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38D-032 (3)
13 HARLOW AVE BP-2017-0324 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38D-032 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:window replaced BUILDING PERMIT Permit# BP-2017-0324 Project# JS-2017-000531 Est. Cost: $11151.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 67121 Lot Size(so. ft.): 9583.20 Owner: LAPOUR LYNN E zonine:URR too Applicant: HOME DEPOT AT HOME SERVICES AT: 13 HARLOW AVE Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVI DENCERI02908 ISSUED ON::9/9/2076 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 12 REPLACEMENT WINDOWS. NO STRUCTUAL CHANGES 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: O1: 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 Sienature: FeeTvpe: Date Paid: Amount: Building 9/9/2016 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Depafttuent use only City of Northampton Stats sot Permit „ <LG1. . Building Department ctlrb CvUDnvewaiPermlt �� Q 2�tro \ 212 Main Street Sewer/Septi Availabildy a " Room 100 Wa er arAWIablilty �" ,G..„s N.-hampton, MA 01060 TwpSetso($WcturatPlans e e.t i." •13-587-1240 Fax 413-587-1272 Plot/Site Plans ' ctg*.110 oalpel Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 'ro.ert. Addre This section to be completed by office ' 3 ' - .. teitx. Map Lot Unit Zone Overlay District Elm St.District ` CB District SECTION 2-PROPERTY 1 OOWNERSHIP/AUTHORIZED AGENT 2.t.Owner oAr rd: ftP0V/� (� ............ Name(Print)• /� Current Mailing Address'. 6 Ci i - / Telephone Signature Ls'nu?, I : _. 2.2 Auth prized Agent: /� q �- •-� OC I • ► ) 12-0//3- Name 20//} /lam L v`7/tJ� I it / �,,. Name{ Current Marling Address_ �,�-- •t Sr { ; 0911 —J . _— Signal re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building i i I r) JI) (a)Building Permit Fee 2. Electrical %/ //(� (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5,Fire Protection 6. Total=(1 +2+3+4+ 5) ))1 t"57 ' 'a e7 Check Number / ](a5/ er979 This Section For Official Use Only Date Building Permit Number — Issued: Signature: Building Commissioner/Inspector of Starlings Date Section 4. ZONING All Information 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 1 1 r -. I I - -___l Frontage [.__ ____ 1 . 1 I --. _.--_1 Setbacks Front 1- _ i L_ _I ! I Side L:L 1 RL 1 Lir�. i RI -. �t 1 _. f Rear _I I - Building Height Bldg. Square Footage 1 il 1_- j / - — 1 1 --- 1 1 Open Space Footage _ _ % _ (Lot area minus bldg&paved I J �_ 1 I I. _ i parking) N of Parking Spaces - - - I FLIP ._. -.._. i (volume&Location) --- �— _. A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued:[ IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book 1 Page and/or Document# I B. Does the site contain a brook, body of water or wetlands? NO © DON'T KNOW © YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: --_ • D. Are there any proposed changes to or additions of signs intended for the property? YES O 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 O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. t SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House n Addition ❑ Repfacemen{ 'ndows Alteration(s) I l Roofing n Or Doors Accessory Bldg. [Th 1,p Demolition /❑,,, ��yNeew Signs (CA Decks [q sf rSiding '[`CJJ Other[0] 4NaBrief DeschPUo of yr�l ri k,yteenitnie) J. hip 37iu 2VA G Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Ba,If New house and or addition to existing housing,complete the following: 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_,,,,,,_ 9. Energy Conservation Compliance. Masecheck 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 WHEN OWNERS AGENT OR CONTRACTOR ,,APPLIES nFOR BUILDING PERMIT I, t„j thi LIQ g— ,as Owner of the subject property 1 yy�� ']� ^'/','yam . hereby authorize .l�///./ J a-o/q. to act on my behalf, in all matters relative to workkkk authorized by this building permit application. q /4 Signature of Owner ...(�^ yam- Date I 11 A./ A-?i ,,j 7 }4/ ,as OwrertAuthorized Agent hereby teclare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed unde sins /d penalties of pe1.--- ) u tiCill Print Nam/ ' �i A Signal of Owner/Agen Date .. SECTION 8-CONSTRUCTION SERVICES -$.1'Licensed Construction upervisor: �jLq�.�, - — - --- — _- Not Appliicaabble...0 _-'7 Nome of License Holder Tl l u /' - `1 °" I/l�'/ -. ..../✓//`JGj ee- } �J-/IfLicense Number ^ Addressclje lVt�y 3�Expiration Date v &T) kGS me- 0/ Signature Telephone Icy l2ri. .DI 523 j3.. Si Registered Home Impryo�areMent Co treetop - Not ApplicJabbl�e/❑ Company ........._ ' Registration Number mberQ/4ec $ 7 -3�3—1 g e _ _ Expiration Dale G9pk% N/✓ jbTelephona[D/ y' %^ t - SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.c.152,§25C{6}t 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 , '$ .- 0 No 0 II. - Home Owner Exemption The current exemption for"homecwners"was extended to include Owner-occupied Dwellings of one(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 M supervisor.CRMR 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"shalt submit to the Building Official,on a form acceftahle to the Building Official,that he/she 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,duringand 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 wilh 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: I ' ))172)n) -iC, ry The debris will be transported by: 1/114--&-q �i ILr' The debris will be received by: W0aCC"7&4 1t14 r Building permit number //� Name of Permit Applicant ' __. +' 11 T J /i r—r � Date Signature of Permit Applicant CA The Commonwealth of Massachusetts Department of IndustrialAccideuts r ° Office of Investigations g km° 1Con ress Street, Suite 100 i •tor.... Boston, MA 02114-20.17 �� wwwmass.gov/din Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: I Are you an employer? Cheek the appropriate box: Type of project(required): 1.ri 1 am a employer with _ 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2,(l I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers` . insurance.) 9. Li Building addition coal [No workers' comp. insurance P required.) 1 ❑ We are a corporation and its 10.❑ }electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I1.❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MOL t2❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.n Other comp. insurance required.] *Any applicant that checks box k must also fill out the section below showing their workers'compensation policy information. t Homeowneswho submit this affidavit indicating they ae doing all work and then hire outside conhactors must submit a new affidavit rndicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state.whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.pokey number. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. InsuranceCompany Name:^ Policy#or Self-ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: _ 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 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 farm of a STOP WORK ORDER and a fine of up to 5250,00 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Sienature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # __ Issuing Authority(circle one): L Board of Health 2.Building Department 3, City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions 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 or 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 tustee of an individual,partnership,association or other legal entity,employing employees. However the owner ofa 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" MGI,chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal ofa 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 subcontractor(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 1..,LC 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 coverage. 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 line. 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 permit/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 he 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 citizen is obtaining a license or permit not related to any business or commercial venture (ie.a dog license or permit to hum 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 Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Fax # 617-7274749 Revised 7-2013 www.mass.gov/dia City of Northampton _3 e Massachusetts I 0 DEPARTMENT OF BUILDING INSPECTIONS b 212 Main Street • Municipal Building OS ne Northampton, MA 01060 11 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HON._= WNEXE . TIC A ; -N2WLEDGEMENT The Stale of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor.The state defines"Homeowner as, " Person(s) who owns a parcel on which he/she resides or intends 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 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 own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages: which include foundationtfootinasbefore backfitlLsonotube holes (before pour), a rgnnh building inspection (before work is co eated ynsulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, fail re to secure these inapectionscan resultln failure _. obtain : _ rtifica - •f.f occupancy until the work can he haeofed 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 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 Aug 111607:16a p.2 HOME IMPROVEMENT CONI BACT PLEASE READ THIS Sold. Brawl Name:New England Dade&f[Car E.hear THY)a-H^1e Services.ices be. dada at Home Depot AI-Hank Services Branch Number:31 XIS BostonTurnpike.Unit I.Shrmsahury,MA 01535 Tal:Free S77-503-3768 ;alma ID R]5-2644afn ME La PC 002639:RI Coat Lick 1661} Cf tic a lac ns65si MHe an Impruvemen:eaacior Rey-et 126893 ILstatlatkn Address: _ ( ? NA 2 . (b ) /1t.)R-- RA po OA e Iz;.J ('v ,>a- IGty Stale Zip Purehrerla: Work Phone Home Phone; Call Plum Ii - k • as I [ 1 [ 1 I [ $ I _ [ _ 1 [ 1 � [ 1 Horn Addams' Ilfdi�lerent from inaellalien Address) City Suite Zip E-mall Address Ito receive projectcmmunications and Home Depot updates:- 0 1 pdates):01 DIO NOT t[ cel )marketingomens l TMH otDepot Prplketldormut Undersigned elC [ me ) the owners of the property led at theh. _t fd addiess. and HD At-Home Services.Inc.( The Hone Depot gree to famish.J li and rnmge forheinstallationI("Installation"):ecs to un4 ' act t• described t belowand on he referenced Spec Shwas),all of whin; p nal into ID Compact Ms r fealoes with any applicebk State S'uppleren and Payment Summery an cha_henna and any Change Orders bilked vey. -CA,ytract'/: JR'll'i Ihuwarsweri P Spec Satneen e: Pm' Amours Edmo I nbltm � w %(/g4778tY% �e ;t rip0 _ j 35L5 s7;9-4 ORiw °siding*wrq GI Ian 1C �Ra OG f D 1 oiSZ ` / /J�1/ ❑Reafwg Ogu' g Windows0 laudation� D o __ s9 5 . 1 bel a//CIA/ I hiErefing OSi fes ]'w-imus ❑inmta:m 1 OGumn/Corers ❑Envy Duan f3 1 • Idl6mm NW Deposit ettootradAmesurdoe upon exrm dWkmnhan. Torsi Commie Amount S l I i 5i MaI{m Pmrievmry not deposer than e4NNoftef naetA n • CushL Icor rr acmes then immediately p pl ( f the wink Y each Product C will execute a Co p Duan Cer;f este /�_/1 bne ,reach Product as defined by ' SpecShat and pay any balance As ce d e epplicable. each Obtainer r[trot r(�✓,/y' Condactagt�s m te jjointly am severally obligated ansti bl hereunder. Throne Doper the right Cb Order emdf ! thisCony anyidividu:l Prcd c )- d hen in.a is di rek if The Home Depot authorized gambler determinesthatitc ot perfIts obligations duet i.: proh nr with dm home,environmental hazards such as mold.este to or led paint.other safety concerns,pricing errors or bca,use wort required to complete the)ab vas tot included ithe Co/luja/c'; Payment Summary: The Payment Summary bi[ B 67,�indded as part of Ns Contract. sets forth the tote: Contact amount and payments required for de deposi3 and final payments by Product(a awplimble). NOTICE TO CUSTOMER You re coned to a completely fdleMin ropy of the Contract at die time you sign. Do not sign a Completion Certificate(note: the is one Completion Cerfif®tc for arch luted Product as demirk defined by individual Spec Sheeets)before on that Product is to pleb. In eveig of termination of this Contract,Customer agrees to pay The Home Depot the clots of materials,labor,expenots and taro k's's provided by The Home Depot or A Wbwixed service Provider through the date of termination.plus any other amo rats til forth in this Agreement or allowed ender applicable law. THE HOME DEPOT MAY WITHH(RA AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIN ING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. At NW Authorira Customer aand understands dial this Agreement b the wire As.seines betueen Customer and'j ie Home lewd wall regain to the Productd[rivalledon sery I tan arm supersedes ald:' u, a agreements,either era!br written. rearing to said Products and Installation This Agreement ct bc ass gnat er amended except hy a ao bog signed by+antler and 311c Home D po- C romao kn w edgeCarlinia d aI e s dial e has read understands. an ar 1.accepts the teen.M' received Rand ha' r ived a copy ends Apvr,ram. el A Submitted by: A O _ t - r1,— tb T ( (M. .. .1 Nutt ate Sales Con•utanfs Signature Dae X I Telephone N.:. Cm:brief's Signature ace Sales Consnhanl License No. _ CACELIATION: CUSTOMER MAY CANCEL THIS "`epri:Link': AGR ENTENT LIGATION BV1()1EWITHOUT LLVERINGWRITTEN' NOTICE TO THE HOMEDE /!� (/, F DAf AMASIIGNING THIS AGREET RV NTIONIGHT ON THE MENT.BUSINESS NT. THk V V SP E SUPPLEMENT ATTACHED HERETO CO ASIS A FORM TO USE IF ONE IS SPT HICALLY PRESCRIBED BY La IV IN Ctt ren re Cr.re 0 ;' 1g :j:)4 ;?11-i•li'l I-i mi id A!A lb h g w t a!i'', a •fd tli i {; 6 M'u14 .ye991 A art 4,7J i['' r(�r i� _ < qty- giiiJi 4 icy'0 3I .: a F.,' I�((, � 11 i�s3 '+"$� q� ^tea 4� ev3 ur9 fR . ,1i1 ill ' rye 'i � 7 $�N � L ,5 ' 0,11 r: r w �� 4I43 p,rk' Pt t E. P r!1 pit _ a ,!. "t E ry " I ! it is I r!II.! If �In to 154 l' �; �I 1111 ! UI2 N _. . Cid 0[9<0 c v_r IN u' tTJ 11;1 u�1 " las' 4,l �,p,,, Is ' H 57 7 - Vii.{, n ,$is .. ' �0i.1 Wm: ,�y. r., Iz P,�' 'I :;g �" el, 4t7 � it j ; I ::nr 1Q r. A Hyl P. n p , 7, ��N i. 1 .'I r 1,o,1' (`A r 4! ,1 it t �}dtt ,�'+f{a` ��, , rc' 4;i 19 IN `" p i= ws 34 1 t0 ,,k a a , P ""'.' k i f,t 'W '?' IT ni k R! 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I t Andersen camorakarc riot ::.,-.- re— env-3", = Standard - Rating Y cmxa<ss PIP".Po-'S1011swxtl® :+:arses. --:E.; Ems illinalliMin 1.111.1.1.11.111111 MUM 1 The^onunon wealth of Massachusetts ieparineat ofudtstrialAceidents k .. f Congress Sh-eot, - 1lO , Boston,MA 02114-2017� w w..massbop!/i1la 1i'orkers'Compensation insurance Affidavit:BuildersICon.ructorsidlectriciaus/Plumbers, TO BE FILED Willi THE ignmrsemc A UfllW RITI'. Annliennrini nuntion �_ ��JJ Please Print LerUbly l,v j Nttne i3usincJO a:missioMndiiv/v�iidnal): S-ifam ?"7 f ) A-1 >�}i?" t- --.1 " .W.. /� " Address: 1-5 ;J c'?i7i-' . ..---r-4_21.." ,lTh, • Mik CityiStat&Icsp� P cY7Vt'6(J1 I,, k: 6 -4h. >b4 An pm an vuptoyer'Clink inerppraprnm hos. Type of project(required): 0I:m a empl t rwiih p!oy'a i:It d&reirmimd' 7. ❑Mcb'cmutruction 2.1_1l snit snit piaeruwrnr F nmsaipa,d hive no nnlplayaas wm941i Baine ie 8. (]Remodeling ow capacity.Edo works camp.sauna ralinal macs'ksS. 0 Demolition n.J inn a home".net Wing drk l w myss;.(4o 'camprmu a irc-requ¢m.!' 4.DIM a homeowa,enngcou enc Wig W1W mew,to wanclzt cry w0*on p.op=rty. Iwip IOQSui(dirig addition sale:hat all conImtarsenher'nv ork.;cr,'comp::swinn insumnevcr a:;:a1:: ' I in Electrical:again or additions prupdcxa•itic;rocnmmvea. 110 Plumbing repairs or addiOnot s. jsn_se:wni tonaomrota I haahimd thcsubmnuecmgr'ned on rh i scca4eel. I},Q Reef re repairs. It'mem s neen'sailon have captor'=s zoor .d isn't work:errohn:•mus Jp� )) 5.ijWe vaa corprsioRzed i's a1tcemhoccao:isn:doh oateniezcrn:l pat MCI.c. 1d O(4er W/ � !Si,SU4).and.ye have no employno.[Nov.-oriea!map-inslnce.a',01,il L tAnv ep0liC:Nl!alta cn8A5koxsi mist also 11i1 mu the=CI=bele:Slamwnig frOW WOF:e-s'c,nta,t,minn hnimy Wnm ori H Me"-wars Wito submit Ns vTnlagt fixlicaan;Cay am0ov'Yeall wars ad man hire omailu.wnlrnemrs MOS"Omit a nay amdL'vil intliaringsuch. :Cararvacrs that cimckhbbor maxmaei:aimarlditionatsiwatsbnmin3ma mea ai the sub-aunracoraoudu mwheeleronot d,mevniueso=va. •::nIluvt-s. ITdm Riu oases have er•,pbsas•day WOE savill.4Wer woicn.'come poliywmic:. _ __ I am um employer arm ispravirtin wortrers'cobaensolimm ineoreacefer may employees. Below as;Po policy andjobsire irncC. -)1/'f-3' .61-}'14'E..- j )J �_,, SIGL�} - n f' J t.l _ Insurance Company iltme; r•- 63w� }} r" -7 Policy Gar SciF ins.i.ip.r. Wit- }� = /�?`/ E:rpimdnn ism: �� i {{ A I TW lob Site Address: G� •• d/ CitytStpte2ip: A 90//fit: /? catch n col•�•=trim workers'compensation pulley declaration page(sllosriugtile policy number and expiration date), ''. S' Failure to secure coverage us required under Ma,y 152.825A is a criminal topiarian pnnishablo by a lino up to$1,500. andtereno-vc r imprisonment,Ss Ball as civil penalties in the Fpm of a STOP WORK ORDER and a fine etup to$250,0D a day against the violator.A copy oVhis statement may be tentacled 101ro Odle Of loycatignions oldie DIA fariiemaaea ?do lrereb .'--.1":tr I AP,' • 1r-Tilrnni ofperinry that the iefa'mation prm`ided above is true fine +r act. Sienateret .. F r tr...-, ,' 1C.,12.-A-,—I �) ,e. ♦ _2"I _1 / Plane g: S r3 U — b 2 Yom+' 'J" '• ._ Ft Official pee only. Bo not write In this ores,loAAtemple-tett aydi),or town official. :Clty or Town: PermiULieease E itt ' issuing Autho,-ity(circle one): At 1.Board offmith L Standing Department 3,CIO-frown Ckrh 4.Electrical inspector d.Plumbing Inspector I B.Other tte Contact Person: _., Phoneg.„ ACORON CERTIFICATE OF LIABILITY INSURANCE n1�p16"YYYn 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 INSURERIS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: It the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED,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 endorsemengs). PRODUCER CONTACT MARSH USA,INC. NAME;— MX ^N9 ALLIANCE CENTER PRE e_EnL- _—_. lac.N 1: . 3566 LENOX ROADSUPE 2400 E-MAIL ATLANTA6 GA 3032 ADDRESS: _.. INSURE,M_APFpRdHG COVERAGE I NAIL4 l004 2.P9meDGAWL IFP INSURER A:Sleadlasl Insurance Company 26357 INSURED INSURER B:2dnd Aramaean Insurance Co ;16$35 THD TT.HOME EPG.INC. - DBA THE HOME DEPOT OTAT-HOMESERVICES INSURER C r New Hampshire Ins CO 23841 2690 CUMBERLAND PARKWAY.SUITE 300 INSURER D:111inois National insurance Company523817 ATLANTA.GA 10339 _._.______—--_. __. . . _ INSURER E: INSURER F: I COVERAGES CERTIFICATE NUMBER: ATLC03746646.14 REVISION NUMBER:8 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 MATH 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 — AWL§YeR POLICY EFF I POLICY EXP LTR TYPE OF INSURANCE IHCD WHO POLICY NUMBER IMMDDVYYYI'./MMIDDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY GL{4e8771406 IAnil012016 0310112017 I EACH OCCURRENCE 3 9;006,003 % ONNTE TO aetrai — — CWMS-MADE _ - CCLLR PREMISES IEa occurrence) = _ __ 100" ,X03 LIMITS OF POLICY XS MED EXP(Any one person I S EXCLUDED OF SIR 51M PER CCC PERSONAL ADV INJURYsa 9A00,000 XpAGGREGATE LIMO.ipoi_ES ucq GENERAL AGGREGATE 13 90�i� X POLICY )s,Y; LOS PRODUCTS-COMPIOP AGG I i 9(000.050 __OTHER 5___ B AUTOMOBILE LIABILITY BAP29386o'S13 wDl 2019 03/01.2917 LONB�INEOSNGLE LIMIT i 1,d'Q603 1Ezdn111_ % ANY AUTO ' BODILY INJURY(Per person) IE ALDVMED SCHEDULED SELF INSURED AUTO PHA CMG _AUTOS AGTOC +BODILY INJURY(Peraccident!' HIRED AUTOS _ AUTOSNON-OED IPReOPERTY DAMAGE S AUTOS • IIP accident) • UMBRELLA JAB _ OCCUR I ' EACH OCCURRENCE— EXCESS HAS CLAIMS-MADE AGGREGATE S 'OED RETENTION s C WORKERS COMPENSATION WC015519215 IAO5i 0301.2015 03/0112017 I X 'PER 1 OTR AND EMPLOYERS'LIABILITY ' 1 STATUTE I1ER L ANY PROPRIETOR/PAR?NERIEXE vrrcE YIN .10 01 5519 2 1/(AK,KY,NH NJ.VT) 03-012016 030112017 1,000 000 OFFICER/MEMBER EXCLUDED' NI'',NIA EL EAEASE. ACH NT ••i 0 (Mandatoryin NH) WC016519218(FL) 033`20'5 03912917 EL DISEASE-EA EMPLOYEE•6 1,000,000 If yes Tescnbe sneer DESCRIPTION OF OPERATIONS oeiew 1 CM onued on Adldbnal Page I EL DISEASE-POLICY LIMIT S 1000.900 • DESCRIPTION OF OPERATIONS I LOCATIONS:VEHICLES(ACORD 101,Additional Remarks BNMuIC,may be a11ac11M Mmore space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT HOME SERVICES.INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DEA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. '1-ANTA.GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukhehee .].ta.. ae' hYst"4R—A-mcrJ- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 126893 Type: Supplement Card Expiration: 8/3/2018 THD AT HOME SERVICES, INC. RICHARD TROIA 2455 PACES FERRY ROAD, HSC C-11 ATLANTA, GA 30339 Update Address and return card. Mark reason for change. Address " - Renewal Employment I Lost Card Office of Consumer Affairs& Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: Office of Consumer Affairs and Business Regulation Registration: 126893 Type: 10 Park Plaza -Suite 5170 Expiration: 8/3/2018 Supplement Card Boston-MA 02 116 THD AT HOME SERVICES, INC. THE HOME DEPOT AT HOME SERVICES r� ) RICHARD TROIA 2455?ACES PERRY ROAD- HSC � c. ATLANTA, GA 30339 Undersecretary 1 01 valid without si6natnre BRIAN C THOMPSON 38 WILLOWBROOK LANE WFSTFIELD NIL01085