HomeMy WebLinkAboutBuilding Permit #934-2016 - 39 WOODLEA ROAD 3/2/2016ZZI
Permit NO:
Date Issued:
BUILDING PERMIT
0
0
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
0 + 2-4- a
Date Received
TYPE OF IMPROVEMENT
PROPOSED USE
Phone::. O_F
Residential
Non- Residential
El New Building
ZOne family
0 Addition
0 Two or more family
El Industrial
El Alferation
No. of units:
0 Commercial
XRepair, replacement
0 Assessory Bldg
El Others:
[I Demolition
0 Other
0 SOptic,;- OWell
oFloodolain 0, Wetlands'
0,,witershed District
0
OWNER: Name:
Address:
Identification Please Type or Print Clearly)
Phone:
CONTRACTOR Name,,-,"-
Phone::. O_F
:F:
0
iAdd V
8,U pervisorsConstructionbb nse?
x
b t
a e:
m-PrIp-q ent License:
---Ex p�
Da
ARCH ITECT/ENG IN EER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDINGPERMIT.-MOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F
Total Project Cost: $ 1;2- FEE: $
U—Z- _;---
Check No.: Receipt No.:
NOTE: Persons contracting wA unre"gistered contractors do not have acces the gu3ranty fund
11,07 J/
of Ant-nt/Ovvnpr,� 7—.Z1, 7777
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued:
I IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
ORT11
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
El One family
El Addition
El Two or more family
El Industrial
El Alteration
No. of units:
11 Commercial
El Repair, replacement
0 Assessory Bldg
El Others:
0 Demolition
11 Other
mmsii wT FV
Y
1Z,
Z,
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
Address -
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License:
Home Improvement License:
ARCHITECT/ENGINEE
Exp. Date:
Date:
Phone:
Address: Reg. No.
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost: $
EE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
r�, - �- � -
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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
E: 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
Mass check Energy Compliance Report (if Applicable)
Engineering Affidavits for Engineered prod uct�---
OTE: 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
4� Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
OTE: 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
Doe: Building Permit Revised 2014
2�.
Plans Submitte.1-11, Plans Waived Certified Plot Plan. 0 Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer 11
Tanning/Massage/Body Art F1
swimming Pools El
well El
Tobacco Sales 11
Food Packaging/Sal.es 11
Private (septic tank etc. El
Pennanent Dw-npster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature'
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS
Reviewed on
Sian
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connectionisignature & Date DrivewaV Permit
DPW Town Engineer; Signature:
Located 384 Osgood Street
DEPA IV I JF7-7- n
,EIR
4 low
MEN - - - - - - - -
Unvida e
5,
Tip,
Vvir
9`11
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
MGL Chapter 166 Section 21A —F and G min.$100-$l 000 fine
NOTES and DATA — (For dei)artment use
M
I U Notified for pickup Call Email I
Date- Time Contact Nam
DocHailding Permit Revised N14
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
All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
IOTE:
Building Permit Application
Certified Surveyed Plot Plan
Workers Comp Affidavit
Photo Copy of H.I.C. And C.S.L. Licenses
�6 Copy Of Contract
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered prodd-&&7
Ail 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
,�6 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (if Applicable)
.4. Copy of Contract
2012 IECC Energy code
Engineering Affidavits for Engineered products
10TE: 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
Doe: Building Permit Revised 2014
tkoRTH '
BUILDING PERMIT 0* r D A14�,
TOWN OF NORTH ANDOVER
10
APPLICATION FOR PLAN EXAMINATION
J5
Permit No#: Date Received
Date Issued:
I IMPORTANT: Applicant must complete all items on this page
LOCATION
Print
PROPERTY OWNER
Print 100 Year Structure yes no
MAP PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
El New Building
0 Addition
11 Alteration
0 One family
0 Two or more family
No. of units:
11 Industrial
0 Commercial
0 Repair, replacement
11 Demolition
0 Assessory Bldg
[I Other
0 Others:
U. �:e!We—q
L--J-
FRI I a
&
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly
OWNER: Name: I Phone:
Address:
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License:
Home Improvement License:
ARCHITECT/ENGI NEER
Exp. Date:
Exp. Date:
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.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantv fund
..........
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0
Location
No. �z)l Date
Check #/17/93/
30072
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
Building Inspector
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Feb 18 16 10:17p Rick 0donnell 6033700151 P.1
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Branch Name: New England Date: _J__j
Branch Number: 31
Installation Address:
Purchaser(s):
Sold, Furnished and Installed by:
THD At -Home Services, Inc.
d/b/a The Home Depot At -Home Services
908 Boston Turnpike, Unit 1, Shrewsbury, MA 01545
Toll Free 877-903-3768
Federal ID # 75-2699460; ME Lic # C 02439; RI Cont. Lic# 16427
Crije XHIC.0565522; MA Home Improvement Contractor Reg. # 126893
" Al AZi�
City
22
Work Phone: Home Phone: Cell Phone:
Home Address:
(If different from Installation Address)
City
E-mail Address (to receive project communications and Home Depot updates):
El I DO NOT wish to receive any marketing emails from The Home Depot
State zip
Proiect Information: Undersigned ("Customer"), the owners of the property located at the above installation address, agrees to buy,
and THD At -Home Services, Inc. ("Me Home 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"):
Job #: aw—i iw—.—) ucts: Spec Sheet(s) #: Project Amount
EIRoofing ElSiding PFWindows U Insulation
P029 -5-3
197C 19 30 -00y
as� C, &,O�
OGuum/ Covers E]Entry Doors 0
1YO29537
Home Address:
(If different from Installation Address)
City
E-mail Address (to receive project communications and Home Depot updates):
El I DO NOT wish to receive any marketing emails from The Home Depot
State zip
Proiect Information: Undersigned ("Customer"), the owners of the property located at the above installation address, agrees to buy,
and THD At -Home Services, Inc. ("Me Home 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"):
Job #: aw—i iw—.—) ucts: Spec Sheet(s) #: Project Amount
Customer agrees that, immediately upon completion of the work for each Product, Customer %vil] execute a Completion Certificate
(one for each Product ns defined by an individual Spec Sheet) and pay any balance due. As applicable. each Customer under this
Contract agrees to bejointly 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 Home 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.
Pavment Summary: The Payment Summary # included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final payments by Product (as applicable).
NOTICE TO CUSTOMER
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 of termination, plus any other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS NIADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements, either
ofal or written, relating to said Products and Installation. This Agreement cannot be assigned or amended except by a writing signed
v Custorner and The Home Depot. Customer acknowledges and agrees that Customer has read, understands, voluntarily accepts the
dMs ofand has rec9kyed a copyoftbis Agreement.
171.
Customer's Signature Date
_j
CANCELLATION: CUSTOMER MAY CANCEL THIS
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
CUSTOMER'S STATE.
-NOTICE: ADDITIONAL TERMS AND CONDITIONS ARE STAT
Submitted
X
Sales Consultant's Signature Date
Telephone No.
Sales Consultant License No.
(as applirable)
ED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT
08-03-15 White— Branch File Yellow—Customer
EIRoofing ElSiding PFWindows U Insulation
P029 -5-3
$
901-2317
OGuum/ Covers E]Entry Doors 0
1YO29537
LIRoofing []Siding U Windows U Insulation
EIGutters/Covers [:]Entry Doors C1
EIRoofing [3Siding LJ Windows C] Insulation
$
(:]Gutters / Covers E]Entry Doors El
EIRoofing ClSiding [] Windows 0 Insulation
$
CJ(3utters/Covers []Entry Doors F1
Minimum 25% Deposit ofContract Amountdue uponexeadion oftliis contract
deposit
Total Contract Amount
1 $
Maine Porchasers triky not mom than one-third of the Contract Amount.
Customer agrees that, immediately upon completion of the work for each Product, Customer %vil] execute a Completion Certificate
(one for each Product ns defined by an individual Spec Sheet) and pay any balance due. As applicable. each Customer under this
Contract agrees to bejointly 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 Home 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.
Pavment Summary: The Payment Summary # included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final payments by Product (as applicable).
NOTICE TO CUSTOMER
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 of termination, plus any other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS NIADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements, either
ofal or written, relating to said Products and Installation. This Agreement cannot be assigned or amended except by a writing signed
v Custorner and The Home Depot. Customer acknowledges and agrees that Customer has read, understands, voluntarily accepts the
dMs ofand has rec9kyed a copyoftbis Agreement.
171.
Customer's Signature Date
_j
CANCELLATION: CUSTOMER MAY CANCEL THIS
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
CUSTOMER'S STATE.
-NOTICE: ADDITIONAL TERMS AND CONDITIONS ARE STAT
Submitted
X
Sales Consultant's Signature Date
Telephone No.
Sales Consultant License No.
(as applirable)
ED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT
08-03-15 White— Branch File Yellow—Customer
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
wwwmass.gov1dia
Nl� orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH TIRE PERMITTING AUTHORITY.
Name (Business/Organizafion/Individual):
Address:
City/State/Zi : lMh, yTJ (e
1P -j-_ Phone#:
Are you a.0employer? Check the appropriate box:
1. F_o;>1a. a employer with _,��employecs (full and/or part-time).*
2.M I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.[3 1 am a homeowner doing all work myself [No workers' comp. insurance required.] t
4.F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.M I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.1
6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. E] New construction
8. [] Remodeling
9. El Demolition
10 Building addition
I I. Electrical repairs or additions
12.EJ Plumbing repairs or additions
13.RlRooprepairs 4
F-1 "
14. C:3-6thr jojf))J��
*Any applicant that checks box # I 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.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' conip. policy number.
I am an employer that isproviding workers'compensation insurancefor my employees. Below is thepolicy andjob site
information. I . I I
Insurance Company
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: Lzq �AA, 1_�q City/State/Zip: �%Xo/m/ �
r �, �n, date).
Attach a copy of the workers' compensation policy &clar6iW bage (showing the policy number andexpirali
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification. n .4
I do hereby certift
ofperjury that the information provided above is true and 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. CityPrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
a
ACC>RV CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDNYYY)
02118/2016
r
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) 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
MARSH USA, INC.
TWO ALLIANCE CENTER
3560 LENOX ROAD, SUITE 2400
ATLANTA, GA 30326
CONTACT
NAME:
MC.N IFAX
No. EA: AIC, No):
E-MAIL
ADDRESS:
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE rq OCCUR
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A, Steadfast Insurance Company 26387
100492-HomeD-GAW*-16-17
INSURED
THD AT-HOME SERVICES, INC.
INSURER B: Zurich Arnehcan Insurance Co 16535
INSURER C: New Hampshire Ins Co 23841
DBA THE HOME DEPOT AT-HOME SERVICES
2690 CUMBERLAND PARKWAY, SUITE 300
ATLANTA, GA 30339
INSURER D : 111inclis Nalional Insurance Company 23817
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER- ATL -G03746646-14 RIZ-VIRION N"MR11=14-8
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. 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.
INSR
LTR
TYPE OF INSURANCE
ADDLSUBR
IM01
WVD
POLICY NUMBER
POLICY EFF
(MMIDDIYYM
POLICY EXP
(MMIDDIYYYY)
LIMITS
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE rq OCCUR
Manashi Mukhedee _3*LMNA.010"
GLO41187714-06
03101/2016
03/0112017
EACH OCCURRENCE $ 9,000,000
DAMAGE TO RENTED
PREMISES (Ea =ence) $ 1,000,000
MED EXP (Any one person) $ EXCLUDED
LIMITS OF POLICY XS
PERSONAL & ADV INJURY $ 9,000,000
OF SIR: $I M PER OCC
GEN'L AGGREGATE LIMIT APPLIES PER:
PRO- D
POLICY Ll IECT LOC
GENERAL AGGREGATE S 9,000,000
PRODUCTS - COMPIOP AGG $ 9,000,000
$
OTHER:
B
AUTOMOBILE
LIABILITY
BAP 2938863-13
03101/2016
03/01120017
COMBINED SINGLE LIMIT
(Ea acciden $ 1.000,000
X
ANY AUTO
BODILY INJURY (Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS
SELF INSURED AUTO PHY DMG
BODILY INJURY (Per accident) S
NON -OWNED
HIRED AUTOS AUTOS
1
PROPERZDAMAGE
(P.,..d S
$
UMBRELLA LIAB
IOCCUR
EACH OCCURRENCE $
EXCESS LIAB
CLAIMS -MADE
AGGREGATE $
DED RETENTION S
$
C
C
D
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORtPARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDS EN
(Mandatory in NH)
If tas e
S6d, scribe under
R PTION-OF OPERATIONS below
NIA
WC01 5519215 (AOS)
WC01 5519217 (AK,KY,NH,NJ,VT)
WC01 5519216 (FL)
Conitnued on Addffional Page
5310-112016
03/0112016
03101/2016
0310112017
03/01/2017
0310112017
X IPER
STATUTE I I 0KH
E.L. EACH ACCIDENT 1,000,000
$
FEL. DISEASE - EA EMPLOYEd S 1,ODO,000
E.L. DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached iF more space is required)
EVIDENCE OF INSURANCE
E;ER FIFIGATE HOLDER flAmrrll I ATInN
THD AT-HOME SERVICES, INC.
DBA THE HOME DEPOT AT-HOME SERVICES
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD
ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA, GA 30339
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukhedee _3*LMNA.010"
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
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ic 'of Consumer Affairs
,off e 2 d'� '��s�Regulation
10 Park Plaza - Suite 5170
Massachusetts 02116
Boston,
Home improvem i it ntractor Registration
THD AT HOME SERVICES, INC.
RICHARD FALLONE
.2690 CUMBERLAND PARKWAYS
ATLANTA, GA 30339
;CA I G 20M-05/11
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- t -IM . PRO - V,EMENT CONTRACTOR
Type: ,
Supplement Card
rHD AT HOME SER�
FHE HOME DEPO,T
RICHARD FALLONE
2690 CUMBERLAND
�tT5,M%, GA 30339
UndersecretarY
Registration: - 126893
Type: Supplement Card
Expiration: 8/3/2016
ite Address and return card. Mark reason for change.
I v— loyment F! Lost Card
Lj Address Lj Renew3 I_j P
Licens e or registration valid.for individul use only
before the expiratio-tv date. If found return to:
office of Consttmer Affairs and Business Regulation
10 Pafk-Plaza - Suite 5170
Boston, MA OZ116