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38B-196 44 FORT ST BP-2017-1354 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B- 196 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:windows replaced BUILDING PERMIT Permit# BP-2017-1354 Project# JS-2017-002250 Est.Cost: $1542.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 105953 Lot Size(sq.N.): 9713.88 Owner: COHEN BARRA Zoning: URB(100)/ Applicant HOME DEPOT AT HOME SERVICES AT: 44 FORT ST Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROV I DENCERI02908 ISSUED ON:5/23/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 2 REPLACEMENT WINDOWS IN BEDROOM 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 it 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 5/23/2017 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner /\ Deparbnent use only City of Northampton Status of Permit Building Department Curb CutfDnveway.Pereal \� 212 Main Street Sewer/SepticAvailabnly Room 100 Water/Wd Availability ,�ti ,� Northampton, MA 01060 Two Sets of Structural Plans ` „/ 's`'*hone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify \ ,s PLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATEORDEMOLISH�A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION e P-' 7 - ' 3b H/ 1.1 Property Address: oThis section to be completed by office Lig, [1 Y /� t . Map 3/1,6 Lot `q(, Unit (/ ) I Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Pont) Cunent allln tl s �� L(�n�/za� � T� Jn1i�. alebG Telephone, _ .� Signature tt 11yy 7— /J 2.2 Aut rite Agent: ICA ?V i1fi qD hP tsn 1"o . N t) ,( Goran ailing Addres --- zkil lad" -- fv 1/ Wiz:' i3O P 11� - aM9 Signature Telephone LrD — 77 ' —/ - SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building • ii 5112--n" (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection Q]� y���"/j 6. Total= (1 +2+3+4+5) / 192 - ©a Check Number 44080 '-/// This Section For 0fcial Use Only Building Permit Number: ie Date Issued: Signature: gefe +.5--W —/ Building Commissioner/Inspector 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 be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R'. Rear Budding Height Bldg_Square Footage % -Open Space Footage (Tot arca minus bldg&posed parking) -.. . #of Parking Spaces (beams&Loculiou) 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 O YES O IF YES: enter Book Page and/or Document It B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® 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 t acre or is it part of a common plan that will disturb over l acre? YES 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 E] Addition ❑ Replacementvymaows Alteration(s) ❑ Roofing Q Dr Doors IIIIIIOOO Accessory Bldlgg. 0 Demolitti�o(n� /V❑ New Signs [Cl Decksc / [C I Y+ Siding[Ci Other[[0] BrieWork n*:iff AYP�p � n-te-n Ta-1}lkf�lx.� J1/lfJ�./LhrAl";-' kr ;✓YK-rit-b LJV�J- 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR, APPLIESyyFOR BUILDING PERMIT Y1'1n� 62 kr-I , as Owner of the subject property hereby authorize P id ra 7fion ifir Z '71LQ' to act on my behalf, in all mtters relative to work authorized by this building permit application. GIs Ire ? /7 Signature of Owner ' Date I, / tAn,TG19 it ,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 urns he rains and penalties of perjury. I Print N. -- • i er/Agent - SignetDate SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not //, �/ Not Applicable ❑ ` Name of License Holder: -et []')i?c� gi - /p...-4- License95 Number 2) 4<))9J c /QC- --.iF,7e' Address Expiration Date 1-lz l l% 4i — V) V?'6 Signature Telephone qp I-5z2 —J-3d2,,,.. 9.Recilstered Home! proveme t Contractor: NotqApplicable//274517.--- Company Name D � 11G�jLi r Registration Number im boo-t---, Pf 2.Z-I9 AdddrrreesJsJ�(' ail /�A// l` �,1r y���� //'1 "7 —fI/'(� Expiration Date .r1Ircif.„ 'r1 a/ 7 !1I t i r G Telephone 7l/1J1/oi' /I�� 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 buildi ermit. Signed Affidavit Attached Yes No 0 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings ofonc(I) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 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 fern)acceptable to the Building Official that he/she shall be responsible for all such work performed under the buildin>;permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also he advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to Employees for 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 by—MGL c 111, S 150A. Address of the work: l�4 4i2-7 Jdb The debris will be transported by: IAM-4-7k mTU The debris will be received by: { Z..—ere," -A Building permit number VGn Name of Permit Applicant I rtY_ 12r'/4' Date Signature of Permit Applicant h. 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: Barra Cohen Boston North 10002529 First Name Last Name Branca Name Lead/t 44 Fort St NORTHAMPTON MA 01060 Customer Address �, tate 4 (413) 336-7144 Home Pnone# Work Phoned Cell Phone# barracohen@gmail.com Customer E-mail 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 Ctiy ate 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 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 05/06/2017 Guelaners Signarme pare 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. 1542.00 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/ Installation Schedule Approximate Start Date: 07/01/2017 Approximate Finish Date: 07/29/2017 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 05/06/2017 Customers Signature Date X Co-Signer Of applicable) Date X - _--- 05/06/2017 Saes Consultant's Signature Date License number(s) held by or on behalf of the Home Depot: 2 WINDOW SPECIF ICA I ION SHEET - Spec.Sheet p: 10002529 Sheet 1 of 1 Customer Barra Cohen Job p: 10002529 Consultant: Timothy[Vast Date 05/06/2017 New Window Exiling Wmouw Measurements Grids Locations GJJs Product Oplmes Labor options Ir ram outside. Felt to Right Bays.Bowls Location Colne Rough Opening a of x of Csm,ns,l Pul. use L R m5 RGIass ie Mist Isms code Serpens For 6°°tF we _ e a Mull "5'--statoiary er Blyle — E — — jp a 2 A _ =aper eng gE Rwm Floor Code (YM) Style Code Seem.Code £ w 3 T 5 r re o u d > I Di > I 1 BED 1st OH r On G1OG BM 3100 At w us Let SPECIAL CONSIDERATIONS. wrap Color 1 Whits,7'White MISCI:Aad l or l vented allutters black,oda the I sh ulterto the right side of houseadd ne Menet Gaffing Type w pair on front second Boor •MISC2:Add 1 or I rented shutters black add the 1 matter 10 Say or Bow window the nom side of houseadd new pair on trail second floor Beatboard material(vinyl onlyElmh or Oak) Bay Project Angle(30 or 051 Bay Flanker Type(DK SH.or CsmnO Top at window to soon line es) flied to soffit color of mnl malenal I nave renewed Rid agree with all nm job apes'talions above and the Construct Roof fffieS Or Nor Special Terms ane Cond bion a on the followmy page Garden Window: Sealboard Material(vinyl only-While Ron ile.Birch or Oak) Wall laGn,ass tinehe 5) CUSt011161 Signature Additional Shell tees oro There is no guarantee Thal new shingles will march existing color `— - The Commonwealth ofjJassacIi, etas r ?Ips/le Department of?ndr•.sl:ialAccidenis yam,41 Congress Siree Suite 100 ) iljt—",a Jr ct l , :l u-I 0ZI1 s-201 naurtuitass.gov/dia - l\oiier; Compensation Insurance aYidnvir Buiiders/Contraciors/El ciricr nsINumbers. Tr) .. ,-.rr ,..,r_ P .L.,.,Uc m:JCR,^-. 901ilinit liti'orrrolou - Please Priv: gins. 1 Lune l _o a -o dr d 2tl. CnyD1 i---a-i---- ii- Address: '�7 1 re Q/ 09-;/ Px 5}IR*At/ o> y� X74—ate.-a»7 5� r�onc plod chug,tl'aii P - __ _- - - I l;vpe of project inquired). 0 : elm rr I t , n:Lan r-rmnI. ❑ V co dove.,,,, ❑ _ ,I r en,t fie m.'.:" 8 ❑ Rcr,rodcling y11 wt yl::c 9. ❑ Demolition 1n .,r hi o i 10 ❑ Building addition that 3!I o ,.,,p on ar. .,:c oc sk 1 _❑ Il Metrical r pa o ldddions nioniiegio;‘,;11nyI 12.❑Plumbing repa trs or additions t rI conH and andI I - l lista.). :he Fl 1 pl 1 l .n .thCer 1i-❑�RRcyst re"p'aiirr /'� ❑ . a . ti, er I pl vl.cr. I,l.(�) ter py�/VL' tai,an:: . ..:have,ic,unIploy.t75vo v.,o:kt-NLcelliP ilinfanCe latiLued.-I rh.hal: . bo-. tT I r _ h 1, mp aann. n .. .. vIeat ll, ol_and E. Ir o [sen s r lr mol .a. t rnil �Ic rrc . u flc 5.1. r .iel.0 til r i. de p: ml h,i,obe: I am an employer Thai is providing rrorlecv'compensation insurance jOr my employees.. Below i% the policy and job site infnuatinn. Insurance Comp.my ti l . it _ ..I)INJI PA/ FGC Policy or Selfi m / �e..- 7963) Expi u r Dine: "�') �j . . •Mb SIR: Addre5S. zpit (�� dtruh r copy ul the workers'u m's' compensation policy declaration page(showing the policy number and asps [i n date). 0/ I a to,;care tt 2e as recuired under )AGo.c 152, §25A tu a oiminal i itiltilion punishable by a fins up to 51.500.00 ar r -1 Ye:n'imm.sorvncnt as %sell as civil penalties in the loon urn STOP WORK.ORDER and a tint of up to 5250.00 a day againse '.be e roltor.A copy of iii is tatcment may be forwarded to the Office of Investigations ofthc DIA forrm onSc coverage verification. I do lr V certh tub lend., part' hal the ill/Munition provii;i above is true and correct � Silit Lan:: JG -2 Date. Per :,_ -._ .f4 -lib— -I( qii- / '-- -- Official use mill.. Do not write in aria area, to be completed by cif),or town official. - --- Cit.) or 101111: Pn'miti[.i cc use# r Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cib;l1own Clerk 4.Electrical Inspector 5.Plumbing Inspector' U. Other Contact Pctisun: _.. . Phmxr $c> cird 'of 'hiuitding} 1ieC; ,,iiat'1o{ns :ind i cense CSSL-105953 . , ; , > ' vi ye + CP; a ,y317: ,`.pix °_ c.. it :br , w . . °>k ! '^vd '-'c..IA^1!f`J e `� i p %'+S,ice 21 IGOR GUSEi/ , 4. ,s :' r 21 KIBBE LANE ' ,F ;c; ,1` HAMPDEN MA 01036 ,A,..."\ 1 '4, _ , ` ,4I. iio ;itic7 :t �3rifrils `, I () r'iei 05/18/2018 CiAe ominoitweailit (J/Q CG&Jackcisi i 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 011 HSC _- ,:; Expiration: 04/22J2019 ATLANTA,GA 30339 update Address and return card. Mark reason for change. 0 Address 0 Renewal 0 Employment 0 Lost Card -777, - Office of Consumer Affairs b Business Regulation _i4=4 NOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Suoolement Card before the expiration date. !Hound return to: Reoistration Expiration Office of Consumer Affairs and Business Regulation 112705 04122/2019 10 Park Plaza-Suite 5170 HOME DEPOT PISA INC - Boston,MA 02116 RICHARD SFE l d 2455 PACES FERRY RD C-11 HSC �� i `~� ATLANTA,GA 30339 Undersecretary Not valid without'signature a A� CERTIFICATE OF LIABILITY INSURANCE DATE 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 INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If Me certificate holder Is an ADDITIONAL INSURED,the pOIIcyges)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 ceNficate does not confer dghts to the I certificate holder In lieu of such endorsementls). PRODUCER CONTACT MARSH ORA,NC. "'. 1AX TWOALLfANCE CENTER HP _ 35&J LENOX ROAD,SUITE 2430 .dWt 094. ATLANTA,GA 30326 ' INSURERIENFROPOINC COVERAGE HAIL• IW4S2-HEmeD.GAWT1748 weuxwax:Od Republic insurance Co 24147 INSURED WyuxeR e,A9 General insurance CAPgafe 14215? THE mac HOME DEPOT U.S A..INC. a unit C:Mev RxARNMaoe Co 23841 24S PACES FERRY I SAO INSURER 0: PULPING 0-20 ATLANTA,OA 30339 _INSURER E: _ INSURER F: COVERAGES CERTIFICATE NUMBER: A11-0O3745]8714 REVISION NUMBER:2 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI00 INDICATED. NOTWITHSTANDINC ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT YSTDI 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 CF SUCH POLICIES.LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS, INSRI �.•.TYPE OF INSUPAxCC •4 +I,- M.WDDCU V6CF POLWY FSP LM13 ' j POO /WO POLICY NUMBE0. , N{YWI IMIgdYYWI A A COMMkRCIAL GENERAL GA/Min NWZY 310022 931002017 ,Q1g1f1016 EACH'MAMEcORENCE MOOSE an MSMACE X OcCuR I .IE*SESO aWSED LEEDOM LIMITS CF PSXICY XS ;IfiD EXP{ Ea EEVAnrAH 60 E%P(ary RN pnml EXCLUDED OF SIR 5100 FER OCC PERSONAL a A0V INJURY 9,CW.000 GL AGGREGATE LIM 7APPUES PER � OUGY E-T LOC ffEM1AGGREGATE PRWKTS-CGYPCP EGG9,0W,LEM 041ER 1 ( A AUTOMOBILE UMIXIW M'Wi8313021 0310111017 03012016 I MWED INC,L9 XWIT 1 I � 1 X I ANY AUTO BOPLY INJURY(POI pNunl ALLOWNED QED Hl1 +uios LEG _SELF INStIR0.1 AUTO PH?CMG ROgLY INJURY INT memMp 1 `HIRED AUTOS t AUTOS tkiiCOWIED O Yt I I IA , UMBRELLA UAB OCCUR F EACH OCCURRENCE EXCESS LIAR CLAIMSAAADEI AGGREGATE I OED - RETENTIONS 1 I I B 'WORKERS COMPENSATOR KR C44t 123Y.10TM 911012017 03/012016 IS PER OR r IRlo 5MPLOYEBS'LmBNTV Y3 TX (+�_ STAME I I6R - I ANY PROPmfidllPAWNERFXECAMAR N NIA 023102423(AR,NH,NJ.N} -0SIti29R 43RVXtiB EL EACH ACCIDENT LitC.cTnS .. IMndatoryIn W WO WC 0231029241 WI} 03,012017 oSO1R010 1 " OmanLNpry MNM1 '� EL'DISEASE-EA EMPLOYEE ISF.U.OLU 0y 4wIW under ICEnInuel ON AddilrvBi P 1000ACO DESCRIPTFN OF OPERATIONS Wow E L DISEASE-POLICY LIMIT I 1 OESCRIPTCH cc OPEMTONS I LOCATIONS I VEHICLES IACORD 101,AdMIgml Renrts SthSuS,may Ca alticME If man apace M enquired) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA.MC SHOULD ANY OF THE ABOVE DRSCRMED POLICIES BE CANCELLED BEFORE Pis PACES FERRY ROAD THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE OI MANX USA Inc, IMaIIVsrP MUXh¢r)EM _Mnums.: L.a` L.4eA. 0 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 2512014(01) The ACORD name and logo are registered marks of AGGRO Ai r4O i 005 COMER io: C61.52 LOC 4: Atlanta �.^... ACORD ADDITIONAL REMARKS SCHEDULE Rage 2 of 3 f AceNcI .RAMC,JNSUNED J 7141.1"ti-.0,E r.,— a9pc'r Nuasea j ME MEE'S'MP vGJ Irk rattt..:M 'ME ADDITIONAL REMARKS THIS ADDITIONAL.REMARKS FORM i$A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TRLE: Certificate Of liability lrsurancs _ 'Harken:m cn O Rt* OAmt.,MemMy'neulana:Amply n Nom Eirerca ?owl•lumtaE efL :nu 4-;AUa.:C;o..A.<.L O.AMS AG NEHA.:0RES0 r NV NR &Arne Bare:03ES,2011 Eaynita Dat o waata (ELI um!:si oco xr1 CAA—Roy wee*ed mama Cora Poky Nemt.r HC 11310241 CC,CE,:,I A mc.MN.1fr NY All Efetln Cate:0E01111E7 EulramnDaa:tNu 39 !Eluert SaMEMO Camer.ACE+mEnctENr1fl-ompanY 1f*attar Ku MairM:DEW.C>a.YCiR ERNA_t Mwder^ab 0E01.2017 Egon Cato.0.10104 4 _RAs:x0.:01 lR:•29.CCE3R Io-'re RARE 9 gfl;:LN:.OPa4(#d CaNaboM Ubn MsMan ;Co ianY a Caw AlAy N4mterAM iteMMICEN ICECYGeME M.MIO+,a&J00 Fbceve OniellEt200 ECaamen gab Mama S $9x:Sue0,3LE St C 0 00S RR or IM Raga A CO.LE,NY,W.C AAA,Ue Si50.0 W SIR be Ne able al GA 5WEI SIR bine ebb al CT^s—r-ee'�'y flanw 4atc4, 'Mie reirsunr.e CAMAY a i PER,/ElCN ; 3s is es;) MLI area1101.:0 i 0i.-081 ..u' rim 0 0 0x213 mt di XEXO i'M 5.00 W it addettR XS Weimar Garrtlires Imn:nrtnect Erten ihct Harter ThS C1d613201?xl O ecroe Mt 03t'r O'T exvJ.cn DEW AROEAa3 [a1 Ent 3'1000.10 n.,.it 0000,0 ACORD 101(2008101) 2008 ACORD CORPORATION. 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