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23A-202 (2) 57 BEACON ST BP-2020-0173 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A-202 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Door Replacement BUILDING PERMIT Permit# BP-2020-0173 Proiect# JS-2020-000286 Est.Cost:$2882.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 104327 Lot Size(sg.ft.): 9496.08 Owner: PARENT KATHLEEN Zoning: URB(100)/ Applicant. HOME DEPOT AT HOME SERVICES AT. 57 BEACON ST Applicant Address: Phone: Insurance: 5 RIVERVIEW DR (401)935-2633 0 Workers Compensation NORTH PROVIDENCER102904 ISSUED ON:8/9/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL I REPLACEMENT DOOR 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 sienature: FeeType: Date Paid: Amount: Building 8/9/2019 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner A :U E epartment use only City of Northampt n Idelmit:- .>> Building Departm n Curb Cut/Dri ew y Permit ` 212 Main Stree i A�(JG - ref p y e e ti A i ability Room 100 % Water ell va la ility Northampton, MA 1 6Q. x� wo Sets o Str c ural Plans phone 413-587-1240 Fax 1 r AMD1) I tBFa3ts 01060 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A22ONE OR T//W11 O FAMILY DWELLING SECTION 1 -SITE INFORMATION �v���� 1.1 Property Address: This section to be completed by office Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name( rint) � Current Mdr�$�� Telepph nene� Signature 2.2 Authorized A ent: Name Cu rr e t Ma ling Address �T Signatur Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permitapplicant licant 1. Building 2� Z, (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total= (1 + 2+3+4 +5) Check Number This Section For Official Use Only Building Permit Num r: Date Issued: Signature: 9-q,26)?-9'26) ! Building Commissioner/Inspector of Buildings Date @ Z2,— elf 2-7 L'42L '?�� 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 Tliis column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® DONT KNOW O YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © 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 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 ® , 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 © 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 0 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 ❑ ReplacementBows Alteration(s) F-1Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[p] Other[dJ Brief Descript'on f Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No C Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building :One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each 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 FOR BUILDING PERMIT as Owner of the subject property � e- � hereby authorize to act on my behalf, in all tters relativ to work authorized by this building permit application. 6a U Signature of Owner Date I, / zneas 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 under the;2 danad enalties of erjury. Prin me Signature/of 0 e Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: v L� / ��� License Number Address Expiration Date Signature Telephone 9. Registered Home Improvement Contr tor: Not Applicable ❑ Company Name Registration /,L , I �^ Addres Expiration Date 0- am/-L J 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 building mit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton Massachusetts ,. ..s.c4r w D"ARTMAIT OF BUILDING INBPSCTIONS 212 Main Street • Municipal Building C Northampton, Mh 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 are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted ti ith a corporation or LLC, that entity must be registered Type of Work: Est. Cost: Address of Work: cJ 'cam/ �i �/l�_ �� Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied 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: 1 hereby apply for a building permit the agent of the owner: _ 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 N: DEPARTMENT OF BUILDING INSPECTIONS 75 x M 212 Main Street • Municipal Building yJ`., Cam Northampton, MA 01060 ss�„ 11 Massachusetts Residential Building Code Section 110.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.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.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 -A W DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Northampton, MA 01060 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: -�-7 g��Zzrl--7 (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) 11-�7 C TN� Signature of Permit Appl cant 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 IndustrialAccidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 www mass gov/dia Workers'Compensation Insurance Affldavit:BuHders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lelaib(y Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with cmployccs(full and/or part-time).* 7. ❑New construction ?.❑I am a sole proprietor or partnership and have no employees working for me in 8. r-1 Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.] -t.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10E] Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL C. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have cmployccs. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepo/icy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$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 under the pains and penalties of perjtiry that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.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 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 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 be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may 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 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 w Home Improvement Agreement: Pagel Home Depot License #'s - For the most current listing www.Homedepot.com/LicenseNumbers MA: 107774, 112785 Rayon Robertson 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. PARENT KATHLEEN New England South 1-MDZU57Z Customer Last Name Customer First Name Store # / Branch Name Customer Lead/ PO# 57 Beacon Street Florence MA 01062 Customer Address City State Zip (413) 586-2219 1 parentbridge@hotmail.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 Shrewsbury MA 01545 Address City State Zip Or Email: I 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: 07/16/2019 Customer'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: $ 12882.00 Includes all applicable taxes. Excludes finance charges.* Sales Tax: $ 10.00 (If applicable) *Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, WI (99%) Dep. 1 25.0 % Deposit Amount $ 1 720.5 Remaining Balance $ 1 2161.50 The Home Depot-2455 Paces Ferry Road, N.W. Bldg. B-3,Atlanta, Georgia 30339-Customer Care: 1-800-466-3337 4601`I HIDE Customer Agreement(24 Jul.18) , p.1.8 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 loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payment(s) made payable to The Home Depot. Insurance proceeds will will not be used to pay some or all of the total amount of sale. Description of Work to be Performed: Installation of 1windows A more detailed description of the work to be performed is included int the section entitled Scope o Work which appears on page F--] of this Agreement. Anticipated Delivery Date/Installation Schedule Approximate Start Date: 09/10/2019 Approximate Finish Date: 10/os/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 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,ini ' ling 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 A ement. Keep it to protect your legal rights. X 07/16/2019 The Home Depot u omer's ignature Date Service Provider Name X 07/16/2019 908 Boston Turnpike Unit 1 Co-Signer (if applicable) Date Service Provider Address X 07/16/2019 I Shrewsbury MA 01545 Si natur half of Home Depot Date City State Zip rvice PrfttlTer Phone Numbe Service Provider License Number The Home Depot-2455 Paces Ferry Road, N.W. Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1-800-466-3337 4601`I HDE Customer Agreement(24 Jul.18) v 0.1.8 I WINDOW SPECIFICATION SHEET - Spec.Sheet#: 1-MDZU57Z Sheet: 1 of 1 Customer: KATHLEEN PARENT Job#; 1-MDZU57Z Consultant: Rayon Robertson Date: 07/16/2019 P► New Window Existing Window Hinge Locations Measurements Grids Product Options Labor Options From outside, Left to Right Bays,Bows Location Color Rough Opening #of bars #of bars Csmnts,1 PM, use L,R or S Glass Mise Items ! Hardware Code Screens For doors use Mull "S"=stationary or W Style Wraps m m a In "X"=operating t Room Floor Code (YM) Style Code Series Code S w 3 = D r'c6 L� a > i > 1 PORCH list PD Y PD-C 6100 WH WH 96 60 176 STD,White,TMP:Full, WRAP, Olasspack:Standard CHRG B/6/ X S 2PNL PD,LSR SPECIAL CONSIDERATIONS: 1:White Wrap Color Interior Casing Type Bay or Bow window: eatboard material(vinyl only-Birch or Oak) ay Project Angle(30 or 45) ay Flanker Type(DH,SH,or Csmnt) op of window to soffit(inches) I Gad to soffit,color of soffit material I have reviewed and agree with all the job specifications above and the Construct Roof(Yes or No)' Special Terms and Conditions on the following page Garden Window: Seathoard Material(vinyl only-White Pionite,Birch or Oak) �• -.... - . -i - -- -- 31es1aa��n'•l.fr,���ra� - { - �� �-^'`'•�y��a !�'-i::wi.=`•LT.:: �.,.. .i..--^^,u r..-.�25 .�'�8i!-�OL'==-�' :;""' .rico3- ! _ •C�'• cast-� }.—tG us j }-em-n-m_.dads_t:Mma ,r--Ra-?T air i�.Ade;o A-rgan -LorLc Sm ifirec tarlred a mor reiHas LtU La Z!Bl.0 M 10 R1.19iile-MOO '( i( '.'tati mi�_aaEmiAgip!Dc!tm at -.-,a i •i ib ;; -_ - --•--��:�:�-�----= -_-=- -_,;-:._-�:-_ - -�_ _ " =--_�.__-�.:= is ^��'..-•�.c+.a�cG!J�-'� ,�--mil,-_.:° t �i � c•-g'�,_�''-`-.-`.��'=���:-:sem;'�y - : _ %; _=•-=^'ice=' ":_�---.:t:? _'��'""� �• _ `-';:_:� UrZigtrHi:�iOi :729af.. rgicnisl-�tati=r:i. at ialy^:ui v6i ual,Soti:ll cants 1, z 72..=:.a_,ITast-aa Sim Aa"x8v, A!�:amain OOtGiass!�;•oSn;.�M-LC��: Fl -J r �l i( l to rciic�P ud-u 'Apps_mk.Ei_tiz8: f a - rl eioD{C?.oi3:cAAMWIDIMliM i3 izo c 64C-Oi)_:3A .?3y6[$t�li3 i Q1?3,.., 'i `t Ss:u:�..� - - � -_:-_vs_`r-.-__...i-y.._.'_�i�.=�:•.�u L7G a.=_..--i.=.-r iit 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 sca 1 1 z0,V.os17 Update Address and Return Card. .�/� �iviiiiiiv�u,ai�/: ���. /�•7-i-i it/��-::-/.!: Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Suoolement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 12785 04/22/2021 1000 Washington Street -Suite 710 HOME DEPOT IDSA!NC Boston,MA 0 118 RICHARD TROIA 2455 PACES FERRY RD C-11 HSC �,T*�1 . ✓��' - �L�G �� ��` ATLANTA,GA 30339 Undersecretary ` Not valid without signature The Co1run3ostive(lith of Allnsstaclrt1se!is r �} Department of IndlistriulAeciden#s ' 1 Congress street,Shite 100 Bosun;Blri 02114-2017 nrivif•.tliass.ovIt la ur#et s'Compensation Insurance Affidavit:Builders/Contractors/E lectricians/Plumbers. TO 13E TILER WITH THE PEP1•IIT iNG AU'F ilORIT1'. Ao flit ant inform tticn Please Print Leoibl j Name (Business/Org;mi:otion/individual): p Address: �� � 9A/ TL)7RA) City/State/Zip: /7 Phone 1 Are you nn employee.Chcclt the apprupriat Loa: Type of project(required): I Q 1 am a employer with —employ.—'s(full andtur pan-time).' i 2.�1 2m a sole proprietor or partnership and have no employees working ror mem 7. ❑New construction uny capatat_v.l"10 workers•com 8. Ren7adt ling p-insurance retluir�.i.j 3T( 1 am a hamaow.ter doing all i,ork myself.RNa earl;eras'comp.insuranrs rrtu;r•_,; t I 5• ❑Demolition a[�t am a homeatitner and will i e hiringcortmcw to condudnll work on my . 10 El Building addition 1 cnsur•tat 211 contractors either have workers'compensation insurance or=-sv)m 1 will P-11 ,fetors with no employees. 11.❑Electrical repairs or additions 12.E]Plumbing repairs or additions r am a general contractor and I have hired the sub-contractors listed on the allached sheet. Tltese slat-eerttracttns have employees and•nave corkers`comp.insurance.: 13.E] of repairs u.Ej—lvcara2corporationanditsatTicershnvecxerciscdtheirrightofexcmptionpertviGl.c. 1`I• Otlier �gQ� i' i2, .1(4),and we have no emplo)-ees.[No%varker'comp.insurance r•.:t uircer.] `Any appliL2nt that eh��ks box !must nlso idl ottl the s�c"a LelovV S11t11Ylna,their ser>ers'contpzrsation policy inrormntion- liuneowners woo submit this aft'tdavit indicating they ar doing all tieor, anj Te'-hire outsit!_contructos roust submit a new arfidsvil indicating such, rCentrctors shat check this sox must onachcd an additional sheet shat.4ng the nerve of the suh•eataractor ono state nhethcr or not those entities have # employees. lithe sub contractorsltave employees,they mtu[provide their:votkcrs'cam p pol"y number. /Clll rr11 e117,r1/G)rer fI1R1lS/7raVidf/!J 71rDr/vers t'0 npenstition irrsrrrnlrcef0r " employees. 3elon=is11ep0/icy Rndjobsilr lllf Ol111R1101I. � ��?>�� 4TM )AZ (CDU,12Winsurance Company Nrrrie; Policy R'or Self-ins.Lic. � Expiration Date: �l ;3 Job Site Address: City/SIaIe/2ip: , Attach a copy Sf the workers'compensation policy declaration page(showing the policy number and expiration flat/� Failure to secure coverage as required under MGL c. 152,S25A is a criminal violation punishable by a fine up to$1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fins: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 11erebp certify 1 de sills nd 11R O !rr y' Jp j } tlini lite i1 jvrnlrrtioit prodded above lr11e and carred Si naitirc: l ,1 Dote_ Phone r: Official use 0r11y. Do not write in this area,to be coMpleted by clty or town ofciai City or Town: Permit/License# Issuing Authority(circle one): i- 1.Board of Iienlih 2.Building Department 3.Citjr/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector G.Other Contact Person: Phone#• A" CERTIFICATE OF LIABILITY INSURANCE ATE(MODIYYYY) 19 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 policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER-' CONTACT MARSH USA,INC. NAME: TWO ALLIANCE CENTER PHONE FAX AIC No Ext: AIC.Net: 3560 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC 0 CN 101642069-HomeD-GAW-19-20 INSURER A:Old Republic Insurance Co 24147 INSURED THE HOME DEPOT,INC. INSURER B:New Hampshire Ins Co 23841 HOME DEPOT U.S.A.,INC. INSURER C:HomeRisk Captive Insurance Comany 2455 PACES FERRY ROAD BUILDING C-20 INSURER D: ATLANTA,GA 30339 INSURER E. INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-00-4353439-28 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR D POLICY NUMBER MMIDD MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY MWZY 314574 03/0112019 03101/2022 EACH OCCURRENCE S 1,000,000 CLAIMS-MADE OCCUP, DAMAGE TO PR A4 S S a o=nccI $ 1,000,000 X SIR:51,000,000 MED EXP(Any one person) EXCLUDED PERSONAL 8 ADV INJURY 5 1.000,000 MX 'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 POLICY PRO- JECT LOC PRODUCTS-COMPIOPAGG S 1,000,000 OTHER: S A AUTOMOBILE LIABILITY MWT6314573 10310112019 0310112022 COMBINED NNGLE Lud1T S 1,000,000 (Ea a cdent X ANY AUTO BODILY INJURY(Per person) 5 OWNED SCHEDULED SELF INSURED AUTO PHY DSIG BODILY INJURY P AUTOS ONLY AUTOS (Per accident) b RED NODI-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident a $ UMBRELLALIAB OCCUR EACHOCCURRENCE $ EXCESS LIAB CLAIMS-MADEJ AGGREGATE b DED I I RETENTIONS S B WORKERS COMPENSATION WC 012717099(AK.NH,NJ,VT) 03/0112019 03/01/2020 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER B ANYPROPRIETORIPARTNERIEXECUTIVE YIN WC 012717100(t^A) 03101/2019 03101/2020 5,000,000 OFFIC.ERIAIEMHERECCLUDED? ❑N NIA E.L.EACH ACCIDENT 5 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 5.000,000 II es,describe under Continued on Additional Page 5.000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Excess Auto 297110011002019 03/01/2019 03/01/2020 Limit 4.000,000 A Excess General Liability MV/ZX 314580 03/01/2019 03/01/2022 Limit: 8,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee �Lavtoo tc t ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CM101642069 _ LOC#: Atlanta AC ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED MARSH USA,INC. THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 ---- ATLANTA,GA 30339 CARRIER NAIC CODE i EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Carrier.Indemnity Insurance Company of North America Policy Number:%VLR C65890549(AL.AR.FL,ID.IA,KS.KY,LA,MS.610,NE,NM,ND.OK,SC.SD.TN.l1(kr.WY) Effective Date:03/01/2019 Expiration Date:03701/2020 iEL)Limit:55,000,000 Carrier:New Hampshire Insurance Company Policy Number:WC 012717098(DC.DE.HI,IN.MD.MN,MT.NY,RU Effective Date:03/01/2019 Expiration Date:0310112020 IEL)Limit:S5,000,000 Carrier:ACE Amedcan Insurance Company Policy Number WCU 065890586(OSI) (AZ,CA,IL.NC,OR,VA.'NA) Effective Date:03101/2019 Expiration Date:03101/2020 (EQ Limit 54,000,000 SIR:$1,000,000 SIR for the states of AZ,CA,IL,NC,OR,VA.4VA Cater:National Union Fire Insurance Company Policy Number.AVC 5565596(QSI)(CO,CT,G.A,ME,MI,NV,OH,PA,UT) Effective Date:0310112019 Expiration Date:03101/2020 1EL)Limit:S4,000,000 51,000,000 SIR for the stales of COAIE,NVAII,OHRA,UT S750,000 SIR for the state of GA S350_000 SIR for 1tie Mate-LC—T—, Carrier:National Union Fire Insurance Company Policy Number XWC 5565597(QSI)(F:IA) Effective Date:03/012019 Expiration Date:0310112020 / (ELj Limit:S4,500,000 SIR'$500,000 TX Employers XS Indemnity: Carrierlllinios Union Insurance Company Policy Number:TNS C65221019(TX) Effective Date:03/01/2019 Expiration Date:0310112020 (EL)Limit.510,004000 SIR:$1,000,000 ACORD 101 (2008/01) C 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD g oa rd o uF cft 1.3 t t�E �+enc.and Shn.-dixrds t3 tti: s ioEder IF ._ ._. _.-..•--•<�..,_.,_-....-,....-..r,-,ems_ :-,•...-.-•.-.-.s-t.-R-.- ._�-•--_..�;..ti�: .c..«r.-�.-v 1