31B-151 (9) 17 TRUMBULL RD-2R BP-2019-0985
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:31B- 151 CITY OF NORTHAMPTON
Lot -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category'window replaced BUILDING PERMIT
Permit# BP-2019-0985
Proiect# JS-2019-001620
Est Cost $2980.00
Fee,$40.00 PERMISSIONIS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 104327
Lot Size(sq.ft.), Owner. NESSY TANIA
zoning: Applicant. HOME DEPOT AT HOME SERVICES
AT. 17 TRUMBULL RD - 2R
ApplicantAddress: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON:3/11/2019 0:00:00
TO PERFORM THE FOLLOWING WORK INSTALL 4 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 q Foundation:
Drwex.y 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 Occuoancv Signature:
FeeTvpe: Date Paid: Amount:
Building 3/1 1/20190:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
R '�(JiNiJOWS
Department use only
--� City of North pto Statu of P mit:
.r Building Dep me t MAO 1 1 201 rb vewey Permit
212 Main feet Sew dee 'c Availability
'( Room 1 0 orP We dWe Availability
Northam fon, T o�i nntnrr'n iltsPF Trftl f Structural Plans
P om Mnm
phone 413-587-1240 Fax 413-587-1 tans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION i6e, /L?— ?�i
1.1 Property Address: This section to be completed by office
�� PA /�y7 Map 3 l Lot �5 ( Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: T -�-
Name(Print) Current Mng,[�tltl -
Telephone
Signature —
2.2 Authorized A nt
N e(Pdn, Current MailgAtltlress:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building O// (a)Building Permit Fee
2 ElecMcal (/ (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) (�
5. Fire Protection 'J
6. Total=(1 +2+3+4+5) •v Check Number Ce 2j
This Section For Official Use Only
Building Permit Number: Date
sued, p
Signature' 3- 11—Z61 f
Building Commissioner/Inspector of Buildings Date
T»a7 @
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
'II...mlunm m be filled in by
Burkina Department
Lot Size
Frontage
Setbacks Front
Side L R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&pave
,irking)
N of Parking S aces
Fill:
(vn r—&t.�rnaon)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O 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 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 Bows Alteration(s) Q Roofing Q
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding[[3] Olher[a
Brief Descri tionro eyed
Work: L
Alteration of existing bedroom Ye 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 Fani 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 healing? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. 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 CrrONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters rel�fpg�lo work authorized by this building permit application.
Signature of OwnerDate
I, g / � z ^ je—
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.
Signed under th /ains d penalties of perjury.
Signature wner/Agerii Data j
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ) Not Applicable ❑ 7
Name of License Halder.
License Number
Address� Expiration Date
Signature Telephone
i---3 --�/ Ali
S.Re istered Home Inprowi Contractor: Not Applicable ❑ _
ComCom aRegistration Number
Address �/ $JJ��y�� /)/�/� /c��i� Expirat nim
5 "/�ll��� / / 'r-P`✓ /� Telephone v/
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 lbuildin&4mri
Signed Affidavit Attached Ves....... No...... ❑
City of Northampton
Massachusetts s+
0LnS B
OF GZLLZNG INSPECTIONS
212 M
313 Main Sheet Hu W, Bio Building
noitEmg»ton, Na 01060 rrr�a
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 most 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
Mhas
�connttr"acted with a corpora on or LLC,that entity must be registered.
Type of Work: ��1pV'-/7d t veli ' 1��-r�jn/�,/j�L/Z/ 6A—T—Est. Cos :2—
Addressof Work: / /2201i//�O7'/cZi/"�L`-L/ �� • ✓`
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 TIIEIR 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 RESPONSIBILII'ES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
t hereby apply for a buildingpe it as the agent of the owner:
Date Contractor Name IIIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the comer of the above property:
Date Owner Name and Signature
City of Northampton
s ..
Q
MassachusettsTNENTOF HpILDZNG INSPECTIONS212 Hain Street • Municipal Building
Nortbampton, NA DISCS
Massachusetts Residential Building Code
Section 110.85.1.2
Homeowner: Person (s) who own a parcel of land on which be/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 I IO.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 1 I O.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
,r Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS ,y
]lI Rain Street •Municipal Building i c
NoutLamPton, KA 03060
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:
17 Te-Pm ,�l Ab �D'2
(Please print house number and street name)
Is to be disposed of at:
A/�r
(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.
- The Commonwealth of Massachusetts
Department oflndustrial Accidents
— ' 1 Congress Street,Suite 100
A?' Boston,MA 02114-2017
www.mass.gov/dia
NA orkers'Compensation Insurance AflldavlL Builders/Contractors/Eleenicians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lee@ly
Name (eusinees/OrganiutioNlndividua0:
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box:
Type of project(required):
I.❑I am a nmploycr, th emphyces(firl and/or pad-time).* 7, New consWetiun
2.❑l am a ante pmYmewr or partnership and have no employees woung for me in S. ❑ Remodeling
any eapacily. Noworkers com,insemncc recoiled.)
9. ❑Demolition
3.❑1 om a M1amauwner Jaing all work myself.INo wnrkrn%comp.insurance reyuircd.l`
4.❑I am a hnneoworrand will he hiring mno-acmrs to conduct all work on my property. lwJn 10❑Building addition
an we[hal alleommcmrs eimethave Workers°u,mpensamnimurmmar am solo
IL[]Electrical repaws or additions
prepremr with no cmployesex 12.❑Plumbing repairs or additions
5.❑1amagenemlwntrurfor and l have hired[hesab-wntmetors Inli,dan the poached shttr 13.�ROOf repair,
These sob-coanaetors have employees and have workers'comp.insmanec.
b.❑We me a camomfion and'as officershavews,ensM Weir dgln of esemption pe,Ml3L e. 14.❑Other
152,c f41.and we have no employees.INo workers'comp insumacc occurred.]
*Ary applicant that checks box sl mast also fill out the section below showing their worker, compensation palicy infcarard on.
t Homemvnets who ck this box in
attached
indicating Wcy arc doing all work and then hire outside conaattms must submit a new indicating such.
Contractors Wer check this box must a[mched an eddilionel sheer showing the name d the subatntlraomrs and stele whether or not thoseemilies have
cnrpluycce. If IM1c subwmrstors M1avc cmpoyca,lhcy mull prmidc their workers comp.palicy number.
I am an employer that is providing workerd compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Num,
Policy M or Self-ill Lic.M: Expiration Datc:
Job Sit,Address: City/state/Zip:
Attach a copy blithe workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure Coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
too hereby certify under the pains and penahtes afperjary that the information prmrsded above is trite and correct.
Sionatum Date
Phone M:
Official use only. Do not write in this area,M be completed by city or town official.
City or Town: Permit/License M
Issuing Authority(circle ane):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
h.Other
Contact Person: Phone M:
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
oldie foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee ofan individual,partnership,association or other legal entity,employing employees. However the
owner ofa dwelling house having not more than three apartments and who resides therein,or the occupant ofthe
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(fi)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 ofpub tic work until acceptable evidence at 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-contractors)camels),addresses)and phone numbers)along with their cernficate(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 maybe 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 rearmed 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 arc 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 sum that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
ofthe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sura to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that most submit multiple peraft/icense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under'Sob Site Address"the applicant should wile"all locations in_(city or
town)."A copy ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proofthat a valid affidavit is on file for future permits or licenses. A new affidavit most 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
f e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street. Suite 100
Roston, MA 02114-2017
Tel. # 617-727-0900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Home Improvement Agreement: Pagel
Home Depot License#'s - For the most current listing www.Homedefot.com/Ljcens-e-Numbers
MA: 107774, 112785
Rayon Robertson
Salesperson Name: Registration No. (if applicable):
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.
TANIA NESSY New England South 1-EBOXZSR
Customer Last Name Customer First Name Store #/ Branch Name Customer Lead/ PO#
17 Trumbull Rd 2R Northampton MA 01060
Customer Address City State Zip
F6-0 7) 339-9358 nessFtani a@g mai 1,c 0 n
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:
908 Boston Turnpike Unit 1 IShrewsbUry MA 01545
Address City State Zip
Or Email' customercancellationnortheast@homedepot.com
Service Provider Email Address
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 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 THE HOME DEPIjOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
AC
AND W
RI NOTICE OF YOUR RICTO CANCEL. PLEASE SIGN BELOW TOWT6jj5;y SICE DGE THAT YOU HAVE BEEN GIVEN ORAL
Acknowledged by: oziz3izols
Customer'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: $ zsso.00 Includes all applicable taxes. Excludes finance charges.'
Sales Tax: $ o.00 (If applicable)
'Maximum deposit ONLY applicable in MD, MA, ME(3301), NJ, WI(99%)
Dep. 25.0 % Deposit Amount $ 745 Remaining Balance $ 2235.00
The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800.466.3337
awFl n of customer Agreement IN Jul.18) , o.19
Home Improvement Agreement: Paget
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 wlodows
A more detailed description or the work to be performed is included int the section entitled Scope o
Work which appears on page = of this Agreement.
Anticipated_Delivery Date/Installation Schedule
Approximate Start Date: 04/20/2019 Approximate Finish Date: 05/18/2019
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 trutialing 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 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 IThe Home Depot
us omer's bignature Date bervice Provider Name
X 1 908 Boston Turnpike Unit
o- igner (if applicable) ate bervice Provider Address
X I Shrewsbury01545
,Signature n Rahalf of Home Depot Date Uty tMA ate Zi
ervi a Provi er Service Provider License Numher
The Home Depot-2455 Paces Ferry Road, N.W.Bldg.B3,Atlanta,Georgia 30339-Customer Care: 1.800-466-3337
anon Hoe anomer Agreement(za Jw.1e) . o.lx
WINDOW SPEaFICAT(DN SHEET - spec.sneer N-. I snoxxsa Sheet ' or
C,,rp,, IIIII onx'. Consultant n - Dare- o '
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pays.nPias
mcanon r.Om, ROapn ol>enms xDmarl r0r Das 0" 1
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SPECIAL CONSIDERATIONS'.
rep CI.r MSC3.Labour ,M13CE-Lab,.,
ntelto,oa6n,Type
Bay Or Bow w:neow:
arwam maININ(cetyl 0nly Bruh 0r Oak)
v Parts Arse(ao 01 sd -
av Flznkertvpe(DN,N.ar Learn)
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fumlemr Pact(vas O,Nolseeclal Terms as!OOnerlons On The,ful,paea
Boman wmmw'.
,,scone Maldr,1 trmyl omy-venae Pmnne.Dend or all
A�ROM CERTIFICATE OF LIABILITY INSURANCE ao vermis
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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed.
H SUBROGATION IS WAIVED,subject to the terms and Gond ffams of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the co tifieate holder in lieu of such endorsement(s).
PRODUCER E.EE
MARSH USA,INC. SAME
TWO ALLIANCE CENTER PHOac xo:
3560 LENOX ROAD,SURE 2400 EqRI �
ATLANTA CA 30326
_IH_S_ MICIRSIAFFOR_DINGCOYERAGE _ NNCF
C1,10164206DROmeDL.4W-1420
INSURER A:DH RQ WiC Insurance P,0 24147
INSURED INSURER.:NMHRm iR Me CO 23MI
THEHOMEO US INC.
HOMEDEPOTFERRY ROA INSURER G,HwneRiskL "se Nsulance Company
2455 PACES FERRY ROAD -
BUIl01NG G-20 INsuaER o:
ATLANTA GA M339 INSURER E:
IILSURE0.F'
COVERAGES CERTIFICATE NUMBER: ATLL04353433M REVISION NUMBER: 21
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.
m3R OL SU.R POUCYEFF POLICYE%P
Lm TYPEOF WSURAHLE PoLILY NUMBER NMN MOOIWY OM115
A X COSWERCMLOWEIFS17 MWZY3145T4 03ro1n019 O3NIO022 EACROCCUFFENCE E 1,005000
CtwIM51MDE OOCCVR PREMISES Ed aaaeorm E 1000090
% SIR.SI,090.W9 MEOEXPtAoymePeao) y EXCLUDED
PERSONALSADVIN UHY S 1.050,000
GEN LAGGREGATE LIMIT APPLIES PER: GENERPLAGGREGATE s 1.9901009
PR
POLICY JECTo-
LCC PRODVCiS.COMP/OPAGG E 1000009
CTNER. E
A Auro nUs,uneelY WOB3145T3 0311312019 031012012 DMUNEEDD MAI UMI y 1000999
X ANYALTO BODILY INJURY Pu v,FPH E
OWNED SCHEDULED SELF INSURED AUTO PITY BAD BODLLYINJURv{ParemXe�I $
AUTOS ONLY gVT05
HIRED NON-0WNEO PROPERTY OAIMGE E
AUTOS ONLY AUTOS ONLY Pm sAPHAs
f
VMBRELIA UAB OCCUR EACHOCCURRENCE E
EXCESS LPB CIAIMSIMBE AGGREGATE S
LED I I NErENilorvE E
B WORNERSCOMPEMSLTION WC 01211T099iAH,NHNJ,VTI OS OLC112020 X PEP OR
ANOEMPLOoe..'LLB6nY STATUTE ER _
B N, YIN we Du2moo wl o3m1no19 o3ro1n9z9
YPROPRIMSERERTNEWE%ECIRIVE O NIP I I ELEACH ACCIDENT b 5,000.000
OFntaory nBERE%CLUDEOt 5,900,000
IMmOa,, In NX1 EL015 EASE-FA EMPLOYEE $
TIO
I
IIY� E.PLOe OFO CAmoued on Additional Page 5,000000
OESOiN OF OPERATIONS bebw EL.DISEASE-POLICY LIMIT E
C Fxress Auto 297110011002019 03101n019 MAH202C limit 4000.000
A Excess General Liability MMI 314580 03012019 0301QO22 Umil'. 5000,000
DESCREP SDN OF OPERATIONS F LOGATONS I VIDIR LES IACORD 101,AOGXoIalR —1.SNWUN.may WdIMCMO M nve sWe is veins,
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
BUILDING C 2 ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA GA 30339
AUTNORO£OREPRESENTATWE
OT Marsh USA Inc.
Moment Mukherjee �MAAnOO� f4...tei.a�-u.
C 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: CN101642069
LOCM: Atlanta
Ali ADDITIONAL REMARKS SCHEDULE Page 2 of 3
AGENCY NAKED INSURED
MARSH USA,INC. THE HOME DEPOT,INC.
HOME DEPOT U 5 A.INC.
un NUN.ER 24M PACES FERRY ROAD
BUILDING 020
ATLANTA GA 30339
CARRIER IC[DYE
EEFE6TVE NATE'
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 26 FORM TITLE: Certificate of Liability Insurance
WOMem6Nnpensatlon Commune,
Carter:Indamury ln5u2nce Company of I Amenea
Pok,Numper:MR Cfi8WN491AL AH,FLID.Ii VC NSN0.NE,NM,ND,Oi50,TN ft WYi
EXtt9ve Dale:03N12019
Expral-Note:03N1R020
IELICUmH S50N ON
Come,New Hampebrelra-mrre C.."
POlayNumber'.M 0127IM98(OC.DEHI.MMOMN,MTHY,Rp
Etltullva Date:0361 19
P.xp,m mDale'03A)IM20
H Limit 55000,000
Camera ACE Amenran msma ma Const
PCSq Numboo-WCU C55M05M(QBI)tAZ.CA IL NC.OR VAWA)
Effaa. 0ate'ONW019
Eepratlon Dais:03N12020
tED Limit:34,OW,W0
SIR:11,000,000 SIR So 9eslatesof AZ,CA,IL,NO,QBVAWA
Came-National m—Ne I.Sumnre Company
P011cy Num,MAC 5505590 LQsp(OD CT,OA.ME,MI,NNCH,PA,Uq
Emil Dare:01
Explmi Date:031012020
IELnlmltS4,NONO
S1 ON M SIR f-ar Ne ehres of DO NEW W,CHI UT
$750Om SIR for me store m GA
SM000SIR_fenjila SRYLCT
Carrier:Namnal U...Fre lnsumnn Comm,
Poicy Number MC 5565591 RAA)
Effiner ale.03N12019 /
I Sunn n Dam 05101121120
\
EQ Limn$4MO 00
SIRSIR.SROg000
T%Emplet XS In0innaft
Cemeenmla Union Massive Gannom,
Pan,Number:TNS e65221019 INC
Elktllre0ale'.OSNIM19
Exprafion0ale:03rMIMM
IELIOmitSIO900.EOo
SIH:$1,003000
ACORD 101 (2008101) ®2005 ACORD CORPORATION. All rights reserved.
The ACORD area and logo are registered marks of ACORD
The Commonwealth ofblassuchnsetts
Department oflndusYriolAccidents
_ I Congress Street,Suite 100
Boston,MA 02114-2017
wlprumuss.gorldin
1Curke s'Compensation Insurance Affidavit:6nilders/Con[mc[nrslElecfricians/Plumbers.
TO BE FILED W ITHTBE PERMI-1-TING AUTHORITY.
A. licantlnfa`mation t—� '-7--'leases iet Legibly
Name(Dusimod/OrgwimdjdaNindivid_w0):--�^ Q p�L1J 6
Address: Q
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City/StatWZjp' 4 r Its Phonc0: �Z`7 ��� -
AreYw nn xmgarer4 Clmelrthe appwpriTh ha'' Type of pi eject(required):
LQ i nm a employer rvuh employees(lall oMlor p o-oca).`
7. ❑New construction
2Q lama PMepropriawrorpanhm,mioMhavenoi.m) axs marking lorme.n }
I unYwCauH�INo wokaa'comR msumn:c rnlvimd.j 8. ORentaleling
]. Inmahaneowuer doing olRwrkm i(R:o vwrkerscnm _
sono. 9. El Demolition
J Ysx Ain caSurad.,t
10 Q Building addition
4❑I out a I:
�.,_ �l�P �C�l/7 Jy1Cll//�F(Clld1 C�I�'�G"�CL;I.i(CCfLIGyL'��i
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 Cd 1 HSC -_, Expiration: 04/2212019
ATLANTA,GA 30339
Update Address and return card. Mark reason for change.
A
1 " 'a"I�" ❑ Address ❑ Renewal ❑Employment ❑ Lost Card
$.............P../i/.
deice of Consumer maim 4 Overseas Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
�.� TYPE:Supplemart Card before the aspiration date. R found return to:
Reaistration Expiration Office of Consumer Affairs and Business Regulation
112785 04/22/2019 10 Park Plaza-Suite 51 To
HOME DEPOT USA INC Boston,MA 02116
1
RICHARD TROIA
2455 PACES FERRY RD C-11 HSC
ATIANTA,GA 30339 Under58Cretary Not valid withoulf signature
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