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10B-012 18 AUDUBON RD BP-2017-1427 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 10B-012 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-2017-1427 Project# JS-2017-002368 Est.Cost: $3412.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Grouo: HOME DEPOT AT HOME SERVICES 082485 Lot Size(su. ft.): 17990.28 Owner: LOCKETT ANDREW S&TAMMY L Zonine:URB(I00)/WP(55)/ Applicant: HOME DEPOT AT HOME SERVICES AT: 18 AUDUBON RD Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVI DENCERI02908 ISSUED ON:6/7/20I 7 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 1 PATIO DOOR FOR REPLACEMENT POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspectorot 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 • JUN Department use only City of Northampt on Status of Permit: da Building Department Curb Cut/Driveway Permit g t. A ]k �- 212 Main Street Sewer/Septic Availability ( + vet - Room 100 Water/Well Availability Ic" _ .i. r ,S• Northampton, MA 01060 Two Sets of Structural Plans wilatCaaa phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR7TWO FAMILYFDWELLING / "-. ec 3 SECTION 1 -SITE INFORMATION it' I t 7 11 Property Affdres/g,.ry/- 1'�) /y��I.-r,, �tThis section to be completed by office J6 1- V y v/t''7l �4 Zoe �V `Overlay District Unit Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: mn7no CT Al ,gip Gaze P Name intim} L1rreM�i < s ^/D �f'1. Telephon �n Signature �31N - /T/-] 2.2 Awl,.rued A.+ t: . LIR lb 9 qDf Tei.t7\ l F— Name " f Come M< n ,Address kl o� 4014, Ad ll ... Pic Signature Telephene 52.3 ' SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to he Official Use Only completed by permit applicant 1" Building . 422 !/p O (a)Building Permit Fee 2. Electrical J (b}Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) q 5.Fire Protection ✓ Y T 6. Total=(1 +2+3+4+5) - Ii Check Number f w This Section For Official Use Only Date Building Permit Number: / ° Issued: Signaturear�� �r."� "^, T/7 Building Commissionedlnspector of Buildings Date Ihasbrouck northamptonma.gov EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING Mt Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to ba filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: Rear Building Height Bldg. Square Footage Open Space Footage oa ._....._....�...— (ta area minas bldg&rimed parkintl #of Parking Spaces FilC (aolbmesloen,iun! 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 © DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document N B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 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 Q 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 Wafer Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement W down Alteration(s) ❑ Roofing n Or Doors Accessory Bldg, ❑ Demolition ❑ New Signs [Dl Decks [I7 Siding[=1 Other[DI Brief Descripf.- of• p r b't L A� ` . work. 1 S . 4 (I 1%/7j had ..• + "Q & f� U" 6 ,j- y Alteration of existing bedroom Yes _No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a, It New house and or addition to existing housing,complete the hollowing: 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 R.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade, A 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 OR CONTRACTOR APPLIESFO R BUILDINGPERMIT t/(! . j as Owner of the subject property f hereby authorize tl art. 1}�f /�nj/( /'1 ""'"-- j P AI to act on my behalf, in all att-ri rela i ork aut or' ed by this building permit application. err 6—#11 7-17 Signature of Owner Dale I, t fJ f nftij• ,as Owner/Authorized Agent hereby declare that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge anti belief. Signed under the}}r: . anl.enaltie of pe ' �y7�'" / i t Eaf • nt Name / .✓ie."._tAW/. Le -7-77 Signature or Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construe ion SiTyiieor: Ai Not Applicable El Name of License Holder: {/`�rfry _66_` L�! tib_ License Number Address Expiration Dam Signature Telephone 91-5,2-9512- 9,Registered Rom mprovement ffiractor yAidL ..— Not Applicable ❑ 12-" e- o n Caae RegiEat _ #_ pa, 17242 Addres / j }��L/j�'''�� f} _ J,, Expiration Date 'AC/1../ a .. ALS ti2tq —'elephonegN-71 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,Ef§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 buildingpermit. Signed Affidavit Attached Yes 7...-111(� No ❑ City of Northampton H �:t '' Massachusetts N Y ittt� DEPARTMENT OF BUILDING INSPECTIONS j, r 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 on 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, removah demolition,or construction of an addition to any pm-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 Fe;istered contractors. Note:If the homeowner has contracted wi h a corporation or LLC that entity must he registered. Type of Work: /SSy� bpEst.Cost: y/2. -f Address of Work: /0 4 VDU ! P A _-kr, vly / Date of Permit Application: / I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): Job under SI.QOO.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 142A.SUCH OWNERS ALSO ASSUME'THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE DITTOING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: ..--, I 6=?-)7 e rfrt c 17,71— )l //200-- )279-5- 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 � r- <>. b: 'l Massachusetts tttwt�t: DEPARTMENT OF BUILDING INSPECTIONS adirkjit 212 Main Street • Municipal Building Y Northampton, MA 01060 svn Massachusetts Residential Building Code Section 110.R5.1.2 I lomeowner: 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 consstmcts more than one home in a two-year period shall not be considered a homeowner. Section 110.85.2.3.1 My homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, 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 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 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. • City of Northampton ]y � - s �v Massachusetts = • It +44 4 DEPARTMENT OF BUILDING INSPECTIONS \ Cr�"s 212 Main Street *Municipal Building -+�C Northampton, MA 01060 iy Debris Disposal Affidavit In accordance of the provisions of MOL 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 t: (Please print house number and street name) is to be disposed of at: k14tTef. MT — 14/0--6. 1111} . (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) —� —7' 1 7 Si na o ermd 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, '44$ Home Depot Contractor License Numbers; MA Home Improvement Contractor Reg. tt 126E193 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. 3uelomer Information: Tammy Lockett Boston North 10031302 -first Deme Last Name 9ranc 'wire Lead 18 Audubon Rd LEEDS gia 01053 sourer Aodross Cry tate [o ;413) 320-7849 ,ome nnonna Wonr Phoned CnI1 Phanep ;m ai I @tammylockett.com usmmer E-mail Address IOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR IBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 108 Boston Turnpike Unit 1 Shrewsbury MA 01545 3dress (Sly State Zip r Email CustomerCancellationNorthEast@homedepot.com V MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE UPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT ONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. OUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME EPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME EPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME DNDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. R YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT )ME DEPOTS EXPENSE. IE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL ID WRITTEN NOTICE OF YOUR RIGHT TO CANCEL. '1rarviedged by , 05/24/2017 :.u+rn,`ak•wm.. Dile 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. 3412.00 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 Customers separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customers 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: nstallation of windows \ more detailed description of the work to be performed is included in the section entitled Scope of Work vhich appears on page 3 of this Agreement. knticipated...Delivery Date/ Installatton Schedule 1pproximate Start Date: 07/19/2017 Approximate Finish Date: 08/16/2017 dl dates are approximate and subject to change based on unforeseen events including inclement feather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if pplicable. iectron>I Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you Dnsent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and ritten communications related to this agreement. By contacting your Service Provider, you may update aur email address,withdraw your consent, or obtain a paper copy of the Agreement or related documents : no charge. By providing your consent and verifying your email address above, you confirm that you we access to a computer that can receive and open emails and PDF documents. y initialing this paragraph, I consent to receive only electronic records related to this transaction. Initial )ceptance and Authorization: By signing below, you authorize Home Depot to (a) arrange for Service ovider to perform Installation and/or(b)order and arrange for the delivery of special order merchandise, auding special order merchandise that may be custom made,as specified in this Agreement. Do not sign plank or incomplete. (Service Provider's/permitting information may need to be provided to You later.) signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety, eluding the,..General Terms and Conditions and State Supplement, if any. You further acknowledge :eiving a complete copy of this Agreement. Keep it to protect your legal rights. y'� 05(2412017 C.ntonwre S onatwe OM* Co _ Cosigner W appurm.) one 05/24/2017 Sops Confuaanrt 3prt.Nrt Date arise number(s) held by or on behalf of the Home Depot 2 Andersen Wood SPEC SHEET SC: WeeMy Orost Measure Tech: MSTALLER: Crani Name: Soma.Norm Job wmiecT Nsoased er. ISM: EC S0R 9nry krLmaimn. Cummer Name Tawe.Lweui oeb. 05,14,05,14,20,*a +r Page i el 1 SHEET* ft6p wM O.Fax Bm I.w.r. gnlgL LFrItlH ,. was WA iS110011NIP IsweR me resserwor rrvPrMan' Vaew re SAL dr Awns seed same S1.1%U *MPS wet WieIWMa NWr.el.. CF�aY NSW Soh e4 seas* Oe[ . FBI S WB WCP MI qva *roe caewe.w Stag dw w MEASURE .par caw.e lawn°W°'^ OM* Pea) 00100*{PEN ase a 0e"°Naw 010110) ua. 001 OPTww wro. Cm Lin,Sio I,. 9'"` ens. P E�cn Oce fs,oCO(inm faa , .O a, ca „k �e_at� ..,,e,m ,Een «! e.�- naeF„P E . an . srb�C ,ae,Ct COPE m Ego w. ,Po i rwwaao. w0*.n.+rw.L..v.w0*..+...P.w..e...m....ro.,..w...l ,.w.*...Flr�h :uw o . _�. twr, Pwe. rPLLLRwr em.Saxe.wax MaYxdrAml I00 py¢p5r CrFF in SC WE MLO?e IO EMISZ 09000 odw 16EP FBI PSCne% Crtva elmrsCpM w'P.M 611ie4T We++ OP1106.11 MISC IE.OP 0PTena Ra 0<12:01 ill I a e n w rra , m r ° ° � ` u5c'at umea:oes 1� PS x 14 4 1111174 - �r a Mal „e rer FIL� II . , I I i I .,..a.,. +«Sao Tamm:Lockett ...Home tamer O 0e A CERTIFICATE OF LIABILITY INSURANCE DATE iM DOffTYYI I 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(S). AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder la 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 endorsement(s). PRODUCER ONSAC MARSH USA,WC. PHONE ' TWO LNCCNER , _ 'It Nm LLOE 2400 ... ATLANTA.GA 3(132 AO•-.ss: INSURER'S)AnnRowO COVERAGE jxuc e 1004S2neU- 'HwGAW'-17.1S M9URERA:Oa Republic c InsuranceCa 24141 METRESTHE HONE DEPOT,NS, rz+aURER a:Ari Gseralaeorete Cemyaq 42751 HOME DEPOT U.SA..INC. INSURER C;Now Hampshire lm Co 23841 24$5 PACES FERRY ROAD INSURER O: BUILDING 0-20 .. ATLANTA.GA 30139 MSURER E: AYSURERF: ...... COVERAGES CERTIFICATE NUMBER: ADANN14e3111-14 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. NOTMTHSTANDING 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. rani Aa sons matt EFF POO $$yypp LR TYPE OF INSURANCE �115$e'wad ➢CLOY NUMOER piNppFrvrr} {Yep {Yfp� t1Y553 A X 1 COMMERCIAL GRMEMLUA&tRY MWZv3MTZT O311112017 10391£2019 I EAcstocc.RRENCE $ 9,009,000 CLP NS-MACE % OCCUR 1 aq SB n81 5 ,�•0O MED EXP' person) S EXCLUDED ILIMITB OF POLICY XS ._.--_... .._ t AUV _ IGF SNT',SIM FER CCC PERSONAL 6AUYINJURY 5 9.000.000 GENT.AGGREGATE L1N1APPLIES PER ( GEA£MtAGfiREGi—S B,DW.OEB X WLICY __ � __ LOC jPa .CCMNpP AGO 9.+XA.CN OTHER 15......... COM5INEn 41NPAE--LIMIT A AUTOMOBILE IYeIVfI M'.Yi&11LY121 03/01/417 03;01201B I'Re=lawn Per 1,C00.000(� i ANY AUTO r sootLvrwuRV I Pr person) S ALLAAUTOS 1/4,„,,„„,4 i SCHEEDUED SELF INSURED AUTO PM?CMG WETLYINJDRx tPer.rm el s I -TEREOAUr95 L-1 AUTOS NaNCW." PROTERTT}.MAGE 5......... S UMBREUA)IAA _ OCCUR EACH OCCURRENCE i5 (EXCESS LAB oimms tong AGGREGATE 15 I I OEO I RETENTION i 5 B iretemOistusweane1ON 4491 12333{11e 03411200 03/912018 1 X 'salt£ IEa` AIN EMFLOYERS`LIAHM1tIY C PROPRIErgWARTNEPIEXECIRIVE Y�"I NIA WC p2311Yt123IAK,NH,NJ,V 0]g12mi 03,912DYA C OFFICERMEMRER EXCLUDED') .In EL ETCH ACCIDENT IS %MOD) " 'MyendiIry N NH) WC 023102424(W11 03/0112017 IO]N12019 EL O¢EwSE.kA EMPLavEES 191A,OCtl I fl S(I.RIPTION OF OPVtATION5 Caw ICm11nLMl on AdalbnaI PpW 1EL CITE/LIE-MICE LIMIT I5 1.000.001 OESCRWTION OF OPERATIONS I LOCATIONS I VEHICLES IAC@q 101,ATPIUan.I Remarks ScN4ule,may be a t and II ncn spate Is npubdl EVIDENCE CP INSURANCE CERTIFICATE HOLDER CANCELLATION HOMEDEPOTUSA,NIC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ATLANTA.GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. AUMORRE PREPRESENTATFYE et Sbnh USA YAC. Manaslli Mukberiee .MaAnaer,: NST..Jeh,n,.-0-a ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014(01) The ACORU name and logo are registered marks of ACORD A 9ENC1 CUSTOM?310: L:gnl LOC K: Atlanta =ORO° ADDITIONAL REMARKS SCHEDULE Page 2 Cf? .1 t oAaaen INSaPED -CME IERETr _ N 11-A' r 55215- r Marilee P4-rVNBEi See AA:'3;e. r 3v 35.15;01015.21: :1O CLErn,3,t ICS ER E"`-GrtvE qa2 ITIONAL REMARK3 ADDITIONAL REMARKS FORM IS A SCHEOULE TO ACORO FORM, la.WUMSER: 25 FORM TITLE: Cer9Acate of Liability Insurance Ines C]mpensalian Senenmlt er;memo'nIlrence Cmmie QI'Just Amerce •R'r eweCer'MU:a411224i=ALM LIO.A tftA.M34Q.NE.AIAD:-K iC„3C?fLK' '¢:n ams:O]Nv2017 '.Argon Cse:•llroLQala Umtsrxava R:SWM eamaeem:m ince:umpavy Sec tljfW NC)2311x44:C,I',E,entemamAi At Meer •ecM Dem ASoki0v ttir3Mn Dar 0101W 3 ELI UrLt s;MC,X0 alar AC=_Ante%•munesa."am?sy G:rr`minteer+MCV Ci I1r 2 CSMIAZCA.LNC,CR,/A.NA I ncM a:e:0064017 ip,abegt5361t7653 �'unatst::CO.:CC IIR:51,ZA,.CC 311A15;te stares el U.lC1.:LTL.CP,LAMA :ern:Natiaral1Mbn Flee Inularaerompany *lay'Aber PAC 8533I441QSI)ICR?GA,NE YUW OH.A.M :eecvn Date:02.1101i2l7 ,.[mtbn 9ae:030I120113 $,lnn 3+88.30 S I,9MSC0 SIR for ue vales el CO.NEN A S%OKRA,ti 57A00 SIR Mem ;tate at GA 00..05505151grOm pale el CT :mew;lapional'Jn00 Eire Tswana Company...,\ etee ewe 558116;CSR tA) aer'.w ma:13i30:e17 uprhgn 33391)3313!2C!3 3€31 ume iTxOM sal0,CO0 /. rc Emrmlas as lraallity Zarrerlemcs 51momnmsence Company arse Member ThSC 281352 YXI Elective Ogle:5201017 iordICn Jae.0YOi,1Ot3 ;E5iUmc313£0.57) 31R.51 5C0 ,CORD 101 (2008101) A 200$ACORD CORPORATION, AO rights reserved, The ACORD name and logo are registered marks of ACORD �.-//C% »/ (yea I1 {li /L (f.i-.iflC'1C,L(.iC't-Cli 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(2078 ATLANTA,GA 30339 Update Address and return card. Mark reason for change. ".tsnr ❑ Address D Renewal D Employment 0 Lost Card - lP ,,» Office of Consumer Affairs a Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Reoistration Expiration Office of Consumer Affairs and Business Regulation 112735 04/22/2019 10 Park Plaza-Suite 5170 1E DEPOT USA NC !! Boston,MA 02116 ////] �.s'' ARO TROW... _..:.._. AUCCC a-/cl.�r?�liS I ,//"� �-f!G PACES FERRY RD C-11HSC ( NTA.GA 11L 3 Undersecretary Not valid witthou signature The CYJnino=--tctl of yt,(PsS fich_ yerYs ( �i era ofC. allrri-. c R- '_- -ty a :li+lt t ▪ 'v pot "lt a ..pUV/Crit L\orvs's' 12mnpretaa1iitit Tnnuenitee r(d 'i..Isuucfts ▪o..c,a(.r)i shElect < na;:.-lri .eiet>. anrilgieti B110.-ainprn :Sa:gn.`i- ai.' P „ cs u J JaII. ya f �//� to ' cu.c1C11 cOCILC. l :1CpClipliatv hx: C Pc o) Proµ t{ utm .i}: I 2 __ .- riII: r -- ., tcl-In 1 Remodeling 9 El d e , Denuil'eiun �a _� t c r t _1oatt retfBstanga.drt . - natu.t arso . . tta a.,r :c _r.az ; 1 Flecnicai lel 1 or eAd Gmi. 1 12 mq r t .tJ Numbing n.. a1 C aclintions r8p 5 Ij - 1 I s45 _r,TIi tt ub 221 MINT cl-, 1 a_cmr hdo:.. ma gra nreph, sanneat.i1 pohcy il.:.. < l.1 a rr t am rutemployer+belt M prm^iding markers'erm+ptymatioa rlcarance Jim my septal c. i#etmr is the polity and jar alt en/D-rnutm t . itasce ilnppaare ame._N Twisr `jji91/ )R( Et? , E � � Policy'? orgelP.P.- Lie- /A, � j� Expiration tr � to 1 )"ea eni �, Jul Site �d 1 �U�✓ copy of the n'orLr r c contpenoat on puttcp dechvratlon pave abusing the policy number and epnvtsoo datel. Yaauro to u' Co:e12cytt wA un -;Hgib c- 132,:„. S4.,.a oriel aalntion l n eh'blo by a line up to Si 900 p0 c.1ata: teal irepriseumorr,as..c11 a.s 221-2'12 penalacr i cum ahe, OP WORK t tt !) 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