Loading...
32A-236 16 POMEROY TER BP-2018-1325 GIS#: COMMONWEALTH OF MASSACHUSETTS May Block:32A-236 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categow window replaced BUILDING PERMIT Permit# BP-2018-1325 Project# JS-2018-002351 Est Cost:$1342.0 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sp.ft.): 12240.36 Owner: NISSON JOEL D zonine7 URC(62)/sC(3sV Applicant: HOME DEPOT AT HOME SERVICES AT: 16 POMEROY TER Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCER102908 ISSUED ON.611412018 0:00.00 TO PERFORM THE FOLLOWING WORK.INSTALL 2 REPLACEMENT WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeTyDe: Date Paid: Amount* Building 6/14/20180:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only -- City of No tha ton DS f Permit: Building part en( Driveway Permit 212 Mai Str et IN plic Avai4bilily Roo 100 lateall Availability Northampto , M aniNc INSPecT, of Structural Plans phone 413-587-124 - A0'C.,,;, Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 60 - 1U -1 3h5- 1.1 Property Address' This section to be completed/b'y�office 1 Map a� Lot � Unit rY Zone Overlay District / Elm SL District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 7.1 Owner of Record: AA/ dnl Id Name(Print) Current� Q / Telephone „_ / Signature 2.2 AuthorizetlA nt: i To�o� 9�rs ���eT7d''k• Name(Pnnl) Cur"Ma ing Address: Signature Telephone — Z SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building /� Ol (a)Building Permit Fee 2. Electrical `r 7/ (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 .213-4-5) Check Number This Section for Official Use Only Dale Building Permit Number: Issued: Signatw Building Commis i er1laspectwaf Baildings Data @ 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 Lik column to be ghat in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg Square Fontge % Open Space Footage (Lot area minus bldg&pavN ming) #of Parking Spaces Fill: volume&I,ocalion A. Has a Special Permit/Variance/Finding ever been issued for/an 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 down Alleration(s) ❑ Roofing Q 0, Doers Accessory Bldg. ❑ Demolition ❑ New Signs (0] Decks [E-3 Siding[C]1 Other[a A55- Work Brief D ript ryas o o /�TS A lOn,yG /) ,(�L Work �7 f."NVVA-YAC"/YJr' !s/ !/ �✓ ,pr/ C/ ULJ Alteration of existing bedroom_Yes No Adding new bedmom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa.If New house and or addition to existing housing, complete the following: a. Use of building:Om Famili Two Family Other In. 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? I. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is constmction within 100 ft.of wellands?_Yes _No. Is construction within 100 yr. floodplain_Yes_No I. Depth of basement or cellar floor below finished grade k Will building write.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 J 1, y /V %./%! -I.1 as Owner of the subject property hereby authorize to achy behalf, in all mar relative to work authorized by this building permit applica0on. (T/>yL C f/rrl t 1 Signature of Owner �r� T �¢ Date I, �] '✓""— lIO as Owner/Authonzed 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 underth aims d penalties of perjury. Pont Name Signature of Owirl gent Date SECTION 8-CONSTRUCTIONSERVICES 8.1 Licensed Construction Sum",.soo : Not Applicable 11 Name of License Holder_' —/}T—✓""/ V Licens �rnbal L Address Expiration Date Signature Telephone l3s-z- 9.Rei tared Hoppe Impro"mont Contiol Not Applicable ❑ Company Name Registration Number Address yj / Expiration Date��� T.lephone/D/ 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 building permit. Signed Affidavit Attached Yes....... fT, No...... ❑ City of Northampton s .. Massachusetts :L DEPARTNENT OF BUILDING INSPECTIONS 212 Nain Street • Nuniclpal Building \ Northampton, NA 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, removal, demolition,or construction of an addition to any pre-existing owneroccupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner �has ,/contracted with a corporation or LLC, that entity must b/e rreegistered. Type of Work:Wlr✓L/!vy Ar e�4n� EcL Cost: (% Address of Work: lb ryp,ry"av/ 4iw�eE: Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): Job under$1,000.00 _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: 1 hereby apply for a building permit as the allent of the owner: Date Contractor Name I UC Registration No. OR: Notwithstanding the abort notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton .rf ' Massachusetts �- i DEPARTMENT OF BUILDING INSPECTIONS i 212 Hain Street *Municipal Building \� Nortbas ton, M 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: o t (Please print Muse number and str63t name) Is to be disposed of at: (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 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. Job Contacts Y Friday,May 18,2018 Comments Lead; 10782015 Go Advanced Searon 6:10 PM Homeowner MMI JOEL NISSON Sale Amount $1,342.00 Balance Due: $1,006.50 Commissions HomeowrwY2 MMM Product AC12(4%) Documents Job Site Acidness 16 Pomeroy Terrace me Status SaleMtatedal Ordered Job Issues Northampton,MA 010fi0 Branch New England South Slebel Lead lO Slebel# Slebsl Order Measures Order Detail County HAMPSHIRE 1-5ZOG9N 1-13035666�0882�27'I6 xx 1fi5950 8799515] Billing Address 16 Pomeroy Terrace Northampton Pam NORTHAMPTON.MA 01060 Commission Rab Permits Consultant Name Term Data Solit Como Plan Primary Phone (917)533-4861 RAYON ROBERTSON 100.00%Straight Commission PO Work Phone Ext. 0 Result Combo Cbl Phone ;.. Work Phone 2 Sale Date 5/1012018 FUP Dab Services Call Phone Credit Data 5/10/2018 FPI Customer Show Mao Email Icelnisson@gmail.wm RTP Dab 5/11/2018 Post Install Data Cross Street Start Dab 6!1/2018 FPD4dome Depot TouchPoints Inspection &Back: No Update Jo D Relertal Stare 8452-HADLEY Work Orders Base Store 8452-HADLEY Lead Paint:Assumed-LSWP Requir Lead Sourea 0390 HD.com Services Web Page �, w •-Charity Nix 51162018 12:51 PM Malenal Ordered No 5/10/2018 10:30 AM RAYON ROBERTSO William Ramcke 5/152018 4:46 PM Order Received-PSG No 5/10/2018 10:30 AM RAYON ROBERTSO William Ramcke 5/152018 4.46 PM Measure Complete No 5/10/2078 10:30 AM RAYON ROBERTSO CYihina Raglin 5/112018 8:52 AM Released to Production No 5/1020/8 10:30 AM RAYON ROBERTSO Cylhina Raglin 5/11/2018 8:50 AM Order Entry No 5/10/201 10:30 AMRAYON ROBERTSO RAYON ROBERTS. 5/10/2018 11:48 AM Credit Pending No 5/10/2018 10:30 AM RAYON ROBERTSO RAYON ROBERTSI 5/10/201 11:48 AM Sale Pending No 5/10/2018 10:30 AM RAYON ROBERTSO RAYON ROBERTS 5/10/2018 71:48 AM Sent to the Field No 5/10/2018 10:30 AM RAYON ROBERTSO RAYON ROBERTS 5/10/2018 11:48 AM Lead Entered No Close Print Home Depot Contractor License Numbers: MA: 107774, 112785 Salesperson Name and Registration Number: Rayon Robertson : 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 Informatbn: OEL NISSON New England South 1-5ZL3G9N net rvema Lasl Name Branch roams keaa xx " ifiPomeroy Terrace, m� Northampton MA �tl O6 Customer Address CXy _ Stale Zip (917) 533-4861 Home PM1anea Work Phones cell Phone, 'oelnisson@gmail.com caammea-mall Amress 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 Andress clty stale zip or Email cu sto merca n cel I ati onnortheast@ homed epot.corn 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 PAYMENTS) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOTS RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOTS 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 �r / 05/10/2018 cino / , o.m 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. 1342.00 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: 07/05/2018 Approximate Finish Date: 08/02/2018 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. ByJ� ' itialing this paragraph, I consent to receive only electronic records related to this transaction. ///�. `--Initial Accept ance 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 complet py of this Agreement. Keep it to protect your legal rights. x��� 05/10/2018 cu.�yr at sig Date X coi9^erel L Data �.._ X 05/10/2018 „eaw, J Data License number(s) held by or on behalf of the Home Depot: 2 WINDOW SPECIFICATION SHEET - Spec Sheat#:1- eLSGEN Sheet:1 of Customer: JOEL RIESONJOb N'.1-lErd.D Consultant, Rlyll nner¢on pale. 0 oto/Role e New WmOOW Trade WraIdea EeI9mg And— Measurements Gods PmOud Ouoons Lessor Opllone From medhe, L&I to HIBM Bey4,Bnws Lma(on Ldor Polgn Opening aol ban Aol had Rem Or 1Pn1 P ors Olaz4 MISOIIdas Hartlware Cotte Sc,...4 For dcorauae 5 _ 9p Mull "5"=sYetlonary or W RAIWraps n `" F_ ceT _omg C Hoo Flaa LWe Or, 6tNa Lo]e flera4 Gotle € 3 — M RGO e 0 t,"I's. 3TO Al Is a i xGeck.emnbero LSF eP RYD WhIle!is' P, 1300 0 0 a C 'STOP 3 3 OR 3 1 31,11PAll,Standard LSF Fp I I I — SPECIAL CONSIDERATIONS. .W nlla,4,W rine rap Cdor MIRECI Mond Land, 'ar..l,Typa Day or How ends. emorant material(VIDA ady-51he or Oak) ay Purred 0rele Do Or _ Bay Parker yce CH,SH,or e"1 op of window to Sorin tmanas) j I tow to so'K aold,of adnl material I hallo mese ed and o9re,who At rho job spectcanoms assWa and In0 un amt Iyer or N.)' special Terms and Condmmnao the Eld,d,page Se Carden Window. ealMeN Malarial(xmy only Wake Pmnle,Blron or Oak) ACC)MY CERTIFICATE OF LIABILITY INSURANCE OLZ [CI8LDATE,2CUT YYYI is. � 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), AUTHORD ED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. M 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 andersemerd(s). PRODUCER 4A"AnE T MARSH USP,INC. NAMPHONEFM TWO ALLIANCE CEIJTER E __ .C...: 3560.EVOX ROAD SUITE SUIT E�MAE IT UNTA.CA 51326 oRE6G NSJUMR S AFFORDING COVERAGE NAICA -N101W2n59-HnInxDCAW-I8-I9 _ _ _ INSURER A'.OM Re mLli[Im..... _._ INSURED INSURERS hcv 19m 5fiMP IDS ILO I'3HJ1 HE HOME UEYO INC. ' dOME OGPO r J y A. GIC. INSURER LHomeZsk C,a IND Inwrarcc am len )Lb PNCH F_RRY ROAD INSURER BUILDING10 AILAN'd.GAA 30139 INGURER E_ INSURER F'. COVERAGES CERTIFICATE NUMBER: ATL 004353J3a16 REVISION NUMBER: T THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 3ELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TIE COLICY 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 AFTORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSICNS AND CONDITIONS OF SUCH POLICIES.'_IMITS THC WN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L*RR Da- POLICY NUMBER IPOLICY EFF POLIGV EXP LIMITS 1YPE OF INSURANCE SUaR MMIOO IWIOOIWYY A X LONBE aceiENERALLUUHLRy NIWZY 31211] 03M"2018 031012019 EACH OSCURRENCE 3 40001RD ' JAMA ET HE 1JUQW11 I�CLAIMSMAOE OCCUR PREMSES Eao¢umnca 3 IMITS OF POIJCI FS VIED FXPAHI one IRI—I 3 LXCI UIIUD OF SIR SIC PER OCC PERSONAL S ADV INJURY IS 9TRIMA SSFNL AGGREGATE LIMITAPPLIRS PER 'GENERAL 4GGREGA[E j IJWOIL K POLICY lEG O M1IWT331Z11flLOC PRODUCTS-OOMPOPAGG 3 VA00.Wq NEB, A AUTOMOBILE LIABILITY Z31p11ZO1H 10391019 LOMRINEO SINGLE LIMIT 6 1,OOII,gOD .N.Ii0enl. X I.WV ALTO BW ICV IN JURY'Pe pVmV) Is `—I CNNE SCHEDL.EC SGINSI REI I=i lA i 300LI INJURY Peracoceall i CJI FRED hgOOONNEp PROP R1)PFWGE zL OS U OS..NC —USEL S 1i3 UMBRELLALUB OCOCR EACH OCCURRENCE '—'EXCESS TRA ST CLT.IMB-MAJE� AGGREGA'E DEO RETENTIONS - B D HERSCOMPENSA T I O N AIC 01412297 AXNHA'J.VTI 03101201 3C 2019 ; PER oiR- M OVERS ABILITY VIN 3 NC Old II25]9 WI1 �W'S,2018 l30 01. _ ON Don N .RO ETRPRTNEPoEXECO➢\- NIA _ C CIDENT F CR MEMBERIXf UOEC? - ds., BHS �li =LDISEASE. AEMPOVER3 -0" TO esia¢rnba" V'1l ed Un AjaeCgal Page 3000 J00 DESCRIP40N OF OPERATIONS cepw EL DISEASE-PODC\"IMIi 3 ucesT AulO i24I-1-Um-I KHIS 1031012018 I'MIC019 LImR. +000200 i i I DESCIPPRONOFOPERATIONSILOCATIONSi VEHICLES ACORI)SUB ApOHIemlWmarMe ScheJub.msy aMCReJ Timm spazal¢ngNntll EVIDENCEI L INSURANCE CERTIFICATE HOLDER CANCELLATION LONEOE°f RR "S" SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2J55 VACFS rERR/ROHU THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BI ALTINS 02N ACCORDANCE WITH THE POLICY PROVISIONS. ATLANIA,DA 300 AUTHORIZED REPRESENTATYE of Marsh TWO. MWITUR MUkherjee StC, .RR i-1 01988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CNIO1642069 LOC#: A88nra Ac oe ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY NAMED INSURED MARSH USA.INC. THE HOME DEPOT.INC. HOME DEPOT U.5 A.,INC. li NUMBER 3955 PACES FERRY ROAD BUILDING 030 ATLANTA.GA 30339 CARRIER XPK CODE EFFECTVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certifficate of Liability Insurance VJare,UCaepen"Im Ccalurr el'. Camey Indemnity Lrsman[e Cmnpany 0 NwIN America DO,NUmmor WLR 064783191(AL AR Pi KV,LA MS.MO NF NM NR OK.SLSD TN NWY) Edsliw Dale.aL01no18 Eawellon Dale 0310111 a (ER Dora.11,000 ON Coria,Ni Hampi8smanre company OR,I.E.,WC 014123576 (DG OE HI OINDMNMLNYRN ENstiw Dale:UNDRESS Esti arm Dale.O3ARi (EL)Limit V EN WO C.S.,ACE AInnleaolteu me Company DO,NumhmWC.C64IM221(OSO(AL CAILNCOR.Vn WA) ENxtlux OAl 03all10D18 LxryrMioa Uale:OLO112019 DQ Nit V Wi SIR:81000000SIRrorlFZSlalesdN.CA.II,NC.OR.VA,WA Came, Na0msel Unkn FIIe Inimanve Company PWcy NuiXWC4595689(OSI)(COfTGA,ME,WNV,OH,PA.UI) EOxIHe Dal?:0 OWD18 Explra0on Dale:OAO 0019 (ED Limit:IT(WIRED s:030.00 SIR far lne slays Of CO)MENV nh ONPA.UT Ver)000 SIR for ma stale of CA 535000 SIR for me s tale uT raukar,n Narmnal Unun Iso.—,anra.Ampaay 'Nar NuDEe SUGIC5N55811O501M41 ENxMe Ua1v0L'Ar U ExplretlSSUSIr03N1R019 Si limtl:5100,000 TX Empbyars XS Imlemnly Carter Mimi USS,lreuroi CO.,ry FOPt NUlpebn NSCAV16693A(TY1. Uf,,PP Datc 030113018 EsErelien Dale SWUM (EU LSRL 610,000000 SIR:SIS TOD ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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: 04i22/2019 ATLANTA OA 30339 update Mdress and return card Mark reason for change. - ❑ Address ❑ Renewal ❑ Employment ❑ Lost Card Mce of Consumer Affairs a Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supolemem Card before the expiration date. M found return to: -_ Bea'shaton Expiration Office of Consumer Affairs and Business Regulation 112785 04;22,/2019 10 Park Plaza-Suite 5170 .HOME DEPOT USA INC Boston,MA 02116 RICHARD TROIA 2455 PACES FERRY RD C-11 HSC I .--"_P ATLANTA.GA 30339 Undersecretary Not valid withou signature The Coraraoinveniffr ofMaesochusens - Department of Indnstrfa[Aceidents I Congress Street,Strife 100 Bostru, AM 02114-2017 'a y naivia;massgov/dia Wurkes'Compensation insurance Affidavit:Onilde's/Contmetors/Eleclricians/]'Iumbers. TO OR M- 0 WITITTKE PE)LSBTrINGAOTIIOR)T1'. AcEicnm Tleflardinfle. 19eled Print Leoib ,Nnule (Business/ONmiyatiorJl/�ndiyvLiddual): Address: P-9; City/StateiZi ; D) lone d: nre,nn.,'rmpminr a:ael.re,pp,uvi,to ba.: rypc of project(required): L❑lam enlol......i,h_.,ba'-C'mdl"We va""deej• 7. ❑Yew communion ].r-1 eme mitgmpriaururpafnmtiipond Favenocmplol'ec;rvink" be m ! 8. ❑ Remodeling ::+y 1V,vvpd<a'[omR inzurnec znuinJ.j I . 1.I�L=r..an%:maon:¢r Juing aihvud:myacL"t�b:vc.!:cr'rnm _' vmmnrrn 1 9. ❑Demolition F ben •pumc• l+ I ' 4�c:un a homa,wnv eae wi11 h:Ndnarnrlmnunm co,Nutldl cork un n,y pmperry. I,val l o❑8uildine addition nn aanlcl cvnmuors eilhpr Lme`:crkns"eon,pmmtian imu:aneaorzrsmla I ME]Electrical repairsoraddidons P:,pricmrs:vial:no nmpio}•ms. + em ge12.C]Piombing irepairs to additions S�l ',xml„mmeardl ham Ui am :N:liembnnvarmrslinzd on e,ed,edsbea. 13- mire ars umae n,hcm:vac:o/s have cmployeB end Love,vo,Acrs'comp.isu,ane.: i ❑ :i.[!No c+e a ca,per.;iun anJ i6 of Ecus Fax ccncisei Ihcir 9ghm(eanrpzion mr faGL c. 1Y.Votber . _.:Ifa).a,tlw=kve,:o cmplagc.}IM10 1AIzRcrs calnp.iRReanccr=.ui;:+1 'Any eppiicmt a,aleubnor}Axelmuvdiodon not lhzs;eien bciat ..f fie and Milena a..,,ves..1sahvitiinen 'nummmaz:v„zubmii rnis Sidaert'rdiraiing3ryardoing all morn uru dmr.hir omvSecwuac.ors mull suhmil a:wvvalfdavil uallmlingsudl,�Cont - anmz d,c;vie b 1i,k box.,en ...eeWan additional 511.1 shli'MI 1hn lied!!of uz suh-:v,u,ac:oraand sole rvi¢1Fv vrnm dmx U166.Acve employes Ir lhesn6wnR.aorseere coad'di-s.,hey num P.M.their awl," camp policynumber. _ /ton orr empfaper flmf is praviAh:�lvarRerr'cnmpensid7u�n//nrys�u�m/�^nre,/or ury ernpfayrer. Bello)A Mepolicyondlob site inniwr. invulancie Company mmeWk)eP, bAiy U / L 'IMI-> //- Policy !� ) h or Self-hes.U..B:[[ ,����j! Expiration Date: ✓�! "l /�y/" Job Site Address: v lr r'r �LN�`[PI�- Cily/Smte/Zip: Ak.. _ Meetly .pv of the vorkess'compensntian polio dceiamfipn page(sbowingfiepolicynpmber and exprm ndalallloaD Failure to secure coverage as required under NIGL c. 151',§25p is a criminal violation punishable by a fine up to S1.500.09 indfor one-year imprisonment,as well as civil penalties in the tato of a STOP:PORK ORDER and a fine ofup to$250.00 a Gay=g1hut the violator-A copy offhis statement may be forwarded to the Office of Investigations blithe DIA for insurance coverage ver:cation. !do hereby cerdfj,ud /tthheej� +n p " thni the rmrdion provided above is lme and correct. Sig rdm Date Officio!use ordy. Do not u,111.In this area,x be coprpleterl by eiN or toevn QNrial City,or Town: Permiduddli c'd issuing Authority(circle one): 1.Bonn[of Henith 2.Building Department 3.Cityfroern Cleric J.Electrical Inspector S.Plumbing Inspector ti.Other i �� CJntnct Persun: Phone': II n ,i Y,FbCW53 lu . H s'r .x 2E£nc LoloaLSS32 II tda'tiS]2Is3�c')SO'!.FJP`5, �; I+ "97.'i=�i25't�.017SL:!hU'dJd�lYa'Crn' i:Yfs-S�JiG: coned `I l t;S^j15QgpNUK'Je�t+"L6't 5'JAS':U�Nd�hIGv48�T11S(vX -=``M'�'QS4"i�!4 tl i' U 1 i Lg�c»_e:vcdH1'h�yd*pw-, li It j I I, I' �£x � L I r cS7HIJz;CSCJd `CY7100 urt:Oidl 1 p IIMS-01, 'le[u2S 4;no3'R' oWON 1 r' Aqj.-PS Jos-�C9alb 7,:n I, awamwa>aaa?o�kcJ.nrt�;2lt'n i+ou�.mxn7 I'.' I �JT�iii�i S�N�V;It3L�N�a i'<NC1iI��J ;I IIHCI 9/_-LO �+ SaIi YJ JO[..m7dp2.D%nn SWO LM mgg hapdonu;A LML'CLILIC 6/6/2018 Details nsee Details Demographic Information Full Name: IVAN KOSOBUTSKYY Wrier Name: License ress information Monson State: MA ipcode: 01057 o nt U ed rates icense n orma ion License No: CSSL-098785 License Type: Construction Supervisor Specialty Profession: Building Licenses Date of Last Renewal: 6/5/2018 Issue Date: Expiration Dale: 4/27/2020 License Status: Active Today's Date: 6/6/2018 Secondary License Type: Doing Business As: tus Chane Reas L'ng Rene I rerequisi a norma ion Licensee: KOSOBUTSKYY, IVAN Relationship: Attribute Of License No: CSSL-098785 Close Window ©2011 Commonwealth of Massachusetts Site Policies_ Contact U= htlp I/elicense.chs.slate.ma.usNerification/Details.aspx[agency_id=l&limnw id-2877148 V1