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38D-062 (3) 59 REVELL AVE BP-2019-0341 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38D-062 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Siding BUILDING PERMIT Permit# BP-2019-0341 Project# JS-2019-000553 Est. Cost: $24641.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const, Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 106106 Lot Size(sq. ft.): 5488.56 Owner: FARRELL KIRBY C&SUSAN R Zoning:URB(100)/ Applicant. HOME DEPOT AT HOME SERVICES AT: 59 REVELL AVE Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCER102908 ISSUED ON.9/21/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.-NEW VINYL SIDING POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 9/21/2018 0:00:00 $60.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Status of Permit: r z�' Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TW/O FAMILY DWELLING SECTION 1 -SITE INFORMATION v t ` -- '3 y/ 1.1 Property Address: This section to be completed by office Map Lot O(jd- Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Rec rd: ,-7�� I,�, �,���L Name(Print) �t A Current ��/.j li / Li� G Tn� 7 Telephdnq Signature 2.2 Authorized A nt: Na Current Maili A dress: Signatu e Telephone Q �� SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection l.� 6. Total= 0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date k dA 7zp /j-/,-�--7 EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 1 Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning 'liis column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L R s L:_�] R:= C� Rear 0 Building Height Bldg. Square Footage 010 Open Space Footage % (Lot area minus bldg&paved ® t� parking) #of Parking Spaces Fill: (volume&Location) -- -- A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® DONT KNOW Q 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 0 Obtained © , Date Issued: C. Do any signs exist on the property? YES © 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 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 Windows Alteration(s) Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding W1 Other[Cq Brief D,,- r; tion of Propo ed ��l L �`�IN/ Work: 1�� D l/ �� Alteration of existing bedroom Yes No Adding new bedroom Yes No ^�+M� Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, L as Owner of the subject property hereby authorize to act on my behalf, in all matter§rela iveto authorized by this building permit application. Ile Signature of Owner Date 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 t and enalties of perjury. Al G � Print Name , Signature of Own gent Date i SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑//� Name of License Holder: �U '►✓t I/ �////f/�i G 1,`ok{06 License Number L-2-q-2,0 Address Expiration Date T y - Signature Telephone 9.Registered HomeImorovemont CgmtEM02r: Not Applicable ❑ Company Name ' "' Registration Number aIV�J Eiq,��Tgr��X . ",q —d Ads pExpi ation Date - Telephone /— SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the build! permit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton Massachusetts �Q}' K- ~;c� DEPAR2WNT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building vsf Northampton, MA 01060 �0 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 pie-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 corporation or LLC,that entity must he registered. Type of Work: Est. Cost: Address of Work: fiiL 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-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 the agent of the owner: Date Contra or 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 Massachusetts ti; sC DEPARTMENT OF BUILDING INSPECTIONS ? ° 212 Main Street • Municipal Building y`I& Northampton, MA 01060 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, 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 Massachusetts to tic DEPAR77-19NT OF BUILDING INSPECTIONS y 212 Main Street •Municipal Building Northampton, MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, 1 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: 5A &4(IL 4� (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) 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 Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 < Boston,MA 02114-2017 www massgov/dia «'orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legible 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 cmployccs(full and/or part-time).* 7. ❑New construction ?.❑I am a sole proprietor or partnership and have no employees working for me in $, ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 1.O i am a homeowner doing all work myself.[No workers'comp,insurance required.]+ 10E]Building addition -l.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 1.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.rl 1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.*- 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] JL "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. Contractors 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 subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a 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 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 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 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)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 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 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)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 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 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia i 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 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)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 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 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 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 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 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax#617-727-7749 www.mass.gov/dia Form Revised 02-23-15 Home Improvement Agreement: Page 1 Home Depot License Number(s): Visit www.homedepot.com/c/SV HS Contractor License__Numbers for latest license info MA: 107774, 112785 Salesperson Name: Joseph Sullivan Registration No. (if applicable): 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. FARRELL I KIRBY New England South 1-684BCCR Customer Last Name Customer First Name Store # / Branch Name Lead/Customer Order # 59 Revell Ave Northampton MA 01060 Customer Address City State Zip (413) 586-0879 k1f@comcast.net 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 The Home Depot @ customercanceIlationnortheast@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 DEPOT'S EXPENSE. THE LAW REQUIRES THAT HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKN WLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT T C CEL. Acknowledged by: I I07/04/2018 I Custome s S nature Date Contract Price and Payme Sche ul : Payment of the Contract Price is due upon signing unless a different payment schedule is require fby w, specified below or in a payment addendum. Contract Price: 124641.00 Includes all applicable taxes. Excludes finance charges.' Sales Tax: 10.00 (If applicable) *Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, WI(99%) Dep. 25.0 % Deposit Amount 16160.25 Remaining Contract Balance 18480.75 The Home Depot-2455 Paces Ferry Road, N.W. Bldg. B-3,Atlanta, Georgia 30339-Customer Care: 1-800-466-3337 Customer Agreement(C,E,I)(31 Jan.18) v 50.1.2 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 ✓ 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: 'F08/29/20187 Approximate Finish Date: 09/26/2018 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 initiali is paragraph, I consent to receive only electronic records related to this transaction. ial Accent__c 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: (i) 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 (iii) all rights and interests under this Agreement are solely vested in the person listed as "Customer" above. X 07/04/2018 The Home Depot Cust is S atur Date Service Provider Name X _ 07/04/2018 908 Boston Turnpike Unit 1 Co- ner (if applic le) Date Service Provider Address X 07/04/2018 Shrewsbury MA 01545 S ature n Behalf of Home Depot Date City State Zip MVendor /Service Provider Phone # Service Provider License Number The Home Depot-2455 Paces Ferry Road, N.W. Bldg. 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A..aPvr wwrwe►r�lwe rack<bMVr naw.4rp, #raraawr mw w a R.a.rn,..R N mss, M+'we r ntnw Pty f[aae,.#ae 3 M caq.._ eR-R\ rniyw+srwgnir►wrWraesrae aao.+I rna.a asv,kre++.wwr wa.pee R ;-Irww•yw.,.e+.c«wex,...a.kw R.+r www.wa a w.arnaw R.'R..rK•rl.nk�"r.•r.'""' .. larlr aww alFna.w.n ulCR.ow„rt4ea WaMa.•,illwlYbwW..aMwwark+aw Mw.r+.... alw■rw.wr awns R11....:-IW M naa nn.e.a w..k,,._,.rr+r•n ra Blwa+araearr..eek.K The Coininoinveaftly of jklassuchiise,t.1s Departrinew of InditstrialAccidents I Congress Street,Suite 100 Bostan.AIA 02114-2017 jin Y)v.niass.go vAlla IN arkers'Compensation Insurance Affidavin Bijilde-.-5/Contr.ictors/Electricians/l'lumbers. TO BE FILED WITH THE PERIMIT17ING AUTHORITY. Aoulicint Information Please Print Legibly Name (13usinesvJOrganizatior.Jlndividual): Address: -7U) qpo -4p P, 11 - ir city/statefzi4 me 4:- Arcyru an employer!Check the apprepriatbot Type of project(required): l.n I am a-ernployar with employees(full antYur p3n-tjnic).� 7. Q Nexv construction 2Q 1 am a sol-,proprivtor or p;irtnership and have no craplayeas working ror.111--in 8. Remodeling any capacity.[No workers'comp.insurance nquired.j 9. ❑ Demolition 3.1:3 1 am homeowner doing all work myself.[No woricus'comp.instinar--requaad.I I 10 Q Building addition i am a lwmuav�ner and-,vill L,.-hiring coniniciurs to conductall wark on my porcrty. I will ensure that all crintractors either insurance urnre.:c.lc 11.Q Electrical repairs or additions proprietors with no employers. I 2.Ej Plumbing repairs or additions 5.g I am a general contractor and I have hind the sub-Lontravors listed on the Litauched sheet. 13 R f repairs T hese stit,-contraclors have employees and have work-ars'camp.insurance..' I — 6.F1 we area corporation and its officers have exercised&mirrightore%cmptioa per?.-tcji.c- 14. 011ier 52.§1(4).and the have no employees.(No workers'corm.insurance r�uirt!dj ','.nv applicant that checks box fl must also fill out the section below showing their%vorkers,compensation policy informitilion. T l4orneauners who submit this affidavit indicating they at-,doing all wort',and 2:--r,hire outside contractors must submit-a newal-fidavil indicating such. 'Ca tractors and state whether or not those entities have ,nmactors that cliLck this rriusi.arachad,an addidonal shea sbotving flio na;nL al!he sub-con empluve,:s. it the sob-Lontraclorshave ciriplay—es.they atust provide their--votPurs*camp policy number. I tint air eriplojier thallsproviding workers'coinpensalion hisurlincefor iny employees. Below is the poficv and job size infortnadon. Insurance Company N.,c=iejc Policy"',or Self-ins.Lie.1": Expiration Dec: Job Site Address: City/State/Zip: 61 AtOch a copy al'the workers'cornpens-ition Policy declaration page(showing the policy number and expiration date). Failure to SeCUTC coverage as required under N,1GL c. 151,625A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as;tell as civil penalties in the farm of'a STOP WORN 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 Investigrtions of the DIA for insurance coverage verificalio-ji. I do hereby certify cur the in e fper that the ornialion provided above is true and correct .:j Phone &129 Official use only. Do not ivirite in this area,to by coinpleted by clip or town officiaL City or Town: ?'ermil/I.icense.T Issuing Authority(circle one), 1.Board o r Health 2.Building Department 3,CittylTown Clerk 4-Electrical Inspector 5.Plu tubing Inspector 6.Other Con'trict Person-. Phone 4: y 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 HSC Expiration: 04/22/2019 ATLANTA,GA 30339 Update Address and return card. Mark reason for change. 1 _5 20M-05!11 El Address El Renewal ❑ Employment [I Lost Card --` Office of Consumer Affairs&Business Regulation _ - HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only e TYPE:SuoDlement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation J' 112785 04/22/2019 10 Park Plaza-Suite 5170 HOME DEPOT USA INC Boston,MA 02116 RICHARD TROIA 2455 PACES FERRY RD C-11 HSC ATi.ANTA,GA 30339 Undersecretary Not valid withouf signature i .ICOR" CERTIFICATE OF LIABILITY INSURANCE DATE 0212212018DrvvYY) �.� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or 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 CONTACT MARSH USA,INC. NAME: TWO ALLIANCE CENTER AICONE No Ext): /C No: 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA.GA 30326 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 9 _ CN101642069-HomeD-GAW-18-19 INSURER A:Old RE uHic Insurance Co 24147 INSURED IHE HOME DEPOT,INC. INSURER B-. m NeVI IlaShire Ins CO 23841 HOME DEPOT U.S.A.,INC- INSURER C:HomeRisk Captive Insurance Com an 2455 PACES FERRY ROAD BUILDING C-20 INSURER D ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-004353439-16 REVISION NUMBER: 3 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 S1iE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADOL SUER POLICY EFF POLICY EXP LIMITS LTR INSD VWD POLICY NUMBER MMIDD MMIDDNYYY A X COMMERCIALGENERALLIABILITY TAYZY312717 03!01/2018 03101!2019 EACH OCCURRENCE $ 9,000,000 CLAIMS-MADE � PREMISESS OCCUR DAMAG—ERENTED 1,000,000 PREMEa occurrence $ LIMITS OF POLICY XS MED EXP(Any one person) $ EXCLUDED OF SIR:SIM PER OCC PERSONAL s ADV INJURY $ 9.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 9,000.000 X IECT POLICY 7 LOC 9,000,000 PRODUCTS-COkIPlOP AGG $ OTHER: $ A AUTOMOBILE LIABILITY MWTB312718 03'01.,2016 E 03/01/2019 COa h•1Bccidende.t SINGLE LIMIT $ 1,000.000 a X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED SELF INSURED AUTO PHl'D\4G BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DANIAGE $ AUTOS ONLY AUTOS ONLY Per accident _ 8 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ B WORKERS COMPENSATION WC 014122577 (AK,NH,NJ.VT) 0310112018 03.,'01/2019X STAER PER OTH- AND EMPLOYERS'LIABILITY TUTE B Y/N WC 014122578(VII) 03!01/2018 03/0112019 5,000,000 ANYP RrPARTNERIEXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICI:RiMECRrMEMB[ft EXCLUDED? N N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ i.000 DOD If yes.describe under Continued on ASditional Paye 5.000.000 DESCRIPTION OF OPERATIONS belowE.L.DISEASE-POLICYLIMIT $ C Excess Auto 297-1-10011-00-2018 03/01018 03101/2019 Limit: 4,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may he 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 BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANT A,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukhe6ee M0-v.040►-A ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta A`OR" ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED MARSH USA,INC. THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING G20 ATLANTA,GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Carrier.Indemnity Insurance Company of North America Policy Number.WLR C64783191(ALAR,FL,ID,IA,KS,KY,LA,MS,MO,NE,NM,ND,OK,SC,SD,TN,WV,WY) Effective Date:03/01/2018 Expiration Date:03/01/2019 (EL)Limit:$1,000,000 Carrier:New Hampshire Insurance Company Policy Number WC 014122576 (DC,DE,HI,IN,MD,MN,MT,NY,RI) Effective Date:03/01/2018 Expiration Date:03/01/2019 (EL)Limit:$1,000,000 Gamer:ACE American Insurance Company Policy Number.WCU C64783221(QSI)(AZ,CA,IL,NC,OR,VA,WA) Effective Date:03/01/2018 Expiration Date:03101/2019 (EL)Limit:$1,000,000 SIR:$1,000,000 SIR for the states of 4Z,CA,IL,NC,OR,VA,WA Carrier.National Union Fire Insurance Company Policy Number.XWC 4595580(QSI)(CO,CT,GA ME,MI,NV,OH,PA,UT) Effective Date:03/01/2018 Expiration Date:03/01/2019 (EL)Limit:$1,000,000 $1,000,000 SIR for the states of CO,ME,NV,MI,OH,PA,UT $750,000 SIR for the state of GA $350,000 SIR for the state of CT Camer.National Union Fire Insurance Company Policy Number.XWC 4595581(QSI)(MA) C� Effective Date:03/01/2018 J Expiration Date:03/01/2019 (EL)Limit:$1,000,000 SIR:$500,000 TX Employers XS Indemnity: Camerlllinios Union Insurance Company Policy Number.TNS C4916693A(TX) Effective Date:03/01/2018 Expiration Date:03/01/2019 (EL)Limit:$10,000,000 SIR$1,000,000 ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD t r .. .....,�.v"s:=tu/,_T3..x'.-+. -t ^r:�:r^:C[s:." =,�'iva;�ja�:x�nY�_''aP_`v^.Y[cii'�L-'s-sem`''.-."....•—.._.____.____._.•- �_•';.a�p7 Ln- ..1-T 'it--".'Tft�1 N g•�•TAy� 6^ b'�' d t7XH.'...t.�_„��''falldt��ai�e'�.'w..S-•'.r•;w+a�illni.",I$:�'Frt3'r"� '• '�'YDrI!isl,`r'w: Massachusetts Department of Public Safety BVIASSAL EIIIJE Tm� D R V E�'� Regulations and Standards �,1 g Board sof Building g � _ ,�r.tHuss �,���i{V�l�e r, Q: I" License: CSSL 'i06106 - Construction Supervisor Specialty ���� �k� � �,, , " �'::�.yfrss• - �r�4,,,� Sb t1P;U11911BtRq rrlttl,�;i�,IX1tI,I��, 44?..}�' •T,�,y sr:. •err'"";�5: �;YI Y���Y.,Y U IY J �f.1�p�'U YII`1�I\-1 fi:u` V�` ,; .t = . .,.�. '•: ,. tt7�f? f, floe `' RO CSS '12 VESi' 9::END 23 BENHAM STREET SPR16\lG6= ELD MA 01109 r: ,j ; ' r 2 hUCa{�NIU 23 BENHAM ST SPRINGRELD,MA 01109.2301 It Ex iration. t j.�oSEI(�� ?SHGT6-OT, Commissioner �9p�I 02'� ►: :. a DD0911613o'16Rev 01J27MIG �x... . . '