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17C-299 (3)
131 CHESTNUT ST MBP-2018-00133 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot 17C-299-001 CITY OF NORTHAMPTON PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# MBP-2018-00133 Project# 131 CHESTNUT ST Est. Cost: 2519 Fee:40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES Lot Size(sq. ft.): Owner: Zoning:URB Applicant: AT: 131 CHESTNUT ST Applicant Address: Phone: Insurance: ISSUED ON: 08/04/2017 TO PERFORM THE FOLLOWING WORK: INSTALL 1 ENTRY DOOR FOR REPLACEMENT. NO STRUCTURAL CHANGES 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: Check Number: Alteration 08/04/2017 40 23094 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only 0,011-4-1','ro City of Northampton Status of Permit: -,� ?? uilding Department Curb Cut/Driveway Permit ( 212 Main Street Sewer/Septic Availability ' ---- Room 100 Water/Well Availability , t �� t.,„ f . Northampton, MA 01060 Two Sets of Structural Plans _, °+' phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH2A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1 ep- (2-1 J 3 This section to be completed by office 1.1 Property Address: e Map /7 C Lot a Unit 3) CFk6itirPe-ri Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Pont) CurrentPirtat6Aiiiirr d1tst c "mi Q/a2....., 1 e'(��-r Telephone .q -z:' ---2 Signature � � 2.2 Authorized A,ent: ji toi qw opli;r1)--,-...jr - Na , -rint) Curren Mailing Address: /� 7--. /�1,k. /9/ 1-/-3 / Signatu e Telephone tf0 — 3,9-2... SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed�jby permit applicant 1. Building `✓..J 7_!, (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 6. Total=(1 +2+3+4+5) ` JO"Zit*) Check Number 430 of / This Section For Official Use Only Building Permit Number: Date Issued: Signature: ��...__ ` 0c'17'1'`'' L 6 -7'i 7 Building Commissioner/Inspector of Buildings Date a 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 Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 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 0 DON'T KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES © NO Q 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 Q 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 Q NO Q 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' Bows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [❑ Siding [0] Other[0] Brief Descriptio Wier) C Ai ,/Work: �>� iv l � rot &Pit, Ti)i �i1��/�V/ ��, :f w, 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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 6'PJ-6 , as Owner of the subject property hereby authorize g‘dri" i) ---T- )4--- — , _. ,, to act on my behalf, in all matters relative to work authorized by this building permit app ication. ,1017113‘ — ---)7 Signature o wner Date I, �d 20 lir , as Owner/Authorized Agent hereby d dare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under t pai and penalties_ t.petJu y. '0 ) A' Print Name Signature of Ow er/Agent Date I SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor:24,.1-v �i�/J Not Applicable I:Name of License Holder: G�2�so) {� ///)X z J —e g 2 7 License Number 21 6i/Ya/Z)A I//) b 2-e 1.0.,_.Z,U- --2 -19 Address Expiration Date 1 t 7Th .//jog- . 0 ).6) Signature Telephone Vt/-7c2:31, 9.Registered Home Im rovement Contractor: ._ Not Applicable I=11+-- /gymr,g 1) 27 Company Name Registration Number Q tT22-/7 Address ,, Expion Date & %'121 O"' °''gid 'elephone It& .)1'J-/ 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 permit. Signed Affidavit Attached Yes No ❑ City of Northampton he •' Massachusetts .k =-- �, DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building fJ/ Northampton, MA 01060 s�ir�. .,-��N.' 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, 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 registered contractors. Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered. f� Type of Work: P izf 12-13-6 ,o47.---- bopEst. Cost: Address of Work: / 3/ CC f�V T 'I 12II eq iiii "' &6, Date of Permit Application: g — II— 17 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): Job under S1,000.00 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 142A.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 permit,a the agent of the owner --1/—)7 TW .4 ' ri - i 1127 Date Contractor Name � � HIC Registration No. (�� j 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 Massachusetts ; > i . A ` IR *. 4 DEPARTMENT OF BUILDING INSPECTIONS { 212 Main Street • Municipal Building ''''.1. 11 ." 212 Northampton, MA 01060 15,yy V l `'. 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 110.R5.1.3.1 Any 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 i$ M Massachusetts yf DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building - r' 4r �; Northampton, MA 01060 St"l ,-, 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: (Please print house number and street name) Is to be disposed of at: , -7i - /4- (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Per 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations • �ii�l= r _ ,,_ 600 Washington Street _.,l.1� Boston, MA 02111 -semi www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. + 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.0 Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] 4- employees. [No workers' comp. insurance required.] 13.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 1 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 the sub-contractors and their workers'comp.policy information. 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#or Self-ins. Lic. #: 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 MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and. if necessary, supply sub-contractor(s)name(s),address(es) and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly_ The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write "all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia 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: John Sass Boston North 10175733 First Name Last Name Branch Name Lead# 131 Chestnut FLORENCE MA 01062 Customer Address City tate Zip (413) 588-8857 Home Phone# Work Phone# Cell Phone# sandquistsass@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 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 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 07/12/2017 Customer's Signature Date 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. 2519.00 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 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 / Installation Schedule Approximate Start Date: 09/06/2017 Approximate Finish Date: 10/04/2017 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. —J 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 07/12/2017 Customer's Signature Date X Co-Signer Of applicable) Date X 07/12/2017 Sales Consultant's Signature Date License number(s) held by or on behalf of the Home Depot: 2 • . 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'i.at�vw.aa- 1. i1 - - 1 : i; - E -:g:i-iii .rinte:�de duct!r cantina-1.1161.o-3 9:iii 1 A o-f1.40 -. -E-Sr I .:::.-a.,--...-,---.6...; :` '.1c c inado-Con-r KLZS 1 _-ice= �, G !�DI-I)1 it CSD-S6•`_ r;-210----,2-000(.19 ;1 ENERGY t E1= O :?I�E.n-,i ori x,11,i i! ; :: ys1A UACI014.t3 RkMl:r$i»i-1 i Q E11Fr.GE41Ct3 i i it -_--• _ Selari1e's Chia Cvi'-c! :: r' 11 :: n �, `I .6 Y 0 a 2-� 11 . !t i`t `t t iii f_�PERFORMANCE :RATINGS Z. EVALUs CtdDi 8i[P_c st^!TAri( DE LENOL 11Ei�rio ii r 1 a f'• 1 Ii f.:-.7,:,-.4:::4,=:7-4:=_-_-.:�.: : _ -7:::;; '-- ▪ �'�._: -. ._ it 11 ^�,;54.2`.'• ti: ,re`rF:'ri--ry_c"•.�"'.:. -_ 1. U:tt quaafP-S tar Eft•.ECy 4 iF tit- =._ mil: _ _-: ": STARS r'oicn s.i la i er i. `'. 1, 1 i • �iti- r� _ { Central,South Cental, .1; t 'fet es =. :,t iii`'=:-.4i` SournefL I _:stat- �:i.. II ..- - _ STC 2 tt,i( I;_ U f ':-.1— 11 - li!E`•_Rain QOf/{ass PreSaar11-t-LC2€ -• l .moi .�t•t-' s.7 t asi�c1.:ize:=8"}:5Q" ,i �I II II tI r:Cride Praductiippr7t;ni rLviaC i. if .1 a 1 II i' 11 - 1 I ii_ I li I li ( Irt ruai:Cu,la SC�ree:Llej. ANSWt=�,1i �!%�Q'PiS. -9!_A4P„LNM NNCS, II 1r!![.52!M40 05„1,-,zr;:!?':\ i`AAJCSAt 11.S JM40-DB. 11 i s:4.40S i-02 C_rmr:la n Supp: i ii II i 1 o0:3331S Howard c7_0:k,'.• }! i, �3 EtSL1O avIf V. 84GO _ (I D _:_-. _. • ::_----C-_.Ys _._ -.71.--.....c—-_Y_.--�.::rte• _a•:. -i_.— w `-1 -'S --,-- ,J 41‘ C) _ cAz ,!-- V.I.. 1 i i ' .. r,.'-- , . ,: .4 — -, -- e'l rn .0'4 0 ,..., r., fl.) 9* ...- 7.,z ,,.., ,,,-., __... (-) ., _ -- v..., — CD :. - - — — . s M CZ 2 c: orl tr) r 0 -.- ,-, L.J ca .,...., --.. * ..a, '1/4,,,d (0 . , .:, L-;s. m ......, , tilt (0 ,,,,....: 7— ci,-) , ,-- ,-÷ —• ' --t-, . -1 ,-- rt -,- c.... - 7-71 ' ' ' V) =7: tr; r • ,, ., . rt... ..,; .- ....0 , or, r-7 .,:. ,:' ...k. C....) r...0 = • - - ,,,,O.'''''*':,''''''":''-''.'.--;'0';;;;V:,744'..; . ,..4.,..;J:Wg,T,is-A*.q,v,-.-7q.,:r0.4$4.,. ',"zr&Y,u,'• 't•,,.„„,,,q,14,..-4,05-1,.441A4"*OW:tttl-',4,!:',.'.'"V) - i-_XC-KrtiS;.::„,-.i,-,..4L4V,V•t4*,*::?!r:A:-4-''-'-gkg4.,,W'-ri'“-;irzr-4-:;:'-'r,.4A4,4?;t-UO .-,r...,..*.t:,44,,,,,-:;AZT;:.;:ef.A.N.;',. -7,..''!:- -,,..-;,-;',,pti--_,,,.,,,,,-:-r-.,..,,...- „--,,,,,•.,-,,.. . -/f/76, ��l��r'C1.�"�t'/l{'>rl��l!I ([� .yJCl C-f'L CEJ o.�� J • 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. t 2OM-" ❑ Address 0 Renewal 0 Employment 0 Lost Card --i/,. ; earl, - lh,;>,,,/,,.ir; Office of Consumer Affairs&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 04/2212.019 10 Park Plaza-Suite 5170 HOME DEPOT USA INC Boston,MA 02116 RICHARD TROIA.,. 2455 PACES FERRY RD C-11 HSC ATLANTA,GA 30339 Undersecretary Not valid withou signature A`3 D :12.17((20172017 CERTIFICATE OF LIABILITY INSURANCE DATE( YYYY) 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 Is an ADDITIONAL INSURED, the pollcy(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 CONTACT - MARSH USA,INC. NAME: TWO ALLIANCE CENTER IA/ rig,EAU:NE I FAX Nol: 3580 LENOX ROAD,SUITE 2400 E-MAIL ATLANTA,GA 30326 ADDRESS: INSURER(S)AFFORDING COVERAGE I NAIC 100492-HomeD-GAW'-17.18 INSURER A:Old Republic Insurance Co 24147 INSURED INSURER B:Agri General Insurance Company X42757 THE HOME DEPOT,INC. HOME DEPOT USA.,INC. INSURER C:New Hampshire Ins Co 123841 2455 PACES FERRY ROAD INSURER D BUILDING C-20 ATLANTA,GA 30339 INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER: ATL-003746387-14 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 BEEN REDUCED BY PAID CLAIMS. NSR !ALM OM- I POLICY EFF I POLICY EXP LTR TYPE OF INSURANCE IINSD`WVO POLICY NUMBER (MMIY IODYYY),(MMIDO/YY'!YI I OMITS ' A X COMMERCIAL GENERAL UABIUTY MWZY 310022 10101)2017 I03111/2018 EACH OCCURRENCE S 9,000,000 CLA MS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 11,000,000 LIMITS OF POLICY XS MED EXP(Any ore person) s EXCLUDED OF SIR:SIM,ER CCG PERSONAL&ADV INJURY S 9,000,000 GEM_AGGREGATE LIM T APPLIES PER GENERAL AGGREGATE S 9,000,000 X POLICY -.__.. PRO- -_— LOC I ECT PRODUCTS-COMPIOP AGG S 9,000,000 OTHER j ' S A AUTOMOBILE LIABILITY I AUTOMOBILE 16310021 SELF INSURED AUTO PHY CMG 03101(2011 03012019 COMBINED SINGLE LIMIT I S I(Ea accident) ANY AUTO 1 BODILY INJURY(Par person) I S ALL OWNED SCHEDULED )AUTOS AUTOS BODILY INJURY(Per acadenq 5 1.040,000 HIRED AUTOS NOTA NN-OWNED I PROPERTY DAMAGE $ I i (Per accident) i I IS � UMBRELLA UAB OCCUR EACH OCCURRENCE 15 l EXCESS LIES CLAIMS-MADE j AGGREGATE I S I DED RETENTIONS f( ! 15 B !WORKERS COMPENSATION WLR 049112300(TN) 03./01/2017 1031012018 X "PER 10TH I 11 AND EMPLOYERS'LIABWTY i STATUTE ER C ANY PROPRIETORJPAR'.NERlEJ(ECUTIVE Y I V WC 023102423(AK,NH,NJ,VTI 03/0112017 03/01/2018 C OFFICERIMEMBER EXCLUDED) I N I N I A E L EACH ACCIDENT S 1,040,000 (Mandatory In NH) WC 023102424(WI) 03/01/2017 03/0112018 E L DISEASE-EA EMPLOYES 1,000,000 If yes,describe under Continued on Additional Page 1,000,000 DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY UMIT I S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) EVIDENCE OF INSURANCE .CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC 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. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi MukherjeerzNanon ".. .4......41--- I - 00 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD A3ENCY CUSTOMER 10: 1:C492 LOC 1#: Atlanta ACORD ADDITIONAL REMARKS SCHEDULE Pa9, 2 °f } AGENCY NAMED INSURED -"CATE 2,l'iA ^CME E?J' 7433?ACJ ?pL7C'f NUMBER 3LILDING O 22 A7LAW ClA :G'3:9 CARRIER nA::CCE eF ocmIE]ATE: ADOIT:ONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUM3ER: 25 FORM TITLE Certificate of Liability Insurance 'Markers Compensation Continued: Corner ineemmrf'.nsurance Company 31 Nash Amerce Policy Numter.WLR 249112294(ALAR.?L.i0.,A.:33..'f LA.MS.MC,'IE MM,NO 0550,50 NV;M'r; Ei'ecve]ate:03101,2017 Eaciration Date:07,01:2713 EL,!,mil:Sl 000.000 Cartier:New Hampshire inet.rance Company PcICJ Numter NC 323102422 CC,CE,MI,IN MD Mi4 MLN'f.Rl Erec'ne Cate:010112017 Erc1ration Dale:031012013 ie..)Limit S1.000,G00 Corner.AC=American'.r.surarca Company Pr.(c-(!hunter'NC U 049112232 C0I;l42., EI!:ctive Date:01012017 E"pira!ion Date:001RO1a S1.00.:00 317: 31.3C0.XC SIR Tor to;ales a AZ,CA.(LMC.CP.,'JA,WA Carrier:National Union Fire Insurance Company Poky Number XWC 358]144(GSI)(CO,CT,GA,ME,1a1.NV.O14,?A,uT) Elective Date:0101,2017 Eecitation Dale:031012019 (=!.11imit S1,OC9,300 5!,000,000 SIR for Ine Mates of C0.`dE,NVAI,OKRA,UT 57:0.000 SIR far the stale al GA 5390,000 SIR for the sate of CT Camey National Union Fire irsurance Camaany / ?olicJ:%enter CNC 5393:43;CSI)Mn) _tec:.ve]a:e:3101:2017 tpiratitn Dam 9301.2013 (EL)Limit 51,000.0O3 3IR:55C9,C00 TX E rtcioyers AS Irdemnity Camerleirlcs 1Jrian'nsurance sompany Patici Number TNS C48613202;TX) Elective Date:031012017 .sciraccn]ate:7?,U1,2013 Ca,Lott 510.:00,000 SIP.:31:00.CC0 ACORO 101 (2008101) 3 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD , ...,.. .._ .. The Colli711 0 i I'eiliiii ()..f 21 u s s if chil3 e.tiS L26/T!.i:iilei Of 137th!:;ti7fIlAce4.?.,-;is •Ili-,-----;- .- '4' -; --"--------T-,4-1-, .- (:; c---:q .0_____, 0 1 ,Co ;,;•(:Js 3ir2,(2!.' Si.:dh2 100 " -.,.. i'li•,--:,17-145 . .;/. ,J3-0.':;.7...'T.?, 1 0.2 7-4:4' \\,k.st-]iei-:: -Comp ensiiiion 7 ithu r:.:,.nee . dtwit: licittler!ii:avarn(qfyisirliirief;P;U_31i0);-T!,. TC: ! ',- !;.1f:'1,-: -''1" 'F'TI.--IF.: !)f;:i':::-..7-lirrli: .: .:, ,_--1711!-T."?,!1'-`,.•. i,.;;ocw-sAnii.ot 1 1.- --- N LIHIC. 131,1,_,.iss'ii, :triL' ik.ni;incl!vi,.. ): cidre : 'PI \re YOH:III;.'MP10)1_1'..'ChM,: tic:113PrOpriati.'bON: Type of project(requireri). 1-7 ,.,,,,,,,,,-,:,:::,-,..,.„, ,,, v , ,, ,„ 7E11 and:or par-,-,:imc I.- 7. Li Nckv corlsil UCNC/11 2.1-1 i 4al a,olc iniplelor or pa;-h1,,n,jop an0 haVe 11. cmptoyccs...; .-d:v. 1,c 11-ii.::", I-1 Remodeling oiria. .iN,J'yea cornp.Ipstnanc; rc.qin:-cd.] 9. ril Drool tout -,...r I,,„,„:.,„„,-,„,,,,...,„,,,,,.,,, '_-,_ii_ - •-' •pd.:.werliei.s .:einp.iil!,!17,!liCit re.cinil 10 11 Building addition 41 I I ,,1 ,I ';'..1::.!'.`..111 t..7 hirt ;:nntr,n:to:s-0‘:;:ncln:::,,H..,..,-:-E':or nry pTcrcy vni:;uce the:al;contEak-Jors;:ith..21- i::,:c wo11,2..-.--;cc mnensalion insutr..nce cc alc ,o1,-.. 11.0 Electrical repair6 or iLiditions pi eprter,-,y:1:ei,,.'in ,,:.r.i . 12.0Pum lbing repairs or additions :),..'..i.L.,.iii..,. :iiii,...,iiii....:,A ,i, Jed;t . ilad''' ,,)terietificii.,,i-ii-ii ..-, ,:.ci ,:tic arrim.i.e :.!1,:"...,: i Ilt!,,C ill,-C.0,111":L'Z:11,,h.1',.'..-."1-11ploye,.,aril has.c wdth,w:comp.insoi-anc.e.= 1311 ki.of repairs ,-- zi.,.,_ _tiller DMZ– dre a;:orwrorion and 'a..,;:f1CCr'S'111v:::Q:“..:-,.. S0d 11,C1r il:?h1.1;...N‘11;ption per\AG'.: 152. .:,Ito),and so:-.:IlIve no.;liploycc.5...:No vvol.!.::-.t.s'cc-cap.alsni.D.no fccf.:tral.! .•p-i4i,:ara that,:lioc;.::41),:r.=if mus:also Lit.:,a;IOC scction:hclov . -x-,‘.‘..aitz.i:1,2.i r..vorl:::'r,=.comper.:‘a:..ion policy inforomtict. 'Hoir.,o,hcri:who-uboht tiles aiiidava inclnlattng t11.2y arc dc-tic alk-vorl:-and Tlicn 1-,iro.ontsici.:contracix.5,nni,.slibt'11;il I:...:V. .1tIlli:P.1'ilidiC:::::-. :1!i,-F.k.,-.:!ro.:::.; ii.o.itod at addiiiohal.Thc,, :,,..,hr..z-Ito-:,,,,,,,of h..:Nui:-.:on!!-.1c1( and.a.A'. wheCic: or!,0 it-ccoo ::,,6,:,L.V.-s• i: 'i ,,.1;-:.01111.11,.;101S lL`,'C craplus.ce ,thcy ina,1 atticpililac wC11::.n.rz',,,cswp.pail,.:inImiv.:y.I am an employer that is providing w(Jrliers'compensation insurance be illy elnplOyCeS. lie/on'is the policy and joh sit P infi».matimi. „ . , ithlItTariCe Company Name:W )4r /* )J111 _ ;,1,1 policy*or Selr-iiis. Lic. ,41: C. t..7 .=6----'1 7'5. - Expiration Dale: -,.. ----) ' ,Wc .lob _,:itii :Addrt-ss: 0 l',d .491—* City/StateiZipffir*.it 449---A ia eh a copy of the',vorkers' compensation policy declaration page(showing the policy number and expiration date).(1/42" failure to sctirt.:covuafre as vt.‘tioired under MCil_.c. 152, 25A is d clitninal yioliition piinishabli by a 1,in;.'up to SI,500.00 iunlior tine-year imprisonment, as well as civil penalties in 'ho form of a STOP VijCIP.K.O1D1=R and a fine of up to S250.01)a day against the violator.A con of this stmoment mar ha airwarcial to die Oilice of investigations of the DIA for insuranoc coveriniQ a.crification. I dr,ii,-.. y certiii'nod,: le mins Ind p 1 , J pegury that the information provided obove is tree and correct. „, ---- , Sioiaturo: - v.7)...-V---1--- Dat : —)7 & 4z.?-2-- I 1- ,,, ,,ifficial use only. Do not write in this area, to he completed by city or town official. f 1 City or'Town: Pct-mit/License tfi i 1 Issuing Authority(circle one): I 1 1.Board ofITierilth 2. Building Department 3.Cityri own Clerk :!. ElectrienHospecti - 5. Plumbing inspector O. Ciller 1 l Contact Person: Phone 4: 1_