Loading...
HomeMy WebLinkAboutBuilding Permit # 4/22/2016 IJILDING P �t�F-E o IT No o� ,b TO OF NORTH ANDOVER /y :;,'• APPLICATION FOR PLAN EXAMINATION l-�' o m• o - LAK � ,,>" � Permit No#: �b�� ' Date Received '�Rp°ggreo PPS y C`� gSSACF0U5�'. Date Issued: IMPORTANT Applicant must complete all items on this page , r r c ':�i ✓ rr >rr' }. ( ,rs.:e✓r .-6 ✓. afr 7.. p•...:r ,f'rt` rr' ,.?j" S� 3. t rx /.r`F rrr` .:,'. .,f lr a,- t-.:.,f z.-.:. 1k' /. E'.:}-/f I /f.l: "-✓. 'k.v:: r,:et`r,/�,+ ef.. .'.;1f�.-a' /.. s ! .. r r %* r rr'k'rCr= ,!. ,� ..0 /:f r' .� .filf 3 c >-•� <.. Yr' '`'' ... �sr�r .r.f�`�/,'` ,=" r ,;' r r. r`ltia ✓. 7 .,f ,7r t. r r IF .../r ,a r .:r k I',, r,! <:M+rr' r..:>C / 5t r ,r,r, .� �.,� ,., it< ✓.,.m,.., m r> 7"! rr',f .f'"r� :.:o r �, .W 6 r.. r ,.; cr waJ :,r':,-�.�. rl.+fr,?r R t�,r,�t�r/ b r"F?' ,. r✓ F�. ;^ ,> ✓ 4 �: s..rr... /:s 1Y / -.} !' r ./ ;�, ., Sri` �-r ....,:� r✓� �Y£z/r,. i 1 Y �n' r.. .-.r,-.rr ;£., S.'c .J f' �f,:'.rsr r. rr-.,.:.,.� r 1: :. .f�;'_ �k;�'' :..,:,/,r,..r .:S✓„ � ��dA. . h ,l.af,,�v, t x ,,i frr.,rrt ..�,,.. ., � I ..'J r .. a� r..r � /:rr:Fr f.. ,qs�(:t n rr/ m -:-.,"; /Ir. ,�,�' /., L�,&.?r' �f fr?�.f i Fvx ..r'r _.s -s�Ilf er,r;rrr, x�,r„ :; .r ,�v.,s✓' .��r'u�`„k rl:5.,r✓1�,�.�w .>� :�>, r ..> • r� ,,�.c.�5,!w x.. .w'., G:c.��r .. „ .: cwt* r F, ..o-c�.j .... .r.. 1 .'s.r` r� r:. / ra r :� a..fy.,,r ..r,r�r.a rF``,. .„...�,� r A r... r ����';s���t�>�yY.r%�; rl l.r fk}y'. J,,s r ✓4� .f r/,. -f " � +%,J .:y,k,2 ;:? saxr',�> yr> .sr v .,�..Ir r��F. r �T9'"• u a .r .fir ,2=y:,},a rrr 'F f n -j! c< 'r,H ..,k,r: f,_..�' d' � ,!,�:ai'?;d�✓'.+r,„•-`}�a /e..:,a`ff F ,f�,,: :�',�,�':"~r` 2'� .'fi`nr '.�.;f".. 5ti �� �� `.,^,�3:,sr�>r r ,�`;,:`j� .ad/r�� �me ..sv. .. 'Pa,�>a'.ke�,�,rf,✓L. !`7,r,{i,7„!//Lm�;ra;Hr.a,. �',rr�:.+-,�",l�,:fi"&s.v rrr'_�1}�'„r ,tom`� '� f rit 9f';. ,.",;. - d. *�,,:: ,;1;.. .. ., .,. -, ,,,,. , ..:,>: ;, .., s:r rfr r r s .TTrJ. v,x'.f.,.s`1,,, rt, r �� y,.c ,..,✓r l r r' :,,„ .- ,,,f k>. r!�? r, ✓'fir a:�`''" .> P r!'d ,r:t.rP`'.x"' ,.,: .,., �x„a (l r J r. m r .,'.�i`r`� ,1 5.,rr,'.a'!. lr:k'3� �?' �-�- /tr'�?..„� fa t .:r,.:.-: ., .��1..rt. <.� �`5. ;rnY.,. �'. / rPn t:�'{�.yk,"r i .kT� r. „�/r i✓.ra'�� P .,✓ � rr, �... r r ,� i*'rr�.,� s�n���,�,�'�:a'�`a:,r:• .r:r9 ;r�.y. �s..-, r � w,.�r. ,r;».,-.r/ -,,.J s _.,,,arr:_r ...,rs'" //.,'r •,„,„�.. x r .,Jz> I. �:� �''.t r a r ���� r� ,��� � err?`, .(.a ,,t�r�� � fir% �✓ 'e:,s�rf,cd':�"aw k � �, d,r, r� a��r � .�arrr �:r .,<J�r«�r/ r,.. � ,'•�sTP,:, 9R, i.:;,�a 7l�. ru ir"�a�#ff?� c ,f".r��,c,:,"��' .dr'r�, �R' vz 'o'�rk„ r1 '/J �G��,„*>�r/r"v%r F ..,, a �r- . r✓ rr�y r F a�;;.�ararxr"',>:a•'£ 'rarr J� .,J�r,�r( .�"r�� d ' .2r�'.:J�'v �`a. rJfxrrr f""�r ,r. ' r"✓'r'rrl,. r '�"? J ! ,,f'.y / rf,, ,mr. ..,P rr^a k' f r! r rw,', hy. (.. �i''a�✓.!?Lr � � >�. � y� OO��ear�8fr�ctu e<,�; �✓ Rr(nt� xr r r rx, 9 � . � � r Y� ��' ..zr�,ra.r r �i"`,v ,r sr r.r,,:.:.J r rr ✓ r�� r -� ,.r r rrr`a,r: r ter. r r.�;,y - ,rr'a, ,r�, .✓.. .,.�r.° �r� �'Y'- z ..e. N,>`,r-.rr•'r��''!'; x....,✓`s r.,�.,.,,fk :,u r rrr....,! ani .r n zralr �c :%�, r -✓es�' ..F!,-,h:>t. u� „e,r tar's, ,zi i�, }r a�u.�F b� ,�. k`/r! xHr a �r,r. ,y<;�..�f ✓Jf. a rr�lxrk � Po-1 f9:?� �i�'tfbl}� .� ��. � ,, ,za�✓ PARCEL r r��,:.v ;� ,; ZONING DISTRICT ! ��� r: r;,r� �1 r�r n 1��7�.r rr !r M/�7��ra �l", f f P r � re2F F r a � v f c r r/i / r r �'rr/t y r r'r', ra,s r t �f 1 ¢✓$r5� ,r r frr x f a i �/ r r r { n r / Machine Shoff�Village U yesno TYPE OF IMPROVEMENT PROPOSED USE Reside ial Non- Residential ❑ New Building - ne family 11 Addition 11 Two ormorefamily 11 Industrial ❑ eration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other --I fr r ry S t.c: Cf 1/Vellr ! ` rr` > ' ❑ Flood' larn r' �Wetlands �, r ' ,`/❑ U1/atershed Qstrrct �..❑. p�.rr fa- t�... ..r: r r pr ✓ '/ cr "r v f �1 M� v � r�(rr. 9,'/ r%G/,,r" 1r.,,,r' a. ar�rr� '?'Yr✓- t r /:.- r, .:. r. r .l-, ,.. � T .'a£ .:✓l' /' / r'. fr?f :k�✓ c r�,r'� � ,> / r it r.r /r+ / r' y rr t` :b a!/:"'S`z Wit/ ,> t yr r�'tf�1/r✓...1 `h it r ✓;„ RIPTION OF WOR BEP FOR Id tificatio leasea or Print Clearly OWNER: Name: T� Phone. n c, Address: Y`r �.rr r y:. ✓s Y r ✓ ✓t r r r -r krJ(If ,r rr r r/ /rr rryy ✓crf/ ,,; rir/rt r.Ye. .^,G✓,,' .f .F Frk.7irr'r}r/ nG" ,k:. 9lr":,. s/{ : s ✓ ✓ Y !r h, z ,.s ..sur r,f �'!�, c r �,'•.. �} r,y: I ,, x 'r r r .f;J�'rti�a ft f ,a r✓i.jr a�� xr+ 7'srye //r r a r, t r/�' .r 3 r ,s ",, y 1' S u- ! a-. r ✓ r rr � a`r �:�r >x`r Fj�•{s��7�`✓'�rlr f 7 nirt f�rf1 ��r;, } "i r r/ � ;> //"/ ,e. },r,, r ✓ rn ! r E/� .r fr'-yr �i�(,r r'l/xr r �*�a ..y+rr t'jf+"�r:rf f/ f / ::r /` r/;. r••a;,- /j x ! ,r J`c"C'r' arf,f :r rrr t f., r .f,_,:. : ,..-s ..:. �.er,`,, Ir..,.,'.... ,>.. / :�✓ r r ""r✓' ,r.>,,"rl S tiY--c r!/..r. � r r-.:„r...c. , ���x�d�S � !ate �" prrFJ�/1�.u/s,✓,}t,�, ,x r r ,.r f :..i 'af a:�r✓1 :£,r/s"..rr 'i3r rfr_ v / rr rfitralr ,r..mr M> �� "?l� u r s �k�"/ r c'/ a:�e�r i 7 r rr ✓`r�Y{ z ,, : y ', ri-irk' a4r��k.�i i .r :av s !. r i ay c�r,^ 5:Pix Jr ;�,?rr1 r" Yy.rc(r.9" s'' tr? J r cr.r'. y 's r`/✓r:, r..y 1 ys reM ra✓ rr �7% s r ✓ I E f r Iz r ✓ rt`7a'� r J Is �r"'r 6' r' !yr,, r r "' Yl.r�.� �, r�?� s....,� r� j'':.c r �U :.I r ,'Y"s ': r/ d %-r.r x' �!r/ Y. ff .ati �".,r„� k:•s4„ >x'r /. �f��r` r ,�`�fr''"''`,'�,:. Y r ✓ ;1 r.; ��/ r:,. / r.: yr!`r .:/r ar fY Y`r,: rr � .x.� ,�- F r r w,"•=� J :.. .r k'!� �;�` / u r rs,' Pi .� y:w:r.tx rr,s,,,.rr.- 7 lr.:::ter ( .f-/ I.r i.Frf r!✓!.F ,,, ,,.� a, :�,.>a -'Pi,�,✓ y,.r'.. s.,. ..»ii`v>, r .a u. ra'rJ,/f."//'.. ,.�v,}.r rf 1-. .a.".f 3.:- t r ..c';rr°✓r'`r�(�/,✓� � ,l If-"£ :fir!ik ;Y, ,f,"`r;''�i�^r rr,,3 rlr,s,,",7�r �rr "�r'�zy� r°�£ r � 4di',�a°"Y yrfr :s ztr ;2 Lr r: �a P / G j✓,�. ,u`�'��`�'�, Nta',� a�a. �S�J dJ I �,. s; e. azr'%✓'>. atfil;� s v r' .-,:Y ;�v'�,'^�'`t u.� �,.e�.r`„T,a J`ru^rr..:��z.`rJar �'%.�Y,?r`; ,s r~l u t ::fir s'�r£r�, r :rr.,. ��� �,;`.�" `��r r%�x.zr<t%; 7N' ..,'r aq:«r` rr ✓;�W „ �,� tr`' . " �". 2" a9.,�,L '�: :� c �3 +adl�a rrr 4..A.. r, J/ar✓r �..,.r �"u, ."i-':'rr,k,, g' ,;�' 1�`>",r',P r;�x ,� ,�: rs 7-^:d".r' a a?`r z .H✓ �r ri'r x P'�..r.r"a`r✓f. r ,rr s..� fvr rr „ , M.rri• ,>�" F11,10 !rte Y r /r�'fa � f ✓.., ��,. ...�:'".�„� -,...�- „�' �,�� �. J�-�.,frar r} ,n .�r ri"....r ✓ a. 5rlr r7/ �.FF .✓ u" �".: ., r 1 ��sad;rrt Lk,1�3/���r"a'�/.�^(: z�':.�:a •fir°. -rr^�.9' „i.,,"„ v 2.s :.x_7r u r nr-:r rF �r'�".r/ ,q �v .:rrr ,rea,c.4r,.i;;; �,2. ,<,,. ,�,,., ,-": .,,. rrl :rr,rs ,.. r.:.7.,.. f.?.1 r;cu�" :{".:..'"`r#' z•.` ..J/r'J .,s 1r 1,.Y� rvr,/f+>err'��2•.r%''''rr ��rir,:"��.r�r�'j,'-�:''rr,J- .�.r•�„ ,?.P. a .v'` ..T'74`:. .,.,y r. ,^ �,.'� ^�a ,-.,.,..: ,,� n. .:.•,/'..�fr,`.�rf' } rj' � , ,:'a=�.-=fir �r,�.m !d ,,.-r,. .ur'�r rrr/N'Yf k r �%d„•,�., vii..s.. �� ,.. ��`„rd��o�,.�,�.arr.�;-':` 2�Rr"L ,%''.G�r! /f'.';ri,:.r r,��,,� r ,':.;t/,r m rrr:x~'rY ra 'a: "� 'z�'�'u`'F,x �,ryo a .✓r _ rJ ,9/ �/!�'.<,:�>�� fr J' N'��..da a^� r, �� , ".,. ;. , ' `�rr✓,`�,Y,r;~a�"v, �r-`'£' ._;;ktr}'� :'f i��t,%i.j rG `i":�X 5}:tDate�..rt,,4ra�• v - r.r , fria„��., ,,,;r�a.',•av� rres/.ri ax4•td rte,€-ias's:�.,..Un,.,,a: r✓1,;,,arl„ rr.,:c yr_ _ ._,_r-.x,J r„e Ue„o,..,..,` :.,,� 2 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ � . Check No.: , 5 / 7 . Receipt No.: 30 -7 1,9 NOTE: Persons contracting with unregistered contractors do not have access he gu an fund 5i` mature of iA ent/Qwner ?� Si nature of contrac °, F to ORTI, IL Ouwn olEAlluluveir �.-.�•• 'y'• ' 191 ® ® �( 6O . _ LAME h •, ver, ass, Da ac COC mc"tw,CK ORATED S U BOARD OF HEALTH P �FM� RMIT �1 L 1) Food/Kitchen Septic System THIS CERTIFIES THAT ,,.....,..,, BUILDING INSPECTOR ...... D. ..1..�.�..1:�....... .I�?.:vc.................................................. has permission to erect .......................... buildings on ....: Q..Q....�.�t�r.'.n. �. �..... ................. Foundation °u e g to be occupied as ..�—..1. :9.. ....V.;.yl... . . .�SQ �rS. .,a. .................. Ch�'mn y provided that the person accepting this permit shal in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES I 6 MONTHS ELECTRICAL INSPECTOR T S Rough ............. Service ........... .... .. ... .... ... ...:: ................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Displayin a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Oulu,rutusueu auu rusiaucu Dy: Branch Dame:Ise+v England Date: 1 THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services Branch Number: 31 908 Boston Turnpike, Unit 1,Shrewsbury, IIIA 01545 Toll Free 877-903-3768 Federal ID# 75-2698460;ME Lie#C 02439;RI Cont.Lac#16427 Cr Lic#II1C.056552?;MA Home Improvement Contractor Reg.# 126893 Installation Address: I C. V� I J/N-1VI _ , f� C4 State Zip Purchaser(s): Work Phone: Nome Phone: Celt Phone: JNO Houle Address: `_. /1A"� C (If different from Installation Address) City State Zip E-m ' Address(to receive project communications and Home Depot updates): I DO NOT kvish to receive any marketing entails from The Hrnne Depot C Pruiect Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and THD At-Home.Services, Inc. ("The Horne Depot") agrees to furnish, deliver and arrange for the installation ("Installation") of all materials described on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contract by this reference, along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively, "Contract"): .lob#: (Int—i liefi—n o) Products: Spec Sheet(s)#: Project Arttount ❑Roofing . din,I Windows ❑ Insulation ❑GnttCl-S/Coveys []EntryDoors ❑ (` ❑Rooting ❑Siding ❑Windows ❑ Insulation ❑Goners/Covers ❑Entry Doors ❑ ❑Roofing ❑Siding ❑Windows ❑ Insulation ❑Guttels/Covers ❑Entry Doors❑__, ❑Rooting ❑Siding ❑Windows ❑Lrasulation -- ❑Gutters/Covers ❑Entry Doors ❑ $ Minimum 25%Deposit of Contract Amount due upon execution of this contract. Total Contract Amount Maine Purchasers may not deposit more than one-third of the Contract Amount. 1 +7 41 Customer agrees that, immediately upon completion of the work for each Product, Customer will execute a Completion Certificate (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 be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at its discretion,if The Horne 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, asbestos or lead paint, other safety concerns, pricing errors or because work required to complete the job was not included in the Contract. Payment StniLmary� The Payment Summary # r included as part of this Contract, sets forth the total C01uu!1Ct amount and payments required for the depos is and final payments by Product(as applicable). NOTICE.TO CUSTOMER You are entitled to as completely fillets-in copy of the Contract at the time yon 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. Its the event of termination of this Contract, Customer agrees to pay The Home Depot the costs of materials, labor, expenses a rut services provided by The Home Depot or Authorized Service Provider through the date of termianatiom, plus an- otiat°r amounts,scat forth in this Agreement or allowed under- applicable law. THF? 1101WE DEPOTP NJAY WITHHOLD A.(%VOUIJ 41'S OWED TO THE HOME DEPOT FROM THE DEPOSIT PARI LENT OR OTHER PAYMENTS tvIADE., W aTHOF13 LHA E;' 'e= II11✓,<, IiflME DEPOT"S OTHER IIEMEDIES FOR RECOVERY OF SUCH AMOUNTS. Accey aarce and Authorization: Cu;tomcr agrees and understands that this ,Agreemenl is the cnlire agreement between CuSton,cr and The, Hoare Depot with regard to the Products and Installation st i v ices and super Seder all prior discussions and agreements,either Drat or written, reIatinI*to said Pro acts and Installation. This Agreement cannot be assigned or amended except by a writin- signed by Customer and The Hoole D ot. Customer :Ick )wledges and agrees that Customer has read, understands, voluntarily accepts the n le1r:;of and has recei,_ i Ct rl this Agreetne. t: Ace d l �' � a Sub sit A 1) X G - —---- ,\' — ---- Customer's Signal r D Sales�' Iso tant's SiL-nature Date X Telephone No.__ 4? 9 v� Customer's Sig ,Cure Dale Bran0i Office: xi /,-,J VINYL SIDING SPEC SHEET Spec Sheet it. rant a... DESCRIP'l-ION OF WORK ........... Customer Nafu(3: Home Phone M Installation Address: f"i Work/Cell Phone#: Streetddress Siding Drop Location: -- DUmpstef Location: City Slake 7q) __ NYL SIDINO -/,6r-z-t0 bn SIDED PROD. DUCT&PROFILE CORNERS COLOR(S) CraneBoard Marf<ot Sqyai:� Partsmiouth Shake sti tarl(kird Sidinc. 9 Clapbonr Cede r Outside vers ,�N 11�5 — I -- -------------------- 5"Clup banod ,a L E'Clapboaf Dutch pU I land-splif 5.5"Ins 1, ed Sill, a ................ I!T. Bo rd&Batten V Clapboard Staggered A it PerfGG0011 Shale 31 3/4" NIA Oracle Carolina Sands Half Rounds oil t ATION, Othr r - 4 5"Dulchlap Beaded 6 5" Yoss S 4"Clapbo EINRAP: FC 1f 'BOARD FASCIA,rRIEZE A F -6 �W��io VERii;` Front Back Left Other Areas 1(01? �XZSoffit fk Fascia Frieze Board' ---------- Soffit Only Fascia Only Cover Frieze Board with: PVC Alum,Crifl Vert.Soffit= Tuck Fascia Under Gutter: Y s E-1 No 1-1 ............ CUSTOM WRAP WITH IVC COIL REMOVE&REINSTALL Qty 'COLOR' --9-ty Qty Windoves i Doors Star"I Windows A%,,v r Qs upCo 8 Garage I Patio Coal Storni Door; A":". over. Double Garage Door Burglar&ars; Existing S1rutIers1:::::1 Build Out Flarne 'Surglar Sol-.can be removed,but not reinstalled. REMOVE EXISTING SIUfqG 3 No 12�1 Ifyos: VinylAil1oodi—I Aluminum Only where,new siding is to be installed. Home Depot will NOT rernoveasbestos material. FUR OVa:R 77 PORCH CEILING,SEAMS POSTS NEW ACCESSORIES YIN DJi3"N'Soffit Color: CABLE VENTS Elan S ,,E] Locatiom oty 'COLOR I-art Rectangle YIN 'COLOR' Wrap Porch Bisar',1,[ 1 r)", ;>< ",P. Porch Be ")""I,P Wrap P s", New SH0,F ERS Y Y, /N 'COLOR' /W Pau.. `��%�OLOR- 'o Ki 13'1, Louver an�l a Vents se Triangular G Raid 'I I F� .......... REPLACE ROTTED WOOD Plywood-Specify(lie Locations: Dimensional-Specify the Locations: SPECIAL CONSIDEFtATIONS --------- No ................ ......................... ...................... ...... I have reviewed and agree with the job specifications described above,all()I have reviewed and agree with the . Special Terms and Conditions listed on the reverse side of the yellow(Customer)copy at this Spec Sheet. If rotted wood is(ifcovyred AF R raT %ving the existing siding,or if it not be identified at tho time of sale thp- 11 d nail arg per-Sq,Ft.for Plywood and$ uisional 117L,-!�:- per Lin.Ft.for Claw 11,MMe"a White-The Home Depot Yellow!-Customer fi-25-IQ SFC-S-VS THD-294 '? 3'Fie Commonwealthof Massachusetts Deparftnent of Xndustr'italAccidents ?' 1 Congress S'tree4 Suite 100 �= Boston,PL4 02114-2017 W� n".mass gov/dia Workers'Compen��o$�InPs�t>r�an�cei��P$ Tr��A�os��trtctanslPlum ers. Please Print LeMy A icant Information Name(Business/Organization/Individual): In �, Q ��n��� • Address: 9 i wU . .,. City/State/Zip: 6 Phone I Are you a employer?Check the appropriate box: Type of project(required): em to ccs full and/or art-tune).*' New construction 1. I am a employer with p Y C P [] Remodeling a sole proprietor or partnership and have no employees working forme in 8. ®Remodeling any capacity.[No.Workers,comp.insurance required.] 9. ®Demolition 3.®1 am a homeowner doing all work myself[No workers'comp.insurance required 3 t 10 Q Building addition 4.®1 am a homedvvner and will be hiring contractors to conduct all work on my property. i will 11.®Electrical repairs or additions ensure that all contractors eitherhave workers'compensation insurance or are sole ,).[]plumbing reps or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13® f rep s' These sub contractors have employees and have workers'comp.insurance t ld Other 6.1 1 we ara a corporation and its officers bave exercised their right of exemption per MGL C. I j3,§[(4),and we have no employees.jNo workers'comp.insurance required.] *Any applicant that checks Dox#1 must also fill out the section below showing their workers'comperisaCon=tD policy information ide Homeowners who submit b6x st artiached an additional sheet showing the nat indicating they are doing-all work and me of then Mre ersub-contractors and stnmust tc whetherbmit a eor not those entirices have #Contractors that check taus employees. If the sub-contractors have employees,they must provide their workers'comp.policy number- 1 ant an employer that is providing workers'compensation insua'ance for ncy employees. Below is the policy and job site tnformation_ Insurance Company Name: Expiration Daf Policy#or Self-ins.Lic.#: r Date: � City/State/Zip: d Job Site Address: expiration date). Attach a copy of the workers'compensation poh y declaration gAge(showing the punis blebe a fine p to$1,500.00 Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation pimtsh y and/or one-year imprisonment,as well as civil penalties in the form of a STOP fiWORK ORDEce of R and the DIA.forQnsu5rane0ea day against the violator.A copy of this statement may be forwarded to the coverage verificati 1 do hereby ce « e th ai trd penalties of perjury tl:at the informatiorc provided above's true and correct Date: Siartature: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit(L,icense# Issuing Authority(circle one); 1.Board of Health 2.BuildingDepartmeut 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.other Phone#: ContactPersoa; AC D�, CERTIFICATE OF LIABILITY INSURANCE =DVIiI2016 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 AFFOR13I=D BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING I l§bRER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(les)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 confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSH USA,INC. NAME TNO ALLIANCE CENTER PNC N 1 ILC NO: 3560 LENOX ROAD,SUITE 2400 E MWl ATLANTA,GA 30326 ADDRESS: _ INSURER AFFORDING COVERAGE NATO 4 100492-HomeD.GAV-16-17 INSURER A:SleglmInsumm Company Vow INSURED INSURER B:hddi Amedcan Insumnca Co 165355 THD AT-140ME SERVICES.INC. DBA THE HOME DEPOT AT-HOME SERVICES INSURER c:New Hampshire Ins Co Z3841 2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D:OUnd9 Nation)Insurance Company 23817 ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003746646.14 REVISION NUMBER:6 .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. ILTR I TYPE OF INSURANCE Ims UHR POUCYNUMBER MIDD EFF PMIDDNY P LMM A X I COMMERCIAL GENERAL LIABILITY GL04BM14.06 03/0112016 0310112017 EACH OCCURRENCE 5. 9,000,000 CLAIMS4AADE a OCCUR DAMAGE tO RENTED P EM S 1,000,000 SES a LIMITS OF POUCY XS MED EXe(Ivry one person) S EXCLUDED OF SIR:S1M PER OCC PERSONAL&ADV INJURY S 9,000,000 GEWLAGGREGATE LIMIT APPLIES PEFt GENERALAGGREGATE $ 9.000,000 X POLICY ERCT r LOC PRODUCTS-COMPIOPAGG "S 9.000,000 OTHER is B AUTOMOBILE UABILriY BAP 293886343 0310112016 0310112017 CaMEiI d slNGt EUMiT S 1,000,000 X ANY AUTO BODILY INJURY(Per person) S A1,LLOS I'OOYMED AUT O SELF INSURED AUTO PHY DMG BODILY INJURY(Peraaidenl) s NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS erarrlden S UMBRELLA LIAR OCCUR EACH OCCURRENCE 5 EXCESS UAB CLAIM34AADE AGGREGATE S DED I I RETENTIONS I S C WORKERS COMPENSATION [riftnue'd 01559215(ADS) 0310112016 031002017 X EAttliE OER� AND EMPLDYEW LIABILITY C ANY PROPRIETOR/PARTrJt3t/EXECUTNE YIN RN 015519217(AK,KY,NH.W VT) 0310112616 0310112017 E.L.EACH ACCIDENT S 11000,000 0 OFFICER/MEMBEREXCLUDEO? NIA 015519216 FL 0310112016 03/01121}17 1,000,000 (Mandatory in NH) ( ) EL DISEASE-EA EMPLOYE S u desai6e`°user on Add'dional Pae DESCRIPTION OF OPEIRATIONS below9 EL EASE-POLICYLimn- S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more apace Is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT ATHOMESERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORUED REPRESENTATIVE of Marsh USA Inc. I Manashi Mukhedee" _JMt10lJNA.0ZD" - ©ION 2014 ACORD CORPORATION. All rights reserved. CSSL-099623 DZhUTRV BR® 70 NORTON AVIe ManchesterNH 0109 06®2612016 P Office of Consumer Affairs and Business \-P-uutation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Registration -, Registration: 126893 Type: Supplement Card Expiration: 81312015 THD AT HOME SERVICES, INC. RICHARD FALLONE 2690 CUMBERLAND PARKWAY SUITE 360 ATLANTA, GA 30339 7 Update Address and return card.Mark reason for change• p loyment Lost Card Address Renewal Ll EMP �A 1 in 20M-05%11 License or registration valid for individul use only == tj rice of consumer Affairs Business Regulation before the expiration date. If found return to: C lj��IE J�jIPROVEMENT UONTRACTOR d Business Regulation Office of Consumer Affairs an 10 parl�.Plaza-Suite K70 Type- [A 02 116 Supplement Card Boston,N� Expli rat!o n FHD AT HOME SERVICES i-.11`lC------�----- rHE HOME DEPOT AT ROME-StRVICES :ZICHARD FALLONE A ?690 CUMBERLAND PARKVI Y ---------- Not valid wi hoot signature GA 30339 Undersecretary