10B-076 42 WATER ST BP-2018-1321
GIs 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10B-076 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Categorv-ROOF BUILDING PERMIT
Permit i< BP-2018-1321
Proiecttt JS-2018-002346
Est.Cost $10795.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 88261
Lot Size(sp.ft.): 10193.04 Owner: CHRISTMAN DORCAS M
Zoning: URB(107)/WP(50)/ Applicant: HOME DEPOT AT HOME SERVICES
AT. 42 WATER ST
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Cotttinensation
PROVIDENCER102908 ISSUED ON.6/14/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.STRI P & SHINGLE ROOF - 19 SQRS
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 ft 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 Sienature:
FeeType: Date Paid: Amount:
Building 6/14/2018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
IN Ii n Y
Department use only
—" City of Northat
n stews P it:
s ' Building Depan JUN 2 2 N Dn away Permd
212 Main
Sit
Sewer epti Availability
Room 10u�ell ailabipty
Northampton, M0�TOFMNLDINDIN $ereof tructural Plans
phone 413-587-1240 Fa TON N e ana
Other Sped(y
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION v v ( ✓ I ✓– /
1.1 Property AddressThis section to be completed
dd9by office
Map 106 Lot O1r� Unit
/ Zone Overlay District
EIm St.Disbtet CB DISnld
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
P0gR)j5_ �l�RnTm i✓ 42 -5F
Name(Print) &Curran Ma' sear yl O�D --
q�} i GJ/'T
5E1� I✓�) W — Telephoned
Signature
2.2 Authorized Anent: �n��.,( m,� --� y���
1 �r/'U r1 / y' e
N ) A Curre_ailtrp Addre �
Signatu a Teleph.r.
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
cam feted by permit applicant
1. Building / (a)Building Permit Fee
2. Electrical l (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 777
5.Fire Protection
6. Total=(1 +2+3+q+5) Check Number
This Section For Official Use Only
Building Permit Number' Date
Issued: Q
Signatu �J
Building Co sionedinspector of Buildings �/ Date
��*rPT 1 / Z7 @ /;;� 61 1
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. aFront
ormation Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Ton,culuum to be filled in by
Buil ding D,tctt t
Lot Site
Frontage
Setbacks
Side L: R L: R:
Rear
Building Height
Bldg, Square Footage
Open Space Footage
(Lot area minus bldg&pato
.king)
#of Parking Spaces
Fill:
(volume&Locnliov)
A. Has a Special Permit/Variance/Finding ever been issued far/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 DONT 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 conslruclion activity disturb(Gearing,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 9-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteralion(s) Q Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs 101 Decks [❑ Siding[0] Other[El
Brief Desoption f Pro .y—
Work:'1l1�1 '9f Prof KfL �[T�'JT/�iU�IC�
Alteration of existing bedroom_Yes Na AtlOinw >etlro> C a No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Sa.If New house and or addition to existino 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?
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 construction within 100 ft.of"lands? Yes No. Is construction within 100 yr. floodplain_Yes No
I. 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 IPERMIT
I /
I, Dy pc--Y�� '`/ /' (Z74� as Owner of the subject
property
hereby authorize
to act on my behalf, in all on �ffe�latiw�e to work authorized by this building permit application.
� rf Gt�/LI��M�iiJ �S/S
Signatureof Owner Date
/ as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signedu r the p ins and penalties erjury.
IA
Prior Name
Signature of Ovine Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su rvisor: �^ Not Applicable El
Name of License N.M., 4: - /
License Number
Atltlress Expiration Dale
ovoz
Signature Telephone��
9.Realisteri Home m vement Cop
o tractor- Not Applicable ❑
Company Name_ Registration Number
Address . /It�., - Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(8))
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...... No...... ❑
City of Northampton
+' Massachusetts
�• z
DMS OF BUILDING INSPECTIONS
212 .
,y
313 Ni. Btxeet • Hanacipal Building
NoxUempton, HT 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 owner-occupied building containing
at least one but not more than tour dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the hommeeojw'ner has contractt,/edd with a corporation or LLC,that entity mustberegistered.
Typc of Work, 'A A" t� �}opo& s Est. Cost lv yy�v n i
Address of Work: ZA�
Date of Permit Application:
1 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:
1 hereby apply for a building permit as the agent of the owner:
6 -)-)K f an�� - /)2
Date Contractor Name HTC Registration No.
OR:
Notwithstanding the abovo notice,I hereby apply for a building permit as the owner of the above properly:
Date Owner Name and Signature
City of Northampton
9 Massachusetts
I DEPARTMENT OF BUILDING INSPECTIONS i
212 Main St eet •Municipal Building �.
NosNampton, MA 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:
(Please print house number and street 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)
46"77 � z -P-le
Sign tune 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.
Home Improvement Agreement: Page 1
Home Depot License Number(s)' Visit www.homedepot.com/c/SV_HS_Contractor_License_Numbers for latest license into
MA: 107774, 112786
Salesperson Name: oseh suulvao Registration No. (if applicable): 0
Home Depot U.S.A., Inc. ("Home-_Depot") or service provider named below ("Service Provider') will
furnish, install or service the equipment listed below at the price, terms and conditions as outlined on
this form.
CHRISTMAN IDORRIE —� New England South 1-6136GJB
Customer Last Name Customer First Name Store #/ Branch Name Lead/Customer Order #
42 water st Leeds MA 01053
Customer Address City State Zip
(914) 262-4644 F— dchristman7@gmaii.com
Home Phone# Work Phone# Cell Phone# Customer Email Address
NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR
OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT HOME DEPOT USA INC.,
2455 PACES FERRY ROAD, BLDG. B-3, ATLANTA, GEORGIA 30339 or EMAIL
he Home Depot (M rustomercancellationnortheast@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 PAYMENTS 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 SERVICE PROVIDER, 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 HOME DEPOT 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 AN
Acknowledged by: 05n3/2018
C stomer's Signature Date
Contract Price and Payment Schedule : Payment of the Contract Price is due upon signing unless a
different payment schedule is required by law, specified below or in a payment addendum.
Contract Price: 10796.24 Includes all applicable taxes. Excludes finance charges.'
Sales Tax: 000 (If applicable)
'Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, Wl(99%)
Dep. 26.0 % Deposit Amount zssa.sl Remaining Contract Balance 8096.43
The Home Depot-2456 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339.Customer Care:1-800466.3337
Cu.—A9rm .l0,E11131 Jan.1.1 , .'r
Home Improvement Agreement: Page 2
Finance-Charges : Any interest payments or other finance charges will be determined by
Customer's separate cardholder or loan agreement, to which 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 payments made payable to 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 : A detailed description of the work to be performed is included
in the paragraph entitled Scope of Work or Specification which is included in this Agreement.
Anticipated Delivery Date./Installation Schedule
Approximate Start Date: o7/1a/2o1s Approximate Finish Date: 08/15/2018
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.
By initialing this paragraph, I consent to receive only electronic records related to this transaction.
Initial
Acceptance_ and Authorization : By signing below, you authorize Home Depot to: (a) arrange for
Service Provider to perform any Services 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 or permitting information may need to
be provided to You later.) By signing, you acknowledge that: (i) You have read, understand, and accept
this Agreement in its entirety, including the General Conditions and State Supplement, if any; (ii) You
are receiving a complete copy of this Agreement; and (iii) all rights and interests under this Agreement
are solely vested in the person listed as "Customer' above.
X 5/23/2018 The Home Depot
st er's Signature N Date Service Provider Name
X 1 1908 Boston Turnpike Unit 1
Co igne�pplicable) Date Service Provider Address
X /23/2018 shrewsbury MA 01545
5
gnature On Behalf of Home DepotDate City State Zip
MVendor/Service Provider Phone # Service Provider License Number
The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B 3,Atlanta,Georgia 30339-Customer Care:1-8004663337
Ous,ome.M,ce en,lne.p(31 Jan,tel o .1.2
Bench: New England South JObm 1-6136GJB Branch e: 31
Cus[mref Nmec OORRIE CHRISTMAN
Job Add.: 42 water st
Nome Monod Cell Phone Y: WON[Phone, (914)262-4644
Emall Addheal dchristman]@gmail.com
Drop Leuticar DumpMer Lwtlpn:
Roofing 1-
Notes:
1 Roofing Nl
2 138]419.66 Sguare r. dmafk Certainteed 10 year Silver Birch 558.00 109]0.28
3 6173 66.00 Lin.Fc Rigid Ridge Vent 0.00 0.00
4 13]42 28.00 Piece Drip Edge White 12.00 33600
5 13745 30.00 Lin.Ft. Step Counter or Base 4.00 120.00
6 2989 2.00 Each Skylight Flashing-Non-Masonry-E& 19600 392.00
3
] 9119 100 Job Disposal Fee:11-20 SO 882.00 882.00
Job TONI $12700.28 Pramot�ryW Percent Off
$1905.04
Selee Tes Promotlon Amount
COnbmt Tool $10795.24
The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B3,Atlanta,Georgie 39339-Customer Care:14MM-4663337
116 HOE csc siwe..(E)(m Fee.19) , o 13
The Cmnrnonroeaith ofAfff machusetls "
Department DflndustrfalAecidents
1 Congress Street,Suffe 100
P Basten.M f 02114 20!7
;m»c,mossgm/din
6 urlters'Compeanniun Insurance Affidavit,Builders/ConiractorsME ctricians/Plumbers.
1'0 3r.]JIMM WITIT TRE PEUir1'fING AUTHOR17.1r.
Aorliea t7nfor .tion Please Print Le-ibI
W ante(IIusinestO,,aaira.arJfi dii-AdwI): e
City/State1zi ' fh D� Phone 1:
- van mnaNyef'Cheer nc�anmm�rialchm° Type ofpriject(required):
re r!zm a cntola}•zr..i!h
! Q __cmF!o)rr(NII:nJiurry'rtti.-.IC)• ], ❑jlCsp CnnSiNChnn
x�11 am c Ante Ci,Fri.....Partn^1sM1ipanJ hrrs n,zmVlaye:a.var4ing ruffin
r:ar cnF-=� Mo lmd;cri coma! svvnca:n illa1 S. []Remodeling
).❑!=_mahnmwnntt JCiny W1.k ^:o;l:crs'cemg.inninnrcm;mmul� 1 I9. ❑ Demolition
10 Q Building addition
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nrso:;i:zi Wl ennrcmrszi!herhwewcr!:c.-,'comF-rrsaoonimnanem:.readn !7,EJ'Electrical repa
irs or additions
nnprs tan:ne emFle,ecs. 12,[]Plumbing repairs or additions
5 !lam x aeanrW conrncmrnlW i navehiW rare subnnaaC!Crs listztl en:hc mmdctl z!letl.
! bcc vnuorshmrFmolCycx^no irvc vvrFFrs .p - i].n�r-�Rcot repairs
60 J cola,raran cnJ 's CTzcrs Fas.rczciscE lira �r 1 F!ol�•r'aOLc 18.LJ Other
I pl(a},,niw•Crr+,vo cmplsgeilCCnor6cr, cpm. ! - c".I
y eVu!irantlhnt ehre05[OS'-rl---miff all aaa'I' i[liaa 1'eI.Sll',111u.1r li,heeP comF .Iien pair,i1,fis cfion.
'Hnmmvners rrmosebmil this arNari:imliculing Ind arc doing all wotc and'Jen hire omsiee cm:vuemrs moil sullmit a newaRrhvil inJiza!ingsuca
rs drat,cloak tiro hot,murtanxchcdan addidannl slraxsfiu+•ring Wa acme ciie ic610 1c.r-nds!am lrlelhn ornx:hox emiricz hive
riulCyzs. lr!hesnE<pnmtlors WacemFla,zes.:hey mas!4:or:Jetbefr:vo:hc amp policz•nnmb::.
i nn+nrz ernpleyer @miser(o/vy�itl�htp lrorkeriy7comptnSotiU!dna Al(te'trranctfdyrtJnly en/lpl`1o_)tees. Belowisis9'rAgppotigividjjoobsue
InsuranceC - `�/t/T�)T I'� /t/ eV!-� V/!t�g� / /�Y SJ/✓"/ /1 Insurance Company P:aine._ L �-•�'` 77 l/.JV
Policy;;or Self-ins.Lic.d':/�yt/L/].. ✓�1 Expiration Datc:
lab Site Address: q� '/ � �� Ciy/Sm!emil,
Attach o cop,„the tvorlserx' faropettsmion policy declaration nage(shoaring the policy number and calibration date).
zilure to secure coverage as required under i dGL c. 152,525A is a criminal violation punishable by a rine up to$1,500.00
and/or one-year imprisonment,as well as,civil penalties in the tor!!ofa STOP WORK ORDER and a fine of up to$750.00A
day against the violator.A copy of this statement may be fon+'ardcd to the Office of Investigations of the D1A for insurance
coverage veri ,cation.
I do hereha ccrr�if/j�yun/r/f/QI' 17in _- /fops, Idraft In rnentimrprovidednh5/ave isV,1,MdCCoormy.
Officio!rrae ortij•. Do not:rrite is this nren,.o ae mnepleter/by clly nr tmvn odriai "
I
Cihr or Tmrn: permil/License� -
!.suing Authority(circle one):
til r noare(ofl;e:rlth 2.Building Deparrmm�t 3.CiFylTmrn Cimdc d-Electrieul Fnspeeror i.Plumbing Inspector
6.Other
Contact Pcrsun: Phan,k:
i
AcoROe CERTIFICATE OF LIABILITY INSURANCE DG2 0190 n
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 CONSTITL3TE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the cardflcate holder Is an ADDITIONAL INSURED,life policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION 13 WANED,subject to the terms and conditions of Me policy,cartel.poltcies may require an endorsement. A statement On
this certificate does not confer rights to the certificate holder in lieu of such endorsement(.).
PRODUCeR "'
MARSH USA.INC. NAM.EE.
TWO ALLIANCE CENTER Mc IR, Na:
3560IENOX ROAD,SUITE 2400 EMAIL
ATLANTA.GA 30326 ADDRESS:
INSURAIRSIAIFFORDINKICOVERAGE NAILe
CNIOIW2GM HmXU GAW-1N-19 INSURER A:OIL R dir Insurance CL 25141
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HOME 0EP01 U.5 A.,INC. INSURER m NovRISk Ca live Inose'.Cam a
2455 PACES FERRY ROAD p6URERD
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BUILDINGANTA CA 30319 INSURER E:
MSUR.F:
COVERAGES CERTIFICATE NUMBER: ATUX14353439-16 REVISION NUMBER: 3
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.
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LIR PEGGY NUMBER Wp
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OF SIR.SIM PER OCC PERSONALaADVINJURY $ 9,001
GEN'L AGGREGATE UNIT APPLIES PER: GENERALAGGREGATE E 9,000.000
X POLIO 1 1MOT DEC PRODUCTS-COMP/OP AGG $ 9000.000
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EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
HOME DEPOT LISA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BUILDING C-20 ACCORDANCE WITH ME POLDY PROVISIONS.
ATIANI A.GA 30339
AMOR=E PRESS ATVE
SH...U$A Inc
Maneshi MukheOee _JYLoo.S+ SAS.«�a4wd+1
®1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016163) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: CN101642069
LOC N: Atlanta
ACCM ADDITIONAL REMARKS SCHEDULE Page 2 of 3
AGENCY NAMED
IN511REn
f.. THE HOME DEPOT INC
MARSH USA.IN .
HOM(DEPOT LLS A..INC.
Feet NUMBER 2455 PACES FERRY ROAD
BUILDING C 20
ATLANTA,GA 3¢339
CARRIER HAC CePE
EFFEmNE GATT
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TRI-E: Cer88cale of Liability Insurance
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ACORD 101 (2008101) ®2008 ACORD CORPORATION. All rights reserned.
The ACORD name and logo are registeretl marks of ACORD
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.' 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.
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_ ., HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Supplement Card before the"piration data. H found return to:
_r- Registration Expiration Office of Consumer Affairs and Business Regulation
_ 112785 04/2212019 10 Park plaza-Suite 5170
HOME DEPOT USA INC- - Boston,MA 02116
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ATLANTA,GA 30339 Undersecretary Not valid withouf signature
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
yonstruction Supervisor
:5 -088261 Expires : 03119/2020
THOMAS M KELUHER
25 BEAUDRY AVENUE
CHICOPEE MA 01020
Commissioner