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38C-001 (3) 220 GROVE ST BP-2020-1290 GIs #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38C-001 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit# BP-2020-1290 Project# JS-2020-002163 Est. Cost: $9020.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 106106 Lot Size(sq. ft.): 16160.76 Owner: WALTON L MOORE Zoning: URB(100)/ Applicant. HOME DEPOT AT HOME SERVICES AT. 220 GROVE ST Applicant Address: Phone: Insurance: 5 RIVERVIEW DR (401) 935-2633 O Workers Compensation NORTH PROVIDENCER102904 ISSUED ON.6/26/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 11 REPLACEMENT WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 6/26/2020 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Louis Hasbrouck—Building Commissioner Department use only n� City of Northampton jl/ Status of Permit: Building Department Cujb Cut/Driveway Permit ^ 212 Main Street Sewer/Septic Ay -ilability i � ROOM 100 Water/Well ailability Northampton, MA 01060 <c Sets Structxfral Plans phone 413-587-1240 Fax 413-587-1272 lans�_ Ot °r aecif APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: r Map Lot 0 � Unit Zone Overlay District i/ Elm St.District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current M ilirkg Addr ^ Teleph e Signature � 2.2 Authorized A �t: Name(Print) Current Mallin Address: Signature/' Telephone Z. 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 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4 +5) U Check Number a This Section For Official Use Only /J� lU ��� Date Building Permit Number: I� �l Issued: Signature: 6- 26 -ZO20 Building Com missionerllnspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R:= L:E- -1 R:= Rear A 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 ® DONT KNOW Q YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW © YES 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 O , Date Issued: C. Do any signs exist on the property? YES © 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 © 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 © 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 ❑ Replacementdoves Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[E:3] Other[a Brief Dies griyt'o Propos / L / ��A�'r�� Work: 7{� GL— 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 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 /O�R.J CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize to act on my behalf, in all m rs retafip to work authorized 15y this building permit application. Signature of Owner Date I, as Owner/Authorized Agent hereby de are that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pa' nd penalties of perjuAc nom^ Print Name ' Signature of Own gen Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Super visor: Not Applicable ❑ Name of License Holder: //,)Z License Number �7~ 4/,/zq zv Address Expiration Date Signature Telepho e 7 �- 9.Re istered Home Improvement Contractor: Not Applicable ❑ TJ 12� O�AVF 1 /z7'� Company NameRegistration Number � � zz Address )` Expiration Date 'W% ^ Telephone SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi permit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton Massachusetts �� N<< DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building p O Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement,removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units.—or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must d �be registered. Type of Work: T��JL �' S Est. Cost: `7, Address of Work: �F Date of Permit Application: f I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 Owner obtaining own,permit(explain): Building not owner-occupied _Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: 6-))-2-�4, Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts IL IN, to DEPARTMENT OF BUILDING INSPECTIONS yti 212 Main Street • Municipal Building Northampton, MA 01060 ��$ Massachusetts Residential Building Code Section 110.R5.1.2 Homeowner: Person (s)who own a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. Such homeowner shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. City of Northampton --.--- sus-'M s'c Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building yv�ti� .ca o 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: �- (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Permit Af5plicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type Of project(required): 1.E]I am a employer with employees(full and/or part-time).* 7. ❑New constriction 2.❑I am a sole proprietor or partnership and have no employees working for me in S. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.J I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[:]Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOf repairs These sub-contractors have employees and have workers'comp.insurance) 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple 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 bum 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 Home Improvement Agreement: Pagel Ink Home Depot License#'s - For the most current listing www.Homedepot.com/LicenseNumbers MA: 107774, 112785 Ronald Engelbrecht Salesperson Name: Registration 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. Volberg Walton and Rachel New England South 1-11ZVXX5E Customer Last Name Customer First Name Store #/ Branch Name Customer Lead/ PO# 220 Grove Street Northampton MA 01060 Customer Address City State Zip (413) 221-7500 moorefitnow@gmail.com Home Phone# Work Phone# Cell Phone# Customer Email Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address City State Zip Or Email: I 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: 05/23/2020 Customer's Signature Date Contract Price and Payment Schedule : Payment of the Contract Price is due upon signing unless a different payment schedule is required by law, specified below or in a payment addendum. Contract Price: $ 19020.00 Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ 10.00 (If applicable) *Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, WI(99%) Dep. 1 25.0 % Deposit Amount $ 2255 Remaining Balance $ 6765.00 The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1,600-466-3337 460 FI FIDE Customer Agreement(24 Jul.18) Generated Date n r,/2-4/2n9 o Lead/PO# 1-11 Z VXX5E v 0.1.11 Home Improvement Agreement: Page2 Finance Charges: *Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payment(s) made payable to The Home Depot. Insurance proceeds will will not / be used to pay some or all of the total amount of sale. Description of Work to be Performed: Installation of windows A more detailed description of the work to be performed is included 1n the section entitled Scope o Work which appears on page P-7 of this Agreement. Anticipated Delivery Date/Installation Schedule Approximate Start Date: 07/18/2020 Approximate Finish Date: 08/15/2020 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 emalls and PDF documents. By in' 'aling 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 05/23/2020 The Home Depot Customer's Signature Date Service Provider Name X 1 1 05/23/2020 908 Boston Turnpike Unit 1 Co-Signer (if applicable) Date Service Provider Address X 05/23/2020 1 Shrewsbury MA 01545 Signature On Aphalf of Home Depot Date City State 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:1-800-466-3337 460 Fl FIDE Customer Agreement(24 Jul.18) Generated Date n-s/74/�_ Lead/PO# 1-117\/XX5F v 0.1.11 WINDOW SPECIFICATION SHEET - Spec.Sheet#: 1-11ZVXX5E Sheet: 1 of 2 Customer: Walton and Rachel Moore Job#: 1-112VXX5E Consultant: Ronald Engelbrecht Date: 05/23/2020 New Window Existing Window Hinge Locations Measurements Grids Product Options Labor Options From outside, Left to Right Bays,Bows Location Color Rough Opening #of bars #of bars Csmnts,1 Pnl, use L,R or S Glass Misc Items Hardware Code Screens For doors use ,4 LC c _ c _ Mull "S"=stationary or Style Wrapsg m £ m o` E 4 C `� "c' "X"=operating LU m v � $c7 3a ? m o d o I:= Room Floor Code (YM) Style Code Series Code S 3 x 5 FT of > x > x 1 KITCH 1st SB-DH Y DH 6500 WH WH 30 58 BB St Dnda dite, GlassPack: WRAP,LSR 2 KITCH 1st SB-DH Y DH 6500 WH WH 30 58 88 St Dnda dile, GlassPack: WRAP,LSR STD,W 3 FAM 1st SB-DH Y DH 6500 WH WH 30 58 88 S andardte, GlassPack: WRAP,LSR 4 FAM 1st SB-DH Y DH 6500 WH WH 30 58 88 St Dnda Oite, GlassPack: WRAP,LSR 5 FAM 1st SB-DH Y DH 6500 WH WH 30 58 88 St Dndard White, GlassPack: WRAP,LSR ST 6 FAM 1st SB-DH Y DH 6500 WH WH 30 58 88 S arida d'te, GlassPack: WRAP,LSR 7 DINE fat SB-DH Y DH 6500 WH WH 30 58 88 St Dnda dile, GlassPack: WRAP,LSR 8 LIV 1st SB-DH Y DH 6500 WH WH 24 58 82 St Dndardite, GlassPack: WRAP,LSR SPECIAL CONSIDERATIONS: 1:White,2:White,3:White,4:White,5:White,6:White,7:White,8:White Wrap Color nterior Casing Type Bay or Bow window: atboard material(vinyl only-Birch or Oak) y Project Angle(30 or 45) ay Flanker Type(DH,SH,or Csmnt) Top of window to soffit(inches) If tied to soffit,color of soffit material I have reviewed and agree with all the job specifications above and the Construct Roof(Yes or No)' Special Terms and Conditions on the following page Garden Window: 'atboard Material(vinyl only-White Pionite,Birch or Oak) WINDOW SPECIFICATION SHEET - Spec.Sheet#: 1-11ZVXX5E Sheet: 2 of 2 Customer: Walton and Rachel Moore Job#:1-11ZVXX5E Consultant: Ronald Engelbrecht Date: 05/23/2020 New Window Existing Window Hinge Locations Measurements Grids Product Options Labor Options From outside, Left to Right Bays,Bows Location Color Rough Opening #of bars #of bars Csmnts,1 Pnl, use L,R or S Glass Misc Items Hardware Code Screens For doors use U.0c c Mull "S"=stationary or LU Style Wraps c m Q 8 o "2 m c "X"=operating LU aPs 3 Room Floor Code (YM) Style Code Series Code 3 = H«i U a > _ > X STD,White, GlassPack: WRAP,LSR 9 HALL 1st SB-DH Y DH 6500 WH WH 24 58 82 Standard STD,White, GlassPack: WRAP,LSR 10 HALL let SB-DH Y DH '6500 WH WH 24 58 82 Standard STD,White, GlassPack: WRAP,LSR 11 HALL 1st SB-DH Y DH 6500 WH WH 28 58 86 Standard SPECIAL CONSIDERATIONS: 9:White,10:White,11:White Wrap Color Interior Casing Type Bay or Bow window: eatboard material(vinyl only-Birch or Oak) ay Project Angle(30 or 45) y Flanker Type(DH,SH,or Csmnt) Top of window to soffit(inches) If tied to soffit,color of soffit material I have reviewed and agree with all the job specifications above and the Construct Roof(Yes or No)' Special Terms and Conditions on the following page Garden Window: atboard Material(vinyl only-White Pionite,Birch or Oak) -� ,) IY I DATE(MM/DDYYY) CERTIFICATE OF LIABILITY INSURANCE 02/11/2020 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE )POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSH USA,INC. NAME: TWO ALLIANCE CENTER ac No Ext);NE Arc No): 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# CN101642069-HomeD-GAW.-20-21 INSURER A:Old Republic Insurance Co 24147 INSUREDTHEHOME 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 BUILDING C-20 INSURER 0: ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-004353439-33 REVISION NUMBER: 25 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I ADDLISUBRI I POLICY EFF I POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER ! MM/DD MMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY 314574 03/01/2019 03/0112022 EACH OCCURRENCE S 1.000,000 —{� D M IS To TED 1,000,000 CLAIMS-MADE X OCCUR PREMISES Ea occurrence S X SIR:$1,000,000 MED EXP(Any one person) S EXCLUDED 1,000,000 i PERSONAL&ADV INJURY -S 2,000,000 AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE S F_X LU� �PRO- 7 PRODUCTS-COMP/OP AGG S 2,000,000 POLICY j JECT " LOC 'OTHER: S A AUTOMOBILE LIABILITY I MWTB314573 03/01/2019 03/01/2022 CEOm, deD SINGLE LIMIT S 1,000,000 X ANY AUTO I I BODILY INJURY(Per person) S �1 OWNED SCHEDULED I SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) S !�AUTOS ONLY AUTOS I HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY I Per accident UMBRELLALIAB H OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS MADE AGGREGATE S DED RETENTIONS S B 1 WORKERS COMPENSATION WC 023096004(AK,NH,NJ,VT) 103/0112020 03/0112021 X STATUTE ERH AND EMPLOYERS•LIABILITY 03/01/2020 03101/2021 5,000,000 B YIN N WC 023096005(WI) 'ANYPROPRIETOR/PARTNER/EXECUT{VEE.L.EACH ACCIDENT ❑ !S OFFICERIMEMBEREXCLUDED? N N/A' 5,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under Continued on Additional Page I E.L.DISEASE-POLICY LIMIT S 5,000,000 DESCRIPTION OF OPERATIONS below C Excess Auto 297110011002020 j 03/01/2020 03/01/2021 Limit: 4,000,000 A ;Excess General Liability MWZX 314580 03101/2019 03101/2022 Limit: 8,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukhedee �LcLuva -tc sv+ e� ©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 • '�� ADDITIONAL REMARKS SCHEDULE Page 2 of s AGENCY NAMED INSURED MARSH USA,INC. THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. PDucY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 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: Carrier:Indemnity Insurance Company of North America Policy Number:WLR C66922716(AL,AR,FL,ID,IA,KS.KY,LA,MS,MO,NE,NM,ND,OK,SC,SD,TN,�VV,WY) Effective Date:0310112020 Expiration Date:0310112021 (EL)Limit:S5,000,000 Carrier:New Hampshire Insurance Company Policy Number:WC 023096003 (DC.DE,HI,IN.MD,MN,MT,NY,RI) Effective Date:0310112020 Expiration Date:03101/2021 (EL)Limit:$5,000,000 Carrier.ACE American Insurance Company Policy Number:WCU C66922753(QSI) (AZ,CA,IL,NC,OR,VA,WA) Effective Date:03/01/2020 Expiration Date:0310112021 (EL)Limit:$4,000,000 SIR:51,000,000 SIR for the states of AZ,CA,IL,NC,OR,VA,WA Carrier:National Union Fire Insurance Company Policy Number:XWC 6559356(OSI)(CO,CT,GA,ME,MI,NV,OH,PA,UT) Effective Date:03/0112020 Expiration Dale:0310112021 (EL)Limit:$4,000,000 $1,000,000 SIR for the states of CO,ME,NV,MI,OH,PA,UT $750,000 SIR for the state of GA 535Q.00t3-SRfffflM3tale'ef-G1.. .. Carrier:National Union Fire Insurance Company Policy Number.XWC 6559357(QSI)(MA) Effective Date:00 01/020 y �) Expiration Date:03101/2021 (EL)Limit:$4,500,000 SIR:$500,000 TX Employers XS Indemnity: Carrierlllinios Union Insurance Company Policy Number:TNS C66932345(TX) Effective Date:0310112020 Expiration Date:0310112021 (EL)Limit:370,000,000 SIR:$1,000,000 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 3 i {3 3 d The Commonwealth oflVTassachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass govldia 'Wrorkers'Compensation insurance Affidavit:Builders/Contractors/EIectricians/Pinmbers- TO BE MUD WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl 11 NaMe (Business/Organization/Individual): Address: �� City/State/Zip: l� _ Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 1 am a employer with employees(full and/or part time).* I 7. El Now construction i i 2.❑1 am a sole proprietor or partnership and have no employees working for me in $. E]Remodeling any capacity.[No workers'comp.insurance required] g, ❑Demolition 3.E]I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10[]Building addition i 4.F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will a ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.F1 Plumbing repairs or additions :A I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. gRf repairsThese sub-contractors have employees and have workers'comp.insurance1 '6.DWe are a corporation and its officers have exercised their right of exemption per MGL c. 14. eT �5 I52,§1(4),and we have no employees.[No workers'comp.insurance required] *Aay applicant that checks box#1 must also fill ontthe section below showing their workers'compensations policy information t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation lusurance for my employees Below is the policy and job site information. /0A ��n� Insurance Company Name: (/_ �'/ ,/ j /_ 2DZ Policy#or Self-ins.Lie.#: � t6 6��� Expiration Date:' I /� l r�� Job Site Address: v�©�� ✓� J City/State/Zip/ V / Attach a copy of the workers'compensation policy declaration page(showing the policy number and expir on date). Failure to secure coverage as required under MGL G. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 (J 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 flus statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. 3 I do hereby certify un th pains,and penalties a perjury that the information provided above is true and correct Date: ��U Si a e: i Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# l 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#• t Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Supplement Card �' — Registration: 1127135 HOME DEPOT USA INC — Expiration: 04/22/2021 P 0 BOX 105451 ATTN: LICENSE MGMT TEAM ATLANTA, GA 30348 Update Address and Return Card. SCA 1 G 2OM-05/17 .T� 1ivnin1nir1n`/�1 f' //n:111110ii.,fv2, 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 112735 04/22/2021 1000 Washington Street •Suite 710 HOME DEPOT USA INC Boston,MA 0 118 RICHARD TROIA 2455 PACES FERRY RD C-11 HSC +�'�•�`moi• ATLANTA,GA 30339 Undersecretary Not valid without signature .•T `.-a=- Pointe ! -%.L:;'.i. '1• r.ct 3c .1FC:.�:ii�m r.-'ir ii ';f�':'�`�_ i� �LTi•�-.t:t�8 ! le. _a ;ac.l _L:{!a na'.ns !G —•r`.-it;1 fQ ;:2SIf: .ir.=C .y^I:: l G.=-76 014 �`elat;.tin•fai l Q ?l�Zt j`= !RA SL44LIUACION DIE P010,510,1170 RI-EFIC-IM700 Sdar'HaA G:iiia Cad_M?t�_ !� ••! 1!?ONI_`7 tJ:ZI lrt.���� i5i.1 I1irES �lE!�lTARIA DE XEt�:DlMIMTr0 !� ti:C-t�18 Ss;cx.siu:r.�M !j 0 Age; 1L -.....- -..., _�_._ �_� _�. ._��d=i-�._C:x.t-sc�tv_eize�u:•�=,rsr,:a ii _ -. .=•�".!.". 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OVUN �t 2EUGGNIU` i ��'�•' •; tr .tt 23 BENHAM MEET _ , „ , +�,�:•:::';;, PR1MFEDLD,MA W109.2301 �•^7.'i :Ir•,..�:• •: :':�• ter. ..•'t•••ji '• ~� �:+5 ` . .. �' • Jr. ' 11i�5rK;r.t:. /J't 1��= i�; _'rr•�--• Expiration: 1° _ 'Commissioner .�., .., FtGT i.•' 09!2912020 ..�i;t. : ;_j._. 5 Do 0911611096 Rov 02(2212016