38B-002 (15) 21-23 PAQUETTE AVE BP-2006-0643
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:38B-002 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2006-0643
Project# JS-2006-0945
Est. Cost: $18160.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 126893
Lot Size(sq. ft.): 106722.00 Owner: WALLACE GRARD R&JEAN M
Zoning:URB Applicant: HOME DEPOT AT HOME SERVICES
AT. 21-23 PAQUETTE AVE
Applicant Address: Phone: Insurance:
345 GREENWOOD ST UNIT 1 (50 8) 341-9401
Workers Compensation
WORCESTERMA01607 ISSUED ON:12/13/2205 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 12/13/2005 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
City of Nort ampton
Building Department
212 Main Street
Room 100
n � Northampton;*MA 01060 '
phone 413-587-1240 Fax 413-587-1272 s
ApPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -sitE'MFORMATION
1.1 Property Address: This section to be completed byoWI
a t
Zone y ove�layOistrtct z
�EItn�Sti°D�str�ct `� r �� , +aGBHDistF�ct
SECTION-2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing;d3� � a
Telephone .4
3igraturc
2.2 Authorized Agent:
� --�i��t.:.�.y7�(,l LZ1({ �� �'r.1�'c�+-�•S-��-(.Ire
Na ( 'i 0 Current Mailing Address:J
n1. 11 CA — Cl 3:�__ -(e3'�)
s nature Telephone
SECTION`3-ESTIMATED:CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)-Building Permit Fee
2. Electrical (b1 Estimated Total Cost of
-Construction from.6
3. Plumbing Buildings Permit Fee g',;7()
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This'Sectiotif r fficial'Use Only
Building Permit Number [date -
Issued;
Signature: r
i
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING All Informati6h Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:3 R:= L:L— Ri
Rear I
Building Height --
Bldg.Square Footage % �I -4
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume,&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
N0 0 DONT KNOW 0 YES 0
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW I YES
IF YES: enter Book Page' and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES I
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: _
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
j that will disturb over 1 acre? YES 0 r NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF-PROPOSED WORK(check all ayolicable)
New House ❑ Addition ❑. Replacement Windows Alteration(s) Roofing
Or Doors F-1
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [p Siding a] Other[O]
Brief Description of Proposed �•
Work: 6� 0, 1)111%41 Q�,!4
Alteration of existing bedroom Yes No Adding new bedroom Yes No -
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
= �? ,,
sa_if eve ouse ra: > dd ion aexts#�n ioftsin'-courts ete fh Mng:
a. Use of building:One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain - Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? -Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER.AUTHORIZATION;-TO BE COMPLETED EN
OWNERS AGENT°OR-CONTRACTOR"APPLIES=f.OR BUIC-IJING=P RMIT-
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit applicati n.
Signature of Owner Date
,r� as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print me
i
Q W
i ature of Owner/Agent Date
SECTION 8-CIONSTRIJCTiON't,,ERVIGES r-'
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
s Not Applicable(❑ g �
CompanvName Registration i-um e—fir --
Address Expiration Date
�Y[ Telephonem_
SECTION 1'0-NVOFtKERS'CONiPENSAT16N-1NSt)kANCE AFFIDA1i'IT IM: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....... No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own 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 homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that be/sbe shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may,be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.-
j Homeowner Signature
I
tls�-\
117 tJ .�arf1�i31111011 _
I R �' E ,�Z,x,iccriasclfa' -
w DEPnRTMEI.IT OP DUILD0,IC 105PEC7lO1.°S
212 Main Strcct Municipal Duddin�
Northampton, Mass. 010GO
I
WoMa. RIS COiti11PI;NSA TION MSLTR.A-NCE AI,MAA11"
(lr Pcrmjttc c)
%Vlth a pri�-tcipal place of busioessfresidence at: ---
A7- ft e+Pr-ff,,
(s>3c...t�cirylnat,✓/zip}
do hereby certify, under dic.ppint and pe-wIties of perjury, =hal
am an employer providing the following Avorkcr's compcnsZ:jon cove age for illy
eruployces Nvorlong on tills job:
�""
(Incur n oar } (Policy:Number) (r; rior, r�zzr)
( } I am a sole proprietor, general contractor or homeov�ner (ci cie one) and have hired
the coouaclors listed below vgbo have the following workers coLopn_adon policies_
i
014'am-, Of C0:I.M?CZ0r) (ln uranc: Compa.n)'/l�ouc jgtum*---,} (-?:a2 JaQx DT1C)
J
1
(Name of Coomczor) (insarance. Camoaawpolim, Numinr) (—EiDirtion Date)
I
(N.me of Comazao,) Omswance Comnan}•/Poti(:) N:frrbc�) (ExDirrion Date)
(Name of Contractor
(Iasurao.(-- Compa..ay/Pobcy Nu.mbcr) (Expirdoa Darc).
(aa.ac3�ddi�'ocar�crz,ifncc�s��•tc arc+ iaforn,,�on pCzaiasas to.0 nz) .
( ) I am 'a sole proprietor and have no one worldng for me.
! ( } I am.a home owner pe
rfor.miog all the work myself.
NOTE:p1r-.c be aw Nz Lr of Ja bemrxa.+ocrs ubo carplcy perso =to do m.;•.,-••,•-• c it-ork oa.d,.
r ctls:Z of
aot taocc
It tc' _ tom in u'aich the bomoowoa^r vd.or oo[bc paancir z�p�rtc�z�6r r wt ono !}y 0,- dn-od to be
c ploys s u t6c.+ �bion Aa(GUI 52-=1(5)},a.ppricaD6m by a bomcoa-Da fv z 6c=.-:or permit=y crid=cc cbc
1� of as cry 1cye uodor d,4 wockOe,c ; ,
t.iada-rz,•od tfuc>OoP'y of th6 antes.— bd fo�dsd to t,s< .
r rx�.-�«�orr>�,�,;a n�d�af>;—orr=�ror tb.
oovcraSc va ireaiioo aad th-L f..irm c to smsse bavcr L.=uode sociioa 25A of MOL 151 caa lmd to tha=P=idoo of cimia-d pcaaltic
ooasi=usg of a Sete or trp to S 1,500.00 zndlor'
of up to oaa yc r ead avi3 pcw-tjcm ita zsc facet ora Scop Work Cnfc and,
fim of S i 00.00 a cf_y apiust ttac -
For ux only --------
�,,,, f cz-mir Numix`s
Lot
Si tturofLi ccrniucc -- `
o4-S�pTo
�ItASDACIticstfllf �
DEPARTMENT OF BUILDIJtiG INSPECTIONS 1
INSPECTOR "212 Main Street • Municipal Building
Northampton,MA 01060 5 •`
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under,780CMR 108.3.4 to
act as i:is/her construction supe: , sor. The state defines"Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fW1 y '
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."
The building department for the City of Northampton wants any person(s)who seek to
use the home owner exemption, to act as their oven construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and Oegulations. The inspection process requires that the building department be called
to inspect work at various stages, which include,foundation/footings (before backfill),
sonotube holes (before nour), a rouzh building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection.:The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work(electrical, plumbing&gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
r
HOME IMPROVEMENT CONTRACT
Sold,Fumisbed and Installed by:
Branch Name:" �t Date: �l ' THA At-Home Services,Inc,
d/b/a The Home Depot At-Home Services
2L) 23 345A Greenwood Street,Worcester,MA 01607
Branch Number: - Job#: Toll Free(SOD)657-5182; Fax:508-756-2859
Federd NDN 75-26P&Wo ME Lie R C 02439 R[Cont Lio#16427
Cf Lief)513522; MA Home Impmvetnwt Contactor Rag.0126893
Installation Address: At 3 ��.. u I* p 404 M Pr 4104
city State Zip
?rtebas s.
Lm 4 Digits of Ilriver•.Ile.#&Ely.Molyv Work P Home?hope:
use+= REa�tk 1_t.c s -7•�S, t tD I ( ) i( )
RoN�t=GT I#aO�E�sct2 ( di 53 � ip
otk s'7ai
Home Address: q(
L t r M -S`rbbSC R E P L--r Y Lt-(- A 6,H �,two :MA- a t33 a
(If different from Installation Address) City State Zip
E-mail Address(to receive updates and promotions from The Home Depot):
Mt n: I/We/You("Purchaser"),the owners of the property located at the above installation address,offer to
t�nlia 1t with Horten epot U.S.A.,Inc.("I-10me D ot" to famish,deliver and arrange for the installation of all materials as
described on the attached Spec Sheet#: f� .d1 1P% incorporated herein by reference and made a pari hereof.
Some Depot reserves the right lo cancel this contract If,upon re-inspection of the job,Horne Depot determines that it
cannot perform its obligation due to a structural problem with the home or because work required to complete the job
was not included in the contract.
DEPOSIT PAYMENT OPTIONS
(Subject to fund veriliationsad/orcredil approval.)
I. 41"'a"cheek or US Peatsl Savwt Momey Order
CONTRACT AMOUNT s Le l b( clam p yabia llttixo�e Depot).,
*LESS DEPOSIT S 2. Credit Coad'Indo othr¢p4yt mL options=Circle One Below
Visa MsoterCatd Discover A
BALANCE DUE
ON COMPLETION $ I�,� Tie Home Depot Horns bupaovemeat Loan Th;Home Depot Credit Card
AvaHabls Credit.S 'e)SO -(Hfl,&HDCC ONLY)
Minimum 25%or Co>.tract Amount due open olecution -
fihiscontraU.
Name as it appears on card:
indicate Payment Method For •By mylora dgastrnebolow,Uwe agroe W allow Home Depot to charge the above
BALANCE DUE ON COMPLETION: referenced credit card for the deposit indicated.
Grdhaldei a SS 5tf — A ta
�y� a HIS. r-HDCC Autho#rYifiodu odes
�� Final
Delneit Payment
o bbWa'3# Oo
7
Purchaser agrees that,immediately upon satisfactory completion of the work,'Purchaser will execute a Completion Certificate
and pay any balance due, Purchaser also agrees to be jointly and severally obiigaied and liable hereunder.
tir �:This agreement and its attachments,including any financing agreement,contain the complete agreement
een t to res and can not be amended or modified unless in writing to a separate agreement signed by both patties.
NOTICE TO PURCHASER
Do not dgn this contract before you read It. You are entitled to a completely rdled4n copy of the contract at the time you sign. Keep
It to protect your rlgJrts. Do not slizrt asp Completion Catiacste or agreement stating that you are satisfied with the enttre project
before this project is complete.Law prohibits home repair contractors from requosthtg or accepting a Completion Certificate signed
by the owner prior to the scrual eomptetion of the work to ba performed under the can raet.
You may caned this transaction at any time prior to midnight of the third business day after the date of this contract. See Notice of
Caaceilatioa for sn explanation of this right, There will-be s service charge equal to 25%of the contract amount tr the job is
cancelled by Purchaser AFTER the third business day.
BY MYIOUR SIGNATURE BELOW,IMS AGREE TO BE 130r31�D'BH T(}E:TERr►IS OF THIS CONTRACT. 1/WE ACKNOWLEDGE
RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATION.
DY MYiOUR SIGNATURE BELOW, I(WE UNDERSTAND THAT THE AGREEMENT IS SUBJECT TO REVIEW OF MYIOUR
CREDIT HISTORY AND VWE AUTHORIZE HOME DEPOT AUTHORIZED CONTRACTOR,TO VERIFY AND REVIEW MY1OUR
CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL LLABIIATY
INCURRED FROM INADVERTENT OMISSIONS OR ERRORS. DO NOT SIGN TI IS CONTRACT IF THERE ARE ANY BLANK
SPACES. Y
SUBMITTED BY: r' -�4 Date: 3-0 S -
Solea neuLant
ACCEPTED BY. Date:
Horttcowner
Date:
1{amaownet
NOTICE,ADDITIONAL TERMS,COMMONS AND WARRANTIES ARE 5TATED ON TKC RIVER.S9 Smir AND ARE PART Of Tf1LS CONTRACT
Wllte-Drssch R. Yeller«-Llseenrtw Piak-Sale Coesulteat
5-27.05 C-SC
6 d OOZE 13rN3Sd-1 dH -Wd6-�, :O T SOOZ ip0 A0W
���` �Ie �arrr�na�zcueallli a��/�izaaac/zu
y Board of Building Regulations aw d Stanch
HOME IMPROVEMENT CONTRACTOR'
Registration: 126893
Expiration:-:8/312006
Type Supplement Card
Y
r THE Home Depot At-Home Servic
RICHARD FALLCNE --.
L' 3200 COBB GALLERIA,PKWY#20
F ALTANTA,GA 30339
Administtat�r ."
MARSH CERTIFICATE OF INSURANCE CERTIFICATE NUMBER
ATL-000915907-02
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
MARSH USA,INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE
ATTN:ELIZABETH BRISENDINE (404)995-3588 POLICY.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE
OR BRENDA BOOKER 404}995-2594 AFFORDED aY THE POLICIES DESCRIBED HEREIN.
FAX(404)760-5768 COMPANIES AFFORDING COVERAGE
3475 PIEDMONT ROAD,SUITE 1200
ATLANTA,GA 30305 COMPANY
105492-IPUSA-GWA-03104 A STEACFAST INSURANCE COMPANY
INSURED CCNIPANY
THD AT-HOME SERVICES INC. B ZURICH AMERICAN INSURANCE COMPANY
DBA THE HOME CEPOT AT-HCME SERVICES,INC.
HCME DEPOT USA, INC. CCMP�NY
2455 PACES FERRY ROAD NW C NE`JV AAMPSHIRE INS COMPANY
BUILDING C-8
ATLANTA,GA 30339 COMPANY
D AMERICAN HOME ASSURANCE COMPANY
COVERAGES This certificate supersedes and replaces any previously issued certificate for the policy period notedbelow. 1
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED,
NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY
PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.AGGREGATE
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO POLICY'..EFFECTIVE POLICY EXPIRATION
LTR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDIYY) DATE(MWDDIYY) LIMITS
A GENERAL LIABILITY IPR 3757 608-00 02/01/05 03/01/06 GENERAL AGGREGATE $ 4,000,000
X COMMERCIAL GENERAL LIABILITY 'LIMITS OF POLICY ARE EXCESS PRODUCTS-COMP/OP AGG $ 4,000,000
CLAIMS MADE a OCCUR 'OF SIR:$1,000,000 PER OCC PERSONAL&ADV INJURY $�u4,000,000
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 4,000,000
FIRE DAMAGE(Any one fire) $ 1,000,000
MED EXP(Any one person) $ EXCLUDED
B AUTOMOBILE LIABILITY BAP 2938863-02 AOS 02101105 03/01106
COMBINED SINGLE LIMIT $ 1,000,000
B X ANY AUTO TAP 2938865-02 TX 02101/05 03/01/06
B ALL OWNED AUTOS BAP 2938864-02 VA 02/01/05 03/01/06 BODILY INJURY $
(Per person)
SCHEDULED AUTOS
HIRED AUTOS BODILY INJURY $
(Per accident)
NON-OWNED AUTOS
X ELF-INSURED AUTO PROPERTY DAMAGE $
HYSICAL DAMAGE
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY*
EACH ACCIDENT $
AGGREGATE $
A EXCESS LIABILITY IPR 3757 608-00 02/01/05 03/01/06 EACH OCCURRENCE $ 5,000,000
X
UMBRELLA FORM AGGREGATE $ - 5,000,000
OTHER THAN UMBRELLA FORM $
C WORKERS COMPENSATION AND 5899472(AOS) 02/01/05 03101/05 X TO v Llai}rs ER
EMPLOYERS'LIA81UTY
C 5899479(AOS) Q3/01105 03/01/06 EL EACH ACCIDENT $ 1,000,000
E THE PROPRIETOR/ X INCL 5899477(NY,WI) 02/01/05 03/01/05 EL DISEASE-POLICY LIMIT $ 1,000,000
PARTNERS EXECUTIVE 5899484 NY,WI 03/01/05 03/01/06
E OFFICERS ARE: EXCL { } EL DISEASE-EACH EMPLOYEE $ 1,000,000
F 0 R WORKERS 5899475(AZ,ID,MA,MD,OR,VA) 02/01/05 03/01/05
F COMPENSATION CONTINUED 5899482(AZ,ID,MA,MD,OR,VA) 03/01/05 03/01/06
D 5899473(CA) 02/01/05 03/01/05
D 15899480(CA) 103/01/05 03/01/06
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS
CERTIFICATE HOLDER CANCELLATION
SHOU40 ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,
THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL„10 DAYS WRITTEN NOTICE TO THE
FOR INSURANCE PURPOSES ONLY CERTIFICATE HOLDER NAMED HEREIN,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE,ITS AGENTS OR REPRESENTATIVES,OR THE
ISSUER OF THIS CERTIFICATE.
MARSH USA INC.
BY: /'Jlt rtn,l /w(r►nrfs�`�
MM1(3102), VALID AS OF: 02/01/05
DATE IMMIDDIYYI
ADDITIONAL INFORMATION ATL-000915907-02 02/01/05
PRODUCER COMPANIES AFFORDING COVERAGE
MARSH USA,INC. COMPANY
ATTN:ELIZABETH BRISENDINE (404)995-3568 E ILLINOIS NATIONAL INSURANCE COMPANY
OR BRENDA BOOKER 404)995-2594
FAX(404)760-5768
3475 PIEDMCNT ROAD,SUITE 1200 COMPANY
ATLANTA,GA 30305 F THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA
1 CC492-IPUSA-GWA-03104
INSURED CCMPANY
THD AT-HOME SERVICES INC. G NIA
DBA THE HOME DEPOT AT-HOME SERVICES,INC.
HOME DEPOT USA,INC.
2455 PACES FERRY ROAD NW COMPANY
BUILDING C-8
ATLANTA,GA 30339 H
TEXT
WORKERS COMPENSATION POLICY#5899476(TX) POLICY PERIOD 2-1-05 TO 3-1-05 CARRIER NEW HAMPSHIRE INSURANCE CO.
WORKERS COMPENSATION POLICY#5899483(TX) POLICY PERIOD 3-1-05 TO 3-1-06 CARRIER NEW HAMPSHIRE INSURANCE CO.
WORKERS COMPENSATION POLICY#5899478(QSI) POLICY PERIOD 2-1-05 TO 3.1-06 CARRIER AMERICAN HOME ASSURANCE CO.
CERTIFICATE HOLDER
FOR INSURANCE PURPOSES ONLY
MARSH USA INC.BY
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