24D-261 1 GLENDALE AVE BP-2017-0737
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D-261 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit# BP-2017-0737
Project# JS-2017-001228
Est.Cost: $1302.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq.8): 5270.76 Owner: MUNOZ NATALIA E&DAVID A BORDEN
Zoning: URB(I00)/ Applicant: HOME DEPOT AT HOME SERVICES
AT: 1 GLENDALE AVE
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCERI02908 ISSUED ON::12/1/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 3 REPLACEMENT WINDOWS -
DOUBLE HUNG - ALL IN LIVING ROOM - 2ND FLOOR
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 Signature:
FeeType: Date Paid: Amount:
Building 12/1/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit:
Building Department Curb Cul/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water,Well Availability
Northampton, MA 01060 Two Sets of structural Plans
phone 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
I
SECTION 1 -SITE INFORMATION 1 6 0 �7-'S-t. 51
1.1 Property Address: /� This section to be completed by office
I kit µ t Z . rim, Map t O um(
Ij. (ls}r°o{'kT� {�4j�yr 'tAlr., Zone Overlay District
_ Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
.1 Owner of R: card: t�//tt�� ' II i�// L/y' � ``y7�J+.y' {�./}� J
+ i sy.. / rJiiNo4 _. I lJ (`V1Vttfri`G 'J rL .7A1,/ r, i
•
Name(Print) Cu" M in s ♦�e ari /4 . 4910k
• 4,4 Citi Tana Jo — r/ (/ +�/ 1 J
Signature +,
2.2A hod a. Are r,: _
Name Ot• t '� r Current Maiii -Add ss:
C��i.: � /.�t. //yy i1[�i /� V/S
Signet r - '� Telephone J .... —J 29 — , ,_...
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building , V Building Permit Fee
(b)
2- Electrical �..._.. }-PtyEstimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection /y/ ! ,
3+4 ,/��'} Check
Nu / 7If7 .. ..
6. Total=(1 +2+ 5) ��'//I/ Check Number
This Section For Official Use Only
Building Permit Number Date
air
.Issued: 9 / // .._
signaturOPPe,
// //` �l % !J
SOP mrtsicnsrHnspector of Buildings care
a4M2tt !
Section 4. ZONING Mt Inronnation Must Be Completed.Permit Can Be Denied Due To Incomplete information
Existing Proposed Required by Zoning
Phi=column m be filled in by
Building Depmiment
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage Ca
Open Space Footage 'Yn
U,ot mea rimy bldg&pa.cd
pdrkiiLO
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special permit/Variance/finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page andfor Document di
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 0 , 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, bavation,or filling)over 1 acre or it pan 0a common plan
that will disturb over l acre? YES O NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTIQN 5-DESCRIPTION OF PROPOSED WORK(check all anvils/able)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing J
Or Doors Mr. __
AccessoryBldg.N❑'gPq V
Demolition y;�f❑yy�>New Signs ID] j�Decks SCJ Siding[DI
Other RI /
workDeson�lio ?lfr7i% a`t:'f b ('`'v/'"44nTTtff AlP71411.& D�k 'V4-��pVIjNd1RU 1Alteration of existing bedrooYes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No at 1 cr.
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
h, 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. 00.TOLfY.LI12 /7.J9-7--
,,,. ,as Owner of the subject
property / -
hereby authorize I bi `p/24) ir -1/70
) rt
to act on my behalf, in all matters r -ive to wet 'zed by this building permit application.
,/ 'Lein /1-24-14
Signature o Owner Date
I. I I
° A ' f e ,as Owner/Authorized
Agent hereby.eciare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the p sand • nett/ies of perjury_
it
.. —,' /seto/P / / 4 1 1
Ph arae r )I fL Y
Signa /if:F'': IAgeni Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: /�-^tf�� /'y,,�,p�-yam I Not AAppplicaabble'0J f
Name of Lieenee Holdgr J�' ' I 7 "_/ v✓r r ( (1✓ t1�/( G// J....._
License
WO H/h Number Address Expiration Date
Mk.' )000
Signature Telephone
S.Registered Home Imo vement ntraetor: Not Applicable LI
Com n Name Registration Number
Com
�.. Expiration Date
(yam i O►
/j `(� ' Telephone 11 A
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.. c. 152,§25C(N)
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 buil 'ng permit.
Signed Affidavit Attached Yes No
11. - Home Owner Exemption
The current exemption for"hontcowncrs'was extended to include Owner-occupied Di,chines Of one(Il or two121 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 188.3.5.).
Definition of Homeowner: Person(s)who own a parcel of land on which Ire/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached stmctures accessory to such use andi or farm
structures.A Berson 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 beishe shall be
responsible for all such work performed under the buildfne permit.
As acting construction Supervisor your presence on the job site will be required from dine to time,during and upon
completion oftbe 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 personts)
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 Slate of Massachusetts General Latsa 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,fa / asy defined by MGL c}11 , S 150A.
Address of the work: i 116- -Z I ii l--
The debris will be transported by: 14*-"Ir
t or
The debris will be received by: %/ - )116--
Building
Building permit number:
Name of Permit Applicant / _ / ' ii,'
r Ai— •
Date Signature of Permit Applicant
Job ContactsinI /
vl/(1'� Tuesday,November
Comments Lead: 19676221 Go I Advanced Search 2:2:20 PM PM
Info/Updates Homeowner Information Job Information
Commissions Homeowner Ms.Natalia Munoz Sale Amount $1,302.00 Balance Due: $872.34
Homeowner2 Product AC12(4%)
Costs Job Site Address 1 Glendale Ave Status Sale/Order Received-PSG
Documents 2Floor Branch Boston North
NORTHAMPTON.MA 01060 Measure*/ 79432685
Sched Measure County HAMPSHIRE Sales
Billing Address 1 Glendale Ave Commission Rate
Homeowner
2Floor Consultant Name Term Date Split Comp Plan
Job Issues NORTHAMPTON,MA 01060 Timothy Drost 10D00%Straight Commission
Order Detail Primary Phone (413)204-0899
Work Phone Ext. B-Back: No Cross Refit 1-9095831652 Siebel Ord... 119819
Order Entry Cell Phone Key Dates
Payments Work Phone 2 Sale Date 11/8/2016 FUP Date
Cell Phone 2 Credit Date 11/8/2016 FPD-Customer
Permits Email natalia@nataliamunoz.com RTP Date 11/9/2016 Post Install Date
PO Cross Street Start Date FPD-Home Depot
Marketing Inspection
Result Combo Referral Store 8452-HADLEY
Job Indicators
Services Base Store 8452-HADLEY Order Entry Hold.
Show Map Lead Source 0080 Store Associate-OLS Lead Paint:Assumed-LSWP Requir
TouchPoints
Update Job —�
ser t. _
Work Orders User Date 'Sime Status Cort. Appt.Date Appt.Time Consultant I
PETER TALBOT 11/14/20161 5:48 PM Order Received-PSG No 11/8/2016, 10:00 AMITimothy Drost
IC ina Ralin 11/9/2016 9:24 AM Released to Production No 11/8/2016 10:00 AM�Timothy Drost
'PETER TALBOT 11/14/2016, 5:48 PM Measure Complete No 11/8/20161
Vm 9 _ 10:00 AM Timothy Drost
Cylhina Raglin 111912016 9:21 AM Order Entry No 11/8/2016. 10:00 AM Timothy Drost
Timothy Drost 11/8/2016] 10:48 AM Credit Pending No 11/8/2016', 10:00 AMMTimothy Drost
Timothy
st
/2016
AM Sale Pending No
Dayend De end 11/]/2016 19:0]PM Sent to the Field 9 No 11/8/20161 10:00 AMiITimothy Drost
y Timothy Drost
.TYRUS RUSSELL 11/7/2016 9:52 AM Confirmed-Left Message No 11/8/2016• 10:00 AM Timothy Drost
'ROSALYN HINSO 10/31/2016. 10:11 AM Pre-Book No 11/8/2016 10:00 AM Timothy Drost
Lavonna 0 Bolar 10/30/20161 2:23 PM Customer Call Back No 11/2/2016. 12:00 PM
CHRISTOPHER MI 10/29/2016 6:57 PM Left Message No
'Internet Lead 10/29/2016., 3:42 PM Lead Entered No
Close I Print
4
Home Depot Contractor License Numbers:
MA Home Improvement Contractor Reg. # 126893
Salesperson Name and Registration Number:
Timothy Drost : HIS 0553710, R-R-073-15-00005
Home Improvement Agreement
THD AT- HOME SERVICES, 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.
Customer Information:
Natalia Munoz Boston North 9676221
First Name Last Name Branch Name Lead A
1 Glendale Ave 2Floor NORTHAMPTON MA 01060 7
Customer Address City State Zip
(413) 204-0899
Home Phoned Work Phoned Cell Prioned
natalia@nataliamu noz.co m
CusternerE-man 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 CustomerCancellationNorthEast@homedepot.cam
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 PROFESSIONAL,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 CONTRACTOR 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:
X 11/08/2016
Cueto.nx's SI * Date
1
Distribution:White-Home Depot Yellow-Customer Copy
•
Contract Price and Payment Schedule: Payment of the Contract Price is due upon completion unless
a different payment schedule is specified in the State Supplement.
1302.00 Includes all applicable discounts, rebates, and , taxes.
Contract Price $ Excludes finance charges.'
Minimum %deposit$ Due Immediately
Remaining balance $ Due upon completion
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 i" be used to pay some or all of the total amount of sale.
Description of Work to be Performed:
Installation of Windows
A more detailed description of the work to be performed is included in the section entitled Scope of Work
which appears on page 3 of this Agreement.
Anticipated Delivery Date/ Installation Schedule
Approximate Start Date: 01/03/2017 Approximate Finish Date: 01/31/2017
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 initialing this paragraph, I consent to receive only electronic records related to this transaction.
Initial
Acceptance and Authorization: By signing below, you authorize Home Depot to (a) arrange for Service
Provider to perform Installation and/or(b)order and arrange for the delivery of special order merchandise,
including special order merchandise that may be custom made, as specified in this Agreement. Do not sign
if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.)
By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety,
including the General Terms and Conditions and State Supplement, if any. You further acknowledge
receiving a complete copy of this Agreement. Keep it to protect your legal rights.
X 11/08/2016
Customers Signature Date
X
cosigner Of mpkaelet Date
X 11/08/2016
Sales Consultant's Signature - Date
2
Distribution:White- Home Depot Yellow-Customer Copy
License number(s) held by or on behalf of the Home Depot:
MA Home Improvement Contractor Reg. # 126893
License numbers are subject to change in accordance with local or state government processes. For the most
current listing of license numbers held by or on behalf of the Home Depot, please visit www.homedepot.com/
licensenumbers.
Scope of Work
Job#: (Internal Reference) Products: Spec Sheet(s)#: Project Amount
❑
Roofing !J Siding • Windows Insulation
9676221 ❑ Gutters/Covers ❑ Entry Doors ❑ 9676221 $ 1302.00
❑ Roofing ❑ Siding Li Windows ❑ Insulation
❑ Gutters/Covers ❑ Entry Doors ❑ $
❑ Roofing E Siding ❑ Windows !] Insulation $
❑ Gutters/Covers ❑ Entry Doors ❑
❑ Roofing E Siding ❑ Windows ❑ Insulation
❑ Gutters/Covers ❑ Entry Doors ❑ -I $
SubTotal
$1302.00
Sales Tax
$0.00
Total Contract $1302.00
Amount
Warranty:
The warranty on the work identified above is listed in the General Terms and Conditions, or if applicable, specified in
the following documents:
Warranty AC86-AC58-AC12
Warranty
Name(s):
3
Distribution: White-Home Depot Yellow-Customer Copy
WINDOW SPECIFICATION SHEET - Spec.Sheet#. 9676221 Sheet. t of 1
Customer Natalia Munoz Job/4: 9676221 Consultant Timothy Dms( Dale. 11/08/2016
New window
Existing Window Hinge Locations
Measurements Grids Product Options Labor Options From outside,
Left to Right
Bays,Bowls
Location Color Rough Opening #of bars a of bars Carnets,l Pnl,
use L,R or S
Class Misc Items
Haw
Screen Code For doors use
= Mull 'S'=stationary or
w style wraps a = _ - m 9 e 22 r 9 fr 'x'=operating
lz Room Floor code (Y/N) Style Code Some Code w E x D g„ 0 a et > I . > I
€
sm.Diesseack Simard i Ss
1 Dv We OH ti OH woo w w a9 00 SO Oil 99
2 Liv we OH N OH 11nD w W 00 60 00 Da
STD &awned. stwewt Lan
SPECIAL CONSIDERATIONS'.
Wrap Calor
ntenor Casing Type
Bay or Bow window
Seatboard material{Vinyl only-Birch or Oak)
Bay Prolan Angle( O or 45)
Bay Flanker Type(OH,SH.or Osmnt)
Top of window 10 soffit tattles)
I Ted to soft.color of soft material I have reviewed and agree with at the bb specifications above and the
_on siuol Roof(Yes or Nal' Special Teens and Condins on the following page
Garden Window'.
Sealboard Matenal(vinyl Only-White Pion°,Birch or Oak)
Wall Thickness(inches/ Customer Signature
Additional Shelf(Yes or No)
'There is no guarantee that new shingles wi11 match existing color.
I
Massachusetts Department of P unlic Safety
e Board of Building Regulations and Standards
License: CS-067121
Construction Slicer: -
BRIAN
s - ;er BRIAN C THOMPSON
38 WILLOWBROOK LANE
WESTFIELD MA 01080
ExQiranor
Commissioner 04130/2018
I� The Commonwealth of Massachusetts
'� Department of lndustriaccidents .
1��e�yyt� llir lA1 Congress Street,Suite 100
3*�
Boston„414 07114-2017 ,
ex=r e
www.massgou/rtia •
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbcrs-
TO BE FILEDWITB THE PERMITTING AUTHORITY.
' Applicant Information ) � Please Print
t Legibly
Name(BusinessiOr9anizatioMndividual): is"' `/r:.� a-t^ i. -�p
� �
Sr
Address: (i1% 5/->tf J)A9
� CLi7., " / 'Shonei:^ ^ ' .f� 'L`L --
City/State/Zip. L
1--
Are you an employer?Check the appropriate boat Type of project(required):
I.❑I am a employer with employees(full aM(oi pan-time)' (�t
Y. u New cpnSENCtiOn
20 l am a sole proprietor or pannership and have no employees workina for me in 8. 0Remodeling
raycrpacity Pio workers'comp.insurance required.) 9. Inr-I t Demolition
lip I am a homeowner doing all work myself.(No workers comp.insurance required j'
i❑l am a homeowner end will be hiringcontractors to conduct all work on 10❑ Building addition
my Pmpeny. I will
ensure bat all comrctars either have workers'compensation insurance or are sole II.[3 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheer l3 r 1' Roof repairs
Thesesub-emeruclon haveemployees see have reamers'comp.insurance.: t_1
6.0 We are a corporation and its olicers have exercisers their riaht efewmrprsn per MGL c. 14.tiaQther
i 32.§1(4),and we have no employees.(No workers compinsurance required.]
,-
'Any applicant tlatciecks box 41 must also fin out theseaion below showing heir workers'compensation policy information.
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indimtiag suck
:Contaetotzthat tuck this box must otacheden additional shut showing filename or the sub:commnors and state whether or not those entiries have
employees. lithe sub-contractors have employees,they must provide their workers'camp.policy number.
lam an employer that is providing workers'compensation insurance for nr)'employees. Below Is the policy and job site
information. ! 1/q pp ',j�`'� COnsurance Company Name: dSf L( Th p(j�, 7. s-..t+k7 ' l� '
Policy#or Self-ins.Lie#3_34/1;33. - 40 it ,j _ Expiration Date: f 1
Job Site Address: 1 . .• t. DI
�/ �' ry/State%LIP: p' fell'
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). D r,q/
Failure to secure coverage as required under MGL e. 152,¢254 is a criminal violation punishable by a fine up to S1,500.00 65
and/or one-year imprisonment,as well as civil penalties in the Form of a STOP WORK ORDER and a fine of up to 5250.00 a
day against the violator.A copy of this statc,r,..nt may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification. n _
I do ltely cerci n rf t n peno)ties of perjuty that the information provided above is true and correct.
Sirnaz. e: <'"v`-.`. 2,-./� //,�� t)))"`y2:`'v1.-.[[^", 7)�''77 � I?ate:�1 I�lt//
Phone al: en P>2_-bc1 i> T i' —_
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#: „,
, . , F✓ ,i
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 126893
Type: Supplement Card
THD AT HOME SERVICES, INC. Expiration: 8/3201e
RICHARD TROIA
2455 PACES FERRY ROAD, HSC C-11
ATLANTA, GA 30339
Update Address and return card. Mark reason for change.
Address -: Renewal Employment I Lost Card
Office of Consumer Affairs& Business Regulation License or registration valid for individual use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Registration: 126893 Type: 10 Park Plaza -Suite 5170
Expiration: 8/3/2018 Supplement Card Boston. MA 02116
THD AT HOME SERVICES. INC.
THE HOME DEPOT AT HOME SERVICES
RICHARD TROIA ! -
2455 PACES FERRY ROAD, HSC -
ATLANTA, GA 30339 Undersecretary ' 616t valid without siMiature
onan
ACORD CERTIFICATE OF LIABILITY INSURANCE overmis�Ym
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 CERTWFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERCS), AUTHORIZED
REPRESENTATIVE CR PRODUCER,AND THE CERT/MATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed, It 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
NATE:MARSHUSA INC _ n .
FAX
TIRO ALLIANCE SER eerfl_ MIR No)
3560 LENOx ROAD.SLUE 2400 E-MAILE-MAISS
.�_.......� .___ __.
ADDATLANTA.GA 3032.5
INSURERISI EPA°RpNG COVERAGE NAICX _
100492-HOmeD.GAWttI617 _ INSURER A:SlePena1111surance CAmPene SW
INSURED _ .. WsuR...- .ARR Aimd(aI NsErate Co trj.''115
T:HO TTROME Ea INC _— _-
DBA THE HOME DEPOTEPOTARHOME SERVICES INSURER c:New Haaodamaa Co 233414I
ArTLANTA 30PARKWAY.SUN'E3W INSURER D:IIiM5NakowllnsUralrce Company ;2381]
ATLANTA,
a,GGA 303333 9
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-C 74x46a.1 REVISION NUMBER:B
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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.
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STIR. TYPE OF INSURANCE IRISH MD POUCY NUMBER (IMINODHYYe).(eaVDWW/YI LIMITS
A ' X commeRCIAL GENERAL LIABILITY GLO4LW771# OD.g1t2D16 '03U1i201]
_ __ .__ fACti4CCllRRF.N(:E :5 9,600.000ROES{Ea rem
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C.L11 M.CWlOE OCCUR INREMISES B 1.00801)0
LIMITS Or POLICY%5
MED EXP lens Ane Berson' s EXCLUDED
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DESCRIPTION OF OPERATORS(LOCATIONS I VEHICLES(ACORD 101,RADARS S RenuvM Schedule.may be tlbchedA more spate is requires)
EVIDENCE OF rNSURANCE
CERTIFICATE HOLDER CANCELLATION
1'HD AT-HOME SERVICES.INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
DBA THEHOMEDEPOT AT-HOMESER1ICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROM-SIGNS.
ATLANTA.GA 70334
AUTHORIZED REPRESENTAINE
OI Marsh USA IDE,
Manashl Mukoeoee .,Mo- Tao.“ bE..z..ns4 .a-
()1SA8-2014 ACORD CORPORATION. All rights reserved.
ACORD 25/2014101) The ACORD name and logo are registered marks of ACORD
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