23A-288 7 MAPLE ST BP-2016-1435
GIS #: COMMONWEALTH OF MASSACHUSETTS
Man:Block:23A-288 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2016-1435
Project# JS-2016-002468
Est. Cost:$2308.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
use Group: HOME DEPOT AT HOME SERVICES 126893
Lot Size(sq.ft): 8537.76 Owner: FOLEY WILLIAM R&JUDY C
Zoning:GI(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 7 MAPLE ST
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (4011935-26330 Workers Compensation
NORTH PROVIDENCERI02904 ISSUED ON:6/3/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 1 REPLACEMENT ENTRY 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: 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:
FeeTvpe: Date Paid: Amount:
Building 6/3/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
rr
1 -» = _ Js: a e fuse-0 r rg-
CI of Northampton Strtra ofPRele -T� "tt er d'
.)��N —3 8 Ming Department OvrGpvonuewaveFermiC' `� .
- '12 Main Street r ' car
Sewert5ep ioraoro a'b`ifitj s` mo- "sr1.
Room 100 to ateM! A7a1 a611`�iyt ,rc w - °
.9Ll.nln,^.INSPECTION n ` `.
i NORTHAMPTON MA ciCro o 871240 Fax 413-587-12720glof/�S PAMMAAAJA`� p e..+ J �
°01 --Sp i1Ke _ y .
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION _
7.7 Property Address '3TFii�ih tior be�.p� ommplefed by officer _ -
kn bverlay-Disttct 'a
Imfst oiso-� E=ca otstr�r'� '�
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT -
2.1 Owner of Record:
S'Dq 109 i.- 1 hikPLEt- " F/DfZWeC Nle-. 1)62
Name(Print) /// T/�.yp./yam Current Mailing Address:
`StE `�nTia fre Telephone
Signature
2.2 Authorized Aoent:
l/] x Tri,A— 57 2v zv/Vu1� 3- ��
NameP Q
Pn Current Mailing
IC: 2.9'Dtil
( 9
Address:
Q yo)-52>3-/R6-2-
Sig
ature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTSI
Item Estimated Cost(Dollars)to be - Official UseOnly
completed by permit applicant -
1. Building i7 9 _ yh-yy (a) Building Permit Fee
2. Electrical d�/i!/7� !/L/ (b)Estimated Total Cost of
from(6)--
3. Plumbing I Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection •
6. Total=(1 +2+3+4+5) .... ,045. . 420 Check Number
/ r This Section For Official Use Only
Building Permit Number Issue
Issued
Signature: - - - -
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING Ali Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This calwm to be filled in by
Building Derailment
Lot Size f H ) I
Frontage + 1—
Setbacks Front L i + I —J
i I 1
Side LT-1 R:[ L:f___J R':_ I, I
Rear / l / I l
Building Height L
Bldg.Square Footage 1 f % I. I I - -
Open Space Footage % t_
(lctreammus bldg&paved = L__1 1 1 i_J
Parting)
#ofParldno Spaces LJ 1 I ,
(volume&Locadon) I� li t
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES Q
IF YES, date issued:iI I
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book I Paget . I and/or Document nI
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 Q NO Q
I
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 location:
I
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 Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Vyindows Alteration(s) n Roofing ❑
Or Doors /6�G
Accessory Bldg. ❑ Demolition ❑ New Signs [PI Decks
Decks [[CI Siding[O] Other[D1
Brief Oescription9ffjogye�dt / r, ,� rTl.._ _ 4 ��Y l, ' �.,ry,�v�
Work: pin Uy//r/�L Y/�" �7L ' v'` Y /['i�I�9-�Y1
Alteration of existing bedroom Yes No Adding new bedroom Yes No G "" ��g
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ear-If:New house-and Dradditiorrtb existinqhousinq; complete the followmq:
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
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 APPLIESFOR BUILDING PERMIT
\.1-V➢r1��'////�� //(�' y���/ �.y///�� yy as Owner of the subject
h hereby
U2-)O 4)2_1 / 720 /
heaety nuthoriee
to act on my behalf, in all matters ve to work th rued by this building permit application.
Signature of Owner �^ Date
1 �1 / e/u J 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 under ti - •ains an,penalties of perjury.
1 ///1)- lY
Print Nameailifii.
/-
` C!! — /G _.
Signature of• ner/Agen - Date
SECTION S-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:�p.� J Not Applicable f �f
Name of License Holder: //7(� 7-4'�L ' 4'-" 96 / �
3 ' �/�n) A)
License Number brie
Address � Expiration Date
(,UTt p ,'i9 - , f 10 5
Signature Telephone
9.Re•IsEdred Home7m•rbvement Coif actor -_ x.; Not ApplicableE
f� 7T 126.893
Com an Name Registration Number
n' /190A/Trtt 7PX '
A.dr:as , `/,1yr' �t `�/yam f� ^ .�y—)'� Expiration Data
se rl�y / 'l D)9// Telephone `i
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§26C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit mil result
in the denial of the issua g permit.
Signed Affidavit Ladled Yes c No...... E
- on ome_ caner--xemp 4on
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinos of one(I) 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 790. Sixth Edition Section 108.35.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is, ors intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or fann
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/sbe 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 he advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injures 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 pewit.
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,
The Commonwealth of Massachusetts
Department oflndustrialAccidents
Office of Investzgations
c 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizatien/Individual):
Address:
City/State/Zip: Phone 711':
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees (`all and/or part-time).* have hired the sub-contractors 6. ❑Few construction
listed on the attached sheet. 7. D Remodeling
2.❑ I am a sole proprietor or paYser-
ship and have no employees These sub-contractors have S. ❑Demolition
worlcn for me in anycapacity. employees and have workers'
g P i3' 9. ❑Building addition
[No workers' comp. insurance comp. msurance.t
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.E Other
comp.insurance required.]
*Any applicant that checks box#1 must also El out the section below showing their workers'compensation policy information.
trio meows=who submit this affidavit indicating they an 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
employees. 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 the policy 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certify under the pains and penalties ofperjury 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#:
City of Northampton
aN�
Massachusetts 0r1
DEFERMENT OF BUILDING INSPECTIONS ;X7
212 Main Street • Mnn•cipal Balding JJ JJJrrI D'.
!• Northampton, MA 01060 x, 70'�Zi
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner as, " Person(s) who owns a parcel on which
he/she resides or intends to be, a one or two family dwelling, attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in a two-
year period shall not be considered a home owner."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you •
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footings (before backfill), sonotube holes (before pour). a rough building inspection
(before work is concealed). insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
ins oected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas)the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
understand the above.
(Home owner/resident's signature requesting exemption)
will call to schedule all required building inspections necessary for the building permit issued to me.
)ate
address of work location
City of Northampton 222 Mata Street, Northampton, MA 01060
Solid Waste Disposal Attl davit
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 Fermit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 11/1, S 150A.
Address of the work: 7 Y97 d�L �- FL ze MA -
°lob 7--
The
The debris will be transported by: {/ wTa
The debris will be received by: ir/f0t;\ '
Building permit number:
Name of Fermit Applicant [2 , d001-2")
Date Signature of Permit Applicant
Apr 2816 05:27a p2
PLEASE READ THIS
II,, 'I t S old,Furnished and Installed by.
Brandt Name:New England Date:a'f I p THDAt-Hone Services,Inc
d/b/a The Home Depot At-Hone Services
Branch Number:33 99S Boston Turnpike,Unit I,Shrewsbury,MA 01545
Ton Free 577903-3'58
Federal IDN 95-2698460:ME Lied C 02439;RI Cern Lick 16427
/
CT be HMC056552?:MA Home Improvement Comrade.acg.ir 126893
Histallaftdress
on Ad : 2 ,A�fP A-9( R
s- aFO.AIet _If 114 of OF-,Z
City Stat Zip
PurduRrjs). Wort rine Home Phone: Cell Phone:
klOr.a,
IL ]
z; snLi C-LD( II 1 ; [ 1 i [ I 1
Home Address: 1 -- —
(Hd:fiernmfrominstalleiionAddrasl City Statezip —
E-nail Address(lo receive project commmicmiom and Home Deist updates)'.
Ll I r8)NOT wish to receive any marketing meals front.The Home Depot --' ---
Proton'information: Undersigned("Customer").the owner!of the property located at fx above indallalien address.agreesto-•Joy.
and THD At-Home Services. ie("The Home Depot")apron to rumish,celiver and arrange:or We instellation('Installation')of
an rnetenals c cribed cat ds below and on the referenxd Spec Sheet's),all of+which arc incmpwated into this Contract by Ibis
reference,arong with any applicable State.Supplement and Payment Summary attached hereto and any Change Olden fcolleccveiy,
'Cantracrl:
Jahr: us.ama.. ProdugeProl
_
°PLN SheeUlPrefect Amount
�
r— Lleaa ma LlSininsGI'.imnwa Llfnwrmn s tri"✓
— ort r ora er Dan ❑ — 3479 X308
-oofin3 Coven g Windows Ll)rwlation
$
04m1uli Coven (]envy Dors[,_ _ (�-49S(
Rwr x User or D Windows U Insulator { V
_ Ocman/Covers Damn annC _ II
■ orobi .JS:ding LI xindwa Li Insuleioa � _^
j Demers n coven phony Doors O_ $ 9 '� I
Minium JMIDepat of Contract Amount Mown.ereormaofMheonasct TOmICO.San Amount f p�
Maine pwebmvl nwumdWmil mareWaen dtiaa.nhe Cw4actAmoam 20
Customer agrees that,itmn liuc'y upon completion of the v.nrk kr each Product Customer wi i execute a Completion CeniErsle
'one for tar: Product as defined by an individual Spec Shcel)and pay any balanm due. As applicable.act Customer under this
Contract agrees m be parody and sere l ly obligated and liable hereunder.
The Hem:Depot reserves the light Dux a Change Order or terminate this Conmet or any Idivinel Producl(s)induced herein,at
its discretion,if The Home Depot or its authorized service provider determines that it Manor peribnn its obligations due to a auuctwul
prob':erm with the home,avironaental Awards such as mold.asbnlos or lead paint,other safety concerns,Pricing errors or because
work required to complete thelob was nor included in the Gunnel_ 11
Payment Scoter-: The Payment Summary.1 �� �
I � -J3 included as part of this Conder sets forth the total
Cornu amount and payments required Mr lhu deposits and anal payments by Product(as applicable).
NOTICE'(0CUSTO.MER
You are Milled tea completely filled-in copy of the Contract at the time you.sign.Do oat sign a Completion Certificate(note:
three is one Completion Certificate for each fisted Product as defined by Individual Spec Sheets)before work on that Product
es complete.
In the event or rermimhon of this Contract Customer agrees to pay Tim Home Depot the caste of materials,labor,expenses
and services provided by The Home Depot or Authorised Service Provider through the date of termination,pis any other
aneuuts see forth is this Agreement or afmrcd under applicable law. THE HOME DEPOT 31.AV WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOTS OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Art once and 4uthor"aab n: Customer agrees and understands that this Agreement IS the entre agreement,benttnr Ctosmmel-
•rad :he ironic Depot with regard to the huduets and Ins:alInion seams outs iperseda all prior discussions anagreemems,either
alai or eniin relanng to said'roducts and Instal briar.. This idreentm cannot he assigned or amended except bye writing signed
by Casmirer and The Herne Depot Customer acknowledges and agrees dim Customer has rend.understands,volrnaely accep>the
term'of and has received a copy of this Agreement.
�/I/t ;��\
A add M: 4---27-.)4/41x SubmiteMb II✓I L Of, J �
co, eros S(Erolcrn Date
Sales Consultant's Signature Date
N IPP _ _ Telephone Nn.
Custarets Signature Date
Salve Consultant iicenseNo. _
CANCELLATION: CUSTOMER MAY CANCEL THIS b'NPtieall)
AGREEMENT W ITHOCT PENALTY OR OBLIGATION
BY DELIVERING ID IIKITTEN NOTICE TO THE HOME ' t( `� 2/ —5�']J
DEPOT BY MIDNIGHT ON THP. THIRD BOSOMS-5
N! ` ✓ c,Jb
DAY AFTER SIGNING TIILS AGREEMENT. THE
STATE SUPPLBIENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS o
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NDrcCE:AkolTIONAL TERM'S AND CONOFTIONS ARE STATED ON TRE kZ):61 SE SIDE AND ARE PART OFTrn5 CONTRACT
q x; 1
BRIAN C THOMPSON
38 WILLOWBROOK LANE
WEST' IE1 D MA 01085
The Coatmonwealth ofMassachusetts
Its= Department of Industria1Accidents
=ei1,t=E!t Office of Investigations
t =teal= 1 Congress Street,Suite 100
`1=�-e' Boston,MA 0211¢2017
asp" wwatmass.gov/&a
Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
•
Name(Busiaess/Ormnizmoolndividunl): / 1i� Jr ,eor/
Address: C70Ig
City/State/Zip:C7A PPS:s`i- 4l,9" o,rY-5". Phone#: S ?6;{ '?9'2-
Are you an employer?Check the apjoioprizin box: Type of project(regnh'ed):
1.❑ I am a employer with 4. tei I am a general contractor and I
employees(fill and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no employees These sub-contactors have
8. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' camp.imamate comp.rosunce.t 9. 0 Building addition
ra
required] 5. ❑ We are a corporation audits 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' camp. right of exemption per MGL 12.0 Rcof repairs
insurance required]t C.152,§1(4),and we have no ,,..,,rt ��
employees. No worke ' 13.�armer
rs
comp.insurmmce required]
,Any applicant at ebectr hex:l most also fin out to Section helm showing Ina worts'compenratm policyiobnnatmo.
t Homeowners who rubmittbis adavit indicating they an doing all west and to hire outside contract=must submit a new affidavit mdicatvgsoet
leant-actors that check this box mustateazhed en additional sheet showing the name afthe cob-rontractom mad Mate whether or not those entities beet
employes. if the suJcomramv bare cmploym,they must pmvidc tbch wallas'comp.policy numbs.
I am an employer that is providing workers'compensation tnsarancefor my employees. Below Is the policy and job site •
infarmtatiotr_ {, J` /l
Inmaance Company Name: Afit2 del- rl St j<t (ter— .{O3 - `tea - / ^9
Policy#or Self-ins.Lin#: Vlt C., 0/5 % :9.�' J�''` BxpnationData: �3�� /���%y / /
lob Site Address: 'ter'
City/State/Zip: P/pizre7Vc(C
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). U/Lf7
Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the napositi n of criminal penalties of t
fine up to$1,500.00 and/or one-year imprisonment as well as civa penalties in the fonn of a STOP WORK ORDER and acme
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded in the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby c ''under hep . and 'r'" p m the information provided above is true
ry a7nd correct
uanre:
Sigd �(� Z� Date: /2 -AZ
Phone#: CO g 6 6 /
7
Official use only. Do not write in this area,to be completed by city or taint official
City or Town: Perminl,ieense#
Issuing Authority(circle one):
1.Board of Health 2.BnidmgDepartment 3.City/Town Clerk 4.Electricallnspertor 5 Piombmg Inspector
6.Other
Contact Person: Phone#:
•
�o �TGLW
L%fL2 �U'/Yt/f;ZQ?2{f1P/,.l 4- vGCc�Q� �i' .
Office of Consumer A and Business Regulation
Wig;; 1 D Pazk Playa- Suite 5170
• Boston, Massachusetts 02I16
Home improvement Contractor Registration
•
Registration: 126893
Type: Supplement Cud
Expiration: 6132016
THD AT HOME SERVICES, INC.
RICHARD TROIA ------
2690 CUMBERLAND PARKWAY SUITE 300 -
—
ATLANTA, GA30339
Update Address and return enrd.Mork reason for change.
sc.:, c, mason, - _ Addrea Il Ammo' mpta5' — :.;m::...,.
•77 49sanrinsonE;
- -0Eice of Consumer altirs&EasinesRtgobdon License or revicVation valid rorindividul us c only
- -: 90tiE IMPROVEMENT CANTRACOR before the expiration date. If found return to:
19 Pie¢ic? aza-Sure517G and Business Regulation
Registration: A26593 Typo: 19 Paris Pian-$uite5P/C
Expiraliom.6'+12016 . Supplement Card Barran,MA 02116
THE AT EAILES.MC.
THEHOMOMEDEPOT
IA AT FIOl-E$ERVILE$
RI9HCUU TRLIA
2690 CUMBERLAND PARKWAY$ "2.
AS al9L,GA 3C339 Cnderxcrerasy Noe valid w'a outsignatare
ACORics CERTIFICATE OF LIABILITY INSURANCE on1M6rm1(M6D'YYTY1
8.....-.---
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 be endorsed. If SUBROGATION IS WAIVED,subject to
- the terms and tondidons 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 ANCCNN o.Eel: INC xo1: .
3560 LENOX ROAD.SUITE 2400 E-MAIL
ATLANTA GA 30326 ADDRESS: '
INSURERISI AFFORDING COVERAGE _ KO
100492 -GAW-11NS
17 INSURER A:ScentScent Insurance Company '1261e]rU
INSURED INSURER B:ninth AxleManlnsMTCe CO 16535
THD THE HOM$DEPAT INC I
26S THE HOME DEPOTDPAT-HOME SERVICES INSUREROC:News Nolboue nsu CO 23&1
269ANTA. 30 P>RK'NAY.SUITE 300 mSUflER D:IEPIUS Walton'Insurance Company 3
>P_ANTA.GA 3OTi9 — .— � ---
InwRERE:
INSURERF: I
COVERAGES CERTIFICATE NUMBER: AR-003746646-14 REVISION NUMBER:8
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
(NSR TYPE OF INSURANCE •
ADDL.SUBR, POKY EPP I POLICY EXP ! WAITS
LIP 'MSD WW POLICY NUMBER IMWWYYYYI'INWODMYYYI
A X COMMERCIAL GENERAL LABILITY GL0488Z7I4-06 IOW/2016 -I03J012017 I EACH OCCURRENCE IS 9800.:33
CLIIME.MASE X OCCUR1,PPRREEMISES Ea ooa I I S L(WT- .000
'UMR6OF POUCY XS MED EXP IAtn we posml 'IS EXCLUDED
•
OF SR$IM PER OCG PERSONAL&ADV INJURY IS 9,000"000
VAGGREGATE L A P LIES PER I I GENERAL AGGREGATE I S 9,p0,OW
POLiCYX 'RO
JECT __ 'LOC PRODUCTS-COMP/OPAGO 15 9CW,0.0
TREK i • 15
a AUTOMOBILE LIABILITY BAP 2938863-13 .0391i2U15 0310112101] 'COMBINED SINGLE UNIT 'Is 1,00,00
. al
(Ea m de
_X-.ANY AUTO j 80OLYINJURY(Pet Persml I5
ALL G:+NEO _ SCFEOULED -SELF INSURED AUTO PH?DRAG •
N BODILY INJURY(PracB.q!s
_ AUTOS __ AUTOS
MEO
MIRED AUTOS NPROPERTY DAMAGE S
_ _,AUTOS
I.
. H
UMBRELLA LIAR OCCUR . •
EACH OCCURRENCES
EXCESS LIAR :CLAIMS-MADE li I I I AGGREGATE I S
•DED RETENTION - I 1 I s
C WORKERS COMPENSATION I IWC015519215(AOSI 1019112016 Jumpyx OT
SERINE I I ETM
E AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNER,EXECUnVE Vlx WCOI SSt921](AX,IR',NH.N39T) 011012016 03i011AR ' E.L EACH ACCIDENT lS 1,OBO,W9
U (mandatory m NH)Exctiuoem M Ix1A IWC01551921fi(FL) 103/012016 i0301201Z • 1
Y IE.L.OISEASEEA EMPLOYED' 1000,009
DESCRIPTION OF OPERATIONS below : ICOnitued On Addlthana Page I EL 6SEASE-POLICY LIMB 3 1'x"099
I
'
DESCRIPTOR OF OPERATIONS I LOCATORS(VEHICLES IACORD 101.Additional Paws SNiSWe,may beettache0e owe space Is need)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT-HOME SERVICES.INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
DBA 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
AUTOR2EO REPRESENTATNE
of Marsh USA Inc.
ManasPi Muknegee -]Ka' . o' 4&*Lc a-ha-a+-
@ 1980-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD