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30A-024 (15) 42 LEXINGTON AVE BP-2017-0325 GIs#: COMMONWEALTH OF MASSACHUSETTS Mau:Block: 30A-024 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Siding BUILDING PERMIT Permit# BP-2017-0325 Project# JS-2016-002492 Est.Cost: $24000.00 Fee:$60.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 98785 Lot Size(sq. ft.): 1041 Q,,84 Owner: Debra Truskinoff Zoning:URB(1OOV Applicant: HOME DEPOT AT HOME SERVICES AT: 42 LEXINGTON AVE Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROV IDE NCER 102908 ISSUED ON:9/9/2076 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP AND RESIDE, NO STRUCTUAL CHANGES POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy signature: FeeType: Date Paid: Amount: Building 9/920160:00:00 $60.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner ",a rt -a Deparinterrf�sec ,� _ City of Northampton otamsofPerrniv � "` "i"a ,,-, '" t "' SMEhialr ;ShMharh: huh, ., Building Department Lg11,9 VDnv wayPermlt,, Ht - 111 co ' ` 212 Main Street Sewer/SeQ icAvaiIabdlty - '� t Room 100irr2ied,Mr.BAvadabl4ty 41 of U / Northampton, MA 01060 Twp Sefs of Structural Plans Q �+hy'ne 413-587-1240 Fax 413-587-1272 plgllsde Plans- • y y Other Speafy' A" •TQ N 0 CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE I' ORMATION 1.1 Property Address' This section to be completed by office 1--7 I yt ��,/{,-'y, J/` Map�- Lot Unit Z Lel`)k.Jj r//7 7 J v C ' Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 21 Owner of Record: pokzig- -M2)#16A/oFF v- is-717-1 Ak arsepec litq- Name(Pr�int)) p,.�„ Current Mailing Address'. 0/06 0Jli-- � giTiiErr Telephone Signature Cfh;hi - 2AL olg Mess halCilt 4 ,T ( n 4 07 Name toolip CurrentzO ? ny Address- �}�-- �t33 / 0/ —÷--2-3---id52—` Sig pure Telephone SECTION 3•ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building &�f//'/�f�fr ) ,i,,.,, • 87.) (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection )y/ �j�� /�� 6 Total =(1 +2+3+4+5) g—/n (in� •G' � Check Number` ,�GJ3 C>7C / This Section For Official Use Only 8uiiding Permit Number: Iss Issued Signature: Building Commissioner/Inspector of Buildings Dale Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information - Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage _ .._1 L___ I .___. Setbacks Front :-_. __ _.I Side L L_ R:i_ Li R:(_._ _ Rear _-_u Building Height -- _ Bldg. Square Footage % 7—I — Open Space Footage % _ (Lotareaminusbldg&paved _ , !_______..] parking) #of Parking Spaces ----� Fill: (volume&Location) L—------ '-- _ 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 '., i Paged and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained © , 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 0 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 Windows Alteration(s) Roofing • n Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signsnt [0] Decks [0 Siding Other[El] brief Desci• ofPro•osed/ , 'jic 6 7f y j l DWI JJg 4e fir/In,.oEy t7+ 4209,6 Alteration of existing bedroom Yes No Adding new bedroom Yes No `Vc",�`' Attached Narrative Renovating unfinished basement Yes No c79-#3-416f3 Plans Attached Roll -Sheet sa. If New house and oradditiontoexisting housing, complete the following: a. Use of building : One Family Two Family Other b, Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f, Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance-_ Masscheck Energy Compliance form attached? h. Type of construction-„,,,,,,,, i, Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k, Will building conform to the Building arid 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 ZVTR /” ` ati, ,O t as Owner of the subject properly /,�'/ gyp... hereby authorize V 4 CA)a/ to act on my behalf, in all matters relativela_ to w•rk authorized by this building permit application_ Or lila S Signature of Ownevt y}�yt,yr,,�Ti, '�(�/).,,� Date An f {r.-•r Age .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 the •-ins d penalties of perjury. '�a MOP"- Print Name +/�'(f'/'//'ry/ ( Signal te of Ow rtAgeni�-.---� Date SECTION 8 CONSTRUCTION SERVICES --81 Licensed-Construction`Superviss rt(I yy��"� tyt-6� l'-�(-r'—,+IC,�-t __. _—. _Not Applicable O ,(y} -�// Name of License Helder ? "/Y jl Vr'21 a ; j q (�1 1, 4 2 % /// License NumMr Address Expiration Date trStfr , 1514-• 1145-7 Signature Telephone 9.Registered Home lmproveme Contractor. Not Applicable 0 Q 3 Company Name V Registration Number ' -"i2Y Ay,, Expiration Date ddr4 1 1902P '� 8)54TelephonOW) �G 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 AtteffiCEI ' No IG 11. Home Owner Exemption The current exemption for`tiorueavners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an indi idual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 1683.5.1. Definition of 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 faun structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form accepable to the Building Official.that he/she shall be responsible for ail 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,von may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with tie State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, 554, 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. '7 y Address of the work: Z � XI V�/G n [ f X 7� 0 662_ The debris will be transported by: k"/9 ,/i � )LFII The debris will be received by: p/ Cry. hit Building permit number: � Name of Permit Applicant A��� //20J/r 16 / 4 1 Date Signature of Permit Applicant ,\ The Commonwealth of Massachusetts Department Industrial Accidents dueofInvtigations r. P_ " _ 1 rnaess Suite 100 ' 3it Boston, MA 02114-2017 tommags.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/ndividual): Address: Ci /State/Zip: Phone 4: __ _ Are you an employer"; Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).` have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp, insurance comp.insurance,- required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL, I2 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other, comp. insurance required.] 'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new a6davit indicating such. IContrnmors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or riot those entities have employees. if the sub-contractors have employees,they must provide their workers'comppolicy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie. #: , Expiration Date: lob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date)_ Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification, I do hereby certify under the pasts and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: _ Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6.Other_ Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"_every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in 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 repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment he 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 ofthis chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es) and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Revised 7-2013 Fax# 617-727-7749 www.mass.eov/dia City of Northampton 44. °" Twpp Massachusetts ( ,,'e9DEPAATMENT—OFHVILDSNG—INSPECTiO1P5= y � r ^' -Y _ 212 Main Street • Municipal Building \ ..y..• Northampton, MA 01060 y 66:6 • INSPECTOR t.nuis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OW„N?_ . X _ ..PTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner' as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner.' The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foun ationifootliugs (before backfill). sonotube holes (before pour). a rough building inspection (before work is concealed) insulation inspection (if required) and afinal building inspection. The building department requires these inspections before the work is concealed, failure to secure th- . _ .ns•-ct'.1s can r: . It in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location Aug 0716 09:19p p.2 HOME IMPROVEMENT CONTRACT PLEASE READ THIS _ p, Sok1,Furnished and installed by BraNew Branch Name w Ecotone/ Date._ LLQ THD At-Horne Ser ee.Lw. • Nola The Home Depot At-Home Scry:res Branch Number:31 908 Bonen 1L:apike.Unit i.Sh wabury,MA 01.445 Tal Free S71-50-3.3763 • ., FCJeal'0075-1698400:ME Lir C MOP;RI Cora OCR 16.4rCT Lit• InslaJmlon Address: 142 Q 1( i int P t�R.CHN R City Siam Zip PmrAaeerta): a Work Phone: Home Phone: Cell Phone 17p,0 Oci 11 ] 1 i LI l I I I Home Address (ifdifietant frost iatalhation Addrann) -_-City State Zip Emmail Address In receive prmet common iced-ions ): ons end Home Depot updatos t DO NO I wiish me_aelve mry nruketerg ersls Pont They Home Depot lEE.I$LJApTIERRRi.URiNlsof'$.Y.2r.N9lpRRC Ir.0kR rRCWp,PERRHP.11iiimN.Al.R'.f a4N itti.IR9ThJ4 rnm,a 3 r T VI? fuatioc,along with any appli,nhle Slate Supplement and Payment Sun-in-coy attached hereto and my Change-Orders(col leareto:y, "Conyane"a: Job YOhooltostit Freidman Spec!Mahal N Projekt Amount i.R � Wk [, wo, t paww944'6?3f1` Wks. ry �'}3ic2y1 o Tilt f Siding wo&ws trim inn $ pea ;Coon ❑ oy COOS❑_�_..._ —4I-Ertlatfing U 'dnbljWindow Qimitation $ peae 'Coors :Entry Do • URcefeig LINEN InW eie; prmml —.. .—. .- $ pc /Covers COD Dona E -k },/y MaimiurS%Dephatelt'.00tNdae attAmonspvicetsd *rd cunt Total CrAilraa Amount $ `VI toe Meirpftrchawe not&p t mine uunaaMhd• aftheCmmrM Amount Coma'oats thee immediacy aphn completion of rhe work kr each Product.Octan .-will cxecwe t Compledun Cm/triage (one for each Product as kilned by un individual S1acc Sheer)and pay any balance duce As applicable.each Customer under rh'it COSMIC!.agars to be jointly art scerally J:ligated and iablc to/COURT. The Rome Depot swages the right to ffiac a Change Order or terminate this COMMIT or any individual Pmdua(e)Reload herein,r. its distortion if 1'ba Home Depot Cr its authorized service provider dN rmi net dint it cannot perform is o`n liywines due m a summon Nubian with the homeenvironmental hoards ssh as maid,arbe ms or lead paint,ohm safely con erns,prie:ng sorra or beaux workaequrcd r000rpielc the jot:was run'includedlIs heCailnct Pnntmnl Summary: TCe PoyM'nl Softneory# t 15.67011 , inauded as part of thiv Contract, ss toot the T.ai Cr nice antra kod payments;v *cd is the deposits aiad6aat payments by Product(s apptarbk). NOTICE TO CUSTOMER You arc entitled to u eonlpleteb Riled-m copy of the Contract at the time you sign. Do mat sign a Completion Certificate tope: there is one Carnal tion Certificate for each Awed Prodder as deflated by individual SpecSheets)briars work nn that Predate is cumppkte. In threvent of termination of chic Contract,Crammer agrees to pay The Herat Death the coa of materials,labor,eayeDxs and services presided by the Hume Depot or Aulbnrized Service Provider through the date or termination,pins any Mier enanhlt ext font in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF MUCH AMOUNTS Acceptance and. Ruch ggh Cone mei agrees and an dattarde dm his Agrceincra is the -ia cateemell1 b roCORSICI mei The Home Dopoi with regard to ire PYfdu[c and l rstall talon serve:ccand sep•rrdss alll prior cand agreement,eiOFr orals inrelating to Aid Products rot i ver ager. ?C s Agreement cann`1 b : ;red or oleander,oleander, ep:N'a tatting s;rcm by Oatou,er and The Ruth<Ikpnc.Cnsromv aesni.rwkdgc, turd agrees tar Catmint has rend.eadervlxldn.snimlan.v Pacer,the teemsoiand Ins rem ted a gory of Gun AE:'ae'iion • Accepted bye x, , 'Submitted byrerocide- b(11pv Cj,_1 Cwt is Siraam: tkit en Censettrmvc Signature Roo_ Telephone No, ..._..._— Clalomcr'sSig halide Dale Sakti Ccrau.Itia L'T(Ise N0. _ _ CAHCFLLAITOR CUSTOMER MAY CANCEL THIS ..,IanL,mla AGREEMENT WITHOUT PENALTY OR OBLIGATION e / BY DELIVERING WRITTEN NOTICE TO THE HOME C.. 3 IVb s/ll J'1 DEPOT BY MTDNIGIIT ON THE THIRD BI:STNESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHER HERETO KXDCTAINS A CORM TO USE ik ONE IS SPECIFICALLY PRESCRIBED BY LAW IN OUSNOOtaaD`f Ott TO ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(mtwop THIS 8/2016 4------ 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 INSURERIS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy.certain policies may require an andorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSH USA INC -Ken'BtioN _.. . eAx" TWO ALLIANCE CENTER cNP_Enl: — — . _— JDS.nt 3560 LENOX ROAD,SDI"E 24cC ADDRESS: ATLANTA_GA 30328 _ NsuicEMS}AFFOROINCCOMERAGE I N's" 100494-HomeDGAW-mill NSURERA-Steadfast Insurance Company 26300 NSUREU —.. _MSORERa:=udet American Insurance CO tGS$ RATHEHa1 ENTAr-H — -'- - ODA THE HOME DEPOT' E SERVICES INSURER C=New 9ampshaB Ins Ce 23841 2590 AT1,ANiTMBEOt303O PARKWAY SUITE 319 INSURER O: In05 Natl00J 1p6ul90rY Company I2391I 3"_4VTd,GA 30334 _ EMBER B: _ INSURER F: COVERAGES CERTIFICATE NUMBER: ATLC53741 5'14 REVISION NUMBER:8 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 VMTH RESPECT TO WHICH THIS CERTIFECATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BV 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. INSR AOa.SA— '- POLICY EFF POLICY EXP LTR TYPE OF INSURANCE N$D MO POLICY NUMBER IMMIDWYYYY) (MINDDITYVYI LIMITS A 5 COMMERCIALGENERAL UAMA, Gi"v4S77140SS 33, i 2115 03101:2017 EACNOCCURRENCE 's 9.0XL6cJ1 -- — DP VAGL IC N ED , _ CLAIMS-MASE % OCCUR ERM BEy Qurrencel = INO,000 UMUS Of POLICY x3 w=.0 2t.POtn4 xe,,,,,, 5 EXCLUDED OF SIR.$1M PER UGC PERSONAL a AIN iNJURY 9000,010 _32Nt kOGREGATE LIMIT AP".ES s=4 GEr1ER GiREGATE 5 9300,010 x_ OLrV __ yep G. _ LOC PRODUCTS COMPIOP AGC 5 9'IDO_DW OTHEi. 3 AOTOMOBILELIA3IIMY .._ BAP 2938$63-13 3c;'B u5o1,20r ISIGtE°M ;s 1.UW..W) X ANY AUTO I I BODILY INJURY(Per pe@On) l a LOS L.,1-Fa SELF INSURED AU `EHY fMi; ,9OIbLV Lruukv(Per re w -x1 SNON-O _ _.... HIRED ALTOS - .LITCS +E0 Prscemed!) . S.. UMBRELLA LIAR OCCUR EACH OCCURRENCE ' S EXCESS LIAB S.MADE AGGREGATE ? ..__T_. DED ReTM1ON s 5 C ANDWORKERSOOLABILITY nON WG01551421$(AQS) _�Ot2011i 0?I01rzp15 x PER fJ H AND EMPLOYERS'LABILITY D ANY PROPRIETMPARTNERSXECUT4E vrN WCO'SStY2R L11(F(Y,NHN:,VTJ B 11`Tg Gi DtGRR E.L.FRCP,Av=GENi S ... iii%M J ER MEMBER EXCLUDEDI D /Mandatory In NH/ N N AWO015519216(FL) 03. 2115 960111017 TEL DISEASE EA EMPLOYEES 1.000,000 lUFBfadRI Mon AE0 con&I Page I EL_DISEASE.POLICY I.Wt 15 4�,000 GR PTOO O Oer PRAT LOWS]slow Cnninnetl ..ETRE _ DESCRIPTION OF OPERA9DNS I LOCATIONS I VEHICLES IACORP 101,Additional Remelts SCN®Uule,may be attache4 II mem xpece is ttyuirtd) EVIDENCE OP INSURANCE CERTIFICATE HOLDER CANCELLATION IPO AT-HOME SERNtCES.INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DEA THE HUMP,DEPOT AT-HOME SERYCES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2e PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. YTLANTA.GA 30339 AUTMORQED REPRESENTATIVE e Marsh 054 Inc Manashi Mukhedee .Ntw%..eo1-e .D44-a-tatetl-e4- Cr 1988-2014 ACORO CORPORATION. All rights reserved. ACORO 25(2014101) 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 Registration: 126893 Type: Supplement Card THD AT HOME SERVICES, INC. Expiration: 8/3/2018 RICHARD TROIA 2455 PACES FERRY ROAD, HSC C-11 ATLANTA, GA 30339 Update Address and return card. Mark reason for change. Address Renewal _I Employment Lost Card Office of Consumer Affairs& Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration: 126893 Type: 10 Park Plaza - Suite 5170 Expiration: 8/3/2013 Supplement Card Boston. MA 02116 THD AT HOME SERVICES, INC. THE HOME DEPOT AT HOME SERVICES RICHARD TROIA %�� 2455 PACES FERRY ROAD, HSC - - - - , ltid ATI:4NTA, GA 30339 Undersecretary of valid without siinature The Commonwealth of Massachusetts jj-WI= Department of Industrial Accidents I Congress Street,Suite 100 Boston.M4 02114-2017 ' ',t www.mass.gov/dia "'"' \\orkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly _ Name(Busmen✓Organiration/individucilea?) -rR.dYYx' ZVL ( S Address: afa / _ a .^^'--.7�,,��,,rr,v// City/State/Zip::O r . L I'' 1'l4'fJ/ + :4Yhone #: 1-;itl�l� Are you ea employer?Cheek the appropriate box:iType of project(required): 1.01am a employer with„ emptaytes(full and/or wrliilr}' 7. 9 New construction 2 Iar a sole mmrpnetoror partnership and have no employees working for me in X. O Remodeling any capacity. No workers comp,insurance required] 01 am a homeowner doing all work myself No workers comp insurance required l' 9. 9 Demolition a.OI am a homeowner and will be hiring10 9 Building addition wntmaonmmndun all work on my{noOenY Iwill tea=that all Coneaaors ether have workers'compensation insurance Cr um sole I LO Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5 l am a general contractor and I Neve hired the sat-contractors listed on the attached sheet 13.n Roof repairs These sub-contractors have employees and have workers comp.insurance) ,{.rh � 6 We are a corporation and its officers have exercised their right ufexemption per MGI.c. (4.IJkyJdyer ///�)/✓ /` , )V 152*10),and we have no employees.(No workers comp.insurance required) 'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information a Homeowners oto submit his aaidavn Innb attng they arc doing all work and then hire outside conamctors mast submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees II'the sub-contractors have employees,they must provide their workers comppolicy number. 1 am an employer that is providing workers'compensation insurance for n?v employees. Below is the policy and job the information. Alt A, i j�(2 gg�> �y CO insurance Company Name: fti4) 1^ nF/'/�',Z.. hJ`r"-7 • C , _ Policy#or Self ins.Lir iii( ,�[>- �'5j{Q��C1Jp! Expiration Date - I r1I'//,/{, q/-7 Job Site Address: No! / } CBy/state/zipR e _ _ tU-' 91O42 Attach a copy of the workers'compensation policy declaration page(showing the policy n mbe�nvion 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 nnprisomnent,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 it/Investigations of the DIA for insurance coverage verification. ]telt ebycera u\e t� Ase �(/ee f --,f.17-7P fp ! T���� information provided above is true andJcorrect. Signature: -124--.... 641,2--W2.--- �.r/L / Date:`tel ��� �/' Y2 1 . Y]2-- -._..... Official use only. Do not write in this area,to be completed by city or town official 41 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#: 5/6/2016 2016 CSL pic.jpg WAN KOSOBU 1 SK.v 2 2 STAFFORD RD MONSON MA 01057 ' , : " r NI^" '., Expiraton: COMMISSso>_ 04/27/2018 haps://mal.google.com/maiV#searchRrom%3Amike_w_bcdartl%40homedepacam+filename%3H(jpg+OR+jpeg+OR+png)/154734e5T7222aPprojecbr=1 1/1