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Home My WebLink AboutBuilding Permit #309-13 - 94 PETERS STREET 10/15/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received F)� Date Issued: Lo ' I P RTANT: Applicant must complete all items on this page PR®PERtGYf®WNER .� fPrim 100�Yea" rfOldlStructure GEL _ZZ-=ZONING�DIS;iTRIC�T' _ 'HistonckDistncf ye no11013PIS1 _. - _ h, r .Q. M. ,�Vil agel �. TYPE OF IMPROVEMENT PROPOS USE I Resid ial Non- Residential El New Buil , g One.family ❑Ad ' [ITwo or more family El Industrial ❑ ration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: 0 Demolition ❑ Other 7 . D;Septic3 .❑Welll ❑1Floodplam ❑1Netlands, Watershed�Dist�ct ❑sWater/Sewer DESCRIPTI�„�_GF--W RK TE FORME ~ 1 Id io a Type or Print Clearly) OWNER: Name: Phone: Address: C®NTRACT®R Name F _ _ - Address r Supe:rvlsor�s�Construction�License "�� _ Expo ®�a_te , _'_ � .. Hornelmproyement}License;.a h i 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: $ uC FEE: $ �� Check No.: ��'��`� /�� Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to a uarai Ntfnd Sr ag _ u _LVA, _. naureonia Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Sta ped Aans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ - TYPE OF SEWERAGE DISPOSAL " Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ 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 APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS ' HEALTH Reviewed on Signature R COMMENTS 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'gown Engineer: Signature: Located 384 Osgood Street FIRE DEPARTNIENI' Temp.Dumpsfer on'site yes ..no . Located at 12NMaih'is eet moa ` ;;M'� u •'_ f +:1 '-f�1' gY..�s''}.2eFta.kv 'L'i Y t� Fire Departmentasignatureldate'`"'";�, ,. „ 'jN f k; 1 . r y f,J a *TIS 0tShE`u" i? ? .'�4' r r✓, < to �S �- t ` .s'`- .i�.'.f ,; x ` , r `t GOMNiEIVTS: _• r a } s f .r. _�: < . �4;44 *+ � � . : Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Dieter 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-$1000 fine NOTES and DATA— (For department use ® Notified for pickup - Date E i I Doe.Building Permit Revised 2010 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) o 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: Doc.Building permit Revised 2012 Location C s No. 1 Date -a e - TOWN OF NORTH ANDOVER, fiat a r � q ` ,x . a Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ x ' Other Permit Fee $ TOTAL $ Check lat�� 25838 Building Inspector NORTH Town of Al. 6 ndover No. t _ LAK, h ver, Mass, d I, p A- coct"C"1%1cw y7' 1S U BOARD OF HEALTH PERMIT T L D Food/Kitchen Septic System THIS CERTIFIES THAT ................... ... BUILDING INSPECTOR ..U 1.............�'r.......... 1.�..! n.;. . ............................... has permission to erect .......................... buildings on ....a.: Foundation ..... - :w.�.o.�[........ ............. Rough to be occupied as .........�.......... '... ........1N..:l 11.'!...�.................................................................... Chimney provided that the person accepting thisermit shall 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough �p Final PERMIT EXPIRES IN 6 ELECTRICAL INSPECTOR UNLESS CONSTRUCT RT Rough Service ..................... ......................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SIDE Oct 01 12 11:50a p.1 HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: Bnch Name- Boston Date: THD At-Home Services,Inc. 5 d/b/a The Home Depot At-Home Services 345A Greenwood Street.Unit 2,Worcester,MA 01607 Toll Free(800)657-5182:Fax.(508)756-8823 Branch Number:31 Federal iD#75-2698460;ME Lic#C 02439;RI Cont.Uc#16427 CT Lic#HIC.0565522;N1 Home Improvement Contractor Reg.#126893 Installation Address: � DS AA City City State Zip Purchnser(s): Work Phone: Home Phone: Cell Phone: L [ 2 [ [ t [ I Home Address: (If different from installation Address) City State Zip [Xmad Address(to receive project communications and Home Depot updates): w�D W`��(0 All,anC ..C Cl—M DO NOT wish to receive any marketing emails from The Home Depot Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy. and THD At-Home Services,Inc-("The 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 Orden(collectively, "Contract"): Job#: u.-o xm.e i Products: Spec Sheets)#: Pr -ect Amount 7Ronfing Siding Windows ❑Insulation -2-3 C, $ f&qW k ❑Gutters I Covets El Entry Dam ❑ ❑Roofing []Siding ❑Windows ❑)nsulatiun �� $ 03utters t Covers []Entry Doors ❑ r !C t✓'=�1 ❑Rooting ❑Sidi.ng ❑Wmdots ❑Insulation ❑3utters/Covers ❑Entry Doors❑ ❑R<a,Cmg ❑Siding ❑W"indows ❑lnsulation ❑Gutters/Covers ❑Entry Doors ❑ minimum 25%Deposit of Contract Amomrtdue upon em-cutionofthis-aontruct. Total Contract Amount � O� Maine Purchasers may not deposit more than one-third ot-the ContractAmmmt Customer agrees that, immediately upon completion of the work for each Product,Customer will execute a Completion Certificate (one for each Product as dcfinud by an individual Spec Sheet) and pay any balance due- Ac applicable. each Customer under this Contract agurees to he 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 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 lend paint,other safety concerns,pricing errors or because work required to complete the job was not included int ntrac t Puvment Summarv: The Payment Summary It � (4�_L+ , 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 livled 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 Authorised Service Provider through the date of termination,plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOWIE DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Aceeutance and Authorization: Customer agrees and understands that this Agreement is llm entire agreement between Customer and The Homc Depot with retard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to sai u s and installation.This Agreement cannot be assigned or amended except by a writing signed by Customer and The Ho epot. -tomer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has receive copy o' is Agreem ynt. Subi by: X (Z Customer's Sig a Sales Consultant's Si nature Date Telephone No. X T Customer'sS rnaurre Date Sales Consultant License No. CANCELLATION--(, STOMER MAY CANCEL THIS (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THF THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A kORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTiCB:ADDITIONAL TERMS AND CONDITIONS ARF STATED ON TUE REV EASE SIDE AND ARE PART OF THN COV fltACl' 10-04-11 C-SC Whita-Branch Fae Yellow-Cu.omer Sep 28 12 05;44p p.1 Sep Zf 12 1172Up PA IM)ba gwmMOVXMKWT COMPACT rPLFAM DI"TM Sold,HaniAwd amd fmtalbdby- Hahc THD At-E� toe.int ` d1Na Ther lime Degmt At-PlaA1--A0 tme Servkcs 345ACriaWWMA SLtoef.Aait2,Woreeaxr WA Diem Tal Frw(Srltt}bS7•SIUZ-F—(3083 7548843 ltraaeM Tera tm:31 Fe3std m d?3,2w"m be Lie f C Mw. COdtac torl�b€126893 LTLiC:«lf 45653T2:3di'iS�� f rttpp +pi` Shale 7jP vvbwk P1 Conn= wYt EL. tome A�nra: , zip(i feom Ad&vw) i�l�Anf Y2` A-C Lo�M (te r-4— -d aDa" mpaaoea): '4 DO NOT w;A ea receive any :�� oa of lite d aloe awn iww'w1ionaaareas.mapo grow b� At-H=9 earn Iac.("� Dqw r)fees m�aeli er gm rttaflB�Em uw ioatr13m6s®f"lost■]rebo® of whisb� "M this hast bT ,u � ,ax t>dcw�a m lite reBaeoexd spec 9BeNa),an Oen(mllxavew. Mfiff=i.B�,daaiE with aw sppamme Suis suP9�aaa Suma --auwJw'd hereto sada�r Chaa�e •Ctisarst"): Jo`# 4m..esa..M) � waataa! ,xtmaoas s ��3 ' t [�c,alrrarCoawa p�t�O �264s W l pX..asicoals❑eeay t)eoes Cl.• w-Mdw- tasstgon g iC,,m O&AyD=Mrl kodtfim s 00somicam"0sn"roe® Q l►a�Zssc e>��oSebaax+A.,®ra,e�,.a�.wa.ss.aei..oaraoe< �cwtlrfUt AZ1�r.B S �f7? ataieelrsrfaessa�e.Id�porRmare�.medtidr[tbet�otrapAmaast. tbata®or sgms t}ma,ie,,,dbwy up=eomipldioa of the wont for tach Prothro.Cu=mw wJ taiaa�lt s Campletsm CetbS= (oat&r cacti prod=m dcomed by as indlvldual Spec Shed)and pay any blamer=dee. As applicable,each f�elamer code r tIIk Coins aprco w tx jofiotly sea and lia�le>loetetrldex. The Home D =ot reoavee the riplrt W iaeas a Oiderorlrlaaieitta Caotmet err aay !s[oda+a(a}inettided lssre196 at hom.s acIdiif IhPHQW.DgW arita aa&==dsuviocptovidwmn dasizers&ait aaertd pafpcmiisobli®alioasduc to a attaabi w peobko visa tlro hoose,emmamm ad hmms salt as mold. -or lead Pim ad-salEty ocai�ms.¢i�46 arm or woilcregairdl m wmptsse the jobwas smut kcbmbd bi tbo C/oausm Domm r The Pay-2d Stammary a lade 14 a 4f as part ai this cam seu tocib ms toter Camraet smamt mad pwjnmiw segahma for"depodts amd5eel paymom bV Peo&Wt(ss app+imbla} NOTICE TO CrSUilaaP3[ .ee you axe ss i ma to■ �el-ia rit9aa Csoaraet sot Bs.tuare Do w alp a Cemepiedoe Ceatilk (awae tears Cosplsfien�la fbt•ase!!laced Pradoct ws ddlord byd Spec )ms's wosic m 111110 1►ndau t is complefir- L tie creat at to�idtna ere!k6 Oaer6+ef.Caamasar awes to Bay The)(iota no aaib Of wtat W Mar,wooers aad arr leesbl,TW How Depot or Au&Ariaed S��Woe llewlder the dale K +Ps.-Y'k.amommu eret hmr*iMita tw snowed man ap p T9E 8r 0 Wor MAY WrKHHOLD AK0U V M aW$D TO TEM AU6d3 DSPD><lFBrl141 TM DITOWZ Plar AYMOM Cat arm= FAVMMM MAME, V1111HIOUT r�d[PYNfi THE HOME oBd' rs O1mm FSS l@01:FaDCOVKRY OF SUCH ADMUNM Castotaor "drmd�kn&tlai flm AKeamm is ehe suite vVccwatt bmwem Ceutmoer sm a-na�¢oe =pat wn rapid ra We and laatalbdmmsvroes and;wtaase�d��m�-au_�d and Sys dArer ornl vrwee tey��to laid Illation.This A aomoftrc i aadende d esoelx try a wnfiag arp}iad by Qsmmix and 3Leliotis i7r�as. a rta+rl -ad�S Out Cnswm er bas rwd,vvdmsbnds,vohmtority a-4ft the terms o bier of Z Csataznces 94-dare Date Sures vltaat's SiHtaeme Dace 7 Uob m N,63 Z Sat q cawmees Saks Coesoh=LkAMW Na CA=93,4711M OMR WAY CAMEL79f� raar+l�> AG&REDaEYT VVYFfaDtitT PTsP(ALTY OR OBLMA110N DSYO'T SY PEMM 1. ON THE maw S DAY AFTEII ffiGIaDZG -1 AGRD<M11111 iP. rm STATE SCY!'1•LZMMXx A.TTMERM 11309WIM COMADS A i+MM TO USE IF ONE 18 srSCRriCAMY PHISCUM BY LAW IN Ct GTCM ER'$i STATIL WOMB=AtlMaT1WALTZR2MAA000)MrSOMA1t2ltATKDCMTM1 1MEMRA MWAMO IMSCaNTaACr i1�9bi1 f3$t: VWMM-t![a , Me Ydar-CsstmeK• 77 Workers j tinnsma0*17n ��9:r.' � . 1', s o��3�t� lty�# ��3 '".a,.y�. r��,l�:y' 3., . �� LOU _r�M kle-W-21111 T_..__._.._....�__ - ......_. ..,.._-. __�--r--ter-- �� H .vg131� ($ustness(CJrganizatioiArdividua;) ' Address. L� �rr a i /Statei Zi Gt.l �0 3 0�3 I Phone#e ?v tY P• Are you an employer? Check the ppropriate box; Type of project(require ft I am a employer with �.p 4. ® I am a general contractor and I 6. [].New construction employees(full and/or partALne).* have hired the sub-contractors listed on the,attached sheet. 7. ®Remodeling t 2.0 I'am a sole proprietor or partner- Thest:sub-contractors have ship.and have no.employees 8: ®Demolition employees and have workers' Building addition working for me m any capacity. - t 9• ® S ' [No workers'comp.insurance comp'Insurance. 10.®Electrical repairs or additions • required.] S. ❑ �Ve are a corporation and its 3.(] I a homeowner doing all work officers have exercised their I I.[]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.®Ra epairs . insurance required.]t c. 152, §1(4),and we have no ] employees. [No workers' comp.insurance required.] ;Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homedwners who submit this affidavit indicating they are doing all work and then bice outside contractors rust 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 whether or not those entities have. employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. .1 am an employer that is providing workers'compensation insurance for my employees. Below!s the policy and job site - information. Insurance Company Name:r Policy#or Self-ins.Lic.#: 19 6 Expiration Date: Job Site Address: City/StatelZip: Attach a copy of the workers'compensa ou 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 DIMor insurance coverage verification. Y do hereby certify u der he irs d aides of perJury that the information provided abo a true and correct. Si afar : L Date• Phone : 4n) ®,f)3cia1 use only. Do not write in this area,to be completed by e-y or town official: City or Town: Permit/License# IssuingAuthority(circle one): a 1.Board of health 2.Building Department 3.City/Town Clerk 4.-Electrical,Inspector 5. Plumbing Vector 6.Other . • DATE,.MMIDDNYYY) 02/2?/201.2 CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTiFIC.ATE 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 BETIJIJEEN 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 Comer rights to the certificate holder in lieu of such endorsement(s). _��O_JN_T_ACT PRODUCER 1-866-966-4664 NAME: Marsh USA Inc. PHONE TA—X -- (AIC,No,Ex 1; [(A/C,No): homedepot.certrequest@marsh.com E-MAILADDRESS: Two Alliance Center, 3560 Lenox Road, Suite 2400 Atlanta, GA 30326 INSURER(S)AFFORDING COVERAGE NAIC Fax (212) 948-0902 INSURERA: Steadfast ins Co 26387 INSURED INSURER B: Zurich American Ins Co 16535 The Home Depot, Inc. Home Depot U.S.A., Inc. INSURER C: New Hampshire Ins Cc i23841 2455 Paces Ferry Road NW INSURER D: Illinois Natl Ins Co 23817 Building C-20 Atlanta, GA 30339 INSURER E: NATIONALUNION FIRE INS CO OF PITTS 19445 INSURER F: Illinois union Ins Co 27960 COVERAGES CERTIFICATE NUMBER: 25776028 REVISION NUMBER: THIS IS TO CERTIFY THAT THE ROLICIES 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 ADDL SUBRI POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSR WVQ POLICY NUMBER (MMIDDIYYYY) (MM/DDIYYYY) LIMITS A GENERAL LIABILITY GL04887714-02 03/01/12 03/01/13 EACH OCCURRENCE $ 9,000,000 X _DAMAGE TO RENTED 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $EXCLUDED X LIMITS OF POLICY XS $ 9,000,000 COMMERCIAL PERSONAL&ADV INJURY X OF SIR: $lM PER OCC GENERALA GGREGATE $ 9,000,000 GENIL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 9,000,000 -, POLICY F� PRO- F-] JECT oLOC $ —.- B AUTOMOBILE LIABILITY BAP 2938863-09 03/01/12 03/01/13 COMBINED SINGLE LIMIT (E,accident) $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident) X SELF INSURED PHY DMG $ UMEIRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ IDED T-TRETENTION$ $ C WORKERS COMPENSATION WC019736915 (ADS) 03/01/1 - TH- , 03/01/13 X I TWOCSTATURY"'ITS OR AND EMPLOYERS'LIABILITY YIN D ANY PROPRIETOR/PARTNER/EXECUTIVE= WC019736917 (FL) 03/01/1, 03/01/13 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? IN NIA E (Mandatory In NH) WC019736916 (CA) 03/01/1, 03/01/13 E.L.DISEASE-EA EMPLOYE q$ 1,000,000 If yes,describe Sdd 6 under e DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000'000 E Workers Compensation WC1192494 (QSI) 03/01/1, 03/01/13 SIR (AOS)/SIR (GA) IM/750,000 C Workers Compensation WC019736918 (WI) 03/01/1 03/01/13 F TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1 1 03/01/13 Occurrence/SIR 30M/1M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES PERRY ROAD NW BUILDING C-20 AUTHORIZED REPRESENTATIVE ATLANTA, GA 30339 USA 1981.!2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORW� Jthornton hd . 0 ice of Consumer Affaar and Bus' ess 1Zegulatioig 10 Park Plaza - Suite 5170 Boston, ssachus at 0211 ,Hoimprove . '. ontractorR.egistr.ation - Registratlon: ..12U0 c� Type: . Supplement Cafr1 ; 4 s--- w Expiration:" 8/3/2014 LA The Home Depot At-Home Setvi ' RICHAF�D' .rALLONE m r ', a 2690 CUMBERLAND-PARKWAY = ' ATLANTA, GA 30339 - - • v \��L'iAr" ��•y�� Update Address and return card.Mirk renson.for change: (� Address Renewal .n .Rmpioyment fJ' Last Cnrd ' bp8-C;A1 0 50M-04/04-G101218' xL\ Office or t;onsumer Affnirs&Business Regulation License or registration valid.for lndividul use only before the expiration date. If found rcturn"Jo:' OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulntion RegiStratlon��;12f8�3 ',Typo: 10 ParkPlazn-Suite 5170 Ex irat(tiii!'8l3' ' 4:.. Supplement Card Boston,IVU 02116 ' - p =1n i-r Tho Home Depol"A1=N4tiie;: ,!'ryf. es RICHARDFALL(SN��1 ,•_-".?' . 7690 CUMEiERLAAQ f?AkfS - rLjat `GA'30339-'.�s*;; of Mid with ut si nature Undersecretary A Massachusetts -Department of Public Safety Board of Building Regulations and Standards Cotistruction Supervisor License:CS-088756 SCOTT A MA6iILLkV �f IO PARK AV x �x SALEM NHA307X t 3T -71 Expiration commissioner 03129/2014 � tOS'a►aurel� $i 9%91' k�Iftil8�R »fl4 * �+. .. 080 Oi�ee 0 oo's IYlCP � HOME IMPROVQMENT CONTRACTOR ACTOR Reptstm tn: 166306 Type. ExplmMon: 117{2014 DDA ill.LAN COW. M*C'1'INq SCOTT MACMILLAN 10 PARK AVE. . SALEM,NH 03079 lJndetzaecry