The URL can be used to link to this page

22D-087 (6) 30 SCANLON AVE BP-2019-0576 GIS* COMMONWEALTH OF MASSACHUSETTS Map:Block:22D-087 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:REPLACEMENT WINDOWS/DOORS BUILDING PERMIT Permit# BP-2019-0576 Project# JS-2019-000936 Est.Cost:$3693.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sci. ft.): 75794.40 Owner: FIERST EVA Zoning:URA(100)/WSP(,100)// Applicant: HOME DEPOT AT HOME SERVICES AT.- 30 SCANLON AVE Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCER102908 ISSUED ON.1111512018 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 1 REPLACEMENT WINDOW 1 REPLACEMENT DOOR 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 Degartmggt 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 11/15/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner t > . City of Northampton els - Building Department CtC� � t 212 Main Street Sev a A" Room 100 Yktr�bi#tr Northampton, MA 01060 �� fa phone 413-587-1240 Fax 413-587-1272 Plof A& APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR E EMWtIorl W114=W ILY 3WELLING SECTION 1 -SITE INFORMATION NOV - 8 2018 6p, /q• �'�� 1.1 Property Address: Tis section to be comple ed b office DEPT.OF BUILDING INSPECTIONS Map N0RTHA?JM1 S Unit � ��N�' , % (/ ✓ Zone Overlay District �D Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT {-�— Q fl 2.1 Owner of Record: ��'O-ftzp2l Aki�— Name(Print) �� Current .jlg d z' / Telepho (/ Signature --' 2.2 Authori e Name(P' Current ailing Addres A)4- r Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building blP -PV (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 6. Total =(1 +2+3+4+5) Check Number This Section For Official Use Only BuildingPermit Number: Date Issued: Signature: �zz /013 J? 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 column to be filled in by Building Department Lot Size Frontage .__ . .w_.,...... Setbacks Front Side L:, R: L: R: Rear Building Height Bldg. Square Footage _ Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW O YES O IF YES, date issued:': IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page. and/or Document#: B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ObtainedQ , Date Issued: C. Do any signs exist on the property? YES ® NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement W' dows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0] Other[DJ Brief Des ripti rf Rrpp Work: &L Alteration of existing bedroom Yes No Adding new bedroom Yes No [� Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Ba.lf<New house and or adidMon to existino housing,complete the folloMng: 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 . 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative t work authorized by this building permit application. 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 the a' is an penalties of perj� Print N t Signature of Ow gen Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date km��Zz Signat re Telephone 9.Resilstemd Home knorovement Ca tract Not Applicable ❑ ��/i%;bl� — Company Name Registration Number Add Expiration Date U Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi g permit. Signed Affidavit Attached Yes....... V No...... ❑ City of Northampton Massachusetts r DEPARTMENT OF BUILDING INSPECTIONS �• 212 Main Street • Municipal Building yv a� Northampton, MA 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, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work: Est. Cost: Address of Work: , 4 Date of Permit Application: 0 —2, 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: 1 hereby apply for a building permit as the agent of the owner: Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, l hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton /' S..•-�` sic Massachusetts Y DEPARTMENT OF BUILDING INSPECTIONS S) 212 Main Street • Municipal Building 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 f b74t 1.` y? DEPARTMENT 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, 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 beingperformedat: ), 2— (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) l Signature of Pe it 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 d I Congress Street,Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lesibly Name (Business/Organization/individual): Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.F1 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.[:]l am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Q Building addition 4.[:]l 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 11.Q Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ p Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: _ Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 andpenalties ofperjury 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 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, 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 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 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. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia Form Revised 02-23-15 i 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: I Brett Tabor 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. FIERST Eva New England South 1-6JOBZY2 Customer Last Name Customer First Name Store #/ Branch Name Lead/Customer Order# 30 scanlon ave Florence MA 01062 Customer Address City State Zip (413) 320-18 1 levafierst@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 The Home Depot 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 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 ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR R HT TO Acknowledged by: I X 1 09/25/2018 Custo er's Slgnat re Date Contract Price and Payment Schedule : Payment of the Contract Price is due upon signing unless a different payment schedule is required by law, specified below or in a payment addendum. Contract Price: 1 1025.00 lincludes all applicable taxes. Excludes finance charges.* Sales Tax: 10.00 (If applicable) *Maximum deposit ONL Y applicable in MD, MA, ME(33%), NJ, Wl(99%) Dep. 1 25.0 % Deposit Amount 1256.25 Remaining Contract Balance 1 768.75 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 A I, 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: FT/-20—/20181 Approximate Finish Date: 12/18/2018 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 initialing this paragraph, I consent to receive only electronic records related to this transaction. Initial Acceptance and Authorization : By signing below, you authorize Home Depot to: (a) arrange for Service Provider to perform 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 09/25/2018 1 The Home Depot usto er's Signature Date Service Provider Name X 09/25/2018 908 Boston Turnpike Unit 1 Co- igner (if applicable) Date Service Provider Address X 09/25/2018 Shrewsbury MA 01545 Si ature On 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.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337 Customer Agreement(C,EJ)(31 Jan.18) v 50.1.2 WINDOW SPECIFICATION SHEET - Spec.Sheet#: 1-6JOBZY2 Sheet: 1 of 1 Customer: Eva FIERST Job#:1-6JOBZY2 Consultant: Brett Tabor Date: 09/25/2018 New Window Hinge Locations Existing Window Measurements Grids Product Options Labor Options From outside, Left to Right Bays,Bows Location Color Rough Opening #of bars #of bars Csmnts,1 Pnl, use L,RorS Glass Misc Items Hardware Code Screens For doors use o R o @ Mull "S'=stationary or xt o o t m to o70 N m N "V=operating StyWraps Style Wrs y d o 0 n(5 0 ` o w x m -- o m o d o o N o Room Floor Code (Y/N) Style Code Series Code c w 3 = - ai v a > x > x STD,White, BF,WRAP 1 KITCH 1st DH Y DH 6100 WH WH 32.00 54.00 86 GlassPack:Standard I I SPECIAL CONSIDERATIONS: 1:White Wrap Color Project Notes:36x80 Wincore fiberglass door.Full lite.Clear glass white finish interior and e Interior Casing Type xterior. Bay or Bow window: Seatboard material(vinyl only-Birch or Oak) Bay Project Angle(30 or 45) Bay Flanker Type(DH,SH,or Csmnt) Top of window to soffit(inches) If tied to soffit,color of soffit material I have reviewed and agree with all the job specifications above and the onstruct Roof(Yes or No)" Special Terms and Conditions on the following page Garden Window: eatboard Material(vinyl only-White Pionite,Birch or Oak) • 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: I Brett Tabor 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. FIERST Eva New England South -1 1-6JNY8RL Customer Last Name Customer First Name Store #/ Branch Name Lead/Customer Order# 30 Scanlon Ave I Florence MA 01062 Customer Address City State Zip (413) 320-1894 evafierst@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 The Home Depot I @ 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 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 ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR R CANCEL. Acknowledged by: 09/25/2018 CompCompfEr Signature Date Contract Price a d Payment Schedule : Payment of the Contract Price is due upon signing unless a different payment schedule is required by law, specified below or in a payment addendum. Contract Price: 12668.00 jIncludes all applicable taxes. Excludes finance charges.* Sales Tax: 10.00 (If applicable) *Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, Wl(99%) Dep. 125.0 % Deposit Amount 1667.00 Remaining Contract Balance 12001.00 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: 11/20/2018 Approximate Finish Date: 12/18/2018 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 initialing this paragraph, 1 consent to receive only electronic records related to this transaction. Initial Acceptance and Authorization : By signing below, you authorize Home Depot to: (a) arrange for Service Provider to perform 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 k 09/25/2018 The Home Depot Cv 6r6hr's Signature Date Service Provider Name X F 09/25/2018 1 908 Boston Turnpike Unit 1 Co- i er (if applicable) Date Service Provider Address X 09/25/2018 Shrewsbury MA 01545 nature On 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.B-3,Atlanta,Georgia 30339-Customer Care: 1-800-466-3337 Customer Agreement(C,E,I)(31 Jan.18) v 50.1.2 U C C U °$ 8 ❑ ❑ I It e ❑❑ ° ❑ Off Is ❑oIt � N c 13C - $ �e O _ C3 & Oil III CIO 0 00, a ❑ ® eel � # D ❑ r ❑ ❑ • o e A ❑ ❑ ❑ I d I f f � QjO -1 0 . I I a 000 1h. ❑ d ❑ ...«ate c�0 ❑0 00ac c a 013 00caaa as 110 El � ❑ � � � � 0❑a ❑❑naaeaoc 0cnn❑a■ �aar�c❑aaaoa � �� ~4 0 . � ` � a a t1 a G a D t7 a C CI �� ❑a,^�a t7 n Q n ❑ ❑❑❑ .�, ��1 �a Pqs ❑ Ij ❑ gg 0❑ aana00 13-0o0 o c000a 8 i i F 0 ❑ �.,WG.,�„ I . Ali .. i--- CI ❑ on❑a❑n 00 acaaaa❑ a titin❑ ¢ p� ❑❑: D 0 fl ❑ ; '� a a❑ 0130 c Ca 013 a_ a 0 g 00 , i G xr«�«s,a.oi» 130 00 CO) 0 1300 a a tt 3c p ❑ ; $� was ❑ :. 3 ` u ❑ ; ;, ❑ xr,at+�sau� ❑ - ao na ac�na0a acaaoco aaaaaaaa ❑° � ❑© A till I a 2P"UL. 1Ills o a s o � r -zT---=s?=saw's £££t?b, b0106L3_80 l �i -vs--vv g 'SO-�,F=�rfIe.S'iir`a s--v c us'C!i�r�a i z»'•i:'y v�':.'�S7i I v y I !I Mqyy,2 t ii�sb � Jtl�iv''4u ?iSt4. s?r% �='S =='.aa�iieor.' i ' VSONF,lCfitii 8CV L• %S'J u 12111 2 i 2; it 'Si�� ,i =GG�'}'i1]BiogQ ip 552}'710D uft=�i�4I —�"(^�1�`'•=tI ice=rte t O U'nOS t�0 WON - d �Ss-✓, �� s-s...Y:::�=::�••-=gra----+ -ni 1. `•. '�✓ i �, 2 1 1 �/:." •r.�.A.e..`M...-•r.}:..�:._ _ .t:^'r!«<-��...�•��:afzi ji •: it - :1 ry S.."^;c-•.Z.�� '�?G.••-�3=-. .. • "was_-:,s----��'c.- -^ r.s.�._-.....:�T.„-:.i._� �r i3 2I `j oREI wits i mow?-,am ioolzivn Nma i s 00133-Mr-I 011%,30,10iM d0 i?4i0Y!?i j- ►i �[tll �3itl�si lldd� �? tiEMB Vgr--;V-O' Ij V 4 v i•' ' -3'E.!'-�-82L '•1^2�Cp^_�'2 _i i ... :�F'��. .,:it 3 1 oil:• l- r= 'x i:T-Ef i 2 ...tea•: .- �! :Tr '`- � ► .. • _C2:IRD 7 1„-.E'2 1051 �; •" 2.13��i4.iv a E''�il•�-i2 [-L.l.v i� SS .1 n�6-!�Ja�'��'-.'1�� BILICI�� 2p. JL 4 `i` ti.. 4 �.► . � .�.s.:� +�� fir.. •' '-•'-,�y'`� ��" `a.. a .�`4 .�;IEi"+��.fri �' ..�� 4 OT twl ti. Cnmmomn ieafth of "Massachusetts 4 ,t. , ,:n of Professional Licensure Board of Su Oiling Reguilations and Standards 1SS - g8 ?85 Expires ; 04 ; 2' ;2020 EVAN KOSOBUTSKYY 72 STAFFORD ROAD MONSON MA 01057 y , ommissioner ZlveCl& C +SCC ZCGCl1�LGzP 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 Expiration: 04/22/2019 2455 PACES FERRY RD C-1 l HSC '''i '= �'T----- <iil' ATLANTA,GA 30339 1k,Of Update Address and return card. Mark reason for change. 11 C. 20M-05/11 ❑ Address ❑ Renewal ❑ Employment ❑ Lost Card /xe fr rnfi1rxet1rrf(X rf G�Cl6rClc�cGJC/l; Office of Consumer Affairs&Business Regulation .^ HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only _ -TYPE:Supplement Card before the expiration date. if found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 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 ATLANTA,GA 30339 Undersecretary Not valid withou signature GATE(mm/OD/YYYY) , 1%. R ® CERTIFICATE OF LIABILITY INSURANCE 02/2212018 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 ANE O N AIC No): 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# CN101642069-HomeD-GAW-18-19 INSURER A:Old Republic Insurance Co 24147 INSURED THE HOME DEPOT,INC. INSURER B:Nevl Nam shire Ins Co 23841 HOME DEPOT U.S.A.,INC. INSURER C:HomeRisk Captive Insurance Company 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 TKi :-SERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMBS LTR INS 4WD POLICY NUMBER MM/DD MM/DD A X COMMERCIAL GENERAL LIABILITY h1WZY 312717 03/01/2018 03/01/2019 EACH OCCURRENCE $ 9,000,000 CLAIMS-MADE AI OCCUR PREM T RENTED 1,000,000 PREMISES Ea occurrence $ LIMITS OF POLICY XS MED EXP(Any one person) $ EXCLUDED OF SIR:SIM PER OCC PERSONAL&ADV INJURY $ 9.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 9,000,000 X JECT LOC PRODUCTS-COMP/OP AGG $ 9,000,000 POLICY❑PRO OTHER: I I $ A AUTOMOBILE LIABILITY MWTB312718 I03/01i2018 03101/2019 COMBINED SINGLE LIMIT $ - 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED SELF INSURED AUTO PHY D`:IG BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per acc dent $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEO I I RETENTION S $ B WORKERS COMPENSATION I,VC014122577 (AK,NH,NJ,VT) 03101/2018 03101/2019 X I PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER B Y/N WC 014122578(WI} 0310112018 03/01/2019 5,0110,000 ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED? a N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 5,000 000 If yes,describe under Continued on Additional Pa5,000,000 DESCRIPTION OF OPERATIONS below 9e E.L.DISEASE-POLICY LIMIT $ C Excess Auto 297-1-10011-00-2018 03/01/2018 03/01/2019 Limit: 4,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukhelee —>1Ltvt0w>" ©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 ACORO ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMEDINSURED 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 Cartier.New Hampshire Insurance Company Policy Number.WC 014122576(DC,DE,HI,IN,MD,MN,MT,NY,RI) Effective Date:03/01/2018 Expiration Date:0310112019 (EL)Limit:$1,000,000 Carrier:ACE American Insurance Company Policy Number.WCU C6478322T(QSI)(AZ,CA,IL,NC,ORVA,WA) Effective Date:03/01/2018 Expiration Date:03101/2019 (EL)Limit:$1,000,000 SIR:$1,000,000 SIR for the states of AZ,CA,IL,NC,ORVA,WA Camey.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 Carrier.National Union Fire Insurance Company (( Policy Number.XWC 4595581(QSI)(MA) \� Effective Date:03/01/2018 PAJ Expiration Date:03/01/2019 (EL)Limit:$1,000,000 SIR:$500,000 TX Employers XS Indemnity: Carrierillinios Union Insurance Company Policy Number.TNS C4916693A(T)) Effective Date:03/01/2018 Expiration Date:03101/2019 (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 The Corirsioirtaealth of Ivlasstichusetts Depai•tinent of IndustrirtlAccidents 1 Congl ass Street,Sulte 100 Bostan,dlA 42114-2017 HIJOV tttass.oYliia IN ot'lters'Canipensation Ynsuranee Affidavit:Bijilde:s/Contractors/Elecfricians/l'lumbers. TO BE F=ILED Y111TII TFT.G Pl;wmiTriNG AU I'IIORITl'. Ao Ilieant InformationPlease Print Legibly 1tt?17)ir (3usinesJOrganiratien/Ind�iv1idual}; '�' Add1---ss: City/State/Zi, Are I nu an empluyer?Check tine appropriate box: Type of project(required): .�1 am a_moloyertt'ith cmployccs(iull antYurp n-timc).` 7. F]New construction 2Q 1 am a sol;0opricturor p nrictship and have no cntployees warking forme in 8. E] Remodeling any capacity. ':o workers'comp.insurance rcauired.j fy. F]Demolition am a hanleovrn:r doing all work rnysel Iia t:o.kcrs'camp.insurnttce required 1' 4.'—'j 1 am c itomeow-ner end st=ill I,--hiring cortracturs to conducinll work on ny propert. t will 10 0 Building addition ensure that ail contractors eitherhuvetvarkers'cornpemalion insurance urarasole i 1.❑Electrical repairs or additions proprietors with no employcos. 12.0 Plumbim,repairs or additions 5.gI am a general contractor and 1 have stir ed the suh-contractors listed on the aiiacL.d meal, Tie se s<th centrscturs base cmplo}gas ortd'nave ttiorkerc`comp.insurance.: 13_❑ of repairs 14. Other 6.�Weare a cont oration and its or ices have exereiscu their right orescmption per 1.101-c. �1 vU� E 52.41(4),and we have no cntployees.(io workrm c 'coma.insurance r•Lyuirei.l z. 'Any applicant that cha_ks box=i must also Fill out tit_section ticlott Rhus ins air:ve;::ers'con: rsutian f:olicy ipformcdion. '1-Iomeottmers wito submit this affidavit indicating they ar doiao uil tvoti and t!s Fite outside conuueto s must submit a new afftdavil indicating such. i`. .cowractors:hat check this vox trust attache=s an additional sheet shutt=ing lite netne of uhe stir-eonimctors and staw tthdhcr or not those entities have employees. 11•the snk-contractee i;ave einpla•;;Ys,they rtst povide their:vttrl:r;'camp policy;+umoer. I am rut employer that is providingzvorlrers'eornpen,'rtion inswra/tce;or rity employees. Below.s the poUg and job site information. Insurance Company Nlnreg g Policy or Self-ins.Li:.9AWL qR?35/'�gV1�/ij Expiration tpira/tM1 i�on Dv1 t tc: 3�1-- Job Site address: _ City/State/Zip: / sttach n copy ai•the workers,compensation pa:icy declaration page(shorting the policy n tuber and expiratio date). Failure to secure coverage as required wider N,1GL c. I12,625A is a criminal violation punishable by a tine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP,',TORI:ORDER and a 61te of up to$250.00 a day against the viciator.A copy of this statement may be fenvardcd to the Office of Investigations of the DIA for insurance coverage venfication. I do hereby certify ten the Mill Mer' r} tient Fire vrnurlion provided rebore is Imre and ccorrecl. Signature Date: �Z 0 671 is Phone �'— affrciol use Only. Do runt:shite in tills Draft,r o be complete'l by rally or iolrrr off.•ciui ` City or Town: ??ertnit/I ieense I Issuing Aulhorit3' circle one): I.Board or Health 2.Building Department 3X1r,/Tn Yn Citric 4.Electrical Inspector 5.Plunibing Inspector ii.Other Contict Person: Phone n: i _4