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42-122 (2) 712 WESTHAMPTON RD BP-2017-0686 GIS a: COMMONWEALTH OF MASSACHUSETTS Map:Block:42- 122 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit BP-2017-0686 ProjectJS-2017-001123 Est.Cost: $2566.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: use Group: HOME DEPOT AT HOME SERVICES 106011 Lot Size(sq.f): 33323.40 Owner: CHALMERS STEVEN M& KAREN A Zoning: Applicant: HOME DEPOT AT HOME SERVICES AT: 712 WESTHAMPTON RD Applicant Address: Phone: Insurance: 5 RIVERVIEW DR (401)935-2633 0 Workers Compensation NORTH PROVIDENCERI02904 ISSUED ON:11/17/20160:00:00 TO PERFORM THE FOLLOWING WORK STRIP & SHINGLE ROOF 4 SQRS - SHED ONLY 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: 01: 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 Occu.anc Si!nature: FeeType: Date Paid: Amount: Building 11/17/20160:00:00 $40.00 212 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 WV 16 212 Main Street Sewer/Septic Availability R0om 100 Water/ Well Availability rthampton, MA 01060 Two Sets of Structural Plans_,,,_,,, -587-1240 Fax 413-587-1272 PIoVSite Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,�7RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 •SITE INFORMATION p 0 -,q - 6' O& 1.1 Property Address: This section to be completed by office Yl.� j, y�/� 1J; kb, Map Lot Unit GS/ Zone—.......... Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2,1 Owner of Record" 021 / 7/z w fritio/ a> - Neme(Print) dne Atl &�UAn � ~ n1 _ S,graiure Teiep one4l 998 �P/ 2.2 Authoe, ed A:en 2D //2 Qo ' ear,- �1y � e(Pin Cu ant ailing Address: / /s//•- Ar ./ /.t om il6lf`/ , ,2?". Signatu - Telephone 4Ir1 SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 2"°5-0. -t i (a)Building Permit Fee 2. Electrical 1 /�([a !f C/ (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) J -[• (/) Check Number r This Section For Official Use Only Building Permit Number: Dateer _. 9 Agee • Issued: /7—A Signature: �i^'��""" �/ v - 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 Ms column to be fitted in by Budding Depanmenr Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg Square Footage .a Open Space Footage ,n (fa area minus bldg&pared parking) sad Parking Spaces Fill: (okra&toc-auoM A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW O YES (J 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 N B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES CJ IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 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 O IF YES, describe size, type and location: F, 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 Q NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check ail applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ ( Rooting Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [Cl Decks (C, Siding[C] Other(Cp Brief Des '• ion of Pr.•o ed 57k'li ml >}' `--� '� Work: / o f .f 1 ,i '-a_ • I . ittil-- ,l ColentlE'S. Attaof existingbedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes _,,,,_No Plans Attached Roti -Sheet Ba.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? L Method of heating? Fireplaces or Woodsloves 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 AGENT OR CONTRACTORAPPLIESFOR BUILDING PERMIT klin -+Znv �.! r'r`L -6 ,as Owner of the subject property R. hereby hereby authorize O- to act on my behalf,in all matters relative to work authorized by this building permit application. a C' TIzt1"fir Signature of Owner Date ,as Owner/Authorized Agent hereby declare that the statement:T d information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed u • - the ins d penalties of porn* F m � .�/21)/ lir Si nature Owner gent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supei Not Applicable El e j(1 Name of License Holder: J PAY iC " • License Number _ 742 T7)-17 ''% 17 Address Expiration Date - Signature Telephone 1161 - l 2- 9. ze•is : ed H,me Imrrovement C•- Da •r:. Not Applicable 17 Company Name —,--•y�f/J• Registration Number / . j(f^t Ad, - 1 Expiration Date Telephone / 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 o u 'ng permit. Signed Affidavit Allac d es O/ No ❑ 11. — Home Owner Exemption The Curren(exemption for"homeowners'was extended to include Owner-occupied Dwellings of one(I) or Iwo(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/shc 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. 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 acceptable to the Building Official that he/she shall be responsible for all such work performed ander the buildinn permit. As acting Construction Supervisor your presence on the job sire 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 Annotate:,you may be liable for persons) you hire to perform work for you under this permit. The undersigned"homeowner'certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General lass 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/ 1by MGL c 111 , S 150A. I Address of the work: / /ile 17 �� LA,+ 4J 16 r ixc J The debris will be transported by: 77rn'' 41: m, � IfThe debris will be received by: &7 r 2__ /n// Building permit number: Name of Permit Applicant pdp- ' 2(91#-- 113376 Date Signature of Permit Applicant Job Contacts Link Leads Ip\ Friday,November 04,2016 Comments Lead: 19669224 Go I Advanced Search -3 12:52 PM Info/Updates Homeowner Information Job Information Commissions Homeowner M/M Karen Chalmers Sale Amount $2,566.00 Balance Due: $1,925.00 Homeowner2 Product Advanced Protection System(8%) Costs Job Site Address 712 Westhampton rd Status Sale/Material Ordered Documents FLORENCE,MA 01062 Branch Boston North Measure# 79226564 Schad Measure County HAMPSHIRE Sales Homeowner Billing Address 712 Westhampton rd Commission Rate FLORENCE,MA 01062 Consultant Name Term Date Split Comp Plan Job Issues Mark Newhouse 100.00%Straight Commission Labor Update Primary Phone (413)584-9311 Work Phone (413)626-6281 Ext. B-Back: No Cross Ref* 1-9070985501 Siebel Ord... 119125 Material PO Cell Phone Key Dates Work Phone 2 Sale Date 10/27/2016 FUP Date Order Detail Cell Phone 2 Credit Date 10/27/2016 FPD-Customer Order Entry Email kapc1027@aol.com RTP Date 10/28/2016 Post Install Date Cross Street Start Date 11/6/2016 FPD-Home Depot Payments Inspection Marketing Permits Referral Store 8452-HADLEY Job Indicators PO Base Store 8452-HADLEY Lead Paint: No Test-LSWP Not Req Lead Source 0080 Store Associate-OLS Result Combo \k \ \" Services �1 V\ Show Mao Touch Po nts User. _. Date Time Status '.Cam. Appt.Date Appt.Time Consultant1 Jermaine King 10/31/2016 2.38 PM Material Ordered No 10/27/2016 3:00 PM Mark Newhouse Update Job '',Jermaine King 10/31/2016 2:32 PM Order Received-PSG No ID/27I2016 3:00 PM Mark Newhouse Work Orders David Richter 10/28/2016 2:48 PM Measure Complete No 10/27/2016 3:00 PM Mark Newhouse Cythina Raglin 10/28/2016 1-13 PM Released to Production No 10/27/2016 3:00 PM,Mark Newhouse Cythina Raglin 10/28/2016 1:06 PM Order Entry No 10/27/2016- 3:00 PM Mark Newhouse Kenyatta Jarrett 10/27/2016 4:14 PM Credit Pending No 10/27/2016 3:00 PM Mark Newhouse Kenyatta Jarrett 10/27/2016 4:14 PM Sale Pending No 10/27/2016 3:00 PM Mark Newhouse Dayend Dayend 10/26/2016' 9:09 PM Sent to the Field No 10/27/2016 3:00 PM Mark Newhouse Sheneetah Chisel 10/26/20161 5:59 PM Confirmed-Customer No 10/27/2016 3:00 PM Mark Newhouse Sheneetah Chisel 10/26/20161 5:59 PM Pre-Book No 10127/2016 3:00 PM Mark Newhouse _ Internet Lead 10/26/2016- 2:41 PM Lead Entered No Close I Print I • HOME IMPROVEMENT CONTRACT! PLEASE READ TELE l Sold,Famished and Installed by: Branch Name:Boston North*South Daae;`.{_.)_ 9'tiDAl-Home Servicer.Inc. d/bia The Home Depot At-Home.Sesrires Brnnrh Number:31 and 33 90S Banton Turnpike,Unit 1.Shrewsbury,MA 0154$ Tull Wes 877-$03-3768 Federal ma 75-}:698460:M£Lir p C 02439:Maw l..id POT WOW- y r1 CT lac a MC.0565522:MA Home lmprovelnenl Convector Rm.11 12693 Installation Address: Citl� "'._^ .c ""`v FIb R.�c..5tate ZIP Putthwerale /� Werk Pine: Hca nem: Ceit intone: ll....w.� t�Mr0.{ WkPl I 1:411.9 seed-13 jjE ' LE 3 Hone Address: RF different from lnstaikdflw AdMew)..... City State Zip Femail Addres(to receive project communications and Home Depot update,.): ❑1 DO NOT with to receive any matketing mails from The Home Depot (fit intxmaa�: Undersigacd("Customer).the Owners of the proper)located at the alone immanence'Mama%egteee to toy, anrHD At-Home Sctsices.Inc.(-The Home Depot)arms to furnish.deliver and arrange for the installation Cinstallatm+'-)of all materials described or Ino below end cm the referenced Spec Slteet(x), all of which aro Incorporated into this Contact by this reference.atm;with any applicable State Supplement and Payment Summary attached hereto and any Change Orders loollecbvely. 'Crntract): Job a, aaraa v.m..ao &gbM+f time SM1lMis)a: Project Annum raang OSwne U WIndos L1 Iormanrc ��pp { Jo zy ] fGnlmra/Comes Ohm"Dom D_ 3V1 2t' $ 2 � URr ling Uridine U Windows U lnwlatlon (Janos/Covcm DEnay Dons 0.. plater ng OSiltltlg U Window. LI mmhl,on ... $ , Demon Covera DEnay[rase 0 I DRaofinP liSitling D Windows LI inrulantm 1 5 CGudca/Cowen DEnay Dern ❑ Mmmnm 25%°mart of Contract Ameetit wpm emrnim ids oumt Total Contract Amount $ MtieeMmehasn may notchpose euaethenor tlIN cif the CAtad,Awmn Costumer agss that,immedimely Upon co nplatim of the work Mr each DMun.Ce4 mer well execute a C..rytttlon Cert Mate (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable. each Customer under this Contract agrees to he jointly and severally obligated and liable hereunder The Home Dees reaerses the fight to issue a Change Order or terminate thisCortuact or any individual Products)included herein,at- its :its discretion,if The Homo Depot or its authorized service provider determines that It cannot perform its obligations due to a structural problem with the home.environmental hazards such as mold,asbmon or lead paint,other safety concerns.pricing error,or because work required to complete WC}ab was not included in theCan at -r' Payment Slmmarv: The Payment,Summary s Cad 8 rO 1..._ included as part of this Contract. sets Forth the total Coma<amount and paym ed required for doe derma and fihai payment by Product(afapplicable% NOTICE TO CUSTOMER You are entitled to a completer filled-in copy of the Contract at the time you tlgn Do net sign a Completion Certificate(note: there is one CsmpkHion Certificate I'm each hated Product as defined hp individual Spec Mints)before work on Mat Product ys complete. In the event of termination of this Contract,Cmlomer agrees to pay The Home Depot the casts of materials,labor,expenses ado Ferviws pruaided by The Home DepM or.Authorized Service Provider timougft the date M terminatim,pts any ether amount ser forth in this Agreement or allowed ander applicable taw, THE HOME Dn Eit MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE. Wyman LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorisation: Certllnler agrees and underneath that this Agreement a me entire agreement between CYSMmer and The Home Depot with rested to the Ralucte and Installation services and.supersedes all prior dismsnma and agrmnentS.either oral or wrttea,relating to said Deducts and InSmllatim.This agreement Cannot he assigned or amended except by a writing signed I, Custzm and received Hoac Doore this Agreement and agars that Oitanner hat read teldersands.rolunta9ly accepts me py Aced p SubmifJ X aKnEPAa St lO z7-7.�C Ix J IP-7.7 Cm ets Signature Date / Sal-s .o 'submit's Signature Date X ITelephone Na_ d '5E.36 636 Cuuomc'x Signature Dare ' Salm Consultant License No. CANCELLATION CUSTOMER MAY CANCEL THIS ,o.onrn,arrr�- AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MDWNIGHT ON THE THIRD SU$IMSS DAY ATTER SIGNING THIS AGREEMENT THEj STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM' TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:MINTIoNAL TERMS MOD CONDITIONS AIM Slated OS THE RUNTIME Sn1FAFn ARE PART Or THIS CC:Teary 0347-15 White-Ranch Flue yellow-Curlomp ` Oanm. 2 ROOFING SPEC SHEET Spec amen 444,1�}0 &arxn# DESCRIPTION OF WORK Jab Ty}jy yifml (....C1 4 `I` Home PMnep I- I J3J�.� 4 CVSIo:T9r Nam l �L ��/�\n�•��V��•�"� Cop Phone N:j �1 +P ^" �- i WPM Phone MITT I Jan Adtlresa', ••[yLC&p D IDi,2- E rep Address. cin Blom Aoc:mk OUmpitC!/t Hr'lagadn' Mr-<+ ASPHALT'SHINGLE METAL ROOPINO SPECIALTY PING Bran Vra's"nt Metal Panne Hat oiling GAF TM/bed/HS HD L • �— GAF Royal Sovereign Concealed Fastener J1 EPDM-BO mil _ GAF Exposed Fastener TPO-60 ma Atlas Pinnacle HP . Thant SBS 2.Piy Modified Bitumen t Atfas alas-Waster caw. AflMJ _ _ KO Cambridge MI Dern Mehl Shingles' Law Slope MAIMS !KO ( "Nl$fathpnBraml: I, I F-� L { f •Specrar wtler Shingle XD 1--- 1 I Colon roam �I'�) 4..`�(//�1 Epec r0Marl Shake ED Caranr`4 riP"Y a' 4mBs Vlua The I 1 _ TN RMRng Poyang -'-�n-T1 r'-°w-1r a'" Nm*' 'Nps System' � I r^ t r Cdnn Odor ASPHALT SHINGLE METAL ROOFING SPECIALTY ROOFING step d ChimnCy Ri0.me'ProIIIII Roof Wall Termination Norr lmemer Drain I l Counter )))I Skylight S eveaake Trim l(—� Slope Change Parapet Coping/Metal� PIPS Packsts1 I Base I_ I Drip Edge IMOChimneyChimney _I Moral Grlp EdgeI I rim soma _tel Tile Pan Fleshing Voile yll Skylight Scuppers) 1 Gnarmt Can L„__ Tia Head PlasNng l II Color + I ' Avila r`/-t Tar A arival1 OSB Recovery Ed Wood Shkgre 11 ll ^MnaSM Gravel SAM L 1 '2'CM ISO Baaral adnnx.+mww.wm aa T'4 oti_au^. -/ -ex Pam Parma berm L4' I ("PAIN r.Pant rod ODX. Plank, m wa: imake ExMVst Eiteigh% Nkr4kneous SOH Vem I Ridge vent 1 Sim r} Mot/ wrrtea Cachet vented Drip Edge ,r w Turtrre VWI i Add.Stones _ Color Low RASPI Pear Aroma Dormer Vent INN MOM Chuyp _. I cap L_.. �� Repko.False LT KA Y mown . month lie...Parr mn+rmnm+.nvMr+n..ntnn �t��r PPMv L 1'E�� mirk .a,t pirw nn, .s Iamm•n'�,,.atim ra-1 w.a>rommr. Ceram oepra 11.11 • wnagq tn- wristarngatiI 1 ��.. .- ...—.. ...- If m - ...—_.� Ir. ar demngea wrioSlarcorroren AFTER rearming fie mating roofing,or come nOt a¢id nhsomIhe rime of aisle. Awe mil he an oedipal arann ads e'rl, per=toot of 4B aneartir arum S_ ___qW Srew nOt ydiment AI kUnhM:feEi pint.knn 'if ehFNnel Limits of mane are dl&c,wed ALTER WINK NV Ant layer orot.Ad mi Ca 4gnaned at time cars. ��--yyCJton o,Oe Peen xktianl Hwy Puren yR4cl tone removed. F. an,rar dermamor rAmil .E._ rim Tv al*enols am S ..._con.*anew Anarma'lrrd filmy re*M1+c are aarae won Melrh c gar%dreeatted NICHT And Km re :mena me Pia Thenpa.gIT,''�m ndeo4: µ ^ "`' `/of rte yroaw TGn:anµrl ecru d MieSparr'Sr.,r Luanne.'slflneNre: }C '�/y(/raAOr. r �Jf' Q,�/jf�v� ./�army Onto: ID-7V-le..I L •••••• ( WMo-Tq Wme Oepc1;Yelk .Oaramr Tin.] Off dr1(lairs h 1.11AintA,R JnG„n license or registration valid for indaidul use onk HOME IMPROVEMENT CONTRACTOR before the ex piratinn date. If found return to: Registration:' ,9.71E Type: Office of Consumer Affair.and Business Regulation Expiration: 3! 22017 Corpora: III Pari: I'Inia-Slate SI TO Boston, MA (12I lb GOLDEN GROUP CONSTRUCTION CORP FREDDY CAMPOVERDE 20 TATTAN FARM RD. VVCRCES ER. MA 01625 I HMI.mrririm Not salid/About_ move 49. rfts CSSL-106011 FREDDY CAMPON'ERDE 20 TA I TAN FARM ROAD Worcester MA 01605 `XL^ - - 06102/2017 UCSattDiego 1 Extension American ercan:norvu snrciEeoo-a,an u:SRLO-r 140 Suretycouncil FREDDY CA:MPOVERDE -- - 03/01/'0!"3 —_. . y- -- - --- • - Scott MacKay ylcrs yrs IMMIDD/MYY AC S C R T kIICATE OF LIABILITY INSURANCE I 02n o 5 " I THIS CEER1FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS 110 RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, TEND OR ALTER THE COVERAGE AFFORDED RY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(SI, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the cer uicate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subicct to I the terms and conditions of the policy,certain policies they require an endorsement A statement on this certificate does not confer rights to the I certificate holder in lieu of such endorsement(s). -. PRODUCER CONTACT N3]Sn USA.PIC. NAME: PMDALjANCE CENTER eNE Fax WeF No=_xg Tac nm: ]555 LENOX ROAD.SUITE?dW - L ATLANTA.GA j0.326 ADDRESS[ INSURER(*)AFFORDING COVERAGE I MAIM IC049 men__"I, D msup-AR A:Sleallasi Insurance Company 125381 INSURED • NSRE bnch ArenMn Insurance Go 11535 :DATSSERVICES,INC. ,OMEE°OATD,C TEALS moos,C:Nap Nampo:ma ins CO 1231347550 DUXI53LAND PORIV'P.EUE9 _ A14NS:=.,GA 'x0339 INSURER D:Illinois tlafoni Insurance Company !nen INSURER E: I INSURER F: I COVERAGES CERTIFICATE NUMBER: A220374ES4N1 REVISION NUMBER-0 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED MOVE 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 NUT PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOPS MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE U IADDLEry93: ! OUCYFF I POUCYEXP ! E e POLICY NUMBER •n.C1VDD/YWYI.MM:JDDM'N0. MMS coM iERCIALOEINERALUaelui -Gmosis 11:;C0OSiO1Z015 `OVDii2Ofl i zacnoecURRENe` 9 o L - ...00T C_CP :PREMIS• ES � -nce CERIMMIC 1.000,01)D Cr,TSPDOCNs • Eu ., -.. FxauOED OF SIR ataP R CCC =PWNAL a AD,/wURY S 9,000,01 DEN-L AGGREGATE UHF?PPLI5$?3. C=_NE_MULaGGREGATE ,s e,000.0O3 1 mots ct p2ouuGe WVPIOP AGO 3 9,OCD ,CW OTHER: S AUTOMOBILE LIABILITY CFR-Tissoxua .02411i2016 101R:2017 COM9!NEOSING_WHIT S 1.LTE000 =a ome YG a ROOMY INJURY U a) OD..Cliff,I :m ) 5AuD_ INSURED AUTO .Y DC.0 uTCRO - _ HIRED AUTOS CH EO O P�Y=AGE a UMBRELLA JAR OCCUR • EACH OCCURRENCE ueoa LIAR „_L.p..l..v= AGGREGA ;5 ' DEC - Er Nn@ s - C T WORKERS COMPENSATION - CO 192 5(AOS) .O3,Dnn201b 031012017 X 'PER ) , . C ND EMPLOYERS'Uneu IN- _ EACH AC ER ' .oP=1 O a R N_Cu NIS- L JCO 19211IAK R^a NNA VT) 0Sm12015 A1m2011 a 1,CC0.000 0. C R.I A m ExCLUD=D'+ I1: E GCHSCCIDE`t" D Juwndamyln NHl - h1C015a1521d1r_) _031Oti20t5 0101/201/ EL SOMME-Ea EaPLOYESS 1pMOC-0 = _MPTION OF CT RATION Sere, '.Conilnuml on a'LCihoTe1.Fen - EL DISEASE-POLICY LIMIT 5 1,000,01 • r DESCRIPCONO ERATONSI TOCP S IVENICLES IAAdditional Remarks Schedule,may ba attatherll more space is nqulred) III EYIO3IC'c OF INSURANCE I CERTIFICATE HOLDER CANCELLATION I ' THD AT-HOMESERIFCI M.INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I DEA THE HOME DEPOTAT-ROME 3ERHCE'a THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN I 2i55 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. _TXIITA,GA 20339 I AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjea -.1`4'n.,I.n.al.L JY - ©1988-2814 ACORD CORPORATION. All rights reserved. ACORD 25(201401) The ACORD name and logo are registered marks of ACORD Office of Cotaufaer Affairs rs and Business Regulation . ' P.a_ �. 1 ;az{ - Suite 5170 v ;Dsto n, Massachusetts 02116 Rome iimiaci 7enter,t Contractor Registration Registration: 126893 Type: Supplement Card Expiration: 8/3/2018 THD AT HOME SERVICES, INC. RICHARD TROIA 2455 PACES FERRY ROAD, HSC (3 -11 ATLANTA, GA 30339 Update Address and return card. Mark reason for change. Address Renewal Employment I Lost Card Office of Consumer Affairs& Business Relmfalion ilAC2 ase Or registcdion valid for individual use only HOME IMPROVEMENT CONTRACTOR Par#'ori the expiration date. If found return to: 11Mer of Consumer Amiics and Business Regulation Registration: 126893 T : ➢.dM1 :'u.i:.Fk:2.1 -Suitr 51743 Expiration: 8/3/2018 Supplement Card s;crr t?- °112116 THD AT HOME SERVICES, INC. THE HOME DEPOT AT HOME SERVICES - RICHARD TROIA 2455 PACES FERRY ROAD, HSC 11TrANTA, GA 30339 UmIcarcretsry Tari salad without ";,-S3atnre The Commonwealth of Massachusetts 1.--4___ Department of Industrial Accidents 174,°•x• Office of Investigations tut 1 Congress Street,Suite 100 ow • �=.' Boston,MA 02114-2017 www.mass-gov/dia - Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 /� �/ / Please Print Leeibly Name(flusinessWOrginieafon/lndtvidual): /Jul/f e. .v01-- 4 !- /l,mt. �.1—tei Cs Address: qc 9 (3044{47) �(�UrTipr&_ City/State/Zip:, t't)S6 0/5115- Phone#: 552 fl. & 7Y Are you an employer? Check the a ropnate box: Type of project(required): 1.0 I am a employer with 4. VI I am a general corrector and 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2-❑ I am a sole proprietor or partner- listed on the attached sheet- 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp.insurance) required.] 5. 5 We re a corporation and its 30.0 Electrical repairs or additions 3.n I am a homeowner doing all work officers have exercised their 11�.❑_�PPlumbing repairs or additions myself. [Pio workers' comp. right of exemption per MGL 12.IJi$of repass insurance required]t c. 152, §I(4),and we have no �� r employees. No workers' 13.0 Other comp.insurance required] 'Any applicant Thar checks box Yl must also fill out thc sconce below showing[hair workers'compensation policy information. I Homeowners who submit this affidavit indicating they an doing all work and then hire outside contractors must submit new affidavit indicating suck tContractors that check this hon must attached an additional sheet showing the name of the snh-contractors sod set whether or mot those endtirs have employees. If the sub-contractors have employees,they mast provide Meir workers comp.policy number. I am an employer that is providing workers'compensation brsurancefor my employees. Below is the policy and Job site information. �,�, . Insurance Company Name: A/P.id f1Lt'in{q s ALi "t% LZ:"-A).5 . L-� • - • r • Policy#or Self-ins.Lie.#: A e 60 ✓z/S Expiration Date: 3 // // / nt- Job Site Address: i - %3 tit rty/Smta/Zip: fri 1�/�� Attach a copy of the workers'compensation policy dee ration page(showing the policy number and erpirafion date). [ Failure to secure coverage as required under Section 25A of MOL 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 m the form of a STOP WORK ORDER and a fore 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 i a e. ce coverageIverification. I do here a, certify ndo he ns an . a t,•of perjury that the information provided above is true and/correct Simature: 4 �(y/ i/f// n/24,—V3..---: Date: 1 ) — / x/17 Phone#: So g L-'F 6 Z Official use only. Do not write Ur this area,to be completed fry city or town officiaL City or Town: Permit/License# ISI Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4, Electrical Inspector 5.Plumbing Inspector 6.Other - ContactPerson: Phone#: