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29-089 (8) 22 BRIERWOOD DR BP-2017-1425 GIS#: COMMONWEALTH OF MASSACHUSETTS Man:Block:29-089 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:Door Replacement BUILDING PERMIT Permit# BP-2017-1425 Project JS-2017-002366 Est.Cost: $2343.00 Fee: S40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 092937 Lot Size(so.ft.): 16291.44 Owner: KOSTEK EUGENE R&CHRISTINE PASEK Zoning: Applicant: HOME DEPOT AT HOME SERVICES AT: 22 BRIERWOOD DR Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVI DENC ERI02908 ISSUED ON:6/7/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ENTRY DOOR FOR REPLACEMENT 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 6/7/2017 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner r_. Department use only JUN ity�• Of N rt mpton Status of Permit: LBullding�ep rtment Curb Cut/Driveway Permit l !a Dr-Cr- 212 Masin treat 0Sewer/Septic Availability t . E, r� - Room 100 Water/Well Availability , , � Northampton, MA 01060 Two Sets of Structural Plans - .r_ + phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH AONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION it , -7-/OS 1.1 Properly Address- This section to be corn eted by office (/�J��,/J ���q-��/(�) l'(�J Map aq Lot D� Unit i"°-"✓ - J>� Zone Overlay District Elm St District CB District SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record:Eukrixbi - ) � , l �2Pj‘p� Name(Print) J(')J /` f/�/ Current Mailing fI.La /hp__ 602,2_ 6,97 6r Telephone L/I35Lg1/_/939 Signature )6040/9— /y. /sy}/J '�/�7/� _ Curre elfin Address. .� 6.701.1--Srgnature Telephone 444L/'v/�/�/_'./ � 6.701.1--Sr-- 1 • SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 34/9_ a© (a)Building Permit Fee 2. Electrical �f (b)Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection JJ,,//`'' a ' /,,, e3 6. Total= (1 +2+3+4+5) /j6, `e/ Check Number ,4f`f7 C, L' / This Section For Official Use Only 7 Date Building Permit Number: — Issued'. Signature: �� / �/ / 7'17 Air Building Comm esioner/Inspector of Bui• gs Date lhasbrouck © northamptonma.gov EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All 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 Bepanment Lot Size FLOnlage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage ,o (Lot area minus bldg&paged parking) re of Parking Spaces Fill: (volume&6acwlmp 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 O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O 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 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 ❑ Addition ❑ Replacement W' ows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. 0 Demolition ❑ New Signs [p] Decks [p Siding[0] Other[0] Wok eac n% P i) J/� Dry�i� .e /n�u/ �v hT�,GTi�t Alteration of existing bedroom!% Yes No Adding new bedroom Yes No �O's/ 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? L 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 Na 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, 5, - ` g- i /.w , as Owner of the subject property hereby authorize /11, 97— x>ta-01/T— 91" -2 — to act on my behalf,in all madative to rk authorized by this building permit application. -6a 64-71 /hr / 7 77 Signature of Owner Date I, �l -i AS /O/�/�// as Owner/Authorized Agent her by declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Sign he p ns and penalties of penin --- la 7 77 Signator f Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor:2)w /y��//� tiny) Not Appppliiccaable_❑ 7 Name of License Holder: ... r V " O 2- 99/ � 190erldRAS �✓ • License AddressExpiration Date k7--&ki_s 41. 9/9-56 Signature Telephone 9.Re. stared Horn= Im•rovement Contractor: Not Applicable ❑ Com an Name Registration Number Addrr ./ / ' y,/ Lam^) Z Expiration Date /r , Ala V_; Telephondo/l2 ,r2---- 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 buildinermil. Signed Affidavit Attached Yes H No ❑ City of Northampton � } Massachusetts 0. it ® _ � t4 DEPARTMENT OF BUILDING INSPECTIONS * 212 Main Street a Municipal Building Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation ("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations oil detached one to four family homes. Prior to performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"he done by rcaistered contractors. Note:if the homeowner has contracted with apcoorrporration or LLC, that entity must be registered. Type of Work: Dail o. fOfL//I*ZT-- Est. 'C,ost �'//y��'9y"7"{3 U� Address of Work: CS'?" lt `warb / . L' �C IYg GivOre / 10-e Date of Pennit Application: — /7 I hereby certify that: Registration is riot required for the following reason(s): Work excluded by law(explain): Job under S I_.000.00 Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter I42A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building perm as the agent of the owner: 4-7-17 �/-k4 �1 T rid- Date Contractor Name / HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS b 212 Main Street • Municipal Building N Norampmpton, MA 01060 Svh Massachusetts Residential Building Code Section 110.R5.1.2 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. Section I10.R5.13.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.85, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. Such homeowner shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall he 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 of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hirc to perform work for you under this permit. City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building ;OS sin Northampton, is 01060 Debris 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. The debris from construction work being performed at: ,71? fi/v2W/7 J (Please print house number and street name) Is to be disposed of at: ) All (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) y , T";); —11,k*77—a -7-17 S gnature of Permit Applicant or Owner Date If,for any reason,the debris will not be disposed of as indicated,the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. Ars 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: Eugene kostek Boston North 10077381 First Name Last Name Branch Name Lead it 22 bierwood dr. FLORENCE MA 01062 Customer Address City tate Zip (413) 584-1959 Home Phanelt Work Phonetl Cell PhoneN gkostek@aol.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 Gy are 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 05/23/2017 cu.mmer aty .wre Date 1 C n rraact Price and Payment Schedule: Payment of the Contract Price is due upon completion unless a different payment schedule is specified in the State Supplement. 2343.00 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 v be used to pay some or all of the total amount of sale. Description of Work to .e Performed: Installation of Entry Doors 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: 07/18/2017 Approximate Finish Date: 08/15/2017 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 initiating this paragraph, I consent to receive only electronic records related to this transaction. r** 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. XI... 05/23/2017 Customer's Signatun '.. —_. -....— Dat. X Co.Spnege appRtaNe; Date X _._ 05/23/2017 Sales Consultant a Signature Date License number(s) held by or on behalf of the Home Depot: 2 {x � �# f>. i it. M 1„,, r e" yr , •, M M kk _� PJi s . e;.1rlcusetts Dep rimnentt of WuUfic. 'Safely Or u ` Lit t ;onrcl of Builciing Regulations; and Standards ��d. License CS-092937 3 SLAV MOP<AN '' 43 SAI3flINA BROOKE LN WES'I'EIEI.I:D MA 01085 • 4i.irrtion : C'ornrrt1s ioriof 04/29/2019 ACOROe CERTIFICATE OF LIABILITY INSURANCE DATE IMWDOIYVYYI 4eame„i 32111200 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 RETVEEN THE ISSUING INSURER(S), AUTHOFUZED 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 Io the terms and condtdons of the policy,certain policies may require an endorsement A statement on this certificate noes not confer rights to the certificate holder In lieu of such endorsemengs). PRODUCER tONTACT .MARSH USA.INC. .DAME. 'WO ALLIANCE CENTER iNCC No Poo —1 C Net 3560 LENOX ROAD,SUITE 24W EMAIL ADDRESS' ATLANTA,GA 30321 -,,, ISSURERISI AFFORDING COVERAGE I RAM• 111492'I4omeDGAW+Y IE INSURER A:OU Repibc Insulatie CO 24142 INSuelG �••. ..^.�•.�. THE HOME DEPOT.INC. WSI,eFns;ABM Gege9llnwraf4S Company PM? HOME DEPOT USA.MC, Ihh uRER C,New Honusnile ins Co 2Th41 2455 PACES FERRY ROAD INSURER a: BUILDING GNI •ATLANTA,GA 38339 E4SURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL.08324R3a2.14 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 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 PEEN REDUCED BY PAID CLAIMS. NryI TYPE OF INSURANCE ,ACdR IMP tqi$ CYEPF, POLI YEYP INSa`jVO POLICY NUMBER I W NYWY11 LINITIS ' A X I COMMERCIAL GENERAL LW01UTY IMWZY 310022 0301/20lT 03/01/1018 I F,pcHCCCURRENCE S.0011 _.. ( 1 GLt WS-MADE Y OCCUR I PREMISES Ra[ane) 1,000,000 LIMITS OF POLICY XS MED EXP{AO n-.option) EXCLUDED Of SAY3,MFEROCC (PERsoNAL A AMMiA1UMi 4,8M% GEN'L AOGIEWTE LIMA IAPPLIES PER r GENERAL AGGREGATE 9,000,G1r1 LX I 78POLICY _ � _ LCC t's.I 1 PROOOCCOMPAP AGO _.. 4,W0,001 OTHER ) A AUTOLOBRE uArUtY MW'TB310021 103/0112012 83012018 0bs40mEO rvGL L LOCUMS I ([a accnwIl X ANY AUTO ab'SLY IMNRY iPer Piens1 ALL OWNS 7 SCHEDULED SELF INSURED AUTO PHY CMG I UTOS TOS @061V INJURY;Pr 60400111 � !HIRED AUTO 1f NON-0WNEO I (f RIN PERTV 00.106E 1 2':Vs UV' PERW _ Li UMBRIMA LIAe f OCCUR I EACH OCCURRENCE .� I EXCEISSIMI3 ,CLANS-UDE T6GREWTF". I I DED 11 RETENTION 5 I S I WORKERS COMPENSATION 'WLR C49112)00(TN} 8]18f12012 8310126)8 ' y PER l ub,. I Y1,1• ;AND EMPLOYERS,;AMITY Yti 'STAR,," AER • ANY PROPRIMOHRARTNEFOEXECM`R �,^1 I Y1C04]10237J1AK,NNNi,Vi) 4]0112017 103NiFa01C IOL EACH ACCIDENT I 1,CCC,OW GF.IOERMEEXCLUDED, NIA W0023102424MP 03/012017 103,0112018 (NanOalary Inn NNNXI I EL DISEASE-EA EMPLOYEd 1000,MO f@isM Older Ilce Ya SCMPTCNOf OPERATIONS Mlw Mlvtl an AdMc,w Pape Et CSEASE-WLKY LIMIT 1,0.)POO I I DESCRIPTION OP OPERAPON5 I LOCATIONS VEHICLES(ACORD m1,Pnanenal Romance Sehea,.,mY ee enuehee If meet epees Ie required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION NONE DEPOT GSSNOULO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I A,INC 245S PACES FERRY ROAD THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ATLANTA,GA 30319 ACCORDANCE WITH THE POLICY PROVISIONS. AUTNORaZD REPRESENTATIVE of Marsh USA Inc Manashi MuRherlee J .11.NA c _ .,$e, e....3.. I ®1888-2914 AGGRO CORPORATION. All rights reserved ACORD 25(2014I01j The/CORD name and logo are registered marks of ACORD Ai.NC'/CUSTOMER ID: Gfd>> LOC e'. Atlanta ACOR0' ADDITIONAL REMARKS SCHEDULE Page 2 of i ENC/ 9MIED iNSURE0 -00E le tic SS;-E-CYE R!C,C'rIUMeex +tai'ACES;XX.oCPa LULLING C X "Le:I A LA :Cr; IER CE I e. ._m/E SAX A DDIT:ONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: Zs FORM TITLE: Gehl/Late of L!ao'tib/Insurance Maters lmr.nsa4]n Somme& Carrier lygmmry"nsuence"amGny 31'bit Alerca Polk/' ae:NO �ALE1' L,IC.dT„<IIA.NiNC.VE:R.I :( ,`I]] iCa"C.N'l.!! 1 e G Emn0ou Sam.03101 XIS (EL,Ln11:S19C0.000 • Lama:'law.'amosmm:1lurmc Compel Peke//lumber NC 123102421 CC.CE:`.I,IRMCMV.'Ur tI?ell Exec'.Bale:0101,1011 'uafaton Dale:0101013 jELi'Ln 3I CC0 SIX Career ACS.Amer_a1 Vsurarca- neem Pice:weer YOU'Lean2M CGUC CA.LYL,:P.,`Ii.N1! Erecters Dale'021002017 E,pxlbn Cae.O Oi1Ola SI :me s:000.X0 SIR.el't4[00 SIR tor'lie stales ol+Z,CA LC IG,CP./a,xa Cane NawY'Mun nm xwrnce Caron EEO,.Number'CAC i5e3IU(CSN ICO,?DA,NE,JI.N'/OX,N,ure Elective Dale:0191;201] ecPsun Dele:O1D1¢afa (EU Glut St.000,)00 S1.GM.CcO3CR lir No sales al COME 005.0.Ch?A,Vi MOOD SIR of the Stam of GA 3350.00SIR for Ne sale of Ci navel lea wCa Comeau/ \ / :011C/klc CNC 15414i CSI.MI She•es Jae 3301.2aI? Ennui Date.MO''GI (ELI'Jnnt S4SOtC0 GU: Xe) TX Eoaoeets x3'Mamnlry" Carer-Arcs Union'.nsvancs:err pane Pate,Nun-her INS GEN ISZR?:<) Greene Dale:0101.207 antcn 9£s:9101,2019 XL Lime S-0::CO.]CO SIP it iCOCO ACORD 101 (2005101) D 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marts of ACORD mora/1/ {rt art'/tl.ysfl c/t,Le Citi 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: 04122/2019 ATLANTA,GA 30339 Update Address and return card. Mark reason for change. A I C 20-M 05/1 0 Address 0 Renewal 0 Employment ❑ Lost Card -7 ,.rr(..J?J.,(• ,,4Y 1–.//.../,..�.n. ��-- Office of Consumer Affairs aBusiness Reputation all y': HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Suooiemmt Card before the expiration date. 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