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HomeMy WebLinkAboutMiscellaneous - 36 Kingston Street (2)"r\\ 'i - 7� % <--%, ��3 c� �,D T�� �� ) rA Q LL 0 O Q co O t O u y �p O LL +O+ 0 lA '}, Q VI O� w z z Z 0 J m O ++ C 7 LL Op :32 2' ? E V _ m LL a z Z m J a to 7 d' _ LL 0 a z u W LU h0 7 Q' U In _ N LL 1=z 0 a IA Z Q 00 =3 _ LL LU a W LLJ LL a� i m Z N N v p Y O Ln r� Cc v p : U : 'QL W :a . CL U) ccc +' Z o¢ U c z C p Q N V L y m •4+ C o (!) �- Lo � a 46: %14 �3 J �z Q- 3 `m a Z ~ A U >A = a) U) W N roc > r U. x z . O W O E c c U Q m ,� tm V) cn O O as U) 0 r • :E.- '- r W > 3 c W J 0 az CL CL O 'y O C r c cm c c 2 O : Q 4)-s N O N v m U) cc w W r- -0. O O �. LL '�.d Cc N C O N y CL = r 0 z W •E v o .� U 0-0 Q as w N N 'O a 0 F— t ..O'. = o 0 > ti ti w y IV i E p� O z 0 c d 0 � .E m m n. F- 'a O �+ v C O 0 a CL ca O U J �CL 0 0 z 0 U tU !Q _ CL U) 0 W D W W W The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Mass 02111 Workers' Compensation Insurance Affidavit: B ilders/Contractors/Electricia Applicant Information ns/Plumbers r aCaae rrlIIT Name (Business/organization/individual): n �, �(u�Ct1'Q City/State/Zip: I;Wpf , 4113 oZ t� q- Phone#:_-- 617- 992-y3o9 Are you an employer9 Ch k f project (required): ec the appropriate box: 1. 1 am an employer with_ -1 employees 4. 1 am a general contractor and 1 (full and/or part time).* 2. 1 am a sole prop0clor or have hired the sub -contractors partner- ship and have no employees listed on the attached sheet. working for me in any capacity. [No workers' comp. insurance These sub -contractors have employees and have workers' required]comp• 3. 1 1 am a homeowner doingall insurance. + 5-_1 We are a corporation and its work myself [No workers' comp. officers have exercised their insurance required] t right of exemption perm MGL c. 152, § 1(4), and we have no employees. [no workers' comp, insurance required.] *Any applicant that checks hf must also fill o ut the tHomeowners who submit thisis affidavit ' d' section below showing their workers' compensation o Type o 6. 1 New construction 7. 1 Remodeling 8. -I Demolition 9. 1 Building addition 10. 1 Electrical repairs or additions I I. 1 Plumbing repairs or additions 12. 1 Roof repairs 13. 1 Other $Co m �catmg they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntactors that check this box must attach an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have em to ees, the must Provide their workers' com , li number. tam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information, Insurance Company Name: At /4u4y4l Zwnm C, Policy # or Self -ins. Lic. #: A wt- ypp .7055 %i .20134 Expiration Date: 31q Job Site Address:_ '.3 G �fN S�Ott• {,, City/State/Zip: d r+h�ndQVe t` M A 6 b 4 rJ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration (date). Failure to secure coverage as required under Section 25a of MGL 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 STOP WORK ORDER and a fine of $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification I do herby Print Name: Official use only under the pains and penaltiesof perjury that the information provided above is true and correct: Date: Phone #: Do not write in this area to be completed by city or town official City or Town: Permit/license #: Issuing Authority (circle one): I.Board of Heath 2. Building Department 3. City/Town Clerk 6. Other 4. Electrical Inspector 5. Plumbing Inspector Contact person: Phone t kM1�J Massachusetts - l e m m ea I , .'". Y t;� Board of BuildIng Regulabm andlta D' 100 Construction Supenlisar I & 21 um l L:cens 4 ° 1719 RONALD A GRIE"E 10 RITA MIEDFORD MA 02M55 "xpi I Npal-1111k.11t ill 11,11hlik: '-ato.N Bilard fit Buildin,-, mid �tandar(k Construction Supervisor License One- and Two- Family Dwell' gs License: CS 61719 RONAL GREENE 10 RITA D E MEDFORD,M Expiration: '10/27/2013 --fill i-qw; Tr--: 5199 Office of cossumr Affairs & Bti-gidr- Regulation ME IMPROVEMENT CONTRACTOR Type-, gistration: 102957 Private CorP0r91tI0i-. xplirabow. 71312014 GRFENE INSTALLAT-tON CO, INC. Ronald Greene 165 Bow street Everett, MA 02149 Undersecretary 07 rax oux,vr✓r' Si8iz013 9:40:45 AM PAGE 2/002 Fax Server GREEINS-01 BSULLIVAN CERTIFICATE OF LIABILITY INSURANCEI 519/2013 DATE(MMIDDlYYYY) THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TMS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE 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(les) must 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 C ACT AME Salem Five Insurance Services, LLC PONE 445 Main Street Al. N,(781) 933-3100 5595 FAX No): (781) 933-9048 Woburn, MA 01801 1 EMAIL INSURED Greene Installation Co. Inc. 165 Bow Street 165 Bow Street Everett, MA 02149 CAVFRAt_CQ INSURERA:Safety Insurance.Compan IN_SURERe:Safety Indemnity Ins. Co. INSURER C: AIM Mutuai insurance Co. INSURER D : F NAIC 0 8 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN KtV151VN NUMBER: ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED HEREIN IS SUBJECT TO ALL THE TERMS," INSR _.... _.__. BY PAID CLAIMS. LTR TYPE OF INSURANCE ADDEs R..... P- �OLICYEFF-POUCYEXP 1M JWP_ POUCYNUMBER MIDDIYYYY MMIDD - --- — LIMITS GENERAL LIABILITY -- A X EnC:H OCG.lggRENCE $ 1,000,00 COMMERCIAL GENERAL LIABILITY BMA0008519 5/812013 5/8/2014 pF2EMIS1 S Ea ^ :u en e $ CLAIMS -MADE OCCUR MED EXP+Any one pe, swp $ 10,00( PERSONAL & ADV INJURY $ 1,000,00 --- GENERAL AGGREGATE $ 2,000,00 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 2,000,00 _ POLICY MT LOC AUTOMOBILE LIABILITY COfdBINED SINGLE LIMIT o Mdent 1,000,00 B ANY AUTO BODILY INJURY (Per person) $ _. 6208932 1/30/2013 1130/2014 WNED X SCI ILOVLEO AALLL AUTOS BODILY INJURY (Pcrii-xident) $ X HIREDAUTOS X NON -OWNED ALRQC PROPER AMA $ PER ACCIDENT UMBRELLA LIAB OCCUR EXCESS LIAR EACH OCCURRENCE $ AGGREGATE $ CLAIMS -MADE DED RETENTION s$ WORKERS COMPENSATION C AND EMPLOYERS' LIABILITY Y 1 N WC STATI L OTH- TORYLIMrSER E.L. EACH ACCIUtN I $ 500,00 ANY PROPRIETORIPARTNERIEXECI_ITNE c7FFICERIMEMBER n WC -400-7025594-2013A 3/4/2013 3/412014 EXCLUDED? (Mantlatory in NH)ad If yes, dEscdbe under N I A 6.L. DISEASE -EA EMPLOYE $ 500,00 DESCRIPTION OF OPERA I ION; Oelow F.L. DI.SFASF - POI ICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additlonal Remarks Schedule, N morn space Is roqulmd) 10 day cancellation clause for non payment, 30 days for all other regarding General Liability. Lowe's Companies Inc. and any and all subsidiaries are named as additional insured per written contract for Auto Uability purposes only. CFRTIFI(`ATF uAl nen Lowe's Companies Inc. IS Insurance P.O. Box 1111 North Wilkesboro, NC 28656 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE A- . ,- ACORD 25 2010105 G r�ov-4v Iv 1"u" �uKt UKAI ION. All rights reserved. ( ) The ACname and logo are registered marks of ACORD 8010290169 ©2011, RR Donnelley. All rights reserved. - 0221 WIF LOUIE'S 000704 MASSACHUSETTS EXTERIOR'.SOLUTIONS INSTALLED SALES CONTRACT INSTALLED SALES SPECIALIST JINUMBER CUSTOMER STORE NO. STREET ADDRESS STREET ADDRESS ) � 9 1S , IM vl.c wtr CITY STATE ZIP 6 1.0; TELEPHONE DATE LOWE'S HOME CENTERS, INC.'S MA HIC NO.: 148688 .[ I 2 FEIN: 56-0748358 CITY `� SjtTAATE�/j ZIP +v'Yi r Gam" TELEPHONE CASH BANKCARD � LC� REG CHARGE This is only a quote for the merchandise and services printed below. Th is becomes.an.Agreement upon -payment- Upon -payment, the entire agreement, including the specifically completed pages of this document, the Terms and Conditionsincluded with this document and any other addenda.and attachments Hereto, shall.bereferred to herein as this "ContracL PLEASE READ ALL TERMS AND CONDITIONS ON-THE.REVERSE SIDE OF THIS PAGE AND: FOLLOWING -PAGES BEEORE.SIGNING, INSTALLATION I LC— t STREET ADDRESS1 _ I t h A S 'i71— .5 STATE ZIP MA- di J a -,A4 I't U -I- -t L L i u 1 Are permits required for this installation?: s . I I No Contract Total *applicable tax included 3 �jfOJ. off" J c NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right. By signing this Contract, Custome acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposur from renovation activity to be performed in Customer's dwelling unit. PHOTO RELEASE: Customer grants to Lowe's and Lowe's employees the right to take photographs of all work performed at the Premises related to this Contract, and irrevocably grants to Lowe's all right, title and interest in and to the photographs for use in all markets and media, worldwide, in perpetuity. Customer authorizes Lowe's to copyright, use and publish the photographs in print and/or electronically, and agrees that Lowe's may use such photographs for any lawful purpose, including, but not limited to, marketing, advertising, publicity, illustration, training and Web content. By initialing here, Customer agrees to the foregoing. [Customer to initial to the left]. Work is to commence upon reasonable availability of Contractor and/or any special order or custo er made Good(s) which is anticipated to bE 1 1 - 2 -(3 [fille in date]. Estimated completion date is % " j - j G [fill in date]. Said estimated substantial completion date is not of the essence. A statement of any contingencies that would materially change said estimated substant completion date is as follows: (if applicable, inserta statment of such contingencies). IF THE CONTRACT TOTAL IS $1,000.00 OR LESS Customer must -pay in full. COM�L�ETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS $1,000.00: kj Customer to Pay in Full; OR [ ] Customer to use the following payment schedule: (1) Deposit $ to be paid upon siging contract. Deposit should be 1/3 the total contract price; and (2) Payment of $ to be paid anytime after this Contract is signed and before commencement of installation, I/We authorize Lowi to do one of the following (check appropriate box below): [ ] Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or [ ] Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed; and (3) Final payment of $100.001to be paid upon completion of the installation and both parties' satisfaction. LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE, CONCERNING THIS CONTRACT,, LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXEC .IVE OFFICE OF_C4..NS:UMER=AIRS AND BUISN�rSS-REGUI- SAND TH -OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATI his is.4 ly a quote forthe merchandise and services printed below. This becomes an agreement upon payment. Upon payment, the entire agreement, including the specifically completed pages of this document, the Terns and Conditions included with this document -and arty other addenda and attachments hereto, shall be referred to herein as this "Contract." PLEASE READ ALL TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWINGPAGESBEFORE SIGNING. INSTALLATION STREET ADDRESS 'CITY 4 - S STATE ZIP M A- d/ r 191c,t L, L .111,.(..,,s Contract Total Are permits required for this installation?:.(..es[ } No *applicable tax included NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right. By signing this Contract, Customer acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit PHOTO RELEASE: Customer grants to Lowe's and Lowe's employees the right to take photographs of all work performed at the Premises related to this Contract, and irrevocably grants to Lowe's all right, title and interest in and to the photographs for use in all markets and media, worldwide, in perpetuity. Customer authorizes Lowe's to copyright, use and publish the photographs in print and/or electronically, and agrees that Lowe's may use such photographs for any lawful purpose, including, but not limited to, marketing, advertising, publicity, illustration, training and Web content. By initialing here, Customer agrees to the foregoing. [Customer to initial to the left]. 4 Work is to c mmence upon reasonable availability of Contractor and/or any special order or custo er made Good(s) which is anticipated to be i ` 2 - (3 [fille in date]. Estimated completion date is f - 4 - / [fill in date]. Said estimated substantial completion date is not of the essence. A statement of any contingencies that would materially change said estimated substantial completion date is as follows: applicable, inserter statment of such contingencies). 1F THE CONTRACT TOTAL IS $1,000.00 OR LESS Customer must pay in full. COUPL-E-TE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS $1,000.00: Customer to Pay in Full; OR [ ] Customer to use the following payment schedule: (1) Deposit $ 'to be paid upon siging contract. Deposit should be 1/3 the total contract price; and (2) Payment of $ to be paid anytime after this Contract is signed and before commencement of installation, I/We authorize Lowe's to do one of the following (check appropriate box below): [ ] Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or - E ( ] Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed; and (3) Final payment of $100.00 to be paid upon completion of the installation and both parties' satisfaction. LOWE'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 EXECUT- IVE OFFICE OF NSUMER"AFFAIRS AND BUISN SS REGU IO SAND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVIDE M. . C.142 . By. Date: �� % 3 :Lowe' Centers Inc. `" 2 By. Date: t( Owner Signature THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES'TO ALTERNATIVE DISPUTE RESOLUTION INITIATED BY LOWE'S PURSUANT TO M.G.L. c.142A. THE OWNER'MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT. BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT. YOU ARE ENTITLED TO A COPY F THIS CONTRACT AT T E TIME OF SIGNATURE. WITNESS OUR HAND(S) AND SEAL(S) BELOW THIS DAY OF�/ 4/ ra r`..i 13. Lowe's,64ome Cbrilers' Anel / s . rf 1 0 "'^"'c' Co-owner or Witness Customer acknowledges receipt of a true copy of this contract which was.completely filled in prior to Customer's execution hereof. You, the buyer, 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. #90981 (Rev. 12/10) FILE COPY-..:. © 2004 by, Lowe's.® Lowe's and the gable design are registered trademarks of LF Corporation.