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22-013 (3) 67 SPRUCE HILL AVE BP-2017-0727 GIS A: COMMONWEALTH OF MASSACHUSETTS MagBlock:22-013 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate/OrY: windowreolaced BUILDING PERMIT Permit# BP-2017-0727 Project# JS-2017-001199 Est.Cost: $1816.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: ConstClass: Contractor: License: use Group: HOME DEPOT AT HOME SERVICES 092937 Lot Si.. zejsq.ft-): 27007 20 Owner: MULL-ANE JEREMIAH J &antng. Applicant: HOME DEPOT AT HOME SERVICES AT: 67 SPRUCE HILL AVE Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCERI02908 ISSUED ON::11/29/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 4 REPLACEMENT WINDOWS IN BASEMENT POST THIS CARD SO FT 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 11/29/2016 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Status of Permit: / "' B ilding Department Curb CuVDriveway Permit t C" - ,i 12 Main Street Sawer/Septic Availability '` t t-� ` Room 100 WateriWell Availability "'Forth mpton, MA 01060 Two Sets of Structural Plans ,. phons4 -587-1240 Fax 413-587-1272 PIouSite Plans Other Specify 1------- APPLICATION „%APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION b r - ( '7 - 7d 2 1,1 Property Address: This section to be completed by office /n �,//77���� f�.Ji , i ,..�y-/�-�,�'/ Map Lot Unit W 7 rkri.'&. ' / / '22 ✓/ 'r Zone Overlay District Elm St District _ CR District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: ^.�. j. d ,LA ; 1) it 1 67 6P/41e.1� *LI-. '4-1/ ' Name(print) Current etgss 2 y 6 y P9I. (7/b62-- -6a J �9 c-/a 4 r& Telephon LH . G.Yy5 `L ,./(i'G+- sonatere 2.2 AutheNzgd.Ayent: - 1 V)4--- ' qpm ho- 7 ' '7 7/ • Nv- Current Nairy- Address: / ©/ -4 Signature / Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS 7 ' Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building / « , u (a)Building Permit Fee 2. Electrical r `f (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4, Mechanical(HVAC) 5.Fire Protection 6. Total ft //(1 +2+3+4+5) /4 " .(!) Check Number�� This Section For Official Use Only Date Building Permit Number: Issued: Signatures ' _± /t� e- / Building Commissionertinspector of Buildings Date Section 4. ZONING Alt information Must$e Complete&Permit Can Be Dented Due To Incomplete Information Existing Proposed Required by Zoning I hi.column to be DEM in he Building Depanrnent Lot Size Frontage Setbacks Front Side L: R; L: R: Rear Building Height Bldg. Square Footage i ,o Open Space Footage liar area minus bldg&plum parka, a of Parking Spaces Fill: Melanie&Lawion) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW Q YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES Q IF YES: enter Book Page and/or Document Ii B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW O YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , 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 Q NO Q IF YES, describe size, type and Location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over I acre or is it part of a common plan that will disturb over 1 acre? YES Q NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check ail aoplicabie) New House ❑ Addition ❑ Replacement W ows Alteration(s) ❑ Roofing El Or Doors Accessory Bldg. ❑ i Demolition ❑ New Signs [Q) Decks (q Siding[MI Other[C Brief Descriytio P�apo 2 L' ml gVnT iii Work: iN�J'LL�o4�- ' � � "lC. zF' � �1VLt•`H✓� • Ail✓ t*l0 .wC 1{pf24 - s Alteration of existing bedroom Yes No Adding new bedroom Yes No 2JtF AM'I .'.i Attached Narrative Renovating unfinished basement Yes No zi�,,/ Plans Attached Roll -Sheet fie jei ,,Cjn4 \r sa.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: ,i 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. 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 APPUES FOR BUILDING PERMIT i..._ ,e' v fcLAIIL[-./ .as Owner of the subject property � nit � hereby authorize )C `ni �4 ,r 1 n— to act on my behalf,in all matters relative to work authorized by this building permit application, 6 ( Lie.. 1I.-/4—lf, Signature of Owner i r ✓] Date t, 1 --"ai ' ii" 1 Y/ )fl._. ,as OwnertAuthorized 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 unde :. •E s a / penalties of en /` ./ r jl-ee' - ' f r L Name we -t- f iJ —ins 11 �. Signature of Owner/Agent o,.- Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Stipend or: � Not/A`pp/licable ❑ enrAlit?Al Name of l lce Hotdet:,_.. gLf`r}:j ( % 'I%","! License Number -... AtltlressExpiration Date Signature Telephone 19) 9,Registered Hams I provement Contractor: Not Applicable ❑ CpmpartY Kerne r��(rifs, / Registration Number OP j1/11Jy-n irk; -AdExpiration Date 2�/ I y/ fTelephoney2 - r ✓ I SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.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 issuanc ing permit. Signed Affidavit Attache Yes ❑ No ❑ 11. - Home Owner Exemption The current exemption for"homeowners'was extended to include Owner-occupied Dwellings of one(I) or twin_)families and to allow such homeowner to engage an individual fig hire who does not possess a license.provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 10#.3.5.1. Definition of Homeowner: Person(s)who own a pared 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 he 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 lime,during and upon completion of the work for which this permit is issued. Also he 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,von 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 1 1, S 150k {{�] Address of the work: �j7 J�� vt;t/ 4Q" , F 2 The debris will be transported by: /31 16• The debris will be received by: kW-4 14IF- • Building permit number: n', Name of Permit Applicant 2I ee ►`]"f \ �Y Date Signature of Permit Applicant . The Commonwealth of Massachusetts 7:'—g- .. Department ofIndustrialAccidents 'k Office of Investigations o "� i} 1 Congress Street, Suite 100 yv g c. ?,y Boston, MA 02114-2017 'y r✓,y wwwmass.gov/die Workers' Compensation Insurance Affidavits Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lenibly Name (Business/Organizationiindividuall: Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project(required)- I.Q I 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 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling have ship and have no employees These sub-contractorsS. Q Demolition working for me in any capacity. employees and have workers [No workers' comp. insurance comp. insurance.: 9_ 0 Building addition required.) 5. Q We are a corporation and its 10.0 Electrical repairs or additions 3.0 I ant a homeowner doing all work officers have exercised their ILO Plumbing repairs or additions myself. comp.[No workers' right of exemption per MGL y c. 152, §1(4), and we have no 12.0 Roof repairs insurance required.] ' 3.Q Other employees. [No workers' —. _...- ......- comp. insurance required.] *Any applicant that checks box#1 trust also fill out the section below showing their workers'compensation policy information. >Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and stale whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy k 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 S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a line of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DR for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: .—_.... 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Numbing Inspector 6.Other Contact Person: Phone#: Job Contacts Link Leads Tuesday,November 15,2016 Commgnts Lead: 19683231 Go I Advanced Search 2:11 PM Info4Updates Homeowner information Job information Commissions Homeowner Mr.Jerry=Dane Sale Amount $1.816.00 Balance Due: $1.216.72 Homeowner2 Product AC12(4%) Costs Job Site Address 67 Spruce Hill Avenue Status Sale/Material Ordered FLORENCE,MA 01062 Branch Boston North DocumentsMeasure# 79432596 Scheel Measure County HAMPSHIRE Sales Homeowner Billing Address 67 spruce hitt ave Commission Rate FLORENCE,MA 01062 Consultant Name Term Date Split COMP Plan Job Issues Timothy Drost 100.00%Straight Commission Lao r Update Primary Phone (413)584.2378 Work Phone Ext. El-Back: No Cross Rote 1-9114563752 Siebel Ord... 261047 Order Detail Cell Phone (413)588-4137 Key Dates Order EntryWork Phone 2 Sale Date 11/8/2016 PUP Date Cell Phone Credit Date 11/8/2016 FPO-Customer Payments Email mullanejeny@yahoo.com RTP Date 11/9/2016 Post Install Date Cross Street Start Date FPD-Home Depot Permits Inspection Marketing plat Referral Store 2610-CHICOPEE Job Indicators Result Combo Base Store 8452-HADLEY Lead Paint:Assumed-LSWP Requir Lead Source 0080 Store Associate-OLS Services \\U Show Map TouchPoints User Date Time Status Cort. Appt.Date Appt.Time Consultant 1 Update Job -.-:dttany Johnson 11/14/2018112:09 PM Material Ordered No 11/8/2016 6:00 PM Timothy rarest Work Orders PETER TALBOT 11/1212016 10:28 AM Order Received-PSG No 11/8/2016 6:00 PMJTimothy Prost ,PETER TALBOT 11/12/20161 10:28 AM Measure Complete No 11/8/2016' 6:00 PM Timothy Drost 1Cythina Raglin 11/9/2016 5:32 AM Released to Production Noi l/8/2016� 6:00 PM,Tirnothy Drost Cythina Raclin 11/9/2019 8:31 AM Order Entry No 11/8/2016 6:00 PM Timothy Drost •Timothy Drost 11/8/20161 6:25 PM Credit Pending No 11/8/2016 6:00 PM Timothy Prost ilimathy Drost 11/872016 6:25 PM Sale Pending No 11/6/2016' 6:00 PM,Timothy Prost Dayend d 11/7/2014 9:04 PM Sent to the ield No 11/8/2016, 6:00 ;KIMBERLY COOK 11F92010, 936 AM Confirmed FCustomer No 11/812016 B 00 PM Drost Timothy Drost im Internet Lead 11l2/2016 10:06 AM Pre-Book No 11/5/2016 6:00 PMTimothy Drost r Internet Lead 112120161 10:96 AM Lead Entered No , Close ( Print Home Depot Contractor License Numbers: MA Home Improvement Contractor Reg. # 126893 Salesperson Name and Registration Number: Timothy Drost : HIS 0553710, R-R-073-15-00005 Home Improvement Agreement THD AT- HOME SERVICES, INC ("Home Depot") or Service Provider named below will furnish, install and/or service the equipment listed below at the price, terms and conditions as outlined on this form. Customer Information: Jerry mullane Boston North 9683231 First Name Last Name Prance Name Lead*I 67 Spruce Hill Avenue IFL[ORENCE rMA 01062 Customer Address Cdy Siete Zip (413)584-2378 (413) 588-4137 Home PhoneM Work Phones Cell Phdnet mul lanejerry@yahoo.corn Customer E-ma'l Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address brry Slate xfp or Email CustomerCancellationNorthEast@homedepot.com BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR PROFESSIONAL,AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIGHT TO CANCEL. Acknowledged by: X 11/08/2016 Custce,a§Siretun Prte 1 Distribution:White-Home Depot Yellow-Customer Copy Contract Price and Payment Schedule: Payment of the Contract Price is due upon completion unless a different payment schedule is specified in the State Supplement. 1816.00 Includes all applicable discounts, rebates, and , taxes. Contract Price $ Excludes finance charges.' Minimum _ %deposit$ Due Immediately Remaining balance $ Due upon completion Finance Charges *Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payment(s) made payable to The Home Depot. Insurance proceeds will n will not v be used to pay some or all of the total amount of sale. Description of Work to be Performed: Installation of windows A more detailed description of the work to be performed is included in the section entitled Scope of Work which appears on page 3 of this Agreement. Anticipated Delivery Date/ Installation Schedule Approximate Start Date: 01/03/2017 Approximate Finish Date: 01/31/2017 All dates are approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if applicable. Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written communications related to this agreement. By contacting your Service Provider, you may update your email address, withdraw your consent, or obtain a paper copy of the Agreement or related documents at no charge. By providing your consent and verifying your email address above, you confirm that you have access to a computer that can receive and open emails and PDF documents. By initialing this paragraph, I consent to receive only electronic records related to this transaction. Initial Acceptance and Authorization: By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation and/or(b)order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this Agreement. Do not sign if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.) By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety, including the General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a complete copy of this Agreement. Keep it to protect your legal rights. XL_..-_ _ _- - 11/08/2016 OMrm.?s Signature Date x[- Cosign lx applicable. Date X 11/08/2016 Sales consultants Signature Date 2 Distribution:White-Home Depot Yellow-Customer Copy License number(s) held by or on behalf of the Home Depot: MA Home Improvement Contractor Reg. # 126893 License numbers are subject to change in accordance with local or state government processes. For the most current listing of license numbers held by or on behalf of the Home Depot, please visit www.homedepot.com/ licensenumbers. Scope ofWork Job#: (Internal Reference) Products: Spec Sheet(s)#: Project Amount 9683231 U Roofing LJ Siding • Windows U Insulation ❑ Gutters/Covers ❑ Entry Doors ❑ 9683231 $1816.00 ❑ Roofing ❑ Siding LJ Windows ❑ Insulation ❑ Gutters/Covers ❑ Entry Doors ❑ $ ❑ Roofing E Siding El Windows IJ Insulation $ ❑ Gutters/Covers ❑ Entry Doors 01 iJ Roofing LJ Siding H Windows E Insulation ❑ Gutters/Covers ❑ Entry Doors ❑ $ SubTotal $1816.00 Sales Tax $0.00 Total Contract $1816.00 Amount Warranty: The warranty on the work identified above is listed in the General Terms and Conditions, or if applicable, specified in the following documents: Warranty AC86-AC58-AC12 Warranty Name(s): 3 Distribution:White-Home Depot Yellow-Customer Copy WINDOW SPECIFICATION SHEET • Spec.Sheet if 9683231 Sheet 1 of 1 Customer: Jerry mullane Job B', 9683231 Consultant: Timothy Brost Date: 11/08/2016 New Window Locations Existing Window Measurement Grids Product Options Labor Options From outside Left to RightRight • Bays,Bowls Locaben Color Rough Opening a of oars «of bars Caroms.I Pm. use L.R or Glass Misc Items Hardware Code Screens For doors use Mull 'S'=stationary or whh 5 K V '%'=odors operating Style Wraps _ — E Room Floor Code /YIN) Style Code Sense Code w x 5 m U a > m > x mamoym standard 2 BSX411 PMI N I woo moo 31 00 13 00 44 S ape 2 Pm_ to pow l000 31 ea 1300 X S SPECIAL CONSIDERATIONS', Wrap Color Manor Casing Type Ray or Bow window Seatboard mataallunyl onlyBlreh Or oak) Bay Project Angle 130 or 5) Bay Flanker Type(OH,SR.ar Csmnt) Top of window to sad(Indies) If lied l0 soffit color of soffit material l nave reviewed and agree with all the job specifications above and the ZonsWct Roof(Yes or No)' Spatial Terms and Conditions on the)chewing p'ege Garden Window Seatboard Material(vinyl only white Pionite,B11th or Oak) Wad Thickness Ouches) Customer Slgnalure AddNonal Shell Lyes or No) 'There is no guarantee that new shingles will match existing color The Commonwealth of Massachusetts Department of Industrial Accidents _ ,_S}?Ji I Congress Street, Suite 100 aleRoston,nL - d 021 2017 A ., www.mass.goohlla as — `.Yorkers'Compensation Insurance Affidavit:Builders/Contrnetars&Elettrieians/Pluothers. TO RE FILED WITH THE PERMITTING AIITIIORiTV. Applicant information i 1 r. (,'? r v�.., Please Print Legible Name tHusiness;Organicotion/IndividueM &b)'%ne' („thy (,Q.'` d-/rn /jp Address:_ L?�•� 3 `7- City/State/Zip:I.-27.ntiiiPhone 1 1 Are you nn employer?Check the appropriate box: Type of project(required): i.D l oma employer uith employeesifun androt pan-time).` Z Q New construction 2.0 I em a foie proprietor or i ser stip and have no employees working Iter me in 8. Q Remodeling any wacky jNouua:erS'mraa_lnsmmxe espfx'ad.j iD I ant a holneowntr doing ell work noxi f,pilo workers compinsurance required 11 9. 0 Demolition 4.0 ane IUnunsemr and wilt be r i ng c",bns c to coMun all twrk no my sole y i wig :o❑ Building addition ensure that all contractors either have upends'compensation insurance or are sole II.[]Electrical repairs or additions proprieters with no employees. h 2.n P1 Laing repairs or additions s.+ Isis s genera coniraiaor and I have hithe subscontractorsized on the narked stect 13. lief ri pair. Them sub-conabciarsI a employees anda ok p ' G0 t:e.ry a m[por.tian and its nailer Neve exercised ihs nein or swoons pm'MGT c. 14. Other kis 62.§It 4),and we have no employees.[No workers'comp.insurance mooned] Any;rpticani dot chcoks box 41 nest also fill out the section Sow showing their workers'compensation policyint non. -_ Homeowners who submit this affidavit indicuing they arc doing all work and then hire oveidc cpntmnnte Inst submir a new affidavit indiwling surd. :Cmuncmrs dot check this box must attached an additional shed shoving the mine or the subcontractors and state whether or not nose entities have simployaes. if die su4mnvaaors have cmaionab they must pmvhY their corkers'comp.poticynumber. I am an employer that Is providing workers'compensation insurance jbr nrP employees. Below is the policy and job site information. p Insurance Company Name:_ Nth() 6,c) +�-agar. #' „ 'rt . /.. , 1 t 12 Policy 1;or Self-ins Lie . }.4!�~e,,% I� ,,!l)�h�„ft expiration Dat - ,,YyI I J//��/p,�,{p.- fob Site Address. 7 ��/ 74772.2. Ctyistaterip: J'L'L /, ' /p+may �/_ Attach a copy of thy workers'compensation policy declaration page(showing the policy number and expiration dateJ. 9f 2- Failure to secure coverage as required under sdGL e. 152,ii25A is a criminal violation punishable by a fins Math$1.500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a Fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ,y da h by cerci n de 1 a penalties of perjury that the information provided above+ is trete and correct Signature: a't/l✓' Date; [„ / l ^ 1t� Phone+: :% -- 1>Z G-- • Official use only. Da not write in this area,to be conipleted by city or town official City or Town: Permit/License;!_ Issuing Authority(circle one): I.Board of Health 2. Building Department 3.City/Town Clerk 4, electrical Inspector I Plumbing Inspector fi.Other Contact Person: Phone R: DATE ACORD CER�4HCATE OF LIABILITY INSURANCE °roaoib ;WYE I 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 RY 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: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must he 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 omits to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSH NA,INC. NAME PRONFax TIDO ALLIANCE VENTED ED WC Ne EC NG No: 35S0 LENOX ROAD.SUITE ERE E-MAIL ,;;TI TETA.CA.30376 ADDRESS- INSURER151 AFFORDING COVBRAOC I CMG IC^v:97 aom•DGAW'10-17 _SleadIsl InsuranceCom ,n 1251137 ItISUTRA. Compmy INSURER JUIN Amerian lnsurnce Co i1E� TAD rLBDOSERPIC 61C. INSOP.Ea3: DEA i.-:EHOME DEPOT AI-,21.1E DERVICcj INSURER C:N2»rimpshira Ins Co 231341 2"D C141EEPLi\G FJP.KVBAT SUITE KO ATLANTA,EIS 30339. v+SUacR D:Ennis rlation0 Insurance Company -231317 INSUR'ERE, ! -IRSURERRF: COVERAGES CERTIFICATE NUMBER: ATLi337=-- - UED REVISIONNUMBER-8 THIS ED CERTIFYNOTHAT THE POLICIES UI INSURANCE .M OR BELOW PAVE BEEN ISSUED TO THE OTHER NAMED ABOVE FOR THE POLICY S INDICATEDER . N MAY SE ISSUED OR ANY RY PERTAIN, TH, T`NSU OR CE FION OF ANY CONTRACT OR OTHER DOCUMENT UB RESPECT TO WHICH THIS CERTIFICATEC -TION OF.MAY PERTAIN,THE INSURANCE N AFFORDED BY THE POLICIES P ID AIMSD HEREIN IS SUBJECT N ALL THE TERMS. ANDEdLUSIO^ISPE CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCEDICYBY CLAIMS.PAID IN_R cOFINSURANC- DL'Nn POUR?11URl3eR Ip1 V0OM!'M�IRV l�01YYYp LINTS -COMMERCIAL GENERAL DID4ABMI4C8 03111112016 I0?(01i201, - 9000BSO EichGETOR CT'c= cal ls.:::-Oe OCCUR - DAMAGE RENTED _ I OW.CIA REPRISES 1EaOn)--cal •_ ISIS...POLICY XE - 1 3 IXCLUDED MED=XP fit.. SE SIR: PER GCC ONAL 3 AM/INJURY 901)5001 O L=GG?C v'NI-•r_5-?: 9UWCCO _aG ^ :PROOUC -COUIPATE I5 :<crr_o1;cY. ! c _.—_ :Rcouc-ca;aProR AGO I a It,GCD.Lch o-ea: E AUTOMOBILE LIABILITY ;e AAAt13 OT01u01S I01012Di7 M Iu D LOIuQtr LIMIT .- LIDO OM Y.:um - Ewer!RUE?ee%cs'zcn) 3 `Vis O +vT]oU—O --_ :.SLRED:MLMO='Y'."G DOLL.I,J1-P(IP a:nn.3 - HIRED AUTOS NON-O kNEO i PROPERTY DAMAGE O _TUTS _n1 UMBRELLA JAB OCCUR a `LESS CAN aCA1Cc �S ! =:.-TIDE I AGGFEGAThGAW S -D=D ' RETENTIONS C WORKERS COMPENSATION ' ;':OCO1S519i5WOS) 10711112015 00112017 x " UTPER • I9T4- C ,.!EMI AEMPLOYERS LIABILITY STATE ' DER Y OP?T GpPAR R-P,;:CU'I 7 N 'AC01519217(ANMa NP'D VT) 103:0112016 03/01/2017 1EEALHACCIDENT I s 1,CCO.000 0 C LY.fE.R'R XRUD-O, I -NIA G orynNTO - n015519216 MI 0011101.6 0310112011 i EL USESE EA U1PLOYv=s -LOCUM RSC : oa NYW Conilnoedon PCddNon2IP- _ 1IOI.600 RRT ION CP CARNATIONS a?Ice °S' i a DISEASE-POLICY LIMIT a i1 I DESCRIPTION OF OPERATIONS;LOCATIONS l VEHICLES WOOED 171,Additional Remaeks Schedule,may Oe attached if more space's required) cY/IDDICE OF INSURANCE CERTIFICATE HOLDER CANCELLATION I THD AT-HOME SERVCES.IMC. DEA IHEHOMEDEPJT AT-HOME SERVICES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2155 FACES FERRY ROAD THE EXPIRATION DATE THEREOF, NORGE WILL 0E DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AZANTA,DA 30339 AUMOR2ED REPRESENTATIVE of Marsh USA Inc I Manashi Mukheijee Cc&,A n..ILL -.1T3-•A-Ce---DAA;-F J 1988-2014 ACORD CORPORATION- All rights reserved. AGGRO 25(201401) The ACORD name and logo are registered marks of ACORD Office of COELSiar, e_r affair's and Business Regulation 10 2'Lc P,:aza - Suite 5170 Boston, Massachusetts 02116 Home IF _ prven_ent Contractor Registration Registration: 126893 Type: Supplement Card Expiration: 8/3/2018 THD AT HOME SERVICES, INC. RICHARD TROIA 2455 PACES FERRY ROAD, !-S C-'i ? ATLANTA, GA 30339 Update Address and return card. Mark reason for change. Address Renewal Employment Lost Card Office of Consumer.Affairs& Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR t3efore ane expiration date. If found return to: Ccrce of Consumer Affairs and Business Regulation Registration: 126893 Type: g IMI-l:Pinta -Suite 5170 Expiration: 8/3/2018 Supplement Card „.„s,00;,, MA : 2116 THD AT HOME SERVICES, INC. THE HOME DEPOT AT HOME SERVICES TT) RICHARD TROIA 2455 PACES FERRY ROAD, HSC \TL4NTA, GA 30339 U rdersc rotaey of valid without vhn turn Simonton I:Rndow.3 r- 850C Vantage-Pointe 'I L.. ---..,;,....2-AA 11•. _ _ - _.. .ii . _dl:c - .?au r:6ss J vtot5-No_ arz:� , - -;I .�., 1 1 - ad..; 0 Pro .Sni Iddo k : _car _E Sr I s .a... 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