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30A-024 (9) 42 LEXINGTON AVE BP-2017-0687 GIS#: _ COMMONWEALTH OF MASSACHUSETTS Map: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) Categonn Siding BUILDING PERMIT Permit# BP-2017-0687 Project# JS-2017-001124 Est.Cost:$607200 Fee:$60.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: e Group HOME DEPOT AT HOME SERVICES 98785 Lot Size(so.R.): 10410.84 Owner: TRUSKINOFF DEBRA Zoning:URB(100)1 Applicant: HOME DEPOT AT HOME SERVICES AT: 42 LEXINGTON AVE Applicant Address: Phone: Insurance: 5 RIVERVIEW DR (401)935-2633 0 Workers Compensation NORTH PROVIDENCERI02904 ISSUED ON:II/17/20I6 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP AND RESIDE 2 SQRS VINYL SIDING FOR REPLACEMENT POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector or 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: FeeTvpe: Date Paid: Amount: Building 11/17/2016 0:00:00 $60.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner _ Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 1 ''11 212 Main Street Sewer/Septic Availability 16 ) 1 Room 100 Water/Well Availability N¢rthampton, MA 01060 Two Sets of Structural Plans o_.,�,r_ _ _ ', phone443-587-1240 Fax 413-587-1272 Plot/Site PWns Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING �.71� SECTION 1 -SITE INFORMATION A� — / 7 -Or, 1.1 Property Address: This section to be completed by office Map Lot Unit L2 /_'.>C)4 - 1Ai( Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: p?,nt772 o✓li{' 47 LeK ti‘-7-027 oI / I/Cp p t yi✓J ' dlia - NameiiCurrent Mailing Address' f- (I1,T Telephone I ) --3' I' —Ire Signature 2.2 Authorized . •ent: q9-413/2d771.651 / , PC I 7 Name( d Current Mel' g Atl ress: A7•4 • Signatu .. Telephone 92.J2 3 /aj SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 0 o 7? Da (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 6. Total= (1 +2+3+4+5) 62 /2 /p. ''1 ) Check Number / /'/ t('O / This Section For Official Use Only Building Permit Number Date Issued: Signature: tat,: /7/O /U Building Commissioner/Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be illed in by Building Depanmcnt Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg Square Footage Open Space Footage ,m (Lot area mums bldg&paten parking) h of Parking Spaces Fill: (volume&Location) 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 0 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 © Obtained 0 , 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 n Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory pBBllod�g. ❑ Demolitiononj/0 New Signs [p] Decks [M Siding ] Other iEl�y Brief De /n/Pro po d -Y%/1l'f: /r/�7� �i�//'✓� �Z1��%Lz' i Work. t/ Alteration of existing bedroom Yes No Adding new bedroom Yes Nor 10 ��` '�. T Attached Narrative Renovating unfinished basement Yes No /� 5 Plans Attached Roll -Sheet 6a.If New house and or addition to existing 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 and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS tt AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, / /! /Lipt/b Fr' ,as Owner of the subject property �� ry�.� T hereby authorize 4- / 0)1 to act on my behalf, in all matters re alive to work authorized by this building permit application. �C 7af_— //3 —S/6 Signature of Owner yam�y '/'/'77 �� ]� T Dale I. ) c. / / , as Owner/Authorized Agent hereby decl re that the state is and i ormation on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under th- •-'ns an penalties of pe ' -A __ to, Print Name �/J1// �, . Jr Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder � 7 �� License Number -72 �7-,41-Er d) y-27 Address ^� Expiration Date 11714D'VI Mfr. S Signature Telephone LIVl 1962- 9.Registered Home Im Groes ent Contr tor Not Applicable ❑ Company Name Registration Number �Addres 42/442 2 p� ///^//y�1- / //_ /� //ry,�� Expiration Date '1YY/'�/•'-/ / '/// ©!517 lelephoneg .2 $2 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 issua - • - • ilding permit. Signed Affidavit - hedyes No 11= ❑ 11. — Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or IIA 0(2) families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780. Sixth Edition Section 108.3.5.1. 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 andi or farm structures.jperson 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 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 he 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 he liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner certifies and assumes responsibility for compliance with the Stale Building Code,City of Northampton Ordinances,Slate 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, 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. ZAddress of the work: 2- 4/2 5 �4 F` CgC The debris will be transported by: („.1,49—&7 t m h' r The debris will be received by: , 4kt a / ' Building permit number: Name of Permit Applicant T J l J .ase "" Date Signature of Permit Applicant Job Contacts Link Leads W\di �> t r +� Friday,November 84,2016 Comments Lead 19657588 Go 1 Advanced Search - 12:54 PM Info/Updates Homeowner Information Job Information Commissions Homeowner M/M Debra Truskinoff Sate Amount $6,072.00 Balance Due: $4,072.00 Homeowner2 Product ColorPlus Fiber Cement(8%) Costs Job Site Address 42 Lexington Ave Status Sale/Material Ordered FLORENCE,MA 01062 Branch Boston North Documents Measure M 79153761 piped Measure County HAMPSHIRE Sales Homeowner Billing Address 42 Lexington Ave Commission Rate FLORENCE, MA 01062 Consultant Name Term Date Split Comp Plan Job Issues Timothy[gest 100.00%Straight Commission Labor Update Primary Phone (413)320-6813 Work Phone Ext. B-Back: No Cross Rete 1-9046137383 Siebel 0rd,.. 118858 Order Detail Cell Phone Key Dates Order Entry Work Phone 2 Sale Date 10/23/2016 FUP Date Cell Phone 2 Credit Date 10/23/2016 FPD-Customer Payments Email dtmsklacomcastnet RTP Date 10/28/2016 Post Install Date Permit¢ Cross Street Start Date 11/13/2016 FPD-Home Depot Marketing Inspection PQ Referral Store 8452-HADLEY Job Indicators Result Combo Base Store 8452-HADLEY Lead Paint:Assumed-LSWP Requir Services Lead Source 0205 SC Working Store el �.t\ Show Map \5\b� —�J Touch Points Date Time Status Corr. ,Appt.Date Appt.Time Consultant t Update Job .them Edkka M Lewis 10/31/2016 10:50 AM Material Ordered No 10/23/2016 12:30 PM Timothy Drost Work Orders 'Edkka M Lewis 1013112016 10:48 AM Order Received-PSG No 10/23/2016. 12:30 PM Timothy Drost David Richter 10/30/2016 4:15 PM Measure Complete No 10/23/2016. 12:30 PM:Timothy Drost Cythina Raglin 10t2812016 3:50 PM Released to Production No 10123,2016 12:30 PM:Timothy Drost Cythina Raglin 10/26/2016 3:47 PM Order Entry No 10/2312016 12:30 PM Timothy Drost .Timothy Drost 10/23/2016! 1:18 PM Credit Pending No 10/23/2016 12:30 PM Timothy Drost 'Timothy Drost 10/23/2016: 1:18 PM Sale Pending No 10/23/2016 12:30 PM Timothy Drost IDayend Dayend 10/22/2016 9:03 PM Sent to the Field No 10/23/2016 12:30 PM Timothy Drost ROSALYN HiNSO 1/0/212016 4:49 PM Confirmed-Customer No 1012312016, 12:30 PM;Timothy Drost 'ROSALYN HINSO 10/21/2016 4:49 PM Pre-Book No 10/23/2016. 12:30 PM'Timothy Drost ROSALYN HINSO 1012112016 4:48 PM Lead Entered No Close ( Print Oct 27 16 05:38a P.1 HOME IMPROVEMENT CONTRACT PLEASE READ THIS • Sold, Furnished and Installed by: Branch Name: New England Date:I f -7 THD At-Home Services,Inc. dibla The Home Depot M-Home Services Branch Number: 33 908 Roston Turnpike,Unit ],Shrewsbury, ]MQAIIIIII}I015i4i ig L,..._... __.....r. .. .... . ,., x _ _ ,,,.,,.„.„ .,. pai. �� .nu s,o11J:I[1 Ibl nl'lii [ Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CLSTOMER You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets) before work on that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials, Labor, expenses and services provided by The Home Depot or Authorized Service Provider through the date or termination, plus any other amounts set forth in this Agreement or allowed tinder applicable law. TIIE HOME DEPOT MAY WITHHOLD AYIOCNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer itgrets and understands [tat this Agreenwnl is the entire agreement between Customer and The Hone pepot with rey.rd.to die Products and Installation services and supersedes all prior discussions and agreements. either oral or written. relating to said Products and Installation. This Aerccnwnt cmnot be assigned or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and aaces that Customer has read,understands. voluntarily accepts the terms of and has received a copy of this Agreement Accepted Submitted by: x ,� x 1, 11A UVi �` - Customer's Signature i.,/ Ore Sales Consultant's Signature Date X �1/ TelephoneNo._ Custom 's Customer's Signature Ore Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS las applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN el)sTOMRR'S STATE. Oct 271605:38a p2 grand,office HARDIE COLOR PLUS SPEC SHEET streshee.a. C" DESCRIPTION OF WORK e cv_ _ �T IGS 7 5 v` Crctnne Hama-. •,(2A 1 ✓ZU SK(UUFE' bald.°:inn Aca,eus 1 a LfA l"eC'/l/IV Au 'aVorlOCEll rrohe et RornAi CI tAA w Blairs>w La:aam Tounpslar Locutho. FIBER CEMENT SIDING SOFFIT!FASCIAE FRIEZE BOARD'TRIM Ind afe areas b be SIDED _ 5ID1110 _ Ci¢n H t amlom V T.ono aMFATA lanNmeatas Inavaieac_ apb Hame O]w rrz n F rT. smr Finn[ L54wxNVES ES FR en cmmrcer . y R: (`0 0 Soffit &IU a V l � : �.(� -di(7.__] Suk ce ll Sierra 0 Risbui SCRION Selent _ 1 SL c0 � 4w Only-. I.� _ Sauer— BeadedOloot Stream Edge nrnoebl Frau Bid N: - V I Se tl a 5 d SIastenc Edge 1 roil Right Banc oar [I 1 I 02.? ODeO Sir IA 1eA- t AVpilie Note Max Cna CAT'(Punier(n 2 cows(Pna(Punier(to-l ads-2nd.or umr REMOVE 2"LAYER' FAR OWEMASONRY WINDOW$DOOR TRIM Indicate Tyva rimeSidgi remove TRII Yet)No C to- } on VIv PVC IF M to.):anDrlamrs Tornmn I I [ flout. CAor Let Seigle G.1 le tid Preto Orr mud..m ss.nn _ e .S.:enwn xneweov.eevnt Rfim' ] sbe 3e. ge Dom H / REMOVE&ROMSTRLL NEW ACCESSORMS How WWI TAW TAY( =r1Vents Shunted Skid � h :ye. . it: ---1_, seI P- e. Star Doan n# v aon — Edda,add ucunpex neeePa ei PORCH CEILING' v SPECIALTY WRAPS Inuiare se:euna naaar ccoin a.e S)lc 4e n'a2e _ 'COLLA' / -COLOR' Hardie Poststs Aq Bea e e Taneuar Gee sine, Oaccv:mona.rot mates-4y baa nen B2- REPLACE ROTTED V.000 twee S,acly hois.n.. Ormeramnal-Speen de rubs SPECWL CONSIDERATIONS _ A I Imvo reviewed and agree wild the job apetiOcetions @urTua above n wdl as.the Special Tenni and 6mTitiom nim Oa the m.orse ride of IM yelled.(Gummier)cop)id cob Spec ieet. If rutted wend is dl.eovered GEE remo.ing me existing skiing,or (wild met be identified at me time or tale. !Sere will be an addilionul ebage o ,Wrb Crv .F1 for Plywood and per Liu Ft.for Dimensional Lumber-See cCs Pricinoltedl Guetaner5nnrt11 SPC b � Date: rx0 as is dopy•Tie Home Dnvl Ynlaa Cop,-C.uettme 5/6/2016 2010 CSL pc jpg V .,iass acr3 _ ., - . Safety Board of B ,. ;c: ,,3ards cense CSSL-098785 IVAN KOSOBUTSKYY I 72 STAFFORD RD MONSON MA 04057 riweladvitC,&__ Expiration: Commissioner 04/27!fl1S Mips lima!.google.caNmailHlsearcrvhom%3Pmike__w_bedard%GOhomedepot can+Llaaame%3A0pg+OR+jpegaOR+pg)/154734011222a72prgector=1 1/1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Mir ,'� , q r. 1 Congress Street,Suite 100 "I\ 'rJ'. Boston,MA 02114-2017 www.mass.gav/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/ElectricianslPlnmbers Applicant Information // //// Please Print Leeibly Nitre (0ustuess/Orgmuanonfndrvidual): kerne,- e121O1— Yf 'F /j n4tt. e CQ ( {cam yv/-z:/9t� l Address: 1 /5eefs C� v City/State/Zip:- `??n.0>4,1) 4111- 11 Sys Phone#: 5 Lg U. Te' Yy,.2-- Are you an employer? Check the ap.ropriate box: Type of project(required): • 1_❑ I am a employer with 4. tg I am a general contactor and l • employees (full and/or part-time).* have hired the sub-contactors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contactors have g, ❑Demolition working for me in any capacity. employees and have workers' P 9- ❑Building addition [No workers' comp.insurance comp.insurance) corporation 5. ❑ We area corporation and its I On Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.111 Plumbing repairs or additions myself. [No workers' com right of exemption per MGL 9 ❑ y ep. I_ Roof ass insurance required.]t c. 152,§I(4),and we have no •� employees. [No workers' 13.�Otirer Of/�-�✓✓ comp.insurance required.] 'Any applicant that checks box al must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicaengthey are doing a0 work and thea hire outside ceatrveton must submit a new affidavit indicating suck )Contactors that check this box must attached an addNonal.sheet showing the name of the sub-comtacrors mad state whether or not those entl/ks have employees. If the sub-contractors have employers,they must provide their workers'comp.policy number. 7 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. //,� /� ✓ Insurance Company Name: (`(JC-w lieL iPs Aire- �./v> �D - / ^7 Policy#or Self-ins.Tic.#: yy r, O/ 65? 9:a/5; Expiation Date: - /f 1 /� 1/��4 Sob Site Address e'l /&-ivfY /i t' City/State/Zip:F p "' / / Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date) /O62- 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 da •w .e violator. Be advised that a copy of this statement may be forwarded to the Office of Investigatio. . oe DIA for ins . .p CO c••erage verification, Ido he eby certify und' the,..1 T• p- nfiojperjury that the information provided above is e and correct Sinnature- ��// 6 (��/J - Date: /1 Phone#: t10 8 C-(yG' Z 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#: i Office of COES])] ir,-1et Aff a:rs and Business Regulation IC Pair"( - Suite 5170 it AD__az,_ J3.csttcui, Massachusetts 02116 Home i::r rD've;- ent Contractor Registration Registration: 126893 Type: Supplement Card Expiration: 8/3/2018 THD AT HOME SERVICES, RICHARD TROIA 2455 PACES FERRY ROAD, H80 0-11 ATLANTA, GA 30339 Update Address and return. card. Mark reason for change. Address Renewal Employment Lost Card Oftice of O'onsnmer AI'fa frs S' Business Regala!ina License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR beloat the expiration date. ff found return to: 4,F.1:29 oir"Onsnmer Affairs and Business Regulation Registration: 126893 Typa: ,r-En . ' .i - Suite 5170 Expiration: 8/3/2018 Supplement Card siur P,a '� 'J3116 THD AT HOME SERVICES, INC. THE HOME DEPOT AT HOME SERVICES __ - RICHARD TROIA 2455 PACES FERRY ROAD, HSC i i i\TCANTA, GA 30339 — ° lladcrscc tas}' i'saaf valid without vlznrture IoecCO 'CERTIFICATE OF LIABILTY dNSURA ODATE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFRRNIATIVELY OR NEGATIVELY AMEND, c.itMID OR ALTER THE COVERAGE AFFORDED RV THE POu0IE5 BELOW_ THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTP.ACV a nmeeN THE ISSUING INSURER(S), AUTIOPIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: It the certificate balder is an ADDITIONAL.INSURED,the polioy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not corder ngms to the cerificate holder in lieu of such endorsementls). - PRODUCER CONTACT MASSE USA.INC- NAME MXnWO ALLIANCE CENTER PHONE N _yl. NC N2): J03O L&IOX ROAD.SUITE?MCO VAN ATLANTA,GA 30325 DDRESC Jrisu ftIS)AFFORDING COVERAGE 1 DWG CCSSStomaGrpilo b UP< A:Seeded Insurance Cowen, '25391 N eisceeo 4G:'FESERVICES,INC P!SURER 3:Nike American Issuances )1E53 T.dE SOME UEFOTAT-:C:IE SERVICE- INSURER c:Nen hairishire let Co 236Ii 0-L,19ERL -...5. INSUR . "11' i5falional Insurance Company 2391, LLP_GA 303SE INSURER_. i II:SUPER F: COVERAGES CERTIFICATE NUMBER- A.TLCO3]=ES:N= 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" NOP:'NTHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRH 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 SHO`VN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .ENKA �..=OF 'odOLSBi: OPCT YF I POLICY UP I I LTC - IN5DOPE POLICY NUMBER I MMJDCWYVf.InllflfDIYYTYI' LIMITS GUM EERCIALOFNEEPML LIABILITY r bLE65711+C0 03i0V2015 10310112017 IEHCH accuRRSICE 9UMWC0 :oe cccue " anal - 1.000.0CA l PREMISES ' "a SMITS CC LACY:SDJ< ? :ram .— - EXCWOED -- L. SIP SIMPER CCC I " so:' &ACVINJURY i- 9,OURG:A `HNC c-o A 'J NII,AE E'E5?�. r Gc11E?AL AGGREGATE 9400-2[0 BOG[ icCE -ii-- EHOouRS-cOMPIOP TGG I EE 9HCgffA Ocy'_... 1 5 5 AUTOMOBILE LIABILITY ✓.- --^113 0a01i2GIS .0101:2017 CU4:alnco3nicteU0T - 1E60060 1_? YC3nn • A • BODILY 15UURY(FE peson/ 1 Do:. cD —=C -]u=_n2E2 iNEURED AUTO EBY p:.1G "=Gist INJUR'rK c CanO"s .0 O MO -0M:= G PAPA:P DAMAGE G .a UMBRELLA HAS OCCUR EACH OCCURR=ENCE 1 3 .. ' EXCESS LIAR OLAVJS<.IAOE - AGGREGAT :5 • -U=9 : =—_NTICNi ' i e C WORKERS COMPENSATIONVi1COiS5192i5IADS) O3hlird!16 OPOIRGI) 'PER IOrn- I C ANC EMPLOYERS'LIABILITY STATUTEER `' w:'t 'e=.OP.=IETO P PTa=eiEXECU-Lv= �Iv I`1lCUni19217(MRK!i.!M':J I>1 030/12076 0101201701012017E_EACH ACCIDENT i= 1,000000 CEFICERMIIELEB EXCLUDED, ,04nmworym NH - 'Nla EY:C(115519215ED 03101/2016 010112017 EL DISEASE-E1 BApmYE=s 1.00000 A Y55-CRIPTION OF OPCRAnoAs aeler ICanilnuEd on Additional 235_ EL Disease.POLICY LIMIT:S 140000 DES . DESCRIPTOR OP OPERANON51 LOCATIONS/VEHICLES!ACERB 121,AtlolUuual Remahs Schedule.may De attache/HI more spam!s required! FeHecE or INSURANCE CERTIFICATE HOLDER CANCELLATION TND AT-HOME SER/CES"INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE OSA THE HOME DEPOTAT-HOMESERVICESTHE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN 21;5? CES FERP:ROAD ACCORDANCENJITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHOR/ZED REPRESENTATIVE of Marsh USA Inc. Masashi Mukheaea _1`&a uissee ? ZB—Odie s_ ©1966-2014 ACORD CORPORATION. AU eights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD /pus G.5 clAciW s< mull . WI /49A vl • II (e' -i\CL; 1 �� /S S3 13Z IP---90C r-- - I, 1 :_-__/ F R5l- 1-u L Sc.r.:aayID F-0 \ PSN Pu\N October 4, 2016 i�.,, �. -m ,� i,b�ny si,c+,o..o ��m A 01 i 1_0 O C • haw 111111111111 Arr,c. ova c 7 IC;rc14REr�Y' - 5'-o cA1).6 � -_. ' ADb Gv1-YJ\CACCA.I,I,' L �o1Sf5 — - �D 33 5t- gattiCki S�PPoaT wA�LS _. 4:b11111111 - t c 13 0 11111111r, ✓ �/ \J-LN-L. STUDS 2I'Mk\D LVL CRC$ pooaw,o\ 2'CG, - }Z,r 11 October 4, 2016--- El02