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HomeMy WebLinkAboutMiscellaneous - 624 CHICKERING ROAD 4/30/2018 624 CHICKERING ROAD 210/084.0-0033-0000.0 Date...7.1-31 , f t NORTH TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ass^cHUsE� This certifies that ....../.:� .c...-l...�`s.......... ��'n �� ....................... .................... has permission to perform .............................................:................................. hiring in the building of.......... ��'�'` at......... 3 ............... �F�� � ..... rth Ando >,M 1. . ... ..............: ... �f �ULic.No.�. . ............5EL . Fee... ........ �/...t%'. .,�..f�..re.. .......... ,.. / CTRICALINSPECTOR Check # Commonwealth of Massachusetts Urfit:iul u,c 0111y Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupttitcy and t=ee Checked [Rev. 11/99) leave bl:uik APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W All wurk to be pertitnned in accordant w' WORK 0 c with the Mae• • ElectricalR K .�.ultusUts (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Uate: t-ode t 1:C). �zz CMR f z.ati City ur Town of: By this applTo the Inspeclor o 'Wirc.N': ication the undersigned gives notice of is oilier intentioat to perform the elecu•ical work described below. Location (Street & Number) Owner or Tenant n Owner's Address Telephone Nc��_� .r/G Is this permit in conjunction with a building permit? Yes ❑ N7uthrization Purpose of Building (Check Appropriate Box) l)tilitY No. Existing Service Atnps / Volts Overhead ❑ Undgrd ❑ No, of Meters New Service Ani cis 1 volts Overlmad ❑ Undgrd ❑ N° °r Meters Number of Fecders and Auipacity -- Location and Nature of Proposed Electrical Work: Com lesion o 'the following table ma be waived by rhe Ircr 'Clar p Wires. No. of Recessed Fixtures No.of Ceil.-Susp.(Paddle) Fails ° ° of ll Transformers KVA No. of Lighting Outlets No. of Hot Tubs "Cenerators I(VA No. of Lighting Fixtures Swimmin Pool Above ❑ rt- ❑ mcrgency ig t tng Swimming °rttd. rud. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRF, ALARMS No. of Zones No. ofSwitchcs No. of Gas Burners °• o llctectioil and Initiating Devices No. of Ranges No. of Air Cond. otal Tons No. of Alerting Devices No. of Waste Disposers !!Tun m _n_s ... ap Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW I unicipa oil ❑ Other No. of Dryers Heating Appliances KW ecurity 'ysterns- o. o aterNo, of Devi r E uivalcnt Heaters KW t o. o f Data Wiring: Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs elecominunicattons firing: No. of Motors ToUl HP OTHER: — No.of Devices or F. uivale:tt Attach additional detail of desired. or as required by the Inspector of Wirer. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue lite licensee provides proof of liability insurance including-Completed operation" o Y e e unless o P p non"covera,e or its substantial equivalent. The undersigned certifies that such cov rage is In force, and has exhibited pro°f of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify: ) Estimated Value of Electrical Work.- (When Datc) (Waters required by municipal policy.) Work to Start: Inspections to be requested in accordance nee with MEC Rule IU, and upon completion. !certify, under opmlins and penalties of perjury, at the information un t/ris applic tion * trite and complete. FIRM NAME: LIC. NO.: Licensee: Signatu' lC. NO.: 0�72SL (If applicable, a ter "exe pt"in the license nee r/ e.) 3 Address: 8 s. Tel. No.: S/ OWNRR'S INSUP ANCE RIVER. t am aware that dte tceast does not overhe liability insurance No.: norma y required by law. By my signature below, l hereby waive this requirement. f am the(check one) owner ❑ owner's ag Owner/Agent Signature Telep'uonc tio. PCRIYMT FEE: S 4r- NORTi-� own of 6 Andover 0 No. - - __ _ dover, Mass., COCMIC EWICK ���oRATED BOARD OF HEALTH PERMIT T DFood/Kitche S tOS m Cq BUIL ING INSP TOR THIS CERTIFIES THAT... ...... ...4 ....Siwe........C'� .......... ........... ,iCl2P.e�;� .... Foundation has permission to erect....... buildiNson ) ........ �rrl� ..... Rough tobe occupiedas................ ........................ . ......��....................................................... c ' provided that the person accepting this permit shall in every respect conform to the terms of the application on file in F' al 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 to PES EXPIRES THS ELECTRICAL INSPECTOR UNLESS CONSTR TION Rough ........ ............. ...................................... - Service y BUILDING INSPECTOR incl Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal 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. IAORTH BUILDING PERMIT oFtLEo 1616 �tio TOWN OF NORTH ANDOVER 1 APPLICATION FOR PLAN EXAMINATION !- z + . /�O i Date Received RQ�RATEU Pea`�9 Permit No#: SITS C us�c Date Issued: I RTA.NT:Applicant must complete all items on this page LOCATION /t tint r PROPERTY OWNER a -16V 4 . 11 Print 100 Year Structure yesCDno MAP PARCEL: ZONING DISTRICT:_ Historic Machine Shop Village yesistrict yes no TYPE OF IMPROVEMENT PROPOSED USE Resid ntial Non- Residential ❑ New Building ne family ❑Fepair, iion ❑Two or more family El Industrial ❑ ation No. of units: ❑ Commercial replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other - -� 0tWate "shed®istrict s . 41 DESCRIPTIO plNetlantls j ❑; ep�c� ❑�Well - - i DESCRIPTIO T RFOR ED: dentification- Pleasq Type or Print Clearly vq OWNER: Name: Phone: Address: Contractor Name: Phone: !.` Email: r--- .�-- Address: Supervisor's Construction License: ( Exp. Date: Home Improvement License: � Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.-$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FLEE: $ Check No.: Receipt No.: 1A vz-� NOTE: Persons con Ing Ith nrregistered contract 0 no have accels to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ [Public YPE OF SEWERAGE DISPOSAL I Sewer ❑ Swin17Y17Y1 Pools Tanning/Massage/BodyArrt ❑ g 41 W ❑ Tobacco Sales ❑ t Food Packaging/Sales : ❑t Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF o U FORM PLANNING DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zo,iing Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer Connection/SDriveway Permit DPW Town Engineer: Signature: DEIaAi �TMd911 Located 384 Osgood Street hl r , - Te um 1, rnp;D Aster on site .,yeS no, Locafetl at 12,4+Main:St�eet • ' - - •� -- -`- _.• - FiretDe par#r�� • gnafiur�/date ,_.. . .... 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, avast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$1oo-$1000 fine NOTES and DATA-- Gorr department use) Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks a, 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 products 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 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 Doc:Building Permit Revised 2014 Location "I No. �JI�o Date . - TOWN OF NORTH ANDOVER LF r, . Certificate of Occupancy $ Building/Frame Permit Fee $ -► Foundation Permit Fee $ Other Permit Fee $ 4 TOTAL $ Check# �� r r► C �/Building Inspector t%O R TH own o ? EAndover 0 k . 0. C, ver, Mass, o L.wN! 1. COC NIC Nl WICK V ��p�RATED APa,`�y S U BOARD OF HEALTH Food/Kitchen PERMIT T LD 11,� Septic System S THIS CERTIFIES THAT ..................... :,,.,,. �. 'J°�i _ , ,,,,,,,,,,,,,,,,,,, ,,, ,,,,,,,,,,, ,, BUILDING INSPECTOR .�4�_t has permission to erect .......................... buildings on .....!� .... !. �,1�!..... ��;�^ Foundation t. Rough to be occupied as ............... ..........ee.lf:�6 .dvr�"..........................`.iJ, .................................. Chimney provided that the person accepting this permit 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TS Rough Service .................. ...... .. r.+...r............................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. NORTH own Of C, ver, Mass, l &C'4 b 2,6 cocNic«ew�cw � A�RATEO AP���S S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ;:4S�^'�-'J0� BUILDING INSPECTOR ..................................................................... ......t............................................... Foundation has permission to erect buildings on ...... 24 .... In Rough ............. ........ee.112611to be occupied as -I....... `........X .................................. Chimney . .. ........" ....... provided that the person accepting this permit 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION �ATS Rough Service ................... ...... .. K,...w:............................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. —HO ME IMPROVEMENT CONTRACT PLEASE READ THIS D !S /S Sold,Furnished and Installed by: Branch Name:New England Date/ / THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services Branch Number:31 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free 877-903-3768 Federal ID#75-2698460;ME Lic#C 02439;RI Cont.Lic# 16427 CT Lic#HIC.0565522;MA Home Improvement Contractor Reg_#126893 Installation Address: OXY5 City State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: r Home Address: (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑ I 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 Orders(collectively "Contract"): ,lob#: (Internal Reference) P oducts: Spec Sheet(s)#: Pra'ect Amount C& j^�( (.� El Roofing Siding indows Insulation �f `r ❑Gutters/Coversntry Doors ❑ Roofing ElSiding Windows Insulation []Gutters/Covers ❑Entry Doors ❑ $ Roofing Siding Windows Insulation ❑Gutters/Covers ❑Entry Doors❑ Roofing Siding Windows E3 Insulation ❑Gutters/Covers ❑Entry Doors ❑ $ Minimum 25%Deposit of Contract Amount due upon execution of this contract. Total Contract Amount $ Maine Purchasers may not deposit more than one-third of the Contract Amount Customer agrees that. immediately upon completion of the work for each Product, Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable, each Customer under this 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 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. Payment Summary: The Payment Summary # II 7�"5�zZ- , 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 AMOUNT'S 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. 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 oral o nt relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed (Ims ustomer a d The Home Depot. Customer acknowledges and agrees that Customer has read..understands, voluntarily accepts the of and h s receiv a copy of this Agreement. epted : Submitted by: dA l 1 a -!s i �, ■ Work area will be contained i� Pre-Renovation Form " Date i NAT-19276 � This form is used to document compliance with the requirements of the Federal 1 Lead-Based Paint Renovation, Repair,and Painting Program after April 2014. t t' Customer Address JobNumber(s) _ Z ct 6 T80 q1 �''�" ' �` V `��✓ 4 OCCUPANT CONFIRMATION -- ■ Dust will be minimized Pamphlet Receipt I have received a copy of the lead hazard information pamphlet informing me of L the potential risk of the lead hazard exposure from renovation activity to be f performed in my dwelling unit. i received this pamphlet before work began. .4 i * Home Year Built llms " ,A Enter the year my home was built. If my Home Year Built is Pre-1978,my home requires lead paint testing to determine whether Lead-Safe Work Practices are necessary per EPA or State regulations. ■ Work area will be cleaned up If my Home Year Built is 1978 or after, Lead-Safe Work Practices are not required. thoroughly Print Name of Own -occupant , { f nature f Ow u " y SignVturof Pe—An Cfiagyrng Lead Pamphlet Delivery W_ Ilk. s " , SEE STATE SPECIFIC FORMS ON REVERSE SIDE The Commonwealth of Massachusetts Department of Industrial Accidents X Congress Street,Suite 100 Boston,MA 02114-2017 www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legribly Name(Business/Organization/Individual): r> Address: OCity/State/Zip: Phone#: Are you employer?Check the appropriate box: Type of project(required): 1. I am a employer wi42(2--employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. EJ Remodeling any capacity.(No workers'comp.insurance required.) 3. I am a homeowner doing all work myself t 9. El Demolition ❑ ng y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property.ro I will 10E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.Q epairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§I(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 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. lam an employer that is providing workers'co enation insurance for my employees. Below is the policy and job site information. r-- Insurance Company Name: Policy#or Self-ins.Lic.#: L9Expiration Date: r Job Site Address: City/State/Zip: ^ Attach a copy of the workers'compensation policy declaraIs n page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the aip ties perjury that the information provided above is ue and correct Si ature: Date: .-- Phone#: Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: PermittLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#- CERTIFICATE OF LIABILITY INSURANCE I CA'tt�l�cc � 07i15C'Q�,.15 } THIS CERTIFICATE IS ISSUED AS A MAT17ER OF INFORMATION ONLY AND CONFERS NO RIGHTS UF4N THE CrR;IF1C:t1 HOLDER iriiS ? CERTIFICATE DOES NOT AFFIRMAMELY OR-NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES R&RE; TN1S..CEI2TIFiCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN! THE ISSUING INSURE4(S), AUTHORIZED REPRESENTATlYE_OR PRODUCER,AND THE CERTIFICATE HOLDER f IMPORTANT: If thecertiT7eate holder is an ADDITIONAL INSURED,the !i ies must be endorsed. If SUBROGATION IS NIANED,;object to the germs and Conditions o€.the .o!!c certain policies may requiro an end dor erneni q statement an this certir?cai_.> oes not confer certificate holder in lieu of such endorsement(s), r rights to the PRODUCER MARSH USA,INC. CONTACT T'A'O ALLIANCE CEN i ER PHONE FAX 3560 LENOX ROAD,SUITE 2400 Juc Not: ATLANTA,GA 30326 DDRE ASS: 100492-HomeD-GAW'-15.16 INSURER S AFFORDING COVERAGE NAIL A INSURED INSMER A.Steadfast lgsurance company 126387 THD AT-HOME SERb10ES.INC. 2tlrch Am''' rrisiiaeR e. .. - encan insurance Co 16535 DBA THE HOME DEPOTAT-HOME SERVICES 2690 CUMBERIAii6PARKWAY,SUITE 300 rNSURER C New HaffiPWte Ins CO 23841 ATLANTA,GA 30339InisusER b:9rtItois Nalidnal Insurance Company 23817 ItJ$URER E COVERAGES1NsuREii ": ..:.. •. . CERTIFICATE NUMBER: ATL-10374065.43. REVISION NUMBER:B THIS f5 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN.ISSUED TO THE.INSURED NAtv1ED AI3dVE FOF:THE POLICY PERIOD INDICATED. PIOTVbI fH8TANDING AN`! REQUIf EIV1EN T`,TERM OR CONDMItIN"OF ANY•. CERTIFICATE MAY BE ISSUED QR MAY.PERTAIN, THE INSURANCE AFFORDED BY THE PO IES DESCR BEDOHEREIEN 5 $UB E T TO ALL i}H H T IS S EXCLUSIONS AND C©NDITIONS OF SUCH POLIIEs.LIMITS SHOVIM MAY)1AVE BEEN REDIjCE4 9Y PAIQ ELHlR$$: LTR TYPE OF INSURANCE A 0 B FOLIC EFF PO lili,Y EXP A X COMMERCIAL GENERAL LIABILITY POLICY NUMBER MMlDDIYYYY MMl0D LI�ATS_ GLO4887714.0 03/01/2015 03101i201t; rich occiiRRENCE s 9,000,ODO CLAIMS-MADE OCCUR )A.A EZOREN D. LIMITS OF POLICY XS PREMISES Ea.o'c`currence $ 1,000,OCO OF SIR:51 M PER OCC MED EXP'(Any dn6 Person) S EXCLUDED GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL 8 A6V.INJURY 5 9,000,000 X POLICY u PRO- JcCT LOC GENERAL-AGGP.E . GATE $ 9,ODO,ODO (.OTHER: PRODUCTS-COMNOPAGG S 9,POO,QD0 D AUTOMOBILE UABILRY BAP 2938863-12 S 03/01/2015 03/01/2Q76 COMBINED SINGLE LIMIT X ANY AUTO Ea accident 5 1,000,000 AUTOSALL 01 SCHEDULED BODILYJURY(per INperson) $ SELF INSURED AUTO PHY DMG NONOWNED BODILY INJURY!Per accident) S HIREDAU70S AUTOS PROPERTY DAMAGE . Peracddent S UMBRELLA UAB OCCUR S EXCESS UAB CLAIMS MADE EACH OCCURRENCE S - AGGREGATE S OED'.-- RETEhCf10N 5 C WORKERS COAIPENSATIQN 0017731493(AOS} 0310112015 03/0112016 X PER 0TH- 8 C AND EMPLOYERS'UI181UTY Y I N ANYPROPRIEYOR/PARTNERIEXECu FIVE C017731496(AK,KY,NH,NJ,VI) 0310112015 03/01/2016 STATUTE ER D OFFICER/MEMJSEREXCLUDED? -N-. NIA El EACH ACCIDENT S 1,000OCO IMandatory In NH) C017731494(FL) 03/0112015 03/01/2018 DqS describe under EL DISEASE-EA EMPLOYE S 1,0(10,00(1 DESCRIPTION OF OPERATIONS balmy Conitnued on Addifionai Page E.LDISEASE-POLICY LIMIT S 1,OOl1,ODC DESCRIPTION OF OPERATIONS i LOCATIONS I VEHICLES MCORD 101,Additional Rema EVIDENCE OF INSURANCE rks Schedule,may be attached 1f more space Is required) E CERTIFICATE HOLDER CANCELLATION THD AT HOME SERVICES,INC. DBA THE HOME DEPOT AT-HOME SERVICES SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELPJtRED IN " ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Ino. � -� '•'-ti�. '�'71f. .1�.•^i�-�•i��••:t:TJl.'i f'_1✓�"avV Y/u� F i�;v'k--�l��'�n?='.•:,i}7:'.•'.ii=t f�;':.'-.:i.._,�. - '�'3ti `°" •, w•is+.•fr £-+f.3•Iniw, ;�� "y�1e ���.'�. �r I� =M �kJ� N� Li .t{ =ie1.i'o: g y _ _ T -. Sued>>iY .•v r-, BAP.1,15 THD AT HOME SER ICES, .. AF FAR, 'AY 6 IT 3.00.PYS 10 .0 $3 -. Vpdeta Adams Ind relan tal-&Kari M-mm fffr col:aAgl- AddrE � � �-19r� t�f•JIrLJ(.I+7J•'Y:f��tJ C��-':�1'�'��f/rlA.:,r'r�� - u3a�i �� 4 3i fflx and i3�si at on' _ tilt-, t�lla`fir(S r 1 73ap3�4`I�3�a's y D3 �ly fiSs�PPuS S Se q O� $ d boret�2_nI6`711�5'11i G��n , am"�r<�,�n��ed;wtr�S�naaES scarf��asime��e n1�it t ti T �J��;�.,'1�^rE�.w�Tala�u:,'f�.5 ', .. 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