24D-267 (2) 4 FRANKLIN CT BP-2019-0251
GIS a: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D-267 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 k BP-2019-0251
Proiect# JS-2019-000403
Est.Cost: $19012.00
Fee: $40.00 PERMISSIONIS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group HOME DEPOT AT HOME SERVICES 106106
Lot Size(so. ft.): 5793.48 Owner: LANNERT COURTNEY N&RYAN C HAYWARD
Zoning, URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 4 FRANKLIN CT
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 0 Workers Compensation
NORTH PROVIDENCER102904 ISSUED ON:8/30/20180:00:00
TO PERFORM THE FOLLOWING WORKINSTALL 15 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 N 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 sienat
FeeTvpe: Date Paid: Amount:
Building 8/30/2018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
nrl Wkv\jo)S
Department use only
City of Northamp Status of
Building Depart AUG 27 W@O ey Permit
212 Main Stre t Sewer
/S Pt
vailabiliy
Room 100 Ebc =n„•I '8
C, ms A ilabiRy
Northampton, MA ', 'n V 3ve�'t$`es o1S aural Plans
phone 413-587-1240 Fax 413-587-1272 PodSite Plans
Other Specify
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 by office
Map�U� Lot d U / Unit
Zone Overlay District
Elm St District CB Distinct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current
af12 Teleph n J7lA'���r1't
Signature
2.2 Authori tlA nt:
N Curr o (ling Add%ss'
L✓
Signa re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building / O (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
yU
4. Mechanical(HVAC) po
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number /y
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature 19 Z7 (8
Building Commissioner/Inspector of Buildings Date
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
This colwm m be filial In by
Building Dcp,ri
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg, Square Footage %
Open Space Footage %
lLol arra minus bldg&Pav cl
hb,61
4 Parking Spaces
Fill:
(volume&Laralion)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoolicablel
New House ❑ Addition ❑ Replacement W' dows Alteration(s) ❑ Roofing ❑
0r Doors
Accessory Bldg. ❑ 0emolition ❑ New Signs [O] Decks [Q Siding [E3] Other(Et]
Brief Des dphan Progo�ry/��-� y�y �y�,r I / il,iG
: iii/✓ 1,/J /%/K YP246 �'H� --
WON
Alteration of existing bedroom_Yes No Adding new bedmom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar Floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I- Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 6� / teORgM
as Owner of the subject
Property
hereby authorize
to act on my behalf,in all matteireative t9 work authorized by this bmlding permit application.
Signature of Owner Date
I, as Owner/Authorized
Agent hereby declare that the statements an mformalion 6n the foregoing application are true and accurate,to the best of my knowledge
and belief,
Signed un the pas and pe It of quq. I
Print Na
Signa is of wner/A eM Dale
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: NotApplicable 11Name of Litems Cn�//lHolder: 2
License Number
-
- "-4
Address � Expiration Date
Signature Telephone
9.Registered Home Im rovement Co frac or: Not Applicable ❑
Com oanv Name Registration Number
Add eExpiration Dale
.phone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152,§25C(8))
Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi permit.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
.a Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS ,y
212 Main Sizeet a Municipal Building
MgrN t.n, NA 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 contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modemization, 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 aro adjacent to such residence or building"be
done by registered contractors.
Note:/f the homeowner has contracted with a/fy°�rp�rorration or LLC, that entity must be registered.
Type of Work: be'/C:L Est. Cost:/ "'W 6D
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 51,000.00
_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:
Date Contractor Name V 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
Massachusetts
D212 TNWMain S e BUILDING icG alINSPECTIONS J S V C
P1Y Main Street • Municipal Building
AerNimpton, MA 01060 ✓p .�,�,
Massachusetts Residential Building Code
Section I IO.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 I10.R5.L3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 750 CMR 110.R5, provided that 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 Northampton
of
f
Massachusetts
1. D2B NOF BUILDING INSPECTIONS VJr
21212Nai.in SLr Mun
• icipal Building
I
'
Northampton, mf 01060
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:
Ll �n A�L�4, &�4�7-
(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)
ti 6"2//VV
Signature of ermit Applicant or Owner Date
1�
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
_ Department of Industrial Accidents
} 1 Congress Street,Suite 100
Roston, MA 02114-2017
www mass.gov/dia
11 to kers'Compensation Insurance Affidavit:Builders/Contracors/Electrieians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name Business/Organization/Individuap:
Address:
City/State/Zip: Phone#:
Are,om m employer?Cheek the appropdate box:
Type of project(required):
L❑I am a wnployer with ar'luyws(rull voul"uyon-ni 7. ❑New construction
2.❑Iamaside pmpnemror Wirehair and have no employees working hateein 8. Remodeling
may esparny. [No worka'i comp. umanm nyuimdJ
3.❑Inmahomeownerdui gallwohmysdC lnownarker mp-i surzwerequireal' 9. ❑Dcmoli[iop
4.❑tmor a hranownerznd will be hiring convactn ecomduct all work on my property. [will 10❑ Building addition
r thus all emilarmn sitha nava wohers'uompereaia...,me l ..,me sole ll.❑Electrical repairs or additions
pmarc prinorz with no cmploycrs.
12.E]Plumbing spans or additions
5 I amnese
general commcmr and I have hired the have
worken; on lined on the attached sheer. 13 ❑Roof reps i r5
'lbesesuh-contaators have employees and have workus'wmp.insurnner.�
L.❑Weno, meantime and its allium have romosed their right or exemption per MCL a 14.❑Other
152,,1(4).and we have,,.employee,,[No workers,ton, ewralwe required]
-Any ii hdm that checks burs#1 mustalro fil I anew scarier below shoring Neinvorkers'roinpensation policy infonratwo
1 funumaoserawho submit this arfidarondratin,they are drum,all work and Man overamide emarecton m.a,-bmit anew andavaindint,such.
:Cmuracmrs that check th'a box must anaehed an additional sheet showing the come aide sub-eamraemra mad nate whether ar a.,done ennne,have
rmi. Iflbcaubaantmemo mvanpl.,,a,they must poode their WrACTS'wmp.policymouser
I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
infarmadon.
Insurance Company Name:
Policy#or Self-ins. Lic.d: Expiration Date:
Jnb Sita 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500110
and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify'tinder the pains and penalties of pevinry 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 S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workerscompensation 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'nn individual,partnership,association,corporation or other legal entity,or tiny two or more
of the foregoing engaged in ajoint 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 ernploys 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 unit acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till our 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 numbers)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 m LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation ofinsurance 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 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
ofthe 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 cement
policy information(if necessary)and under"Job Site Address"the applicant should wale`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 proofthat a valid affidavit is on file for future permits or licenses. Anew affidavit most 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 bum leaves etc.)said person is NOT required to complem this all-tdavit.
'I he 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 1-877-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 lot 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 ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of ter 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,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 aeceptahle 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. Han LLC r LLP does have employees,a policy
is required. Be advised that this affidavit maybe 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 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
Deparlmem 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 perninlicense 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 the affidavit that has been Officially stamped or marked by the city err town
may be provided to the applicant as proof hat a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out cath year. Where a hone 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.govidia
Goan Revised 02-23-15
Home Improvement Agreement: Page 1
Home Depot License Number(s): Visit www.homedepm.cram/r/SV_HS_Contractor_License_Numbers for latest license info
A: 107774, 112785
Salesperson Name: oseph sallivan Registration No. (if applicable): 0
Home Depot U.S.A., Inc. ("Home Depot") or service provider named below ("Service Provider") will
furnish, install or service the equipment listed below at the price, terms and conditions as outlined on
this form.
lannert Icourtney ew England Southj -6A68093
Customer Last Name Customer First Name Store#/ Branch Name Lead/Customer Order#
4 Franklin court Northampton 01060
Customer Address City State Zip
(413) 341-3245 ourtney.lannert@gmail.com
Home Phone# Work Phone# Cell Phone# Customer Email Address
NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR
OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT HOME DEPOT USA INC.,
2455 PACES FERRY ROAD, BLDG. B-3, ATLANTA, GEORGIA 30339 or EMAIL
he Home Depot @ ustomercancellationnortheast@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 PAYMENTS 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 SERVICE PROVIDER, 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 DEPOTS EXPENSE.
THE LAW REQUIRES THAT HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO
CANCEL. PLEASE SIGN BELO TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND
WRITTEN NOTICE OF YOUR T TO CANCEL.
Acknowledged by: 07/23/2018
Customer's Si at t�� Date
Contract Price and Payment Schedule : Payment of the Contr ct Price is due upon signing unless a
different payment schedule is required by law, specified below or in a payment addendum.
Contract Price: soll.so Includes all applicable taxes. Excludes finance charges."
Sales Tax: o.00 (If applicable)
`Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, WI (99%)
Dep. 25.0 % Deposit Amount 752.so Remaining Contract Balance 14258.70
The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Gsorgla 30339-Customer Care: 1.800.166-3337
Cve wb—w44ep n1 den.is) r0.is
Home Improvement Agreement: Page 2
Finance Charges : Any interest payments or other finance charges will be determined by
Customer's separate cardholder or loan agreement, to which 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 payments made payable to Home
Depot.
Insurance proceeds will will not v be used to pay some or all of the total amount of sale.
Description of Work to be Performed : A detailed description of the work to be performed is included
in the paragraph entitled Scope of Work or Specification which is included in this Agreement.
Anticipated Delivery Date/Installation Schedule
Approximate Start Date: os/17/zole Approximate Finish Date: 10/15/2o1e
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 entails and PDF documents.
By initialing this paragraph, I consent to receive only electronic records related to this transaction.
nn Initial
Acceptance and Authorization : By signing below, you authorize Home Depot to: (a) arrange for
Service Provider to perform any Services 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 or permitting information may need to
be provided to You later.) By signing, you acknowledge that: (1) You have read, understand, and accept
this Agreement in its entirety, including the General Conditions and State Supplement, if any; (II) You
are receiving a complete copy of this Agreement; and (111) all rights and interests under this Agreement
are solely vested in the person listed as "Customer" above.
ri
I
X 07/23/2018 he Home Depot
Customer' Si s e Date Service Provider Name
X 07/23/2018 908 Boston Turnpike Unit 1
Co-� a plica le) Date Service Provider Address
X 07/23/2018Shrewsbury MA 01545
Sloffature On Behalf of Home Depot Date City State Zip
MVendor/Service Provider Phone # Service Provider License Number
The Home Depot-2455 Paws Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1-800-466-3337
Curbew/ens,wel lC,EII M I..,11 v wl R
AnEereen Wa SPEC SHEET SC +e:eon smn... MAGI TecM1: INSTALLER:
S—h Nvme: 4E.s.ei..e sewn Bopp 1 EA—E we ne ISM:
� b
9 h �y Yfi dio M'^
Y + wp A
n.
GI
MID"
TI ft- Tll
HH 11.
E- IGGE GH] aw
fi
cdw .eob
G �EE HE I -M. ,H -H.
A
m E J -Z G- EDGE G- -h HT HIJ -11 1-1� wat
,n
Andersen Wood SPEC SHEET SC: d—P^3 %eee.re Teoh: INSTALLER:
areae H.re..a. E u.a z^m^ dour. .^euu3 P.. iw a ISM:
9eN 7Q ARRI POSA 11,1111"SPage of a SPEC
ARA
SHEETY
ww. Ra�mmae« ''oraGv �e�
da m w:
�eeo;eeeeeee 7'.
ED
PAC, Ej TO I T I A .—S R, —n
JL
� m s
CAAA Am c� CODE HAILET w']TP OCR 1— A ROD, CAR,
Andersen Wood SPEC SHEET SC: +.••an ais^. Measure Taoh: INSTALLER:
e�arcn rvame. .mu+.a so.m coos. s.esom a.. .w ISM:
snit'T.L e- • aswmv uame. =•. .•. ..... Pagel of + spec sae
sHEsr• REF>
u
.�
- rsua.a.s� of of
w sw
coos oo coo
To
xswoomwr
�., oW
»reg»E S( .. ..,.e .
Andersen Woof SPEC SHEET SC: +a•nn-T— Measure Tech: INSTALLER:
Barcn Name x.maims sown fop. —A—C wepa.ae By: ISM:
STIR T.DIP— C....... CAC�C— Page° of ° APRN SrveeTr asp
.�n�xew a �� ao ART � DDII C-1 CATE ARI '-I —A —1 A. CODE COUP TRA, E'DD t— CODE CODES
LARANN, TRIAT ON 'TJ I
yce JE.-- M :i ��,
A». oow�,
CAR DID
TINT
DE]NO
C,P, CNIN CODE —C.' "I URALNAI PRON. D. Oz,, EV, A.,P—, m
AC`s Off® CERTIFICATE OF LIABILITY INSURANCEGm-ni OribR W
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: It the certificate holder Is an ADDITIONAL INSURED,the pohry(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,suh)ect to the terms and conditions of the policy,cedaln policies may require an endorsement. A statement an
this certificate does not curler rights to the certificate hDlder in lieu of. ED endomemem(s).
PRODUCER O.N.
MARSH USA,INC. xAME'
TR'0 ALLIANCE CENTER vxoxE ED,
I FAX
350 LENOX ROAD.SUITE 2400 BMAIL SC No:
ATLANTA,GA 3D326 ADDRESS:
INSURIERES1 AFFORDING COVERAGE NAIG6
CNI0RM2M9HanCOGAW-MI9 INBVRER A:Oh Ra [1IFLn 11YC2 Cn 24147
INSURED
THE HOME DEPOT.INC xlsuaERe-.EId4Y Ham sM1'ae ins Ca 230.43
H(JML DEPUT U S A.,IVT:. INSURER C:4 GNI2RISl Cd IIVp OLRdRC f.0nll dA
245.5 PACES FERRY ROAD
BUILDING C20 INSURER D:
ATLANTA,CA 30339 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATLa0435363916 REVISION NUMBER: 3
THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
gEXCLUSIONS AND CONDITIONS OF SUCH POUCHES.LIMITS SHOWN AMY HAVE BEEN REDUCED BY PAID CLAIMS.
ILm TYPEOFINSURANCE A�LSDBR POLICY EFF POtICE%P
0 POLILYNUYBER MWp BM
LIMITS
A X CO MMERCWLGENERALUSERITY RIWZY312)11 03111112018 O'wInN19 FACHOCCUMENCE $ 9000 '1'6
cwlmsNAOE OOccuR PRE GER 6 c=mOrervx E 1000600
LIMITS OF POLICY XS EXCLUDE[)
MER EXP(MYPxmnl 5
OF SIR SIMPER OCC PERSOxALapDVry WJURv $ 4061
GENL AGGREGATE UMITAPPLIES PER: 9000,000
GENEMLAGGREGATE S
X POLICY El 1Eo- [71LOL
PRODVLLS-COMP/OP AEG 9.660OY.1
omB $$
A AmomOBLLEugaILI1Y IrNJi6312718 03'OL2mR 0316112019 COMBINED
DILY,Dr IxGLE LIMO $ 1000000
I
A PNV AUTO BOINJURY TPN pN50n) b
OMMED ""'LEI SELF INSURED AU IO PHI'U`.IG
OS ONLY gUT05 BODILY INJURY P¢=a[tiEmN E
PROPERTY DAMCGE
ACT. NLV A OS ONLY Per $
VMDRALAUAa OCWR
EACHOCCURRENCE $
EXCESS LAB LLAIMSM40E
AGGREGATE $
OED RETENTION$ $
R WORKERS COMPENSATION VJC.6141225TT (AK NH.NT.1/f) 0.U1R018 Oli01R019 g I PER OTH-
r EMPLOYERSLYBIUTY STANIE ER
B ANYPROPRIETOwPmTNER1 ECUDVE YIN WC0141225TBIWl) 03MI12018 03M12019 5.00.060
OFFIC-MEMBER CXCLUDEDt ❑N XIP EL EACH ACCIDENT E
IManJala=y.n NNf EL.DSEASE-EAEMPLOYEE $ SOLD Dun
0 CCDELL.R wee. CGnlNuetl on Aitlit'lonal Pa
OEECRIPTION OF OPEMiIONS Ccbw 9C EL DISEASE-POLICY LIMIT $ 1000000
C Ex Ill ADW 2971-10611,0 18 TERRARIA 03^J112019 Unni 4000006
DESCRIPTION OF OPERATIONS/LOUTRINS I VEHICLES AEORD 101,AE SS—D Wmn YYxJvI, ay Oc atla.-Ald 0m—pau Is mqulmM
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
HOME OEPoT USA.INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
2455 PACES FERRY ROAD THE ESPIRAILON DATE THEREOF, NOTICE WILL BE DELIVERED IN
BUILDING C 20 ACCORDANCE WOR THE POLICY PROVISIONS.
ATLANI q,GA 30339
AIIIHORIIEOREPRESUNTATVE
of Marsh USA Int
Manashi Mukheow
O 1988-2016 ADORE,CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: CN101642059
LOC#: Atlanta
l4 O® ADDITIONAL REMARKS SCHEDULE Page 2 of 3
Bell NAMED INSURED
MARSH USA.INC. ME HOME DEPOT,INC.
HOME DEPOT U.S.A.,INC.
MUCY NUMBER 2455 PACES FERRY ROAD
BUILDING C-20
BRIERATLANTA,Co, 30339
rUlc roof
EFEEGIIVE DATE.-
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM 13 A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificale of Liability Insurance
Wak"C.11,11lbo Canllnaed
Comer.laefommly 111.11,C.,A,m Nunh AiMi[,
Palley Norme, WLR C64 783191 SLAR FULL[AID KV LA M500.141 ND OK SC ED NVN IW)
Ef iw Oale'.0310112010
Expvalan Oale'.0310112019
(EL)Om0'.$1,000 ME
Caul,-New H1.11hm I.1,I eCompoay
PuP,NmMx.WC 0141225]6 IOC,DE,HI,IN,MO,MN.MLNY,RI)
Hrslice Dale'.031O i
FxmaeNI Dale:m101121119
ILL)LOU.$1,000,CUP
e-.ALL Amerc,9lm bmbro.Company
Poll WCU COM322T RSO(A2.CNLN( ORVAWA
ELI Date'.030117DIB
Expl/dl n Dale'.O101k019
(ELI Dmd.S1.0DD.aoD
SIR SI OOO,OW SIR 1m Ilre SIaIe50l AZ.CADU N6,OR,VA,WA
Camm Nalmnal Uuun Em I.I.al Company
Pdl_ry Numha )VT 4595500(OSO EDICT OA,ML MI,NV AH,PA,Jr,
Eel Dale'.0211
Explraten Dale 0310112019
(ELI OmiI'.S''.00D OLD
$1001 W.SIR for lh=11,11501 COME NV A11,OH PA,UI
VD)0W SIR lu be 1141 oI CA
S3'D ON SIR(rc lM%lae of Of
rr.Nalwval arse Foe Ilowavnecvmp,m
FallIal V Dale )Wc 4591101(OSl1 MA)
Enxllrre Dale D310I e
Fapnafan Date.OWISU19
(ELI OmIe$1 IWO,ON
Tx Null)S hill
Cam III.nms Umm(alrarce Compt
Pdiey Numheee IES C4916693A ITA)
Hudem Dale 03N1a01R
bi,mmon Dale OA112019
LEU LIDO 6100110 COO
SIR El No WO
ACORD 101 (2008101) 02008 ACORD CORPORATION. AN rights reserved.
The ACORD name and logo are registered marks of ACORD
�J f1 F' �07421'yCC�11 Ct/�rll�f? C����6'LCCSiCCC`LCG6B�.i-
. , ' Office of Consumer Affairs and Business Regulation
- 10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
-. Type: Supplement Card
HOME DEPOT USA INC - Registration: 112785
2455 PACES FERRY RD C-11 HSCExpiration: 04/22/2019
ATLANTA,GA 30339
Update Address and return card. Mark reason for change.
15 ❑ Address ❑ Renewal ❑ Employment O Lost Card
Office of Consumer Again 6 Business Heguladon
s - HOME IMPROVEMENT CONTRACTOR Registration valid for inilMdual use only
T ^. TYPE:Supplement Card before the expiration date. H found return to:
Reoistration Exointion Office of Consumer Affairs and Business Regulation
_ 112785 04/22/2019 10 Park Plaza-Butte 5170
HOME DEPOT USA INC - Boston,MA 02116
RICHARD TROIA -
2455 PACES FERRY RD C-11 HSC / -J
ATI-ANTA,GA 00339 Undersecretary Not valid withou signature
The Com inonwenIilr ol"Mossuchuseus
Delawounelit of lndaslrialAccidents
I Congress Street,Suite 1110
Bostonr AM 03114-2077
Bnvli:InasSgov/rlia
M orkers,Compensation insurance AtTdavir:6nilders/Conine[orslIIledricians/Plumbers.
TO BE FILED WITH THE PERMITTING AM 110RIT1'.
Antillean,lnfarmnrion Please Print Lanibiv
N01Bef3usincss/Org;wizalioNlndividuaq:
Address: l� W /(/iv�y1 L
Cily/State/Zi ivy �� Phcne i!: l7�— Z y'J 'pZJJ�
Memnon mnde"er'CaecF iheappmm!nit5.n: Type of project(required):
L[Jlama:.rap!uyerailn__cmnloyca(fullaMlur Cen-tine)•
7. ❑New conswetion i
?.�1 nm a sole Prapriewror Pr,na.rsMpand M1.va n.enPLYe,narking tori m
env capacin_IN'.,mrlxri rare,nrsman-e md' S. C] Remodeling
l.n!en a ne"Neeer Join ml cork -• I 9. 13 Demolition
s m':e[ITo nndxri comp.insivanrc¢gmrm.l+
+ ire a lomcnoner old ill he din .mmccaru!.matlurtai vtxk on my 100 Builiingnddifion
Qi, gc pro". Isvill
enoaa den-'I el@er lmveumrkea'e.mpeniai.n iasoae,e or-.a.alz II.❑Electrical mail.or additions
'eLo curs wdh no cmp!.yes. 12.[]Plumbing repairs or additions
i�IIana seneml comm.,and I nave hied ate sulxonnadnu Hued on the,:eel dsheet.
use albe.nvae:.rshove uaplo}'ca ond'nsve workea'comp.imoneee; I3 CJR9nfrepairs
E.�Wc are zv.rp.mli.nsnd its officers hole u-c¢ised th[irrirj:rofeemp:ion F=r Clpl,e 14nX,LVlher
.i±.411x1.antl ar imvu:o emPi.pees iNo ao+5eri mon ins:vene'e cvui:ed.1
'Any upplieam than chttksMxi:I must.Iso rill ouni:zs.•c:ion Mlosyshmvim N.i:o'm:'srs'comDeuminn poli, r.mutien.
*H FLLI n1 01K ehsdmsin. an'Novl:filed ing:ncy acdoiti un Mnl fie oven n!rs outsiJ'_emuuc:ors rarer submit a nnvaffuill. indicating sad+.
rCemrctors!ba:chwk ilia rax m:utunachedaaatltlitlanalahM snw•nng ti:e na3 uien m wnvoicer. dsum mhdhsr.rno:dose mtidei have
empluycs. If IM1e snC[unmgon irz'mempl.yrs.tluY n st Provide their:vmC_rs'comb paiey numcar.
l nm all errpfoye,Mat is p ai idinglearkye's,�'a npensnllon i(xsnxrmacefo„r Arty em/pljo-y(ee+'. �B,eeloonb rheeppoScy�midjjoobbsite
Insurance a -, 4 �Ll� /VV� N�— V(V�g/It 7/KY (Lp'J
jnsumnce Company Name. /�
policy::or Self-ins. U...'.:�W(i�J /,7;/g� Expiration Date: ^✓�J�'
Job Site AddressrJ"67-/]✓/L LWL
Attach a copy of the avorlters'compensation policy declaration page(showing the policy nambe d eipintlon dw.) I
Failure to secure coverage as required under AIOL c. 152,?25P,is a criminal violation punishable by a fine tip to 57,500.00
and/or one-year imprisonment,as ivell 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 ofihis statement may he forwarded to the Orce of Investigations ofthe DIA for insurance
coverage verification,
I do hereby C""tl^fy�mii' the in per that iG/y/r�vrmrgion provided abyooerIs mue and
correct.
it& is m //_ //�n� /�� �iY �,li1.Y D t -
?boma .tel R/]J '" Ci��-16 y
Ofjfcirt!rrre otdj% Bo nohM!a i/r l/ds arca,:o be rampfettm ray div nrimmciv1
City or Town: Permil/Leame S _
Issuing Authority(circle one):
1.Board orHealth 2.Building Department 3.Cityrrorn Clark 4.Electrical Inspector 3.Plumbing Inspector
ii.Other
Contact Person: Phone.`.':
Massachusetts Department of Public Safety MASSACHUSETTS DRIVERS M�
Board of Building Regulations and Standards
LICENSE w i
License: CSSL-106106 �"��
Construction Supervisor Specialty y ss
i , r 0911512016884543160'6
EUGENIUCIUROTARl6 r 2912 21 .
0912911982
23 BENHAM STREET ^
SPRINGFIELD MA 01109 ' NONE, NO}E .,
i ,x23 SENNAM STREET
:. ; SPRINGFIELD MAQttO9.nM
Expiration: +ssExM +excT GA2" +
Commissioner 09129/2020 snuosnsmtsawo,�mms :_. p9I291s2. t
- a =,naw IDul final:orin cac;dltlp 'A,, aoal'rd ut,r3
2 YJIM
b Y
Renewal
ron c by derserLCM
.,,,,,,,
/
FI, alo-ri-23l '4 �
:SNu.J :!:.,M::.. VOOtl/Y'n'/ 'OTpoSite POSIIe IF
:::> •;':•''u"` Dual Arlon Lora-=1
°raduct i/tie. Doable Hung
` _-- ENERG'I 'ERFORNIANCE -A-'NGS
-r3cfor 3clar'-eat 331r �oerlicB�
0 .. %: 9 1 . 65 0 . 31
?DCI GNAL °E FORNIAN^_E RA—NGS
S', IE T-3,smt1arce
0 . 53 —
— — — ,.,,. :,u... e — —
mrr,.;;•�Num..,1
=vq
I —
__ CCL 129-X-935.09�CCL 129-W935.07
Antllusen Comore m RA Ooude-Hung
' ' ,r;O:uMa;:::lrmycaa Sa.frNq xreaps
Startlar7 Rating
F I X-00'. i I'-d4