32A-258 (4) 44 MARKET ST BP-2019-1429
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mau:Block: 32A-258 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
remit# BP-2019-1429
Project# JS-2019-002312
Est.Cost:$2940.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor.- License:
Use Group: HOME DEPOT AT HOME SERVICES 104327
Lot SIZe(sp. ft.): 5314.32 Owner: LAPOINTE JONAS
zoning: URC(100V Applicant. HOME DEPOT AT HOME SERVICES
AT. 44 MARKET ST
ApplieantAddress: Phone. Insurance.,
5 RIVERVIEW DR (401)935-2633 () Workers Compensation
NORTH PROVIDENCER102904 ISSUED ONAIJ&2079 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# 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:
FeeTyoe: Date Paid: Amount:
Building 6/1820190:00:00 $40.00
212 Main Street,Phone(413)587-1240,1":(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Dnveway Permit
212 Main Street Sewer/Septic Availability
Room 100 WaterNVell Availability
Northampton, MA 01060 Two Sets of Structural Plans
\\ phone 413-587-1240 Fax 413-587-1272 RoVSite Plans
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVAI OR O F ILY DWELLING
SECTIONI -SITE INFORMATION 7ThIs
14 0019
1.1 Property Address: section to be c mple ad by office
Map DEPT OF BUILDING IgSRECTIONS Unit
0 ORT 1 01
Zone Overlay Dktdct
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(P�/nm)y,�/ //•rte current Bn D D D
Telephone
Signature
2.2 Authorized Agent:r
NameCu"MM 41 Address: /M//A/yl
V
Signature Telephone 2
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building r'7 /��0 v,i) (a)Building Permit Fee
2. Electrical 6 i lam!/ (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fes (('�
4. Mechanical(HVAC) "0 .00
5.Fire Protection
6. Total=(1 +2+3+4+5) Cheer Number HI
This Section For Official Use Only
Date
Building Perms Num Issued: // O
Signature:
Building Commissionedinspector of Buildings Data
7-/) :;-> 7 @ CD
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
L
�1 _ 1 �
L � .]
�e �I i ��i ,_ � �!
_ �..2 '_ _.... . ._._J
Section 4. ZONING All Information Must Be Completed.Permit Can Be Dented Due To Incomplete Informatlen
Existing Proposed Required by Zoning
Thio coloum a lefilled in by
Building Dcpammmt
Lot Size
Frontage
Setbacks Front
Side L: R U R:
Rear
Building Height
Bldg.Square Footage °ra
Open Space Footage
(W mea..no bldg a paved
parking)
ofParking Spaces
Fill:
volume,[ uxi
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,excavalion,or filling)over 1 acre or is it part of a common plan
that will disturb over lam? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION DESCRIPTION OF PROPOSED WRK check all applicable
New House Addition ❑ Replacement W1 ows Alleration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [L7] Docks [q Sidinti Otheerr-[.C�
Brief Description 1
Work: Y�/�� / ,✓/°'`r�r��� C%/Ri'J,/»�"�•"_r
Alteration of existing bedroom_Yes No Adding raw bedroom Yes No
Attached Narmuve Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga.If New house and or addition to existing housing, complete the following:
a. Use of building:One Family Two Family Other
Is. 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. Numberofstories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
1. 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_ CilySewer Private well_ City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUIL/DING PERMIT
I. V ✓[✓�/r C/��// �����Z as Owner of the subject
Property
!//\ n�1
hereby authorize
to acton my behaff,in all matters rel veto" `�utharizad7�-t-his building permit application.
Signature of Owner Date
I, )elwxb /O z� ,as Owner/Authorized
Agent hereby declare that the statements and Information on the foregoing application are two and accurate,to the best of my knowledge
and belief.
Signed undart h ins a penalties of pe' �/
Ile
Print Nam
Signature Own eM Dale
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not A/p/p/licable ❑/
Name of License Holds, )Py:4 /7
�J�✓ C/ C�9/ LC. � livens Nr�//
Address Expiration Dale
Signature Telephone
9.Re istered Home Ira wm nt Com c or. Not Applicable ❑
Comeafly HAM Registration Number
Dg
Address I Expiration Date
Telephone D
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(11i c.152,§2SC(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 buildin 6m- ft.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton _
S
Massachusetts i. ""•,
212 aaln atraat • MOniclpal nulldi'y .` y
NortEOupton, IA 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 anypre-existing mmero Wpled building containing
at least one but not more than four dwelling units....or to structures which am adjacent to such residence Or building"be
done by registered contractors.
Nate:if the homeowner has coiltracied wwitth'a corporation or LLC,that entity must be
registered.
Type of Work: (�" CSS/K.t^/jI,/ �� / �Fsst.Cost:
Address of Work: �-!
Date of Permit Application: Lf2
1 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 owneromupied
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 RESPONSIBI ITES 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 as the agent of the owner:
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit n the owner of the above property:
Date Owner Name and Signature
City of Northampton
•'� Massachusetts
� Y
- � DEPARTMENT OF BUILDING INSPECTIONS
313 Main Street • Municipal Building
Northampton, . 01060
Massachusetts Residential Building Code
Section 110.115.1.2
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 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 I 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
Oficial,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
Massachusetts
( z
DBFA MEW OF BUILDING INW=rzONB
Z C�
212 Main Stceat 1 auilein4
NortM1avpton, MAw NA 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 frro/mq construction work being performed at:
(Please print house number and street name)
Is to be disposed of at:
weA -4WT - ) '
(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 efMassaehuseus
Department oflndustrial Accidents
1 Congress Street,Suite 100
Boston, MA 02114-2017
wwn:massgov/dia
Workers'Compensation Insurance Affidavit:Buflders/Contractors/ElecMclans/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leathly
Name (Business/Organimtion/Individuaq:
Address:
City/State/Zip: Phone#:
Arc rnn an employer?Cbeak Na approptlate bow: Type of project(required):
I.❑I am a employerwith mployee,(roll and/or sm-limn).' 7. ❑New construction
2.❑lamasolePmprietorarmtmerstipandbanememployeesworking fnewm g, ❑Remodeling
any capacity.[No workm'ver,.insurance required.]
3.❑lam a homeowner doin Il woh If workers'com nest. 9. Demolition
g e myse [No P��nmmnce'aqui ]'
4 D am a horreomer and will he hrz' tractors so conduct all work on n Iwill 10❑Building addition
mg can yprope y.
ensure and ellcontmcmrs eidter,have wntkers compensation hnuuan«or arc sole 11. Electrical repairs or additions
propreams with no cmploye s.
12. Plumbing repairs or additions
501 am a sexual Monomer and 1 have rated the subcontractors listed on the muched sheet. 13.�ROofrepBtla
Thesesub-commet osmov,employees andhave workers'comp.imsutmtcv:
6.❑We are a corporation and its oR e s have caercimd their right ofewemption per MGL c. 14.❑Other
152,§I(4),and we have no employees.[No workers coml insurance required]
JL
•Any appliam Nat checks he.pl must also fill on,the section below showing Their wotkem'compensation policy information.
t Nomeowvets wed submit thisaffidavit ivdicatwg they are doing all work and Nen hire outside connections most submit a new affidavit indicating such.
:C trsuxa dust check this how tram attached sed additional sheet showing the name ofthe subconuamors and smce whether or not hose counties have
empWyecs. Ifthe subcontractors have employees,duty must provide Meir workers'comp.polity,number.
loan an employer that is providing workers'compensation insurance far 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 W secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00
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.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 andpemahies 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 oJrcial
City or Town: Permit/License#
Issuing Authority(circle one):
I.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 ail employers to provide workers'compensation for their employees.
Pursuant to this statute,an earployee is defined as"...every person in the service of another under any contract of hire,
express or implied,and or written."
An emphryer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint 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 repay 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 in your situation and,if
necessary,supply sub-contractors)morels),address(es)and phone numbers)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,me 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 thein
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 in contact you regarding the applicant.
Please be sure to fall in the penniti icense number which will be used as a reference number. In addition,an applicant
that must submit multiple pemtit liccase 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 bum 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
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
" w
Home Improvement Agreement: Pagel
Home Depot License#'s - For the most current listing www.HomecLegot.com/LicenseNumbers
MA: 107774, 112785
Kyle Harmon
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.
LaPointe Jonas New England South I 11-MlM8PUT
Customer Last Name Customer First Name Store #/ Branch Name Customer Lead/ PO#
44 market street INorthampton MA Ot060
Customer Address City State Zip
(413) 512-0797 F— evolution.lonas@gmail.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:
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 REQUIRESTHAT_TjjE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE OW TO ACKNOWLEDC* HAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN NOTICKOF/Ypo RIG T TO CAN9EE.
Acknowledged by: 05/20/2019
Cu tgnature Date
Contract Price and Paym nt Schedule : Pay 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: $ 2sao.00 Includes all applicable taxes. Excludes finance charges.`
Sales Tax: $ o.00 (If applicable)
`Maximum deposit ONLY applicable in MD, MA, ME(33%), NJ, WI(9901.)
Dep. 25.0 % Deposit Amount $ 735 Remaining Balance $ 2205.00
The Home Depot-2455 Paces Ferry Road, N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care: 1.600.466.3337
4WH Hoe CW—AR eM(24 JUL 10) r01B
Y� 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
oan 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 v be used to pay some or all of the total amount of sale.
Description of Work to be Performed:
Installation of lWindows
A more detailed description or the work to be performed Is included in the section emit a cope o
Work which appears on page 0 of this Agreement.
Anticipated Delivery Date/Installation Schedule
Approximate Start Date: 07/15/2016 Approximate Finish Date: oa/12/z019
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
r ive and open emails and PDF documents.
B i ling this graph, I consent to receive only electronic records related to this transaction.
at
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/per itting information may need to be provided to You later.) By signing,
you acknowledge that you have rez, understand, and accept this Agreement in its entirety, including
the n al Terms and Conditions and State Supplement, if any. You further acknowledge receiving a
c plate y of H' me Keep it to protect your legal rights.
/20/2019 The Home Depot
ust er's ignature ate ervlce Provider Name
X 05/20/2019 909 Boston Turnpike Unit 1
r ' ica ate @rvlce Provider Address
X 05/20/2019 Shrewsbury MA 01545
i re ehaf o ome a of Date city 5tate zip
@rvice Provider one um er service Vrovider License Number
The Home Depot-2455 Paces Perry Road,N.W.Bldg.B4,Atlanta,Georgia 30339-Customer Care:1.900-065-3337
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Office of Consumer Affairs and Business Regulation
1000 Washington Street-Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: supplement Card
HOME DEPOT USA INC Registration: 112785
P O BOX 105451 Expiration: 04/22/2021
ATTN: LICENSE MGMT TEAM
ATLANTA,GA 30348
update Address and Return Card.
su� o aug.mfn
office of Consumer Affairs a Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Suoolement Cad before the expiration date. If found return to:
Reoisbation fap®ge6 Office of Consumer Affairs and Business Regulation
1127M 04/222021 1000 Washington Street -Suite 710
HOME DEPOT USA INC Boston,MA o 118
RICHARD TROIA �/[lG
2455 PACES FERRY RD C-11 HSC �eG..✓�(
ATLANTA,GA 30339 Undersecretary Not valid without signature
ASR& CERTIFICATE OF LIABILITY INSURANCE DA9w�amrt9l;s"rv"
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
REPRESENTATWE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: It the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or he endorsed.
N SUBROGATION M 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 W the cengjcate holder In Hau of Such endorseme I
Prtopecm
MARSH UM,INC.
TWOAUTANCECENTER NwHME,
EAX xo:
35m LENOX ROAD.SURE 2,100 EHMR
ATLANTA GA 3033 AMOSESS
INS AFFDIIDRCCOVEMGE NWO,
CN101M2089HaneDGAW-1920 ..RERA:OM IkI.(a CO N147
1M4111�D IIwIRFAB:New Hmm ire ins Co
THE HOME DEPOT,INC. ml
NONE DEPOT NC. INSYRE1C:HmNRsB HgIRNeC
N68PACESRERRY ROAD
BUILDING GA-20
INSURERD:
ATLANTA,6430339 1xsUREa E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL4M35WM8 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.
1Lint TYPEOFNSURANCEns Anes POLI WuusERF%XJCYEFF PoIILYEXP LYTS
A X COMMERCMLOENEMLLNPoIITY MWLY310.5T,1 Miami 93BinOn MCHOCCURRENCE f 1•D3a•L00
CLPIMSMADE IT]OCCURpREMIBES Fs 3 t•999.9W
X SR:SI,OW,ODJ Mm ExP aiw Peron i EXCLUDED
PERSONALaAWN.NRY S f"Um
GFNLAGGREG41ELMiAPPLE4f£R GENEFALAGGREGATE 3 1.mxw
X POD D T 0- PRODUCTS-COMP/OPAGG S I.9D3.p99
amt R: s
A AVTpIOBILE WB11arY LM'TB314sT3 pl•➢trzpia 93115922 I.—c!OSIN ELM] 3 IMMa lEm
X pNY pU TO BODILY INJV0.V(Palxm'n) S
OWNED W.EDuum SELF INSURED AUTO PHY OW BOMLYINJURY(Pe.—n+ ) S
AUTOS ONLY AVroa
HIREG XO-- PROPERTY WMAGE 3
WTOSONI AUTOS ONLY exklul
S
UMBIELLAWB OCCUR EACHOCCMmEWE I
SaCESS WB CLANSMAOE AGGREGATE i
I. I I RETFNTGNS i
B WORXERSCOMPENSATNN WC 9f2Tt)993 AkMH.NIVT) 03191 R 0114
MD EMPLOYERS- MBNTV ( •T STATUTE ER
B .WYPROPRIEmWPARTNER CUTNE YIN WCOt2H7100(W9) 031015919 031015020 EACH ACCENT S 5,00000
OFFCEWTEMSEREXCLUM07 N WA
(MendemYin NXI EL INS1ASE-EA E.PLOYEA 3 5'000000
Ir aeeaib—dn ClNroma0 an A650Drel Page 5,000,000
CESCWPTIQY OF OPEMTONS bebw ELmSEASE-POUCYUMIT f
C E SAA. M7110011002019 93115019 o3nn= Ulnit. ,1,000.000
A ExonSGenelel UeNY'y MW29(314500 00015019 03D150V Uldt - 8.01M..
mo Ces.DFOPEMTNX$ILOCATONSIVEMCLES IACORD 1.1,Adl..n 6-1.i—Q
EVDENCEOFINSURANCE
CERTIFICATE HOLDER CANCELLATION
HOME DEPOTUSA,INC SHOULD ANY OF THE"ME DESCRIBED POLICIES BE CANCELLED BEFORE
N55 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BUXDING 629 ACCORDANCE UNION THE POLICY PROVMIONS.
ATLANTA OA 31331
AUnmRMI)REPRESENTATNE
0MBn1HUSAln[.
M..SN MUkheNee -]KNAyaa " Jl+t4_w,1A�el-
(91988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016113) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: CNIO1642069
LOCl/: Aflame
ACORO ADDITIONAL REMARKS SCHEDULE Page 2 of 3
AGENCY xAMI.Seasso
NARSH USq,INL. THE HOLE DEPOT.INC.
HOW DEPOT USA,INC.
PDIICY HUMBER 21551`ACESRARYROAD
BMLNNG CIO
ATLMlT0.GA Miss
cARR1ER xAaccope
EFFECTIVE WIE
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
Waken Cairyenastlon Cordruen: '
rawer meemrtq Imrvaee mmpay a Mom nnHnm
IN OW Number:WLR C0890599(ALARFLID.M,NY,L ,W,NE,NM,M,MKSD,iN..WM)
EBdliye Dale:03101 019
Ewranan Deki
RQ Limit S5.000A00
Caner.New Hmmrffiie Ireunrre Comlwm
Pd y Number wC 012717096 IDC,)E,HI INW W,W.NY.RI)
ElMlirenale-.OXIMI9
EapnS Dad:03M112020
101 Lmm 3Sao0.mD
Cana:ACEfmairan Naurace CDmpaly
Pi HUmbm:MU C65SM(QSD 1A2,CAL,XL.CR.VAWA)
E6a4.e mm:03m12019
EymWn Dam:03M1
(EL)LimA SR.M.OW
SIR.51,000.000 SIRmr me smbsalAZ,CAILNLp11,V0.WA
Caen NanwlUnbn Relmpanumm6rry `
Ramp Nuad.MC SMSSN IOSO ICO.LT,GAME.M,HVGIPAUT)
EBothe Dam:O3M12019
Lanni Dem:Oafi
IEU Ji SI,000.ODO
$1,W],W 0 SIR kr Ne aLslea of COME JN,MI,ONPA NT
8150.Om SW Mme sWm of G6
$3M,m0 SInLCT
mina Natlonal unron arelnsumu�� ,
Palcy number:MC 5505591 OWL
EBeare Wm.03301019
aan Oam
Erpn '.031011MM .T/I
(ELILmn:N,500,000
SIR:5500.000
TXEm6byenlr mmum
Carter II
er:ImWIHa LhmmInsleass Carwrry
Pah,Nim4w,TNS C55211D19(TO
Eli Cale'.MInO19
Eapnllan Dem:031014920
(EU LimoSIO,000ON
SIR:SI ONLOOO
ACORD 101(2008/01) C 2008 ACORD CORPORATION. All rights rescrvetl.
The ACORD name and logo are Registered marks of ACORD
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The Consmoriwealth of MassaehuseOs
Department aflndusvrialAceidenti
I Congress Street,
Bestms,MA OIlI4-20d-1017
www.amssgov/dia
TV Workers'CompeusaBaa Imnrunce,ADfdavitt Builders/CoatractorsfEledricians/Plumbers.
'M BE nLED WMT TRE PEILNITTING AUMORITY.
,spulicuntInfiarnmajort y (� —')--�1'le. ePNnI Leaibl
NaDte(13esinas/OrganionfloMndividua0:•-1-'
Address: ��y5iUy
CiTy/StntelZip /��I Phone 0: Z �1WR;
Arereunn emplayce Chess flollompriat boa: Type of project(required):
I.❑lamaemploymwilh_rnmbyen(NIIaNhrpaniirrer' 7. ❑New construction i
2.❑lomamlcpropricmrurpanncnhipmdhmnoemploymazw mg formem S. Remodeling
any m,ciry
❑I .INo wMers'com0.iesunnce reuvirmd
] am a homeoxnixr Juin II work m avis 'm,m 9. ❑Demolition
- ea S aci r tokcr:emi all maw paa,cr, 10❑Building addition i
tQ l nm a l:onwarmerpad will Lx hiringmnuonms la conduct all nmk w nti proPerry. I will
mum rau rnmranpn xrther havnwrkc
. ampermmn i�uomnmwmmle II.❑Electrical repairs or additions
cmn whb nu cmplayecs. 12.E]Plumbing repairs or additions
s. t ire svnsnlsmwcwr and l leve ldmincsutsasame I=m:he mmchetlshut I7.❑Raofrepairs
T mcanuamars Nix nmPla)ees andleotlleascmms.insumna:
6.❑lVe aux a coryam:ion anJ ds oRiexs hove acniscd Ihcir dghwfamngiau Per MCL.
Other
Per
s32,¢1141.uM.K Wvc:ro amlmees.INo parkas'coons.ievzmarnpJrcll y
'Any coal that chmksbox at must nko all mu the ttnion Mlmv xhuwing Nei:a'olkers'eampnamian polity infomaiion. [N
tNoneo,wera,vw aubmil thio afi,tloritiWiceing 0q amtlaiagall xroR and Uen M1ire omsi�mnuocwn mmtsubmita new amJavilinlimih,g such e
eCammnarsrthesacon hi mhanemhnu-g.LbWilaldlznshem'ngN IkCM of Ne sPh-mnlrHnlaa Pnd slave xhahaar m:utmecntida have
em tlowes. If:M1esubconaacleshave em in¢es,0 e
1 P > ey mull goviJedeir aohers mmP Folicy numixr. s
lantanemplayerrhatkproaiding2porkaYeampensationinmmncefornryenWloyers. BelmvisrhepofrryTndjoobbsfnri
it
Insurance Company Namr.
Policy;:or Self-ins.Lie H:X�LUl /�13�/
Expiration Date:
Job She Address: City/SmterZip: ;
Attach a copy of the worker,'compensation policy declaration page(showing the politty number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up W$1,500.00
andlar one-year Imprisonment,as well no,civil penallies in the farm ore STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy ofthir statement may be forwarded or the Office of Investigations ofthe DIA for insurance
coverage verification.
Ido hereby re MY 96de ins Id a of jary lhW theirrformnlfon provided above it tare and correct.
Shmatur Neta,
Oficial osc anljs Do not write in rhfr area,to be cmnpleled by city or town oJjcial
City or Town: Permii/Lieeose 4 _
issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Ciyfrown Clark 4.Electrical Inspector S.Plumbing inspector
6.Other
Contact Penom Phone 4:
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UMt7W33dOWD
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61-0ZF5211 `som. �5f?
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alfill"'2211 teuorssajWd jo uGmuaD
s aesnuaersett 40 411varauoumm ZI