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23D-007 (7) 58 NONOTUCK ST BP-2019-0787 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23D-007 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv:Door Replacement BUILDING PERMIT Permit# BP-2019-0787 Proiect# JS-2019-001310 Est. Cost: $2370.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sq. ft.): 62290.80 Owner: RIDABBOCK ANNE Zoning URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT. 58 NONOTUCK ST Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCER102908 ISSUED ON.1/10/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 1 DOOR FOR REPLACEMENT POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 1/10/2019 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner _ City of North mpt E C E I V s »=, Building Dep rtm n 77 212 Main S reet s Room 1 0 JAN 1 0 201 Northampton, 01 60 phone 413-587-1240 F x 4 T_ NORTHAMPTON."AA APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION --] 6 A , LJ5 2 1.1 Property Address: This section to be completed by office Map Lot 00 (] Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: :5T-NAI,41,d/Ul%9 -:57— Name ame(Print) J Current Signature Teleptfone 2.2 Authorized Anent: Na mt Current Mai'ng Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Buildingr�' ,��D _ / (a)Building Permit Fee 2. Electrical !1� (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: 140-1 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 Setbacks Front Rear Building Height Open Space Footage % (Lot area minus bldg&paved of Parking Spaces (volume&Location) A. Has aSpecial Permit/Variance/Finding ever been issued for/on the site? NO �� _ DDNTNNOW YES �_� |FYES, date issued: ! '-----------� IF YES: Was the permit recorded atthe Registry ofDeeds? NO «��x�� DON7KNOVV ��»�� YES ��^�� - - '- - - [------ IF YES: enter Book Page_______ | and/or Document#____ _ �� B. Does the s�econtain abroo� body ofwater orwed �� VV �.�wetlands? NO �_� DONT KNOW YES �~� VFYES, has apermit been oxneed tobeobtained from the Conservation Commission? Needs tobmobtained 0 Obtained 0 Date Issued: C. Duany signs exist nnthe pvmper� �� YES �~� NO �_� [---''---- --'- --------------' ---' ------ IF YES, describe size, type and location: i D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 IF YES, describe size, type and Location: . `----' -- ----'--- ---- — ' - - - -' — ' E. Will the construction activity disturb(clearing,grading,excavation,orfilling)over 1acre nrisdpart ofmcommon plan that will disturb over 1acre? YE8K�� NO K�� |FYES,then aNorthampton Storm Water Management Permit from the DPW inrequired. i SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoalicable) New House ❑ Addition ❑ Replacement dows Alteration(s) ❑ Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[a] Other[EJ Brief Description f Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa if New house and or addition to existina housinsa. complete the followina: 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 I, ✓/a'v�' C- ,/�)bA 8044 as Owner of the subject property hereby authorize to act on my behalf, in all matte' �rs r lative to work authorized by this building permit application .Z � i Signature of Owner Date l 12L as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains a enaltie of perjury. Print Name < Signature of Ow r/A a eDate SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: )�, Not Applicable 11 / Name of License Holder: l/'�� " /0.��iC7 CJ � Al License Number Address Expiration Date Signature Telephone �/Pj 9.Registered Home ImDrovement Contractor: Not Applicable ❑ Company Name � Registration Number Ad ress � Expiration Date &14�091ephone_� // ,:;� SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152,§25C(6)) Workers Compensation Insurance affidavit m t be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin ermit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton i�,� - ' Sys :{•;.Sic Massachusetts �o #► '<< c DEPARTMENT OF BUILDING INSPECTIONS ; 212 Main Street • Municipal Building vyb Northampton, MA 01060 ��a 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 he registered. Type of Work: fL Al ef��`�yT_ Est. Cost: 0, — 7� � Address of Work: �T `i4G Z 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 Contractor Namv 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 F° `G wt � N[ DEPARTMENT OF BUILDING INSPECTIONS 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 r w' •.yam :. �. DEPARTNENT OF BUILDING INSPECTIONS 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 being performed at: (Please print house number and street name) Is to be disposed of at: (11/ 9/ i (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 d 1 Congress Street,Suite 100 Boston, MA 02114-2017 www mass.gov/dia «"orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): I.❑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. ❑ Remodeling any capacity.[No workers'comp.insurance required] 9. El Demolition 3.[3 i am a homeowner doing all work myself.[No workers'comp,insurance required.]`' 10❑Building addition 4.❑1 apt 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 I.[]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.❑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.] *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 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.Lie.#: 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. Ido 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 permitilicense 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 y 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-MASSA-FE Fax#617-727-7749 www.mass.gov/dia Form Revised 02-23-15 } Job Contacts Thursday,December 20,2018 Comments Lead: 110860255 —201Advanced Search 10:12 AM Commissions Homeowner M/M anne ridabock Sale Amount $2,370.65 Balance Due: $1,777.99 Homeowner2 M/M Product Wincore Entry Doors(8%) Documents Job Site Address 58 Nonotuck Street Status Sale/Material Ordered Florence,MA 01062 Branch New England South Job Issues Siebel Lead ID Siebel# Slebel Order# Measure# Order Detail County HAMPSHIRE 1-AUTRKWN 1-23631804311 183709 89039630 Billing Address 58 Nonotuck Street ��€ ? � Payments � Florence,MA 01062 Commission Rate Permits Consultant Name Tenn Date Solit Comp Plan PO Primary Phone (413)695-8944 KYLE T HARMON 100.00%Straight Commission Work Phone Ext 0 Result Combo Cell Phone Services Work Phone 2 Sale Date 12/6/2018 FUP Date Cell Phone 2 Credit Data 12/6/2018 FPD-Customer Show Map Email anneddabock@gmail.com RTP Data 12/10/2018 Post Install Date TouchPoints Cross Street Start Date 1/28/2019 FPD-Home Depot Inspection B-Back: No Update Job K Referral Store 8452-HADLEY Work Orders Base Store 8452-HADLEY Lead Paint:Assumed-LSWP Requir Lead Source 0250 Store Associate-Siebel Lead Paint in EWR:ASSUMED Document Status in EWR:PENDING Jerome Harris L 12/13/2018 9:49 AM Material Ordered No 12/6/2018 12:00 PM KYLE T HARMON Jerome Harris 12/13/2018 9:47 AM Order Received-PSG No 12/6/2018 12:00 PM KYLE T HARMON Brandi Johnson 12/10/2018 10:21 AM Released to Production No 12/6/2018 12:00 PM KYLE T HARMON Brandi Johnson 12/10/2018 10:11 AM Order Entry No 12/6/2018 12:00 PM KYLE T HARMON KYLE T HARMON 12/6/2018 12:51 PM Credit Pending No 12/6/2018 12:00 PM KYLE T HARMON KYLE T HARMON 12/6/2018 12:51 PM Sale Pending No 12/6/2018 12:00 PM KYLE T HARMON KYLE T HARMON 12/6/2018 12:51 PM Sent to the Field No 12/6/2018 12:00 PM KYLE T HARMON KYLE T HARMON 12/6/201 12:51 PM Lead Entered No Close Print Home Improvement Agreement: Pagel Home Depot License#'s - For the most current listing www.Homedepot.com/LicenseNumbers MA: 107774, 112785 Kyle Harmon Salesperson Name: eglstration No. if applicable): Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/ or service the equipment listed below at the price, terms and conditions as outlined on this form. ridabock anne New England South 1-AUTRKWN customer Last Name Customer First Name Store # Branc 1Name Customer Lead 58 Nonotuck Street I IFlorence IMA 101062 Customer Address ity State Zip (413) 695-8944 1 anneridabock@gmail.com Home Phone# Work 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: 908 Boston Turnpike Unit 1 1 IShrewsbury I MA 01545 Address city State Zip Or Email: customercancellationnortheast@homedepot.com Service Provider Email Address BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN-YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR 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 THE 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_QF YOUR RIGHT TO ANCEL. Acknowledged by: 12/06/2018 ustomer's Signature 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: $ 12370.65 Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ 0.00 (If applicable) *Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, Wl(9991o) Dep. 125.0 % Deposit Amount $ 592.67 1 Remaining Balance $ 11777.98 The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1-800-466-3337 460 HDE Customer Agreement(24 Jul.18) v 0.1.7 Home Improvement Agreement: Page2 Finance Charges: "Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payment(s) made payable to The Home Depot. Insurance proceeds will will not -/ be used to pay some or all of the total amount of sale. Description of Work to be Performed: Installation of JEntry Doors A more detailed description of the work to be performed is included int the section entitle cope o T::] Work which appears on page 0 of this Agreement. Anticipated Delivery Date/Installation Schedule Approximate Start Date: 01/31/2019 Approximate Finish Date: 02/28/2019 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 ini ialing this paragraph, I consent to receive only electronic records related to this transaction. Initial Acceptance and Authorization: By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation and/or (b) order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this Agreement. Do not sign if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.) By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety, including the General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a ;co;mllete copy of thi-a Agreement. Keep it to protect your legal rights. 12/06/2018 J The Home Depot Customer's Signature Date Service Provider Name X 12/06/2018 908 Boston Turnpike Unit 1 o- I e) Date Service Provider Address X 12/06/2018 ShrewsburyMA 01545 Behalf o Home Depot Date City tate Zip Service Provider Phone NumberService Provider License Number The Home Depot-2455 Paces Ferry Road, N.W. Bldg. B-3,Atlanta, Georgia 30339-Customer Care: 1-800-466-3337 460 HDE Customer Agreement(24 Jul.18) v 0.1.7 w PROJECT SPECIFICATION Date: 12/06/2018 Branch: New England South Sales Consultant: Kyle Harmon CSC Phone: HOME DEPOT PHONE: (877)-903-3768 Sales Consultant Phone#: (407) 276-4300 License(s): INSTALLATION ADDRESS: 58 Nonotuck Street Florence MA 01062 Job#: 1-AUTRKWN PURCHASER(S): Work Phone Home Phone Cell Phone anne ridabock (413) 695-8944 PROJECT NAME: Entry Doors Quote Customer 12/06/2018 Signature: 6', Date: St 1 Entry Doors Wincore Entry Doors Project Name: Entry Doors Quote Sheet 1 of 1 ... ,�,�` �,. +•;mow� ;F;� r � b. x • - + 1 '7i .ie y 7 .x Yyy�� of Massachusetts ,.t-f stop of Professional Licensure Beard of Burldmg Regulations and Standards _r F i _ c txpIres . 04i2r '2020 UAN KOSOBUTSKYY 72 STAFFORD ROAD MONSON MA 01067 it ommissioner r � The CorF mon3vaulth of kfassachmsetIs M. Deparii;•rment nfIndtistrialAccidents 11 �otzgr-ess Street,Suite 100 gostarz,AL-142113 2017 mnp):)sassgo3rltlia Workers'Compenshiion Tnstrranre Affidavit:finildea S/Con:ractnrs/Elecfricians/1'lumbers. ?"C3 Br Irll,il�tI'I7'fi i NG PElirl•IITPI ti'G:11I'�iIOR17'Z'. Ac1lfeant Information !'lease Print Legibly I��17t2(IIusintsJOrg:usi otienllnt��livi11dual): Addl-ess-. D� /!/ 1r ./V PKE: City/State/Li '� (yj �1 Phone 1 Are lnu an employer?Check liteappruprisic boa: Type of project(required): .Vith employ:es(full andlur p r[-timd).� 7_ �Xexv constntclion i l an e:sole is rietar ur partnership and NYC no em to`e_s warkin� Por ire to '-Q p p p' p s 8. [] Remodeling cny capacity.ii`:o workers'comp.insumlicc reilufre'.� 1 9. ❑Demolition 3.1 ?mn a humea%v:ter doing all vlar:nays elF.1\o r.or).cr`enmp.insun!mre,n:gmrc_1 t � f 10[]Building addition ` 4.J 1 am a homeowner cad ivill''I hiring carlraciars to conductail work on ny property. I will f I ensure 61at 211 contractors either huve:cort;c.�cotnperdation insurance urnrzsrie i 1.[]:11cctrical repairs or additions pro;trietors:sett no cmployeos 12.0 Plumbing repairs or additions 5 I am a genera)contractor and I have hired the sub-uonirastor listed on the anachad sheet. 13-Q R repairs T nese s[ih ce:ltrsctals have cinaloyces crtd have::rockers`comp.imumnea. ��}4✓' r-�we are a corporation and its officers have exercised their right or escinpticn_ei Ia01.C. 52,x 1(4),and.v-have no employees.(tio s orb crs'comp.insssaice utred.) 'Any applicant that checks box=1 must also fill ow til_=tion)claw shu;vins ibci;tsei cis'conlp:rsatian policy inromution. I Honeo::ners who submit this affidavit indicating they ar dain_all wor'tc and Ulan hire ouisioa conuuetors Bust submit a new airrdavit indicating such. is ,Contrcto;:char checY.this box TusE anacstec alt additional=_hm[eke:Ang the n_me ci ttc sub--muraetora one state tvh:ti:r or fiat dlosc entities hive �- employe'-s. lf•the sub-runty_torsiia,eetnpluyces•they rrstparAdetheir woti:ars camp policynurriu:r. _ i Wit all is imirrillce f yr my etnployees. Below is the policy algid jobsite Insurance Company Policy or Self-ins.Lie.$A , ./5� EXUiration bate: Job Site Address: ��// ' Citylstaielzi A t'lelt a-,Opti of the workers'compensation policy declaration pttge(showing fire policy umber and expira�on date). ®1/42 Failure to secure coverage as required under MGL c. I,52,§25A is a criminal violation punishable by a fine up to SI,500.00 and/or one-year imprisonment,as,yell as civil penalties in the form ora STOP,VORK ORDER and a fine of up to$250.0.0 a day against the violator.A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance ccvcrage;ert :cation. '- ii i do laere�p certrJt«n i the ill r to f per' r}that lite' ornrrrlion providers above is!rile and correct. i 3.: Signature; ie: 'honer Ofjiciai rtse Orflf: -001-fat Wrsle in tills area,io he co1:Fpleteit by cltp or rown OfJ.ciaL i Ciiy or Town: 'Permil/1 icense 44 t =ssuing:authority(circle one): I.Board of Iieslth Z.BuildinDepartment 3.Ci:rt Fawn Gerh 4.Electrical Inspector S.Plumbing Inspector _ ii.Ot her u0ntact Person: Phone r: t =ate 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 + ---? „FExpiration: 04/22/2019 ATLANTA,GA 30339 Update Address and return card. Mark reason for change. ❑ Address ❑ Renewal ❑Employment ❑ Lost Card =J��• I�nIi�I/e CIi�I!Ptllf�rf�(�iii:iClr�UJ[aY.i -� - Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only -+ X TYPE:Supplement Card before the expiration date. If found return to: R2gistration Expiratign 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 D1YYYY A�V CERTIFICATE 4F LIABILITY INSURANCE Do2fz norma ' THIS CERTIFICATE 1S 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 actio Ext): A 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 Republic Insurance CO 24147 INSURED THE HOME DEPOT,INC. INSURER s-.IdeC!Hampshire Ins Co 23$4I HOME DEPOT U.S.A.,INC. INSURER C.-HomeMsk Capthe hsurance Compn 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 THE'TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE ADOL POLICY EFF POLICYEXP LTR 1 SD D POLICY NUMBER MMIDD A X COMMERCIAL GENERALLIABIUTY Mli2Y312717 03/01/2018 0310112019 EACH OCCURRENCE $ 9,00D.1100 CLAIMS-MADE a OCCUR DAMA T R TEO 1,000.000 PREMISES Ea occurrence 5 LIMITS OF POLICY XS MED EXP(Any one person) S EXCLUDED OF SIR:SIN,PER OCC PERSONAL&ADV INJURY S 9.000.000 GENT-AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S 9.000.0OU X POLICY CLOC PRODUCTS S 9'w0'000 OTHER: $ A AUTOMOBILE LIABILITY rOWTB312718 0310112018 03/01/2019 CEfaA�EeD,SINGLE LIMB S 1.000,000 X •ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED SELF INSURED AUTO PHY 0%.,IG BODILY INJURY(Peraccident) S AUTOS ONLY AUTOS HIRED I NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Wer accident 5 UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED I I RETENTIONS S B WORKERS COMPENSATION tPlC 014122577 (AK.NHJIJ,VT) 03101/2018 0310112019 X ER UTE ER AND EMPLOYERS'LIABILITY B YIN tlICp14122576 ' 03/018018 03101@019 5,000.000 ANYPROPRIETORIPARTNER/IXECUTn/E ❑ �� E.L.EACH ACCIDENT 5 OFFICERWEMBEREXCLUDED? N N 1 A (Mandatory in NH) E.L.DISEASE-EA EMPLOY S 5.000.0-0 It yes,describe under 5.000.000 Page DESCRIPTION OF OPERATIONS belrnr B EL DISEASE-POLICY LIMIT $ Continued on Additional Pa C Excess Auto 297-1-10011-00-2018 03/01/2018 03/01/2019 Limit: 4.000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I 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. ATLAN I A,GA 30339 AUTHORR ED REPRESENTATIVE of Marsh USA Ina Manash)Mukhedee ©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 ACO Ii ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMEDINSURED MARSH USA,INC. THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. POUCY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 CARRIERATLANTA,GA 30339 NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM 15 A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Carrier:Indemnify Insurance Company of North America PolicyNumber:WLR C64783191(AL.AR,FL,ID,IA.KS.KY,LA.MS,FAO,NE,NM.ND,OK.SC,SD.TN;'N kl1r) Effective Dale:03/01/2018 Expiration Dale:03/0112019 (El)1_imil:S1,000,000 Carder:Nero I lampshve Insurance Company Policy Number.WC 014122S76(DC,DE,HI,IN MD,MN,MT,NY,RQ EftxBve Date:03/0112018 Expiration Dale:0310112019 (EL)Limil:$1,000,000 Carrie.ACE American Insurance Company Policy Number.WCU C64783221(OSP(AZ.CA.IL,NC,OR,VA,r11A; Effective Date:0310112018 Expblion Date:03/0112019 (EQ Limit:$1,000.000 SIR:51,000.000 SIR for the slates of AZ.CA,IL,NC.OR.VA LYA Carrier:National Union Fre Insurance Company Policy Number.XWC 459S58D(OSI)(CO,CT,GA,&iE,MI,NV,OH.PA,UT) Effective Date:03/012018 Expiation Date:031012019 (EL)Limit:51,000,000 S10000 SIR for the states of COMEAWNII,OH,PA,UT $75D,000 SIR for the state of GA 5350.000 SIR for the state of CT Cartier.National Union Fire Insurance Company Policy Number:XWC 4595581(OSI)(M7 ^ Effective Dale:031012016 Expiation Date:0310112019 (EL)Umil:$1,000,000 TX Employers XS Indemnity: Carder:iilinios Union Insurance Comparry Policy Number TN$C4916693A(TX) Effective Dale:031012018 Expiation Date:0310112019 (Eta limit:$10.000.000 SIR:51,000,000 ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD