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30B-111 (2) 100 MILTON ST BP-2020-0569 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:30B- 11 I CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate,gorv: Door Replacement BUILDING PERMIT Permit# BP-2020-0569 Proiect# JS-2020-000977 Est.Cost: $3000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: LOWES HOME CENTERS INC 103003 Lot Size(sg. ft.): 15986.52 Owner: DELUE CRISZEL Zoning-: URB(100)/ Applicant: LOWES HOME CENTERS INC AT: 100 MILTON ST Applicant Address: Phone: Insurance: 22 GRANVILLE RD (413)272-8931 O WC SOUTHWICKMA01077 ISSUED ON.111412019 0:00:00 TO PERFORM THE FOLLOWING WORK:NEW ENTRY 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 Occupancy sip'nature: FeeType: Date Paid: Amount: Building 11/4/2019 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner / en Sfi* City of Northampt Building Departm nt R� >✓ut/Driveway Permit ` 212 Main Stre t ��� rlalily Room 100 e0Av iiability „ . 1 Northampton, MA 010 NOIR ` , Se of S ural Plans phone 413-587-1240 Fa 4131587-1272 2 it Pla DEa _ APPLICATION TO CONSTRUCT,ALTER, REP h +� ISH ONE OR TWO FAMILY DWELLING � - ao - s�9 SECTION 1 -SITE INFORMATION 6P 1.1 Property Address: This section to be completed by office 100 Al row `7 T Map ? v Lot /Lt Unit �(Ae/Vt;(7 r J• �!J A4 o (U r—L Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT I 2.1 Owner of Record: '� berg L. DE LL) k _ 100 M I t— y t e(Print) Current Mailing Address: t �7 (� _ 1' �9� Telephone �� _ �` Sign tune 2.2 Authorized Agent: Name Print) Current Mailing ddress: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee n 4. Mechanical (HVAC) yv 5. Fire Protection 6. Total= (1 +2+ 3+4+5) J v tJ Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: h h 9 VU Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOV NER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows �llteration(s) Roofing F7 Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Deeks [M Siding [O] Other[0] Brief Description of Proposed Work: t�.r ,:.,e �.,;' , r /` !,`, l C ��n �I Gv+c► Alteration of existing bedroom_ Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.if New house and or addition to existina*6issinc coalip#ete �,feftwing: 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 Woostoves Number of each g. Energy Conservation Compliance. Masscheck Energ1 j 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 S upply SECTION 7a -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date j�wPS �y��Q C 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 and penalties of perjury. ���► �✓1f � � 2 Print Name'` Signature o Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder: /LA(ILE �'1Gih19�1 'Z� 1 �ab Lice aNumber Ad s Expiration Date 41� _2z7--�3z�1 i Signature Telephone CE3 Not Applicable ❑ p U C�ille�S (C(q&K S Company Name Registration Number �D41 /Lk/(? v>^oV�I Address/� j Expiration Date/ Telephone`1(� —Z Z.- 3 l SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§26C( Workers Compensation Insurance affidavit must be completed and submitted with th s application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... No...... ❑ &N i ne c.ommonweann of massacnusetts Department of Industrial Accidents lag Office of Investigations 600 Washington Street Boston, MA 02111 quo www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep-ibly Name (Business/Organization/Individual): GOW,,-?S 1`C()A-,e CeA )eJ S Address: C ��� L AA-°zpS 6�vl� City/State/Zip: yotPT,L) ,((P, kl& ZO7 Phone #: C{ Z— �� I Are you an employer? Check the appropriate box: Type of project (required): 1.❑ 1 am a employer with 4. a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. * E] Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. q. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 131-1 Other comp. insurance required.] *Any applicant that checks box#1 inust also fill out the section below showing their workers'compensation policy information. ' 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 their workers'comp.policy infbnnafion. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. insurance Company Name: '`� �i f�j�C ��ely�CPS �j G Policy #or Self-ins. Lic. #: �/` U t -71 / I Expiration Date: ( — Z CJ .lob Site Address: 100 I''i1 L�O`N �� City/State/Zip: �Of JenCle U Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ` Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine ftp to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine Of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains r enalties of perjury that the information provided above is true and correct. nature: r ~ Date: U _ �JJ_ Si f Phone# LO ` Z7 Z- �q (_ Of 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#: ^`"c�►rrr' CERTIFICATE OF LIABILITY INSURANCE iHIS 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 UELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A gONTRACT 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 eeriificate holder in lieu of such endorsemenl(s).. PROuXER CONTACT v ar,,: E'.4 Seaviee :.KatIll, Im , ttAllE �_. ... - h,u'1ott.c VC Office 1211vutrnptliitan Avenue, suite 400 EAML o iov IC'rte vc ?A.'.iM !f'ca ADDRESS/ = INSURER(SI AFFORDINO COVERAGE NA/C 4 __...__�......�.... ....-........_.„........._ "....-. _. .. ....... ..-.... . .NSL!REv 'N4URERA Cfedi. AIIN,'r1Ca11 A51 ur'antV' C/lripany rah J41 no-'•. romnanies. Inc.. N3URER8: National Union fire Tr%% Co of 11144: - ++-) ILS 'i UI1M11CIl Af lG9 -- In;ut aoalewlyd 'NStlRERQ New Hampshire In%uranre Crmp.trty JT$41.- lls Nt. 2811; USA 'NStRtER O NStMER E: NSURER r: COVERAGES CERTIFICATE NUMBER:570075483114 REVISION NUMBER- THIS IJ TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PCRIOD NOICATED.NOTWITHSTANDING ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WI+tCH THIS -CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERE114 IS SUBJECT TO ALL THE TERMS, EXCLUSiONS AND CONDITIONS Or SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLIJMS. Limits%hown are as rerluestett fusH rR TYPE orwsuRANCE POUCYNV"rp Pou elm -v ukits COMMERC AL GENERAL LLA UTYV Y Self Insured 04101/2019 04101/202(3 :.1h'.V•r.MAIL.. o:�C:.Uci - pq yK. S.�Crarr ,r: Nit:U E%P,Any s>s+Pc'sr•`r rERCONAL ti A':'J IT..URr "r ..r+zt".a:ct!yi*APP'.r;'iPER CE NPRA:.Ar[;RIiGAT" -- , 1'w`' ❑ !!4 FRt7t.�i.'.T:i.:.f•V:n:,l..":.'r � NJTOM401LE 11A$UTY Ca 4993101 04101/10 19 04/0It 1020 c;OUNI Ff>SiN:•t t t:+.r+: v' :fr L_..-..._,-... AD!; �- .. CA 4993101 04!01'2014 04,101.:2020 RnL l r+d;tRY,rr ,Kra, O 2 NA PCtLNCYSY.X.?rictt%xre.str•t, L CA 4093102 04i01I201904.r01'20:UVA WO M140"Tf I•ttcKtif7sY:;Awc;E �' ..rel r:.•;t+q•, ':vti-+.2.at_) v A t UMEPJtLACIAO X oo''u Um"27, S Vs 04f01/2019 04?Ol/ U2 EACNG'CCLRRFt:._-�- SIU,INN(,00,1 V SIR applies per ptrlicy ter%% R condi ions E4CE53 UAtl CLA IMO VAUE AliiNct,'.AS t,i(1,f11.t1,i3rtit "'I x IqEItFIF504 C WORKERS CWIPENSATION ANO wcOI2717161 04/ 1, 19 04!01 1 0 X VCR STATtII” i! EMPLOYERB'LIABILITY Y t N AOS ,T —'- N,i:Y1.'�r R YTORtIVfJ!:r 11,�.XECUTrJL f N E: EACHAC.V:^I.tti S:.I)ou,owl ".r,� ESIAAL&WR EkC,.U:1�i:T9-' NI SIR applies per policy terns. 6 condi .ions t&Uw a"in N141 t a1JEA y`.{-w k#�tit'F= S;.t1tNt,11(Ht -rs dewc t,e urteCr i?SFASE f01.'<',v tlMt: 1— F I. Sl.ttrxi,uqr r C%trsti wC xwCSitiS603 04/01/201904?01/,020 EL Path ArCidenr J'0 h,r)f)o ADS, EI_ Disease - Policy S1.r)(w",0,7/) SIR applias per• pal icy ter % 6 condi ions EI. Usrase - Ea. fmp Si,ili)1?..will Lir Cr SCRIPTION OBI OPERA770Na J LOCATK)NS 1 VEFdCIE E(AGGRO IQt,AAttMglYt Ramatka SGMQtda,mat/M r41KIMC d mnrw apwcw h.wqurwAt rtr(id) Grrrrral IAAI)*1lity policy is Self-Tnsurec(. �y CERTIFICATE HOLDER CANCELLATION w-_.+ SHOULD ANY Or THE AGtGVC. OE8CiQ8E0 POLICIES 8E ffit/CELlEO BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILT OC DELIVEREO IN ACCORDANCE WITH TOE POLICY PROVISIONS I.tn+ru'% i:rJ)J0IeS, III-L. AUTHORIZED REPRESENTATIVE anti its s t"idiariei I(Of! towt% NIVd. v<'aresville uE. 28117-81,10 USA :)'1988-2015 ACORD CORPORATION.All rights reserwd. AGORD 25 f2016103) The ACORD name and ltxjo are registered marks of ACORD A[_C_►1'"1` CERTIFICATE OF LIABILITY INSURANCE D05/(MM/nD 9Y) �._..- 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 be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT Remillard Rejean J Ins Agency NAME: Berkley Assigned Risk Services 1040 Springfield St A/C No Ext.): (888)548-7431 FAX No.): (866) 215-8118 Feeding Hills, MA01030 EMAIL ADDRESS: assignedrisk@berkleynet.com INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:Acadia Insurance Co 31325 Michael Burgamaster INSURER B: dba: BURGERS HOME IMPROVEMENT 22 Granville Road INSURER C: Southwick, MA 01077 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN INSSUED 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 LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS INSR WVD (MM/DD/YYYY) (MM/DD/YYYY) WORKERS COMPENSATION AND ®WC STATU- OTHER EMPLOYERS'LIABILITY TORY LIMITS ANY PROPRIETOR/PARTNER/ E.L.EACH ACCIDENT $100,000 A EXECUTIVEOFFICE/MEMBER N/AMAARP300120 10/06/2018 10/06/2019 E.L.DISEASE-EA EMPLOYEE $100,000 EXCLUDED?(Y/N) ❑ E.L.DISEASE-POLICY LIMIT $500,000 (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below. DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Election Category Election Status Name Effective Expiration All Insured Entity Sole Proprietor Excluded Michaelurgamester Michael Burgamaster Risk Location 119 High ST 1st Floor,Agawam MA 01001 COMMENTS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Lowe's Companies, Inc. &any and all subsidiaries EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE Mail Code: A3ESS POLICY PROVISIONS. 1000 Lowe's Blvd AUTHORIZED REPRESENTATIVE Mooresville, NC 28117 " ignature: ACORD 25 (2010/05) BRAC 3139 A ® DATE(MM/DD YYYY) CERTIFICATE OF LIABILITY INSURANCE 06/06/19 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Mike Pelletier Rejean J.Remillard Ins Agency (AJC.NoPHOEll: 413-789-3070 FAX Nol: 413-786-0193 1040 Springfield Street Feeding Hills,MA 01030 ADDRESS: mikep@rejeanremillard.com INSURER(S)AFFORDING COVERAGE !!AIC k INSURER A: Main Street American Assurance INSURED i INSURER a: National Grange Mutual Burgers Home Improvements INSURER c: Acadia Ins Co 119 High St. 1st Floor INSURER D: Agawam,MA 01001 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 CONTRACTOR OTHER DOCUMENT WITH RESPFCT TO WHICH THIS CERTIFICATE MAYBE 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 RUM K POLICY EFF POLICMV- LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM DDIYYYY MM/DD/YYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE FRI OCCUR PREMISES Ea occunence $ 500,000 MED EXP(Any one person) $ 10,000 A Y Y MPK6213N 06/08/19 06/08/20 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X POLICY❑PEC LOC PRODUCTS COMP/OPAGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident UTO BODILY INJURY(Per person) $ 100,000 BJANIA OWNED rx SCHEDULED MIT3385E 06/10/19 06/10/20 BODILY INJURY(Per accident) $ 500,000 AUTOS ONLY AUTOS _ HIRED NON-OWNED PR ERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE E L EACH ACCIDENT $ C OFFICERIMEMBEREXCLUDEDI N/A Forwarded by Co. (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ It yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Lowe's Companies,Inc.and Lowe's Home Centers LLC are named as Additional Insured with respect to General Liability and Automobile Liability Coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Lowe's Companies,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. and any and all Subsidiaries Mail Code:A3ESS / 100 Lowe's BLVD AUTHORIZED REPRESENT Mooresville,NC 28117 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ��t'1��1��"Ma'`Y�` t'��', C'w�>.t►.b"F°',`,t` �t,�'c`,�•�t`�'�^ � .tir Commonwealth of Massachusetts ; Division of Professional Licensure t� c pl Board of Building Regulations and Standards Constrvction Su , CS -103003 Expires , 09/0812020 s MICHAEL W BUROAMASTER 22 GRANVILLE ROACH f SOUTHWICK MA 01077 At Commissioner F .F r �. ✓ SFat"''°�+'st'�` � �$1�..k}�� +s ..1'"��sy��r �`y�`'•n.,�ssy '7'�" �,�,K ay+ aP�� Y � f , • Ifr�" �r'tt<ti<rtNf'fvr Mains&Business Regulation office of Consumer HOME IMPROVEMENT GONTRACTQR TYPE SUODIemen%Card 148688 tgwiL"I BSQ'AWdo0itT;2OZt LOYVE S HOME CENTERS.LLC CHR4STOPHER MINIE 1OOD LOW ES BLVQ SERvii,ES COMPLIANCE UndBrS2CreG31Y MOORESVILLE.NC 28117 STORE COPY INSTALLATION SERVICES CUSTOMER CONTRACT- MWORK - INT/EXT/PATIO DOOR LOWE'S OF HADLEY, MA, STORE# 1916 STORE PHONE: (413)588-0270 282 RUSSELL STREET SALESPERSON: BRUCE HUNTER HADLEY, MA 01035-0000 SALESPERSON ID: 1508948 Document Print Date : 10/22/2019 This is only a Quote for the merchandise and services printed below. This becomes an agreement upon payment and issuance of a Lowe's receipt, upon which the entire agree- ment, including the specifically completed pages of this document, the Terms and Conditions included with this document, the applicable portion(s) of Lowe's receipt, and any other addenda or attachments hereto, shall be referred to herein as this "Contract." PLEASE READ THIS ENTIRE DOCUMENT INCLUDING THE "TERMS AND CONDITIONS." BEFORE SIGNING Lowe's Registration or Contractor License Number/Lowe's Contractor Name Lowe's Home Centers, LLC's MA HIC NO.: 148688 Lowe's Home Centers, LLC's FEIN: 56-0748358 Customer Name Home Phone S ROBERT DE LUE 413-584-7292 O Customer Address Other Phone 100 MILTON ST L City State/Province Zip/Postal Code D FLORENCE MA 01062 Installation Address T 100 MILTON ST O Installation City Installation State/Province Installation Zip/Postal Code FLORENCE MA 01062 MERCHANDISE AND INSTALLATION SUMMARY MERCHANDISE SUMMARY 14560 : FB35ON V PLY 505 605 : STK : SCH BB COMBO SGL PLYMOUTH : Keyed Entry Door Knob : SCHLAGE LOCK - QTY 1 15634 : 230612 : STK : 120Z DOOR AND WINDOW FOAM : GREAT STUFF Window and Door 12-oz Spray Foam Insulation : DDP SPECIALTY ELECTRON- IC - QTY 3 110073 : F60 V CAM 716 ACC : STK : SCH ABZ HNDLST CAMELOT/ACCENT : SCH ABZ HNDLST CAMELOT/ACCENT : SCHLAGE LOCK - QTY 1 145691 : 145691 : STK : 1-5-8 TOP CHOICE EWP PREM S4S : 1-5-8 TOP CHOICE EWP PREM S4S : IRVING FOREST PRODUCTS (MAINE) - QTY 1 242989 : 43156171422 : STK : SCH ABZ COMBO SGL GEORGIAN : SCH ABZ COMBO SGL GEORGIAN : SCHLAGE LOCK - QTY 1 253118 : SSCD4E28RB : STK : 32 TTBM FG 9LITE EXT GRL SMTH RH : 32 TTBM FG 9LITE EXT GRL SMTH RH : TRU LOGISTICS INCORPORATED - QTY 1 Store 1916 Project No. 598689643 for ROBERT DE LUE Page 1 of 8 STORE COPY 280485 : PLSEL 1.000 6.000 8. : STK : 1-6-8 EASTERN WHITE PINE BOARD : 1-6-8 EASTERN WHITE PINE BOARD : EMPIRE COMPANY, THE - QTY 3 331"348 : 1 X6-PFJ8 : STK : 1-6-8 PRIMED PINE : 1-6-8 PRIMED PINE : METRIE INDUSTRIES INC - QTY 9 615268 : 266-PFJ8 : STK : 1-1/2-IN X 8-FT PFJ LATT S4S 266 : 1-1/2-IN X 8-FT PFJ LATT S4S 266 : METRIE INDUSTRIES INC - QTY 3 741093 : 741093.0 : STK : MAS 32 15-LITE LO E LH : MAS 32 15-LITE LO E LH : DOOR FABRICATION SERVICES INC - OTY 1 833539 : BMTT626371 : STK : 36 TTBM UNF SHKR 6L RH : 36 TTBM UNF SHKR 6L RH : TRU LOGISTICS INCORPORATED - QTY 1 Materials Price $ 1289.57 INSTALLATION DESCRIPTION Door type : Exterior Location of new door(s) : Porch Door Select new door : Single Pre-Hung Hardwood door : No Sidelights or transoms : No Number of additional holes bored for accessories : None Install specialized mortise hardware : No Install storm door : No Lead safe practices : No Door type : Exterior Location of new door(s) : Front Door Select new door : Single Pre-Hung Hardwood door : No Sidelights or transoms : No Number of additional holes bored for accessories : None Install specialized mortise hardware : No Install storm door : No Lead safe practices : No Door type : Exterior Location of new door(s) : Back Door Select new door : Single Pre-Hung Hardwood door : No Sidelights or transoms : No Number of additional holes bored for accessories : None Install specialized mortise hardware : No Install storm door : No Lead safe practices : No Total linear feet of custom trim to be Installed : 0 Deliver door : Yes Customer understands scope of the project : Yes Who will obtain permit : Lowe's Permit fee : Yes Additional miles traveled over 20 : 0 Access fee : None Dump entry Fee : Yes Describe other work needed : None Comments : customer has three exterior doors looking to get quoted Labor Charges $ 1659.25 Detail Deduction -$ 35.0 Additional Specifications: Store 1916 Project No. 598689643 for ROBERT DE LUE Page 2 of 8 STORE COPY Notation: Lowe's will not make structural modifications, paint or stain or remove/reinstall security system equipment. Customer is responsible to advise if prop- erty is governed by Historic District Regulations. LEAD SAFE INFORMATION: Federal and applicable state laws require that You be provided with a lead hazard information pamphlet such as the Renovate Right: Important Lead Hazard Information for Families, Child Care Providers and Schools. By signing this Contract, You acknowledge having received a copy of this information pamphlet before work began informing You of the potential risk of the lead hazard exposure from renovation activity performed in Your dwelling unit or facility. A copy of the pamphlet is also available at the following website: ht- tp://www2.epa.gov/sites/production/files/documents/renovaterightbookletwsept2011.pdf. PHOTO RELEASE: Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photographs of the Premises where In- stallation Services will be performed and all work performed at the Premises related to this Contract, and irrevocably grants to Lowe's all right, title, interest in and to the photographs for use in all markets and media, worldwide, in perpetuity. Customer authorizes Lowe's to copyright, use and publish the photographs in print and/or electronically, and agrees that Lowe's may use such photographs for any lawful purpose, incl ding, but not limited to, marketing, advertising, publi- city, illustration, training and Web content. By initialing here, Customer agrees to the foregoing. [Customer to initial to the left]. NOTICE TO CUSTOMER-PRICE CALCULATIONS: If this Contract includes Goods and related Installation Services sold by unit of measurement, such as per square foot, the Price may include more Goods than the actual measurements of Your project area. The Price includes the total amount of Goods required by Lowe's to fulfill the Contract (including surplus materials and overages) (together the "Estimated Product") and the Installation Services required based upon this total amount of Goods. For instance, a 120 square foot room may require 140 square feet of carpet to properly match the carpet seams, pattern, or unique room characteristics, and the Price would include Installation Services based on the 140 square feet of carpet. The total amount of Estimated Product is based upon the total Goods recommended by the Installer, based on industry practice and the Installer's assessment of the unique characteristics of Your project. If any useable Goods are left over, Lowe's may, at its discretion, initiate a Price adjustment. Lowe's will not adjust the Contract Price for the related Installation Services. By signing this Contract You acknowledge You are aware of Your project area measurements and the amount of Estimated Product, and that the Es- timated Product may exceed Your actual project area. TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES where applicable SUB-TOTAL $2913.8 *TAX $ 0.0 DELIVERY $ 0.0 ORDER TOTAL $2913.8 BALANCE DUE Work is to commence upon reasonable availablity of Contractor which is anticipated to be 2, Z�P V [fill in date]. Estimated completion date is 17- 2_ ;.?C / >n [fill in date]. Store 1916 Project No. 598689643 for ROBERT DE LUE Page 3 of 8 STORE COPY NOTICE TO CUSTOMER All items listed in this contract and specification sheet(s) are to be installed under conditions agreed upon at time of purchase and at the price appearing on this contract form. This assumes sound existing substructures, superstructure and points of attachments. Extra labor or material incident to installation necessitated by defective substructures, superstructure, points of attachment, or the moving of fixtures or appliances to be billed at extra cost to custom- er. IF THE CONTRACT TOTAL IS $1,000.00 OR LESS. Customer must pay in full. COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS $1,000.00: [X Customer to use the following payment schedule: (1) Deposit of $ 71 .27 to be paid upon signing contract. Any deposit collected at the time this Contract is signed will not exceed one-third (1/3) of the contract price; and Q-c� S s (2) Payment of $ (� l Z to be collected upon or after the commencement of work. I/We authorize Lowe's to do one of the following (check ap- propriate box below): [Pq Charge my/our credit card for the amount of the payment indicated above upon or after the commencement of work; or [_] Deposit my/our check for the amount of the payment indicated above anytime upon or after the commencement of work; and (3) Final payment of $100.00, to be paid upon completion of the installation to both parties' satisfaction. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CON- TAINED IN THIS CONTRACT AND WHICH FOLLOW THE SIGNATURE PAGE(s). BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH IN THIS CONTRACT. YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L. c.142A LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CON- TRACT, THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRET- ARY OF THE EXECUTIVE OFFICE OF CONSUMA AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUB- MIT TO SUC ARBITRATION AS PR VIDE.e'N G.L. c.142A. c� By:-(,- — Date:- Lowe's-Home ate:-Lowe' ome Centers LLC C �J'' �.� -- -- Date: wner Store 1916 Project No. 598689643 for ROBERT DE LUE Page 4 of 8 STORE COPY By: _ Date:------- Co-owner or Witness THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWE'S PURSUANT TO M.G.L. c.142A. THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES WITNESS OUR HAND(S) AND SEAL(S) BELOW THIS 4� 2 DAY OF © c �. Lowe's Home Centers, LLC By: . �— (Seal) Print Name: � � �'� i���C Address Owner (Seal) City State/Province Zip/Postal Code Print Name Co-Owner or Witness (Seal) Print Name Customer acknowledges receipt of a true copy which was completely filled in prior to Customer's execution hereof. You the customer may cancel this transaction at any time prior to midnight on the third business day after the date of this transaction. See the attached Notice of Right to Cancel for an explanation of this right. Store 1916 Project No. 598689643 for ROBERT DE LUE Page 5 of 8