HomeMy WebLinkAboutBuilding Permit #859 - 27 PUTNAM ROAD 6/16/2011TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO: iq� Date Received
Date Issued /�D —//
IMPORTANT: Applicant must complete all items on this page
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Print
PROPERTY OWNER � � ! C
Print
MAP NO: Q_pARCEL: ZONING DISTRICT: Historic District yeno
Machine Shop Village ye no
TYPE OF IMPROVEMENT
PROPOSED USE
Residen " I
Non- Residential
------------
13 Jew Building
ne family
❑ Addition
❑ Two or more family
❑ Industrial
No. of units:
❑ Commercial
❑ AlWation
❑ Others:
epair, replacement
❑ Assessory Bldg
❑ Demolition
`:®Septic `' ®Well" '•
❑Other
- - l -tx
D�Flooclpla`� f ®Wetlands
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�.® ers edDistrict� t
T:OWater/Sewers x k:�
-
SOTIN.
-
Iden I on jZsee or Print Clearly)OWNER: Name: 1 Phone:�%`��
Address:------O?-71 min -t � Nett ;r 1"l�•
CONTRACTOR Name: D t7 Phone: V(
Address:
Supervisor's Construction License: lb 143'-5 Exp. Date:
Home Improvement License: Exp. Date:
QI3oIT
ARCHITECT/ENGINEER Phone:
Address: Reg. No
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925 00 PER S.F.
Total Project Cost: FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to th,�, arantyjund
Plans Submitted ❑
Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools 0
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
PLANNING & DEVELOPMENT ❑
COMMENT
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
,Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
tanning Board Decision:
Comments
Conservation Decision: Comments
W -Iter & Sewer Connection/Sianature & Date Drivewav Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main. Street
Fire Department signature/date
COACV1ENTS
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 Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$10041000 fine
NOTES and DATA — (For department use
® Notified for pickup - Date
Doc:.Building Permit Revised 2008
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 Permi
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
10TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
1 all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
U, t the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
u st be submitted with the building application
Doc: Doc.Building permit Revised 2008mi
Location �i� 'P" 4 vl,� ,,, (U -
No. Date
TOWN OF NORTH ANDOVER
"Go
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check# 3L/33
2 4 � o,i
Building Inspector
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rrmob Addrew (to fcLci%.,e pro*( cots Mrtiratiom alld Home DqM upda(my -
1 DO NtYr wish to ria:-dw any ncirivting culdds fmm The Hot= Depot
1•miat infarmatian. Undraxiignxi CL'Wdbaler"). the owrlCn of the property located at the ubovc inmilatilrn addn�s. agrCQ1 to buy.
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au mawiial5 dc%MbW on die bcls w sad on der: rct;-, $ Spec STIuu(z). nit of which :ao itieotporamd into this Canuma by dri4
mramncrr, along with any applicable Statc S1lpplametlt arrd pigment Sumu ary aturched baem and any Cheng[ Otdcm (cnllmlivAy.
"Coutrnct"1:
A&*2 Prudads Sorch'heeuzle_ Pit iettAmnunt
QL4toma ngirry that. immediately uram cuntplcitnn ul' 1he work for gorh Prailuct, Ciictniner will exculic a Conlnletitin Cartilwaid
toric fur each Pnilhua a% LICACWd Uv an iridividual Spec Sheet} and pay any balance due An applicatile, cns;h Castnrricr under ihi>
Onrltacl agici: Cu (tc juibily and wvcrutly t bl(jrJt w arnl H4,11e btalniink-r.
I he i(ome 13cool rewrvux th(i nt•hl in r nuc a (1inap Urderor lemiyate tRls 0m(rat:t ur nny tihltvtdtut Nrudw;t(c) inclaticd twwin. at
ilia di%Crotion, if Thd Ui,rnm Ddrini ur iu. uuthahn.'d service provider dri mnines that it catmui pufont) its ptttiptions dwr to a .gM10 Lral
prof ltlln %%i(11 1110 home, t;nvirontncntal har tr&s :.Leh a,5 mcild. asbestos or load paint, Wtur vi(Cty coneww. pricing curns err liMalesc
work requited to Complete the jab wiry iinl iru:iudcd in die Contact
msivmrni tiuirunarrt The favilmit Summary 11_312 S 1119) --„- ,included :u llsrt uC thio (:nnlraet. set Cal1h WC tol.il
Cunnaut aniounr and pnymcnts reelpirod for the depusiLs. mid final paymcnn by Prodito (aN applicable).
NOTICE z0 CUSTOMER
4'11•! cM ;rtiliert to c +s.nB,Feidy Guetil-4e cam of tint C^PirRet ret the tirtte,+ta sigp_ Do nut :ign n rote; tMti.•t: C ertiGeute (note_
then: is m
one Copletion: CerOrksle for am:h nal aP.Aua as defined by indlielduai Spm Sheets) Avert: wort; hal that Product
rnrrnotMc-
In if. evr,tt of tcrnli n iieu of this Contmct. t urtnrner aphrt Lo pay The Nome Dena, the A;ML-f ur uurleziul . Iabor. expensch
artd 3lerTkvs pravidrd try The Home Depn3 or An:hot73ted Seniirn Piinider thruarli the date of tennintt,iari� plus any .Niter
2--imunts set rorth in this ARret:mrn, r.- ul:aord under applieahk bw. Mv. fin�-e PETIOT zkmy WYM1101,9 :tiSs7rJNTS
OWFTt 1-0 11(E I:CIMF 1)F:I't7i FTkOM Tiff I) JP11Sfr PAYtYIr-NT hitt ty('HFR PAYMEN"Vi VE,:JIS, WITHOUTI.IMI'tING THE HOME DEPOT'S OTI"ei°_R :rteVrDIEsS FOR RECOY tr-RY ,0FStICII AnSaCiMS.
..ccenL•lhce Mtsd Authntiznt tin. Cumower .voim and uMkTata?W, ih2i ilus .%([chichi( i% the entim atmcuwui 1wtwcon C ultnille,
and Thd IInmc Depot with nTwd Ia the PiTAuets and (nsfitualinn mxwiuc and vupotatiti all rri*r disers-•inn% and agimonitnu. lalhci
vml tM wriven. relatitu; 1111 said prndirciv and li .tailutiint_ T hN Ani-mmrrd r_-inrint hd .axi_-rn d nr annrlded CRr,Cn6 fly a wriiitlz >irnrd
by Cuslnmer and The lit"ric 1XI)EI . Customer xklmwltalM anti a; jtri dint Custaina has rad. itodumiq idq rulut tidily ac,-LPLs the
tam, or and haancmmi,, l orthilAxrrcmdriL
A to v: t Slrht 1-A hist
, ffelo X
of MY s Signature (bell jj Saks Consultant's Signatiirc Dra,
)(_
CustrntleesSip mrr Date
CANCF1.I,ATION- C:USLIGMER MAY CANcEi. Tins
AC",EMENT WITHOUT PENALTY OR ORI.I(:ATIUN
13Y DELIVERING WRITTEN NOVICE. TO THE HOME
DEPOT BY MIDNIGHT ON THE T7tIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE, $VPPt kMFNr ATTACHED HERI:TU
A Ihal:ni rc? LSI: II, urvL S:
SPECIFICALLY PR”- CRIDErD BY LAW IN
CUSTOM,k:R'$ STATB,.
Hnrn'F.:.tn11Mf INAI. ThRNfK tMh (Y1NI)ITInpc ARP %TAT
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(A'5,
70K-;:;-
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MaiticPSrrel>ett+tremw_ untdepl+ditranrethwtmatterdoftbeCardractAuwmA.
QL4toma ngirry that. immediately uram cuntplcitnn ul' 1he work for gorh Prailuct, Ciictniner will exculic a Conlnletitin Cartilwaid
toric fur each Pnilhua a% LICACWd Uv an iridividual Spec Sheet} and pay any balance due An applicatile, cns;h Castnrricr under ihi>
Onrltacl agici: Cu (tc juibily and wvcrutly t bl(jrJt w arnl H4,11e btalniink-r.
I he i(ome 13cool rewrvux th(i nt•hl in r nuc a (1inap Urderor lemiyate tRls 0m(rat:t ur nny tihltvtdtut Nrudw;t(c) inclaticd twwin. at
ilia di%Crotion, if Thd Ui,rnm Ddrini ur iu. uuthahn.'d service provider dri mnines that it catmui pufont) its ptttiptions dwr to a .gM10 Lral
prof ltlln %%i(11 1110 home, t;nvirontncntal har tr&s :.Leh a,5 mcild. asbestos or load paint, Wtur vi(Cty coneww. pricing curns err liMalesc
work requited to Complete the jab wiry iinl iru:iudcd in die Contact
msivmrni tiuirunarrt The favilmit Summary 11_312 S 1119) --„- ,included :u llsrt uC thio (:nnlraet. set Cal1h WC tol.il
Cunnaut aniounr and pnymcnts reelpirod for the depusiLs. mid final paymcnn by Prodito (aN applicable).
NOTICE z0 CUSTOMER
4'11•! cM ;rtiliert to c +s.nB,Feidy Guetil-4e cam of tint C^PirRet ret the tirtte,+ta sigp_ Do nut :ign n rote; tMti.•t: C ertiGeute (note_
then: is m
one Copletion: CerOrksle for am:h nal aP.Aua as defined by indlielduai Spm Sheets) Avert: wort; hal that Product
rnrrnotMc-
In if. evr,tt of tcrnli n iieu of this Contmct. t urtnrner aphrt Lo pay The Nome Dena, the A;ML-f ur uurleziul . Iabor. expensch
artd 3lerTkvs pravidrd try The Home Depn3 or An:hot73ted Seniirn Piinider thruarli the date of tennintt,iari� plus any .Niter
2--imunts set rorth in this ARret:mrn, r.- ul:aord under applieahk bw. Mv. fin�-e PETIOT zkmy WYM1101,9 :tiSs7rJNTS
OWFTt 1-0 11(E I:CIMF 1)F:I't7i FTkOM Tiff I) JP11Sfr PAYtYIr-NT hitt ty('HFR PAYMEN"Vi VE,:JIS, WITHOUTI.IMI'tING THE HOME DEPOT'S OTI"ei°_R :rteVrDIEsS FOR RECOY tr-RY ,0FStICII AnSaCiMS.
..ccenL•lhce Mtsd Authntiznt tin. Cumower .voim and uMkTata?W, ih2i ilus .%([chichi( i% the entim atmcuwui 1wtwcon C ultnille,
and Thd IInmc Depot with nTwd Ia the PiTAuets and (nsfitualinn mxwiuc and vupotatiti all rri*r disers-•inn% and agimonitnu. lalhci
vml tM wriven. relatitu; 1111 said prndirciv and li .tailutiint_ T hN Ani-mmrrd r_-inrint hd .axi_-rn d nr annrlded CRr,Cn6 fly a wriiitlz >irnrd
by Cuslnmer and The lit"ric 1XI)EI . Customer xklmwltalM anti a; jtri dint Custaina has rad. itodumiq idq rulut tidily ac,-LPLs the
tam, or and haancmmi,, l orthilAxrrcmdriL
A to v: t Slrht 1-A hist
, ffelo X
of MY s Signature (bell jj Saks Consultant's Signatiirc Dra,
)(_
CustrntleesSip mrr Date
CANCF1.I,ATION- C:USLIGMER MAY CANcEi. Tins
AC",EMENT WITHOUT PENALTY OR ORI.I(:ATIUN
13Y DELIVERING WRITTEN NOVICE. TO THE HOME
DEPOT BY MIDNIGHT ON THE T7tIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE, $VPPt kMFNr ATTACHED HERI:TU
A Ihal:ni rc? LSI: II, urvL S:
SPECIFICALLY PR”- CRIDErD BY LAW IN
CUSTOM,k:R'$ STATB,.
Hnrn'F.:.tn11Mf INAI. ThRNfK tMh (Y1NI)ITInpc ARP %TAT
Tckplwnc No. /p -
6G -Hot
Salts Caruulram Iiituw: tits_
lx:.�li.rs6le)
I.Y) (IN THY. RF;V&It\Y. RInF: ANI1.\kH P,% RT 'IF THIO MKixai T
1170.11151 r -sr, White-PrAndi File Yellow.-r,.,sfnnw Pink-tinkueammltant
(A'5,
70K-;:;-
818-4 500/lO0'd £02-1 + 1MUSIVld 1WOMOH-AOU WV6£:Z1 110Z-ZO-V
. � �,/K8IJO�Ilt/I920�ILUJCQ�GLI� ����"CGG`LlL6CLGti .
Office of Consumer Affairs & Business Regulation
OME IMPROVEMENT CONTRACTOR
Re91strait on: X26893 Typc
Expirafta_n.81.312.0.42- Supplement:
• M: .:_ -"_�� .
The Home Depot-!At__ome;Services
RICHARD FALLONE
2690 CUMS.ERtAIVO PatKWAY S ���
NIfIEMt% GA 30339 Undersecretary .
E.
The Commonwealth of Massachusetts r rIk F'
- =
Department of Industrial Accidents
.�
Office of Investigations
I Congress Street, Suite 100
Boston MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organiiation/Individual): eoo} _
Address:41�`�1
l u
city/state/zip:
Phone #:
Are u an employer? Check the appropriate
box:
1. I am a employer with
4. � I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. El am a sole proprietor or partfier-
Listed on the attached sheet.
ship and have no employees
These sub -contractors have
working forme in any capacity.
employees and have workers'
[No workers.', comp. insurance
comp. insurance.
re
required.]
qu
5. � We are a corporation and its
3. ❑ I a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
coma. insurance reauired.l
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8.. E] Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roof repairs
13.0 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whethef or not those entities have
employees. If the sub -contractors have employees, they must provide their. workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. .k w �„
Insurance Company Name:
ii r V
Policy # or Self -ins. Lic. #: � 1 C�� � Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certify unl r the p7tins ofd penalties of perjury that the information provided above is true gnd correct
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 #:
• ®
ARO CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDONYYY)
02/21/2011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND. CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy�ies) mist 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).
PROOUCER 1-404-995-3000
Marsh USA, Inc.
•
CONTACT
FAX
homedepot.certrequest@marsh.com
Two Alliance Center, 3560 Lenox Road, Suite 2400
Atlanta, GA 30326Fax (212) 948-0902 _
:
IINSU
INSURERS AFFORDING COVERAGE -
NAIC4
A: Steadfast Ins Co _-
26387 ---
INSURED
INSURER8; Zurich American Ins Co_. -
16535
INSURERC: New Hampshire Ins Co
23841
"-'`-
TheHome Depot, Inc.
Home Depot U.S.A., Inc.
2455 Paces Ferry Road NW
INSURER 0: Illinois Nati Ins Co -- -_- y
23817 -
INSURER E: NATIONAL UNION FIRE INS CO OF PITTS
~^ -
19445
Buildin C-20
Atlanta, riA 30339
27960
-- -
INSURERF: Illinois Union Ins Co—
r�r'f TI CI!`ATG h111aaUFVJ- 1 4 H 44 hK/ K! VE1Ilim n/111VIM r -K"
VVYGiJ1Vt-� - -
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.' NO" 41THSTANDING ANY.REQUIREMENT, TERMOR 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.
AOOL SU POLICY EFF POLICY EXP
INSR TYPE OF INSURANCE ,_ IN, POLICY NUMBER MbIl00IYYYY MMIOO/YYYY LIMITS
A
GENERALLIAOIIITY
GLO4887714-01
03/01/1
03/01/1.2
EACH OCCURRENCE S_ 9,000,000
TORENTED 1,000,000--
PREMISES Ea occurrence S
XDAMAGE
COMMERCIAL GENERAL LIABILITY
MED EXP (Any one person) S EXCLUDED
CLAIMS -MADE. ITI OCCUR
PERSONAL dADV INJURY S 9,000,000- -
X LIMITS OF POLICY XS
X OF SIR: $1M PER OCC
GENE RAL AGGREGATE S 9,000_000- _
GEN'LAGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMPIOPAGG I S 9.000,000 _--
X POLICY PRO= LOCS.
B
AUTOMOBILE LIABILITY
BAP. 2938863-08
0--3-TO-171:
03/01112
COMBINED SINGLE LIMIT1,000,000
a acddent J. —.__
X
BODILY INJURY (Per person) S
ANY AUTO'
—_ - -
ALL OWNEDSCHEDULED
BODILY INJURY (Per accident) S
AUTOS AUTOS
NON -OWNED
-
_.-_-_. •...
PROPERTY DAMAGE S
HIRED AUTOS AUTOS
Per a cidenl
X SIR AUTO P Y
S
UMBRELLALIAR
OCCUR
EACH OCCURRENCE S --_ •__•• _•_-
EXCESS LIAR
CLAIMS -MADE
AGGREGATE $
OED RETENTIONS
$
C
WORKERS COMPENSATION
WC061967352 (AOS)
03/01/1
03/01/12
X _TORY IT
MS OTR• •__ ______
D
AND ROPRIEERS'IIRTNER
nNYPaOPR1ETORlPARTNERIEXECUTIVE Y�
N
NIA
WC061967354 (FL)
03/01/1
03/01/12
E.L. EACH ACCIDENT $ 1,000_000 _ _
_
E.L. DISEASE - EA EMPLOYE S 1,000,000
E
OFFICE"EMBEltEXCLUDED?
(Mandatory in NH)
WC061967353 (CA)
03/01/1
03/01/12
_
E.L. DISEASE -POLICY LIMIT S 1,000,000
Ityes, describe under
DESCRIPTION OF OPERATIONS below
C
Workers Compensation
WC061967355(KY;MO,NY,WI,
)03/01/1
03/01/12
F
TX Employers XS Indemnity
TNSC46244151 (TX)
03/01/1
03/01/12
Occurrence/SIR 30M/1M
£
Workers Compensation
WC1192378 (QSI)
03/01/1
03/01/12
SIR 141
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required)
RE: EVIDENCE OF COVERAGE
CERTIFICATE HOLDER cANctLLA l IUN
THE HOME DEPOT, INC.
HOME DEPOT U.S.A., INC.
2455 PACES FERRY ROAD NW
BUILDING C-20
ATLANTA, GA 30339
USA
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
U 19tst5-ZU1U ACORU CORPORATION. All rights reserved.
A'Ofl.9C 1-,n4nrncl - The ACORD name and logo are registered marks of ACORD
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authorize The Home Depot to pull permits using my
CS License # /0/ 012�j17 and my
HIC Registration # / `� ��.�� $ 2 '3 /
Any questions please call me at 6-(7 � J � .� VG 5
Installer Signature
Company Name /7, !.:o V r'',�/V `-- G
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