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23A-112 (4) BP-2021-2128 7 PINE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23A-1 12-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-2128 PERMISSION IS HEREBY GRANTED TO: Project# door Contractor: License: Est. Cost: 3000 LOWES HOME CENTERS INC 103003 Const.Class: Exp.Date:09/08/2022 Use Group: Owner: KALISH ALEXANDER M&JULIE C Lot Size (sq.ft.) Zoning: URB Applicant: LOWES HOME CENTERS INC Applicant Address Phone: Insurance: 1000 LOWES BLVD (413)272-8931 0 WC016393105 MOORESVILLE, NC 28117 ISSUED ON:11/03/2021 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. Signature: I • j` . �� . Fees Paid: $40.00 212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner City of Northampton Massachusetts <r^ DEPARTMENT OF BgILDII FS' 212 Main Street t Mun'cip- + tip` --- Northamn, 01060 rrryt _ N' Nov 1 2021 os pT OF l NORTHgpUM DING INSP�CTIpN MA 01060 S PROCEDURE FOR OBTAINING A BUILDING PER RJ'NEW 1 &2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES, FENCES, GROUND MOUNTED SOLAR, ETC. I. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work. (Digital and hard copy) 3. Site plan with location of proposed structure(s)and set backs. 4. Construction Debris Affidavit filled out and signed by applicant. 5. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance. 7. Energy Conservation Compliance Certificate (new/ replacement windows). 8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable). 9. Note any Conservation and/or special permit requirements (if applicable). 10. Driveway Permit (if applicable). 11. Proof of Water and Sewer entry fees paid (if applicable). 12. Trench Permit -public land by DPW/ private land by Building Dept. 13. Stretch Energy Code -all new construction will require a HERS Rater Affidavit to be submitted with permit application before issuance of permit. 14. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton. The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR !,F Massachusetts State Building Code, 780 CMR MUNICIPALITY li USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Jr ` a I • �) Date Applied: KE I ti.)/ .1/ - /I'3-2021 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1Zroperty Address: 1.2 Assessors Map& Parcel Numbers / Pine 54 . 1.1a 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 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private El Lone: — Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 sylt,tvnerl of Record; Ire 1CY1 I t'i i Par twgn)v.., ,l-14, of �- Name(Print) City,State,ZIP Q}ne -lay-c (.) No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work Aret,t/ 4115, puo A- cyl-eKcst.i reif Catter. 2 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ Zj( d t? G 1. Building Permit Fee: $ Indicate how fee is determined: '.Electrical $ ElStandard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Total All Fe $ Suppression) Check No.4127 Check Amount: 40 Cash Amount: 6.Total Project Cost: $ 27( ,) t 0 ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) O►'1 (4 OpArie, k/ License Number Expiration Date Name of CSL Holder List CSL Type(see below) at G-ft'nUi lie 04 No.and Street Type Description Unrestricted(Buildings up to 35,000 cu.ft.) '7UH4444Aela " C 107 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding / SF Solid Fuel Burning Appliances C4 j "+�1.2-V'1y P7UrC,c �g @v'14-0. C- 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ( (` cs'C ( (6 -0 6 -0 ,00 Lj tq''P) 4di,.,p C•Pvi k,S HIC Registration Number Expiration Date HIC Company Name or IlIC Registrant Name uuo a,c .i1) L'►v�'��( �. ✓j'lrrt. e63' tuK a.v� No.and Street Email address 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 .❑ 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:OWNER'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 is true an cc o st of wfedge and understanding. CLtr<< M(r‘' Print Owner's or Authorized Agen a e( ctronic Signature) Date NOTES: 1. 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.gov-oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 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 halfTbaths 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" City of Northampton ier.714% Massachusetts �. / f a * . DEPARTMENT OF BUILDING INSPECTIONS } 212 Main Street • Municipal Building Northampton, MA 01060 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, 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, S 150A. The debris will be disposed of in: : )--)• � �"I1-(rti / n>>,�4, 0( aT Location of Facility. The debris will be transported by: Name of Hauler: \5Ar'l )--6-c��� /hnr�✓* Signature of Applicant. Date: ="— The Commonwealth of Massnehuseus Department of industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.gov/din I%utters'Compensation Insurance. ("lido it: Ilu iltlersiContractorstElectrkiims/Plumhers. 10 at:FILED lik 1 I 11 I 111_ l'F R‘11111M:AUTHORITIt Applicant Information Please Print Legibly' Name(liusiness:Organiza t ion:Individual): (—U4/el 1-(0%I-t0 C el. Address: tiO 06 C.,a5 _ . City/State/Zip: [fil U7'14°w"A 1 1 r" if.,( )-C i i) Phone :.:- CH-1, )04—C6c7 --e j -/- , Are yam an rinployert Clerk the apprupriere twi: Type of project(required): I..0 I an a einployor with Intapioyees(full aralin pan-tuner{• 7. 0 New coils/ruction ..DI an a wale aroprxetor in pannetahip and lain e no cniptiry,za working tut OW ui K. 0 Remodeling any capacity [Nu winters'comp.'gramma:. roquircd„) 9. Ei Demolition l.0 I ant a horn...ow-nor doing all work rtiralf[No wualicti vonip,train-awe required]' la c] Building addition 4.0 I ant a homeowner and will be hiring court to conduct all 4t ark un no/property. 1 will mare that an contra-tura either laic wort:cri."emititikatain 111.11A fano:tit we aolt II fj Electrical repairs or additions proprictura w ith nu citipluyek,s. 12.D Plumbing repairs or pit ,s,61-4nt a general contractor arid 1 haii-e hired tht aub-curitractuti.listod on the attachod alien. 13 Roof repairs Me*:sub-eilfkilal:60IN have employer.and have worluers'comp,iinurancc.; 14.E1 Other are a ene-puratiori and it....officen have catimnad their nett of exemption per!Wit e. 152, 1 ta t.,and see haw no ernplowea.(No nAtticn•ceaTIn.ITIMMItteerequirett) f An applicant that ehoeltx box ul aunt alto fill out the wetniti tit:low Alva in.'then worker..evinponation pvIwy utfitrindfion. +tionittioniers who aub(nhl dux alrula,,it indicating the.,are doing ail tx ink and then hue euttode conlractorx mntt,utnmt a nets affidavit truth:smog buck :Contractor.that heck aria box mutt atuelied an additional%beet%bowing di,.name of the xulreontractoes and aate*holier or nut thuaa mtst34,7,have ...Itiployeci (Ida: ill••-cotitroctiit.N 11.0 V CIttpler.CC,.Hwy;mot povinIc then moikeri,•oitip polici nianlica . . I am an employer that is providing worAers'cantpetnation insurance for my employees. Beloit'i8 the policy and job site information. Insurance Company Name: Al IV 47 k u461)— Policy$or Self-ins.Lic.4: IA/C 0 I C236(47)I° 5 Expiration Date: 4— 1--Job Site Site Address: 7 9 i'neo. i)- ,City'State:Zip: 0/arti,,,,ni ,cZ1.14 of 662,)-- Attach a copy of the workers'compensation policy declaration page(showing the policy nu 1111)C t and uks)iration date). Failure to secure coverage as required under MCil.c. 152.§25A is a criminal violation punishable by a line up to S1,500_00 andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 herein certif. +niter dr, lin an . . te.' f perjury t e information pro'kitled abort.Is true and correct. Sa5tulLirc. Date: I°'I' t —'2 r Phone.::: 1-)).-- 7dTri i Official use only. Do no:write in this area,to be completed by city or town official ' City or Ton: Permit/License# Issuing Authority (circle one): I. Board of Health 2.Building Department 3.C'hyfrown Clerk 4.Electrkal Inspector 5. Plumbing Inspector 6.Other Contact Person: one 4: — Ph City of Northampton Massachusetts ��+' • DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT I, (insert fill legal name), born _ (insert month, day,year),hereby ' Jose and state the following: 1. I am seeking a bui ' g permit pursuant to the homeowners' exemption to the permit requirements of the Massachusetts State But ,'ng Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I Ito , egal title. 2. I am not engaged in, and the pro]'. or work for which I am seeking the aforementioned homeowners'exemption, does not involve the field erection of •nufactured buildings constructed in accordance with 780 CMR 110.R3. 3. 1 qualify under the State Building Code's '> nition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns a parcel of land on ich he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-family dwe ' g, attached or detached structures accessory to such use and/or farm structures.A person who constr is more than one home in a two-year period shall not be considered a home owner. 4. I do not hold a valid Massachusetts construction supe '.ion license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's :,uirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision ' connection with any project or work involving construction, reconstruction, alteration, repair, removal or dent. ition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the orementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for s 'd project or work. Signed under the pains and penalties of perjury on this day of ,20 . (Signature) INSTALLER COPY INSTALLATION SERVICES CUSTOMER CONTRACT-MWORK-INT/EXT/PATIO DOOR OWES OF HADLEY,MA.STORE#1916 STORE PHONE:(413)588-0270 LOWED 82 RUSSELL STREET SALESPERSON BRUCE HUNTER ADLEY, MA 01035-0000 SALESPERSON ID:1508948 Document Print Date:10/14/2021 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 JULIE KALISH 860-324-9200 O Customer Address Other Phone 7 PINE ST 860-324-9200 L City State/Province Zip/Postal Code D NORTHAMPTON MA 01062 Installation Address T 7 PINE ST O Installation City Installation State/Province Installation Zip/Postal Code NORTHAMPTON MA 01062 MERCHANDISE AND INSTALLATION SUMMARY MERCHANDISE SUMMARY 999241 :SOS:WTS TT REEB ENTRY HOM STN LLT:33 5/8 x 82 Single Door:REEB MILLWORK OF NEW ENGLAND-QTY 1 15634:230612:STK:12OZ DOOR AND WINDOW FOAM:120Z 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 117995:117TK 5 CP:STK:RB AB GALLO COMBOPACK:RB AB GALLO COMBOPACK:KWIKSET-QTY 1 333358:1X8-PFJ8:STK:1-8-8 PRIMED PINE: 1-8-8 PRIMED PINE:METRIE INDUSTRIES INC-QTY 1 Materials Price $2809.16 Store 1916 Project No.703963535 for JULIE KALISH Page 1 of 4 INSTALLER COPY INSTALLATION DESCRIPTION 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 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:None Dump entry Fee:Yes Additional Work:tricky install,R&R interior trim and new sill support. Additional Work Charge:Yes Comments:Looking at a therma tru door with oval. Labor Charges $ 690.50 Detail Deduction -$ 35.00 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: httos:Nwww.eca.clovlsites/oroducfionffiles/documents/renovaterlohtbrochure.odf.For more information see:httos:Uwww.eea.00vllead/lead-renovation-repair-and-oainlina-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 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 andlor 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 Goods 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. TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES *where applicable Store 1916 Project No.703963535 for JULIE KALISH Page 2 of 4 INSTALLER COPY SUB-TOTAL $3464.66 *TAX $ 0.00 DELIVERY $ 0.00 ORDER TOTAL $3464.66 BALANCE DUE Store 1916 Project No.703963535 for JULIE KALISH 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 certiy 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 deflective 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/Independent 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.703963535 for JULIE KALISH Page 4 of 4 ) DATE(MMi0D/YYYY) ACORL] CERTIFICATE OF LIABILITY INSURANCE 03/29/2021 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 CONTACT Marsh USA Inc NAME' PHONE - -- 1FAX 100 North Tryon Street,Suite 3600 (A/C.No.Extl: LAC No): Charlotte,NC 28202 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# 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 23841 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) tMMf00/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR Self Insured-See below DAMAGE PREMISES O RENTED (Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ O1 HER: 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 ONLY SCHEDULED CA7030893 (VA) 04/01/2021 04/01/2022 BODILY INJURY(Per accident) $ AUTOSHIRED 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 $ 5000.000 DED RETENTION$ $ C WORKERS COMPENSATION WC01 63 9 31 05(AOS) 04/01/2021 04/01/2022 X I PER I I OTH- AND EMPLOYERS'LIABILITY STATUTE ER D Y/N WC016393104(ND,WA,WI,WY) 04/01/2021 04/01/2022 2,000,000 ANYPROPRIL I ORIPAR I NLWLXLCUTIVL E.L.EACH ACCIDENT $ OFFICER/MEMBLRLXCLUDLD? N N/A 2D00'�O (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 2,000.000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Excess Workers'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/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Commercial General Liability policy is Self-Insured,effective 4/1/2021 to 4/1/2022 CERTIFICATE HOLDER CANCELLATION Lowe's Companies,Inc.and Subsidaries SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1 COO Lowe's 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 «t >•-- 4._<<- ,., ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN102776519 LOC#: Charlotte ACC)RLI 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 -T 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 Pdicy Number EP0000016700 Cartier North American Specialty Pdicy Effective Date:01-Apr-2021 Pdicy Expiration Date:01-Apr-2022 Limits:$8,9 0,000 Each Occurrence I$35,000,000 Aggregate XS TX Employers XS Indemnity(Excess) Pdicy Number:XCB3095 Carrier:Evanston Insurance Company Pdicy Effective Date:01-Apr-2021 Pdicy Expiration Date:01-Apr-2022 Limits:$15,000,000 Each Occurrence/$35,000,000 Aggregate XS Workers'Compensation and Excess Workers'Compensation pdicies indude a self-insured retention of$2,000,000. General Uabtiity:The insured is self insured for$10,000,000 each occurrence for the period of 4/1/2021 to 411/2022. The Automoble Liability policy evidenced above is subject to adcitional self-insured retentions excess of limits 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 Am Rd' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) `.,. - 10/12/21 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 CONTACT NAME: Kefl Rusciano,CISR Rejean J.Remillard Ins Agency PHONE,Eat): 413-789-3070 (ac,No): 413-786-0193 1040 Springfield Street E-MAIL ADDRESS: Keri@RejeanRemillard.com @ 1 Feeding Hills,MA 01030 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Main Street American Assurance INSURED INSURER B: National Grange Mutual Burgers Home Improvements INSURER C: Ace American-Travelers Ins Co. 22 Granville Rd INSURER D: Southwick,MA 01077 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 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&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X POLICY PET 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 X HIRED X NON-OWNED PROPERTY DAMAGE $ _^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 OFFICER/MEMBER EXCLUDED? Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE N/A 6R09227AUB 10/02/21 10/02/22 E.L100,000 EACHACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It 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:ISI / 1000 Lowe's BLVD AUTHORIZED REPRESENTATIVE Mooresville,NC 28117 r' ©1988- 5 AC PORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD N nazon com eBay 8 «. i •corn C hea Tn Adva or c k Office of i, iii i t .piBusinessf + til tt of Division oI' tandar it ::,,,,„ Office of b Safety and inspections LEcens'ing Home 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 creditfdebit 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 e ��F��, Building Licenses 01, NI CS-'030€03 �:> €,t_,s Active j 8i1012009 �`_. t r , <�t.‘ 9'8/2022 • Zip code Click on the registration number to view complaint history. You can also view arbitration and Guaranty Fund history. The list is current as of Wednesday, October 27, 2021, Search Results RESPONSIBLE : REGISTRATIONADDr' EXPIRATIONSTAT:US %tk.rt,t,Wr'.x/f kttl!tP,'"?-r1 nATr LOWE'S HOME White, Gary q'r 1000 LOWES 1 0/17/2023 Current CENTERS, LLC BLVD Services Compliance MOORESVILLE, NC 28117 Site Policies Contact Us © 2018 Commonwealth of Massachusetts. Mass.Gov0 is a registered service mark of the Commonwealth of Massachusetts.