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32A-164 BP- 022-0898 100 BEACON ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23A-164-001 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-2022-0898 PERMISSION IS HEREBY GRANTED TO: Project# door Contractor: License: YANKEE HOME IMPROVEMENT Est. Cost: 16618 INC 066324 Const.Class: Exp.Date:03/28/2023 Use Group: Owner: MONTEIRO ARTURO JR Lot Size (sq.ft.) Zoning: URB Applicant: YANKEE HOME IMPROVEMENT INC Applicant Address Phone: Insurance: 36 JUSTIN DR (413)341-5259 1151034 CHICOPEE, MA 01022 ISSUED ON:07/28/2022 TO PERFORM THE FOLLOWING WORK: REPLACE 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I >2 . • j • Y CIP-'1 Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner C( t The Commonwealth of Massachu etts R L C F' L`� ;I,j p. iiilf. c, Board of Building Regulations and St ndar F R Massachusetts State Building Code, 7 0 C R JUL 2 5 SEBuilding Permit Application To Construct, Repair, novto Or Demolisl �a"" IN1c'IPALITY ises Mar 2011 One-or Two-Family Dwellin L nr- o aun.DING INSPECTION$ This Section For Official Use_Qttig t'0RTHAMPTON S ECTI _�_ Building Permit Number: 6,- , o 9q9 Date A lied: 41)/n-) 712y>: 7.Z8 zi)Z7 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers l coo eo oc S# • . 31- i CiY 1.la 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 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of R^e�ord: Pi r�-u r o Ur1 N o }e i r o -Tr . r ef\c . ma C 1 4(0 Name(Print) City,State,ZIP 1OD Qeacvr -- • (y13ti3$1-20 9 S-hnon+.e_t'roe mS .COrYL 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 Addit'on 0 Demolition 0 Accessory Bldg. 0 Number of Units Other of Specify: r le Brief Descriptioncp of Proposed Work2:'L�.p c.,(‘(�V vh '} re pI ca ca 1 .er h_s et O 1(\ C.)4 t SA-1. t to m-e to crr-VL . J SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ I(j) I ts(Q o0 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ U ❑ Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees. ` 440 Check No, eck Amount: Cash Amount: 6. Total Project Cost: $ i Le ) (.p I S bt 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CY1�chC Q. Ptre t rc Number Cs y License Number Expiration Date Name of CSL Holder .d . 011 'u List CSL Type(see below) No.and Street J� Type Description �/� ,, /� U Unrestricted(Buildings up to 35,000 Cu.ft.) t ' W` 01 oK R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances (.HI 1 I-5a9 hued-erwuod@VanVethome. I Insulation Telephone Email address ti)m D Demolition 5.2�Registered Home Improvement Contractor(HIC) �05 �, I a10 1cu�Vef 1-4offve- 1 rbv-c -' HIC Registration`Number expiration Date HIC Company Name.DIIIC Reg�rant a e 3c.p }�S{-1 r . bur burvi Pr1.00(Z1.Man\ece-InCrne kand Street Email address ��m cu se . IT\a 010 as LL ia),N4i`5a59 City/To ,State,ZIP I Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6)j Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issua ce 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 -, f I,as Owner of the subject property,hereby authorize '( �? _ 1"QOC`I'1- prbve_k`(1-e. nT to act on my behalf, in all matters relative to work authorized by this building permit application. Pk-eas- siopm ckAtegived con-f-cax.r is . a -a a Print Owner's Name(Electionic 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 containe 'n is application is d accurate to the best of my knowledge and understanding. eai - ate Print Owner's Authorized Agent's Name(Electronic 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. I42A. 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 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" City of Northampton �. Massachusetts Atv - 'este, DEPARTMENT OF BUILDING INSPECTIONS gr 212 Main Street • Municipal Building °>.,, e ° Northampton, MA 01060 �34,.. lO 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: Location of Facility: _ br . Ch is . a. The debris will be transported by: Name of Hauler: NanYCt' P c- 5 llv-ov-enn �V " Signature of Applicant: Date: ✓�� 1-9�' Page 1 of 7 Yankee Home Improvement MA Lic#160584 p CT Lic#0673924 YANKEE 36 Justin Drive RI Lic#33382 Chicopee, MA 01022 413-341-5259 or 877-88-YANKEE www.yankeehome.com Customer Information Arturo Monteiro Jr Cell: 413-387-8079 Date: 06/13/2022 100 Beacon Street s-monteiro@msn.com Rep: David Curtis Florence MA 01062 ProVia Entry Doors Legacy Single Entry Door in FrameSaver Frame MEM -36" Nominal Width Quantity — l -83"Custom Unit Height -12"Sidelite Width _ -Unit Size:64 1/16"x 83" -Frame Depth:5 1/4" -2"Standard Brickmold -Left Hand Inswing-Inside Looking Out 8766023 -Frame -Textured Snow Mist White Aluminum Frame Cladding -Snow Mist White Inside Frame -FrameSaver Inside Mull Cover-Snow Mist White -Bronze ZAC Auto-Adjusting Threshold -5 5/8"Threshold Depth Inside View Outside View -Antique Brass Ball Bearing Hinges -Security Plate Entry Door -2 Panel 420 Style 20-Gauge Smooth Steel Door -With High-Definition Embossing -ComforTech DLA-UV -Cottage(6-Lite)Contoured Internal Grid-2V x 1 H -Snow Mist White Inside/Coal Black Outside Grids -Snow Mist White Inside/Coal Black Outside -Hardware -All Hardware in Antique Brass Finish -Addison Grip Entrance Handle Outside -Accent/Addison Handle Inside -Addison Thumbturn Deadbolt Sidelites on Both Sides -1 Panel 130 Style 24-Gauge Smooth Steel Sidelite -ComforTech DLA -Cottage(3-Lite)Contoured Internal Grid-OV x 2H -Snow Mist White Inside/Coal Black Outside Grids -Snow Mist White Inside and Outside Door Location Front Door Unforeseen costs that could occur. - Homeowner is responsible for removing and replacing any window treatments or air conditioning units in or around any windows/doors to be replaced. - Homeowner is responsible for removal and reinstallation of alarm components on any windows and/or doors to be replaced. Contractor will NOT replace alarm components. 41/1"\ (Customer Initials) This space i iteneu pally left wank Page 2 of 7 Acknowledgements & Notifications. -Any furniture must moved at least 5 feet away from windows and/or doors to be replaced. -All pets shall remain secured in safe location inside of the home away from windows and/or doors to be replaced. -All driveways shall remain clear during date of installation. -Any HOA approvals are the responsibility of the homeowner and will be provided by homeowner unless otherwise stated on this contract. 4-47\ (Customer Initials) Special Instructions All discounts applied. Labor Discount Applied Please note 36" wide door in design. Do Not Do We do not do any painting or staining. Work Schedule Contractor will not begin the work or order the materials before the third day following the signing of this Agreement, unless specified herein. Contractor will begin the work on or about 08/13/2022 Barring delay caused by circumstances beyond Contractor's control,the work will be completed by 10/13/2022 The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor including, but not limited to strikes, Acts of God, shortages of materials, accidents, and all other delays beyond its control, shall not be considered as violations of this Agreement. Customer Initials A-14N It is agreed and understood by and between the parties that this Specification Sheet, along with the CUSTOM REMODELING AGREEMENT, constitutes the entire understanding between the parties, and there are no verbal understandings changing or modifying any of the terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both Buyer(s) and Contractor. Buyer(s) hereby acknowledges that Buyer(s) has read the front and reverse of this Specification Sheet. /A AL--- Arturo Monteiro Jr 06/13/2022 Date Page 3 of 7 Payment Schedule YHI agrees to perform the work,furnish the material and labor specified above for the total sum of: $16,618 Form of Payment Cash Deposit Amount $5,539 Deposit Type Credit Card Cash Due Upon Completion $11,079 David Curtis Notice: No agreement for home improvement contract work shall require a down payment (advance deposit) of more than one-third of the total contract price or the total amount of all deposits or payments which the contractor must make, in advance, to oder and/or otherwise obtain delivery of special order materials and equipment, whichever amount is greater. Arturo Monteiro Jr 06/13/2022 Date This space it f;sa iaanally left blank Page 4 of 7 ADDITIONAL TERMS AND CONDITIONS Delay/Unknown Conditions: Contractor's failure to perform any term or condition of this Agreement as a result of conditions beyond its control such as, but not limited to, strikes, fires, floods, acts of God, material shortages, Buyer's inability to qualify for or obtain financing, delays by local government authorities in issuing or otherwise approving inspections, permitting, or other required authorizations do not constitute abandonment and are not included in calculating time frames for performance by Contractor. Contractor and Buyer(s) have determined that a definite completion date is not of the essence to this Agreement. Late Cancellation/Late Payment/Default: If Buyer(s) attempts to cancel or repudiate this Agreement after midnight of the third business day after the date of this Agreement, and Contractor accepts such cancellation, which shall be in Contractor's sole discretion based on economic factors including, but not limited to, the status of Buyer's ordered product, all work under this Agreement will be stopped as promptly as is reasonably possible and Buyer(s) agrees to pay Contractor a cancellation fee equal to 15% of this Agreement's purchase price. Buyer(s) agrees to pay a late fee of 1.5% per month on all amounts due and owing from Buyer(s) to Contractor accruing from the date due and running to the date the payment is made. If Buyer(s) is in default of this Agreement, Buyer(s) agrees to pay Contractor's attorney's fees equal to 15% of the defaulted amount or as otherwise allowed by applicable law. Buyer(s) also agrees to pay any other costs or expenses of repossession or collection as allowed by applicable law. Contractor's Right to Cancel: In the event that Contractor determines that this Agreement cannot be performed as intended by the parties due, for example, to incorrect pricing, unforeseen structural defects, or pre-existing conditions to Buyer's property, Contractor may cancel this Agreement within thirty (30) days of its execution, notify Buyer(s) of such cancellation in writing, and return all monies paid by Buyer(s). No Set-Offs or Retentions: Upon substantial completion of Contractor's work under this Agreement, Buyer(s) shall pay to the installer assigned to the work, all amounts due under this Agreement without any right of set-off or retention. Substantial completion is defined as the job being materially completed, functional as intended, and a final inspection, permit or occupancy certificate, as the case may be, having been obtained. If after paying all amounts due under this Agreement, Buyer(s) alleges that Contractor's work is defective in any respect, Contractor, without waiving any of its rights, shall cause an inspection of the work and perform any remedial work to the extent Buyer(s) is entitled to under this Agreement or Contractor's warranty at no cost to Buyer(s). Buyer's Representations: Buyer(s) represents and warrants that (a) Buyer(s) owns the premises where the products and/or services are being provided by Contractor; (b) Buyer(s) will provide Contractor with reasonable access to the premises, including access to electrical outlets as may be required by Contractor; (c) Buyer(s) shall be responsible for the preparation, moving, and reinstalling of all wiring, water lines, power lines, plumbing, and the moving of any shrubs, plants, or other items as required by Contractor under this Agreement; and (d) Buyer(s) acknowledge(s)that any excess material not used by Contractor shall remain the property of Contractor and will not be considered part of this Agreement. Contractor's Responsibility: Contractor accepts no responsibility for any damage resulting from pre-existing structural or other defects in the property at which work is performed under this Agreement. Contractor is not responsible for remedying structural defects in Buyer's property. Buyer(s) acknowledges that Contractor's products do not correct or cure structural problems. Contractor shall not be responsible for (a) any damages arising in whole or in part from strikes, fires, accidents, floods, governmental actions, or any other causes beyond control of Contractor; (b) any incidental or consequential damages including, without limitation, lost profits or reduction in value of Buyer's property arising from Contractor's delay in performing under this Agreement or due to Contractor's breach of this Agreement; and (c) unintentional damage to flooring, window treatments, landscaping, driveways, sidewalks, gas lines, electrical wiring, plumbing, telephone installations, collateral or incidental damage to interior walls and personal property, it being understood that Buyer(s) is responsible at Buyer's cost for all preparations, protection, and/or moving of such items prior to Contractor's commencement of work. Contractor intends to use subcontractors on all or a portion of the work. Page 5 of 7 Condensation, Mold and Related Matters: Condensation, which can form on or within walls or other surfaces (such as on windowpanes), results from pre-existing conditions in a home and internal or external temperatures. Condensation is not a product or workmanship defect. Reducing the humidity in a home will often remedy any condensation problems. Buyer(s) agrees to indemnify and hold Contractor and its employees, agents, and subcontractors harmless from any claims as to the identification, detection, abatement, encapsulation, or removal of mold, asbestos, lead-based products, or other hazardous substances inside or outside of the property at which work is performed. Contractor does not provide mold testing or remediation services. Miscellaneous: No waiver of any breach of this Agreement shall be construed as a waiver of any prior, concurrent, or subsequent breach hereof. The section headings contained in this Agreement are inserted for convenience only and shall not affect in any way the meaning or interpretation of this Agreement. In construing this Agreement, the gender and number of words used may be changed to meet the context. Both Buyer(s) and Contractor agree that this entire Agreement constitutes the entire understanding between them, and that there are no verbal understandings changing or modifying any of the terms and conditions of this Agreement. No alteration to or deviation from this Agreement will be valid without the signed, written consent of both Buyer(s) and Contractor. This Agreement shall be governed by and construed in accordance with the laws of the state in which it is performed, except as may be preempted by federal law.Any part of this Agreement contrary to the law of this state shall not invalidate other parts of this Agreement. If a provision of this Agreement is held to be invalid or unenforceable, this Agreement shall continue in full force and effect and shall be construed as if the invalid or unenforceable provision was omitted. Assignment: Buyer(s) agrees that Contractor can assign any of Contractor's rights under this Agreement without Buyer's consent and that the person to whom Contractor assigns this Agreement shall be entitled to all of Contractor's rights under this Agreement. Buyer(s) understands that Buyer's rights will not be affected by such assignment. Neither this Agreement nor any rights or benefits hereunder are assignable by Buyer(s) without the prior written consent of Contractor. Any such prohibited assignment shall be null and void. Arbitration of Disputes: Contractor and Buyer(s) agree that any and all disputes, claims, or controversies (hereafter referred to as a "Claim") arising under or relating to this Agreement and any related documents, loans, security instruments, accounts, or notes, including by way of example and not as a limitation: (i) the relationships resulting from this Agreement and the transactions arising as a result thereof; (ii)the terms of this Agreement; or(iii)the validity of this Agreement or the validity or enforceability of this arbitration provision may, at the election of either party, be subject to binding arbitration to be determined by one arbitrator, in accordance with and pursuant to the then prevailing Consumer Arbitration Rules of the American Arbitration Association ("AAA), to be held and arbitrated in Hampden County, Massachusetts. Buyer(s) agrees that Buyer(s) will not assert a Claim on behalf of, or as a member of, any group or class. The findings of the arbitrator shall be final and binding on all parties to this Agreement. Each party shall be responsible for its own fees and costs, unless otherwise determined by the arbitrator.This agreement to arbitrate, and any award, finding, or verdict of or from the arbitration, will be specifically enforceable under the prevailing law of any court having jurisdiction. The party asserting a Claim shall file a notice of the demand for arbitration with the other party to this Agreement and with AAA. The demand for arbitration shall be made within a reasonable time after the Claim in question has arisen, and in no event shall any such demand be made after the date when institution of legal or equitable proceedings based on such Claim would be barred by the applicable statute of limitations. Any arbitration proceeding brought under this Agreement, and any award, finding, or verdict of or from such proceeding shall remain confidential between the parties and shall not be made public. Both Contractor and Buyer(s) are hereby potentially agreeing to choose arbitration, rather than litigation or some other means of dispute resolution, to address any grievances or alleged grievances. The parties believe this may allow fpr a faster and more cost-effective method of addressing a Claim. By entering into this Agreement and this arbitration provision, both parties may be potentially giving up their constitutional right to have any dispute decided in a court of law before a jury, and instead are potentially accepting the use of arbitration.(Massachusetts Sales)Contractor and Buyer(s) hereby mutually agree in advance that in the event that Contractor has a dispute concerning this Agreement, Contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and Buyer(s) shall be required to submit to such arbitration. Page 6 of 7 (Massachusetts Sales)In Massachusetts, all contractors and subcontractors must be registered by the administrator of the Board of Building Regulations and Standards and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of Consumer Affairs and Business Regulation, Ten Park Plaza, Suite 5170, Boston, Massachusetts 02116 Telephone: (617) 973-8700. In Massachusetts, Contractor is responsible for applying for and obtaining any and all necessary permitting. Homeowners who secure their own permits will be excluded from the guaranty fund provisions of Massachusetts law. (Connecticut Sales)The owner(s) of the home improvement contractor is or has been a shareholder, member, partner, or owner of the following corporations, limited liability companies, partnerships, sole proprietorships or other legal entities that have been a home improvement contractor during the previous five(5) years: None (Vermont Sales)ACKNOWLEDGMENT OF ARBITRATION. I understand that this Agreement contains an agreement to arbitrate. After signing this document, I understand that I will not be able to bring a lawsuit concerning any dispute that may arise which is covered by the arbitration agreement, unless it involves a question of constitutional or civil rights. Instead, I agree to submit any such dispute to an impartial arbitrator. (New York Sales)Any contractor, subcontractor, or materialman who provides home improvement goods or services pursuant to your home improvement contract and who is not paid may have a valid legal claim against your property known as a mechanic's lien. Any mechanic's lien filed against your property may be discharged. Payment of the agreed-upon price under the home improvement contract prior to filing of a mechanic's lien may invalidate such lien. The owner may contact an attorney to determine his rights to discharge a mechanic's lien. Arturo Monteiro Jr 06/13/2022 Date Page 7 of 7 YOU,THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. NOTICE OF CANCELLATION NOTICE OF CANCELLATION NOTICE OF CANCELLATION Date of Transaction 06/13/2022. You may cancel this Date of Transaction 06/13/2022. You may cancel this transaction, without any penalty or obligation, within three transaction, without any penalty or obligation, within three business days from the above date. If you cancel, any business days from the above date. If you cancel, any property traded in, any payments made by you under the Contract property traded in, any payments made by you under the Contract or Sale,and any negotiable instrument executed by you will be or Sale, and any negotiable instrument executed by you will be returned within 10 days following receipt by the Seller of your returned within 10 days following receipt by the Seller of your cancellation notice, and any security interest arising out of the cancellation notice, and any security interest arising out of the transaction will be canceled. If you cancel,you must make available transaction will be canceled. If you cancel,you must make available to the Seller at your residence, in substantially as good condition as to the Seller at your residence, in substantially as good condition as when received,any goods delivered to you under this Contract or when received, any goods delivered to you under this Contract or Sale; or you may, if you wish, comply with the instructions of Sale; or you may, if you wish, comply with the instructions of the Seller regarding the return shipment of the goods at the the Seller regarding the return shipment of the goods at the Sellers expense and risk. If you do make the goods available Sellers expense and risk. If you do make the goods available to the Seller and the Seller does not pick them up within 20 days to the Seller and the Seller does not pick them up within 20 days of the date of your Notice of Cancellation, you may retain or of the date of your Notice of Cancellation, you may retain or dispose of the goods without any further obligation. If you fail dispose of the goods without any further obligation. If you fail to make the goods available to the Seller, or if you agree to to make the goods available to the Seller,or if you agree to return the goods to the Seller and fail to do so,then you remain return the goods to the Seller and fail to do so,then you remain liable for performance of all obligations under the Contract. To liable for performance of all obligations under the Contract. To cancel this transaction, mail or deliver a signed and dated cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice, or copy of this cancellation notice or any other written notice, or send a telegram to Yankee Home Improvement Inc.,36 Justin send a telegram to Yankee Home Improvement Inc.,36 Justin Drive, Chicopee, MA 01022, NOT LATER THAN MIDNIGHT OF Drive, Chicopee, MA 01022, NOT LATER THAN MIDNIGHT OF .(Date) . (Date) I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION. BUYER'S SIGNATURE BUYER'S SIGNATURE DATE DATE Arturo Monteiro Jr 06/13/2022 Date ` The Commonwealth of Massachusetts _ � z Department of Industrial Accidents ; 1_— " 1 Congress Street,Suite 100 0 #i1sr Boston,MA 02114-2017 /_V wwwmassgov/dia • Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly r` Name (Business'Organizationrindividual): \Q r\ e•L ---1(Dr.(1_ _t �DV- �P \'e_,V1 j- Address: ? C\us-t t1 'Or • 1 City/State/Zip:CA\(to kIet- fro, , ()I Da'a- Phone#: Lu`3) '3 4 I --5 a5�t r i Are v u an employer?Check the appropriate box: Type of project(required): 1. am a employer with employees(full and%or pan-time).* 7. 0 New construction 2.0 1 am a sole proprietor or partnership and have no employees working for mein 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 10 []Building addition 4.0 lam 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 arc snit I 1.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5. 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1�. O Ot)f repairs These sub-contractors have employees and have workers'comp.insurance: 6.0 We are a corporation and its officers have exercised their right of exemption per MCL c. 14. Other � � � i : '► S 1 152,s11(4),and we have no employees. [No workers comp.insurance required.) ` oo r "Any applicant that checks box ill must also fill out the section bolo':'showing their workers'compensation policy information. •Homeowners who submit this affidavit indicating they are doing all.work and then hire outside contractors must submit a new tdavit indicating such. :Contractors that check this box must attached art additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy n:imbcr. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information.. Insurance Company Name: II(�� J-Y 1� .._.. SeiC) Policy#or Self-ins.Lic.#: Q ( Expirati n ate: t b — t —o� e Q g- Job Site Address: t bD R �D IA - City/State/Zip: 1'-�lor4it _?-� 1 ma, b I b to a- 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, f25A is a criminal violation.punishable by a fine up to S1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance coverage verification. 1 do hereby certify u der t e poi; nd penalties of perjury that the information provided above is true and correct. Si nature: G Date: al -a a Phone: L-1 I PO Li I - o1sc) _.. Official use only. Do not write in this area,to be completed by city or town official. I I City or Town: Permit/License# Issuing Authority(circle one): l.. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: �...44 YANKHOM-01 BROOKE J4 WME:, CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) �--� 9/23/2021 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 Nr4ME CT Brooke Barre Phillips Insurance Agency,Inc. PHONE No,Ext):(413)594-5984 FAXtac,No):(413)592-8499 97 Center Street E Chicopee,MA 01013 ADDRESS:brooke@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC S INSURER A:Ohio Security Insurance Co 24082 INSURED INSURER B:Selective Ins Co Of South Carolina 19259 Yankee Home Improvement,Inc. INSURER C:Ohio Casualty _ 24074 36 Justin Drive INSURER D: Chicopee,MA 01022 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIM TS LTRINSD WVD (MMIDD/YYYYI (MMIDD/YYYYI A X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE CLAIMS-MADE X OCCUR BKS56702381 10/1/2021 10/1/2022 DAMAGETORENTED 300,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO A 9106918 10/1/2021 10/1/2022 BODILY INJURY(Per person) $ AURTEOS ONLY AWNED , UTOS BODILY BpOR INJURYD (Peracciden;)_ $ AUTOS ONLY _ AU OS ONEDV (Peer a deT DAMAGE $ C X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE US056702381 10/1/2021 10/1/2022 AGGREGATE $ 1,000,000 DED X RETENTIONS 10,000 $ C WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN XW056702381 10/1/2021 10/1/2022 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Property BKS56702381 10/1/2021 10/1/2022 Building Limit 3,342,468 A Property BKS56702381 10/1/2021 10/1/2022 Personal Property 450,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers Compensation coverage is included for the following states:MA,CT CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ),'`2-1 dr,JA. t-„..� ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC ® DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 07/12/2022 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 David Jarry Neill&Neill Insurance Agency Inc PHONE FAX 662 Riverdale Street IAIC.No.Extl: 413-732-4137 ( No):413-731-6629 West Springfield, MA 01089 ADDRESS: dj@neillandneill.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Western World Insurance Co. 13196 INSURED Pro Solution Construction,Inc. INSURER B: Zurich-American Insurance Grou ZUR 116 Lancaster Ave West Springfield, MA 01089 INSURER C: INSURER D: 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 TE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPE T TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT T ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRLICY EXP LT ADDLTYPE OF INSURANCE INSD SUER POLICY NUMBER IMPM/DDY/YYYYf (M EFF M/DD//YYYYI MITS LTR INSD WVD , A Ni COMMERCIAL GENERAL LIABILITY NPP8746152 07/11/2022 07/11/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE RI OCCUR PREMISES Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 VI POLICY PRO- LOC 1,000,000 JECT PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB — OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE 1 $ DED RETENTION$ _ n _ $ B WORKERS COMPENSATION 1151034 11/04/2021 11/04/2022 V PER STATUTE OTH ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? Y N/A 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Yankee Home Improvement THE EXPIRATION DATE THEREOF, NOTICE WILD BE DELIVERED IN 82 Industrial Drive ACCORDANCE WITH THE POLICY PROVISIONS. Northampton, MA 01060 AUTHORIZED REPRESENTATIVE ta....LiR4fe, I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 0frliI)r)fly t?dit ')t Massachusetts , v► s 4>+ Pr . to sign t Lae re Board of 3 if dtn€q Reguirttiryns and Standards ' tron S ' 03/2e/20423 O MICHAEL PEREIRA PO BOX1066 mM WARREN MA 01083 • } Commissioner N N co lf) THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration 'In wr . Type: Corporation I Registration: 160584 YANKEE HOME IMPROVEMENT INC Expiration: 08/11/2024 36 JUSTIN DR. CHICOPEE, MA 01022 ,-<IS / Update Address and Return Card, THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: - TYPE: Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 160584 08/11/2024 Boston, MA 02118 'ANKEE HOME IMPROVEMENT INC 3ERARD RONAN - r7 7 --, I6 JUSTIN DR , ^''s(a,,'/QGle,s0 HICOPEE, MA 01022 Undersecretary Not valid without signature