38B-242 IO OLIVE ST BP-2016-1540
GIST: _ COMMONWEALTH OF MASSACHUSETTS
Map:Block: 386-242 CITY OF NORTHAMPTON
Lot:-OW
Permit: Building
Category:window replaced BUILDING PERMIT
Permit# BP-2016-1540
Project# JS-2016-002630
at.Cost: $2804.00
Fee:540.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 082485
Lot Sizef sq.ft.): 8232.84 Owner: SINGH MAHAN
Znina:URB(t( Applicant: HOME DEPOT AT HOME SERVICES
AT: 10 OLIVE ST
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401) 935-2633 O
NORTH PROVIDENCERI02904 ISSUED ON:6/27/20I6 0:00:00
TO PERFORM THE FOLLOWING WORK:Replace 6 windows with Simonton windows .29
U-value
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 Denartment 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 6/2712016 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner
RE-!
Department use only
r i;; 2 7 iCity of Northampton Status of Peimit:
wilding Department Curb.CtiVDriveway Permit_� •
__,
212 Main Street SewerlSeptic Availability ..
DEPT.pl'eunLNc W"s`'`"0Ns
NQJfiMrrcN.MA mese Room 100 Water/Wel Availability
Northampton, MA 01060 Two Sets of Structural Plana
phone 413-587-1240 Fax 413-587-1272 PIOVSite:Plans ,
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit
/61 a/dt 4r. Zone Overlay District ,., „_
Elm St.District CB District _
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT I
2.1 Owner of Record:
Name(P(Print) /r�� �'� Current Mailing ':
Address
-6cc (�.o7l f7MOj_ _... Telephoneu
Signature -_
2.2 Ant deed/gent: �L�
t / tea _ 9D r 11 • 4�e� e� fi1
Nan- ntrSc Current Mailing Address: / ,y.
ms's.'- .� 2--
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 241:9/1 I v0 (a) Building Permit Fee MEN
2. Electrical j {b)Estimated Total Cost of
Construction from(6)
3 Plumbing Building Permit Fee /v
d
4 Mechanical(HVAC)
5 Fire Protection _ '�--/
6. Total=(1 +2+3+4+5) -- , � Check Number Ti,�Q�
This Section For Official Use Only ,
Date
Building Permit Number _ /Issued:
Signature: „ cT - 4:017-7.1
+.11/24/S
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING Ant information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be fiibed in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:'.. R:i.. L:'. R'
Rear
Building Height
Bldg Square Footage
Open Space Footage °o .
(Lot area minus bldg&paved
pzr*(ngj ,_
it of Parking Spaces,
Fill; —
(volume&Location) _. .. . .... ...
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW a YES O
IF YES, date issued:'.
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book Pagel and/or Document d
B. Does the site contain a brook. body of water or wetlands? NO O DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO O
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
that will disturb over 1 acre? YES NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
pECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Fl Replacement Wigdows Alteration(s} I J Roofing I I
El ^ Or Doors �„�"
Accessory Bldg. I l Demolition 1 New Signs [t I Decks [ Siding[0] Other[0]
Brief Description of Pro tl }
Work 11JL�(�� opw? �, ! 1 . l(/0
0/r1/`
"'eilinv /€5
Alteration of existing bedroomYes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea. If New house and or addition to existing housing,complete the following:
a, Use of building:One Family Two Family Other_,,,
b. Number of moms 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 200 ft of wetlands? Yes No. Is construction within 100 yr. fllwdpiain Yes_No
j. Depth of basement or cellar floor below finished grade
k Will budding conform to the Building and Zoning regulations? Yes No.
t. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN I(
OWNERS AGENT OR CONTRACTOR APPLIES FOR
BUILDING PERMIT
I, A r ��p`1i 6� /! ,as Owner of the subject
property / 1.^��, ,
hereby authorize t fry✓/gam) /l NO/
to act on my behalf, in all matters relative to work authorized by this building permit application.
oil_ 6oil 27-16
Signature of Owner YY�� j� Da
te
1 'A7`-.p /,701+3' ,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 underrpie,peine d penalties of perjury. r
l/�.r '411 .. 11/ _
Print Name se
et
1 l� -2-7-/
Signature of ei neri•gent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Not
Applicable £
Hama of license Holderir vtA /52.yJJ5
^
rcese
Number
)?1 / /*J v I
Address Date
1A/ Lx- r'i/) �T _
Signature Telephone
G�Of 1 �
9.Registered Home linprov ment Contractor: Not Applicable £
244
Company Name n Regis ration Number
d d
loo 7 ` ri! --314
mExpiration Date
y(3
1
- 0/2h Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.0.152,§25C(8))
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 th - 'ng permit.
Signed Affidavit Attached V No f
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings afore(I) 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 19$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 he/she shall be
1 ponsi ie far II such work erformed under the militia! ,emit,
As acting Conufrnction Supervigor your presence on the jobsite will be required hon 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 ofEmployers 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.
Homeowner Signature
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: /O 19/IVC '
The debris will be transported by:
The debris will be received by: _f _ In l9- '
Building permit number:
Name of Permit Applicant R1d 7 e
fa
Date Signature of Permit Applicant
May 31 16 08:21p P.1
IIOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,ld,Furnished and in:m!led by:
lamest.Naomi New Enabled DrteSPI.,i. a>. THD A:-home Sen;aa,Inc_
&bra The Home Duper Ar-Home Saniice
Branch Nuntrt 33 909 Bosamr Turnpike.Veda.Shrewsbury-,MA 01545
Telt Free 1377.903-3468
Federal lop I9-d69E450dN9 Lich C 02134 RI Cent Ha I642i
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Cr t 4 I ICD5655�2:MA Honnpi7c�llmpowarwm Commaar Rag..126193
IastaUafi.n Address: ID01WC 1`T ami` IM
City t 5.;,r Zip
Perednsert,ArN Wank Phare: Homo Plemen Cell Moe:
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j IPI Or f N.1c434.'L,r [ [ 7
R/.Ilh l [ t 7
Home nddnai:
C fd.IFamnt from Installation Addmw City State Zip
E-mail Aad %I,to receive Added emornunicariom aid Etime Deem updaesi:_
]: WNO '.sat rr: .ve any g means f. The Home Depot
Pmrtct tofirertalien: anifemifired13fleztomerfi,Ibe Nunn;sift .pcty Icc4l& the abovemm*ia[ .adeee,!Trap 'try
and THD Al-llama Ser✓ncv5,lot,(TEMHoneDepot)epics re;isrr ,delver and erraure f acv irraafiation(lnstaliation"3 of
aC materials dascnbed on the buow and of sed mfncn sd Spee abatis),all of width are Incorama:ed tale Ws Content by this
refsence.alone with airy applicable Shut Supplement and Perelett Summary atlnched teem
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and Chn
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fictively.
"Contract"):
Juba: .. S. zSScyin. Project
//iCcor sea wen L ' rihn
•b • !Dry . b T �- m4
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in.
M w d —0 liar[GimesrGofers pantry Peon
Rooting Sa
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wionalaisOi ton
CG :Roy D fl fG ����
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L`taoy'as J>a O w .asyaiar E
err en.Corers Davy Dwte J irX
Mlimem NMDeposit et CandesetAmourd doeepe numatian RPM mntr.G rota)Contract Amount 5
Malne Pumnaren may nor*peek more than anarnintoidieCommeNHIMIL
Cexeteeet ette,(hat,immediately upon completion of the weak fret each Product,Curiumer will execute a Cannkriev Certificate
;enc for each Pndmd as derived by an mdividrel Spec Sheet)and pay lay balance dr¢. As applicable,each Cedar-Per under chis
Centrad agrees to b:jointly and severally ohfimied and Boole hereunder.
The Hex Depot reserves the:iglu to Issue a CluingcOrder or rermitue:his Contmci or any ridiviaoal Pmducps:included herein at
iv discieiiort fThe Home Derv:Oe i s authaizet service provider determines that it canto[pert it obligattons Gee to a ntmcimal
pntIem rit)t Pe 10131e,deviroonient2:hears:etch is mold,ashsro:Or lead paim attics safety eartrems,pricing errors or becarse
work reaurd w wmplexabeichava3 cot included ,,thZee,C,�ar eco�./�.�
Payment Serrparv: The P m t Summery s . .�.. L , mended as pan of thio Contract sets Corti the mal
Cone:act amwiat and oaymems monied for she d apnsits and final payments by P ocher(as applicable).
NOTICE TO CUS.1 OMER
Yon ere entitled to a completely idled-in copy of the Contract t the limeyou Siam. Po notign a Completion Certificate Mote:
rtiere is one Completion Certificate for each timed Product as defiled by individual Spec Sheets!before maid:on that Product
1s comptne.
In the event of termination of this Contract,Customer agrees te pay The Home Depot the costs of materials.Tabor,expenses
and services presided by The Home Depot or Authorized Service Provider Omagh the date or tetminafiea,plus and ether
minuets set forth in[Lk Agreernlnt or droned under npplicahit low. THE HOME DEPOT MAY WI IHHOLD'MOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE. WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOP RECOVERY OF SUCH AMOUNTS.
Acceptance a[gl Authorization: Customer aVedy and titidetStidttlt this A€rccrvn the emit iriteettle et tai:meu tmwnrr
and The Home Depot with regard lc the Products trod Lii02 eert tees and mpei tde all prior discussions and agrxrau;either
ral or wr.that,dlh Home Dem. CEeudrvnekfowlegernd sIibc assigned r'tmd.'
l rw cmexcepts«
by Cs eland
ai"Na Home ply of is rag! molt, led xnapee;tlm a a:mmar 11 lead,ucdenwuds.voluntarily ucccpx Jm
terms dia'sceivrzala copy
this 4"reemeiLL o
Aa t -vac, 4 bre• �y ft` Y
�� yv- i 'i 1s .i,IDYL 2 fW• —
C.s is5'gp lure ) Date b s hmEsSih .m. Dam
% _. ........ tc,.epbon No
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[..rev c<'�Prmtam Date -_-
Sales Consultant Laic run
PANCELLkftON; CUSTOMER MAT CANCEL THIS; Sao-""
.AGREEMENT WITHOUT PENALTY OR OBLIGATIONBY TO THErlG, _tl
DEPOT DELIBV MIDNIGHT
EN 3&--5THECE THIRD BUSIINE S Lr / C3b 2.3;)
61(
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
C'crOMER'S STATE.
-_-
3033 C8O82485
RAYMOND M HUNT
14 MELIKIAN DR ' f
WILBRAHAM MA 010952i_45
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_I-oiczi" -onna iJ= PgeeesePrint'.ea_a
i.Name(Etsinessrer,rsi 'doisdtvidt=):_../ OPP _actitiF 4,:1- /17,hj? f heirs.
Address: G/1./PI Op-4(te t) i )OD ; ° • .�.
Cit Fl$?3idlLz3�:[Jr��ss''�J.� In* r31u1-415:� acne a. rag C [�A 4,,,y-",---
Are
Toe an employer? Check fthez_iti opriab bar aype ofproject(razla*rad):.
1.0 I an aemosyer with d- N,tam a generalcontactor ands
employees;,dii mdfor partdirde}.` one hiredtie sub-contractors 6. [J New mush-intim
ID I^-a sok uropietor or parmc_ listrd on the attached she= 7. 0 Remodeling
These sub-contractors have Shin and have no emalcyzesS. 0 Demolition
Gorham for ore&any caoacity. employees and have victims'
We
9. 033a1diae addition
No workers' cur=a.'ssn�.ce ms�ura=
re 10.0 Electoral repairs wad-Mons
xz�airad,l 5. 0 Ware a corporation d?:s
3.-1 S an ahomeowner dotes allwork officals have exercised their 11.0 Plumbing Agars or zddi5ons
myself. 17eie winters' comp. nghr of exemption per NIGL
A 152,q1(?),and we have no 12.[]Rcofrepaas
ieslr.,,ce rem.>zrti+}+ 13111616er 1.4.//It/l' eJ btiS
employees.No workers'
_ comp.inssnoe revived]
it-tr,yapdtedthat Cs imc_l atrac:zisa kR our the swim below showing theirparkas*mmpearsatmn polcyiarwmancs.
'famecwnr who_; It ,is saintt irdimdagwey a:&dog,s woi:anddm hire oumide=sans mutt submit nom al5aavirmdiczong=b.
Tanean:or did cheek.diSba<mustaeac5ndvnadm'anmlah=shosrirg Soaactithe srb<manntarsnt4ittwthcaroattthosc anbigLwa
=ploy=Asir.subconaaw nbavac@pIoacrs,thcy viaspmvidtiucir cvriora'mma policy mumb .
I ca as emplyerthat is providing workers'camperucruon brontistefar my employees Pelow is She policy and job Ste
tnfbnnctfon. - `./ �� -
Insn1ttce Company Name: e�,: i'c -sirs_ A+rf2 -1-;o;;'�
t _ t' 17Policy mor Self-ins.Lie.r ft, cV, . % ExfionData: .3 /
/ f/ 7
iah Site Address: /1) (ykei U t
City/Srat&Zip: A M: stA0011 PA? 1' )*
.Attach e copy of the workers' compensation poileg electarat en page(showing the policy member and cep` ,ion date). 0 Jodi
Fatima to secure coverages as recoiro4 under Sectimt25A ofivIGL o.152 Gardena to the imposition of ctiv>mal penalties of a
-me up to$1,500.00 and/or one-year imprisonment,as well as civil penalties inthe Pm of STOP WORIC ORDER.and a fore
afro to 5250.00 a day 1rJttstthe vlol zr. Be advised that a copy of dais stateme.at may be-rorwarded/nibe Office of
Aro s igadars of the DIA for rasvreeee coverage verification. _ .
Ido hereby cerg h. a�r i isiterptryi:aatthe afomreEonp;avkiedabove is twee and cawed
',�a;,,y, - .awl 1. - Date: , —17-16
phone rt 570 87 '9:v4 enn6 Z q
Ofciei ese only. Do not write loafs emo. to be corp feted by Gip or toms officio?
City or' creat ,,, ,,, Pem arraeease# _
I sat g Authority(circle one)_
1.Board o€Be ltb 7,.BufdingDepartmat 3.City/TOM Clerk t.itlecd1cai iaee.dor 5.?lombiag Inspector
5.Other
Coataei'rerson: P.bone _M1�
AC 03 CERTIFICATE OF LIABILITY INSURANCE I ;.a1 1s n
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 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 endorsementls).
PRODUCER CONTACT
. ARCH USA.INC. YAM[:APN.0.NE D _ FAX
IO ALLIANCEAUIIUC
No:
3990LENOXROAD.
SITE24Cy Ef
ATLANTA,GA 30320
INSURERISIAFFORDING COVERAGE I NN6a
I ce492-H9me DG.AW 13—I 7 INSURER A:SIeadlasl Msut3NR Company 120F7
INSURED INSURER 9:LNch American lnwrmlce Co 15£35
THD ATAGME SERVICE,INC 123841
DBA ME HOME DET WT-'MCME SERVICES INSURER c New Hampshire Ins CO
2550 CUMBERLAND RARIC3'-Y.SUITE 330 INSURER 0 L.&pis Hans Insurance Company 123917
ATLANTA.GA 30332
INSURER E: I
INSURER F:
COVERAGES CERTIFICATE NUMBER: A11n037'364614 REVISION NUMBER:0
THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTV/I THSTANDING 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.
ANaTSUBR. POLICY EFF POLICY EXP :
LR TYPE OF INSURANCE I W Si/VD POLICY HUFIBER !IMWODIYYYYI IMrADOTYfff LIMITS
• X COMMERCIAL GENERAL LASILnt GLOJ097114-:`a 110310112016 O301R0I1 I EACH OCCURRENCE I5 900O,0®
-- d.s-M.AL=_ _LPDA PREMIS SCEa�otngT nes)to !s I,OW,CLU
-- - : :LIMITS OF POLICY Xs -.MED Exp nw mm p�aAm EXCLUDED
GF SIR:JIiM PER CCC PERSONAL E.ADV INJURY 1S 9'00I0I0
iEN'_:GGPE:aaT=LIMIT iF= _ j GENERAL AGGREGATE i 5 9000000
v. TOL CY JEIT - C .PRODUCTS-COMP/OP AGC Is 901)0.000
S
• AUTOMOBILE LIABILITY BAP 2E3383-I3 03012O16 031019017 COMOI£D SINGLE LIMIT i.5 1000000
• :(Ea amomn
Y ANY AuT.D i Wolr INJURY(Per person) 1S
+LL 0,DNE- CFE_SULED I SELF INSURED AUTO PHYD'C I RODDYINJURY IPV ZLvaemf"s
____ AUTOS TOS
�C"Lwi4ED I PROPRDAMAGE a
HIRE AUTOS __AUTOS Le0Aomori*
UMBRELLA LIAR OCCUR I EACH OCCURRENCE '1S
EXCESS LIA3 CLAIMS-MADE AGGREGATE -
10E RETENTIONS • 5
C WORKERS COMPENSATION .WC015519215(AOS) :030112015 110310115117 X i STATUTE � 100TH-
AND EMPLOYERS'LhA91LRY rix' 1031012016 !03IO12m7 1,030,Dm
L' ANIY PPOPRIETCRIPAHTNEDEXECUNV'c �wC0155192171AK,W1. HNJ,VO E.L EACH ACCIDENT IS
D OFFIeENMEMNHI EXCLUDED? N !NIA W[B1551921B(FL) 10J31T$I115 10310112017 1.M'J.dW
I Res R ory in ,E L DISEASE-EA EMPLOYEE$
IDESCRIPT!ON OFO COIIINYm011 AdC40n21 P2J9 : E.L DISEASE-POLICY LIMIT 15 1'�'�
ON OPERAllONS Cdnv
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DESCRIPTION OFOPERAMONSI WCATONS I VEHICLES(ACORD 101,AEMNonal Remarks Schedule.may be attached IF mem space Is requited}
E VIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT-HOME SERVICES.INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES RE CANCELLED BEFORE
OBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455FACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA,GA 30339
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
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O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
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Office of Consiuner Af i—s'and1 Busikess Regulation
vzssr 10 Park Plaza -Suite 5110
Boston,Massachusetts 02116
Home Improvement ContactofReg stration
Registration: 126893
Type: Oupptemenl Card
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THD AT HOME SERVICES, INC. _
RICHARD TROIA ------ �.
2690 CUMBERLAND PARKWAY SUITE 300_
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ATLANTA, GA 30339
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