HomeMy WebLinkAboutBuilding Permit #961-16 - 39 WOODLEA ROAD 3/9/2016*1 il� A� W �i L -F
Permit NO:� W 1 .11
Date Issued:
-_ i� - 'I . _ - I 9;��c
BUILDING PERMIT
0
TOWN OF NORTH ANDOVER #_
APPLICATION FOR PLAN EXAMINATION
Date Received
'TED
AC US
IMPORTANT: Applicant Must complete
all items on this page
Resio4ntial
Non- Residential
El New Building
ne family
0 Addition
'10CATION
14CIA
4.0
0 Oferation
No. of units:
El Commercial
/Repair, replacement
D Assessory Bldg
0 Others:
D Demolition
PROPERTry--OWNER.'r
Septic O.Well
El F 0
-16 dpI6'ih' El Wetlands'� 111;�:Jj.'Wa'tershedois
0 Water/Sewer K-
I
,MA PARC EL
Z ONING DISTRICT
Historic, Distric��,',, yes..
no
a chine, hoo,,,Village yes
_�m
TYPE OF IMPROVEMENT
PROPOSED USE--
Resio4ntial
Non- Residential
El New Building
ne family
0 Addition
0 Two or more family
0 Industrial
0 Oferation
No. of units:
El Commercial
/Repair, replacement
D Assessory Bldg
0 Others:
D Demolition
0 Other
Septic O.Well
El F 0
-16 dpI6'ih' El Wetlands'� 111;�:Jj.'Wa'tershedois
0 Water/Sewer K-
I
OWNER: Name:
Identification Please Type or Print Clearly)
P
ARCH ITECT/ENGI NEER 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.- A - 12� 10 10
NOTE: Persons contracth;g;vith unregistered contractors do not have
,bEcrals Vthe guarantyfund
- Z� P_ - F
7,117-
7— ign�aturlb') 0
i nature of Agent/OWnror e
f
2, ---,
'RBUILDING PERMIT h 6 "6
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Date Received Fr C1
Permit No#:
Date Issued: IMPORTANT: App icant 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 qew Building
11 One family
[I Addition
El Two or more family
El Industrial
0 Alteration
No. of units:
0 commercial
0 Repair, replacement
El Assessory Bldg
0 Others:
0 Demolition
El Other
N
517
GAPIVII 7.
L)tbL;KIV I 1UN ur vvumn i u 1- L-1- -A-11--
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
A -1 -1.-- _
Contractor Name:
Email:
Address:
I Supervisor's Construction License:
Home Improvement License:
Phone:
Exp. Date:
Ell]
ARCH ITECT/ENGINEER Phone:
M
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: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
L
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
IOTE: All dumpster permits require sign off from Fire Department prior to i ssuance of Bldg Permit
FTTI�'��R
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)
- E n . g . i n . eer . i . n . g Aff . id - avi . t - s - for-'E-ngfneered- products
TE: 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)
.1. 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
Plans Submitted Plans Waived Certified Plo�:Plaeh-`[] Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swim'Ring P00J1 El
Well El
To
Tobacco Sales
Food Packaging/Sales 0
Private (septic tank etc. El
Penuanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
I
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature'
CONSERVATION Reviewed on Si
qnature
COMMENTS
HEALTH
COMMENTS
Reviewed on
nature
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes
Planning Board Decision: Comm
Conservation Decision: Comments
Water & Sewer Connection Driveway Permit
DEW Town Engineer: Signature:
il
I 130A
Street
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.$100-$l 000 fine
NOTES and DATA — (For department use)
... .... ... ........ . - - ----- -
L3 Notified for pickup Call Email
Date Time Contact Name
Doc.Building Permit Revised 2014
W 'i I I -- —
-51- 11 J1
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
OTE: All dumpster permits require sign off from Fire Department prior to i ssuance. of Bldg Permit
Addition Or Decks
�6 Building Permit Application
4, Certified Surveyed Plot Plan
zi-, Workers Comp Affidavit
4- 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)
- Eng in . eer in . g .. A I ff . i .- d - avits- for E-ngineered products
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
,j- Building Permit Application '
4�. Certified Proposed Plot Plan
4z Photo of H.I.C. And C.S.L. Licenses
4�, Workers Comp Affidavit
6 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
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
T%oRTfJ
BUILDING PERMIT 'r- D ll 41,
TOWN OF NORTH ANDOVER 0
APPLICATION FOR PLAN EXAMINATION
Permit No#: Date Received
Date Issued: 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
USE
—PROPOSED
Residential
Non- Residential
El New Building
[] One family
0 Addition
El Two or more family
El Industrial
El Alteration
No. of units:
El Commercial
0 Repair, replacement
El Assessory Bldg
0 Others:
0 Demolition
El Other
Lell
Le
'all
U1=bL#K1r I [UN ur vvvmm i %j uv- F— xe
Identification - Please Type or Print Clearly
OWNER: Name: Phone:
A -1 -1
I-ItuUIU00.
Contractor Name: Phone:
Email:
Address:
Supervisor's Construction License:
Home Improvement License:
Exp. Date:
ARCH ITECT/ENGI NEER — Phon
Address:
Date:
Reg. N
FEE SCHEDULE. BULDING PERMIT.- =00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED 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
17
7
a
WA
5�" I' K�
Location C)
No. Date
Check# 1999 05
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee $
TOTAL
Building Inspector
2:
69k
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Feb 20 16 10:04p Rick Odonnell
6033780151
P -
Sold. Furnished and Installed by:
,rI-ID At-Honic Services, Inc.
Branch Name: New Wand Date:
Branch Number: 31
Installation Address,
Purchitser(s):
d1h1a I lie I Ititne Depot At-riollic acry cesW18 Boston Turnpike, Unit I—Shrews1wry. MA 01545
Toll Free 877-903-3769
Federal ID # 75-2698460'. MI: Lic # C 02439. Rl Com. I jc# 16427
C,7 I-ic 0 1-1101565522: MA Honic Improvement Ctinlractor Reg. IF 12WB
1? 9 Aa 11f,4 —a�g—Y5-
City State Zi p
Home Addrcsw
(li'difrercni from installation Address)
Work
City
9 79-15?0 - 03 W
State Zip
E-mail Address (to receive project communicalions and Home Depot updales')`
0 1 DO NOT wish to receive any marketing cmail% from The Home Depot at tile above installation address. agrec" to bu)%
Project Information: Undersigned ("Customee'). the owners of the property located n
and THD At -Horne Services, Inc. (**The Home Depot") agrees (oi furnish. deliver and arninge lor the installation (-InstRilatiri ) of
all materials described an the below and on the referenced Spec Shect(s)� all of which 11-C irkC0rp0r-1lCd into IlliN Contract by this
i-cferericc, along with an), applicable State Supplement and Prtyment Summary attachW hereto and any Change Orders (collect iVOY.
"Contract");
T.i.
Q cSheet(s)#: Project Anitaint
Customer agrees that. immediately upon completion of the work for each Product. Customer %vitl e.xL�cute it Completion Certiticate
(one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable, each Cust0mer under thi%
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 individuat Product(s) included herein, at
its discretion, if The Home Depot of 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 err4jrs Or bCCause
work required to complete the job was not included in the Contract.
pavnw _rv: The payment Summary included as part or this Contract. sets forth tile total
Ig Summa
contract amount and payments required for the deposits and final payments by Product (as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filledmin copy of the Contract at the time you sign. Dit not sign a Completion Certificate (note:
there is One Completion CertW'cate for each listed Product as defined by indi-wititrAl Spec Sheets) before work an that Product
is complete.
in the event of termination of this Contract, Customer agrees to pay The Home Depot the costs of materials, labor, exWnses
and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any other
meat or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
amounts set forth in this Agree %A1ITHOUT
OWED To THE HOME DEPOT FTtOM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE,
LIMMNG THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH ANIOUNTS.
d Authorization: Customer agrees and understands that this Agreement is tile entire agreement between Customer
-sions and agri-en nts. either
tance an iscus, le
CT
, c
and e Home t with regard to the Products and Installation services and supersedes all prior di
or coded except by a writing signed
oral or written, relating to said Product% and installation. 7bis Agreement cannix be assigned am
by customer and The Home Depot- Customer acknowledges and agrees that Customer has read. understands. volunturilv accePts the
terms of and has received a copy of this Agreement-
npAled dc4dow �rified S!ubmitted by-:
0212(VI61:1-MEST X
X GF7M-SQ7L-KWB7.5QGC _�ted by
Date Sales Consultant's Sienature Date
Customer's Signature Telephone No.
x Date Sales Consultarit Ucense No.
Customer's Signature (as applicah1c)
fLANCELLATION: CUS'fONIER MAy CANCEL TIUS
lmvpzAij VV no d'jR1.1V.ATI()N
Product%:
ation
Windo,vs- U ln,.I�
Roo
90-3 / 0 �,Z
or,.u.rjc-o,,cr, [3Entry DrKrs El —
LJRoofing USiding U WIT100MU'S Insulation
OGutters, /Covers OlEntry Don" 0—
EIRooring []Siding U Window% LJ In%ulatiOn
$
OGutters I Covers OEntry Doors 0-
-----7R—oofin—g
Siding 0 Window; 0 Insulation
oGutters/Covems 013.ntrylDoons 0—
"it.,
Mirsimnin 2s% Depoisit of Contract Aniount due up- exemdon of this -sitract.
Total Contract Amount
$ �ZS,0(3
Maine purchams nay not dqww intre than ane4hird oftbe Contrad AmmuL
Customer agrees that. immediately upon completion of the work for each Product. Customer %vitl e.xL�cute it Completion Certiticate
(one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable, each Cust0mer under thi%
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 individuat Product(s) included herein, at
its discretion, if The Home Depot of 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 err4jrs Or bCCause
work required to complete the job was not included in the Contract.
pavnw _rv: The payment Summary included as part or this Contract. sets forth tile total
Ig Summa
contract amount and payments required for the deposits and final payments by Product (as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filledmin copy of the Contract at the time you sign. Dit not sign a Completion Certificate (note:
there is One Completion CertW'cate for each listed Product as defined by indi-wititrAl Spec Sheets) before work an that Product
is complete.
in the event of termination of this Contract, Customer agrees to pay The Home Depot the costs of materials, labor, exWnses
and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any other
meat or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
amounts set forth in this Agree %A1ITHOUT
OWED To THE HOME DEPOT FTtOM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE,
LIMMNG THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH ANIOUNTS.
d Authorization: Customer agrees and understands that this Agreement is tile entire agreement between Customer
-sions and agri-en nts. either
tance an iscus, le
CT
, c
and e Home t with regard to the Products and Installation services and supersedes all prior di
or coded except by a writing signed
oral or written, relating to said Product% and installation. 7bis Agreement cannix be assigned am
by customer and The Home Depot- Customer acknowledges and agrees that Customer has read. understands. volunturilv accePts the
terms of and has received a copy of this Agreement-
npAled dc4dow �rified S!ubmitted by-:
0212(VI61:1-MEST X
X GF7M-SQ7L-KWB7.5QGC _�ted by
Date Sales Consultant's Sienature Date
Customer's Signature Telephone No.
x Date Sales Consultarit Ucense No.
Customer's Signature (as applicah1c)
fLANCELLATION: CUS'fONIER MAy CANCEL TIUS
lmvpzAij VV no d'jR1.1V.ATI()N
The Commonwealth ofMassachusetts
Department of IndustrialAceidents
I Congress Street, Suite 100
Boston, AM 02114-2017
www.mass.gov1dia
Workers' Compensation Insurance Affidav'it: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERAUTTING AUTHORITY.
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #:
Are you a employer? Check the appropriate box:
I.E;�Iarn employer with ;� employees (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.[] 1 am a homeowner doing all work myself [No workers' comp. insurance required]
4. M I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensur6 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 -t
6. F] We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no employees. [Nio workers' comp. insurance required.]
Type of project (required):
T E] New construction
8. E] Remodeling
9. El Demolition
10 Building addition
I L Electrical repairs or additions
12. Plumbing repairs or additions
13.[]R
. ;P13.
14.[2r6ther I () 15n
14 - -
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
� 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' comp. policy number -
I am an employer that is providing workers'compensation insurancefor my employees. Below is thepolicy andjob site
information. I I i — -
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Job Site Address: `2- 1 1A I V
a - .0
Attach a copy of the workers' compendation policy
Expiration Date:
City/State/Zip:
(showing the policy number and expiration date).
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 penaltiesin 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
I do hereby un�r thy �� and
,, raldes ofperjury that the information provided abover true and correct.
cerl IT" I
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town:
PermitUcense #
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 #:
ACC>R" CERTIFICATE OF LIABILITY INSURANCE
DATE (MMiDDNYYY)
02/18/2016
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 poficies 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:
PHONE
(AIC. No. W*
E-MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC 1#
INSURER A: Steadfast Insurance Company 26387
100492-HomeD-GAW*-16-17
INSURED
THD AT-HOME SERVICES, INC.
DBA THE HOME DEPOT AT-HOME SERVICES
INSURER B Zurich American Insurance Co, 16535
INSURER c New Hampshire Ins Co 23841
INSURER D Illinois Nalional Insurance Company 23817
2690 CUMBERLAND PARKWAY, SUITE 300
ATLANTA, GA 30339
INSURER E:
INSURER F:
r1n1k1=0Af1_=4z CERTIFICATE NUMBER, ATL -003746646-14 REVISION NUmBER:8
THIS 13 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 INSURANCE
DDL
SUBR
WVD
POLICY NUMBER
POLICY EFF
fMMIDDNYYY)
POLICY EXP
(M DNYYYI
LIMITS
A
-OF
X COMMERCIAL G I ENFRAL LIABILITY
GLO488T714-06
03/0112016
03101/2017
EACH OCCURRENCE S 9,000,000
CLAIMS -MADE M OCCUR
DAMAGE TO RENTED
PREMISES (Ea occurrence) $ 1,000,000
MED EXP (Any one person) S EXCLUDED
LIMITS OF POLICY XS
OF SIR: $1M PER OCC
PERSONAL & ADVINJURY S 9,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $ 9,000,000
PRODUCTS - COMP/OP AGG $ 9,000,000
POLICY 1:1 RO- —] LOC
JPECT F
S
OTHER:
8
AUTOMOBILE LIABILITY
BAP 293886343
0310112016
03/0112017
99=)SINGLE LIMIT $ 1,000,000
BODILY INJURY (Per person) S
X ANY AUTO
BODILY INJURY (Per accident) S
ALL OWNED SCHEDULED
SELF INSURED AUTO PHY DMG
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
AGGREGATE
EXCESS LIAB
CLAIMS -MADE
rDED RETENTION$
S
C
C
D
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETORIPARTNEFZ/FXMI. I
OFFICER/MEMBER EXCLUDED? N
(Mandatory in NH)
�NIA
WC01 5519215 (ADS)
WC01 5519217 (AK,KY,NH,NJ,VT)
WC01 5519216 (FL)
0310112016
03101/2016
0310112016
0310112017
03101/20`17
03/0112017
X ERTU -l'
I PSTA TE OETR' -
E.L. EACH ACCIDENT $ 1,000,000
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
E.L. DISEASE - POLICY LIMIT $ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATION!
Conbued on Addifional Page
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD '101, Additional Remarks Schedule, may be attached if mom space is required)
EVIDENCE OF INSURANCE
THD AT-HOME SERVICES, INC.
DBA THE HOME DEPOT AT-HOME SERVICES
2455 PACES FERRY ROAD
ATLANTA, GA 30339
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POUCY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukhelee _JVtDU%AAA931" I'V��
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
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Office of Consumer Affairs Business Regulation
10 Park Plaza - Suite 5170
Boston, Mas achusetts 02116
Home lmprovem�w ntractor Registration
THD AT HOME SERVICES, INC.
RICHARD FALLONE
2690 CUMBERLAND PARKWAYS
ATLANTA, GA 30339
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,�E IMPROVEMENT CONTRACTOR
THD AT HOME SER' v
THE HOME DEPOT �
RICHARD FALLONE
2690 CUMBERLAND
XtAL5kM, GA 30339
Type:
Supplement Card
CES
UndersecretarY
Registration: 7 126893
Type: Supplement Card
Expiration: 8/312016
ite Address and return card. Mark reason for change.
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L_] Address [] Renewal Lj rmpioymenL L_j —
License or registration valid for individul use only
before the expiration date. If found return. to:
Office of Consumer Affairs and Bus - mess Regulation
10 Park Plaza - Suite 5170
Boston, MA 02 116