18D-053 80 DA MON RD $5/414177 BP-2017-0806
GIS g: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D-053 CITY OF NORTHAMPTON
Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit 4 BP-2017-0806
Project d JS-2017-001343
gst.Cost: $8661.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.CIaS.y,;, Contractor: License:
Use Group:._. HOME DEPOT AT HOME SERVICES 67121
Lot Size(sq, ft.): Owner: DELOSSANTQS KATHLEEN
Zonfn2:Gi:8 +SC 12 ,/NP 12 / Applicant: HOME DEPOT AT HOME SERVICES
AT: 80 DAMON RD
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCERI02908 ISSUED ON:12/28/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 11 REPLACEMENT WINDOWS **
WINDOWS IN HAZARDOUS LOCATION PER R308.4 REQUIRE TEMPERING**
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 k 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:
FeeTvne: Date Paid: Amount:
Building 12/28/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner
j'/ , \ Department use only
City of Northampton Status of Permit:
/` \ Building Department Curb Cut/Driveway Permit
/ - 212 Main Street Sewer/Septic Availability
t Room 100 Watermell Availability
c) 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
SECTION 1 -SITE INFORMATION 6}' - /7 3'Q4
1.1 Property Address' This section to be completed by office
/J" / /,//�}/�) Map Lot Unit
49 ]) f/V II J/- 4 51 ° 7' Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
K4- - l bfFfMoD � kb -
Name(Print) CurmnntJlMliils�g layM2i /�1 rn z2 i eo
% , ets //�/K1f// Telepfione0/(/` T7 ! /Y�'�/ (/YJ
Signature
2.2 Authorizedgent:
Pie:Aiiriv-VT:e)ir boli P4oh7.�-.T�'dL-
Nam Current Mei ing Address:
nig-- PIT2/3
Signature ' Telephone )— , .- . `—/ 5-'Z---
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building /�/„�/I- i °I (a)Building Permit Fee
2. Electrical I (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection //�y/L�((,, 1 /� //pp
6. Total=(1 +2+3+4+5) gith� UD Check Number /7O50 (l
r This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: � ��� /2'-' 7./(l
Building Commissionerllnspector of Buildings Date
Section 4. ZONING AU Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to he filled in by
Building Depanmen,
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage 1/0
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
Prowse&Locallull)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 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 1 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 applicable)
New House n Addition ❑ Replacement W ows Alterationis) ❑ Roofing ❑
Or Doors �Wd
Accessory Bldg. ❑ Demolition New Signs [O] Decks I Siding[0]
Other[0]ther[0]
Bnef, flat oaEr Sd ` Dp%LvlNeNT� h& ti�uieg[.efJLWork: /Ag
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
AGENTORCONTRACTOR APPLIES FOR BUILDING PERMIT
/k9 *4-e / DLD / J
as Owner of the subject
property � ((�� T
hereby authorize gil dk /h�//a--
to act on my behalf, in all matters relative to work authorized by this building permit application.
A
Signature of Owner Date
,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 the rains l nd penalties of er
�) )
Pdn[Nam-
Signature• Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor, Not
f/��L-�-�� Not Applicable 0
Name of License Holder. P 'r`)4/f r � 1 —` "" C:' 967/ z/
k4)1-41161a2/2#7e- ) License Number
Address Expiration Date
Signature Telephone
j _41"Z�,
9.Registered Home Im royement Contractor: I Not Applicable '93
Company Name �L " �---- �. Registration Number
BA'/tTT �� ' 4
Address
Expiration Date
A )a�� ✓ f�1 /1nO 'L
Telephone } CZ'
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes No 0
11. - Home Owner Exemption
The current exemption for"homeowners'was extended to include Owner-occupied Dwellines 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 he 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 1531 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 byMGLc 111 , S 150A.
Address of the work: 90 P..7vl /22
The debris will be transported by: (vim f l l
The debris will be received by: 1 t'Ot2L :5'7 — 1/1171—
Building
Y/iBuilding permit number: D
Name of Permit Applicant i(//'tn/t>
Date Signature of Permit Applicant
Nov 071606:16a p.1
HOME IMPROVEMENT CONTRACI
PLEASE READ THIS
1(4�I I Sold.Famished and Installed by:
Branch Name:Mn.Ergtaad Date: THD AAa-Home Services,loc.
delve The Home Depot At-Home Savior
Branch Number:33 908 Hasson Turnpike,Unit I.Shrewsbury,MA 01545
T'cll?me 877-903-3768
Fedora:ID:75-269846th i1E Ge#C 62419;RI Cent Lax 16427
CT Lie 41-0C.OSMS2];MA Hume improvement Cmlmc`orr Reg.Y 126893
Insonation Address: ,"iO T)1}fekt alxl L. l . .il V'41�t-
City ' ZIP e107(✓
Purchasr Work Phone Home Phone Celt Phone:
KA-41 L?Cfu /6551n OS [ 1I _ 1 _ -- 1_
1 � 1
Home Address:
(If different front Irma]Iaaan Address) - __ ay _ - state Zip
E-mail Address(to receive project communications and Home Depot updates).
E I DO NOT wish m receive any marketing mails(mai Phe Home Depot
Protect lnfnrmution: undersigned COis ]mer'L the owners of he preperty located al the above installation address,aoymxs to buy,
and THD At-Home Se glees,Inc.( The Home Depot")agrees to furnish,deliver and arrange for the installation("Installation")of
all marrials described on the below and on the:eferenced Spec Steeps),el!of which are Nairn:dated into Ih.s Canna by this
reference,along with any nod:able Sotc Supplement and Payment Summary attached hereto and any Change Orders Molleetively,
'Contract'):
Joh*: . onoll mlooxo Products: _ Spec Skeane)* __. Profen Amount /�
�L'IRmfog Osding❑winmwa ❑Insulation — t/I iYV�..
�b oGnttera Covers ['dory Doors o aeD2 x:0-7 S I /� / r
DRoof g ❑%ding 0 Windows ❑Irnularioa Ws
I -
❑R s Diann L. ye 0 tat ibon S
- CIr
c DE Doors q _
011-0031/3 Lighting CWindows L11ns :n $ /�V
DOutters(Coven DennyDoors ❑_ r
AlinLwm2S:UepmitufCaMaRAnwnldue opatemenitiesafNk contrastTotal Contract Amount $ VGOI
Melee Purebnfera may not deposit arm than moment tithe CennatAmovet
Customer apses that immediately upon corpleano of the work for each Product Customer will execute a Cernolet on Cert F at
(onc for each'eroded as defined by ar Individual Speo Sheet)and Ry any balance due. As applicable,each Customer under:his
Contract agrees to be jointly am!severally obligated and liable lierctmecr.
The Home Mout reserves:he right to Issae a Change Order or tentnate this Contract or any individual P:odum(s)included herein,at
Ps discrviiun, f the Home 0.put or its authorized service provider deternines that it cannot perform its obligations due to a slitour l
problem will, no iaome.rn mental;mzanls suet as mold,asbestos Cr Iced:oink other safety concerns,pricing errors or bece'ase
work required to complete Mulcb was not included ir.the Contract. `+.r��
Payment Sunman.: The Payment Sunman t 1_3ZZC l\ , included as part of this Contract,Sem forth toe-mal
Corinna amount end payments required for the deposits and final payments by Product(e.applicable)
NOTICE TO CUSTOMER
lheu are entitled to'a completely filled-hi copy of the Contracted the tine you sign. Do not sign a rempktlon Certificate(note:
there is one Completion Certificate far each listed Prodnet as defined by individual Spec Sheets)before wnrk ma that Prod.a
is complete.
In the event or termiaotion of thin Contract,Customer agrees to pay The Horne Depot the costs of mater66,labor,expenses
mid services provided by The Home Depot or Authorized Service Provider through the date of termination plus any other
wallah set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY W ITHEOLH AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and AutbaHhatian: f s Doper agrees and urdtislsds that this Agreement is the croim agreeneet between C,,stemer
and The Yame Depot with regard In the Products and Installation scn ices and superades ail prior discussions and agreements,either
owl or written,eclat inn to said PI much,and Installation.this Apecment cannot be assigned o:amended except ay a writing spud
ry Customer and Th:Diome Depot.Customer acknowledges end agrecs that Customer has read,understands,vo untariiy accepts the
terms of and His relived a vom of this Agreement.
AcrypI-hyI Submitted by:c .—
x X �y ,g NIB 4* II/ol/16 X [ I irVL bIti ,�
Customer' Signature Dau: Sales Consonant's Snmarne Date
X _ __ _._- Telephone Nn_
Customer's Sb stare Dale Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS t_.anroNlen.
AGREEMENT WHOUT PENALLY OR OBLIGATION er
BY DELIVERINGITWRITTF,N NOTICE TO THE HOME ( o ( 3 5 5 3,-)DEPOT BY MIDNIGHT ON THE THIRD BUSINESS ` J U
DAY AFTER SIGNING THIS AGREEMENT. THE:
STATE SUPPLEMENT ATTACHED HERETO I 1'
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBE') RY LAW IN
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F Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-067121
BRIAN C THOMPSON
38 WILLOWBROOK LANE '. .s
WESTFIELD MA 01085
4
..M lJ . Expiration
Commissioner 04/3012018
The Commonwealth of Massachusetts
!-WJr-0Department of Industrial Accidents
1 Congress Street,Suite 100
.. _..__. ... _R._,vb.., MAIll 11d-2n//7
www.mass.gov/din
R urkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information 7 Please PrintriLegibly
Name (Business/Organization/individual): H'Qjfn4ib'{!bf J ,±�' (�-�})�y_ f� r.2V7C S
7 in
Address: �J ���_ __may_/ r� / (/1'_)t; j_ N // _/1,�
City/State/Zip Lli eti;LP'Cv iVij )1.!): /~61/Y !phone it: ' 2 fl'2)2—
Are you an employer?Cheek tw appropriate box:oType of project(required):
LQ l an,a employer with employees(full and/or pan-thine). 7. ❑New construction
'❑ am a solo proprietor or pannership and have no employees working For me in
I
p 8. ❑ Remodeling
any capaciry.[No workers'comp.insurance required.]
3❑I am a homeowner doing all work m self INo workers'comp.insurance required.l' 9. ❑Demolition
45Iamahomeowner are will behiring conhactorstoconduct all work onm properly o I will 0❑ Building addition
ensure that all contractorseither have workers'compensation insurance or are sale 11.0 Electrical repairs or additions
proprietors with no employees.
.o0 12.❑Plumbing repairs or additions
5ati am a general contractor and I have hired the sub-contractors listed on tie attached sheet 13.�Roof repairs
These subcontractors have employees end have workers'comp.insurance airs
6We are a corporation and its oil icers have exercised their right or exemption la,. her_
5 152.$1 0.ntl we have no employees. Yorkers'comp insurance requirededr�IGL c.
O [Nop ct ml
-Any applicant that checks box:I must also lilt out the section below showing their workers'compensation policy information.
r Homeowners who submit this affidavit indicmini they are doing all work and then hire outside contractors roust submit a new affidavit indicating such
[Contmnors that check this box must attached an additional sheet shoving the name oldie sub-contrznow and state whether or not those entities have
employees. If the sub-contractors have employes,they must provide their workers'comp.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information. .71/1k—
9 �� 7
Insurance Company Name: �f�' /�Jyry� C - i
Policy if or Self-ins.Lic.#: 1,41‘.-' irib--)a.7.; ' !6 _ Expiration - J r `7
�) 6- `\ Date: �t�(y]__
lob Site Address: 4// C JIT )C2 o[/ City/State/Zip l /9/%/ 91.960
Attach a copy of the workers'compensation policy declaration page(showing the policy number and e iration date).
Failure to secure coverage as required under MCI,c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do I:< eby redly-,u de I .-,.0 T peen ties of perjuIy that the information provided above is true and correct.
...N, S "k&
Signature: ' ./ f/t 'L ' ,) - Date: 12 2 —I h
Phone#: -16-- t,2_- r'{`j,
Official use only. Do not writewrin this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk A. Electrical Inspector 5. numbing Inspector
6.Other
Contact Person: Phone#:
• li no u x a. ICI 1,1.1 ' t I f; it .__. , P IIat
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AC®RL) CERTIFICATE OF LIABILITY INSURANCE ATEmayo
I THIS CERTIFICATE 15 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 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 endorsemenus).
PRODUCER CONTACT
MARSI USA.INC. PRN.
A LI/INCE',EIITER PRONE ' FPS
PND
IAM Na�cytl; _fNC NOT:
350L=hoer ROAD,SUI-E2+09 E-MAIL
ATLANTA,GA 30326 ADDRESS:
INSURER&AFFORDING COVERAGE NAICX
100,192-HOme`UCAA"16-li INSURER A:Steadfast Insurance Company 15387
INSURED INSURER 8:Zanotti Melton Insurance Co 16535
THD A-HOME SERVICES.INC. I
DBA THE HOME DEPOT AT-HOME SERVICES INSURERC:New Hampshire Ins Co 123861
2550 CUMBERLAND PARKWAY.SUITE 300 INSURER D:HMIs Nalional insurance Company 123817
ATLANTA.CA 30339
INSURERE: I
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATI-003746646-14 REVISION NUMBER:0
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NCPMTHSTANOING 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OFIX$URAXCE ADbC3LaR : parr en POLICY EXP , LIMITS
NW AND POLICY NUMBER .IMNIODIYYYY)11MWMR
ODY)'
A X COMMERCIAL GENERAL L!AR!UIY GLGI89T/1446 034i12015 '0310112017 t,EACH OCCURRENCE IS 9.000,IX0
I DAMAGE TO HEMEO
- CWMS.M IDE CXCIJR • PREMISES(Ea 0¢warcel 1000.000
LIMITS OF POLICY XSMED E%P(My one Pe,mn) EXCLUDED
S
OF SIR:SIM PER OCC I PERSONAL a ADV INJURY S 9,OOg000
aT-AG3REVAT VMIT AP _ SBER •
1GENERAL AGGREGATE 9�91)0E000POLICY - JE,... __ LOC 1 PRODUCTS•COMP/OP AGG I S 9,I000.MA
OTHER: s
9 AUTOMOBILE LIABILITY RAP 2938263-13 010112016 0101001 ECOMBINEDa (SINGLE UNIT ".1 5 1,000,000
X ANY.AUTO 'BODILY INJURY Ws person) SIS
OWNED OCHE:ULD SELF INSURED AUTO PHY'CMG BODILY INJURY IPV amden01,S
AUTOS - AUTOS '
NONADWNED PROPERTY DAMAGE MI5 _.
reEDABMS auras BBB apsden)
•
UMBRELLA JAB OCCUR EACH OCCURRENCES
EXCESS LIAR CLAIMS-MACE. AGGREGATE S
DED ' RETENTION5 ,s
C WORKERS COMPENSATOR 11h1C015519215(AOS) 10310112016 10310112017 X PER 1 ERS
AND EMPLOYERS L W BILITY
G ANY PROPRIETOR/PARTNER/EXECUTIVE Y'" wc015519217I4u,I Y.Nr1.NJm 0301/2016 •0310112017 • El.EACH ACCIDENT 1S 1,000A00
D C:'CEPry in NH)R EXCLUDED') N ".NIA.. 'ryC01551921"OIFL) 031002015 1031O1R01] I EL UUSFOSF-EA EMPLOYEQ$ 1f&0
(mandatory
If yes.desmde,under 1 ! 1,000A00
'DESRIPTION(OF OPERATIONS'AAA !COnilnned on A[dlAOnel Page ',FLDISEASE-POUCY WAFT LS
DESCRIPTION OF OPERATONSI LOCATIONS I VEHICLES IACDRD int AddilionaI Remits Schedule.may be attached if more space is requited)
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 N
2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA.GA 30339
AUTNORELED REPRESENTATIVE
of Ment USA Inc.
Manashi Muxheljee 3 o &Deb ,S'A-ae-A4-÷<
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
Office of C✓L : oer Affairs and Business Regulation
10 Park - Suite
Boston, Massachusetts 02116
1-T071'i, 1IL..._,_Uv ,'31i.,!.1t "oti11a6a6D3 RecIlitl(7iIL7y
Registration: 126693
Type: Supplement Card
THD AT HOME SERVICES, ;NO.
Expiration: 8J3/2018
RICHARD TROIA
2455 PACES FERRY ROAD, ',SG 0--f -]
ATLANTA, GA 30339
Update Address and return card. Mast reason for change.
.Address Renewal Employment Lost Card
Office of Consumer Affairs Cu Business Regain on L;ceuse or eugistratiou valid for individual arse only/
HOME IMPROVEMENT CONTRACTOR Defore the earairation date. fl found return for
Mince of Ctnsame'.Affairs and Business Regulation
Registration: 126693 Type: i+.kPark Han -Sake 5170
Expiration: 6/3/2018 Supplement Card Fa;nut...FAA :02116
TND AT HOME SERVICES, INC.
THE HOME DEPOT AT HOIVIE SERVICES ._.
RICHARD TROIA /� -- � T •.
2455 PACES FERRY ROAD, HSC
ATI:ANTA, GA 30339 r
lirder:varclary t Nit valid without stenetue