HomeMy WebLinkAboutBuilding Permit #283 - 164 MILL ROAD 10/21/2008 OORTH
BUILDING PERMIT o�tt,�o ,bgti
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION # ,�
Permit NO: Date ReceivedTeO�PP�,�,
SSAc USS
Date Issued:
IMPORTANT: Applicant must complete all items on this page
`"LOCATION , I� u;
Tint
PROPERTY OWNE
-- Po t
-MAP NO:_R_L0 PARCEL; ZON'2G DISTRICT- 'Historic District yes no
' Machine Shop Village Vires no_
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more family Industrial
Alteration No. of units: Commercial
Repair, replacement Assessory Bldg Others:
emolition Other
Septic'" _ Well: Floodplain Wetlands Watershed District f
A
.Water/Sewer .
DESCC O OF RK TO EJE PREFORPAED:
O
Ide ' i tion Please ype orjpqint Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR Name: ' Phone: d
Address: ,
v
Supervisor's Constriction License; - - _ Exp., Date: f,
Horne Tm rovement License: exp. Date;
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: $ !q� I — FEE: $ �a—
Check No.: ort q5Lf) Receipt-No.: Q6
NOTE: Persons contracting with unregistered contractors do not have access t th an d
ignature of Agent/Owner = u Sigriature,of contracto
i
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to Issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art Swimming Pools
i
Well Tobacco Sales Food Packaging/Sales
Private(septic tank,etc. Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPRO E V D
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
r
if
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTIVIE'NT -Temp Dumpster on site -yes` . no
Located at 124 Main=street
Fire Department-signature/date d -F
COMMENTS,- "�
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector p Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
Location
No. Date d
M0e70V TOWN OF NORTH ANDOVER
? Oj••� ••••o0A
� � 1
^e Certificate of Occupancy $
Building/Frame Permit Fee $ —
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
4.
p;
u Building Inspector
�G
Nlussachusetts - Department of Public Safety
Board of Builtlin,_, Re-,,ulations and Standards
MW Construction Supervisor Specialty License
/� License: CS SL 99124 -
e -S �t}- Restricted to: WS
t ° 1 JOHN AMERO
12 CARRIAGE CHACE LANE
h't5 ATKINSON, NH 03811
Expiration: 7/16/2012
( nuni i mer Tri: 99214
NORTH
T0VM Of ? O Andover ,
No. = �`
o dover, Mass., l U • I • 01T�
T Q LAKE �, T
/� COC MIC KE WICK V
7��oRATED
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
�nA _
BUILDING.INSPECTOR
..........Y.I!
THIS CERTIFIES THAT .1 1..�1.Y1r1 .................. ... . ... . .�j....... ................... ....................................... Foundation
00
has permission to erect........................................ buildings on .......:..b.:. :., Rough
(fit.u...... . . .......................
Ci 1V Chimney
q �,�,(-- P"' S
Itbe occupied as............................... ........P................................. ........ ........................................................................
provided that the person accepting this permit shall.in every respect conform to the terms of the application on file in Final
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
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR'
TRU
UNLESS CONSC T S - Rough
............ ................................................................................................ Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in 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.
SEE REVERSE SIDE Smoke Det.
FROM KIMBLY FAX NO. : 6033629675 Oct. 02 2008 09:26PM P5
1M1,t;aVVMEN't,CONTRACT
III&ASE REAL) 11115
,hrd and Installed by:
At-liome Services,Inc.
larapell Native! Bo'it0l' Date; Depot.Depot.Al-home services
315A(',I.C'Xrlw()0(JSIIc-.CL,Ui)it,2,WOI'L;C.Stcr,MA 01607
Ilranc),N1111,I)EW: full Free.(800)6575182- rax(508)'/56 98'23
Srtul'h 31 fi'J5_';i699460;ME J,ic#C 024[3q;Iti Cc)tlt.Licil 16427
'QK401 33
Cf Lic(156557.2;MA 140MC J-1)rOyr-ment Coltrilctf)r Reg-#12689
� .-
----
Installation Address. Zip7- City
Puratimpr(s); Work Phone: Hoxn6llhono:
t1d]TR-391D
home City Stt1(c
Zip
(f fdjffarcnl frpniIstillat.ioii AddTOSS)
project cOW11111nicatiolis and JJomc Depot updates):
F_rnj�jl Address(to r0q1vc
I poAIOT wish tti recciveuily marketing emitils from The Ilutne fXfint
") theownets Of the pl-opk7.ty loclitpd at theabove iftstallatiOn address,ag"ecs to buy'
Ln n-,Undersigned("Custolne, er end arrange for the insLa.11,11ion("Ingtlifiltfori'l of
.Icct InfarmAtIn . : );Or,)4grecS to furnish,deliv
and Ina ("The Rome shoct(s);'ail 6[Which aro ilicoquirated inLp t1li-,Contract by this
I M'low and on the rcfe",011�cd spoc.
all xnatc�gjs dus�ribed on the b any Change Orders(collectively,
reference,(11(]18 with airy ax�idpayninnt SI)MrnafY�Uabl)Cdherc`tO
ect(s
Job )..!!__,
U: (i o pce
E]Gutteri fC'&01'B C]RatryDoor-R
_iba6
[TfS djDF"rj Wlndjj.�qs=J Tvttilation
Ropring E❑
.]
rioutit'.5/cOVOTS[JEntry fmors . ... __. .......
--ETS_i_di_n_g rl Window bl-Ulat'011
MGUtjr.r.;I Covers 0Enirypours 17J—.
RoofinY 77
-C❑FSidirr 0 WindmvR Insulation $
Ociiltters/coven; E]FntryDuors
mil.it' n, total Contract Amount $
i
TA4jft?1L".h,x�ePxo1&y nt(4posil:lloletUnotiL-tiiirdofiliepDnIrALIAMiJLLI�t.
ust0mcr will OxectIte t CampIction CeKtif
Custonw.r agnecs that,immFdiately uP011 comPletiOR Of 1he work for each Product,C caFh(D�stoxneq,under t1l in
14 d pa bilauce due. As applicable,
(one for each Ptoduct as d�tined by an individual Spec S�ceo an y any
el Cont:rucl'a&-ceS to be'j6iritly and severally obligated and liable,hereunder.
Hoino Dopol re'sicryes tile.right to issilo.a Clongr,Order or terifti0ate tbi,.;Coriftziot or any individual prc)Llu,;tq.�)included herein,at
is -ri ions dile to a snuc;tLyf"
problem with tike hoLae,crivitonalentul hazardsdiscroijon,if The I-Iqlllie,DOW or it"authori=.4 service provider determines that it cjntiot perfor its obqlig�Ljoic)g.orro�s or becall.-'Ic
such as mold,asbestos or lad paint Other Safety colic;ern ,P'r
work recore<l to'eorrlp�ete the job Was not iticinded in thv.Contract,
11�2,r as part of this Contract, gets forth the toll.1
� *file rayrritait Summary tf_ it.ichided
Kay—D C,
Contract amo:U111 and p�yzxienls i-equiled for the&posits ulild f1riall p�ym�_nts by Product(35 hppliUbl
NOTICE TO CUSTO'NIFIt
You 21,entitled to l,compleiQly fiffied-in Copy of Clic CnyitxAct at ikkc time y0k.1 sign. J)o not sign a ComplFlioli Ce'rGil"t"0)0%4:
there is Pile Coplpleapn Certilicle fox,each listed pir0duct an derbled t{y bllliv'doai Spec.Sheets)beforevV01-k oil that PrOdlict.
is Complete.
In the eyeit of turridtlatifln of this C010"'lict,Customer 391'ecs to pay The llo)�e Depot the costs'ot'ninterials,labor,expenses.;
I
pl,6VidLj t 1,rnUgh the dilte of te:l InjilAtJ011,Pins AVIV Otl'c
alldscrvick.s Provided by The Home.Dp.pot or Anth6rizid Service fft�.HOLDAMOUN
amount;set forth in ibis Agreement oi-allowed untlet applicable law- 14()Mr""POT MAY W T
ROM THE DEI PA-�M'J�,NT 09 OTHER PAYMENTS MADE, W111100
oWE'VTO TOY, Hf)Ml�i DEPOT F
I A MW Kbmy�blmor.5(YE11
Accc ta-lt.and Ai1.ttorizaUg)1: w on er ua
)(s J111tI this A
gl'00ne
llt is the eli.itcagTetlpetit bdw0<dr) Cus
to=
.J
V)d-Ih10mc'10,i regard to the Products and Installalioll gervk*n find sVperstvles all priox d)scu%2i0,19 91dugrteffelts,eitbcr
offal or Wi tic Telmi."to said dueand hstall ioli. f1isAerec16t cannot be assigned oraincrded excret by a wtiting si9lcd
by Custimier ano Thp0 at.Cusomerfto owle,ges avid agrees tbixt Clist(Flerhas feud,undclHtandsvoluntarily accept.
tcrrnsofandhasrceciv. a copy of this Agreement.
Subm
pte4 b
I mltaxlt,VSU
n
Sit o sultant?s S at Date
Wo.4", Date
I PI'O
Tc 7� ?-_a�225---------
CnStornor'l;ftxiature Date Salen ConsultWunt License No,
(113 ap�licnbla)
CANCELLATION: CU�TOMER MAY CANC'rL THIS
�GiZE]s1vXIZNT w J') OUT PENALTY OR OBLIG,TION
-BV'uELIVtJ:qNG*RI#EN NOTICE TO THE)HOME
Dripoli, a-k ?AJI)MG11T ON THE TMRI) 1111JOESS
DAY A . SIGNING THIS AGREEMENT. THE
STATE, 8U1111tEMENT ArrAcmel) HERETO
N9 rG� TO USR IF ONE IS
CONTII� , A -
S1'f;C'YPCA1A,y FRACRMED By LAW IN
CU9TQMF,R'S STATIE. -
ADDITION}r•TERMS AND CoNf)VTIONS A,1ZE!RATAD ON 1'0kH RL'VFRSR SIDE AND ARE pAfT orTnis cwrRACT
rite Commonwealtfa of Massachusetts
Department of Industrial Accidents
n. Oce of Investigations
r 600 Washington Street
Boston, MA 02111
www.mass.gov/din
Workers' Compensation Insurance Affidavit: BuilderslContractors/El Please Print Lecribly
A Dlicant Information
Name(Business/Orgmi=tion/Individual):
Address: -
Phone.#•
City/State/Zip:
Are y an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
to er with [ 6. ❑New constrnctioa
1. I am a emp .y I�i have hired the sub-contractors
employees( �aad/or part-time). 7. Remodeling
emp listed on the-attached sheet
2.❑ I am a'sole pf oprietor or partner- . These sub-contractors have Demolition
ship and hove no employees employees and have workers' 9 Building addition
working ifor me in nay capacity. COW.insurance.t
o workers.comp.insurance 10.0 Electrical repairs or additions
[N ' ce 5. � We are a corporation and its
required] work officers have exercised their 11.�Plumbing repairs or additions
homeowner doing all ' n per MGL
3.❑ I am a ho right df exemptio p 12.❑
go* epaus
myself.(No workers comp. c.152;§1(4),and we have no 13.
insurance required.] employees.[No workers'
comp.insurance required.]
.Any applicant that checks box#1 must also fill out the section below showing their wotioxs comp
enation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating
have.such.
tContnctora that check tbis box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entitcea
i they must provide their workers'eonv.policy number.
employees. if the sub•contrectors haw emp oyw.
I"amemployer that isproviding workers'comperuafion insurance for my employees. Below Is thepolky aradJob.slue
lnformadon.
Insurance Company Name:_: — -
Expiration Date:
Policy#or Self-ins.Lic.#: ®��,,/_�
City/Statempt ��
Job Site Address:
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 a l�hces in theorm ofa STOP of �RD R and of
fine up to$1,500.00 and/or one-year imprisonment,as well as civil pe
u to 5250.00 a day against the,violator. Be advised that a cop} of this statement may be forwarded to the Office of
of p e covera a verification.
' tions of the for insuranc
Investt rovided abov is and correct
I do hereby cern d r p s d penalties of perjurythat d:e information p
' ate•
Si azure: '
Phone#:
Offuia!use on y. Do riot write lr:this,area, to a comp eted by c or town off IciaL
PermitUcense#
City or Town: '
j Issuing Authority(circle one):
1.Bdin;Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
oard of Health 2.Buil
6.other
li Phone#: I
rnntact Person:
ai3-A-779 43-43 D8 Vin;L 1 .Vinilu
DiPRC 513111 Product
Doubit-Yung I Vsatana de dableLig
q�iilotina
3.rgon/PsaaaLa_ I Argon/?rasoiar ._
NatlofWFwsshkn 3/32" C1a2a 1 2.38 mm Vidrio
RaftczuncA® No Laminatad Clans l sin vidrio laminado
No Cnida ( sin rajillas
ENERGIE PERFORMANCE RATINGS
EVAUIMON DE RENDIMfENM EdEEROETICQ
U-Factor Solar Heat Gain Coefficient
Fa=r•U Coelidente Gananda de Energia Solar
0 . 32 1 . 80 . 29.
nom► •
ADDITIONAL PERFORMANCE RATINGS
EVALUAC1oN SUPLEMWARIA DE REND01IE00
Visible Transmittance
TransrnWon de Luzftble
0 . 52
MarMa tm Mom mops conform to appal abb NERC procarhaee for&ftmk ft wtmle product performance.N%
ralinpe are dete...kW far a&W set of&NhoamenW cwdI ne and a spm*ploduet slm.WC does rot mm m and any product
aMdoesndwarrardthe sul0lftd?nyproddloranysp ftuee.ConsrdfinemAedmes MnILntbrotlwproductWbrmer=
hdomad a wwa rdre mp
- _ •_Este tatrth�rree eetlpuht qua aeon wdorea aarrpfen can bs pocedrNerdoa apAceblea de NRAC para determhmr�rerrd4rrierdo total del
prbdu t Las v*M rieadm porNRIC amr detemrhradoe poem cw*mto qo de carrdlcbm amblm*M y rn tamarro de produeeo
eapectllco.WZ no m mlendd nkq m producbo y no pararift quo d producto sea adecrado para un=eepeciAca 001"con el .
bft del bbdmo para d ueo'aproplado de este predrr h www.Nro.ap .
Unit gaalifias toe ENERGY STAR
ragion(s) : Northara, North
Cantaal, South COAt■al, 40athara.
ST
La anidad oalifioa pa:a la(a) fNEWAR
rag1en(22) ENERGY STAR: Norte,
Norte Cantral, Sur Cantral, S%=.
•• 46 IND: Rain GO/Class 3/32"/11-R43 .
Tasted Size: 39" x 63"
IND: Rafaano GG/Vidrio 2.38 man/11-1143
DP : +4 51-4 5 TamaAo probado: 91.4 C:, x 160 Cb
417711. H9 Hoffman 2931120.
Keep ft label for passible ENERGY STAR•rebates.To team more vW www.energys mgcv
Guarde esto etlquetA pam pcslks reembolm ENERGY STAN"Pare mnomr mds ocerm de am,Me www.1Merpjftl;c t
• I --,p`—. ✓!ee TOammwn�,l� o�,�a�aett.
�-\ Board of Building Regulations and Standards .
HOME IMPROVEMENT CONTRACTOR
Registr-4>19ftk 126893
-
I /2010
I � IKpe^upplement Card
The Home Depot;AWQ l
RICHARD FALLONE= '=+�
3200 COBE GALLEF) l{V y. 0
ATLANTA,GA 30339
Administrator
oArEiNIN/o0nrrr) -
16 , CERTIFICATE OF LIABILITY INSURANCEsa/aa/4B.
I-404-495-3000 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION
RCOUCER - ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE
,.9h USA. Inc• HOLDER. THIS CERTIFICATE ODES NOT AMEND, EXTEND OR
;made�ot.Cer==eque9Cma}dr9h.Cam ALTER.THE COVERAGE AFFORDED BY THE POLICIES BELOW.
1?5 ?:edatont Rd -NZ, Su; 1200
::aata. GA 30305 I INSURERS AFFCR01>•IG COVERAGE I NAIC f
lX (,:,1 943-090, ( d 12; 37 -
NSuaea,�:5.ea ,a3t Zn! Ca
raEO,5ca= V.3.a• Zne NSUAc.43' ch Abler cart i'! Ce :Si3: _`
:e Ceocr, Znc• wSUaEaC:+==-.^.oi9 Jet Zas --
?ace! Farr.1 Road
.,ding C-8 iNSUREa0:%meriein Home A9aur Co L93:80
;:ansa, GAUR
:30339 e.;� NSERE:mew H=inshirs Ina Cc x3841
OVERAGES
i 7HE POLICIES OF INSURANCE LISTE08 1 ELOW HAVE BEEN ISSUEdr'CO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
NOITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
ANY REQUIREMENT;TERM OR CO
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH.
POLICIES.AGGREGATE LIMBS SHOWN MAY HAVE BEEN REDUCED BY PATO C OUCY 6FFECTNB POLICYEXPIRATION
LIMITS
'.R 0 POUCYNUMIGR
IPA 3757 608-OZ 03/01/08 03/01/09 EACH OCCURRENCE 54.00.0,000
GENER.ALUABILRY. / =1,on.000
X COMMEFiCIALGENE LBILITY LIMITS OF POLICY ARE ERC S9 PR I' me
-OF SIR: $1,000,000 'PSR CC- MED EV M we Person) f=XCLDD4D
CLAIMS MADE :OCCUR 4,ado.000
• PERSONAL i ACV INJURY 3
GENERAL AGGREGATE 14,000,000
PROOUCTS•COMP/OPAGG $4,000,000
GEOLICY Nt AGGREGATE OMIT APPLIES PER:.
X PPRT LOC
08 03/01/09
1938863-05 0]/01/ COMBINED SINGLE LIMIT
m BAP 51,000,000
AUTOMOBILE LIABILITY
(Es
X ANY AUTO
OWNED AUTOS Bar ILYper INJURY f
ALL (Par person)
SCHEOULEO AUT09
BODILY INJURY
f
. Per accident)
HIRED AUTOS ( 1
NON.OWNEO AUT09
X SELF INSURED AUTO PROPERTY DAMAGE f
(Per amdent)
PKYSICAL DAXAGE
AUTO ONLY-EA ACCIDENT f
GARAGE Wf1ELITY EA ACC f
OTHER THAN
AN
Y AUTO AUTO ONLY:
AGG f
APR 3757 608-03 03/01/08 03/01/09 EACH OCCURRENCE 37,000,000
EXCE9SAJM0RELLALIABILITY AGGREGATE =7,000,000
X OCcuR F CLAIMS MADE
f'
• f
DEDUCTIBLE f
RETENTION f. WC 9TATU• 0TH
1938757 (FL) 03/01/08 03/01/09 X
WORKERS COMPENSATION AND 0]/01/09 E.L.EACH ACCIDENT 31,000,000
EMPLOYERS'LIABILITY 1918756 (CA) 03/01/08
ANY PROPRIETORNARTNERIEXECUTNE03/01/08 0]/01/09 E.L.DISEASE-EA EMPLOYEE S1,00 0,000
OFFICEfNaEMBEREXCLU0ED1 1918755(AOS) E.L.DISEASE•POUCYLIMIT 31,000.l 000
II yyea.da'=under,
5 e6lAL PROVISIONS Dhow
OTHER TNS-045197967 (TX) 03/01/08 03/01/09 ccurrence/SIR 15K/3K
TX Employers ixeess 1938759 (p9I) 03/01/08 0]/01/09
workers Compensation
workers Compensation 1918758 (XY; ff0, NY, WI) 03/01/0! 0]/01/09
3CRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLU31DNS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS
OR'EVIDENCS ONLY
CANCELLATION
cRTiFICATE HOLDER
314OULO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL ]0 GAYS WRITTEN
6 HONE DEPOT, INC.
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO 00 SO SNAIL
! IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR.
SS PACES FERRY RD.>+ N.W. BUILDING C-B REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
LMTA, GA 30339 USA •
0 ACORD CORPORATION 1988