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43-041 (4) 58 AUTUMN DR BP-2019-0841 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-Block:43-041 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categ_o : KITCHEN RENO BUILDING PERMIT Permit# BP-2019-0841 Project# JS-2019-001389 Est. Cost:$13131.00 Fee: $85.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin HOME DEPOT AT HOME SERVICES 101342 Lot Size(sq.ft.): 18382.32 Owner: MARTIN BRUCE S&SOPIE H Zoning: Applicant: HOME DEPOT AT HOME SERVICES AT. 58 AUTUMN DR Applicant Address: Phone: Insurance: 5 RIVERVIEW DR (401935-26332_ Workers Compensation NORTH PROVIDENCER102904 ISSUED ON:1/28/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-DEMO AND INSTALL CABINETS, NEW 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 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 Occupant Signature: FeeType: Date Paid: Amount: Building 1/28/2019 0:00:00 $85.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-0841 APPLICANT/CONTACT PERSON HOME DEPOT AT HOME SERVICES ADDRESS/PHONE 5 RIVERVIEW DR NORTH PROVIDENCE (401)935-2633 O PROPERTY LOCATION 58 AUTUMN DR MAP 43 PARCEL 041 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST EN OD REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid Typeof Construction: DEMO AND INSTALL CABINE PLACEMENT DOOR New Construction Non Structural interior renovations Addition to Existiniz Accessory Structure Building Plans Included: Owner/Statement or License 101342 3 sets of Plans/Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF911MATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay 1- Z8-2o�q Si ature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit I , 212 Main Street Sewer/Septic Availability '•, Room 100 WaterlWell Availability Northampton, MA 01060 Two Sets of Structural Plans < = phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Oth!f3qWi APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE 04 DEM LISH A O MILY DWELLING JAN 2 5 ' �/ SECTION 1 -SITE INFORMATION 2019 ,3—O-/ I, This section to be comp ted y office 1.1 Property Address: �EaT.of r, D SPFCTioNs r/` � Map NORTHAMP7{ Unit- 2 nit 7rr� �I�/% Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Curre i n res Tele—pho a Signature 2.2 Authodzed A ent: ame r Current M cling Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building / Z (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee os'5- 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number l This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissionerlinspector of Buildings Date 1Z de 9 A T-7 11�2 t 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 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 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® 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 ® DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® 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 Q 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 ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[01 Other[dJ Brief De r' tion of Ppo Work: s JGZ 1�) ,44/X�;� yI//Lhl, ,�,t �✓/,� [L Alteration of exis mg bedroom Yes No Adding new bedroom Yes o 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 1, Aeyzl'g—r � as Owner of the subject property hereby authorize kyz� to act on my behalf, in all matters relative to work authorized by this building permit application. J ---) Signature of Owner Date 1, / ' 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 p;a6insnd penalties of perju . > �, Print Name c Signature of Own nt Date / SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: P /{--� Not Applicable Elen—r Name of License Holder: „ ) a�O�/ (_� / �1 / ,6� License Number qV )?221-26;—� IZ Address Expiration Date T ,�► -• D 1 zea Signature Telephone /-3 - 9.Registered Home 1 r veme t Contractor: Not Applicable ❑ -T Y4,r A27` 1/22 4- Company Name � Registration Number / �� ��� y� g Addr, s Expiration 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 buildin rmit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton Massachusetts l A ` DEPARTMENT OF BUILDING INSPECTIONS y 212 Main Street • Municipal Building Northampton, MA 01060 s N 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 pcontracted �with �,pa�cod. corporation or LLC, that entity must be registered Type of Work: 1�---� �/ Est. Cost: Address of Work: 1 • �(l% �7 I 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: 1 hereby apply for a building p rmit as the gent of the owner: w?A Date Contractor Nade 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 �S S� Massachusetts X DEPARTMENT OF BUILDING INSPECTIONS D' 212 Main Street • Municipal Building Northampton, MA 01060 Jft 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 Sx5 ~` SSC �' '• Massachusetts c I. DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building yJti tea' 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: I IV (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 7 Signature of Permit App nt 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 4 y Department of Industrial Accidents 0 I 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 Leeibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): I.[3 1 am a employer with employees(full and/or part-time).* 7. E]New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in S. [] Remodeling any capacity.[No workers'comp,insurance required.] 9. ❑Demolition 3.[:]l am a homeowner doing all work myself.[No workers'comp.insurance required.] 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 1 ].E]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.F]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.] IL *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. 1 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 thepolicy 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. [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-contractors)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 perfonnance 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 �~ FINAL INSTALLATION QUOTE Bruce Martin–REVISED 10/4118 ustomer Name: 7� / / / 10/04/18 final Desi n:# AO-0"lPIP- fZa0, � - 01"-2- 52426160 /� � — 21 OK TO FINAL re-Construction,Demolition,Removal,and Haul Away $3,211.24 Remove existing countertops,cabinets,appliances,and flooring Haul away debris removed from kitchen,cardboard,and install debris Site protection Per Box Cabinet Installation $3,450.27 Cabinet Installation(includes Wall,Base.Includes Shelves,Fillers,Scribe,Toe Kick,Handles,i£Knobs.) Custom Assembly or Installation $211.20 Finish back of island olding Installation $822.69 Molding,each layer priced separately(includes blocking at no charge.Tall filler as backing is charged as a separate layer) 2 layers Electrical $0.00 NO ELECTRICAL WORK IS INCLUDED Plumbing $0.00 NO PLUMBING WORK IS INCLUDED Appliance Installation $0.00 NO APPLIANCE INSTALLATION IS INCLUDED Flooring and Backsplash Installation $1,672.00 Install CeramiGPorclain the backsplash NO FLOOORING WORK IS INCLUDED Drywall Work&Painting $1,689.68 Patch drywall where door Is removed and new door is installed Prime new drywall Additional Charges(if applicable) $1,689.60 Remove doorway and frame in Frame new doorway Install new exterior door Permits Plumbing Building $220.00 Please note permit fees,if listed,are only estimated. By signing this KIW form the customer agrees to pay only the permit fees accessed for this project. Any difference between the estimated fee and the actual accessed fee will be collected from or refunded to the customer. LEAD PAINT TEST–IF LEAD PAINT IS DETECTED ADD$750 FOR LEAD SAFE PROCEEDURES. $165.00 Asbestos may be present in a home built between 1940 and 1990 and Lead Paint may be present in a home built before 1978. Additional charges may occur if the customer does not dispose of product per Federal j Mandate of Lead Safe Practices. General Notes on the Project ON RARE OCCASIONS,ADDITIONAL WORK IS DISCOVERED AFTER A PROJECT HAS STARTED,THE CUSTOMER AGREES THAT THIS ESTIMATE IS VALID ONLY FOR THE WORK LISTED AND THAT ANY ADDITIONAL WORK THAT IS DISCOVERED AFTER THE PROJECT HAS BEGUN THAT WAS EITHER MISSED ON THE ORIGINAL BID OR ARISES DUE TO UNFORESEEN CIRCUMSTANCES WILL RESULT IN ADDITIONAL CHARGES THAT MUST BE PAID FOR BEFORE THE WORK CAN BE COMPLETED. Cabinet Total Installation Total Customer Signature: Date: /Z C Signature: Date: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Su'pervisor CS -101342 Expires : 08/ 11 /2020 JOSEPH S ROTH "v 40 RUSSELL S STREET GREAT BARRI NGTON MA 01230 Commissioner The CojivPoilwL'ftlt>tl t fit'1•tlssaeliifsetts ;—` Deprzr raent rlflitdustridAecidents 1 Coai;gress Street,Shite 100 l osttti,MA 0211-4-2017 `tom--��,� tY3s%i'r.ftillsS aoY/f�Il7 Workers'Compensation Insurance Affrtlavit:Builders/Con:ractorstLlech•icians/l'lumbers. TO BE i-IL D'VVITIT TITG PElirl•IITrING AUTHORITY. ctrl tlicant.informanon Please Print Legibly 110I71ir {I3usine_JOr�;uri�tiarJlnd�i1idual}: Address: 0�7 City/Smite/Z1 �Z(Xj t}1 Pltcic I' ��% _ 2/✓ 'p��� Are i nu nn empluy er?Choate 11tc npprupriate bot: Type of project(required): 1 Q I am a_rnWover-Mill empl0VCes(tut{andiurpsro-ti neJ.` 7. i<le»'construction i 3.011 a:n a sole p:oprictarur panncrship and have no entployw tvarking ForMle in 3. Remodeling nay cape tv.!`:o worlers'comp.insurance required-j � 3.17 1 air.a i-:umaov:acr loing,all:vont tnscl."". \o=.:ea;cr_-'cams. 9. ❑Demolition { 10 Q Building addition I I i am a homumvncr cad;:•ill t..hiring coriraciurs to conduct-all tvork on nv pror gy. /'viii crsure thrall eartrciarseitherhuveivarkei-s'compensation insurance, 1I.[]Electrical repairs or additions pro,rectors:with no employees. + ioti- 4 I_.�Ptutna'in2 repairs craddit.__.� I am a general contmetor and 1 have hind the sub contractor,listed on the ai•_ched sheet, ! j] cot re IS t nye stili co:ttnclors have c[nployeas snd'nave ieorkcrc'comp.insurance. 14. Olher l 6-F I We are a corPeration snd its oI;cels have exercised their right of t:cmpiien per t,101-c. l 53,S 1(4),and%w:t have no employee-lNo r.orkcr'comp.ins<.rance 'r•.ny applicant that=hacks box=1 mut also fill oai inlbrmntion. 'Homeateners alto submit this atlydavit indicaiing they at:doing all%vork attd dil n hire Dorsi'a contractorsnilL;t submit;i nc5valttSYvit indicating such. :r., ra n^cross'lira cited:this box?7u5E attat:he•�alt additional sheat ilrtavmg the n_:ne GF the sub-eontrr:c:or and state nhctirr,orno:drove en[irics have c:mrl ogees. It'the sub cnntrcior ita:e employees.they rust pinyide their worU •camp policy nurrioer. 1 arm rut er,rploper t?131 is providtrg 1porfters'c0111pe1sif/i011 i.-ISurrviCe f or nzy employees. Below ds the policy and job sire Insurance Company i`arrrle. U / Policy f;or Self-ins.Lie. :XWL �� Expiration Date: 3 l Job Site Address: r ''�1 �fY�!/ a Y �' Citylswle/Zilr A arch n copy a-f the workers'Compensation policy deci2raflon page(showing t-he poiicv number and expiry l0 datc-). Failure to secure coverage as required under ivlGL•c. I12,�2?A is a criminal violation punishable by a line up to$11500.00 andlor one-year imprisonment.as well as civil Pena ties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the viciator.A copy orchis statement may be fonvarded to the Office of Investigations of the DIA for insurance coverage verincatiol. 1 do herebt,cerriif 11n r the i11 to f per' r}that Villeormation provided ubnve is trite and correct. 56anatur_: Date: b cite -- O'Ticiarl use 0114. -0o not:write i11 this LIM%10 by COIIYDlelef/by Ci10 Or t01F11 OfJXieL Citic or Town: Pertnit/License -- issuing Authority(circle ane): 1.Board or Hailih 2.Building Depnrtment 3.Ci_,y/Town C"terk 4-Electrical Inspector 5.Plumbing Inspector ii,Other �5ntnct Person: Phone i A� CERTIFICATE OF LIABILITY INSURANCE 0��8D"'"1/' 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 WANED,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 �iC N Ext): ac N91: 3560 LENOX ROAD,SUITE 2400 ADDRESS: ATLANTA,GA 30326 INSURERS AFFORDING COVERAGE NAIC CN101642069-HomeD-GAW-18-19 INSURER A:Old Republic Insurance Co 24147 INSUREDTHE HOME DEPOT,INC. INSURER B:New Hampshire Ins Co 23841 HOME DEPOT U.S.A.,INC. INSURER C:HomeRisk Captive Insurance Company 2455 PACES FERRY ROAD INSURER 0: BUILDING C-20 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 SHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADOL SUR POLICY EFF POLICY EXP LIMBS LTR IN POLICYNUMBER MMIDD A X COMMERCIAL GENERAL LIABILITY IAWZY312717 03/01/2018 03/01/2019 EACH OCCURRENCE $ 9,000,000 CLAIMS-MADE OCCUR DAMA T R 1 01)0 DDD PREMISES Ea occurrence $ LIMITS OF POLICY XS MED EXP(Any one person) $ EXCLUDED OF SIR:$1M PER OCC PERSONAL 8 ADV INJURY $ 9•000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 9,000,000 X POLICY ECT �LOC 9,000,000 PRODUCTS-COMP/OP AGG $ PRO- OTHER $ A AUTOMOBILE LIABILITY MWTB312718 03!0112018 03/01/2019 COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED SELF INSURED AUTO PHY UNG BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per dent $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ B WORKERS COMPENSATION WC 014122577 (AK,NH,NJ,VT) 0310112018 03101/2019 X PER oTH- 5,000,000 B AND EMPLOYERS'LIABILITY YIN WC 014122578(WI) 03/0112018 0310112019 Y STATUTE ER ANYPROPRIETOR/PARTNERIEXECUTIVE ❑N NIA E.L.EL EACH ACCIDENT $ OFFICCRIMEMBER EXCLUDED? 5,000 OOD (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ If yes,describe under Continued on AJdilional Paye 5,000.000 DESCRIPTION OF OPERATIONS below 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 I LOCATIONS 1 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 Mukherlee __y4_1lun4D" �ji4Jul tca u ©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 ACoRV 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 I 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: Cattier.Indemnity Insurance Company of North America Policy Number.WLR C64783191(ALAR,FL,ID,IA,KS.KY,LA,MS,MO,NE,NM,ND,OK,SGSD,TN,WV.WY) Effective Date:03101/2018 Expiration Date:03101!2019 (EL)Limit:S1.0N,000 Cartier.New Hampshire Insurance Company Policy Number.WC 014122576 (DC,DE,HI,IN,MD.MN,MT,NY,RI) Effective Date:0310112018 Expiration Date:9310112019 (EL)Limit:S 1.0D0,000 Cater ACE American Insurance Company Policy Number WCU 064783221!OSI)(AZ.CA.ILNC,DP VA.WA) Effective Date:03101;2018 Expiration Date:03101!2019 (EL)Limit:S1,000,000 SIR:S1.000.000 SIR for the states of�Z.',A.IL.NC,OR,VA,WA Carrier.National Unwn Fin:Insurance Company Policy Number,XWC 4595580(QSI)(GO CT.GA,ME,MI.NV,OH.P.4 UT; Effective Date:031012018 Expiration Date:0310112019 (EL)Limit:51,000,000 S1,000A00 SIR for the states of CO,ME,NV.MI.OH,PA.UT 5750.000 SIR for the state of GA S350,00D SIR wr the state of CT Cater.National Union Fire insurance Company Policy Number.XWC 4595581 fOSI)(MA) ,1rfV Effective Date:0310112018 ✓' Expiration Date:03!0112019 (EL)Limit:S1,DD0.000 SIR:S500.000 TX Employers XS Indemnity: Carrierlllinios Union Insurance Company Policy Number TNS 114916693A(TX) Effective Date:03101/2018 Expiration.Dale:0310112019 (EL,,Limit:S10.00.000 SIR:S1,000 0 ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r— �_�' _, n✓�L� �'C��121�2-C1 y7lL�PCc!L�� C� `��"G-CCJ%�CGCIZGG:SP�f�.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: 1 12785 2455 PACES FERRY RD C-11 HSC Expiration: 04//22/222/2 019 ATLANTA,GA 30339 Update Address and return card. Mark reason for change. 1 i3 20M-0511 C3 Address E3 Renewal El Employment C3 Lost Card � =�li �%oo-ri+»!orna!all�r.`��.G"�cra5c�c�rrJetfJ 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 I-fOME DEPOT USA INC " Boston,MA 02116 1 � RICHARD TROIA 0 --- 2455 PACES FERRY RD C-11'HSC ATLANTA,GA 30339 Undersecretary Not valid withou signature