23A-228 (6) 113 NONOTUCR ST BP-2019-1093
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:23A-228 CITY OF NORTHAMPTON
Lot: -OQ I PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorr window replaced BUILDING PERMIT
Permit BP-2019-1093
Project# JS-2019-001778
Est Cost$3630.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 104327
Lot Size(sp It.): 10715.76 Owner. PAPOUCHIS ALEXANDER
Zoninw URB(100)/ Applicant. HOME DEPOT AT HOME SERVICES
AT. 113 NONOTUCK ST
ApplicantAddress: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON:4/3/2019 0:00:00
TO PERFORM THE FOLLOWING WORK INSTALL 5 REPLACEMENT WINDOWS
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 Occuoancv Signature:
FeeTvpe: Date Paid: Amount:
Building 4/3/2019 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
zv//u acv
-- _ Department use only
Ci[y of No ham CC�, /C Permit:
.ar Building D partL. V L rbC dveway Perms
212 Mai Strjet N pdc Availability.
Roo 100 APR 3 2019 at_ ell Availability
Northampto , M 01 OBO M S of Structural Plans
-` phone 413-587-124 F F,r nc - 72 IoVS'®Plain
Nr eUll OIN, NS11CTlo her pecify
1114rnp�nN In
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
A )DAIDT C5' ) Map d Lot a�`� Unit
(/y /� / Zone Dverlsy District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
XV(
Name(Print "-r' �T Current
Signature
2.2 Authorized ent: ?off
Name(Pnn Current Ma)i gAtltl��
Signature Telephone Z
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
completed by ermita plicant
1. Building 2,l_ ,ya (a)Building Permit Fee
2. Electrical (b)Estimated Total Cast of
Construction from 6
3. Plumbing Building Permit Fee e
4. Mechanical(HVAC)
�O
5.Fire Protection
6. Total= (1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: DateIssued'. //II
Signature' 7-3-Zo)9
Building Commissioner/Inspector of Buildings Date
1 / Z7 • e'*�
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
'lids column to be filled In by
Umidiu5 DWanmwl
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
Qua arm minus bldg&paved
mk'n )
#of Parking Spaces
Fill:
(volume&U—t...m
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 Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T 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 O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 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 O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
uECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement dows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ Neew,,Signs [E3) Decks [1-3 Siding[[3] Other[a
But,
Work: b
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
5a.If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other
It. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attachetl?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
E Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is constmclion 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 FOR BUILDING PERMIT
I. pzf ��-- �ol��y�/JLI ,as Owner of the subject
property � ^ �
hereby authorize 1041/O/UJ -Zino—
to act on my behalf in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, as OwnerlAuthonzed
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the an penalties of perju
02-> i
ame � g
Signature of Own gent Date /�
..NON 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suupp'endsoor:/ NotApplicable '❑/ '7
Name of License Holder' E K' �GfJ�J✓/ /✓ //c-'r� /\ �/ /D7 �z/
License Number, /�
Atltlmss ( 7 ,� 1 /x � � Expiration Date
Signature Telephone
8.Re istered Home Im rovemant Co tractor: Not Applicable El _
Company Name Registration Number
Expiry 2a-/9
Atldress '7 ation Date
Telephone 1 �
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152,§25C(i
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 buildlingp6mrit.
Signed Affidavit Attached Yes....... DVI No...... ❑
City of Northampton
s Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS ,t
m
212 Main Street • Municipal Building
Noxihemp[on, N>\ 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which am adjacent to such residence or building"be
done by registered contractors.
Note:Lf the homeowner has contracted with a corporation d.
�ation or LLC,that entity must be registered
Type of Work: N1b')0V y dry, 7/!'/�r� Es/t.'Coosst: �5"Z 3�j--'Op
Address of Work �(� W�nZw✓U/v/� /� L i'/L .%eI PJ ' r'��d�Z
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under 51,000.00
Owner obtaining own permit(explain):
_Building not ownef-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITII UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
I- /9 ->r 1l2-7i�
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
M
��' � assachusetts A+'
�- A i
I D£PAR9TPNP OF BUILDING ZNSPSCTION$
212 Main Street a Manieipal Building
i
QNazN.Pton, M 01050
Massachusetts Residential Building Code
Section I10.R5.1.2
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.
Section 110.85.13.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
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.
City of Northampton
� • Massachusetts
l DEPARTMENT OF BUILDING INSPECTIONS
313 Nacn Sizeet •Municipal Building
NorNa ton, NA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, 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.
The debris from construction work being performed at:
I1'�7 dJ'pkxFGlk -,--:5T—,
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
s� 1 Congress Street,Suite 100
Boston, MA 02114-2017
www.massgov/dia
\Corkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
)dame (Businces/Orgeaizanov/Ipdividaap:
Address:
City/State/Zip: Phone M
Are you an employer?Check the appropriate box:
Type of project(required);
1.[3 1 am a anployc,,uh rnployacs(full and/or ponaimr).` 7, ❑New construction
2.❑I amasole,molnene,m,a marsh pond have not employe..working for mem 8. E] Remodeling
any capncily-[No work—'comp.insurance raqui cul
3,E] er aloin all work-yae l ams homeowner IL No warkni cam,.nsnrance re.viree.l` 1 Demolition
all [
4.❑I nota homeowner and will be hiring e o sem,ne cookon all work on my properly. twill
10❑ Building addition
re mal all m,mm,un,eimer have workm 'exonereamo morsomor aur.solc I ❑Electrical repairs or additions
propnemrs with no employees.
12.❑Plumbing repairs or additions
5 1 am a general conn error and I have hired the sub-eomrnema listed on the attached sheet.
'Ibese.vnl.ronn-avrors have employ.. and nave xorkers 13.oRuof
c.w,i sumnsa. -pans
6.❑Wem,.empormioemun,.fliwrshaveexereiwi mearigla ofexcral pe,MCL c 14.[—]Other
151,Q1(4),and we haven.employees.[No workers cam,mmamr c required.!
`Any a, ieam that ohecks box#1 must also fill out the section below showing their workers'compensation policy mlormation
`Homeowners who mbrut this of luded[ivdieamg they are deing all work and then him outside wnnaemrs mast submit a pew atHd.,a imitating suck
:Conexcmrs met check this Ixm must-!ached an additional shoot showing the llama of the mbaimuvcmrs end smm whcthu or nm chase emitia have
employee . I(the subtioutmemrs have mployees,lheymustpnvuh,their workers'com,policy nomhor.
I am an employer that is providing workers'compensation insurance jar my employees. Below is die policy and job site
information.
Insurance Company Name.
Policy 4 or Self ins.Lie.#: Expiration Date:
Job Site Address: City/Sate/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 MGL c, 152,g25A is a criminal violation punishable by a tine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of S 1 OP 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.
I do hereby certify tinder the pains and penaddes of perjury that the information provided above is true and correct
Sixonal Date
Phone N:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License M
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Cool Person: Phone W:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workerscompensation for their employees.
Pursuant to this stamtc,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 ajoinl enterprise,and including the legal representatives ofa deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a 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 bean 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 ofthis 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 subconnactor(s)mortis),addresses)and phone numbers)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
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 Ocpartment 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 permulliuense number which will be used as a reference number. In addition,an applicant
that most 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 be provided to the
applicant as proofihat 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 pemnit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston. MA 02114-2017
Tel. #617-72711900 ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Home Improvement Agreement: Pagel
Home Depot License#'s- For the most current listing www.Homedepot.com/LicenseNumbers
MA:107774, 112785
Kyle Harmon
Salesperson Name: Registration No. (H applicable):
Home Depot U.S.A., 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.
Papouchis Alex INew England South 1-GS341RR
Customer Last Name Customer First Name Store#/Branch Name Customer Lead/PO#
113 nonotuck street IFlorence MA 01062
Customer Address City State Zip
(413) 923-8423 r lalexpapouchis@gmail.com
Home Phone# Work Phone# Cell Phone# Customer Email 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 IShrewsbury MA 01545
Address City State Zip
Or Email' customercancsllationnortheast@homedepot,com
Service Provider Email Address
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
DEPOTS RECEIPT OF YOUR NOTICE.YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR SERVICE PROVIDER, 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 HOME DEPOT 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 RI T AN L
Acknowledged by: 03/07/2019
Cus o 's Signature Date
Contract Price and Pa M ch ' Payment of the Contract Price is due upon signing unless a
different payment sch uie is required by law, specified below or in a payment addendum.
Contract Price: $ 3830.00 Includes all applicable taxes. Excludes finance charges.'
Sales Tax: $ o.00 (If applicable)
'Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, WI(99%)
Dep. 25.0 % Deposit Amount $ 9075 Remaining Balance $ 2722.50
The Home Depot-2055 Peen Forty Road,N.W.Bldg.",Monte,Gowgin 30389-Customer Can:1.500-088.9737
wm wsar.,��w..•.n,tax,e . o.0
Home Improvement Agreement: Page2
Finance Chamea:
'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
aan 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 will not v be used to pay some or all of the total amount of sale.
Description of Work to be Performed:
Installation ofwindows
A more detail escn ion o t e wo to a performed u is inc rn a section entitled cope o
Work which appears on page of this Agreement.
Anticipated Delivery Date/Installation Schedule
Approximate Start Date: 05/02/2019 Approximate Finish Date: 05/3o/2o1s
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 Areement 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.
rplMaling this paragraph, 1 consent to receive only electronic records related to this transaction.
V�lp� J 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
com late cop of this Agreement. Keep it to protect your legal rights.
-31
X 03/07/2019 The Home Depot
usto r Signatur Date tservice vroviaer Name
X1 I I03/07/2019 908 Boston Turnpike Unit 1
tg i tca a ae ervce Provider Address
03/01�2019 Shrewsbury 0545Xt nn Behalf p oma a at Mate
i
ervice Frovil hone Number ervice vrovider LIcenSG Number
The Hoare Depot-2455 Pea*Ferry Read,N.W.BWg.e4,Atieota,Georgie 70339-Customer Care:14MO400.9937
em Noeawnr�W",al r A.
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ACCN?a CERTIFICATE OF LIABILITY INSURANCE D2A,62m9
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 polis,les)must have ADDITIONAL INSURED provisions or be endorsed.
N 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 dghM to the certificate holder In lieu of such endhomement(s).
PRODUCER
MARSHUSAINC. xME.
PHONE
TWO ALLIANCE CENTERINC.it plc no
35601ENOX ROAD,SURE 2400 EMAIL
ATLANTA GA 30326 ..am$$,
INSURE SAFFDRONGOOVERAGE NNCI
CN101M2069HnneDf.AW-1420 INSURER A:OU Re bre lmuance Cc 24147
IHBUREDTHE HOME DEPOT,WC. Ieumm R:New Hem fine Inc Ce 23MR
HOME DEPOT USA..INC. INSURER c:HMneBisk Care lnsuameC Xn
2455 PACES FERRY ROAD INSURER D:
BUILDING C-20 --
ATIANTA GA 303N INSURER E:
INSURER F.
COVERAGES CERTIFICATE NUMBER: ATL D1 3139-28 REVISION NUMBER: 21
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 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.
WSR nL BUs. POLICY EFF POOCY EXP
LTR TYPEOFINSURANCE POIX:YNUMB9i IMMINGODY,1, fles,M)"yY) Users,
A X COMMERCwLGENERALLMNUTY MWLY 3145]4 DXIM019 03MON022 FACHCCCURRENCE $ 1,008000
CIAIMSMADE M OCCUR PREMISES Ea o„ -- $ 1810,000
X SIR:51.000,400 MED EXP(Any one yewn) $ EXCLUDED
PERSONALaAWINJURY $ Tom 000
GEN L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGAM $ 1,000,000
X POLICY jEQ LOO PRODUCTS-COMPIOPAGG $ 1000,000
V HER $
A AUTONaNLe LIASILnY MWTB3145TJ MM112019 038112022 COMMBIINKE0 SINGLE LIMIT $ 1000,000
% PNY AUTO a00I1 INJuRY(F.penin) S
OWNED SCHEWLED SELF INSURED AUTO PHY DMG SGOaTWRJ3r(Pe.ewam) S
AUTOS ONLY AUTOS
HIRED NON-0WNE. PROPERTYOAMAGE $
AUTOS ONLY AUTOSONLY PoL xu4n
$
UMBRELLA IIAB OCCUR EACH OCCURRENCE $
E%CESSWB CLAIMS#UOE AGOREG/.TE S
DEC RETENTION$ $
B MRNERS COMPERONTNN WC 01 V 17099(AR.NH.NJ,VT) 03p12024 % PER ERTM
AND ENPLOYERS'LMBILT'
B A WROPRIETOWPARTHEWEXECUTNE IN WG 012II]10B(W) 0314112019 0314112020 E'EACH ACGOENT S 5.000,000
IOERMEMREREYCWDm] O NIP
(Manylpy in NN) E.L.DISEASE-EAEMPLOYE $ 5.043000
n eewmeume. Conowell on Ad9NUmi Pae 5.OW.000
DESCRIPTION OF OPERATIONS Eel— 9 EL.DISEASE-POLICY LIMIT $
C @cess ADR 29]11001,002019 031018019 03 lQD20 Ued'. 4100800D
A Excess Geneal Habili, MWLX 314560 03N12019 GMV2022 Grnd. 8,000000
OESCIiIPnON OF OPEMMW I LOCAPONSI VEHICLES MDDRD1pJ,Aa41HONI RenwN$tlietlulq mey0e erlxMaHmae sWw isnquiM)
EVIDENCEOFINSURANCE
CERTIFICATE HOLDER CANCELLATION
HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
24M PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BUILDING C 20 ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA,GA 303N
AUTHORID3DDREPREEEMATNE
M Meeh USA Inc.
Manashi IWGiegee
QD1933-2016ACORD CORPORATION. All rights reserved.
ACORD 25(201&03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: CNIO1642069
LOCM: Atlanta
---'i o
ACORLIADDITIONAL REMARKS SCHEDULE Page 2 of 3
AGENCY NI.MEDIN6110.Ep
MARSH USN,INC. THE HOME DEPOT,INC.
HOME DEPOT U.S.A.,INC.
Pouer RuMeER 2455 PACES FERRY ROAD
BUILDING G20
ATIPNTA,GA 30339
GRgrER NAF CODE
EFFECTIVE eATEe
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TIRE: Certificate Of Liability Insurance
WOMen C.'Assion Cumin-0-.
Came,Iinni Ireurznrefnm"0NOT Pmenrs
Poi Number.NtA CeONJO 491ALAR FLIn,W.KS,KV.MMS.MONENM,ND,OK,SGSD,TKWV.WY I
Eros.Di(MV2019
Eryralan Dale:031
JELL Limit RENOON
Corer New Hansomr,Iw.Imnce Compels
Pdcy Number'.NC 012717M(DC.OE.HI INMO,MNMT.NV.RI)
Eflocs.Dale:03N12019
E.pralion Data.0310112030
RL)Lmnt S5,000 000
Carrier ACE AmMimm as nce Company
PA,Numbed IVCD 065690566(DSQ A2,CA,IL,NC,OR VgWA)
Eq.Wle:031
Ewimmn Dale:03101
(EL)Ums 51000000
SIR:$1 ON."NR Nr is erase o1 AZ,CAIL,NCOR.VA.WA
Camey NeOmel Unon Fre IneuMnre Company
Poky Numb,MC 5505%IWO(CO CT GAMEMI.NV,CH P&U9
E6ectw Ces OX1019
ExpraPon a. 03MI 020
(ELI List$/600.000
StONNO Sift for Ne stales oI CO.ME,NJ,K1,DH,PA IIT
17500WS1111 Neale@WGC
SiOW SIR(or Ne ewr OLCT _
�V\
Co—NaOwal Union Fln Inwmo Company
?A,Mini MC NOSS1()9111NA)
ERe,t w Date:0101121119 1�/
Expmtion Dale:03MI020
(ELI Limo'.S4,5m NO
SIR$50,M
TAEmp'Oyen ESmd,mnby:
c,slillnwe union hemi CumPsy
Pon,Nome,TNS 0 6 5 2 21019 OA)
Effoo-Dale:OM112019
RipiaOOn!).610112920
IEL)LirM:S10,WU.000
SIR:$19W.000
ACORD 101 (2008101) ®2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
._ ��f'C f' L'-(1 ylC ill Ct/JCIt/'CC!�12- C�n�LCCS.iCCC62GC:Le�I:r
_: - Office of Consumer Affairs and Business Regulation
- 10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: Supplement Card
Registration: 112785
HOME DEPOT USA INC
2455 PACES FERRY RD C-11 HSC .
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SERGIY SUPfgJNCH
37's cmcopfl ST.-
MCOPEEMA-ai613":
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The Commonwealth ofMassuchnsetay
Department ofjndustrialAecideffts
_I Congresssfreey Strife 100
Boston,MJ 02114-1017
wo,millass.govAlia
91%others,Compems tion Insurance Afrdavtt:Builders/ContractorsBleclricians/Plumbers.
'1`0 BE FILF-D WITH THE PERallf-£ING AUTRORM.
A slieantlnformatiere ]')ease Print a ib]
Name (Business/OrganiznUONledividua0:-7— / ( 24 ir—4 ]pew ,6
Address: —q�—,0,19 �it(4�N f�7J7/d' T /7� e �1�, 7 7
City/Statefzip7/l�`(� ✓eA !7` Phone 4: —.;7;7� G7
Arernunn empkyera Qmak lheopiannoiat boa: Type of project(required):
L❑lamaemplpyer with_cmplaya(lall eadkepamtime). ]. ❑New construction 1
2.❑Iamnsnlepmprinlarvrpaf arshipaM haveno cmpioyvu svukinE rprmem
M rnpear, [No wokxli cum 8. ❑ Relnodclirg
a
0.insurance r.WireJ.] 1
a.❑lare a herr.orwr Juing alisark mpdr.!N.nvrF'mmp. mgead l a 9. Demolition
4 1nm a Immcawuernwwill bc hiring mead..,Iv condvdallwmkon my pmlerry. aunt 10E]Building addition
' al all cmnreaorseither havenorkem•rempercrivn imumnn ureresole Il.❑Elapbkal mind.or addlttm5
Pr lamrssvim wemploycn 12.❑Plumbingrepainoradditions
5. l am a amcmi cmwu0.ar and i have hired the suoepnuacmrs linad on a¢allaahe0 steel. 17.❑Roof repairs
Ti esc sllneceaclorz Imre emplyrasaM haveuvrkers`comp.insumna o
d we asum lion and itsaR�mshove ucrtiscd txird torutmn tion 14.❑Other
-❑ mora Eh p Pv a1(il.c.
!SS,§IW},and ve buena employxa.Mosvmkcrs'comp insoranve rcyvircdl
`rtny aUUlia�,nt lith chmksbm.1 must vtm nli aunha satian hiowsM1awinE tlrtinvolkurs'campnwmion polityinrormdise. fl
Bamep.unemwhy rrbaell tis.Malum iWiml'mg day am detai all work and Wm hireaeeide conuucWrs earl mhmila new anidsvil indiaoing such.
aCantmcm¢Ihas rbN dill box muslonvrbmanaddidaml sh«t drove,Warrants arm reaeanlmearnnd acre.J hr,or not those caddee have
emplaytu If tire adth vamaas leacemplayrer,try anon provide awir workers'comp polky camber.
r:
I nm mr emptoyer LRat irpropitlhkg wprherr'emnpensntion inaunmrcefor my enrployres. Befmvtr Ore pulley nrNjob rife
information.
Insurance Company Name: �,)�/p� ^/V� -y�,m/
Policy 4 or Self-ns.Lm FA C
25Y Expiration Dae: l/I/
Job Site Address: / Ng�DT L. ✓ City/Stme/Zip:
Attach a copy of the workerar compensation policy declaration page(showing the policy number and espten cndate). F/ vVV
Failure to secure coverage as required under NIGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,w well as civil penalties in the form ofa STOP WORK ORDER and a fine ofdp to$250.00 a
day against the violator.A copy of Ihis aurnment may be£arwarded to the Office ofinvestigations ofthe DIA for insurance
coverage VOT11 4011.
I do hereby certify r die ahrs nd t of ferry that fire itformationprovhled above is nneand emnct �S
jqSicnetur.,=�Yf�s1, __ Date, 3 � ��
Phone": :1rr✓//"-9��-ra-r�/2�
Official use only, bo not cattle in thisorea,to be ronrpleted by c/ry or town aJffciai
City or Town: Permil/f.icense k
feeding Authority(circle one): 1<
1.Board orld calth 2.Building Department 3.CIty(roum Clerk 4.Electrical Inspector i.Plumbing inspector
G.Other
Contac,Person: Phone$: