37-016 (6) 748 FLORENCE RD BP-2019-0986
GIS#: COMMONWEALTH OF MASSACHUSETTS
MaR.Block: 37-016 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: Door Replacement BUILDING PERMIT
Permit BP-2019-0986
Project# JS-2019-001621
Est.Cost $2182.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group' HOME DEPOT AT HOME SERVICES 98785
Lot Size(sa.ft.): 86684.40 Owner: ROTHMAN RACHAL
Zonin : Applicant: HOME DEPOT AT HOME SERVICES
AT: 748 FLORENCE RD
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON:3/11/2019 0:00:00
TO PERFORM THE FOLLOWING WORK INSTALL 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 Finat:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: 91 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 Sionatu
FeeType: Date Paid: Amount:
Building 3/11120190:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
moo�-
Department use only
-'� City of No hart EIVE talus (Permit:
.,> Building D part rb C t/Driveway Permit
212 Mai Str et Swed optic Availability
�I -- Room 100 MAR 1 1 2019 mer ell Availability
Northampton MA 1060 T Se of Structural Plans
phone 413-587-1240 Fax
oar n- .ilii�,.I, ^ Fcr B�Y/Sit Plans
.nn� m.m oo �n�arv° scify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISHQA ONE ORTWO FAMILY
/DWELLING
SECTION 1 -SITE INFORMATION B �- ` -I
1.1 Property Address: ^ This section to be completed by office
70 f/P�_// r ZMapone
�7 Lot as�O Unit
(� `L/KX �^L/ Zgne Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: /
Name(Print) Current Mail rrg Atlyes�^/�-
(%GAS//Gf'R%/ Telephoned
Signature
2.2 Authorized Again 2 ,� �
=I — l Zodi-' �/i�rt 2oj' �NaCur nt Mailin Add( 'V'
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION CGSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermitapplicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee 'yo
4, Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) lry Check Number JAS
This Section For Official Use Only
Building Permit Number: Date
Issued: 2
Signature: a-11 - z(9
Building Commissionerlinspector of Buildings Date
� @
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Sectional. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
'IIii,column m be filial o by
Building P,m.iem
Lot Size
Fronmgc
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(I_ot area minus bldg&paved
mAiv )
#of Parking Spaces
Fill
(volume&Lo,n n)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Documeni
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement W ows Alteration(s) Q Roofing O
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [OI Decks [i Siding
[[C3] —)OttSlyer[a
Brief D: esN/ Zt '0py0 —Work
rD7°— =7�Dr�/6J)�Gs / /lr 9/•�/T/ Z//
Alteration of existing bedroom____—Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ss.if New house and or addition to existing housing, complete the following:
a. Use of building ;One Fani Two Family Other
o Number of rooms in each family unit: Number or Bathrooms
c. Is there a garage attached'
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
L 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 BUJ�IL,D,IN.G P'ER/1MIT
I Od JPjOV as Owner of the subject
property
hereby authorize / o✓/Jw"'� T�—
to act an my behalf,in all mattfive to work authorized by this building permit application.
17,011 �
Signatureof wner �q—Dante
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 gins an penalties of perjuo�
Prii ame
Signature of Own Date
-.:TION 8-CONSTRUCTION SERVICES
S 1d Construction Sucervisor: ,� ) R� Not Applica le ❑ —7
Noma..f Li of License HoMar:
License Number
Address Expiration Date
Signature Tel hone
9.RenisteredHoma�I]m,.�rovem n ontracfor: Not Applicabler❑
Comoanv Nama Registration Number
�� 4f
Address Expirati n
elephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8))
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 buildirjoh5ermt.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
( MassachusettsOF BUILDING INSPECTIMS
T2s`
212 Main Street • Municipal Building
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 owneroccupied 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:Lf the homeowner has contracted with a corporation or LLC, that entity must he
registered. �7
Type of Work: //t�� �'i? 1��G/ i'�"' ES}t Cost:
Address of Work:
Date of permit Application: e59 —, /�
t
1 hereby certify that:
Rcgistration 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 RESPONSIBIL11 ES 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 Name I IIC 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
' I. UEPAATNENT OF HpZLDZNG ZNSPSCTIONS
212 Main Street • Municipal Building �tir ^R
Northampton, MB 01060
Massachusetts Residential Building Code
Section I10.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 I IO.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 11 O.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 maybe liable for person(s) you hire to perform work for you
under this permit.
City of Northampton
Massachusetts a�ull��- A,IDEPARTMENT OF BUILDING INSPECTIONS212 Hain rt ai, •Municipal BuildingNoxNampton, m 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 property 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:
'/Xzk-�— h�c�w+ -
(Please pant 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 oflndustrialAecidents
_ I Congress Street,Suite 100
J o'
Boston, MA 02114-2017
www.massgov/dia
R4trkers'Cnmpensatlon Insurance Affidavit:Builders/Contractars/Eleetrictans/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Apollonian I [ fi Please Print Legibly
Name (Business/Organizatimaindividuap:
Address:
City/State/Zip: Phone#:
Art,...emplmee?Check the.....prime has: Type of project(required):
I.[]I am a cap loycr with employees Cal anther patbrav) 7. ❑New consWction
2rl l amasolc prcoloron,r vactnershipwtd teveroempikols,or king for me in $. El Remodeling
twenty [No workers,comp.insurance oncomd7
rM I um wpa howmacer dam,of work aysdf,IN.worke.. ...mp.....at,s my,a red_1 0. ❑Demolition
J.❑[am a hmemo
rowan,snit will he Locomraave,to conduce all wrk on my property. [nor
10❑ Building addition
ensure that all evmmcow either have workers'eompensutan andancec or are sole II.❑Electrical repairs or additions
pra,mcmcs with no someyece,
12. Plumbing repairs or additions
51 um a general roamed,and I have hired the su entaroacmts listed oa the attached cheer 13.E]Roof repairs
IDcnsuh-confradors have,mpleYce and have xotknrs entnp.i swans.
e_❑we are a corporation and its olHcna haw exercised dheir tight of exemption per MGL a 14.00ther
152,00)_andwehewrteapployees.[Noworkers'comp esnrancertquircd]
'Any applioant that checks box Ill must also till out the section below showing their workers compensation policy Information_
t Homeowners who action this affidavit indicating tho,am doing all work and then hire outside carcho aas most eabohn a nos mods,a indicating sudr.
lCmainemmthat,heok this hex mut,attached an additionalsheet showing the coma or theaubeonh.ctooandstate whether om caman wines,base
mployce . lfthcsuheuntmetorshaveomploym.thcymusiproaidetheir xotkers mp.policynumhcr.
I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job sire
inforaiadon.
Insurance Company Name
Policy s or Self-ins. Lie.R: 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,g25A is a criminal violation punishable by a fine upon$1,500,00
and/or one-year imprisonment,as well as civil penalties in the form of SOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under thepains and penalties ofpsaii that the information provided above is nue and correct
5 on t re' Date:
Phone N:
Oficial use only. Do not write in this area,lobe completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
t.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phonep:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this sh ure,an employee is defined as"_.every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee ofan 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 ofthe
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,MCL 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)tame(s),addresses)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 m 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 permitAiconse applications in any given year,need only submit one affidavit indicating current
policy information(ifnecessary)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 proofthat 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 attuning a license or permit not related to any business or commercial vcnmre
(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
Roston, MA 02114-2017
Tel.#617-727-4900 ext.7406 or 1-877-MASSAFF
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Home Improvement Agreement: Pagel
Home Depot License #'s - For the most current listing www.Homedepot.com/LicenseNumbers
MA: 107774, 112785
Ronald Engelbrecht
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.
ROTHMAN IRACHEL INew England South 1-DYUPNXC
Customer Last NaM- Customer First Name Store # rant ame ustomerLead/ Palt
748 Florence Road Florence MA 01062
ustomer Address it atZi
14131 210-0005 Rothman.rach@gmaii.com
Home Phone# Work 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 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 OF YOUR RIGHT TO CANCEL.
Acknowledged by: t oz/os/2o19
ustomer' ignatu 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: $ 21az.00 Includes all applicable taxes. Excludes finance charges."
Sales Tax: $ (If applicable)
`Maximum deposit ONLY applicable in MD, MA, ME(3301), NJ, WI(99%)
Dep. 25.0 % Deposit Amount $ 5as.s Remaining Balance $ 1636.50
The Home Depot-2455 Paces Ferry Road, N.W.Bldg.a-3,Atlanta,Georgia 30339-Customer Care: 1.800-466-3337
aw noe e.—I 11...em R'1.1161 o.v
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 I be used to pay some or all of the total amount of sale.
Description of Work tob_e.Performed:
Installation of Entry Doors
A more detailed description of the work to be performed is included Int the section entitled cope o
Work which appears on page P--] of this Agreement.
Anticipated Delivery_Date/_Installation Schedule
Approximate Start Date: oa/os/zo19 Approximate Finish Date: os/o3/zo19
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 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
complete copy of this Agreement. Keep it to protect your legal rights.
X 02/08/2019 The Home Depot
ustomer's Signature Date Service Provider Name
X 1908 Boston Turnpike Unit 1
Co- igner (i applicable) Date Service Provider Address
X 02)08/2019 Shrewsbury MA 01545
I nature On Behalf o Home Depot DateitC y tate Zip
HIS 0554523, R-1-073-13-00004
Service Provider Phone Number Service Provider License Number
The Home Depot-2455 Paces Ferry Road, N.W. Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800466-3337
asp eoe eonome,n,—.lea dm ,sl , C
rSOJECT SPECIFICATION
h6 M
Date: 02/08/2019 Branch. New England South
Sales Consultant: Ronald Engelbrecht CSC Phone: HOME DEPOT PHONE: (877)-903-3768
Ronald Engelbrecht : HIS 0554523, R-
Sales Consultant1-073-13-00004
Phone#: (413) 231-4707 License)s)',
INSTALLATION ADDRESS'. 748 Road
Florence MA 01062
Job#'. 1-DVUPNXC
PURCHASER(S): Work Phone Home Phone Cell Phone
RACHEL ROTHMAN (413) 210-0005
PROJECT NAME: Entry Doors Quote
Customer \�/ 02/08/2019
Signature. 7l /�/�gg� y�. Date'.
RA �09
1 Entry Doors
Wincore Entry Doors
Project Name: Entry Doors Quote Sheet 1 of 1
lie Coutmollwou(tll ofivinssackasens
Departrnea t of lodustrialAecidents'
I Con_5ress Street,Sulfa 100
vw); 1)ostmr. 111A 02114-2017
. NOVW n3ass.pul ila
1Corkel's'Compensation insurnnee A!Tidnva:gnilde:s/Con;mctnrslE)ectririans/Plumbers.
TO BE FILEDWITITTRE PERMITTING AU TiORITY.
Acnlicant to rmatwo, Please Prirt Leoibiv
\Innle(3usines=10rgavir�rioN!(vJ�ivi�duap: —P'�'✓J � ) G
\ddres5: ��DVV�7J
CiryJSrateiZi Ki/ �� Phcnc i.`: J7/ —Z r"✓ ®`���
m,a .n elnpmY¢r.cauda ri,e annranriam haa:
a Type of project(required):
.. I:maemplupanvhF_c Pi J;v: n.in'.`
' � r:: yCS1.`uli 2n ry' I ,G %_ ❑NC1q C0n5InICt!On
?.�l am a sok Praprinvrvr panmrship ane nar¢no erlolv5'es war5in, For. m
8. Relnodclinn
C'c:cY.iko•varker>>'mmn:luv:an:¢inI4,V) ❑ .
I 9. ❑ Demolition
.1-]izmah,neo:eaar avinaoll am m,,i.- o:.nd:cr mmp.inn�nrxc rcqu:n*1 ' I
al,�Imm�l:omuovracr pad aAp a_hidngevmmuvm m mnducmn em,k—vIO❑evildine sddidon
P:opcm. I ,in
cmae:hpl all cvnlraors ei@¢rhmc+ru::eG eamp¢Nmian imv:v¢¢urmeolz I It-El electrical ,,I-or additions
nrvpri¢mrs avhh no unplaNrs I 2.[]Plumbing repairs or additions
.. Iam a aznzml cpnrmcmr,•.nd 1 Fae rhi:N
' rhe rvb.¢nVaa:v¢lisetl on rhGuv2Cr:ean:2l.
:.^n:t.wanac:ursi,av¢maplayeu andh¢vnroharstorrq.aaumnm.: !1-❑R repairs _
'_❑ Je - comer!vncntl ro n..&.I,,cira�m C,.S'e .ro. . rnl(n-c. 14, ti^r
'_i114).zvd me A.vm:o in..&.I,,
nPPlicanuhm Chr_ks p3=1 must alto on ma ayszuion F9mo On,11.1 ID:ai;:cm!:vrs'mmY sminn policy roo.- ion
s,aa.:iuI'M amdnvit Wivaki,fair arc dolne on".,t al el V@a ah¢ Lasida cvauuCrma..it eub:nitc oavamd:viGndicarinds.
.,z;L•C: tis bx su=t xlcev.ean addidanalsb�r sTuorinE me ne:m.cit¢sro-cwusaor-ondstam ahaF.c yr nm dmseenlfdrse
CNn1aYCCS. IIl1CLSlIF'aalriCla6i:aYC ern S'�;,IIICY IIISI Gu'!id¢IIRir::nC:xrC CC:� poni,Y n
1m12 aur enrplrl'er amt is prmdaing"'juar"emnu.ASndmrinazlrmrce;or my ruick,(ces. �B llon,,ahoppo:iryn!idjobsne
insmanci: :. ,' C R���h Ti�r l/®V��alt T�/� 11(/•
insurnn¢Company :ane. // ��----••���� )
Policy Jim Selfins.Llc.t?. [/ 7;/� Ezpnabon Dat.: ! tel
Job Srte Address: �� / Ciry/Sute/Zip: r-e� �O/�2-
Atiacil n cops „rbc:voricersr compensnllon po':i.y dec!"inian nage(shoving the policy number and expiration dale).
Failure to secure coverage as required under A4GL c. 152,§25A is a criminal violation punishable by a fine up 10 51,500.00
and/or one-year imprisonment,as^well as civil parities in the tom of a STOP 1,1101U-1 ORDER and a fine ofup to$250.00 a
day against the viclamr.A copy oflhis s�tement may be gORIT,ded to the ORcc of Investigations ofthe DIA far insurance
rwcrsge vorilcaiion.
r do berebv cert!^fjJn�m/ JhI, m r :_ /pier }dmt the u..limr provided abo•e is tare and correct.
Srann[ure. �G/� [.{+/�j�/l Dale'
YY l:Y= �."" )
Official use ani}'. Do not;vr hf in rhisnrea,in tie completer!by elly or talar ojjch L _-
1 City or Town: PenninLkense
I1I =asuing:uthority(arcle am,): I .
1.Board of Hea71h 2-Building DepnrtmeS 3.CiryITmrn Cin9: 4 %Iec;ricai fnspeeror S.PIum0ing luspec[or
o.Olhcr
gill Qmfict Pcrsmr Phone:
II
✓u0® CERTIFICATE OF LIABILITY INSURANCE 3
ON4 OwouR
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, EIITEND 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 LCHIgC.tU holder is an ADDITIONAL INSURED,the policy(hes)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION 15 WAIVED,subject to the wi ms and Conditions of Me policy,certain policies may require an endorsement. A statement an
this certificate does not confer rights to the Certificate holder in lieu of such andarsement(s).
PRODUCER CONTACT
MARSH USA.INC NAME'
TWO ALLIANCE CENTER PaeCD a Faz
A x
3560 LENOX ROAD,SUITE 3400 ADDRESS
ATLANTA,GA 30326 a.OR
INSUPEPS APFOROMGCOVEPAGE A.B.N
CIF 01542069.HmmD GAW 1819 INSURER A'Old REDONr I0SUran4 C0 24147
INSUREDHE HONE UEPUI.IHCINSURER.:M9vllam sme NSC. ZCLU
HOM
1455 ACES FERRY
PJC. INSURER.:Vbm.MSY.Cd iue MCVaKP F,qn
BUSS PACES FERRY ROAD IxsuRER D:
BUILDING C20 _
ATLANTA.GA 30119 INSURED E:
INSURERF:
COVERAGES CERTIFICATE NUMBER: ATLM435343916 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 TH£T£RMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR DaisSUER PIXJCYEFF TOLLYEXP
LTR TYPEOFINSURANCE POLICYNUSEER MN M14➢oIWYY LIMITS
IT X COMMERCNLGENERALLIANI-Or" LICZY 312212 0111018 03,01,2019 EACH U.LURRENCE Is 9,WBDOB
CLAIMS-MADE OOCCU0. pREM6E5 Eam'u,rence 5 IOW OW
LIMITS OF POLICY XS MEDEXPO. P I S L%Cw.GEO
OF SIR:SIMPER OCC PERSONALSAIry WJURY 5 9000000
GEN'L AGGREGATE OMIT APPLIES PER: GENERALAGGREGATE S 9004000
X PoLICY LECT 0 LOC PRODUCTS-COMP/OP AGE 5 9.400000
O HEP;
A AUTOMOBILE upelUry A3WTB312718 0391,2018 0300112019 .EONaWEO SIrvGLE uurt 5 1,OW.000
AUID 90DILY INJV0.Y IPp IRaem) b
^
OWNED
u o9DONLv ECHOSULED
SELF INSURED AU lO P41'UbiG aoOILY INJURY IPeravitlercl S
HIRED NON-0WNED PROPERTY DAMAGE $
AUTOS ONLY AU TOS ONLY Pd asii.
5
UMBRELLADAa OCCUR EACH OCCURRENCE 5
EXCESS LMB CWAISMADE AGGREGATE $
DEO RETENTION$ $
B WORKERS COMPENSATION WC01412293 (AK,NH.N1.Tg) 0111112018 03i0112019 X PTR ER -
AND UAMUIN
G A YIN APIC 0144298 03N11I018 03N1Rm9 SAGO WO
.11NCJCV.Lr.U.Ec` UTNE O NIA 0e^ EL FALHACCIOEXT 5
FFICCR:MEMOCRC%LLUOEO?
IMantl#ory in NR) E.L DISEASE-EA EMPLOYE 5 5400 CW
Il CRIPTION OF
E yJas ONOIOPEINifON56elmv nr C.nfinNEB WA dIpmI PJ9e EL DISEASE-POLICY LIMB 5 4404400
DES
C Excess ANl. - 292-I-10011 c0 2018 03N112016 0310112019 Lmil'. LW0,000
DESCRIPTION OF OPERATIONS LOcAU ONSI VEHICOR(ACORD 101,AEENmW Remoo SoUed,11,NINE W atlxl,etl Umora SPUN IS rUrAmd)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
HOME DEPOT USA.INC SHOULD ANY OF THE ABOVE DESCRIBED PODCIES BE CANCELLED BEFORE
2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANIA,GA M239
AUIHORQED REPRESENTATIVE
d MYcn USAmc.
M.U.shl M.Mi.Qee �Hl.nv Saw: �d.wLA.Iwdei.
®1988-2016 ACORD CORPORATION. All Tights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: CN101542069
LOC I AOanta
/1
ACi ADDITIONAL REMARKS SCHEDULE Page 2 of 3
III
ANENCY HpMEO INSURm
MARSH USA.INC. THE HOME DEPOT,INC.
HOME DEPOT US A.,INC.
noLlcY NUMBER 2455 PACES FERRY ROAD
BUILUNGC-20
ATUNTA.GA 30339
CARRIER xplc.—E
EEECOVE mie
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 26 FORM TITLE: Certificate Of Liability Insurance
WOAus Corr-o"'obn Canard,
Caner YNemNly Imnraem C empmy N Nw al 0.1re1w
Per,Number:WLR C64183191(ALARFLIDN.Y. (YI A MSMO.NENM.NOOK SC,SO T4'."N NY)
EN3tive Data 0111
Expira(n Dale:010112019
(CUT...I 11000m0
Came-.Ner Ia"Hrr Inrv2rte Company
Pdl:y Numbr WC0111225]6;DC.DEHIIN MD.MN,MT,NV,IiI)
E1130ve Data 0310112018
Explralbn Can,1191
EQ Door 31,000,LOU
iT ACE Ainerkan WUrr aCompany
Pdry Nano WCU C662B3221(OSQ(AL Ci NCOR VANIA)
Hill-Dae.010112018
Enplralgn O7,'.OLOTR019
IW UmIU 31.(00,X0
SIR.0 ODUO00 SIR ni Nlalel d AZ,CA.ILNO.OR VA4VA -
Carne,Naconal Union We Inei Company
PdUq Numba.M'NC459558D(OSO(CO,CTGAME,WNVWLPAUT)
ED".Data 03RIOD18
Exp6allOn Dae 010112019
III SIT00,00
5140q(20SIR Im the slalgol CO,NIE,NV,MI OH.PA UT
3150 MOSIR brlM stole 91 W
5350000 SIR Ia Dan sinte DICT -
rf '
a'.National Unun.....
le lm'uanaaCwry y
Pdry wnmhec xwe 4595se1(C59(MA)
Ellsllue Dale:0101I101A Q
Expnalpn Date.01(EL)OmiP.61."D
T%Emte,,XS lnaennily'
Car,.Hi Lear h,rarve,Conei
Polityeunber TNSC4916693A(IX)
EOeew Dale:TWICU1B
ExpiraOon Dale 03hi
IEq Lrml:ri 0000300
SIR SI MO00
ACORD 101 (2008101) O 2008 ACORD CORPORATION. All rights mserven.
The ACORD name and logo are registered marks of ACORD
�l llo r�C�lJ71':tt;l2llrTtl(�`I t� ��G GCI:litCCi`L U:�B
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: Supplement card
HOME DEPOT USA INC Registration: 112785
2455 PACES FERRY RD C-11 HSC --_ Expiration: 04/22/2019
ATLANTA,GA 30339
Update Address and return card Mark reason for change.
❑ Address O Renewal D Employment O Lost Card
/.. $,".,.,,..,,...e,./i/�,,.�/sem,./.,.✓/,
Office of Consumer Affairs a flue...Reguladon
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:supplement Card before the expiration data. If found return to:
Reo'stratioi EEaplretlon Office of Consumer Affairs and Business Regulation
- - - 112785 N2molg 10 Park Placa-Suite 5170
HOME DEPOT VSA INC -- Boston,MA =116
RICHARD TROIA
2655 PACES FERRY RD C-11 HSC 4 "
ATIANTA,GA 30339 Undersecretary Not Valid Withoaifsignatare
` �• s r�fix,-,,9. .e �.-_
Qt
_. ommon ;realth of Massachusetts
of Professional Licensure
'u► Board of SmIding Regulations and Standards
Supervisor Special- ;
SSL 3QS?�5 expires : 04/ 27i2020
If
[VAN KOSOBUTSKYY
72 STAFFORD ROAD
MONSON MA 01057
Commissioner