22D-069 (4) 90 FLORENCE RD BP-2019-1358
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 22D-069 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-2019-1358
Proieet# JS-2019-002188
Est.coat:$9482.00
Fee: $40.0o PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 104327
Lot Size(sc.ft.): 11891.88 Owner.- FRANKEL NORA
Zoning:URA(100)/WSP(100) Aooticant. HOME DEPOT AT HOME SERVICES
AT: 90 FLORENCE RD
AvyUcant Address. Phone: Insurance:
5RIVERVIEWDR (401)935-26330 WorkersComnensation
NORTH PROVIDENCER102904 ISSUED ON.512912019 0:00:00
TO PERFORM THE FOLLOWING WORMINSTALL 16 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: Fre Department Fireplace/Chimney:
Rough: OR: 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 5/2920190:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of No haLt
talus I Permit:
_
Building pe urb ul/Drivemy Permit
212 Ma St2 9 ZQ�9 ewer Septic Availability
Roo 10 its ell Availability
Northampt , MDiNn mEPFCTno WO is of Structural Plans
phone 413-587-124 I 72^1rr% --c Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION B P-(9'/-"S
1.1 ProoeMAddress: // This section to be completed by office
//�
^D J/ Map �a0 Lot Unit
GAG 'try Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Caner of Record:
s✓o✓Z� �iz�n' L 9D� -C�
Name(Prim) Curren Atltl aa'
TebPhom! /V'9
Signature
.2h dz
AnD �/ZO/J3 ����Dih, j 5
Curanl Mai g Md'ss:
Stodimme Telephone — >—
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Rem Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building v/�2 , ��j (a)Building Permit Fee
2. Electrical 7 C/ (b)Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee �YV
4. Mechanical(HVAC)
S.Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building PermumDate
Issued.
Signature: 5-28-Zoq
Build,ng Commiss,"Onspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING7 Air Information Most Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Rationed by Zoning
Thi,r h.m he fiBN in by
BuiWimg Dcpmmmnt
Lot Size
Fronts e
Setbacks Front
Side L: R: U R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(tm mm minor bNg B paved
pi"U19)
#of Parking Spaces
volume&Iu[aiiov
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 N
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 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 pan of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Stam Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement W tows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [O Siding[0] OMer(M
Brief Desc" lion f /L ✓J �n T�fw/ �• Q
Work: V r� iv �'!•I�^l'�s
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes No
Plans Attached Rol -Sheet
G.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?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
If. Type of construction
I. Is construction within 100 ft.of wetlands?_Yes _No. Is construction within 100 yr. floodplain_Yea_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
SFFOR
/BUILDING PERMIT
I, y✓�91,44 �'"'�J QCT �y .as Owner of the subject
property
hereby authorize
to act on may be/haytl,In all matters rola va to work authorized by this building partnit application.
Q
�i7FGSG C��i _�'��/
Signature or Owner Date
OEM-
I, as Owner/ rized
en ereby declare that the statements and Information on the foregoing application are true and accurate,to the best o ow edge
ef.
Signed u er Me Ins and nalti2latipsg�^ury,
OW
Signature downer M Dale
------------
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suuoe�Mya/m. Nott Applicable 13
l
Name of Liwe�nae Hold.,.
%75Number
m /9
AddressC qj/'� Expirmon Date
Signature � , Telephone
.Re isten N r n Not Applicable ❑ �-
--i7 //Z 7
n Regishration Number
AdExpiration Date
Gdress �
0��� Telephone &)--�
SECTION 110-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§25C(6))
Workers Compensation Insurance affidavit must be wmpleted and submitted vrilh this application. Failure to provide this of is avt vnll result
in the denial of the Issuance of the buildin t.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
z
.�� Massachusetts
D]PMIS6NT or ]WILDING IN"Kerims
212 Nein $twat • Imniclpal aullainq
northm,t , 1u 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("H IC").
M.G.L.Chapter 142A requires that the"reconstruction,alteration,remmsion, repair, modernization, conversion,
improvement mrnoval,demolition,or construction of an addition to any pm-existing ownerbccupiad building containing
at least one but not more than lour dwelling unas..,.or to structures which are adjacent to such residence or building'be
done by registered contractors.
Nott.If the homeowner has contracted with corporation or LLC,that endly crust be d.
bee registere
Type of Work: fog ,17*ha�! Fsst.� t % :0 2- �
Address of Work: %[/ L��-//mac/- �QG
Date of Permit Application:
1 hereby certify that:
Registration is not required for the following reason($):
_Work excluded by law(explain):
—Job order$1,000.00
_Owner obtaining own permit(explain):
_Building not owneroccupied
—Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH 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 ag nt of the owner:
i/Z �
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
Massachusetts
DYPANTNBNT OF BUILDING INSPECTIONS _.
212 Ma" 5[zeet • N iN ip-1 Building
NorNampton. M 01060
Massachusetts Residential Building Code
Section 110.85.1.2
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 110.115.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.115,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
'f Massachusetts a "%
DHPAR6}IDIT OF HOII',D)TX. IMSPiCS10Mb
212 Main fi r t 91e iaipal Wilftn
HortE ton, ML 02060 qc
Debris 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.
The debris from construction work being performed at:
9D �= G� RZ
(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 annd 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 pi Massachusetts
Department of Industrial Accidents
/ Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
WNVorkers'Compensadon Insurance Affidavit:Buflders/Contractors/Electrlclans/Plumbers.
TO BE FILED WITH THE PERMITTING AIDI DIUM.
Applicant Information Please Print Leeibly
Name(Business/Orpnizanon'Individuap:
Address:
City/State/Zip: Phone#:
Ara you an employer?Caark We appropriate bar: Type of project(required):
I.[]I am a mryloyer with rngloyces(inn auditor pearl-larr ' 7. []New construction
2.❑Iamawicp demrorparmashipmdhavenoemployeeswodiag torment 8. Remodeling
any rawcily.[No woken'corny.,m ..ea d.l
9. Demolition
Ieme hersawer doing on wh myself Moworkmicomp.insurance '
4.[]l am a tamowocr and will be hiring canmcrors to conduct all work on my property. I will 10❑Building addition
nnan that all ranmcwrs either hove worken'compensation insurance or she sale IL❑Electrical repairs or additions
politician with no cmployeca.
12.[]Plumbing repairs or additions
5o I am a general ammo lar and 1 have hired the sub-connecrors IisMd on the auxhed stem.
These subaonnauors have emploYW^and have wcialki comp.in,mareat 13Q11oofrepairs
6❑We ere a corrwnnon and in inters have monvisd Weir right ofsh emption per WL c. 14. Other
152,g1(4).and we have no empbyees.[No workers carry.insurance related.)
•My
affluent that checks box#1 man alw fill ve..he vection below showing Weir worker',mar,atwtion policy information.
t Hom caner who submit a¢affidavit indicating they an,doing all work and than hire outside conh.cmrs must submit a new affidavit indicating such.
:Conawmrs that check this box moa...had no ddidoned sheet showing the name of the,wbavharmhors and slam whether or not those entities have
cngrloyas. Iflhcsub nt tomhavicemploycs,Wcymuaporidclhcir wmkas'wmp.policynumW
I am an employer that is providing workers'compensation insurance jar my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#in Self-ins.Lic.#: Expiration Date:
Job Site Address: City/SroerlLip:
Attach a copy of the worker,'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MOL c. 152,§25A is a criminal violation punishable by a fine up m$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy oflhis statement may be Forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cerafy under the pains and penaaies ofperjnry'thm the information provided above is true andcorreem
Simmture' 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.CItyrrown 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 m this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,om1 or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or my 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 ufan individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more thm three apartments and who resides therein,or the occupant of the
dwelling house of mother 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 my contract for the performance ofpublic work until acceptable evidence ofcompliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill am the workers'compensation affidavit completely,by checking the boxes am apply in your situation and,if
necessary,supply sub-contractor(s)annals),address(es)and phone namber(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 tarty workers'compensation insurance. If anLLC or LLP does have
employees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial
Accidents fm confrmation of insurance covemge. 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 ifyou are required to obtain a workers'
compensation policy,please call the Deparunmt at the number listed below. Self-insured companies should enter their
self-insurance license number on the Mmpriaw 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 pemdUlicense applications in my given year,need only submit one affidavit indicating current
policy information(if necessary)and under"lob 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 proofthat 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 in any business or commercial venture
(i.e.a dog license or permit to bum leaves mc.)said person is NOT required in complete this affidavit.
I he Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel.#617-727-4900 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. (if 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.
FRANKEL NORA New England South 1-LXRU118
Customer Last Name Customer First Name Store #/ Branch Name Customer Lead/ PO#
90 Florence Road Florence MA OlOfi2
Customer Address City State Zip
(3101351-6797 nora.frankel@9mail.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 CUstomercancellationnortheast@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
DEPOT'S 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 RIGHT TO CANCEL.
Acknowledged by: I 04/16/2019
C tomer's Signature Date
Contract.Price and Payment Schedule : Payment of the Contract Price is due upon signing unless a
different payment schedule is required by law, specified below or in a payment addendum.
Contract Price: $ 9482.50 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 $ 2370.63 Remaining Balance $ nns7
The Home Depot-2455 Paces Ferry Road, N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1-8004W3337
aeon Noe c�..—A,,—"m 11(NI A I, I + U a
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Home Improvement Agreement: Page2
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
an 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 � be used to pay some or all of the total amount of sale.
Description of Work tobe_Performed:
Installation ofwindows
A more details
a Description Or me worK t0 be performed Is incTuded Int the section entitled cope 0
Work which appears on page = of this Agreement.
Anticipated Delivery Date/Installation Schedule
Approximate Start Date: 06/11/2019 Approximate Finish Date: w/o9Jz01s
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.
nitialing 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.
04/16/2019 The Home Depot
umers gnat
stoure ate bervice 11roviaer Name
X I 04/i6J2019 908 Boston Turnpike Unit 1
Qq-Mler p Ica a ate ServiceProvider Address
_._ � � � �
X 04/16/2019 Shrewsbury MA 01545
lure Behalf o Home De of ate tate I
ervlce Frovider Phone Number t5ervice Provider Liceran Um Br
The Home Depot-2455 Paces Ferry Road, N.W.Bldg. B-3. Atlanta, Georgia 30339-Customer Care: 1-600-466-3337
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Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: Supplement Card
HOME DEPOT USA INC Registration: 112785
P O BOX 105451 Expiration: 04!22/2021
ATTN: LICENSE MGMT TEAM
ATLANTA,GA 30348
Update Address and Return Card.
SCA t O 20M1 17
.T� �nrinrnu rvp/// � /�2Aiirbiniry/L'
won of Consumer ARain B Business Rpulatlon
HOME IM PROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Supplement Card before the expiration date. N found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
112785 041=021 1000 Washington Street -Suite 710
HOME DEPOT USA INC Boston,MA Ila
t
RICHARD TROIA /
2455 PACES FERRY RD C-11 HSC �r(�rw...YlGy.11r�r
ATLANTA'OA 30339 Undersecretary Not valid Without signature
i
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ACOROB CERTIFICATE OF LIABILITY INSURANCE F
1O2ANA,9
V
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES HOT AFFIRMATIVELY OR NEGATIVELY AMEND, E)CTENO 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: R the cerllOcate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED Provisions or be endorsed.
If SUBROGATION IS WAIVED,aub)ect to the terms and condBlons of the policy,certain policies may require an endorsement. A statement on
this cartlRcats does not confer dgMe to the cetRlcate holder in lieu of smh endorsament(s).
PRODUDfe
MARSH USA.INC. PHONE
1WONUANCECDTTER
AND
FAX
35 R)IENOX ROAD.SURE 2100 Erna
ATLANTA GA 303N
msu s MFORONGgOVEINrE MIAMI
CN10IM2099H=sD-CAW-,420 MoURPMA;Ok)RMPsICIMWMM8CG N147
IMMUD
HOME DEPOT,INC. MsuRota:N6a Nam ire Ms Co 23041
HOME DEPOT U.SA,INC. aMus.C:Hanelbu,Camn,hu..
NM PACES FERRY ROAD
SULDINGC.TD amuneao:
ATLANTA,CA 30319 MDRfRf:
NNMER F:
COVERAGES CERTIFICATE NUMBER: An4MG5N31a20 REVISION NUMBER: N
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 SE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMB.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS.
IYPEIi MSUMMCFMar, MMINUMM AMMAXVYMYN
POMCYEFF PGLLYEMP �a
A % eoerMRCNLoss.unaury MWZY 31494 03038019 03018022 EACHOCLTrRENOE t 1,OMJNO
CV.IMSIMOf OOCCIIR RMrU—
Pnmmmca.l $ 1,034WD
% SRSIM001 MEUCPI S E%CLUDw
PEPspMLa.hO/NMIY S 1.000.000
BENLPGCREGIELgyMry AP0.ES FFR GBIEWLLAGOEfMTE f t•�AO
% PG1CY❑JECr 016 PRLWC3-COWmPAGG 1 1.004.004
Oecaus e
A AUmtoelhs wevlr MWTB114513 01018019 B40iR022 aINFD SN LMT f 1,0003100
% INY"M BODILYINIURYIPerpeiv,) f
OWNED BCH®UL(D SELF INSURED AUTO PINY DWGBOMLYIMJURYIPNaGleO f
AUTOS ONLY AUFOS
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AUTOSOKY AUiggY.V f
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F. PE" TIONS s
B Manes COMPENSATION 01221T0991AN.NH,NJ, 0301 % A
11ID EMP ..IV WBILT'
B NIYPROPPPITe.PATI NPN ECIRIYE YIN YA"Di2F1T1UB(V/) D3B1/(U19 D3,t11 RD2Il ELEnC1hA S 5,001000
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EVDENCE OFINSIXUNCE
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 V2L BE DEWERED IN
BUILDING C10 ACCORDANCE WRNTHE POLICY PROVISIONS.
ATLANTA GA 319
Am HMAZEDRERIESENNUINe
M Ihvsh USA Inc.
MaI M.kh.q. �YL0.Lt4Oh-� �}LuJc+e✓.a+A-
01938.2018 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: GN101642069
LOC#: AUenla
ACOR& ADDITIONAL REMARKS SCHEDULE Paye 2 1a a
aae1cr xaxmw THE N
MARSH USA,INC- THE NONE DEPOT,INC.
HOfE IIEWTUs.A..NIC.
watt xuYBEN 2A3 PPtESFERRY ROVI
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ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: CerlifiCale Of Lia0illly Insmi-ice
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Guru.IMxnaly Inwntn Comsry a IMvh anwis
PdNy Number tun L65M0599(aVR.R,oJA,lsmlAef,NO,xENM,ro,ON,uSO,Mwvwv)
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ISULi iI'510.000,001
SIR.S1Om.m0
ACORD 101 (2008101) ®2008 ACORD CORPORATION. All nghts reserved.
The ACORD name and logo are registered marks of ACORD
The Commoniveahh ofMassachaselts
Department of 1ndru1r1ulAccidenfa
1 Congress Street,Suite 100
Bostms,MA 02114-2017
www.massgovfdlo
Workers,Compensation Insurance ARdavtl:SondeNComraetorsfElectricians/Plumbrss.
TO BE PILED Yy1T1ITRE PER1,117TING AU77JORITY.
Apidicant Information 11).Print Isvibi
Nerve(Business/Organimdm✓Indai'v�iddell -' ` ' y 2
Address: DPj �i 1alhl 79x)11 T /j� e
City/St¢te/Zip• )�L Nl �PhDn60:
Alar9D on ernplayer^Check the Dltpmprat boa: Type of project(required):
L❑Iama emplty"'ith_cmnloyeu(:un amllarmnaimDj' _ 7. New construction
2.Qtamamlepmprielarorpann=hipmdhamaocnmtoyen%wAmg rorm:•n 8. ❑Remodeling
any mp9nn.INo awkcss'mmp insane.r:yoiredj 9. ❑Demolition
l.�I and homeDaimr doing all emrk mymlr.M.a9rAers'comp,inawnro mTylr a.15
❑Iamel:otteavSacr Dtti will4h'uingrnmmc;tars lD ronducmll\wean my w9Pmm. tall IOQBuildingaddidon j
nt ail camrcmrseimenmvu\xrteti cxmP`omODlmemnceoremmm 11.❑Eledrieal repairs or additions
mon wish ne cmployecs
12.❑Plumbing repairs or addidom
3. amagencd cantruaor mile
Ondlhavc ulna mcwuaantmcmn lilN an tM marLedsM1eei. I]_ Roofre in
TtnsoPcon , rsbave cmPloycm and haK\v9rkers`camP imumnce.t ❑ Pa
d.❑WCM a consomme ana its oRmmlmivemcbcd One dxhtoresanpme e,Mots 14.06Iher
153.§I(a},Nd\K ImYe pD e1pp�,0)C4 p'rD99rtert�P In5m911aC Ittjuir[11 C
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'Any nVPiimnuM1ar submiluoel must DBD ell Dnl the maion udew mM ang ann nineous'eempaamion polity llormnsmn. F
t Xonmmvmers.vbesubma the andarit iulivating tory amdoing all xnm xPl ORn'nire omsi�mnmeme rami submit a MvaatJavil imfiruina such.
tCommctorstuatdmek Ot6 uosmminttachmlmaddiytim5ttrsuetNng wOM,*orN, policmumbt,.sum\eMtMrar rat dwm mriticz have 1.'
empluycn. II'tbe snb.mnmdorshavicetnployms,tM1cy mea pmviJetM1eir wm4rs'[tamp Polity numue-.
I ontmr wrployer rho Sprooirdd/'1mapwY�or`kers'cmnpumalqqllon�iiynn�surance/foorary'einnpollo/yees. Belmvistbeponcyandj'oolshee'q^
infor,mccC 69wV g )VkbA)A7 6WXW
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Policy d or Self-ins.Liu 4:XbX, 255: 1635W Expiration Dam-
Job
Job site Address: 9U )Qhei.✓G� Ae Citylsmte0p:1 ,, :,� 0 D/OGZ
Attach a copy of the workera5 compensation policy declaration page(slamming the policy lioaltbv dcxpi (ion date).
JPailure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a fine up W 41,500.00
and/or one-year imprisonment,as well w civil penohin in die form of a STOP WORK ORDER and a fine of up to$250.00 a N
day against tiro violator.A copy of this statement may be fewardcd to USE DIE.0 oflnvcstigarions of the DIA for insurance ti
wvcrage verification.
I do hereby cerdfy ph de ms nd r of }tryJhnl fee infornmlion protided uba is lraennd ro reet
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Offrcterl use only, Do oaf wrl!e In this area,to be completed by city or faun official k-J
City or Town: ParmiJ/Liceace a
turning Authority(circle one): .
1.Board of Health 2 Building Department 3.Chyfrown Clerk 4.Electrical Inspector 3.Plumbing Inspector 1'
G.Other
Contact Poem': Phoned:
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