6C HALSEY WAY - BUILDING INSPECTION EITY aF�XLE'
PUBLIC PROPERTY
DEPARTMENT
KmalEwlY DIUSC)LL
MAvat 120 WASMNiamw b-MEEr•SALEK MAMACHLSLI-M 01970
,�Vo I m-,97&73S-959S 0 FAX 97&740-9g"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: a , q Q Building: E - G
Property-Address: - ----
6-C I-IA15ekn wac�
Property is located in a; Conservation Area Y/N„sL_Historic District Y/N .4,,l _
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
Name: e -F' A,v
Address:
S-c tt AI se-L) wr•1y
Telephone: 6/-7 -6C3- 7c?8,q
3.0 COMPLETE THIS SECTION FOR WORK IN EXIQTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
A2e.�70ue oJW f/zew A� 5 55Te /N57-A 'mew
S �� peen i e- S ,3 Ste,n.`
-- Mail Permit to; lvi A 0)4L50
What is the current use of the Building?
Material of Building? If dwelling. how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone Po
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$��'— Permit Fee Calculation
Permit Fee $.� Estimated Cost X$7/$1000 Residential
--- ---Estimated-Cost-X$11/$1000-Commercial -- ----
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X
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,
CITY OF SALEM� MASSACHUSETTS
• PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 360
MAYOR FAX: 976-740-9846 t
lO-1-7 C�
Salem Building Department
Debris Di�;f aosal Form �� y
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
p 5�t2 (Location of Facili
j'I �� G
Signature of Applicant
Z
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Department of Industrial Accidents
Office oflnvestigadons
600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (BusinessAOrpnization/Individual):
Address: ® �l e/,0N AA/ e S
City/State/Zip:S" f� 40b/U f{�('¢ D�G?'7 : . Phone #:
Are you an employer?Check the appropriate bozo'
Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' bave hired the sub-contras fors
2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition-
working,for me in any capacity.. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp,insurance 5. ❑ We area corporation"anti its .
required.]..
offices hay o exercised their . 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of ez'emption per M. I L[] Plumbing repairs or additions
myself. [No workers',comp; c. 152,§1(4),and we haven 12.❑ Roofrepairs
insurance required.]t employees. [No workers' . 13.❑ Other
comp.insurance required j .
'Any applicant that checks box#1 must also fill ourthe section below showing thec.workers'compensation policy mfommtioa'
t Homeowners who subnut this affidavit indicating they are doing all work and then h6e'&xWde eouhactms must subrtrit a new affidavit indicating such
tContrsctors that check this box must attached an additional sheet showing the nw. of the sub-cone Berm and their workm,comp.policy information
I am an employer that Ls providing workers'eompensadon Insurance for my employees Below b the policy and Job site
information
Insurance Company Name: nl �U(N . S4elllz L
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address:� City/Stawzip:-14&oo /
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to segue 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 hereby certi und#r the paim and peC
ofpejury that the information provided above is truce,and correct
Signature: g �' ✓f V 7pG Date,
Phone#: ( —�C139 .
Oftial use only. Do not write in this area,to be completed by city or town ofjiciaL
City or Town: PexraltlUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 3.Plumbing Inspector
6.Other
Contact Person: Phone#:
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10/17/2006 9: 57 : 13 AM Jackson, Sandy Page 2
Client :64763 EMPIHOMI
ACORDTM CERTIFICATE OF LIABILITY INSURANCE 1 7/oB°""m
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Construction•Remegi Team ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Mesirow Insurance Service HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
321 N.Clark Street
Chicago,IL 60610 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A. Netherlands Insurance Company
Empire Home Improvement,LLC. INSURER B:
333 Northwest Ave. INSURER C:
Northlake,IL 60164
INSURER D:
INSURER E'
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTA WSR TYPEOFINSURANCE POLICY NUMBER POUCY EFFECTIVE POLICY EXPIRATION LIMITS
A GENERAL UABIUTY CBP8183087 09/16/06 09/16/07 EACH OCCURRENCE $1000000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
PREMISES(Ea ocaur.w.l $300 000
CLAIMS MADE OOCCUR MED EXP(My ore ermn) $10000
PERSONAL B ADV INJURY $1000000
GENERALAGGREGATE $2 OOO OOO
GENT AGGREGATEUMIT APPLIES PER. PRODUCTS-COMP.OP AGG $2000000
POLICY PRO LOC
A AUTOMOBILE UARINTY BA8183187 09/16t06 09/16/07 COMBINED SINGLE LIMIT
A X ANYAUTO BA8183387 09/16/06 09/16/07 (En accident) $1,000,000
ALL OWNED AUTOS
BOURY $
SCHEDULED AUTOS (Per
W perwnrwn)
X HIREDAMOS
BODILY INJURY $
X NON-OWNED AUTOS (Per acciderh)
PROPERTY DAMAGE $
(Per xaden)
GARAGE LIABILITY AUTOONLY-EAACCIDENT $
ANY AUTO OTHER THAN EAACC $
AUTOONLY AGO $
A EXCESS/UMBRELLA UABILITY CUS183487 09/16/06 09/16/07 EACH OCCURRENCE $10 000 000
X OCCUR CLAIMS MADE AGGREGATE $10000000
$
DEDJCTIBUE $
X RETENTION $10000 $
A WORKERS COMPENSATION AND WC8183287 09/16/06 09/16/07 WcsTATIU I OTH-
EMPLOYERS'UABIUTY
ANYPROPRIETOR/PARTNERIEXECUTIVE EL EACH ACCIDENT $1000000
OFFICERNEMBER EXCLUDEWY ELDISEASE-EAEMPLOYEE $1 GOO 000
II yeu,describe uN r
SPECIAL PROVISIONS be E L.DISEASE-POLICY LIMIT $1 000 000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
*****PROOF OF INSURANCE'**'** DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 'AD_ DAYS WRITTEN
NOTICE TO THE CERTI RCATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION O R UABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001/08)1 of 2 #S407353/M401662 SXJ 0 ACORD CORPORATION 1988
IPGO 008297 III liIIIIIIIIIIIIIIIIIIIIIPIIIIIII OP30 865oG8 III IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
ell M HMI CM' AMI
LR� NFRC
MODEL 0501 ; D MODEL 0204 - FIXED LI1E
CPO# RLS-A-3B-00B CPO• RLS-A-041-002
National Fenestration National Fenestration
'Mhg Counrl SOLID UINYL - UELOED - TRIPLE GLZD Rating Council SOLID UINYL - UELDED - DOUBLE GLZD
• 1" TIG. SS LOE2. OBL ARGON. GRIDS < 1 13/16" IG. DS LO-E. ARGON
RE59 RES97
ENERGY PERFORMANCE RATINGS ENERGY PERFORMANCE RATINGS
U-Factor (U.S /I-P) Solar Heat Gain Coefficient U-Factor (U.S./I-P) Solar Heat Gain Coefficient
0 . 23 0 . 23 0 . 28 0 . 34
ADDITIONAL PERFORMANCE RATINGS ADDITIONAL PERFORMANCE RATINGS
Uisible Transmittance Uisible Transmittance
0 . 34 0 . 60
�r
.III IIIIIIIIIIIIIIIIIIIIIIIIIiIII Manufacturer stipulates that these ratings conform to applicable NFRC procedures for determining whole
OP55 0IM40 product performance NFRC ratings are determined fora fixed set of environmental conditions and a
HMI specific product siEe Consult manufacturer's literature for other product performance information.
cM - www.nfre.org
NF r �
MODEL 0201 - DOUBLE HUNG K
National Fenestration
.�`' CPO# RLS-A-011-002 \
Rating Council �.f SOLID UINYL - WELDED - DOUBLE GLZD
13/16" IG, OS LO-E. ARGON
RES97 �
ENERGY PERFORMANCE RATINGS
•
U-Factor (U.S./I-P) Solar Heat Gain Coefficient
0 . 32 0 . 31
ADDITIONAL PERFORMANCE RATINGS
Uisible Transmittance
0 . 53
Manufacturer stipulates that these ratings conform to applicable NFRC procedures for determining whole
product performance.NFRC ratings are determined for a fixed set of environmental conditions and a .
specific product size.Consult manufacturer's literature for other product performance information. ,�-
www.nfrc.org
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EMPIRE TODAY®, LLC
333 Northwest Ave.
Northlake, IL 60164
PHONE (847) 683-3000 FAX (847)583-3099
(000) 688-2300
LETTER OF AUTHORIZATION
I Steve Silvers, Senior Vice President, Empire Home Improvements, LLC authorize my
representative employees Anthony ward, Kevin .Croce, and Rico Bartalini and Bernard
Slowinski, upon proper identification, to transact business with the towns of Town
Massachusetts,to obtain building permits on behalf of Empire Today.
Empire Home Improvement,LLC
Steven J.Silver/SVP
bate
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toder
d o Building R e g U 11 10to ns an4dt an ards
no
One Ashburton Place - Room 1301
Boston. Massachusetts 02108 ,
Home Improvemerit'Colltractor Registration
w
n Registration: 138967 �
Type: Ltd Liability CorporationLO
4tz 1I-IJr Expiration: 6121201}7
EMPIRE HOME IMPROVEMENTj° LC. _..,..> :.._,:
STEVE SILVERS ---
333 NORTHWEST AVE,NORTHLAKE; IL 60164 i tCj J -1
:,.:.. �.:. r....r
'vi, .,-rl„��,�• Update Address and return card.Mark reason for change.
[) Address Renewal Ll Employment Lost Card
nP3CA1 Q 69h1dNW-01a72l8
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✓ha'IOor�Wnonlnaa�Vl a�,/�/,tr,6rralu�deQt Z
11aard of BuildingRogulatlons and Standards License or registration valid for Individul use only
HOME IMPROVEMENT CONTRACTOR before the espiratloa date, If fouad return to:
ReglatYatl6i 138967 Board of Building Regulations and Standards
:-1'raflcnt=t; r20a7 One Ashburton Place Rm1301
Wilton,Ma.02103
�7rleT at¢.iiab6ily Corpor�don -
c Y� I
EMPIRE HOME! LG. + -
STEVE SI'VERS
10/30/2006 09:34 7812972032 EMPIRE TODAY BOSTON PAGE 09/09
'dosed """' Empire Home Improvement LLC
MA lJG A 1M67
em 1013 TURNPIKE ST,GTOUOKTON,IAA OW2
` /�
CUSTOMER SERICE HUT:l6.So"am-2321 Sraln�G
V
• HOME IMPROVEMENT SALE AND INSTALLATION AGREEMENT
)ATE ORDER N•. SALESMAN SALESMAN Nh. BPEa.SNIT N•.W
�a-MAZH8 03831 ire
"is)Hama Buyerts)TeW—Number
C-tE&2Lf kRa(4s Ririe.s4. 56R8
auyor(s)StreetAddre9e
70 InQffA7M �c v
guyeds)Cary.State and Zip Cade
_ 12A LeM A 1719 y
tie Buyer(s)fisted above hereby Johnly and severally agree to purchase the goods andtor services rm below and an the accompanying addendum or Spec.
heat,in accordance with the prices and terms deschbed on to frail and the reverse of this Agreement and Buyers)have requested that Such 900da or services
e Installed or pr(Mded at Buyer's address rated above.Empire Home Improvement LLC(°['4lftraamr'1,hereby agrees to install or cause to be Installed the
roducts or services Listed in this Agreement at the Buyers)address written above.Ba"Kil)agree to sign a completion certificate Upon Completion of the Instal-
than of the goods.Detailed Dmdudt dsscriptions forali siding,windows and certain other orders are contained inthe acemnpanyinq addendum to this Agreement
PURCHASE PRICE: DEPOSIT AMOUNT: BALANCE PAYMENT TERMS:
DEPOSIT AMOUNT(MINIMUM 25%): 0 CASH/MONEY ORDER O CASH I MONEY ORDER
Mot applicable for 100%flnandnrj (f ❑CERTIFIED CHECK #qW ❑CFATIRED CHECK
SUBTOTAL: �� ,O(f"gEDIT CARD ` ❑CREDIT CARD
BALANCE DUE UPON OEUVEHY: t� �" PKEM NAL CHWA/'y 0 THIRD PARTY RNANCE ACCOUNT
BALANCE DUE ON RNAL INSTAL: .a3 •*q�p� S B I 4 07 CREDIT CARD/RWINCE ACCOUM N0.
Estimated Starting Date: 91. — Estimated Completion Oats:
IUYER AND CONTRACTOR HEREBY AGREE:
• Buyer is required to have any security/alarm system disconnects prior to me commencement of vork-Contractor will not dsarm, arm, remove,
[retail or reinstall a sacurey or alarm system. Buyer Is required to have a codified radon mnedlation expert remove and reinstall any radar
remedadon equipment pri0rto the oemmencemant of work.Contractor will not dtsommed Or reconnect any such equipment
• Any surplus materials remaining after completion of this Jab Shan remain the property of Comrectnr and no credit Is due to the Buyer wren respect
to such excess materials. Buyer Is required to remove any window teatnents that present an Obstacle to installation of new windows. Window
treatments may not fit inolaromd the on YArMow after Installation. Certain window stNas cannot be changed due to building codes unless the
now window unl4s)meet egress codes.
• Guyer indOmnHlss and holds Contractor and its amployees,aDhadi oommetors and their subcontractm hem arty dais m to the identification,
detection,abatement,encep8rrloaon or removal of mold.asbestos,lead based products or corer hazardous substances inside or out side of the structure
Doing unpaved.
THIS MSTRMW IS BASED UPON A HOME S01.11M T OIN SALE,WHICH SALE IS SUBJECT TO THE PROYMIHS OF THE HOME SOLICITATION SALE4 ACT.
THIS MBIHUMENT IS NOT NEGOTIABLE
Do rat Shan this conbaol a there art any Walk Santee Nonnegotiable Corl6nrler Rose
Notice to buyer.(1)Oa not sign this agroomerd If any of the Won handed for the agreed term to the Iedemof then avaBablo lnfort rattmn are tell black
(2)you are notified to a OW of the,egreemem at the floe yoo sign it (3)You may at any Home pair off the fall Donald balance dire under IM agraenhxrt,
and In so doing you any be entitled to retells a partial rebate of ale Moll and Laurance charges.(4)The Sager to no right to enter unlawfully your
pmml m at mmmtt any breech of tic pace to mpoasasL Sends purchased under tide appendant(5)You may caned ads agreement N N hog not been
Signed at the main OHie or a branch Office of the seller,provided you hoary,Bit weer at his main office or branch office shown In the agrson In by
reg arch"a caratind mall,wNrfi shall be posted not later than midnigha of the third calendar day alter the day on which to buyer signs the agreemeN,
excluding Sunday and any holiday on which regMaTMal detbariee am not mada.Sur the attached notice ofcancd nfion tam for an mglanaaon of buyeM
right.
If Is agreed and understaod by and fr bvem the parkin Bat tide Agmmnmd,had and back and any addendum,eamandes the 0_1Le untleaafg ri
between the panles,and there are oo veytN u daeaadlage changing of modU Sa
y ny of the ISTM Of ft Agreement Buyers)hereby abooMedgO gat
gtyW has mad the had ao the rewersa of this Agreement and has recehed a completed,signer and dated copy at this Agreement.Including are loon
atat2ad Notice of Comeennalon forms,an the date first wsdtao Shove Bly")also aelmowlidgn ant theywere Orally mfOnnM df aeb dgld a wmxl tide
trarnmasm
EMPIRE HOM P NT.LLC
A&A 7 ld.�•,�, �-*—Qrn
Signature Data FIus Date
Print Name(Address listed attop of Agreement) Cate PHtH Name Date
License Number(U Applicable) Signature Date
Prim Name Dade
ft,the BuyeryS),may cancel this traaaction at any time pia to midnight of the third buslcess day after the date of this transaction.See the attached NOt OO of
Cancellation form for an explanation of this right AddIdenaNy,the seller Is prohibited from haft an Mdepende d courier satrim or never third party pick
up your payment at your resldence bMOre the ant of the 34malrass-day period In which you can cartel lM tra sacton.
Ar>PmiL0W4_T.RIMSANO C*RaYlpM
Delay/Unknown Conditions:Events bey0rd the contal of the Contactor,such as AILS of Gad,labor striae,Inclement waathcn material shortages.Buyers Inability
to quaafy oar or obtain tmncing,or amPr events resWerlg In delays in Dufamlance of MIS Agreement do not mnseMe abandonment and am not Included in callllatIng rime
-.r,u.. m.,sns
10/30/2006 09:25 7812972032 EMPIRE TODAY BOSTON PAGE 03/09
II aeoe
XAe .b-Q 843da1 Empire Home Improvement u.0
IC.fiaesoT
rT
CT UC. season
1053 7URta•ME ST,STOUph11'ON,MA axon
CUSTOMER SERVICE HOTLINE HISS)eee-laae "`^W WJ
• HOME IMPROVEMENT SALE AND INSTALLATION AGREEMENT
LATE O N RM me. IALFSMAN No, SPEC.SHWT NOABh
/d.>Jld16 AS 03829 f�; &hbl 1 &14V
Nyer(s)Nan Bdyer(s)Telephone Number
CEQec,� 1MAS .
Buyerts)SthemAddress
178t7 .4T
Buyers)City,Stale and Lp Code
�} , 04G1r1D
he Buyerys)listed above hereby jolydy and severally agree to purchase the goods and/or services listed below and on the accompanying addendum or spec.
last in accordance With the prices and tems described on the from and the reverse of th Is Agreement and OUyetfs)have requested that such goods or Santa$
e Installed or provided at Shyers address listed above.Empire Home Improvement,LLC("Contractor"),hereby agrees to Install a cause to be Installed the
mducls or services Listed In this Agreement at the Buyers)afteas written above.&ryer(s)agree to sign a complegun ceftif sate upon completion Mine Nasal-
man of the goods.Detailed product decal torsfor all siding,windows and certain other orders are Contained In the accompanying addendum to this Agreement
PURCHASE PRICE: DEPOSITAMOUNT. BALANCE PAYMENT TERMS:
DEPOSIT AMOUNT(MINIMUM 25%): 0 CASH I MONEY ORDE ( 0 CASH/MONEY ORDER
(Nat applicable for 100%financing) + ❑CERnFIED CHECK P�qM T ❑CERNRED CHECK
SUBTOTAL; f 0CyE91TCARD "#t51• OCREDIT CARD
90WIL CHECK hl ❑THIRD PARTY FINANCE ACCOUNT
BALANCE DUE UPON DELIVERY; Alry-��y`1 67 CREDIT CARD/FINANCE ACCOUNT NO.
BALANCE DIE ON FINAL INSTALL•
Estimated Starting Date:—W50. ,a Estimated Completion Date:
WYER AND CONTRACTOR HEREBY AGREE:
• Buyer Is requhed to have any securityloulm system disconnected prior d the commencement at work. Contractor will not disemt,anti,remove.
Install a reinstall a security or alarm system. Buyer Is required to have a carnage radon remedlason expert remove and relnskdl any redan
remedsten eduipmemt polar to tha commencement Of work.Contractor will rot dIscannect Or romm ect alhy such Blhfipment.
• Any surplus materials remaining after omnpkton d this lob shall remain the property of ConVlCtor and no credit is due to the Buyer with respect
to such excess maturate. Buyer Is required to remove any window treatments that preened an obstacle to mstaKatdn of new windows.Window
treatments may net fit inloramund the noW window after installation. Certain window styles cannOt be changed due to building codes unless the
new window UnR(9)moat agress codes.
• Buyer incem *6 and holds Contractor and Its employees,authorized contrectorS and their subcontractors from any claims as to the Identification,
detection,abatement encapsulation or remmol of maid,aobeaKa,lose based products or other hazardous substances inside or out We of the sOUChae
being improved.
THIS NSTRIIMENt S BASED UPON A HOME SOLICITATION SALE,WHICH BALE Is MZGT TO THE PROVISIONS(IF THE HOME SOLICITATION SALES ACT.
THIS INSTRUM9R IS NOT NEGOTIABLE
Do Rot sign this mntrad N tone are any blank spews Nonnegotiable cornsumer rote
Noticetd buyer,(1)Colet sign Meagramw HanyofthespewsIrMrhdedfortheagreedtermtotheexientofthen"ableInforationamleftblank.
2)You are entitled M a copy of tide agreement at the time you slgn It (8)You may at any flare pay of the Bill unpald balance due under this agreement,
and m m ddng you may be oMod to nselw a pwM Mbaa ar to rtrsalce and i steranbe Bargee.(4)The seller has no right to enter umawfur y your
xemf9es or commit any bmtoh of the peace to repossess goods purchased under Mrs agreement.(6)You may cancel this agRement N B has not helm
aged at the main office or a hatuch office of sa eager,Provided you retry to seller at his mdrl Or"of breach of lice erewa In the agiam n by
2gIsi or cord dman,vAhbch shelf be pasted notlaberthan mldelghl of to thind calendar day after the day an which the huger r4ns Ma agreement,
Onckding Smmday and any holiday an which regular mail dehTft Interact made.See the MOW notice of cancdlatmn form Its an eeplanallon of buyers
lights.
I Is agreed and understood by end boomers the parties tat thhio Agreement,Oont and hack and any adderdern,constitutes the AtIM understanding
erlweeu the pertes,and them are No verhal understandings changing or modRAg any of the tome of this AgrednsN,Buyer(s)hereby acknowledge that
Buyers)has rend the front and the reverse of thte Agreement end has received a oontplob4 sOrhed and dated copy of this Agreement indrdkth the two
Mahe Notice d Gancllmtimn idea,M time date Mat wrBtell abma.OLyerp;)elm aokrmwkdge thatgey hyMe omflY IntomleQ Of tl106'rfged to eanwl tors
kanswom.
EMPIRE HOME I VE ENT,LLC BUYERS
I uy2,q,dl-
3lgnature 1 G Date Signature . — .,' Date
im
fried Name(Address listed at top tAgVyrmrreemmarU Date Print Nome Date
1U•3�,oC,_
Junse Number(If Applicable) Signature Date
Prom Name Date
You,the Buyer(s),may cancel this transaction at any time prior to midnight elf the third business day after Mo des of this transaction.Sea the attached Notice at
Cancellation form for an explanation of this right AdOtgonmly,the seller is pmnighiled from having an Independent courier service or other thud peaty pick
up your payment at your Te6idanen ham der end of Has 3-ha;hau;&day period In which you can cancel the transaction.
APM51861-7011ANo OONrZIMS
Delay A Union own Condition:Events beyond the Mail of the Con motor,such Re Arts of Gad.labor strikes,mckmem weadla,mateal shortages,Wfir§InsNINy
to quolty far or obtain financing,or other events resulting in ways In performance at this Agreement do rat constitute abandonment and are not MCludbd In Calculating Ime
lniormation anu 1113ii uvA;1.111f1I1.7
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership, association,corporation ur other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity, employing employers. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings In the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152;§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverages Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy;please call the Department at the number listed below. Self-insured companies should enter their
_ self-insurance license number on the appropriate lime.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the pemrit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.where a home owner or titian is obtaining a license or permit not related.to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
011ce of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia