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06-022
BP-2022-1025 46 EVERGREEN RD#207 COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 06-022-023 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-2022-1025 PERMISSION IS HEREBY GRANTED TO: Project# window Contractor: License: Est. Cost: 1329 LOWES HOME CENTERS INC 112271 Const.Class: Exp.Date:09/01/2023 Use Group: Owner: E KASPER NATHAN Lot Size (sq.ft.) Zoning: URA Applicant: LOWES HOME CENTERS INC Applicant Address Phone: Insurance: 282 RUSSELL ST (413)588-0270 MAAARP300120 HADLEY, MA 01035 ISSUED ON:08/22/2022 TO PERFORM THE FOLLOWING WORK: 1 replacement window 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: Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner . , --7-:I--------------12.p ' I ' ------=- 0 i n I n a t 0 N N Pj 0)(1-6 1 -0/J-wel . np, , s 0 /(7/62,o . C.,,)--n g,cv The Commonwealth of Massachusetts '� Board of Building Regulations and Standards MUNICIPALITYFOR Massachusetts State Building Code, 780 CMR USE BL ldiig Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011 CD One-or Two-Family Dwelling a This Section For Official Use Only Building Permit lilutnber:eI' . •k (() .5" Date Applied: _J W /t 8-22-2OZZ Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Pryiyty 44dress: 1.2 Assessors Map&Parcel Numbers (c viKikrpin edj . 1.1a Is this an acce)ite l)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 i f yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owe ofXecord: Name(Print) City,State,ZIP A (✓fY ,16--) , L. Lisa.2a/-I227 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) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Wor NC /D/94 405 Grit A J•rikTo2. 30 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ / / 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2. Other.Fees: S 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: S Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 13'/ 0 Paid in Full ❑Outstanding Balance Due: r SECTION 5: CONSTRUCTION SERVICES 5.1 Construed Supervisoroffli // License(C L) // h s� �/ (� �,/� Y/ f��t f/� License Number 9/1Expiration e Name of CSL Holder 1 0/ P(lISA, List CSL Type(see below) No.and Stree , Type Description ` . /e, i/ / 4 D/` -/Y U Unrestricted(Buildings up to 35,000 cu.ft.) Cityflon,State,ZIP .'�/ J R Restricted 1&2 Family Dwelling w M Masonry RC Roofing Covering WS Window and Siding 6 Jt00U ' B'l, �a / � ^ SF Solid Fuel Burning Appliances C�(J I Insulation Telephone Email ad 7/ D Demolition 5.2 Registered Home mprpvemen Co r-aacct^or(HIC) /Y��j / / /Z3 �i 1--ff//DD 0 '1< HIC Registration Number Exouaatiofi Date HIC Company�o�; C Re strat 'attl., No.an a// riot, �/r/� /� / U N •�C !J P /II96 - ,�C yA oat, /ve �d i/7 91t— /35---690 7 Email address City/Town,State,ZIP /1/ 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 Cd/ No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I 1,as Owner of the subject property,hereby authorize 48. d��v� to act on my behalf,in all matters relative to work authorized by this building permit application. L1 11-ep � ,grfl/ �',� / e-7- /ez� Print Owner's Name(Electronic Signa ) ate 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 contaited in this application is true and accurate to the best of my knowledge and understanding. >-.."--..e oat j)tio 09/22__ Print Owner's or Authorka 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. 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 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" M Store 1916 LOWE'S OF HADLEY, MA 282 RUSSELL STREET HADLEY, Massachusetts 01035 Low ENso Contract Prepared for: Nathan Kasper 46 Evergreen Rd Leeds, Massachusetts 01053 (413) 207-1227 Prepared by: Steven Lockwood (413)588-0270 steven.lockwood@lowes.com Store 1916 LOWE_S OF HADLEY_MA-Contract-589393-Page 1 of 27 LOWE'S MASSACHUSETTS SERVICES SOLUTIONS INSTALLED SALES CONTRACT LOWE'S AUTHORIZED REPRESENTATIVE SALES ID DATE CUSTOMER NAME Steven Lockwood 3070929 08/01/2022 Nathan Kasper STORE NO. ST REEF ADDRESS STREET ADDRESS 1916 282 RUSSELL STREET 46 Evergreen Rd CITY STATE ZIP CITY STATE ZIP HADLEY MASSACHUSETTS 01035 Leeds Massachusetts 01053 TELEPHONE TELEPHONE (413)588-0270 (413)207-1227 EMAIL EMAIL steven.lockwood@lowes.com nathankasper90@gmail.com LOWE'S CONTRACTOR LICENSE a LOWE'S REPRESENTATIVE LICENSE S CREDIT/DEBIT CHECK LCC CARD GIFT CARD #148688(home improvement contractor),3070929 435194 This is only a quote for the merchandise and services printed below.Lowe's does not offer services to paint,seal or stain fences. This becomes an agreement upon payment and issuance of a Lowe's receipt, upon pay-ment,the entire agreement,ircluding the specifically completed pages of this document,the Terms and Conditions included with this document and any other addenda and attachments hereto,shall be referred to herein as this"Contract."PLEASE READ THIS ENTIRE DOCUMENT, INCLUDING THE "NOTICES,""TERMS AND CONDITIONS,"AND"ADDENDUM"CONTAINED WITHIN THIS CONTRACT ON THE FOLLOWING PAGES BEFORE SIGNING. INSTALLATION STREET ADDRESS CITY STATE ZIP 46 Evergreen Rd Leeds Massachusetts 01053 MERCHANDISE AND INSTALLATION SUMMARY:(I.E.ITEM NUMBERS,COLORS,DIMENSIONS, CONSIDERATIONS): Windows Product Windows Project Installation of one ReliaBilt Series 3201 Double Hung Equal Sash 35 1/2-in x 52 1/2-in White Low-E w/Argon(Northern Energy Star) Clear Single Strength Replace inner window sill front plate and Stops Proposal and pricing dependent on installer second measure to ensure suitability, sizing, and estimated installation costs. Installation Process • Remove&haul away existing windows • Check existing windows for leaks and evidence of pest infestation • Install new windows&accessories, including caulk, stops,and fasteners • Follow Lead Safe Practices(if required) • Follow Health and Safety Guidelines Store 1916 LOWE_S OF HADLEY_MA-Contract-589393-Page 2 of 27 Clean-up/Final Inspection • Complete final clean-up and haul away all job-related debris • Test product&perform complete inspection with customer • Review warranty information Project Preparation Process • Dedicated project support staff keeps you up-to-date through every process • Installer conducts Pre-Installation Inspection • Provides appropriate protection to home during installation • Obtain& post any necessary permits • Perform Lead Assessment(if applicable) Work is to commence upon reasonable availability of Contractor and/or any special order or customer made Good(s)which is anticipated to be 08/30/2022 . Estimated completion date is 09/30/2022 .COV/D-19 has affected manufacturers and labor markets,with the production of fence,deck and generator material experiencing significant delays and installation start dates that are at least four(4)months away in most cases. Please also note that weather can delay start dates for these and other exterior categories,particularly in colder climates. CONTRACT TOTAL $1,329.00 Paid upon signature of Installed Sales Contract(33%) $405.57 Paid upon or after commencement of work(67%) $823.43 Paid upon completion of Installed Services to both parties satisfaction $100.00 Store 1916 LOWE_S OF HADLEY MA-Contract-589393-Page 3 of 27 NOTICES LEAD SAFE INFORMATION. Federal and applicable state laws require that You be provided with a lead hazard information pamphlet such as the Renovate Right: Important Lead Hazard Information for Families, Child Care Providers and Schools. By signing this Contract, You acknowledge having received a copy of this information pamphlet before work began informing You of the potential risk of the lead hazard exposure from renovation activity performed in Your dwelling unit or facility. A copy of the pamphlet is available at the following website: www.lowes.com/EPARRP. For more information see: https://www.epa.gov/lead/lead-renovation-repair-and-paintinq-program. 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 order 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. NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L. c. 142A: LOVVE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT, THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN/{APPROVED BY THE SECRETARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L. c.142A. THE SIGNATURES OF THE PARTIES BELOW APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWES, PURSUANT TO M.G.L. c. 142A. THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES. If customer has a complaint which cannot be resolved informally, the home Improvement Contractor Law(M.G.L. c. 142A) may provide Customer with the right to request arbitration through a private arbitration program approved by the Director of the Office of Consumer Affairs and Business Regulation, as an alternative to court action. The same right is not afforded to Lowe's unless this Notice is signed and dated by Lowe's and Customer. All claims by Customer or Lowe's concerning this Contract which cannot be resolved informally, and which are not covered by M.G.L. c142A or subject to the jurisdiction of a small claims court, shall be resolved by binding arbitration as set forth in the Terms and Conditions. By: gf,.,-.(,.Cnr nrn.� }J1 0 02r8/01/2022 Lowe's Authorized Representative Ud[ By: Ut `"f' Date: 08/02/2022 Customer PRICE CALCULATIONS. If this Contract includes Goods and related Installation Services sold by unit of measurement, such as per square foot, the Price may include more Goods than the actual measurements of Your project area. The Price includes the total amount of Goods required by Lowe's to fulfill the Contract (including surplus materials and overages) (toge her the "Estimated Product") and the Installation Services required based upon this total amount of Goods. For instance, a 120 s uare foot room may require 140 square feet of carpet to properly match the carpet seams, pattern, or unique room characteristics, and the Price would include Installation Services based upon the 140 square feet of carpet. The total amount of Estimated Product is based upon the total Goods recommended by the Installer, based on the Installer's assessment of unique characteristics of Your project. If any usable Goods are left over, Lowe's may, at its discretion, initiate a Price adjustment. Lowe's will not adjust thecontract Price for the related Installation Services. By signing this Contract, You acknowledge You are aware of Your project area m asurements and the amount of Estimated Product, and that the Estimated Product may exceed Your actual project area. If You project includes the installation of flooring materials, by signing this Contract You further acknowledge having received a competed Flooring Detail Diagram (the "Diagram") prior to execution of this Contract. Upon request, Lowe's can provide You with ad itional copies of the Diagram, which identifies the square footage of Your project area and the square footage of the Estimated Goods. PHOTO RELEASE. By signing this Contract, You grant to Lowe's, its representatives, and Installer the right to take and use photographs, videos, or other representations of the Premises before and after the Installation Services and all work performed at the Premises related to this Contract (the "Content"). Lowe's irrevocably keeps all rights (including the copyri ht), title, and interest in the Content for use in all markets and media, worldwide, in perpetuity. Lowe's can use the Content, in ny form or medium, internally for any purpose (e.g., customer service, planning, and claims. NOTICE REGARDING PAYMENT SCHEDULE. If the Contract Price is$1,000 or less, payment of the Price b Customer to Lowe's is due in full upon execution of this Contract. If the Contract Price exceeds $1,000, Customer shall use t e following payment schedule: (1) Deposit of $ 405.57 [enter 1/3 of the contract Price] to be paid upon signing this ntact. Any deposit collected at the time this Contract is signed will not exceed one-third (1/3)of the Contract Price; Store 1916 LOWE_S OF HADLEY_MA-Contract-589393-Page 4 of 27 Rev.03/02/2021 (2) Payment of $ 823.43 [enter 2/3 of the contract Price minus $1001 to be collected upon or after the commencement of work. Customer authorizes Lowe's to charge Customer's credit card, or deposit Customer's check, for the amount of the payment indicated in this section anytime upon or after the commencement of the work; and (3) Final payment of$100 to be paid upon completion of the Installation Services to both parties' satisfaction. NOTICE OF CUSTOMER'S RIGHT TO CANCEL. If this is a "door-to-door sale" as defined by 16 C.F.R. §429.0(a), or if this Contract is signed by Customer at a place other than the address of the seller as set forth in M.G.L.�c. 93 § 48, You, the Customer, may cancel this Contract at any time prior to midnight of the third business day after the date of this transaction. See the notice of cancellation form sent as an attachment to this Contract for an explanation of this right. By executing this Contract, Customer acknowledges receipt of two(2) completed copies of the Notice of Right to Cancel form and certifies Lowe's has informed Customer orally of his or her right to cancel. NOTICE TO CUSTOMER. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Lowe's Home Centers, LLC EXECUTION DATE: 08/01/2022 LOWE'S AUTHORIZED REPRESENTATIVE SIGNATURE OWNER'S SIGNATURE CO-OWNER SIGNATURE P .1119141 Customer acknowledges receipt of a true copy of this contract which was completely filled in prior to Customer's execution hereof. Store 1916 LOWE_S OF HADLEY_MA-Contract-589393-Page 5 of 27 Rev.03/02/2021 City of Northampton erg S,$..--; s,� Massachusetts �� _ '� c. ,y tj DEPARTMENT OF BUILDING INSPECTIONS j,� sr 212 Main Street • Municipal Building yJi PD` '—' Northampton, MA 01060 sNry ,‘ 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: 2/ idzawal ,-/ -f 04/6 The debris will be transported by: Name of Hauler: ,G 10/ id—{-- C Signature of Applicant: Ai Date: / l21•Z. City of Northampton at AMpt sus_"• si Massachusetts �47 - c d t 4i'it DEPARTMENT OF BUILDING INSPECTIONS �. z . j' y CDC �-, 1 212 Main Street • Municipal Building J \ ri Northampton, MA 01060 sbwarOx^J '/� HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT 1, 0.`� / &'( 6,(401,- (insert full legal name), born (insert month, day, year), hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the Massachusetts State Building 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 hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition 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 aforementioned project or work on my parcel,I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this / 9 day of...AUJu — , 20, - (Signature) THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washingt4: -Suite 710 Boston,Mahu118 Home improvergeii str t-t ' v 11 Type: Supplement Card t ►: 148688 LOWE'S HOME CENTERS,LLC ; \ Y Expiration: 10/17/2023 1000 WINES BLVO SERVICES COMPLIANCE MOORESVILLE.NC 28117 ; + = Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME WPROV NT CONTRACTOR expiration date. If found return to: TYPE ent Card Office of Consumer Affairs and Business Regulation . E4it 1000 Washington Street -Suite 710 141.11P111 10/17/2023 Boston,MA 02118 LOWE'S HOME askew.tic -f NEXEDES SOTO 1000 LOWES BLVD y,,w! % ff�s.�' /12e1 d4. �BtB SERVICES COMPLIANCEN UndersecretaryNot valid without signature MOORESViLLE.NC 28117 9 The Commonwealth of Massachusetts 1 Department of Industrial Accidents g;', ' Office of Investigations Lafayette City Center rJ 2 Avenue de Lafayette. Boston,MA 02111-1750 ��4- www mass.gov/tka Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individual): LOWES HOME CENTERS I Address: 1000 LOWES BLVD City/State/Zip: MOORESVILLE,NC 28117 Phone #: 860-505-9314 -- Are you an employer?Check the appropriate box: Type of project(req red): 1.❑ I am a employer with 4. ®I am a general contractor and I employees(full and/or part-tune).'' have hired the sub-contractors 6. ❑New construct n 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' p t 9. ❑Building additi n [No workers' comp.insurance comp. insurance. requi red.]ui 5. El We are a corporation and its 10.❑Electrical reps. or additions 9 ] 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing reps. or additions myself [No workers' comp. right of exemption per MGL 12.El Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13. X❑Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box trust attached an additional beet showing the name of the sub-contractors and state whether or not those entities have employees. If the cub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: AIU INSURANCE COMPANY Policy#or Self-ins. Lic.4..a6(17/11,4tlit #: WC035901712 AOS Expiration Date: 4/1/2023 Job Site Address: ///L City/State/Zip: (lit/0J ,'Xi (,/ Attach a copy of the workers' cothpeisation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do her v certi v under the painsand allies of perjury that the information provided above is true and correct ".„), . Signature: Date: f/ 9/2-o 2-2 _ t Phone#: 860-505-9314 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(check one): 11:1Board of Health 2❑Building Department 31:3City/Town Clerk 4.0 Electrical Inspector 51:1Plumbing Inspector 6.0Other Contact Person: Phone#: ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/0D"YYY) 7/18/2022 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: ff 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&McLennan Agency LLC-New England PHONE Gregory Mathews FAX 100 Front St,Ste 800 JAIL.No.Exti: (AIC.Nek Worcester MA 01608 ADDRESS: MMA.NewEngland.Cert@marshmc.com wfSU S)AFFORDING COVERAGE NAIC/ _ INSURER A:Selective Insurance Co of America 12572 INSURED OMEGABUILDI INSURER B:Selective Insurance Co of the Southeast 39926 Omega Building Company, Inc. 516b Franklin St INSURERC: Worcester MA 01604 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:33250650 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. INSRJ ADOLSUBR _ LTR TYPE OF INSURANCE rISO yyyp POLICY NUMBER IMMIDINTYYY) MIMOWYY Y) s A X COMMERCIAL GENERAL LIABILITY S2516314-00 7/13/2022 7/13/2023 EACH OCCURRENCE $1,000,000 l CLAIMS MADE X OCCUR DAMAGE TO RENTED PREMSSES Me occurrence) $500,000 MED EXP(Any one poison) $15,000 _ PERSONAL&ADV INJURY $1,000,000 GEML AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE S 2,000,000 POLICY C LOC PRODUCTS-COMP/OPAGO $2,000,000 OTHER S AUTOMOBILE CITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS NON-OWNED PROPERTY DAMAGE AUTOS ONLY A0 LD aocderR1 $ S A X UMBRELLA LIAR X OCCUR S2516314-00 7/13/2022 7/13/2023 EACH OCCURRENCE $3,000,000 EXCESS LIAB CLAPAS,MADE AGGREGATE S 3,000,000 DED X I RETENTION$n 8 WORKERS COMPENSATION WC909893800 7/13/2022 7/13/2023 X PER OTH- ANDEMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER'EXECUTNE EL EACH ACCOENT $500,000 OFFICER/MEMBEREXCLUDED? NIA (Mandatory in NH) El.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Lowe's Companies Inc&any&all subsidiaries are included as additional insured,on a primary and noncontributory basis as respects the general liability if required by written contract,for work performed by named insured.Waiver of subrogation applies in favor of the additional insured as respects the general liability if required by written contract.30 day notice of cancellation except 10 day notice for nonpayment. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE MILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Lowe's Companies Inc&any&all subsidiaries Mail Code: ISI 1000 Lowe's Blvd AUTHORIZED REPRESENTATIVE Mooresville NC 28117 • ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Board l 41rt`Pri 41,00 l L #`11% e kiafd of Spoilt q glt]ul4ltions ar Stariifar' C00.0410.111A404100Vtf401 CS 112271 xptres' 09 1.2021 RAMAt4 M FERREIRA 401 PLEAS MT STREET LEICESTER MA 01024 CsymrtttiSsipnrr Ce4 Saar Public Safety011 Mass.Gov Home State Agencies 0 Mass. Licensee Details Demographic Information 'Full Name: RAILAN M FERREIRA ;Owner Name: License Address Inforinntitm City' LEICESTER State: MA Zipcode: 01524 'Country: United States License Information 'License No: CS-112271 License Type: Construction Supervisor (Profession: Building Licenses Date of Last Renewal: 8/9/2021 ;Issue Date: 6/8/2018 Expiration Date: 9/1/2023 License Status: Active Today's Date: 9/9/2021 Secondary License Type: "Doing Business As: Status Change Reason: License Issuance Prerequisite Information No Prerequisite Information No Available Documents Close Window A` �RQ® DATE /YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/23/2022 /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 Marsh USA Inc. NAME:PHON 100 North Tryon Street,Suite 3600 INC.No.Extt: WC.t4o): Charlotte,NC 28202 E-MAIL ADDRESS: NSURER(S)AFFORDING COVERAGE _ NAIC/ CN102776519.LowesSl-22-23 INSURER A:National Union Fire Ins Co.of Pittsburgh PA 19445 INSURED INSURER B:Interstate Are&Casualty Co 22829 Lowe's Companies,Inc. and sjbsidianes INSURER C:MU Insurance Co 19399 1000 Lowe's Boulevard INSURER D: Mooresville,NC 28117 INSURER E: - INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-004976909-11 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. USSR TYPE OF INSURANCE ,N.D W VD POLICY NUMBER Y) LIMITS COMMERCIAL GENERAL MERRY EACH OCCURRENCE S CLAIMS-MADE OCCUR Self Insured-See below DAMAGE PES Ea occurrence) $ MED EXP(Any one person) S PERSONAL&ADV INJURY $ GENL AGGREGATE LIMIT APPLES PER GENERAL AGGREGATE $ POLICY LOC PRODUCTS-COMP/DP AGG $ OTHER: $ A AUTOMOBILE LIABILITY CA7030892 (AOS) 04/01/2022 04/01/2023 COMBINED SINGLE LIMIT $ 5,000,000 C (Ea accident) X ANY AUTO CA7030891 (MA) 04/01/2022 04/01/2023 Finns Y INJURY(Per person) $ A OWNED SCHEDULED CA7030893 (VA) 04/01/2022 04/01/2023 BODLY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED I PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) $ B X UMBRELLA LIAR X OCCUR USZ00024220 04/01/2022 04/91/2023 EACH OCCURRENCE $ 5,000,000 EXCESS LIAR CLAMS-LADE AGGREGATE $ 5,000,000 DED RETENTIONS $ C WORKERS COMPENSATION WC035901712 (AOS) 04/01/2022 04/01/2023 X PER OTH- C (AND EMPLOYERS'LIABILITY Y/N WC035901713 ND.WA,WI.WY) 04/01/2022 04/01/2023 STATUTE ER ANYPROPRIETOR'PARTNER/EXECUTIVE ACCIDENT EL EACH $ 2,000,000 OFFICERIMEMBEREXCLUDED? N NIA (Mandatory In NH) E.L DISEASE-EAEMPLOYEE S 2,000,000 N yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY MUT $ 2,000,000 A i Excess Workers'Compensation XWC1647325 (FL) 04/01/2022 04/01/2023 (WC per statute) 3,000,000 A Excess Workers'Compensation ' I XWC1647324 (AOS) 04/01/2022 04/01/2023 (WC per statute) 3,000,000 i I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Commercial General Liability policy is Self-Insured,effective 4/1/2022 to 4/1/2023. CERTIFICATE HOLDER CANCELLATION Lowe's Companies,Inc.and Subsidiaries SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1000 Lowe's Blvd. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Mooresville,NC 28117 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATrVE fre ©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 Aco ADDITIONAL REMARKS SCHEDULE Pogo 2 of 2 AGENCY NAMED INSURED Marsh USA inc. Lowe's Companies,Inc. and suosidiaries 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 Workers'Compensation and Excess Workers Compensation policies induce a sett-insured retention of$2.000,000. General L abiity Tie insured is sel`insured for$10.000.000 each occurrence for the period of 4/1/2022 to 4/112023. The Automobile Liability policy evidenced above is suoject to addit oral self-insured retentions excess of limits shown for vanous perils covered. ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD