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38C-004 (6) BP-2022-1615 166 GROVE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 38C-004-001 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-2022-1615 PERMISSION IS HEREBY GRANTED TO: Project# DOOR 2022 Contractor: License: Est. Cost: 8100 PHIL BEAULIEU 62638 Const.Class: Exp.Date: 06/13/2023 Use Group: Owner: GIFFORD JESSICA S&NICOLE R ROCHEFORT Lot Size (sq.ft.) Zoning: URB Applicant: PHIL BEAULIEU & SON HOME IMPROVEMENT Applicant Address Phone: Insurance: 217 Grattan St 413-592-1498 WMZ80062050 CHICOPEE, MA 01020 ISSUED ON: 12/13/2022 TO PERFORM THE FOLLOWING WORK: DOOR REPLACEMENT 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: • • a 9 CO) d' 9. Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner `The Commonwealth of Massachusetts /we �' Board of Building Regulations and Standards 0EC j 3 � Massachusetts State Building Code, 780 GjVIR � ��� > C ALITY SE Building Permit Application To Construct,Repair,Renovate-pip r lish a evise/1 Mar 2011 One-or Two-Family Dwelling !^isaF ' ,,: r,(y,.' This Section For Official Use Only Build, Permit Number: A).•/(//5 Date Applied: I / 5 .// I Z- 13-ZOZ2 Building Official(Print Name) Signature Date; i SECTION 1:SITE INFORMATION 1.1 Proper Address: 1.2 Assessors Map&Parcel Nuummberss 1 ll1 C3)rO�re S +, No✓ umber P ca3reTNwi�ber 1.1a Is this an accepted street?yes ./ no Map 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 CI Private CI Municipal_ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 1 flwnP of Record: NiCOle. l f+t.JPssica Giffvia. No�cm p Mrs oioto Name(Print) tip',State (088 Nrr oche,Cor�' aid mai I. corn ilkGrOve St .l- 41 D-3 k,-7020 J tss►ca.Q pcQjwl-Conned--us.corn No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building lit" Owner-Occupied liti Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. ❑ Number of Units Other IS/Specify: boor re plaf2 next" Brief Description of Proposed Work2: t.rnov an e x 1 d+�liq window, B'- m.e o pc.r)I 5 at o .tomod.a+c. 8' wide pouf;o dmr, ,Cfls+a (tI I1 deor. �JJ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ ' 7 0 0 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ Cl Standard City/Town Application Fee 00 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing S — 2. Other Fees: $ 4.Mechanical (HVAC) S List: 5.Mechanical (Fire S Suppression) Total All Fees: $ c Check No.t419%eck Amount: Ct O Cash Amount: 6.Total Project Cost: $ D I 0 0 0 Paid in Full 0 Outstanding Balance Due: 4E SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSLI /1 S_O(p 21,3 (D/13/23 Phil Beaulieu&Sons Home Imp.,Inc. License Number V Expiration Date N.il 217 Grattan Street,Chicopee,MA 01020 HI REG#100073 List CSL Type(see below) u, CSL#CS-062638 Alain Beaulieu Type Description N' PH:(413)592.1498/Fax:(413)594.6008 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding 13 _ SF Solid Fuel Burning Appliances 51 2- 14°i$' rn bt a A I ► P&L*ti, 11. i- I Insulation Telephone Email address D Demolition 5.2 Registered Home tor(HIC) (000/3 /Z4' Phil Beaulieu&Sons Home Imp.,Inc. HIC Registration Number Expiration Date I 217 Grattan Street,Chicopee,MA 01020 HI REG#100073 rn b ecw� . Ver PQ ttl-• CSL#CS-062638 Email address Alain Beaulieu PH:(413)592.1498/Fax:(413)594.6008 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 1 No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize Pk'I BettIAIMA is 5 lS I-I'ery . ,rip(eyeing/It-- to act on my behalf,in all matters relative to work authorized by this building permit application. 1\4ole Rode' ,.Io( *Jesic . 6114 orci 12 / 7 /22 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 and accurate to the best of my knowledge and understanding. Phi I &CatAIIKA. cconS HWnL 1 mproyervrf I z /7 I22 Print Owner's or 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. 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" City of Northampton ?i HaMP>° SAS .: SI „ Massachusetts �� ice. 4e DEPARTMENT OF BUILDING INSPECTIONS ti 212 Main Street • Municipal Building vti (,• Northampton, MA 01060 st+jy TON 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: Vkp43 s Location of Facility: uS PL\?IC I S mulls-0 2A C-r " The debris will be transported by: Name of Hauler: Signature of Applicant: 77/0 Date: f 2/7)22 • Your Proposal has been Approved! Phil Beaulieu &Sons Home Improvement, Inc. �/'' 217 Grattan Street _ ___ Chicopee, MA 01 C20 Phone: (413)592-1498 ` Fax: (413)594-6C08 Beaulieu IIODtli IMPROVEMENT,INC. al.1.0 Print.dato: ( 8.4-2022 �l Nicole Rochefort and Jessica Gifford 166 Grove Street Northampton,MA 01020 Phone:413-548-4688/413-387-7020 nrrochefort©gmail.corn / jessica©projectconnect-us.com 6 Patio Door • Remove one(1)existing window on the rear wall of the garage porch-dispose of an debris Frame a new opening for an 8'wide patio door Furnish and install one(1)8/0 x custom height Harvey vinyl patio door OX from outside White interior/white exterior Full screen on operating door Standard locking system and handle-set White hardware Energy Star glass No grids or binds between the glass #2 clear pine interior casing-To be painted or stained by others Manufacturer lifetime warranty on frame/20 years on glass/10 year warranty on parts and mechanisms Furnish and install 1"x 4"PVC exterior casing Repair siding if needed around door-Painting to be done by others Complete finished carpentry inside and outside Note:This price includes a$500.00 electrical allowance to install a homeowner supplied light fixture outside the patio door, any additional electrical fees will be applied as a change order $8.100.00 General Includes removal and disposal of aff debris Any rot found during the project is to be repaired or replaced at a rate of(S185.00)per hour+materials+15%of material Payment Schedule S2,700.00 deposit is due at signing;half the total price due upon the start project;remaining balance due upon completion • Work Schedule The anticipated work commencement date will be determined and communicated to Homeowner.at signing, but not to exceed nine months from signature,with substantial completion within 45 days after commencement.Contractor to'notify the Homeowner if factors outside our reasonable control require any material changes to this time frame. Price Escalation: In the event of significant delay or price increase of material,equipment or energy occurring during the performance of the contract through no fault of the Contractor, the Contract Price, time for completion of contract requirements shall be equitably adjusted by change order. A change in price of an Item of material, equipment, or energy will be considered significant when the price of an item increases twenty percent (20%) between the date of this Contract and the date of commencement of work. Substantial Completion: To the extent that work has been substantially completed, but certain materials need to be replaced or repaired by an original manufacturer or third party supplier (the cost of which does not exceed 10% of the overall Contract price), the remaining balance shall still be due and payable minus the commercially reasonable cost of such items,which may be held back by Homeowner until such items are replaced and payment hold-back shall then be due. Change Orders: To the extent that Homeowner requests and/or agrees to the addition or removal of products and/or services after the execution of this Contract,the Homeowner shall sign a change order specifying the changes In the scope of the Contract and pricing,which shall modify such provisions of this Contract but otherwise incorporate all provisions of this Contract as if fully set forth therein. f inance Charge: 1 A%monthly(ANNUAL PERCENTAGE RATE OF 18%)will be added to the unpaid portion of the balance due.Homeowner agrees to pay these charges. In the event of default of payment,Homeowner agrees to pay reasonable Attorney's fees& court costs. This agreement does not constitute a release of liability. By Homeowner's signature below, Homeowner acknowledges and agrees to the above. Arbitration: Contractor&Homeowner hereby mutually agree in advance that, in the event either party has a dispute concerning this Contract,either party may submit a dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs & Business Regulation and each party shall be required to submit to arbitration pursuant to M.G.L.c 142A,§4. Contractor Oblf tons: All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.Alterations or deviations from above specifications involving extra cost will be executed only upon written orders, and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.The Home Improvement Contractor Regulation Statute,M.G.L.c.142A gives you certain warranties and homeowner's rights thereunder.Contractor shall inform Homeowner of any and all necessary permits, and it shall be the obligation of the contractor to obtain said permits.If Homeowner secures his/her own permits,he/she will be excluded from the guaranty fund provisions of M.G.L.c.142A. gegistration: Contractor to have all registration,license number and insurance required by the stale. tractor to be registered with the Director of Home Improvement Contractor Registration.Certificate of Registration#100073.My inquiries about Contractor relating to registration should be directed to the Consumer Hetfine at (617)973-8787. Contractor to carry commercially reasonable insurance.Contractor's workers are covered by Worker's Compensation Insurance. Customer Acceptance of Proposal: Upon signing.this.document becomes a binding contract under law. The above prices, specifications and conditions are satisfactory and are hereby accepted. Contractor is authorized to do the work as specified. Payment will be made as outlined in the payment schedule. Contractor may withdraw this proposal at any time prior to signature by Homeowner.Homeowner may cancel this Contract without penalty or obligation within three(3)business days from the date signed.Contractor may withdraw this proposal if not accepted within 30 days. Customer Consents: Contractor is authorized to use media for promotional purposes.Contractor is granted permission to access property after signing until project completion. Homeowner's signature grants permission to Contractor to obtain all necessary building permits. U Sul (:c,or,le /�+ O `7.q Beaulieu ❑u]ll 1,11.e Vtl dll N 1.1.I. Stay Connected with our social media and helpful links above• Proposal Date:August 3,2022 Revised From:July 12,2022 Estimate Date:July 7,2022 PBHI Representative Cameron Beaulieu Authorized Signature I confirm that my action here represents my electronic signature and is binding. f));)not sign this contract if there are any blank spaces. • C1 -a-,-.--ti tit Signature: Approved by: Nicole Rochefort and Jessica Gifford Date: 8-3-2022 8:07 PM ACORN DATE!MMlDD/YYW) CERTIFICATE OF LIABILITY INSURANCE (MM/Dzz 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). CONT PRODUCER NAMEACT ERIC MASON THE MASON AGENCY INC PHONE WC.No.Ext): (413)569-2307 /AC,rio): (413)569-2308 504 College Hwy ADDRess: themasonagencyAamerIcan-nationa).com Southwick, MA 01077 INSURER(S)AFFORDING COVERAGE NAICf! INSURER A: FARM FAMILY CASUALTY INSURANCE 13803 INSURED INSURER B PHIL BEAULIEU&SONS HOME IMPROVEMENT, INSURER C: INC. INSURER D: 217 GRATTAN STREET INSURER E: Chicopee, MA 01020 MA 01020 INSURERF: I 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 REOUIREMENT, 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 SUER POLICY EFF POLICY EXP UNITS LTR ,INSD INVD POLICY NUMBER 1MM/DD/YYYY) 1MM/DD/YYYYI X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $ 300,000 BUSINESS OWNER'S MED EXP(Any one person) $ 25,000 A x x 2001X2810 02/25/22 02/25/23 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER'. GENERAL AGGREGATE $ 3,000,000 X POLICY LOC AGG $ 3,000,000 PRODUCTS-COMP/OP OTHER: i $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I $ (Ea accident) 1'000,000 ANY AUTO BODILY INJURY(Per person) $ A AAINNED 'V UTOS ONLY X AUHULED x 2001C7139 02/25/22 02/25/23 BODILY INJURY(Per accident) $ XHIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY X AUTOS ONLY (Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 A EXCESS�/UAB CLAIMS-MADE 2001E1738 02/25/22 02/25/23 AGGREGATE $ 3,000,000 DEC X RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y I N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatary in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS bellow E.L.DISEASE-POLICY LIMIT $ • DESCRIPTION OF OPERATIONS%LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CARPENTRY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE SAMPLE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIV I O 1988- 015 ORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD PHILBEA-01 CHRISTINE AccrRcr CERTIFICATE OF LIABILITY INSURANCE DAz/1$/2022 TE ) 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 Christine Sullivan NAME: Phillips Insurance Agency,Inc. PHONE/C,N (413)594-5984 FAX No):(413)592$499 97 Center Street (A/C,Miss: Ext): Chicopee,MA 01013 ADQREss:Christine@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:A.I.M.Mutual Insurance Company INSURED INSURER B: Phil Beaulieu&Sons Home Improvement Inc. INSURER C: Phil Beaulieu 217 Grattan Street INSURER D: Chicopee,MA 01020 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 10 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 LIMITS INSD WVD IMM/DD/YYYY) (MM/DD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 7p8f n LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSRE ONLY AUTOS BODILYO INJURY(Per acciden9 $ AUTOS ONLY _ AUTOS ONLY (Perr acadentDAMAGE UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A AND WORKERS COMPENSATION Y/" X STATUTE ERH WMZ-800-6205-2022A 2/25/2022 2/25/2023 ANY PROPRIETOR/PARTNER/EXECUTIVE 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 $ DESCRIPTION OF OPERATIONS/LOCATIONS/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 Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • • Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constatrtteu Stipervisor CS-062638 Expires:06/13/2023 ALAIN M BEAULIEU 217 GRATTAN STREET CHICOPEE MA 01020 ,,r\r Commissioner dive ,' Cl6i/7(11.a. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation PHIL BEAULIEU&SONS HOME IMPROVEMENT, INC. . Registration: 100073 217 GRATTAN STREET Expiration: 06/07/2024 CHICOPEE, MA 01020 : fir, 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 100073 06/07/2024 Boston,MA 02118 'HIL BEAULIEU&SONS HOME IMPROVEMENT, INC. 1Y LAIN M.BEAULIEU 17 GRATTAN STREET L.r / vFf. HICOPEE,MA 01020 Undersecretary of v id without signature — Department of Industrial Accidents Office of Investigations 1,1 Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Phil Beaulieu & Sons Home Improvement, Inc. Address: 217 Grattan Street City/State/Zip: Chicopee, MA 01020 Phone #: 413-592-1498 Are you an employer? Check the appropriate box: Type of project (required): 1.Q I am a employer with 25 4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ® Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' 4 P tY i. 9. 0 Building addition [No workers' comp. insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] Any applicant that checks box#1 must also fill out the section below 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 affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have mployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site nformation. nsurance Company Name: A.I.M. Mutual Insurance Company 'olicy#or Self-ins. Lic. #:WMZ-800-6205-2022A Expiration Date: 2/2512023 ob Site Address: I lk if a r8'v'C City/State/Zip: 01C +0 r\ tk Mach a copy of the workers' compensation policy declaration page (showing the policy number and cxp ration date). 0 10(9f :allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK 0 DER and a fine ►f up to $250.00 a da/against the violator. Be advised that a copy of this statement may be forwarded to the O ice of nvestigations of th&,DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. >ignature: 'R g24Gli Date: 12 � 7 I? 2. 'hone#: 413-592-1498 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): 10Board of Health 20 Building Department 3OCity/Town Clerk 4.0 Electrical Inspector 5E/Plumbing Inspector 6.00ther Contact Person: Phone#: