25C-235 (10) 183 BRIDGE ST BP-2016-1476
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:25C-235 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit- BP-2016-1476
Project JS-2016-002530
Est. Cost: 510683.00
Fee:$69.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 101342
Lot Size(sq. ft.): 19079.28 Owner: RANSOM GARY
Zoning: SC(67)/URC(33)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 183 BRIDGE ST
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401)935-2633 O Workers Compensation
NORTH PROVIDENCERI02904 ISSUED ON:6/14/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMO & INSTALL CABINETS, FLOORING, BACK
SPLASH DRYWALL AND 5 REPLACEMENT WINDOWS - NO STRUCTUAL CHANGES ***
SEPARATE ELECTRICAL & PLUMBING PERMITS REQUIRED***
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: OI: 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 6/14/2016 0:00:00 $69.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1476
APPLICANT/CONTACT PERSON HOME DEPOT AT HOME SERVICES
ADDRESS/PHONE 5 RIVERVIEW DR NORTH PROVIDENCE (401)935-2633 0
PROPERTY LOCATION 183 BRIDGE ST
MAP 25C PARCEL 235 001 ZONE SC(67)/URC(33)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT - / .(] -----
Fee
Fee Paid C.
Building Permit Filled out
Fee Paid (p/�
Typeof Construction: DEMO&INSTALL CABINETS. FLOORING,BACK SPLASH DRYWALL AND
REPLACEMENT WINDOWS-NO STRUCTUAL CHANGE /
New Construction e ,,,, •1 ��
Non Structural interior renovations _ lit Isr
3,ddibon to Existing _
noret
Access() Structure afi
Buildin° Plans Included: a --- .0 if;
Owner!Statement or License 10 342 r C�LA, I, �p Q i i
3 sets of Plans/Plot Plan / ` G
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION :ASED ON
INFORMATION PRESENTED:
roved rmits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
_
Septic Approval Board of l lcallh Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
D— r • I� � /
. ure of Buil ng ffimal Date
Note: Issuance of a Zoning permit dues not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
Department use only
T�� r, City of Northampton Status of Permit_,
R�.0 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
I .IUM 13 Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
p _ -- J ph ne 413-587-1240 Fax 413-587-1272 Plot/Site Plans
__ _. __.. Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
/� ,/,/�/n /vim/p/'y�_ Map Lot Unit
1 X13 eag�`�t — Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Gey 1"3 $7zi7> 5T- 11/4/B )1p9-J
Name(Print) Current Mailing Address: OMR)
Telephone
Signature
2.2 Authorized Agent: t Pik
�
uts
Nam p /, � Current Mailing Address:
/ dol 73 y
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1 Building /rfl)((�KJ (// �y3 60 (a) Building Permit Fee
2. Electrical (b)Estimated Total Cast of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5 Fire Protection
6. Total=(1 +2+3+4+5) I Jjr - 1 Check Number tor
—
This Section For Official Use Only
Building Permit Number: Issu
Dal etl:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING ALL Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size ... . ._. _.. _.
Frontage -
. _.
Setbacks Front
Side
Rear
Building Height
Bldg Square Footage
Open Space Footage %
(Lmareaminusblde&paved - --
parking)
#of Parking Spaces - -'-'
(volume&Location) _.._ _...- __. _...-___.-_..
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q
IF YES, describe size, type and tocation:
Will the construction activity disturb(clearing,grading,excavation, or filling)over acre or is it part of a common plan
that will disturb over 1 acre/ YES Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) I r Roofing n
Or Doors [ —
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [q Siding[0] Other •A 7_/J
Brief DesI,•n of Pro•• ed / � .tLG. G • -`JA"�Z/'Sa �d>H�/ = �i •
Work NN . ,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
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 APPLIESS FOR BUILDING PERMIT
�0,71/✓Pas Owner of the subject
property ./�/j, /Y,� T�f �. yam,
hereby authorize /✓/LA\M 1/ /< <-O•)o/
to act on my behalf, in all mat era relative to work authorized by this building permit application.
C * H3
Signature of Owner q� �1 ra Date
t ' 4st Q,�"6/)// ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed u••- the pai s and penalties ofefiur-v
/,• d 0 / /•
ri• dSri"—
Signatur of Owner/Aged Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction S�-u-yyp--ee�rvisor: N057/�
blot Applicable E
Name of License Holder: JV` e4 / ?.--
License Number
40 £ LL
Atltls" Expiration Date
lYrrrc09T gy9ieppviTir. 122*• 017-30
Signature Telephone
2./91- --23"13
9.Registered Home Improvement Contractor: Not Applicable £
12�14.93
Com pan ame 1 Registration Number
Addr s
Expiration
tion Date
i, - Up/STelephone0) 3—h _
SECTION
10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance vit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance Id' ermit.
Signed Affidavit A hied s £ No £
11. - Home Owner Exemption
The current exemption for`homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780. Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official.that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: X72?-)D4C —"017
The debris will be transported by: P--)14
The debris will be received by: R/M-Ca nit/
Building permit number:
Name of Permit Applicant / -707- 1
4P-43-1, IV a
Date Signature of Permit Applicant
The Commonwealth ofPlaasseclument .
Denertmer'ofbldm•L—lei 4ccife:/s
I
Office of?xver[ 2rimns
I Congress Sfr eeta Sale 100
. Boa,0%,M4 82114-2017
` . tnnumessgov/daa
Workers'Cornpensees imam-site 2ff d2v1L Buil ie-rs/ContractoisalecfriSns/?Inr'-beis
tan ezn-_latia—'ata_ Please Print beffilh17
Name(Husiaas/Orgnizadaa/tnaridvc}: 1-( (v i
yil � �erfe/CAS
Address: Cr V.x I).S-a\tnk.' 07-71- 4'r f'A -
CiRy/Stateiz?P:7hr 2Q_(Juni ,/14/1- e;FTC_ Phone n: 66 as ?6A Cef�
f_,-e you an employer? Check the appiopriam box: Type of project
I.❑ 2:s a employer with ?- fInnagenealcontactor andl P 7 (required):
employees(Ell mid/or part—doe).-4 here hired to sub contactors
6. ❑Now construction
2.f j Iu a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship end bare no employes These sub-contractors have s Demolition
wortg for me in any tenacity, employees and havewarkrs' h
[No worfze comp.TMr-s_ce camp.msmance.+ 9. ❑Holding addition
zyurdl 5. ❑ We are a cementionm1dits I0.0 Electric:dr:pairs or addition.
3.0 I am ahomeownes doing allwons o ons have exetcisedtheir 11.0 Plrmrblog ieicira or additions
ayseL. =rio wo±sers' comp. tingly,ofa:ptlau per MGL 12.0 Roof tz ITS_
,
insurance reciting c.152,§1(4),and we have no ./A-//./��-
employees.[No workers' 13- Cher
comp.rostrate require' d.]
'Any appliconr thatcrrs bac 1 m steiso MI out hesetimabdow showing their mata'wmpemaDmpoaeyitPomaam.
I Homeosncn who submitTis omdavit ia&etmgtbey m dojos oll waft and Iva hire outside mef rmutmbmhaaew alndavamdc®pgsm .
reonh,ctara that chcol this bccmust inehrd aeadmaomishcrmovrm henmeaitor Kminommsudatoo whether or not 0use wtitiecban
employees. TZ Ma suborn am bavc®ployca(boy most pmvidcihcb nmicaa'comp.policymmnbm.
i urn am employer Eh d is providing workers'compmumion insnrwicefar my employees Below IO the policy antjob site
inf rm-01c . / n
r,a„+�c ComnayName: Net/• Plump P6 f1;re- .y`1S - e-o -
Policyl or Sell-ins.Lie.d: 'nI v V//�0�4D f 6I fL) Expnafi nDate: � / 1 /I /�
Yob Site Address: I f59 �o O i cayismte/Zip:/ I t i / : oh- -
I.
Attach a copy of the workers'compensation policy declaration page(showing the policy amber and • -.tratmn date).
Failure to secure coverage as required under Section 25A oflr43L c.152 canleadtotho imposiion of e.al penalties of a
ale up to$1,500.00 and/or one-year imprisonment,as well as sivilpem:hies inthe teem of a STOP WORM ORDER and able
of up to$250.00 a day againsttbe violentr. Be advised that a copy ofmis statement mayheforwardedtothe O&ce of
l vestigaions of the s . . insurance coverage veriiicatian.
ido hereby c.''': son then erjwy tithe iajornwdonpravidedabove is hoera/nA&CO?re •
Siaaatare. l el r Date: ' `(2 �W
Phone;* v!eE 9v? 6 "/
Official use only. Do nor write in this erer.,b be conepleted by city or tom Ciao'.
-
Cit;or Town: Permit/Limn 2t
Issuing Authority(circle one):
1.Board of Health 2.BondingDepartment 3 City/Town Clerk 4.Electrid?nspector S.Plumbing Inspector
6.Other .
Contact Person: Phone tfi
6110/2016 Ranson-Gary-PC-52420671-BATH_1181V810475461463756814.dnp
. .//771(
City of Northampton
Building Department
Plan Review
212 Main Street
Northampton, MA 01060
hnpsl/mail.goggle.com/mailpAnbav/15532e364S7f5ec?projector=l
1/1
'6/10/2016 Ransom Ntchen plans jog
t
/ �L/
;.u"
.10.,,_,-,,,
—
_____— _
_ .4—I-1
110,, ` iBirk
I
r
---T _ -
■
. ___
City of Northampton
Building Department
Plan Review
212 Main Street
Northampton, MA 01060
Mips://mail.google.com/mail/Wnbnc/145.12e3g4eClt5ec'p`gector-1 1/1
w ryc b: FINAL INSTALLATION QUOTE
"'Weyer Name: CiAr g4,/60/0 Ransom
06l02/16
Anal Daeiyn:1 9 3 1121 Ddt 5T
NORTNAnp7�ui YEA. o)Dbo
pot 62980671 OK TO FINAL
Pre-Construction,Oemoldon.al/mental.and Saul Away $3,723aq
Imtall required floor and site protestior
Remove laminate and drywall at ange Corner
RemOvc existing Cabinets and muntenonfrom two kitchens ILL and Zt
Kemoni all lob.related debris from site
Per eux Cabinet Im1Wa1on 1D,304.61
install new base and wall cabinets m both kitchens
Cabinet lnstallat0nlinckidas shelves illlps,Scribe,Toe Kick,Handles,&Knobs.
Custom Assembly or Installation 570140
Prepare and install new laminate carterternoin both kitchen.
Molding Installation
Se.m
ND MOLDING INSTALLATION IS INCLUDED
Electyicel Sp.DO
NO ELECTRICAL WORK IS INCLUDED
Plumbing $0A0
NO PLUMBING WORK IS maUDEO
Appliance Installation 12022e
Remove and then re-install the existing appliancw
Flowing and 8acksplaSh Installation WOO
NO FLOURINGOR SACKSPIASH WORK IS INCLUDED
Drywall Work&Painting Stase.50
Install drywall and drywall finishes at new shower
Repair drywall at range cwmr,kitchen SL: tape and sand to a finish ready tor pain
NO PAINTING WORK IS INCLUDED
Additional Charges(it BOSH: al $2,217.50
Frame shower poCkct
Install shower unit
Install nuc radasmerl widows
Permits
Plumbing
Buding Sn.00
Lead Sate Work Practices WOO
may pe Prawns,n a tome Milt Newman rYW ass ants an0 read rain[may Oe pRffim Ina tome cos
before 1971. Additional Charges may emit if the customer does not dispose of predact per Federal Mandate of
Lead Safe Fracdus.
General Notre on the Project
ON RARE OCCASIONS.ADDITIONAL WORK IS DISCOVERED AFTER A PROJECT HAS STARTED.THE
CUSTOMER AGREES THAT THIS ESTPAATE IS VAUD ONLY FOR THE WORK LISTED N40 THAT ANY
ADDITIONAL WORK THAT IS DISCOVERED AFTER THE PROJECT HAS BEGUN THAT WAS EITHER MISSED
ON THE ORIGNAL BN OR ARES DUE TO UNFORESEEN CIRCUMSTANCES WLL RESULT IN ADDITIONAL
CHARGES THAT MUST BE PAD FOR BEFORE THE WORK CAN BE COMPLETED.
CuaiOMOrsiinemro: !a :tGC$trasre.
bale Sy/� P
neL ,
Z0/Z0 35Vd 3DIA O JIOVB EZBLLBSETD SE:LT 9I0Z/80/90
I.
Simonton Windows
II / '- 1 6.C.0 VRnssgePoir e
1 , . I
IIr..: C� l: ,L,...=i:iT=-i,:_ -.aa G' Mon-Lai.--SD:o_rtnP�
77>......4"-s.' 9 .lxi aids
=—`gym Ii ��sn»s 3ccda lloY-tl:�.0-'13:In 1dt.O Argon-tow-E-Sr
:r -‘1-11:315'i f' :1&ta Letcirzco-Carrelles 1
ii'CPD.S8i-A-4-21C42-GE.GG2 0=75DH111
ANERGY PER oRRmanicr RATInics I
=_Ve acio!DEEREfDIMIMe'TO EFERQ!CO
U-Fat S:IeM+sSGil CockaA • II
n.2q 1 .65 i . 0.24 !I
x_ II
ADDITIONALP RFQRPAANG RATINGS 1
EVALVACLOM SDP' ltARIA Dc RENDER-aria
Iie iei s 1 ,�"vE ,
II
.
0.45
--_ �_h�.--__�� r-=.._-1_ _
- .:. ___: . - - -- - S. - __- :,
~ . c_ I
ii
datge-Seatd:AC-
'".. -`. - z`'T`"— Urit qu es for EESICY E
; §.'t:ia -2 St IRO MIionls).Natert • . 0
. i II
n ^- t
-. '^ _,,, 4a!i Cenral,Saaflt CerhalIN
r r..e . ,,,t.....,..,:.,* SateT.. •
�� s`4! a- "yam� z•`
STC Za
= -a i
I Ps C__.Tud ;I
rtn-
I' ?an. - WIC:Rein D01C-Iass PraSdxrM-Lea: 1i
�, - /'a,r7 TwteDJze:48"x8O" ,I
'i
t II
I Pala Fruauct Ap -aai:Fla ic: Ii
1 II
0
_ 1.
I II
Ii
V Amicable-festSsSarjst ANSI&9FANOIMITI.A.1Gi/LS.Z-a7.AAl7AmDWAICSA 1.
ii iO111.82/A44C-05-RANI?FIAVANCSA1oia.5JA??0-GB- I
MC-SI-1MCa_rrv' 2nSuop: I�
Il 8358/90101 x00333 HS Howard 34COO?4A Iit
71 }
—^ Office of Consumer Afai, and Busirttess Regulation
10 Park PIa?R - Suite 5170
- Boston,Massachusetts 02I16
Home Improvement Contractor Registration
Regisira& n 125893
Type: Supplement Card
E cpirattn_ B!32016
THD AT HOME SERVICES, INC.
RICHARD TRDIA ----
2690 CUMBERLAND PARKWAY SUITE 300
ATLANTA, GA 30339
Update Aside=find enure and Mark reason for change
SCA Ci mown •
71Addits C Remand .mploy:t r.: :.:u^i Lam
- ' O_Efice of uonneer ARairs£Hosioesslteguistion License ori e:istradon valid forindrvidul use only
gaa `—'
OBSE iPR01ECaI CAN'T-RAG-TORbefre theexpiration dam. If found reborn to:
Officeo:o s-SuiaSfairz and Huvnm Regolalioa
-_ _citatss .Lb>?3 mora i93azkMt 02 SuiseSi'N
"-' E pIca orz.8t3)Ola Supplement C+rd Boson,hta OZi18
1110 AT HOMESFRVICES,INC.
THE HOME DEPOT AT ROME SERVICES
RICHARD TROIA ' '
25Sa CUMBERLAND PARKWAY 5 ! 'a
4 N`Ia,GA 3C339 Undersecretary Hoiyalid tra&Ut signature
AC'OR0a CERTIFICATE OF LIABILITY INSURANCE DATE
YYYYI
I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFiRMATNELY 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(SA AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT: If the cenificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
- the terms and conditions of me 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. WINE. pX
PRO AWANCE G?RER INC.N.Ea_ 'INC,Not
35E0 LENOX ROAD.SUITE 240.0 EMAIL
ATLANTAGA 30328 AODRESE: '
INSURER'S)AFFORDING COVERAGE I NAICa
1130492-HOmED.GA`N.I6-i 7 INSURER A:9eadlasi Insurance CAADaly :263437
INSURED_ msumat a:Dina American Insurance Co x'16535
THO AT-HOME SEP,VICES.INC.
OSA THE HOME DEPOT AT-HOME SERVICES amm e:NAW Hampshire Ins Go 121841
2550 CUMBERLAND PARKWAY.SUITE 300 NSUREN O:IBIS National Insurance Company 0817
ATLANTA,GA 30338
COWER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL003746646-14 REVISION NUMBEFt8
THIS 15 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
CaRTIF!CATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POUCHES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILL TYPE OF INSURANCE —,M".MID POLICYNUMBER IMIaebYryYH IM mnY�Il MOTS
A X COMMERCIAL GENERAL LIABILITY 'GL04881714-06 1,0391RB16 0310112017 (EACH OCCURRENCE I$ 9600.808
' f-0RENTED
___CLVmS'nd`u= ,% CCCUR • I PREMISES IEE masmnau I5 1.0002300
.UMNS OF POLICY X$ 'MED EM Ally me person/ Is EXCLUDED
.-. _ —.._ ..— OF SIR SIM PER DCC I PERSONAL SAOV INJURY IS 9,6d3.D33
"EWA AGGREGATE Lli °+.Pl!Es P I CENERALAGGREGATE IS 9.000'000
X POUC iECT LOC I PRODUCTS•COMPIOPAGG S 5.0X0,'000
OTHER: iS
9 AUTOMOBILE LIABILITY . BAP2538M3I3 03101:2016 .010112017 COM3emSINGLE.LIMIT I s 1,800,000
XTNY>UTO _ I BODILY INJURY(Pee amen) i$
ALLDX:NEO SCREW-ED ''SELF INSUREDAUTO NV EMG !BODILY MUM!OM(EY-MIAMI S
_ __AUTOS _AUTOS
N9E00.705 NCNIOIIED FROPERIY OAMA E IS
AUTOS ./Per=keno
IS
UMBRELLA LIAR •OCCUR : I I EACHOCCURRENCE I s
EXCESS UAB I GUMS-MADE !AGGREGATE IS
OED RETENTIONS •
. 1
I IS
C WORKERS COMPENSATION IWC015519215 MOS/ OAR/2016 183011$17 I X I STRTUIE 1 I FAQ I
/. AND EMPLOYERS'LIABILITY
ANY PROPRIC GILPARTNEWEXECUTIVE TIN iW(015519211(A(KY,NI{r4I.Un 'OLBH$l6 .'BM0ti GI7 I EL EACH ACCIDENT IS 1.008000
OFFICER/MEMBEREXCLUDED+ I VOA.
D .IMandaoy MINI �MC015519216(FL) 10101/2016 1010112017 I EL DISEASE-EA EMPLOYE S 1000•WO
IFI' nesaI under CnrMnued onA IllO P I 1,000,000
'DESCRIPTOR OF DPERAIIONS below ase TEL DISEASE-MOLLY UMn 13
•
I
I 1 I
DESCRIPTION OF OPERAT0N5/LOCATNNSIVEMCLES IACORD im,Ad Sr,al RMNrksSTMWe.maybe ameba,If mem apace la required)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD ATHCME SERVICES.INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
OSA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA,GA 30339
AUTHORIZED REPRESENTATIVE
or Marsh USA Inc.
MariaMH MukheTjee . ta-.Sae+nae .$bacc..�rs
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014)01) The ACORD name and logo are registered marks of ACORD
4
, i, .
�. -•'
./
,.ate, . , . .,.
CS-101342
JOSEPH S ROTH
40 RUSSELL STREET - -
Great Barrington MA 01230
08/11/2016