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18-002 (28) 99 PINES EDGE DR BP-2021-1484 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18-002 CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Door Replacement BUILDING PERMIT Permit# BP-2021-1484 Project# JS-2021-002466 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(sq. ft.): Owner: SLATTERY KIERAN Zoning: Applicant: LOWES HOME CENTERS INC AT: 99 PINES EDGE DR R Applicant Address: Phone: Insurance: 1000 LOWES BLVD (413) 272-8931 () WC MOORESVI LLENC28117 ISSUED ON:6/15/20210:00:00 TO PERFORM THE FOLLOWING WORK:new patio slider 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: i ' x )Certificate of Occupancy si;;naturc: . • � . w -� •� I h'cc"1'vpe: Date Paid: Amount: Building 6/15/2021 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner - : --Ar.,..._____,______________ Cif iji [s.x. N 1 1 2021 The Commonwealth of Massachusetts FOR 4; Board of Building Regulations and Standards i • Massachusetts State Building Code,780 CMR MUNICIPALITY �CDrn� USE a^4n'c > �r �Tlit Application To Construct,Repair.Renovate Or Demolish a Revised Mar 2011 oho_ One-or Two-Family Dwelling ection For Offi cial fficial Use Only Building etmit Number: 7P'4'((1 0ti Date Applied: �C Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION l.1 Property Address: 1.2 Assessors Map&Parcel Numbers K' P;n vS txcye P/o I 0O 7 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided I 1.6 Water Supply:(M.G.L c.40,§54) 1 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private 0 Zone: _ Outside Flood Zone? Check if yes❑ Municipal 0 On site disposal system ❑ SECTION 2: PROPERTY OWNERSEIr 2.1 Owner'of Record: r.;tercin 4 L cr,L,1efy AA)r,I-,r,,,•,i� � 4 u(o C&U Name(Print) City,State.ZIP `f cl P me ,c C..e 1)R ')IS--. 0 =6,5,y No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 Alteration(s) ❑ Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed VWroric2: A.,,,, (?c 4<U 47 I,k,kc /lit, C. trH(.1.t4,9( C 0 ce,c, Q . SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only _SLabor and Materials) 1.Building $ r2I( I.I. Building Permit Fee: $ Indicate how fee is deternmined: 2.Electrical $ O Standard City/Town Application Fee 0 Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (IIVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: Check No.14 Check Amount: Li Cash Amount: 6.Total Project Cost: S'27t J tJcJ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 01,14( (77,41411 06,M'/ License Number Expiration Date Name of CSL Holder n List CSL Type(see below) ).01- No.and Street Type Description ��" ("C�C G(o ) U Unrestricted(Buildings up to 35,000 cu.ft)tYl Ah(�t/ /� Restricted I&2 Family Dwelling City/Town.State,ZIP Masonry RC Roofing Covering WS I Window and Siding SF Solid Fuel Burning Appliances -(pN1ref-e/ n"rjt'1,C"i. I s Insulation Telephone Email address D 1 Demolition 5.2 Registered Home Improvement Contractor(FIIC) Lax 44/4"'P C-P/1 `' S WC Registration Number CBLxpirCalioonn Date-te HIC Company Name or HIC Registrant Name / No.and Street Email address ,t J4,,M .,0te, ,�,c ?-' «l `I("3 ,1?mo4 7/ City/Town,State,ZIP Telephone SECTION 6: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 building permit. Signed Affidavit Attached? Yes No . 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,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. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application(i1 is true and ac o st of my knowledge and understanding 01/ten trrj Print Owner's or Authorized Agent's Name(Sec tc Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.covioca Information on the Construction Supervisor License can be found at www.mass.Pov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" . The Commonwealth of Massachusetts "— Department of Industrial Accidents F -"v 1_ 1 Congress Street,Suite 100 Boston,MA 02114-2017 ° www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PER1vIITTLNG AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): LOA-°5 Ila'- . C 'Pak f Address: ( 0t/t) L 6i.,-O(m /1/4,0 1" City/State/Zip: }/i-,Ou t-DiJ 1l ie, it-,C )4.6(i) Phone#: Li(; -)-me) �Cf 2 1 Are you an employer?Check the appropriate box: Type of project(required): 1.1::1 I am a employer with employees(full and/or part-time).' 7. 0 New construction 2.0 I ant a sole proprietor or parmersbip and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 30 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Q Building addition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions pro 'etors with no employees. 12.❑Plumbing repairs or additions 5 l am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0Roof repairs These sub-contractors have employees and have workers'comp.insurance t 6.❑We area corporation and its officers have exercised.their right of exemption per MGL c. I4. ther V Uv 2_ 152,§1(4),and we have no employees.[No workers'camp.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 nzy employees. Below is the policy and job site information. Q'�"" 4 ( f Insurance Company Name: (/IA h�`� 1 � 1 IL' ( (,� Policy#or Self-ins.Lic.#:L(j C G 101 /1U� Expiration Date: lr( •-- Job Site Address: 9.-f pin") `['Oc--& 0L City/State/Zip: it/oI1'1 1n1A �' G(of G 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 cert;fy er t ains and penalties of perjury that the information provided above is true and correct — Si ature: Date: 6 -q!-' 1 Phone#: 4("27— 01 791.-cC9 9 ! 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#: The City of Nofthampton Building Department r-M „ti • 212 Main Street Northampton, Massachusetts 01 060 Phone (413) 587-1240 Fax {413) 587-1272 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVAT ION PROJECTS) in accordance with the provisions of MGL c40, s54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, s150A. The debris will be disposed of in: 00mtl Location of Facility '(►�1 cn It/PO(16)( 0(63 The debris will be transported by: Name of Hauler APeird<A6(e "`/(1 /` %(,(Ld-rc4 Signature of Applicant: Date: • City of Northampton YNaMrr', cY`e�• Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building J�, a Northampton, MA 01060 s ;r3r0 HOMEOWNERS'EXEMPTION ELIGIBILITY AI-1-IDA VIT • I, (insert full legal name), born _ (insert month, day,year), hereby depose and state the fallowing: 1. I am seeking building permit pursuant to the homeowners'exemption to the permit requirements of the Massachusetts tate Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel • land to which I hold legal title. 2. I am not engaged i and the project or work for which I am seeking the aforementioned homeowners' exemption, does not ins olve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Buil•'ng Code's definition Of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns a parcel • land on which he/she resides or intends to reside, on which there is, or is intended to be, a .ne-or two-family dwelling, attached or detached structures accessory to such use and/or farm tructures. A person who constructs more than one home in a two-year period shall not be consi.- ed a home owner, 4. I do not hold a valid Massachusetts cons action supervision license and, except to the extent that I qualify for and will abide by the Massachuse•. State Building Code's requirements for the supervision of the project or work on my parcel, I am not en:,•ed in construction supervision in connection with any project or work involving construction, reco• truction, alteration, repair, removal or demolition involving any activity regulated fry any provision o the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in corm.,tion with the aforementioned project or work on my parcel, I acknowledge that I am required to and will a As the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of , 20_. (Signature) I"----" gj DATE(MM/DDlYYYY) ACOR>D CERTIFICATE OF LIABILITY INSURANCE 0329/2021 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 CONTACTNAME: Marsh USA Inc. PHONE FAX 100 North Tryon Street,Suite 3600 (A/C.No.Extl: (A/C,No): Charlotte,NC 28202 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC t CN102776519-Lowes-SI-21-22 INSURER A:National Union Fire Ins Co.of Pittsburgh PA 19445 INSURED INSURER B:Interstate Fire&Casualty Co 22829 Lowe's Companies,Inc. and subsidiaries INSURER C:AIU Insurance Co 19399 1000 Lowe's Boulevard INSURER D:New Hampshire Insurance Company 23641 Mooresville,NC 28117 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-004976909-08 REVISION NUMBER: 10 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ Self Insured-See below DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JEC LOC PRODUCTS-COMP/OP AGG $ OTHER: A AUTOMOBILE LIABILITY CA7030892 (AOS) 04/01/2021 04/01/2022 COMBINED SINGLE LIMIT $ 5,000,000 (Ea accident) A X ANY AUTO CA7030891 (MA) 04/01/2021 04/01/2022 BODILY INJURY(Per person) $ A OWNED SCHEDULED CA7030893 (VA) 04/01/2021 04/01/2022 BODILY INJURY(Per accident) $ _ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ B X UMBRELLA LIAB X OCCUR USZ00024220 04/01/2021 04/01/2022 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I RETENTION$ $ C WORKERS COMPENSATION WC016393105(AOS) 04/01/2021 04/01/2022 x PERTUTE I tER ) D AND EMPLOYERS'LIABILITY Y/N WC016393104(ND,WA,WI,WY) 04/01/2021 04/01/2022 2,000,000 ANYPROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N NIA 2,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under EL DISEASE-POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS below . . A Excess Walters'Compensation XWC1647266 (FL) 04/01/2021 04/01/2022 (WC per statute) 3,000,000 A Excess Workers'Compensation XWC1647265(AOS) 04/01/2021 04/01/2022 (WC per statute) 3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Commercial General Liability policy is Self-Insured,effective 4/12021 to 4/1/2022. CERTIFICATE HOLDER CANCELLATION Lowe's Companies,Inc.and Subsidaries SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1000 Lowes Blvd. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Mooresville,NC 28117 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee —M..-.---.2.e.^- --44-^a-1.^---a-•— I ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • i AGENCY CUSTOMER ID: CN102776519 • LOc it: Charlotte ACOREl ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh USA Inc. Lowe's Companies,Inc. and subsidiaries POLICY NUMBER 1000 Lowe's Boulevard Mooresville,NC 28117 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance TX Employers XS Indemnity Policy Number EPG000016700 Cartier:North American Specialty Policy Effective Date:01-Apr-2021 Policy Expiration Date:01-Apr.2022 Limits:$8,000,000 Each Occurrence/$35,003,000 Aggregate XS TX Employers XS Indemnity(Excess) Pdicy Number.XCB3095 Cartier:Evanston Insurance Company Policy Effective Date:01-Apr-2021 Policy Expiration Dale:01-Apr-2022 Limits:$15,000,000 Each Occurrence/$35,000,000 Aggregate XS Workers'Compensation and Excess Workers'Compensation policies indude a self-insured retention of$2,000,000. Genera Liability:The insured is self insured for$10,000,000 each occurrence for the period of 4/1/2021 to 4/1/2022. The Automobile Liability policy evidenced above is subject to additional stiff-insured retentions excess pilings shown for various perils covered ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Ae.,GRG1 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD/YYYY) 06/02/21 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 CONTNAME ACT Keri Rusciano,CISR Rejean J.Remillard Ins Agency PHONro,EXtr 413-789-3070 (AI No): 413-786-0193 1040 Springfield Street E-MAIL Feeding Hills,MA 01030 ADDRESS: Keri@RejeanRemillard.com INSURER(S)AFFORDING COVERAGE NAIC• INSURER A: Main Street American Assurance INSURED INSURER B: National Grange Mutual Burgers Home Improvements INSURER C: Chubb Group 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 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 ADDTYPE OF INSURANCE INSD WVRD POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD (MM/DD/YYW) (MMIDD/YWY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �/ DAMAGE l O REN fED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A Y Y MPK6213N 06/08/21 06/08/22 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY ri JE 0. CI LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 100,000 B OWNED X SCHEDULED AUTOS ONLY AUTOS Y Y M1T3385E 06/10/21 06/10/22 BODILY INJURY(Per accident) $ 300,000 HIRED v NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER C ANY OFFICER/MEMBER/EXCLUDEDXECUTIVEY/N N IA 6S62UB-4N50542-5-20 10/06/20 10/06/21 E.L.EACH ACCIDENT $ 100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICYLIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/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 ACCORDANCE WITH THE POLICY PROVISIONS. Lowe's Companies,Inc. and any and all Subsidiaries Mail Code:A3ESS I 100 Lowe's BLVD AUTHORIZED REPRESENTATIVE Mooresville,NC 28117 ©1Sti 5 AC PORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ..- •.s'-';:,,--:::".-,',"',;',.",",',..1 e,..,,I. .'.'i''4,4,-,4,,,i., .''''A:04,7S,S,1444VAi,- ""44:41.4.Na': -,, 2 ? x 7:` a,�ti.i ° , e •� tom' K �.'-'-•-— -4••"'''''Sk.:,,N. -,-.1sitsto."14 i ft.4'..t-O,'.'1,4414,,-„t,,,...•... erg', ' .$ f K)� + 2'F' , r 1, "•.' ° rt` 16 r 7 :f -y t 3 sg 'Lwi�"3�,� r.^'«a+r i; "• ,. 'pi* 7 t., .-.114, -'7: `4 g't q •, t \ t °a tr ,tC'\ firl�*v. ;i 4x' 7 ', s ' • � ;1� s ,.! i.Yta ,,r a•���. i�ySt`40.�,.� y r[, m`vx cp � 1.,ii,- ,t- d � � Massachusetts ` n � � � 111 rstandards ii w i5 t ." , •�►' r, 7 ,, 322 . e 1 4t Z� • " e `YY rw '` ' � � x p kiASTER C7 22 � � ROAD v KMA � � �� ` z 44r.„....,400_, z" • CommIs s � " °d , � _ • - ...„ H. ` t�m ` % e`. *;+?< r# 6� a� " - a°.. + ? u -W� r „+4;M 's 'tdv y ` ' �," g °�r.."p s,� ��• ` »1Ar' ,.' , sfa : ., -,..4‘,#4*-e;r A:40.`f-471.:4'::1:•:: :3*•'--$44,*-7. ''''''''''. xw • ,•.G ! - on.com eBa'Y P99‘<irigiici°nvi C.hea,. 1'rrpAddvr,or in gior Office of Consumer Affairs & Business Regulaation DIVISiki41 ift Standard anti Ottice of Pet iic Safety and inspections Licensing HomePage Duplicate License Application Logout Select the license you would like to submit a duplicate request for from the list below. If you have multiple duplicate requests, you can only submit one request at a time. Complete the process for each license you would like to duplicate After completion of this application process you will be redirected to an external payment processing site.Acceptable payments methods are Visa, Mastercard, or a Funds Transfer from your bank account. There is a 2.49% processing fee if you pay by credit/debit card,There is a $0.40 processing fee if payment is made by Funds Transfer.This is a REQUIRED fee. Eligible Licenses Construction Supervisor Continue P,(:= Building Licenses t.ir;e < CS-10 003 Eice, S.t-ttr,;; Active 8,1012009 Expiration Dale: 9/8/2022 .7„. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:SucoRment Card Rg..eltatign 148688 10117=2021 LOWE'S HOME CEN7E RS,LLC CHRISTOPHER MINIE 1000 LOW ES BLVO SERVICES COMPLIANCE Undersecretary MOORESVILLE.NC 28117 INSTALLER COPY INSTALLATION SERVICES CUSTOMER CONTRACT-MWORK-tNT/EXT/PATIO DOOR OWES OF HADLEY,MA.STORE#1916 STORE PHONE(413)588-0270 LE W E 82 RUSSELL STREET SALESPERSON:BRUCE HUNTER ADLEY, MA 01035-0000 SALESPERSON ID:1508948 Document Print Date 06/04/2021 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 KIERAN SLATTERY 215-287-6578 O Customer Address Other Phone 99 PINES EDGE DR 215-287-6578 L City State I Province Zip/Postal Code D NORTHAMPTON MA 01060 Installation Address T 99 PINES EDGE DR O Installation City Installation State/Province Installation Zip/Postal Code NORTHAMPTON MA 01060 MERCHANDISE AND INSTALLATION SUMMARY MERCHANDISE SUMMARY 15634:230612:STK:12OZ DOOR AND WINDOW FOAM:12OZ DOOR AND WINDOW FOAM:DOW CHEMICAL COMPANY THE-QTY 1 34660:356-PFJ7:STK:PFJCSE 356 2-1/4-INX11/16-INX7-FT:PFJCSE 356 2-1/4-INX11/16-INX7-FT:METRIE INDUSTRIES INC-QTY 3 66646:07832:STK:1-2-8 ROYAL PVC BOARD: 1-2-8 ROYAL PVC BOARD:METRIE INDUSTRIES INC-QTY 3 238345:2827:STK:1-6-8 ROYAL PVC BOARD:1-6-8 ROYAL PVC BOARD:METRIE INDUSTRIES INC-QTY 1 310630:02709:STK:5-13/16-INX8-FT PVC UTLTY TRM WHT:5-13/16-INX8-FT PVC UTLTY TRM WHT:METRIE INDUSTRIES INC-QTY 3 333346:1X4-PFJB:STK:1-4-8 PRIMED PINE:1-4-8 PRIMED PINE:METRIE INDUSTRIES INC-QTY 3 1358874:JW237500002:STK:JW 6FT CLWD SL 1 LT LE OX NBM:JW 6FT CLWD SL 1 LT LE OX NBM:JELD WEN WINDOWS-QTY 1 Materials Price $1321.99 Store 1916 Project No.684665100 for KIERAN SLATTERY Page 1 of 4 INSTALLER COPY INSTALLATION DESCRIPTION Door type:Patio Location of new door(s):Back Door Select new door:Sliding Sidelights or transoms:No Number of additional holes bored for accessories:None Install specialized mortise hardware: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 Permit Fee:Yes Additional Mileage:0 Access fee:Yes Dump entry Fee:Yes Additional Work:cut back siding,build jamb,exterior pvc trim/j-channel Additional Work Charge:Yes Comments:No Comment Labor Charges $1252.00 Detail Deduction -$ 0.01 Additional Specifications: Notation:Lowe's will not make structural modifications,remove cabinetry to accommodate new appliance,or upgrade electrical service. Additional Specifications: 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 to be performed in Your dwelling unit or facility.A copy of the pamphlet is also available at the following website: httosj/www.eoa.000v/sitesloroductenffiles/documentslrenovateriohtbrochure.odf.For more information see:httos:/rwww.eoa.00v/lead/lead-renovation-repair-and-oaintina-orooram. PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photograghs of the Premises where Installation 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 fo 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,including,but not limited to,marketing,advertising,publicity,illustration,training and Web content.By initialing here,Customer agrees to the foregoing. [Customer to initial to the left]. NOTICE TO CUSTOMER-PRICE CALCULATIONS:In order to properly perform the installation of certain Goods,the Contract Price may include more Goods than actually will be installed based on the measured square footage of the Project Area.As a result,the parties agree that the lump-sum Price stated in this Contract is calculated upon both the value of the estimated Goods required to ful- fill the Contract(including waste),which may exceed the actual square footage of the Project Area,and the labor which may be estimated based on the amount of Goads required to fulfill the contract (including waste).By signing this Contract below,Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may not be refunded once the Installation Services are performed.. NOTICE OF ARBITRATION AGREEMENT This Contract provides that all claims by Customer or Lowe's will be resolved by BINDING ARBITRATION.Customer and Lowe's GIVE UP THE RIGHT TO GO TO COURT to enforce this Contract (EXCEPT for matters that may be taken to SMALL CLAIMS COURT).Lowe's and Customer's rights will be determined by a NEUTRAL ARBITRATOR and NOT a judge or jury.Lowe's and Customer are entitled to a FAIR HEARING.But the arbitration procedures are SIMPLER AND MORE LIMITED THAN RULES APPLICABLE IN COURT.Arbitrator decisions are as enforceable as any court or- der and are subject to VERY LIMITED REVIEW BY A COURT.FOR MORE DETAILS:Review the section titled ARBITRATION AGREEMENT.WAIVER OF JURY TRIAL AND WAIVER OF CLASS ACTION ADJUDICATION found in the Terms and Conditions of this Contract. Store 1916 Project No.684665100 for KIERAN SLATTERY Page 2 of 4 INSTALLER COPY TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES •where applicable SUB-TOTAL $2573.98 *TAX $ 0.00 DELIVERY $ 0.00 ORDER TOTAL $2573.98 BALANCE DUE Store 1916 Project No.684665100 for KIERAN SLATTERY Page 3 of 4 INSTALLER COPY WAIVER OF LIEN and ONE YEAR WARRANTY(TO BE SIGNED BY CONTRACTOR) I,the undersigned Installer/Independent Contractor,having been employed by the Customer who signed the Certificate of Completion below do hereby certify that the work for this project will be or has been completed in a workman like manner and to the Customer's satisfaction.In consideration of the receipt of one dollar and other good and valuable consideration,and to the extent permitted by ap- plicable law,I hereby waive and relinquish all liens and all rights and claims of liens which I,the undersigned,now have or may hereafter have for labor or materials furnished,and Further certify that all work performed and materials furnished,if any,by any other party or parties upon the order of the undersigned,have been fully paid for-Further,I the undersigned,agree to cause the prompt release of any mechanic's lien(s)which may be filed against the Customer's premises by any subcontractor,laborer,mechanic or material supplier claiming the right to file such a lien through work related to Customer's Contract with Lowe's.In addition to any warranties provided by law or specified elsewhere,including the Customer's Contract with Lowe's,the undersigned further warrants that all work fur- nished for this project shall be free from defects either in material or workmanship.If any defects in material or workmanship shall be discovered in the work furnished or material used during the course of the work or within one year from the date of the Certificate of Completion,the undersigned agrees to replace or correct such deffective work or material,free from all expense to Lowe's and the Cus- tomer in a manner satisfactory to the Customer- I further represent that I have given Customer the option of retaining some or all of the surplus materials or having some or all of such surplus materials removed from the Customer's premises. If applicable to the performance of the work required for this project,I,the undersigned installer/lndependent Contractor,do hereby certify that I have complied with all requirements of the Lead Renov- ation,Repair,and Painting Program Rule("LRRPP RULE"),40 C.F.R.sec 745.80et seq.,or any applicable state laws or program regulating lead-based paint safe work practices,including compliance with all information distribution,notice requirements and work practice standards in performing the work required for this project.I certify that I have provided the Customer with all documentation re- quired to be supplied under the LRRPP Rule or state program,shall retain all records required by law,and have attached to this document copies of all the records required to be retained by the LRRPP Rule or applicable state program. Signed and delivered this day of (Seal) SubContractor Print Name CERTIFICATE OF COMPLETION 1. I,the Customer,certify that the Installers/Independent Contractors or their sub-contractors,have furnished all Goods and/or services,that installation,repairs and alterations or improvements("the installation services")have been completed as set forth in my/our contract with Lowe's,and that I have been offered the oppor- tunity to request that Lowe's allow me to retain some or all of any unused,receipted surplus materials rather than have such surplus materials remain the property of Lowe's. 2. Buyer's initials(Buyer INITIAL ONE only) There were no such surplus materials. I accepted all surplus materials I wanted. I declined to receive any surplus materials. Date: Owner's Signature Owner's Printed Name Store 1916 Project No.684665100 for KIERAN SLATTERY Page 4 of 4