38C-035 23 CEDAR ST BP-2017-0307
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 38C-035 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Pemtit# BP-2017-0307
Project# JS-2017-000511
Est.Cost:$11856.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq. ft.): 19819.80 Owner: BALL DAVID R&NICOLE
Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 23 CEDAR ST
Applicant Address: Phone: Insurance:
5 RIVERVIEW DR (401) 935-2633 O
NORTH PROVIDENCERI02904 ISSUED ON:9/8/20760:00:00
TO PERFORM THE FOLLOWING WORK: Replace window with replacement unit .29 U-value
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 If 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 Signature: FeeTvoe:
Date Paid: Amount:
Building 9/8/2016 0:00:00 540.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner
Department use only
RECENT:0 Cir of Northampton Status of Permit:
B •Iding Department CurbCwDriveway Permit
2016 r 12 Main Street Sewer/Septic Availability
! Room 100 Water/Well Availability
o t ampton, MA 01060 Two Sets of Structural Plans
tome N, W, 3-'67-1240 Fax 413-5874272 PlouSite Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
r jl/"j _- `:/� This section to be completed by office
P "4 •
Map Lot Unit
(�`L Zone Overlay District
Elm St.District CD District_
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print)
4,71),
tinCurrent Maiin/gtypUresiY-/^ ✓P^7- �/t 4 ' )0ZtZ)
[(//UU ii rr
Telephone
/ •/�,(Sli'/ �^ /Y 7 (/
Signature
2.: Authzed ten.
i _ � . / 7--- 714
Name(Print)/ Cement Ad?". % -e /fief4.4(/ 7
,/4 Akita
Signorine
.—...—_ Telephone a-, -- �.---
SECTIOy 3-ESTIMATED CONSTRUCTION COSTS
item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
I. Bolding 0/ (a)Building Permit Fee —
2. Electrical (b)Estimated Total Cost of
Construction from(6) _
3. Plumbing Building Permit Fee jO
4. Mechanical(HVAC) j/J
5.Fire Protection Q y'—'_
a Total=(1 +2+3+4+5) >1 � ' Chock Number /712/—
(1
This Section For Official Use Only
Building Peit Number: _, _— Date
t
m+ Issued:
Signature:
auilding Commissionerfinspector of Buildings Date
Section 4. ZONING Ail Information Must Be Completed.Permit Can Be Denied Due To incomplete Information
Existing Proposed Required by Zoning
This column to Ge filled in by
Building Depanment
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg Square Footage ,o
Open Space Footage
Ow area mmus bldg&paned
parking)
#of Parking Spaces
Fill:
(macaw&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW Q YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES 0
IF YES: enter Book Page andtor Document ft
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q 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 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
[
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all eDFliceble}
New House ❑ Addition ❑ Replacementrows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [(] Siding[C] Other[pJ
Bdef Description of Pr nerdy 0 �Xy.-e I�„4„' j7 ) N e )„-, / Alp p Tr .
Work: 1f✓h/f7fl.^'' C-7G / , 1 (iT.'' /yC/!/s'.^ 6t/
Alterationof Narrative
bedroom Vas No Adding newn bedroom Yes No
Attachedlans Na edte Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
St If New house and or addition to existing housing,complete the following:
a. Use of building : One Family ,,,, Two Family Other
b. Number of moms 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. Massoheck 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
I. 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
9-,,r-LL
FOR
�BUILDING PERMIT
L t� /t i' IP r-G^'/T` L ,as Owner of the subject
property
hereby authorize 2y%i t 2 'J'
to act on ry behalf,in al a ern r_ague to wo rized by this building permit application,
r t`' 1 (24" - X16 _ .
Signature of Owner y'�� � n., Date
I. p r n -J 1p G€l )i39--- ,as OwnerAutherized
Agent hereby declare that e statements and information on t e foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains -. . „nalti-1of perjury. "
fiPrif e:') : i2-- i I/—
Print
nt Nam / �, {/may ��
Signatu!of Owner/Age Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction
Superrvisor: Noltt_Applicable
Name of license Hollder: //0i ) _a ^6License Number
/pjR /M)–y\rr_ [/ --912-157
Address
/.1.2/J//
Address y^�, Expiration Date
w 17i Mfr. 491t)e5`
Signature Telephone
L/d)-- —.
S.Registered Home Imorovoment Co tractor: Not Applicable ❑
f„ Sa. •4.
x-6"93
Company NameRegistration Number
0d6 OP/R.-in res
Address / yyyJJJ���r Expiration Date
I �4 '1 it ��elephone, J ' —
9/5
SECTION 10-WORKERS'COMPENSATION/ INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(8))
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; • • permit.
Signed Affidavit AIL ed Yes 0 No ❑
Ur-
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwefines of one(1) or two(21 families
and to allow such homeowner to engage an individual for hire who does not possess a license,orovided that the owner acts
as supervisor.ChM 780, Sixth Edition Section 1084.5.1.
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 ands or farm
simctures. 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 fora 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 he 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 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 Slate 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: )?-1372-
The
ZThe debris will be transported by: Piff-
The debris will be received by: l'A8ci 1-Y\14-
Building
-Y\,4Building permit number:
Name of Permit Applicant 77)0//,-
4'2-3 /b
>z�
Date Signature of Permit Applicant
Aug 1216 08:52a
p.2
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
qqScald,Furnished and Installed by:
BrnitcBName New England Date:_±J/,�_ THD At-Home Services,in:.
gbh Tin Hone Decd AtAnnie Services
d.
Branch Number:31 908 Boston Turnpike.Unit 1,Shrewsbury,MA 0152.5
Toll Pa S77-903-3765
Feral ID 4 75-2198460:ME Geo C RF4)Y,RI Gua Lick 16427
CT Lie 0 Hi Q5655a MA Home lirymvemem Cccractor Req r 126893
tostaartfua Address: l 5 &get P;n- 5!— JItu l• QVt
City State Zip
Purtnbser(sl: Work Plaine: Home Plwne'. Cell Phone
9 e kill0_ [ i -7--) V( 1
L -/ I [ 1 It I [ ) ]
Home Bddress:___-
Of different from Ins'dllnrim Address, City Stare Zip
R- 't Addreer(to realize project communications and Home Depot update):
J I pp NOT wish to comma any mann ting emails from The Home Depot
Protect InF tion Cn&rs:gned("Customer),the owner of the prope=.y located a:the above installation aldrns,ogees ro buy.
and TAt-Home Services.Inc.CTue Hone Depot")agrees to famish.deliver asd amaauc For the installation("Istalla6m ')of
MI m. ads described on the below and on ;he referenced Spec Sheet(a all cf which me incarpabled LOC this Colwact by this
fere e.along with any applicable Sem Supplement and Payment Summarymmdted hereto and any Change Orders(collectively,
ton racC):
Job Y:)1virnalama,aalSeducer: SIM 5heeps)Y', Project Amoursr`ffr fl7q �Rodrn QS d. P VI d ❑lutiletim.r____
is.\i
I }ct f
[IGn C Q£nrrl 0.v DO
CIA'? �:J r 5 ' ` C1`> //t/
' LJR fir [JS l: F t,7 WS d - U lna,lation
Ec 2ry CF.trl Du C I S
Jft7e5ng LJSlmos [J Wind ❑to .,nine _
Demers Goon patty Do •C b n
I ORforag Csidiny D Windows J Insulation $ i
DG:d -.coma CEn n
Doa ❑ y�‘�J�—
Mldiivem25%DososhrtConl d Armin dexlnne+.cudonertlitcmntt.a
MdnePmdanersmaynmdwm)t mare than meahhalordeC.dra1Amead row CataractAmouot $ f 1t�(
CLsmta agrees that, immediately upon corm/mien of the work for each Product,Cuvomer will exam a Completion Ceni.cate
tone for each Product as defined by an individual Spec Street)and pay any balance due. As applicable,each Customer under:lob
Contract agrees to b_lointty and severally obligated and liable hereunder.
The Irma apo:(esarva the rain to issue a Change Order or tan 1 carve his Contract or any individual Produa(s)Included herein,et
as Jamaica is Ilio Home Depot or its authorized service mother determines that it canna perform in obli tions due to a structural
problq.,with the home.environmental hazard to h as moi.asbestaor teed paint.other sap concerns,pricing emirs or bemuse
work IiIegaired to complete the job was not included in tic,Co .TL
nr _ `I included n
Pavt Summon: The Payment Summary S I +lD lac s part of Otis Contract, %u Porth the total
Coianct amount and payments required for the deposits and anal payments by Product(as applicable).
NOTICE'10 CUSTOMER
You fire entitled to a nompletdy Hllediia copy off the Contract at the time you sign. Do not sign a Completion Certificate torn
therelrs one Completion Certificate for each listed Prodoct as defined by individual Spec Sheets)before work on that Product
is coripkt¢
s
In the event of terminationedb of this Contract,Customer agrees to pay The Hose Depot the costs of materials,Daher,expenses
and,wise provided by The Home Depot or Authorized Sema Provider throughthe date of termination,plus any other
its tat forth in Ihts.Agreement or allowed under applimble law. DIE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE, HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITINGIITHE HOME DEPOTS OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acm4la ad Authorization: Customer and understand',Wm this Agreement is the t agamment between Custonier
and Te Home Depot with regardt the Products d Installation ices and:ujrru:los all prier disc and agreements.eine,
oral
Agr
y irte tell go id Pod t- dl tall ' This AFes t nohen c V nde pby n. signal
yC S
by
dhanThe Hrona onaDepopthuiCustomer tent acknovIcdges and un la: CLemm t 'read. "cru n'u the
tarn
Ane b>: / Submitted by: l�Vl VISLS
CSF
Can mss Signamfe X /aic Sales Consultant's Signature Date
X l Telephone No
Cud¢mer s Signature Date
Saks Const lima License No-
CANCELTATIO,: CUSTOMER MAY CANCEL THIS saworku+ln^
AGREEMENT WFTHOCT PENALTY OR OBLIGATION e / /E _ f± ��
BY tiELIYERING WRITTEN NOTICE TO THE OG 'll , �J
D HNT BY MIDNIGHT ON THE THIRD BUSINESS
OAP AFTER SIGNING THIS AGREEMENT. THE
STARE SUPPLEMENT ATTACHED IIEBETO
CO?TAINS A FORM TO USE IF ONE IS
SPEJOTCALLY PRESCRIBED BY 14W Its
ACCRia CERTIFICATE OF LIABILITY INSURANCE el 6 m
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION DM1 Y 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
I 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 ADDmONAL INSURED,the poicy(ies)must be endorsed W SUBROGATION IS WAIVED,subject to
the terms and conditions of the polity.cefain policies may require an endorsement A statement on this certificate flus not confer rig*to the
ceniticate holder in lieu of such endorsement(s). .
PROWLER -Van
MnRSH USA.INC. fPxWINE PAX
COD AWAHCECENTER
Affil LGIOA ROAD,a't!I E£IC6 1 L _ JI X
ATLANTA,GA 29325 le_
.
INSt*ER(5)AFFORDING.COVERAGE i epic
= �__ _ --
a19UUtGn A:S Insurance comer"
iNSUREGAAAA...._. Th AIRIMPn..Rlrare Co ?ME
'MD A -DME 5ST6rCES.INCInsuRERa:
DEA THE HOME ONa.O7.4T—F i:;SENVICES eGpltERCAMMO In1)51m Im CO !VW
26:9 CUNSEP.LANC?:c?Kn!Af. _T_FC MAU a.INlmb National 4wm.Re Company 1121011
AiLAJITA.GA TER __.. �..
'USURER e':
{ 1
L...... - (NOVREa F: i
AAAA.
COVERAGES CERTIFICATE NUMBER: ATLCO3746646-14 REVISION NUMBER:1i
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. :NOTNWTHSLANDING ANY REQUIREMENT.TERM OR CONDUION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE:NIAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE PUUCIES DESCRIBED HEREIN IS SUBJECT TO ALL SHE TERM&
E`:CLVStONS AND CONDITIONS OF SUCH POLICUIS.LM+NTS SHONEY MAY HAVE RFFN REDUCEDBY AND CLAWS.
Ns:Ns: : POPPY@P POUCYEXT I
TYPROf MSURANCE NUMBER.%Am POPPY :paNmMY'D
D �IMWoa1YVYY) 4Mn5
A X COMMERCIAL GENERAL IJAaRTvO! QM:48E0714a :03.10l2016 O3,O112O17 I PAPPOCCURRENCEi- 9.000091
I ,ILWAOETO PERMS I_
CLAIpi3 As G=- OCCUF. mL5E5 :.A LtU'�
UlAITSGFPCI,'LY X5 MED CAPv 1S UCLUDED
.._ _. __ A^Y aapazken!
Cr 9P._SF3 PER CtC • PERSONALE AIDtRwnY 9.000{ro
I s,...,.._GGFE1LP=d
,41JMIT AP-LS P=d' . GENERAL i6GRFGP.IT'. i9 90'A,000
POLICY Jc,= __L=C .'PRDWre
C .COM?AIP ROG i 3 9.SO.CC9
_Dix-2-
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D SINGLE MDT - rpprm
'
IEa Am kon
>tA
AAT Auto SppILV INAlY IReFFNRmt f>
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—'ALL PATEC —SCARPS :SELF INSURED AUTO PHI'DIG —..
._AUTOS __AUTOS (BCIUILYIwuI:x lPeTeYAeMi s
vl?EOLO
: I5 AL"'c''VAIED : � i B
I(PIPorsdUun i
—•... UMe2EL:h Ma ^ Can! !+utCIt0Z1RR@KC i
_-EXCESSBAO rlANST•SOE -
DEo H =NHO>la - B
C WORKERS COMPNSATON •VW W015519215(AOS) 9Y0112Ol6 :11391/2917 ! X i IAT'- I
,AND EMPLOYERS'LIABILITY MUTE i !Syr- !
C 3 YpROiac CRIP:.PTNER:.:cEcuTM; WCOI51921T(AKIculittJ.Vil 039112018 '03X11)201, F ELEAGHA '1 NV l a 1,900X00
Gs cCP+4E.'a3EP.iao1uD U. F IV NtA
0 Nm;�matmYln Nx) �r. WCOi514218{R) 9ialt Bib '9941/1617 rel.=sass-Ga mow?Ed5 I.UPPOR
eesc:in_.aax G4nAnuMm NbitlMISA+ 4 AAAA t 0
1!-.JS, or CPEaTilo.•Is3ac« -9a 1 RT.PIPETTE MATT.5 •NI
i
DESCRIPTION OF OPE ATINSI LOCAMONS/VEtICLS IACORe rrtf,AdRtimvNftdnXez sdreavls MAY Marrmeea merv%Pavarepuveq)
El/MICEOf IFISURAN=-
CERTIFICATE HOLDER CANCELLATION
11-0 AT HCME SERVICES at SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Oak THE HOSIEOF.WT AT-H1AESSR CES THE EXPIRATON DATE THEREOF, NOTICE WILL BE DELIVERED IN
14f PACS r`E?RYMAD ACCORDANCE WIT;THE POLICY PROVISIONS.
ATLANTA.GA 3D319
AUTHOBBED REFRE.YEMATVE
of Manh USA Inc.
Mads MPTPTOTe --T4-0 nae- .34 .e4t✓- y
_
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 2s(2014(01) The ACORD name and logo are registered marks of ACORD
•
The Cornacoarvenith ofdlass¢Glusetis
•
X411- • Department of IndustrialAccidents
ti=i7il!= i t 1 Congress,Streei,Suite 700
':IS -Boston,MA 03114-3017 : .
i71 i'iM tnP.SS.p o PIdI(I
Workers(Campeasation insurance Affidavit:Builders!Conntractors/Eleciriouus/Plumbers.
Tu SL FILEDwrnii TEE PLRMFTPlN6:AUTHORITY.
Anniiggalin ornMtiOn Please Print L2rlble
Mn (13usinccstOv_ani=tlendmis^dual): i4slp Cr '= ✓L
- ^1 IAT' r 1 - --> �9
IC..f:,4
Address:. %4 Q- r-r <!ri- _
CitytStaw(ZipV'. L1. •LLVJ -Vi`�-L1A9 b$ hone : f7&$ ' (4' ~`✓"ii11-"'"
"-
- ye n
nn einpirsycrf Oink 3:e npp 'r
rapriac tans: E
Type of project(required):
I.I •1 z =_arnni 'zn it erro:orttz(fml anu/minn-tuna].` 7. ❑New construction
?.ta lame sok pmpricorut pnnnmmpmnd have no employes working llama in $. ❑Remodellers
my erste A•.i"attkers sten Oven=renguu.j
rem a aumea:,ane doing ill nonewei:?:o c„k,z,cum ir.sumnett 9. ❑1lemolition
'-'D• R tmita,%--
I I0(]Building addition
4.0 lam is renounce agcefiiriesi imcustapntactaitsutt on myarupam IA) •
.. ere time all cammnushuw etheraad�compttranlian invtatin arsfi: ! 11.0 Electrical malts or addidOrit
in-.,pricn•.r:-:n ea depletes 12.0 Planting repairs r addii:.;ls
i in agiant con-ker.-WI lmn:kirrd;Iv sut-omB mrlived on Eraa:,x:redsleet. ii Roof repaid
:Ina atnconumdnr h vt umpiccts u'd irvtwwkn'tamp.in!U..t>n. A ' I9 „fr
d.L1tYc are a mrpn,.-rpnad As eiTt relentczsucd gairswMaieaariy on stL c 14.4y''se` ��Iv t/te"
1i3.§]l3!.and wxhave no c-n*Inyas.phi wo Lad man insnaancaw d.l r
`Any applicant der sh r rboa=i rnor,^b=a fdl mu exrctiaauciry shoving St•sa;i -s`mng_rssst;nrt pon=y eiomciioa
Hnr..entacrs,rfiorohrh this^u'ndavit IA-diming Ccy a.[Join all wet-aridonr,hire outside anunctnrs must submit a new stoat lndianngsuch.
70-1mrri ors i,.T.NtaerainCT.vata:Oiadsc[.N.addiaaraisiat.01,w1T'Ina Ritaui Use N.lomracar3nna aniewiaha or nut than mtirisnwe
:mio{=s. I!;tan inleo nries int tattaitsthey man vn.iTdnuiv.t' -ta'earn)colitYa`antr-
I%nn as earolpper tfia isprovaaI=tvarkara'ronmensalien insrmrcejaa aW engTiapaes. ReiMPfrill=povcy wtdjob Sire
i aim-merlon.
Insurance Company Name: �t. -..fr i i'7% n l `�... c=- N e—r��. -
�.,r. .—a '-7
Policy g or Self-ion.Lin.°: �/titit - �j�^'�f-'^�ywy ) ‘ts:2/�L.�p5' E:oiration Daatc 7 ' ' r �/}� '.
lob She Address: 2/7 („f{N'//r"' r,�! CltyisimeiabcAVLAIss � � I '� /y
,t7aeha eap -niche tourhers compensationptElsydednratortInge(sho iog:ie Po!icpnambermosxp tis• moo). e...),/04,0;
Failure to secure coverage as requited nada MGL G.152•(list is a criminal tinolatiunpunishablo by alsncup 10 31.500-1D
anther me-attar imnrdvnnient,as en 3s chill pasties in the Sema or a STOP WORK ORDER and ofine of up toUMW el
day acainsrthevioiahx,a copy of this ccsmem may be trw3r od tp me Office oslnvrs ia2tionso3"the Da-for incumacg
coverage va1li Caiibit. _ _
I do beret er EPs -- • ifllis of�perNry that az bfarmalien proratedaattmat IItflraa Emii carnal.
Sihnattra. rlr-.“,Jirjar- Date `rJ /•� /�•'
.. Phan 5 is --.C?./2 a( 412
Ofcil site anijc Donafmi2 in this arm iuk cm wined by dry or(manaffieiaL
1 C8-ty or Toon' Petiglitensn: ii
ut
Issuing Authority(chicle one):
Pe
I.Boar.-:oYBealtb 2.Bnild!ng began-not 3.eityrown Clerk 4 Etetrical inspeemr S.Numbing inspector
S.Othcr IS
IE
iContact Persue: Phoncitt
•
Office of C0➢ "1' e: Aftans and Business Regulation
10 Park li :a a - Suite 5170
Boston, Massachusetts 02116
Home htrip { ' e iheryit & fDii11ttractor Registration
Registration; 126893
•
Type: Supplement Card
Expiration: 8/3/2018
THD AT HOME SERVICES, INC.
RICHARD TROIA
2455 PACES FERRY ROAD, H J..11
ATLANTA, GA 30339
Update Address and return card. Mark:reason for elrrnge.
.Address ' Renewal " 1 Employment 1 1 Lost Card
• Office of Co;rsaraer Affairs & Business Regale:ion Lieeniie or rendst'raikm valid for individual use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. Iii fonaaat return to:
Offike_e o£Consuaner Arfairs and Business Regulation
Registration: 126893 ype Il0 i'a;rt:Dula a -Suite 5170
Expiration: 8/3/2018 Supplement Card l;nz;tima, MA D21.3.6 .••
THO AT HOME SERVICES, INC.
THE HOME DEPOT AT HOME SERVICES �)
RICHARD TROIA
•
2455 PACES FERRY ROAD, HSC - . - ( ��
,7t'ANTA, GA 30339al -\/44` r u �. \ c- /At' . /
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38 WILLOWBROOK LANE:
'' STFIELD MA 01035