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36-184 (8) 908 BURTS PIT RD BP-2017-1325 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36- 184 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-2017-1325 Project ft JS-2017-002194 Est.Cost:$8700.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(so. ft.): 25874640 Owner DOLE CHARLES S&ELINOR L Zoning: Applicant: HOME DEPOT AT HOME SERVICES AT: 908 BURTS PIT RD Applicant Address: Phone: Insurance: • 24 SUNRISE DR Workers Compensation PROV IDENCERI02908 ISSUED ON:5/16/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 7 REPLACEMENT WINDOWS 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 5/16/2017 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only - -- - ---pity of Northampton Status of Permit: uilding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability N rthampton, MA 01060 Two Sets of Structural Plans phone;41 587-1240 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 eta' 7-73- 0" 1.1 Properly Address: This�nsection to be rppletgd by office • }(��i)pT � �� Map �lX Lot OV f7i Unit 4 J Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: n -�- 6 (fPLt gvi6Ac>72 ) /' Name(Pooh � CurrerN-fal� gg,A 111t Mfr 0/Pb Telephhoonn'ej ti //'/ 9795_ Signature 2.2 Authorized •gent: �n G . dad )!'— 9941 �/j24-e--,1 —TP, , (P'nt) i Current Jing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1- Building na (a)Building Permit Fee 2. Electrical %/ ''G' (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection �[' �7 6. Total= (1 +2+3+4 +5) '�/ 7 fir 'a6 Check Number a/ &J? 7 sice0 This Section For Official Use Only te Building Permit Nu • // - - Issuetl'. Signet - S/ • 77 Building Commissioner/Inspector of Buildings Date Section 4. ZONING Alt 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 Depanment Lot Size Frontage Setbacks Front Side L: R: L: A: Rear Building Height Bldg. Square Footage °o Open Space Footage (Lot area minus bldg&pared parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O 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 and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , 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 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavationor 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 ❑ Addition ❑ Replacement ' doves Alteration(s) ❑ Roofing El Or Doors Accessory Bldg. ❑ Demolition ❑.l y,�Neew Signs s/[0] Decks [CI J Siding 0] Other[/O] Wok°eschptpf • ;op.., ; ,f ��//cam /'r'Trc�Y�rxi,siew . ' OVo /ry L% �fYY or Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT O/ �� R CONTRACTOR APPLIES FOR BUILDING PERMIT //, I, )i ppu_ , as Owner of the subject property T hereby authorize /P i . - 4 / /Fr to act on my behalf, in.aII allfers reja've to work authorized by this building permit application. arc C�B�/�+f 'Gl h- 9/ 7 Signature of Owner Date • I. y' d' ,as Owner/Authorized Agent hereby •eclare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed us• e p- ns -penal['-s of p not Namara. �i• / 67-19—/ SignaWc of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name or License Holder'_ y ` i /J//• � C. �^ d9e;�"� 72 7- / License Number2-71^2- /d Address Exp,Expirationtion Date /4/1/1/2/777 Signature Telephone #h k-z 9.Registered Home Improvement Contractor: Not Applicable ❑ b krrin tSJ,y!/ // 7 Company Name Registration Number q2)43 - Jo 77)f 9 az/y Address / Expiration Date �' " (/ Telephoned r i SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.152,§25C(6)) Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi permit. Signed Affidavit Attached Yes No ❑ 11. - Home Owner Exemption The current exemption for"homeowners'was extended to include Owner-occupied Dwellings of one(II 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 hand 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 Oficial,on a form acceptable to the Building Official that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability ofEmployers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may he liable for person(s) you hire to perform work for you under this pemtit 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/ofacility, as ddeefinedd by MGL c 111 , S 150k /� Address of the work: 49� T�'Ly�/7�Q�/// �� mintr,e pur " The debris will be transported by: �,fl (:4 /1(0Z‘ The debris will be received by: / vt t / ' \$ Building permit number: Name of Permit Applicant 1414 / $ �s�fir 4.0;ji/k-LL Date Signature of Permit Applicant The Commonwealth of Massachusetts ç Department of Industrial Accidents OJjiceofInvestigations 1 Congress Street, Suite 100 Boston, MA 021!4-2017 y� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leziblv Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: _ Are you an employer? Check the appropriate box: Type of project (required): 1.0 I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have g_ ❑ Demolition working fur me in any capacity_ employees and have workers' [No workers' comp. insurance comp. insurance.+ 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 110 Plumbing repairs or additions .[No workers myself.m se ' com right of exemption per MGL Y P 12.0 Roof repairs insurance required.] ' c. 152, y51(4),and we have no employees. [No workers' 13.0 Other_ comp. insurance required.] *Any applicant that chocks box til must also fill out the section below showing their workers'compensation policy information. ' Homeowners who submit this affidavit indicating they are 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 die sub-contractors and state whether or not those entities have employees_ If the sub-contractors have employees, they must provide their workers'camp_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 A or Self-ins. Lie. #: 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 MUT c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 andlor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DR for insurance coverage verification. I do hereby certify under the pains and penalties of perjury 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#: • 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 Home Depot U.S.A., 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: charlie dole Boston North 9976150 First Name Last Name Branch Name Lead 908 buds pit rd. FLORENCE MA 01062 Customer Address City rate_ Zip (413) 584-0795 Home Phoneg Work Phoned Celt Phone# nhchas@comcast.net Customer Email 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.com 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 DEPOTS 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 04/19/2017 carom..:semure Dare 1 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. 8700.00 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 ' 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 I Installation Schedule Approximate Start Date: 06/14/2017 Approximate Finish Date: 07/12/2017 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 04/19/2017 customers Signature Date X Co-Signer(if ppguwel Date X 04/19/2017 Sales Consultant's signature Date License number(s) held by or on behalf of the Home Depot: 2 WINDOW SPECIFICATION SHEET - Spec.Sheet W'. 9976150 Sheet I of 1 Customer. charlie dole Job R. 9976150 Consultant'. Timothy Does( Dale. 04119/2017 • New Window Hinge Locations Ex,sling*endow Measurements Grids product Options Labor Options Froin outside. Leg to Right Bays,Bowls ' Location r Color Rough Opening pclbats tl of bars CJSCL R Pell, use L.R or S Glass Msc Items Hardware Cade For doors 9 Mut 'S"= tatlonary or Style Wraps R. ` e y ® 2 'R'stationary ng LE Room Floor Code (EN) Style Code Series Code w § x 5 ISm u a > x STD HassFact sunsets WRAP I Sir STD GiassPeck Standard WRAP 1 SR OWL GlessPea „seer WRAP.LSD STD (31/wwa swore,/ WRAP.LSD • • I SPECIAL CONSIDERATIONS' wrap Color 1'.While.d'.Weile,3:White.4'.White,5'While,6'. MISC] oak seaboard Hence Casing HIR Colonial Bay or window Seatboard material Nine only-Birch or Oak) Bay Protect Mgle(a0 or 45) Bay Flanker ype(OH.51-1.0y Csmnt) Top of window to scam(inches) 10 I tied to soffit.color of soffit material I have reviewed and agree with all the job specifications above and the OonaWc Root(Yes or NO. Special Terms and Conditions on the followng page Garden Window' SealmN Material(vine only-White Plunge.Birch or Oak) Wall ThIckneas(Inches) Customer Signature Additional Shelf(Yes or No) There is no guarantee that new shingles will mate,existing color. 56/2016 20160S1pcjpg Massachuse* > * _ ,; ouc,, Safety Board of BL= a ,/z s ,nci Standards L :cense: CSSL-098785 WAN KOSOBUTSKYY 72 STAFFORD RD MONSON MA 01057 t4;-1' souk. }1.. Expiration: k.- toner Siar . • Ittps'.//mail.g.55e.Gan/maillttsearc5famY3Amike w betlartl%40v,makPacm+filename°h3A(IF9'OR,IP50+00+pg)/154734afif1222ariprpjectnr=1 1/1 lite t!-011L monmill o/CiCG:io-a&`I1 Je/7J, Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Supplement Card HOME DEPOT USA INC Registration: 112785 2455 PACES FERRY RD C-11 HSC -. - _. Expiration: 04/22/2019 ATLANTA,GA 30339 Update Address and return card. Mark reason for change. ❑ Address 0 Renewal ❑ Employment O Lost Card Office of Consumer Maus S Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 112785 04/2212019 10 Park Plaza-Suite 5170 HOME DEPOT USA INC Boston,MA 02116 RICHARD TROIA ,Fk — ' 2455 PACES FERRY RD C-11 HSCee ATLANTA,GA 30339 Undersecretary Not valid withou signature ATITT ACORna CERTIFICATE OF LIABILITY INSURANCETEISO1I2C 1 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(SI, AUTHORI=ED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcyfies)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 thla certificate does not confer rights to the certificate holder in Ileu of such endorsemant s). PRODUCER CONTACT NARIET HARSH USA,INC. 'Emma 'PAX TWC MOO LENOX ROAD.SUITE 24('A Sopor R ATLANTA GA 30325 WSURER(SIARDROING COVERAGE NAIC0 100492-HomeD-GAW'-1149 NSYHER A:Old NOSING Insuraom Co 124141 INSURED +USURER E:AER SBI 1n5L'fcnCe ColI$9( 142757 THE HOME DEPOT,INC. _..... — HOME DEPOT U.S A.,nVC. SURER C'New Ha4pthve as Co 14141 2455 PACES FERRY ROAD D: I BUILDING C-20ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL00374630214 REVIStON NUMBER:2 THIS IS TO CERTIFY THAT THE POLt'CIES OF INSURANCE GSTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERiOO INDICATED. NO1WTHSTANOING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO PARCH THIS CERTIFICATE MAY BE ISSUED CR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS DF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. In NMI I" PoOCYQ4A POL6YEXP Lq TYPOOFINSURM CE 11E40:MD POL.CY NUMBER I IMMJODUYYN)I IFMeNDttYfrl l LWITS A X i COMMERCIAL GENERALUARIUin 'SAVOY 310022 03i0WO 7 O3OV2018 I EACHOCCURRENCE S mooICIAMS-MADE _X OCCUR SWEIOaHtP 1,090.000 LIMITS Result $ EMZES!Es .IMRS OF sate xS MED EXP Anvane Pmanl iS EXCLUDED OF SIR SIM PER OCC i PERSONAL a ACV INJURY S 9,200,000 GE L AGGREGATE uta �G£NEPALAGGREGAI£ S 9,000,000 APPLIES PER j i I POLICY EC `x ! i I PRODUCTS•COMPERE AGG,S 4iUb],LCd A ' AUTomositEWBIItt -IPNY AUTOoSmED SCHEDULED uoAIWT913$021 SELF INSURED AUTO PRY RAG 01N1001] 0501/2012 I JCE.acOatldMw US S KiBLNT 1 i I BOGLY INJURY(PH-person) IS 1.LW,C� ROSILY (peeaNmnl s `IIREQAUTOS I wrOS NEe i I, DA r (Pc cccm,o S 4 x UMBRELLA DAB (OCCUR U I 1 EACH OCCURRENCE S —1 ' EXCESS 8 l CLAIMS-MADE ADE. AGGREGATE s IDEO Ti RETENTIONS � f p Is B 'WORKERS COMPENSATION 'WtRC491123g(TN) 103NtZ+V I03C1122015 x 15Ta#re I_ I OR" 1 G 'AND EMPLOYERRLIS&Utt YIN t WC 0Z11G2423 PX NHWMi} IO3✓<J5.23fi (p32t}(3{4t8 ft fK11ACCOENT [ RRCFRlc ORPAR'NEt44A£CM1£ N NIA I f iGC-0 U D OadEWMEnNH E%CLUDEpJ WC 01x102424 MP) 03/01.2017 O31L1RO18 EAEMPtOYEEI {4W4Lary In NitEL DISEASE- I.o00000 [Ie eete0NN OFar Cmlinued on Addilunal Page 1,000,009 p SCRIpi10N OF pPEMTION$,belw EL DISEASE DIRT 5 I 1 i DESCRIPTION OFNSI LOCATIONS I VEHICLES IACORD let,ATRI11onal Remarks Sebtlulq mn B n aY es 9ackaen man space EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOVE.DEPOT USE NC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ARABIA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE erManh USA inc. �y����������� Ma,astl F.lomesee .Mnsw.awi .Dk.a.itsarylsh (41198&2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD AY-rtrar CMSTCM`cR ID: CQ1jj LOC M: Atla^t3 ~_ �+1 a ACORD ADDITIONAL REMARKS SCHEDULE Page2_6f 1 A,ENC? I N.MEowaraFa -CME:E$.:.i a.re; .—.. ken'- -CA - "Orme auMaER 24M Aaata a_E', �Ay 3l4Xt0 ea n ecnv€Amer .. 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