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24C-094 (6) 63 MASSASOITST BP-2018-1232 GIS 4, COMMONWEALTH OF MASSACHUSETTS MamBlock:24C-094 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit, Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categom REPLACEMENT WfNDOWS/DOORS BUILDING PERMIT Permit# BP-2018-1232 Pruiect4 JS-2018-002202 Esc Cost,$6259(q Fee: 540.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 104327 Lot Size(sp. ft.), 6098.40 Owner: MILMAN ANITA zoninz URB(100V Applicant: HOME DEPOT AT HOME SERVICES AT: 63 MASSASOIT ST Applicant Address: Phone: Insurance: 5 RIVERVIEW DR (401)935-2633 0 Workers Compensation NORTH PROVIDENCERI02904 ISSUED ON:5/22/2018 0:00:00 TO PERFORM THE FOLLOWING WORK•INSTALL 6 WINDOWS AND 1 DOOR FOR REPLACEMENT 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: FeeTyoe: Date Paid: Amount: Building 5/222018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner 6viA)0ow3/P002 Department use only City of Northampton Statue of Permit ..r Building Department Curb GapodVeway Permit 212 Main Street SewedSai Availabisly ','f( Room 100 Water/Well AvallabSity ` ' Northampton, MA 01060 Two Sob of Structural Plans phone 413-587-1240 Fax 413-587-1272 Pk*Sfie Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH AAn ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION Brr I &- I 1.1 Prooerty Atltlress: This section to be completed by allies JTMap d-40 Lot Unit / Zone Overlay District Elm SL District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEDAGEthT 2.1 Owner of Record: Iar✓fTA- �11m� �� jM�i,�01Tv� Nama Print) /1 CurreO/Ao Signature 22 Authorize ant: Na C rr t Mailing Addre Sig ure Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Oficial Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2. Electrical (f( U (b)Estimated Total Cost of Construction from e 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 7 L/ 5. Fire Protection 6. Total=(i +2+3+4+5) - Check Number --a-?705 This Section For Official Use Only Date Building Permit Number / Issued: Signa re: T / lr/ Building C issioner/Inspeclor or Buildings Data EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed, Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning nu culumn to be filksl In by Building Depanmenl Lot Size Fronto c Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage i l Wr area minus bldg&paval tltin ) 4 of Parking Spaces Fill: (volume&tuceriaa A. Has a Special PermiUVariancel Finding ever been issued forfon 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 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 411 disturb over 1 acre? YES O NO O IF YES,than a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(cheek all applicable) New House ❑ Addition ❑ Replacement dows Alteration(s) Q Roofing Q Or Doers Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding Iol Other[a Brief Description of Proposed ] C `� ' - Work: 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 followlirm a. Use of building:One Family Two Family Other It. 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? U Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? If. Type of construction I. 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 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT L STI 01 '!/" ,as Owner of the subject property hereby ath iz to act/onnmmy behalf inn,all y /yrs re�lati a to work authorized by this building permit 7n./_ {p/ Signature of Owner Oat. 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 unde a pas and penalties rjury. Pont Name / '/- Signature of O r ge Date L/ SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Suvemnsor. Not Applicable 117 Nameof License Holder: !V ` /�i/ 1,9402/ License Number 075 I/-29-/Y Address Expiration Date Signature Telephone 9. I!N Re Is! No" N�men o Not Applicable ElCom an Nam �� ��"✓I� -7-PK -r'b���� Address ) Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(i Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial 01 the issuance of the buildi e-d Signed AffidaNt Attached Yes....... No...... ❑ City of Northampton r ! � Massachusetts \' DEPANTNENT OF EUZLDINO INSPECTIONS n 213 Min St ..t • Nunicipnl Building \.` Northanp[on, NE 01060 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 cou Tactor 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 addifion to any pre-existing owneroccupied 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 hos contracted with a corporation or LLC,that entity must be registered Type of Work: W�N�B�ii;�' I(/py? BsL Cost Address of Work: Date of Permit Application: 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-occupiedOther(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 the agent of the owner: S�ZI-lid �l � 1127,97 Date Contractor Name �I ynl I1ICRegistration No. OR: Notwithstanding the above notice, 1 hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton SS.. Sic d Massachusetts � << c l z \ DEPAMINSNT OF BUILDING INSPECTIONS ;t 212 Min Stieet • Munieil.l Building North m on, MA 01060 rYry yOPa Massachusetts Residential Building Code Section 110.85.1.2 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 1 IO.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, provided that if a homeowner engages a persons) 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 Northampton •'' Massachusetts c s DEPANTNSNT OF BUILDING INSPECTIONS o_ 212 Main St eat •Municipal Building i N..Na ton, HA 01060 fyri; y�^C Debris Disposal Affidavit In accordance of the provisions of MGL c 40, 554, 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 (Please print house number and street name) Is to be disposed of at. (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) ����'� ✓jam. �zll� Signature of Permit Applicant 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 Commonwearth of Massachusetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston, MA 02114-2017 www.massgov/dia Workers'Compensation Insurance AMATO t: Builders/Contractors/Electricians/Plumbers— TO BE FILED WITH THE PERMITTING AUTHORITY. Apolicant Information Please Print Leeibly Name(BvsineselOrgpvizp[iorvinJividvaq:^ Address: City/Stale/Zip: Phone#: Are you an employer".Cheek the appropriate box: Type of project(required): L❑I an,a unploycrw0n cmployccs(full armor parl-NmcY T ❑Never astruction '_❑Iwva.cnle proprictororpannersM1ipend have uo employees working formcin R. ❑ Remodeling dry Capacity.[No workerscomp-insurmrce required.] l.❑Iamahorce.—C,dniny all.6cmyselr.lNn coo wn'mmn inaumrcc uquhwJ, 9. ❑Demolition 4n on—hoaeow rand will Fe hiring conbaa, cordae[all went,or mopery y pr . Irvin 10❑ Building addition ...usToo ull,nowcons other have woders'compena.I n monsaceor me sole II.❑Electrical repays or additions propncmr wnh no cnrpleyed, 12,[]Plumbing repairs or additions 5,rllamageneril Contractor and l have hired thesub-cohnnewrs lisredon the atracheducet. ]3.�Roof repairs 'ltrcx subloyew eowne.have Ca and hon workers'mrd.iouranm� F-❑Wom<eerryomlian and ilsotacers have axercised theirnghl otcxemptmn per MliLc 14.[:]Otbef 152,)1(41.and we have no cn:ployees[No workers comp-iniourverequir,T] "Any applicant that cheek,box MI mustalso fill out the section below showing Their workers'compensmion policy infomation Y Homeowners who subvht this affduvit indicating they am doing all work and thw hire outside vonvaava must submit a new etHdavit intllcermg ancR K;on[racwm,rat check this M,x must vtmehad un additional sheet showing the uama ofrhe aubconuaemrs and state x6ethrx or nut❑mso vmiries Fave omployms. Ifno nub<ontrwmrs nave employees,lFoy must prmido their workers omp.polipynumber- I an an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information Insurance Company Name: Polity#or Self-ins.Lip.#: _ Expiration Date: Job Site Address: City'Statc/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 MGL c. 152, 925A is a criminal violation punishable by a tine up to$1,500.00 andfur one-year imprisonment,as well as civil prnaities in the form of a S101 WORK ORDER and a fine of up to$250.60 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 hereby certify tinder thepains and penalties of perjury that the information provided above is nue and correM Sig to Date' Phone#: Official use only. Do not write in this area,to be completed by city or town olfle aL 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 defined as"._every person in the service of another under any contract of hire, express or implied,oral or written." An employer is delmed as"an individual,partnership,association,corporation or other legal entity,or any two or mor, of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee ofan 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 bean employe" MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGI,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 ofthis chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply in your situation and,if necessary,supply sub-contractors)camels),addmss(es)and phone numbers)along with their ceinficate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LI_P)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 reNmed to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant- Please be sure to fill in the permit/liccuse number which will be used as a reference number. In addition,an applicant that must submit multiple peromc 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 f.c.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-977-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov,/dia 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 defined as"...every person in the service of another under any contract of hire, express or implied,oral or written" An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoinl enterprise,and includingihe legal representatives of deceased employer,or the receiver or truster of an individual,partnership,association or other legal entity,employing employees_ However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority," Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply your insurance company's name,address and phone number along with a certificate 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 altidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)_ A copy of die affidavit that has been officially stamped or nnrrked 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 alTidavit must be filled out each year. Where a home owner or citizw is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and Pix number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/ilia Form Revised 02-23-15 Home Depot Contractor License Numbers: VA 107774, 112785 Salesperson Name and Registration Number: Joseph Sullivan : 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: ANITA MILMAN New England South 1-5XS4HU5 rnmName — txsr Name Branch Name Lead n 63 Massasoit St Northampton MA 01060 Customs,Address city stare _ zip (510) 508-4755 Home Plmme#. work 'Worm C.H anita.milman@gmail.com 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 Addressity- stets 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. TH4LAWQ IRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YO R RIGHT TOE E SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GI EN ORAL AICE OF UR RIGHT TO CANCEL. Ac 05/02/2018 X oma 1 ConyTact Price and Payment Schedule: Payment of the Contract Price is due upon completion unless a different payment schedule is specified in the State Supplement. 6259.40 Includes all applicable discounts, rebates, and , taxes. Contract Price $ Excludes finance charges.` Minimum 33 %deposit$ 2065.60 Due Immediately 4193.80 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. Antici ated Delivery Date/Installation Schedule Approximate Start Date: 06/27/2018 Approximate Finish Date: 07/25/2018 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 kitialing this paragraph, I consent to receive only electronic records related to this transaction. I 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.) Bys"nn',>0nacknowledge that you have read, understand, and accept this Agreement in its entirety, including a eneral Terms and Conditions and State SU_Wsment, if any. You further acknowledge receivi a c ete copy of this Agreement. Ke rotect your legal rights. 5/02/2018 X CU.,. 19nN are X 1 05/02/2018 Co519 �apPllwde) ane 05/02/2018 X 9ek neeralgnaw om License number(s) held by or on behalf of the Home Depot: 2 WINDOW SPECIFICATION SHEET - Spec.Shedd,#1-5x"HU6 ri t 01 t G YstOmec AN' MAN Jpbkl 11.1Hu5 Cirri "s" riven Date Ohm vzmB —- rvew wllleow - Hinye L R.d,s' e6gms wmEew Meacuramnn6 Onea Rnaucl Cott on¢ Lahr Opnona From nYtvloe, to R.", Tom. Days,Bowe Locanw cemr Rnugnocenbg xomers xomarc IIse L6R oPo rs Glass Mse llem rs Hard— Cone is or 9 MMI "5F1ali0nery 0r E sMa wraps _ = 3 5 pcmin _ floom so 5 FIOor C., I.) 51yle CNe Series COO. S z TDo venue. plaesPz RAR Lsa oFC m 2Pnt zvwL 6+00 )m0 3zop -Ene�9v star-ck onnern iR 11,1 L L 11. A3t L0 0 86 V 9 - i0,W5ae, Glass P so k'. 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THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S).. AUTHORD:EO REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certirficatIT holder is an ADDITIONAL INSURED,the pDlicy(ies)most have ADDITIONAL INSURED provisions or be endorsed. H SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this cin-ifcate RUNS not confer rights to the certificate Holder in lieu of such endorsementhu. PRODU6ER 6UNUAuf MARSH USA.INC AAME FAX TWO dLJANCE-ENTER • N E»= AD xo: 3560 LENDS ROAD SUFE NC(I BAIL I INTA.SA 31)126 PDDrrtSS INSURERS AFFORDING LOVERPGE _YAILC i'M1d211h¢iamnllvAYJ.`rl IN-09 _ . /1 ,17 INWREO I HE HOME DEPnT INC NSUaERB N�l4am ynrcP IN Cp _ 121Pd1 -GA1f FP01]SA Ilk,. INSURERC'R ILry-dL U,1a0R AampanV :iopr^5 ERRY RCAD INSURER 3WLOING J20 ATLANTA 6A 3@}9 1XSUREA E'. INSURER F: 1 COVERAGES CERTIFICATE NUMBER: ATL 004352CP 1d REVISION NUMBER: 3 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 3ELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NO VITHISTANDING ANY REQUIREMENT. TERM DR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO NHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBiECT TO ALL THE TERMS. EXCLUSIONS AMC CONDITIONS OF SUCH POLICIES,LIMITS SHCWN MA"HAVE BEEN REDUCED BY PAID CLAIMS. IXSRi TypE DF INSURPNLE DOL SUB0. POIILY EFF PODLY EXP LIMITS LIR. I50 PoLILYNVMBE0. MMDO MXDOIYVW X Emfflu GAL CENEIRA�,L�LIA®L1TY !M YIYiIDL' D3ID1i2016 '1ir0112f119 IACHOCCURRENCE : E Y000 EM CLAIMSNAOE A CLJR PREMISES'E E rterne E 200 N o rGosOF PIFI1 dS 1:AEDE%PA- LXUUOEII _ "F SIR.DIV PE@UCL I—ASONAL a ADV INJURY s 1.00 Dr0 .SNL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE_�E IN0)(100 =C POLICY_�' ,EC- C Loc - PRCOUcrs-COMP ovAGG . Tn0N W0 A 'AVTOMOSLLELIABIL(IY NWiD312118 I91 Olr20lft 113,1112019 1COMBINED 6INGLE LIMIT j 'QIXI 000 Ea accgen[. ANY alio I aoMLv wmev Pg Pesorll - �iAOWYO 6CHEOULED S-LFlNSSRE d.'Y`t . ',Is BODILY IN+uNr PxawaenNS FIR os NL vOO6WNEJ +aOP�R'V oAn1AGE j E _ AJTOs NL• 1,-.BaNLY UMBRELULIAB 'Cc, I I'. SICHOCCURRENCE EXCES6LUB C"...ADE AOOREDAIS IE DEO NETENTIGIB E 3 APPRIKERS COMPENSATION I '1C 91LP517 'AKAH.Ni IT 93(11rJ')If V 011014 g 'ER OM- P O a RRI IN SATUTE ER IL 1314�]29N PII 3012C+A �J13120 ) 3000.00 LN P EO E.E£E TVE �N NI _L C CCIDENT @ E aE ECL Ep. H'M`T D SEASEEAEMPLOYEE a IF . Un AMUXCjI1UH 3:0.000 .6C 1I 1.OF OPEMTIONSo bry U'U'LEL.OISEAa'E-0OLIC1'LIMIT S _Fv3wr 1 IZW 1J100-1 K 2CI9 031012018 1032N19 �Umd I I ME 00 DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES(ACCAUS IDI,AEOIWMI Remaft SIRWI may W vNTheY 11 TIP,+pxeI+[quid EVIDENCEJF RSUPANEL CERTIFICATE HOLDER CANCELLATION KIEL LrEPJT USA,AVC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED REFUSE 2455 PACES FERRY nOAU THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN RIIILCING 411 ACCORDANCE WITH THE POLICY PROVISIONS. NTLAN I A.C✓1 30139 AUTHOR DED REPRESENTATIVE of Manl,USA Inc MAROXIS Mukhegee (D1988-2016 ACORD CORPORATION. All rights reserved. SCORE)25(2016f03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CNIO1642069 LOC III: Agana /1 ACORO° ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED HARSH USF INr THE HOME DEPOT INC H 5" ' LLSA.INC, ROLRN xuaeER 2455 PACES FERRY ROAD Blllil]ING C-20 ATI NTA CA 30334 CARRIER XAp[PoE EEEECIIVE DATE ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM 15 A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CerlifiCate Of Liability Insurance wmeR COT'SOO1F"rpmmueh -&nR-maemmym,umnre EDmpanyd Nmmeaep,a Pdty Number WLR C6416.19T,AI ARF.ID IAKS KY LS'ffi Ido NENM N'J DN SCSD iV`Nv W1') EHVYme Dale 05181128=B Opl'allop E)Oc CS0930,i ffl;Idni11 L00,Tf ro-Nen Hamp,Ire Ins ranee COmPan Ptlicy XamLer WCOlCP25]6;IlC DE HI IV MD 0IV,M.NV Rp [I1swe Dalo 03101nD',e upFauon Dae Ovn@m4 Iu: mr.'_"C;ILO '$'r.A Am—O lI —I,,i% 'Num [ M1 1 . 403);1 Ll l[ .A 4 N, OR VF WA EOecYVEDam 0310112018 Upvailon Dale OVPIIp019 RJ Hm, S OW X4 SIR 11 NOON SIR IPIhG Gere,PI AS I-A L NC OR 0 AA dme' Nx o a 1—1.1,Immanc p0;m+ PdlF,Nunt,r XO/C 11114S Z11 '<O CT CA WC Al W OH PA I Tl RO 1-DdO 03O1I201F Evpiztu,Dale.0300019 (EL)LImP 6-DOo Ao C COO ICC SIP Or W star,o CD ME%NI OFFS, N S750000 SIR H me staled C,A vEs FOG SIR 1n ON IA,OFC =,. a.m, orcmrpan,� uar"Ir"I"C" IMSmnDlc0 1 r Enployeu x£I sH 1p �rrw llllnu,Or.oOlosuana Cpnirzm Pd2n'Number.INS C49166WA n XI EnttOWOal,NO112018 Evpvalmn Dae OYO112019 1EL)Gme CC MONO SIR s No 000 ACCRA)101 (2008107) ©2008 ACORD CORPORATION. All rights reservee. The ACORD name and logo are registered marks of ACORD The Co lm n nl. a th of lvlassfxfzuses Department of lydus/+'ralAcc+tients ' Co¢press Sheet,Sttite 100 osrc , 1-4/1 72114-201-7 :+acaatass.'apirtia -" \{urmtiu kers'Croeasnn insurance Af&lavi;:3nilde:vConiractnrs/i;ectricians/1':umhers. ':'0 3L MUD tl'IT!i TIT.?L O1ITT11'G,,UTIIDRITac yr=ni:cunr m!ormnlion 1'!nlse Print i,=_oitrie Jame;3�xh:c'JOre_mizaliaciffidiivid.,l) :�.ndress: �Oyf7l /�//V�V7^')J�� G-7_�• �j .n emPioye!'Cheei:!I:cnpprvnriatc hoc. � Type of Protect irequiredl: 1 rah a5 J P P r A 7 R Yew camimelion I a r r I'p an a n f c 3 ] RenwdPhng =Pr r,. t Demolition �,o md 41 , himpgmpzld 1 all 1, 'T"C,_ ,vol 10 I1 Building addition []cleetrlca mol...or addlnans h all .v-tl nu En�lq..Ps ♦Si ul. JPIemJ n0 r2p01 C5 or 3d41i:nni av dd L uY t - -• �I � _ i]RWi repairs dpscoi-=ts 'te I 'r.-o IQ Iher �✓ ✓ Q( n19ut= clE ws'1 m.un6arll av:z.xucn I + IYvin�bcc - onY-a.r n :Yi,Y-'lorm;uon. s b '1; .ivar,!nd as n3 vc/ar.dor dll ar m1]Jrtr - Is--Eoavve:on aeSl suhrilavevordava inJrWl n3 such. - L. :o['rv.an.c mdin.nal Ir. '?wm.E.am ana,la:x x,..N� ar+a J:o=omit cz hs•e bam;ut ernpfnl'er tha!is pravitluh lVarirers'canpensrttiun is rsurarrcefor my eohpinyrer. $elmvrs t%re policy u!NJob sire :(anrirtiotx //��{Jyy�� TT yy�� �q�p�-• yy/f 1 `),�f � ) ��q',py �/� //'�� ' nsumncc Company m-,aneL'C gk)g Ja r/ //�✓�' ✓(V��/}! 7 /%2`L /L�'�/ W rho ar Self=n c ".-:�yy22� cxpinnon Data ✓�J I,e. ddras_ e l ' Cilyisou"Zip t M4�64�p !iac6 P coo_ rhe wodaers compmsa uon policy deciara5on page(shuwin-the policy umber nntl 'piles 'an date}. arsuC is sevum coverag.as required under @ICL a. 152,;25,:s a criminal violation punishable by a fine up la SL500.00 ;,mckr onz-veor imprisrnmem as well as civil oernles in the form of a STOP NORI:ORDER and a fine ofup to$250.00 a gay sgninst the'ialalnr.A copy Crthis vas may tie fanvardcd m Inc Office of Investigations ofthe DIA for insnr.aae s,.c,age'ren-'sxiien. 7d izereir_o¢:riJ'mt Me inF-71e2qk11-1- nNne rrnrcdian prmiderl n5m:e is lruetmtt rorreCt � D Offrctal rise owy. Do not virile in fins area,ro tra war vfetetf by div or full!,afficial. I City or Ton: ^ermilQSeense 3 1 su 1 AuthariN(drole one) 1 ?toes d Q Aon l lb 2.3mlding Dep.moon t 3.Ci'pTrrrn Ciel. J Electrical Napecror S.Pluolbing lnspuafor l Olhcr C -1act?::caw: Pa.",S: I - r e Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Supplement Card Registration: 112785 HOME DEPOT USA INC Expiration: 04/22J2019 2455 PACES FERRY RD C-11 HSC ATLANTA,GA 30339 Update Address and return card, Mark reason for change. - ❑ Address El Renewal Cl Employment 11 Lost Card Mice of Consumer AMaae b Business Regulation i= HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return is - - Raeist on Expiration Office of Consumer Affairs and Business Regulation 11Zrn 04222019 10 Park Plaza-Suite 5170 HOME DEPOT USA INC Boston,MA 02118 RICHARD TROIA --- ��.E, -- „Zj4l 2455 PACES FERRY RD C-11 HSC ATI NTA,GA 30339 Undersecretary - Not valid withouf signature L SimaTan•F.-�ntiocas ,•� IIj .�:, j; a5 L if�l'.=.a�•c?oi�te I dcCa;,�:.5�1io-r:a5r. ice�e a'in es�:c;:rinzav-[',or r`cTss —mF1 all"LuAcic'M cc dct:01.14 i0 EN5RCIFFMC L-Fac Saler 4=0.Gr.Coed rif ,.?g ,.x'0.24 ;?CSI T tONAta P4t?PORMF`.NGG RATINGS n �' £HkIJ.iClaAi 9!Rl'c;1S\TA?IP.Oe P.0\01!v11E0.:"i0 hi ii r I I'. .� U:eiquefine=io: OiciG y ON '�jO � .Ivtii Certual,Swh Cev7zl, �-�:-��,.j !; — smm&m STC,1- f!' � IP!C'?aln Oc/Ga-s RoSdzHH-LCA^� ;!' 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