38D-042 (25) 40 HARLOW AVE BP-2017-1227
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 38D-042 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-2017-1227
Project# JS-2017-002062
Est.Cost: $3262.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grouo: HOME DEPOT AT HOME SERVICES 92937
Lot Size(sq. ft.): 5706.36 Owner: PARENTE ANNE
Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 40 HARLOW AVE
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCERI02904 ISSUED ON:4/26/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 3 REPLACEMENT WINDOWS - ON
PORCH
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 4/26/2017 0:00:00 540.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
f ---- -T Department use only
' C y of Northampton Status of Permit:
`L6 'ijjiI B 'Ming Department Curb CwDdvewayPermn
• JI 12 Main Street Sewer/Septic Availability
I ------\ Room 100 Water/Well Availability
L __ mpton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 6,8- 17-1 d 7
1.1 Properly Address: AA This section to be/cTompleted by office
9 / /2� Aix
Map 3!/ O Lot V �� Unit
T�� Zone Overlay District
Elm 5t District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
TY �T 3"ti h19/2.int) .4/4-
Name(Print) ' rJ� Curregt fyllln rrp9' �Lyt JD4/
SL�L ��/(l//-1 r/ r'
Signature 7J
Telephone _ 7_ � 6417
2.2 Authorized A!ent:
) , 'AT — 1S ,T�f TAX
/ / Ginn ailing - . kin- • a, L r
4' J
Signatur= Telephone y-Q .51-jt- 12_-
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 242 OO (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 JJ qv I(
6. Total= (1 +2 +3 +4+5) 4�� 'CO Check Number p/ I
This Section For Official Use Only
Building Permit Number: Date
Issued.
Signature ,a /�� ///y
/
Building Commissioner/Inspector of Buildings 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 he filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R'.
Rear
Building Height
Bldg_Square Footage
Open Space Footage ,n
Wei arca minus bldg&pasta]
parking)
h of Parking Spaces
Fill:
(volume&Loeminn)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document it
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O 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 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 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 pal of a common plan
that will disturb over 1 acre? YES O NO O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement ' dews Alteration(s) 1 1 Roofing ❑
Dr Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Cl Siding[D] Other[U]
•
Work.Brief escdApp✓ //9'ii-Zi—-Ow/F. asy •//C 'Y/f�/✓!/ ✓/ V/u/�G. e k
Alteration of existing bedroom Yes No Adding new bedroom Yes Na / L
Attached Narrative Renovating unfinished basement Yes Not
Plans Attached Roll -Sheet YT
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 constructon. _ 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 WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FORBUILDINGPERMIT
I, r7/VAI Qry9;f22T(Al/i-- y� J��,,/ass-Owner of the subject
property via/met //l op -- r ,/ 'W /
hereby authorize
to act on my behalf,in all matters relative to wo k a orized by this building permit application.
Signature of Owner /J,lf�l "" ��1 Date
I. 7 L I '�//"1) 7 p9 ,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 u ains d penalties of perjury.
'1*
_li , /
I'S 7 /5-17
Signature of Own /Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �M n�/J/�j7� Not Applicableic ❑
Name of License Holder: &/// / U/ 9-4 (�J '-092-q-;7
License Number
li ZA [�/D zq/7
Address �- Expirabod Date
Signature Telephone
8.Registered Home Imrovement Contractor: Not Applicable ❑
7�� e r) f /26442
Com an Name Registration Number
•
Addr / ''')[ /''�� Expiration Date
me, F�I �
r%e7 Telephane��� Q3/
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 issuance of the buildi permit.
Signed Affidavit Attached Yes No ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(2)families
and to allow such homeowner to engage an individual fin 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 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,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 Inning 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
/J ved by MGL
. e
c/111, S 150A.
Address of the work: ,44m -
The debris will be transported by: /142,2- E0—
' / /21
The debris will be received by: fri tz e0 /771* •
Building permit number:
Name of Permit Applicant „Wei* "of A
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
• mac Department of Industrial Accidents
Us
7......;r____,, OJfice of Investigations
sI Congress Street, Suite 100
t e
Boston,MA 02114-2017
‘11- 7,‘ www mass.gav/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone#: _
Are you an employer? Check the appropriate box: Type of project (required):
1.❑ I am a employer with 4. ❑ I am a genera! contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
listed on the attached sheet. 7. ❑ Remodeling
2.III I am a sole proprietor or partner-
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. employees and have workers'
comp. insurance.% 9. ❑ Building addition
[No workers' comp.insurance P
required.' 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] " c. 152. §1(4),and we have no
employees. [No workers' 13.❑ Other -_
comp. insurance required.]
*Any applicant that checks box a I must also nil 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 state whether or not those entities lane
employees. If the sub-contractors have employees, they must provide their workers'comp.policy number.
7 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company 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
tine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 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 da 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):
I. 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 trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es)and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he 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 pennit'icense number which will be used as a reference number. In addition,an applicant
that must submit multiple peimiUlicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn 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
Revised 7-2013 Fax#617-727-7749
www.mass.gov/dia
City of Northampton
Massachusetts s
^��
DEPARTMENT212 MainS OF BUILDING INSPECTIONS
212 Main Street o Municipal 1l Building
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State 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
foundation/footings (•efore backfill). sonotube holes (before Dour). a rough 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
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
Apr C6 17C7:C5a
pt
IS
Home Depot Contractor License Numbers:
Maine #CO2439; Rhode Island # 16427: Connecticut# HIC0565522;
Massachusetts Home Improvement Contractor Reg. # 126893
=VI 11o�4 ( 3 3L- 53;1
Salesperson Name and Registration Number.
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.
Custon,ar Information:
RCP fJ A YIP A� Last Ware _ �nch N
New England ame �� 1q
5 CJ fo ; 3
psi: 35 P.Q_CoL- Pc'.0 CJ -AkikcLV�9kk� fli ✓�tate aPaSc C`.
Home Phunetl WOAPhone•' Lal More#
ILSMimmEmal.btl,ess .-
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
or Email CustomerCancellationNortheast@homedepoLcom
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 DEPOTS 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.
Aslmw try:
X t t r ' '
1
Cistnbuuon: White - Horne Depot Yellow-Customer Copy
Apr 06 1707.05a
p.2
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.
Includes all applicable discounts, rebates, and , taxes.
Contact Price $ 3 2- L 7 Excludes finance charges.`
Minimum _ %deposit$ k O g E t Due Immediately
Remaining balance $ 2 17 ^t 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 Customers payment(s) made payable to The Home Depot.
Insurance proceeds will❑will not"be used to pay some or all of the total amount of sale.
Descri _:on of Work to be Performed:
Installation of
A more detailed description of the work to be performed is included in the section entitled Scope of Work
which appears on page of this Agreement
Anticipated Delivery Date/. n tallation Schedule
Approximate Start Date: Approximate Finish Date: jj d({ -3v
All dates are approximate an ubject to change based on unforeseen events inc u ing 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, 1 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 Condi ' s and State Supplement, if any. You further acknowledge
receiving
acomp)yy//yy(/(/}}e copy of this Agr ent. Keep it to protect your legal rights. 2.
cu.mmate' s§„+rv,.
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06111
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Distribution:White-Horne Depot Yellow•Customer Copy
Apr 06 17 07:05a
P.3
License number(s) held by or on behalf of the Home Depot:
Maine # CO2439; Rhode Island # 16427; Connecticut # HIC0565522;
Massachusetts 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.homedeoot.com!
licensenuntbers.
Scope of Work
Job t: °mese tensest Rad tots: Spec Sheet(s)M� Project Amount
Roofing ■ Siding 1, Windows J insulation ------yy
.et ^, (o L Gutters/Covers LI Entry Doors ❑I-7 1 tGS
Roofing I Siding J Windows L1 Insulation
1 Gutters/Covers ❑ Entry Doors EL _ $
C Roofing L Siding L Winnows L insulation :...$
Ll
Gutters/Covers ❑ Entry Doors ❑I
Rooting Siding LJ Windows L Insulation
E Gutters/Covers E Entry Doors ❑t $
SubTotal
Sales Tax
$
Total Contract $
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.
Name(s):
3
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/mu on employer that is pro oirhhg nmr/tens'compensation invertume for,ny employees. Below is the policy andjob,Sitz
inJ'onuotinn. I,q.., / ' .r�, t FIRE.
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insurance Company Name: PV r ETh2Njt"L Jjrii P� / /RE. __. :___L.�71/•
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PolicyScl; il 1.1e r: a �/ 3 1 ulnD;re -�1� f'27
I Slut Adores 1 p0 L t 1) JIat2 z1PAb 7/72 "lir
Atl Ic b a tope of the woricei's' compensation policy declaration pare(shunlug the policy number and espu'a on date). f)/ped
( iurc Li stuff e a_ as housed tinder VICE c. '5d.§25a . c.inii to violsfvn punishable by a lm:an m'S1,5'110.00
prulinle-y ear lttacnmcnr.as melt as civil pn kits in time fon r.ti2 a STOP WORK ORDER and a tine of up to S250100a
I_nin_t theviolatorA cop , of this statement may be forwarded to the Office of investigation::of the DR for Insurance
cot erar verification.
tC ginprovided Td !� heftily n.,.,,, _ ._
+ u/jcn .' .Jury lull themfarvurtJ g above is true and correct.
SI ITitrill: —P911 .--
�_�_. Date —)
Q)jtrrct iY.only, Do not larere in tins area, To he completed ht sol to town official
Cita;or Town: PerntitiLiceuse g
issuing Authority(circle one):
1. Hound of Health 2_Building Department 3.Cityfloniit Clerk O.Electrical Inspector 5.Plu m biug inspector
1 O. Other
L mllld Person;
Plume
ACORLI CERTIFICATE OF LIABILITY INSURANCE CIATEIMµ CI
12`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 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: If the certificate holder le an ADDITIONAL INSURED,the pollcyfies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy.certain policies may require en endorsement. A statement on this certificate does ant confer rights to the
certificate holder In lieu of such endorsements).
PRODUCER CONTACT
MARSH USA,INC „NPM¢. I
TWO ALLIANCE CENTER i Me EM I ttNq.Net.
35W LENOX ROAD,SUITE 2400 EitelL
ATLANTA,GA 30325 APDRE93:
NSYRERIS)AFFORDING COVERAGE I HAKE
100492.HomeDGAWIT-18 INSURER A:O!d REWElc InsulmCe CO I21197
INSURE. INSUgER 8:A3A Genera IRSurAc G05Mp H7/17
THE NOME DEPOT INC.
HOME DEPOT U.SA..INC. INaURERC:Sea HanpshNE MS Ca 0941
2455 PACES FERRY ROA° INSURER a: I
BUILDING C-20 -'
ATLANTA,GA/039 .INSURER a: •
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL00274E382.4a REVISION NUMBER:2
TIPS IS TO CERTIFY THAT THE POLICIES OC INSURANCE LISTED BELOW HAVE BEEN IC 1IED TO THE INSURED MANED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWiNSTANDING ANY REQUIREMENT. i tHM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WINCH 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.
T SRI O-5 128.460. CT PP EXP ..
LTq Dere OF INSURANCE gBn'.WV� PIXICT XYMBEP RIMPIX11 IAeWYNYYYI POLICY
A ' A L,COMMERCUL GENERALUABUTY ;MAZY 31A022 01/01214 II0,13I12013 I'1,Lnoccu EKc $ SAUCE
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E X OR PAEWAFaiaaa�otgpq(E) $ 30Yt.TF9
LIMITS OF POLICY XS MED EXP(Any,mo OHMS 5 EXCLUDED
OF Sift SIM PER CCC 1 PERSONAL a PDVINAIRY I5 9.000.1100
Gina AGGREGATELim iARMIES PER O OEP PRO- GENERAL AGGREGATE S 9,0133.0(10
I 141 FO.CY EC l'JC 1 PROOUCTS-COYPOP ACG 15
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AUTOMOBILE aluAIW 1W21 103/01R011 0341/201E8 40SL^e.DMrt IS 1,0/0,040
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▪ OFFICENMEMBER EXCWOEDI WCB2310242.4 WI 03/01/(011 10310112018
Myendaory In NH) ( ) f EL DISEASE-EA EMPLOYEES ICCdLtGO
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X „Ray as etched Ir mate spate Nwa
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EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
:ROVE DEPOT USA.NC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF. NOTICE WILL SE DELIVERED IN
ATLANTA,GA 30319 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTH ORIZEe REPRE MEMTATR'E
et Marais USA at
Manashi Mukhetlee .14a &ge L ,f(...r ..s. ...,
I
01988-2014 ACORO CORPORATION. All rights reserved.
ACORD 2512014401) The ACORD name and logo are registered marks of ACORD
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ACORD 4 ADDITIONAL REMARKS SCHEDULE Raga 2 Of 3
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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 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: [0 Park Plaza - Suite 5170
Expiration: 8/3/2018 Supplement Card Boston. MA 02116
THD AT HOME SERVICES, INC.
THE HOME DEPOT AT HOME SERVICES
RICHARD TROIA ,
2455 PACES FERRY ROAD, HSC - - - a
ATLANTA, GA 30339 Pndcrsacremn t valid w[hoot sr�n•()Kg,
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