- E_• ` ��r,r.Ftyytt 5>1 rnrn UN , ; t Y iiiiii Q�} �{ 9 'Q �uk ' am'' 0 m 02. rd" Lrit 0. 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' II ) Y : 3 crOo v Ln } T�t 9Ay - NUv 44KT u,y lum 111 •A1,111411114' '41'11'411'0.k ACC)R5 DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 02:'171201 �� 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 pollcy(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). PRODUCER CONTACTNAME: MARSH USA,INC. • TWO ALLIANCE CENTER INC.No.Seth (ac.Not 3560 LENOX ROAD,SUITE 2400 EMAIL ATLANTA,GA 30326 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL It 100492-HdmeD-GAW'•17.18 • INSURER A:Old Republic Insurance Co 24147 INSURED INSURER a:Agri General Insurance Company 42757 THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. INSURER c:New Hampshire Ins Co 23841 2455 PACES FERRY ROAD . INSURER O BUILDING C-20 ATLANTA,GA 30339 INSURER E: . INSURER F: I COVERAGES CERTIFICATE NUMBER: ATL-003746387-14 REVISION NUMBER:2 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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTSRRI TYPE OF INSURANCE I NSDISWVD POLICY NUMBER UBR I(MMIODYIYYYYY) IMMIDDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY 310022 031012017 0310112018 EACH OCCURRENCE 5 9,000,000 CLAIMS-MAGE X OCCUR D PSETO aEcuR MIS(Eocrrence) S 1,000,000 LIMITS OF POLICY XS MED EXP(Any one person) S EXCLUDED u_ — — OF SIRR:$1 M PER OCC PERSONAL a ADV INJURY S. 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 9,000,000 XI POLICY'~E� LOC PRODUCTS-COMP/OP AGO S 9,000,000 I OTHER: $ A AUTOMOBILE UABIL)TY MW T 8310021 0310112017 03101/2018 COMBINED SINGLE UMIT $ 1.000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) S — ALL AUTOS NED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) S HIRED AUTOS NON-OWNED PROPERTY DAMAGE 5AUTOS (Per accident) i ` • $ UMBRELLA UAB OCCUR LEACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE S DED " RETENTION 5 I s B WORKERS COMPENSATION WLR 049112300(TN) 03101!2017 031012018 X iH STATUTEI ER AND EMPLOYERS'LIABILITY C ANY PROPRIETOR/PARTNER/EXECUTIVE YIN WC 023102423(AK,NH,NJ,VT) 03!0112017 03101/2018 E L EACH ACCIDENT s 1.000.006 C OFFICER/MEMBER EXCLUDED? N NIA WC 023102424(WI) 03(012017 03(012018 1,000,000 (Mandatory In NH) i E L DISEASE-EA EMPLOYE $ It es•descdbe under Continued on Additional Page E L DISEASE-POLICY UMIT 15 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee -IststuvaI..:. .114......-rs•►uv4ku- I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD •••=01.•••••••••=. The Commonwealth of Massachusetts . • . Dept:0101e*of IndnoriulAceidents . , mom no''mmar li . ./ Congress Street, Suite 100 ... ,..a d -..-- SU... i Boston, MA 02114-2017 411W iita.S'S.g0V/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE RUED WITH THE PERMITTING AUTHORITY. , Applicant Information Please Print Legibly Name (Business/Organization/Individual): -i-) pi E..... .7,-) ..,. Y29 1 Address: lq0P49 -1.DAI TP ,h_ oi City/StatelZipSgRfra #11. Phone #: 41)Vgli Are you an employer?Check the appropriate 00x: Type of project(required): I.0 I am.a employer with employees(full and/or part-time)." 7. J New construction 2.0 I am a sole proprietor or partnership and:have no employees working for me it 8. Eil Remodeling any capacity.[No workers'comp.insurance required.] 9. 0 Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]I' 10 D Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on iny property. I will ensure that all contractors either have workers'compensation insurance or are sale 11.0 Electrical repairs or additions proprietors with no employees. 5, I am a general contractor and I have hired the sub-contractors listed on the attached sheet. '%1Xtr hese sub-contractors have employees and have workers'comp.insurance!. 12.1:Plumbing repairs or additions 13.0R9repairs tl Wil/Pri . 6.0.0 We area Corporation and its offiecrs have exercised their right of exemption per MOL c. -ter 14, 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.. rContractors that check this box must attached an additional sheet Showing the name of the sub-contractors and state whether or not those entities have employees, If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 ant an employer That isproviding waded's'compensation insurance far my employees. Below is the policy and jot site information. ) 11j) ii Insurance Company Mine: Najii2dPft.. kfr)VA/ Fi RE fi,/,-Aig.• Cs) , _ ,......,, , Policy#or Self-ins.Lie.#: ...WL p646, -,....,--p5' Expiration Date: Job•Site Address: /Li 2__ 14-k?gz, late/Zip: 13-7912- -- 1/11,97j Attach a copy of the:workers' compensation policy declarti on page(showing the,policy number and expiration date). Liii./.0, ---• Failure to secure coverage as required-under MGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00 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 of this statement may beforwarded to the Office of investigations of the DIA for insurance coverage verification. . ._... I do h • iy certffj,un le aim lid i. : 'perjury .hat the information provided above is true and correct. ,... - , ''e -)---)7 , Signature: Date: Phone II: - of 4 -- Official use only. Do ildi write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 1/: AGENCY CUSTOMER ID: 1C04g2 LOC#: Atlanta A COR D� ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY' I NAMED INSURED M SH '-(CME CEPOT;74.3.,1.,.(IC. �191A THE HCMEsCEPOT POLICY NUMBER Z455 PACES FERRY ROAD 3LPL:ING C•ZG ATLANTA,GA-^.0339 CARRIER UAC CCE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Walters Compensation Continued: Cortier.Indemnity Insurance Company of North America Policy Number.'MLR C491 1 2294(AL,AR.A,IO,IA,;3,K?LA,MS.MO„IE,NM,;ID:CK,SC,3C,'.W N'!I Effective Date:03101,2017 Eapirllbn Date:03101(2013 • (EL)Gmlb 51,000,000 • Cartier:New Hampshire Insurance Company Policy Number.WC 023102422(CC.CE,11I,IN,MD.MN,MT,,14Y,RI) Effective Cate:03101/2017 Expiration Date:0310112013 (ELI limit 51,000,000 I i Carrier.ACE American Insurance Company Pnttcy Number.'NCU 040112232(CSI)(A2,CA,II,NC,R,'IA,NA) • Effective Date:0740112017 Expiration Cate:03101/2018 (EL)Limit:51,000,300 SIR:51;00,CC0 SIR tar Ore slates at AZ,CA,IL,MC,GR,`/A,'NA Carrier:National Union Fire Insurance Company . Polity Number.X'NC 55,73144(051)(CO,CT,GA,ME,MINV,OH,RA,UT) Effective Dale:03101/2017 Expiration Dale:0310112018 (El.)Limit:51,000,000 51,000,000 SIR(or the states a1 CO,ME,NV,NI,ON?A,UT 5750,000 SIR For the stale of GA • 5.750000 SIR tar the stale of CT Cartier National Union Fire Insurance Company Policy Number.(NC 5583145(CSI)(MA) Effec::ve Oa:e_0101/2017 Excitation Date:07/011201i (EL)Umib 31,0c0.000 SIR:3500,000 TX Employers XS Indemnity: Camerllinlos Union Insurance Company Policy Number TNS 048813202(TX) Effective Date:03101(201.7 Expiration Dale:03101/2013 (EL)Lint:S ta,000;000 SIR:31.000,CCO ACORD 101 (2008/01) V 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ice , ,Th_r77-7 Q/fiv7yt ow(vecda a a'iakf/aft; q\ / Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improveme4Contractor Registration Type: Supplement Card HOME DEPOT USA INC Registration: 112785 2455 PACES FERRY RD C-11 HSC 1''l - ��� - Expiration: 04/22/2019 ATLANTA,GA 30339 ' rM ry-, J. � -- , Update Address and return card. Mark reason for change. 20M-05/11 0 Address 0 Renewal 0 Employment 0 Lost Card :Ate Wommanweccia cl lataccc/ cella __ _ Office of Consumer Affairs&Business Regulation ? HOME IMPROVEMENT CONTRACTOR Registration valid for individual use onlyTYPE:Supplement Card before the expiration date. If found return to: Re istration Expiration 9 Office of Consumer Affairs and Business Regulation 112785 04/22/2019 10 Park Plaza-Suite 5170 ,vim; HOME DEPOT USA_INC ' Boston,MA 02116 RICHARD TROIA 6,Q„ Q,1,.--> 2455 PACES FERRY RD D C11 HSC ATLANTA,GA 30339 Undersecretary Not valid without signature *rel • j �T�^�'`'s••-a-7 '1i Civ sV 1 GLi3� 4"+"Ll1=:Lw I . 1 11 t ' 4.j S r`-+ - n1i- 7 M x w' s ?..l� t m:_t.No t.w 'irta`t r I -, .. c."i t",.�.. . .,Lr�.i�.'Lh» l t G1.1.-as... 6t i• a,,,,,—*"z f{. • fir=, adds ' • . li v 1::...t.-At.:151.: I1 V v t., dodd. &Gitort@"V;i:IIG-3-18;ilr Jidro-ri Taz -..Ce4,-E Sin. i 1* -zeTa. s: is L'1 e.clar inaaz a Cori ce I s 1� r{GPO`s P::�=4 2 42 0,00 2 a.—r8 cu11 7.811 i.1ACI01,1DEREN71MIENTO 1.1ERC-E1100 1� ii 0 il I: `E=477: t { 3_. 11 DPI s Q ..�L PERFORMANCE- RATINGS 111 Vk'ri�Eiiiwicr» �44i i 4 ll• �i • if _._ _ .a," .-c. -- ....,.. - - -':.;:`x:-:.`..'...j=:::=«:"-.;.:i ice.=r3.sa: %•S3 11 tt r.tti. =%4-1:-: --... .. c_.»+a._-.... .. ..L mow' ...... �-•^r'��:r':.w uG rY+Vy' »:- t • �-J•.y_.;:.a-i_- ^.-...._v__:t=: _....`.ate- -- .�»..-..--_:..... -s.»--'—r:r...-.r.». t q "::,..27:::- V —...._ ti _ - 4. -. a ti II ii ...�.{:ti":-s4-.-r_.w` Jam_ ' 24"'.f it %."+r-.r'.t`r%fs..J'!.= l`s 'i 1-7:0 f:'�Y wusi 5: -,.- .kiY'` ri ,•44.� :i`n'%;e47."+ t.::F4» :C-,'�»ZP Unit Qu@ Idea Lor�r.R.GRV ' t . 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