HomeMy WebLinkAboutMiscellaneous - 28 Kingston Street-C—\ The Commonwealth of Massachusetts
j, JV, Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
- www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/individual):
Address:
�,Phone 7-2!
0�11,
City/State/Zip-&_ �Ji
Type of project (required):
6. El New construction
7. Remodeling
8. Demolition
9. El Building addition
10 -El Electrical repairs or additions
I I -El Plumbing repairs or additions
12 -El Roof repairs
13.1� `6ther_)4����,
— . sect on below showing their workers compensation policy information.
Homeowners who submit this affid it indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
�Contractors that check this box mustavattached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurancefor my employees. Belowisthr� andjobsite
information.
Insurance Company Name:
Policy # or Self -ins, Lic. #: W
Job Site Address -
Expiration Date:— :�3 1_/
City/State/Zip N i &t��
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify un in that the information provided above is true and co)
S Date:
Phone #:
Official use only. Do not write in this area, to he completed by city or town officiaL
City or Town:
Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
Contact Person:
4. Electrical Inspector 5. Plumbing Inspector
Phone#:
Are you an employer? Check the appropriate bo
1. 0 1 am a employer with
4. Vam a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. am a sole proprietor or partner-
listed on the attached sheet,
.1
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. We are a corporation and its
required.]
officers have exercised their
3. 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1 (4), and we have no
insurance required.] *
employees. [No workers'
—alsoril+
comp. insurance requi red.]
*Any applicant that checks box # I must +1,
I
Type of project (required):
6. El New construction
7. Remodeling
8. Demolition
9. El Building addition
10 -El Electrical repairs or additions
I I -El Plumbing repairs or additions
12 -El Roof repairs
13.1� `6ther_)4����,
— . sect on below showing their workers compensation policy information.
Homeowners who submit this affid it indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
�Contractors that check this box mustavattached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurancefor my employees. Belowisthr� andjobsite
information.
Insurance Company Name:
Policy # or Self -ins, Lic. #: W
Job Site Address -
Expiration Date:— :�3 1_/
City/State/Zip N i &t��
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify un in that the information provided above is true and co)
S Date:
Phone #:
Official use only. Do not write in this area, to he completed by city or town officiaL
City or Town:
Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
Contact Person:
4. Electrical Inspector 5. Plumbing Inspector
Phone#:
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AT-HOME
SERVICES
Job # 7693981
To whom it may concern,
Re: address: —Solomon Berman- --28 Kingston St. N. Andover Ma
Concerning the above location, We give the Home Depot approval to install
Number of winclows-8
Style ( Double Hung/ Casement, name type)_DH's & front window DH/Pic/DH_(All same as exsisting)
Color White.
Manufacturer —Simonton by Vantage Point
Exterior finish as agreed to be PVC (wrap trim)? _Yes (were needed) color—White
We agree to the grid or lack of grid configuration _N/A
Are grids between the panes of glass? N/A
******All Window styles are to remain the same with exact same look and style
As stated these proposed windows do meet with the Condo Management approval.
Signed
orrfiq �
int name
V q
Title 4-11 Phone #
Date: 71311.11-1
HONIE 1AMOVEMENT CONTRA.C17
PLEASE READ THIS
Branch Name: Biaroollorth &South Datel-A-Ij Iq Said PUMi-od and Installed by
T140 I
d/b/a The Rome Depot At -Home Srvinc
11r. her: 31 and 33 cch
908 Boston Turnpike- Unit -1. Slirewsbury, MA 01,545
Fedcril ID - 7.1,.2 roll Free 87? 903-3768
696-M; MF Lie M439,,1110.mu L,,: i64ip
Lit 4' HIC 0565522-14A Honic kapro%enjeor Cow,,a_ Re, - 12158913
- �Vl
Inswilation Address: L4L ��64ni
city
State Zip
Purchmser(s):
r-- -- -- Alork Phone. Home Phoj!�L
> --Tr - Cell Phone:
(101DAA 6A 1qN1 771- 1-7VS
r
Rome Address:
(If different from Ingallaraoin Address 1
City State Zip
E-maii Address (to reccive, praject communications and Home Depol updates)
El I DO NOT wlsh to receive arx, marketing emmh from The Kon�
e Depot
PrOject Jultirmatill - Undersigned ("CiLstomer"), the Owners of the property localod at the aboNc jistallarlo
and I HV At-flonle Services, in n addi c�,, jgret:�, to but
ne. ("Tile Home Depot") agree-, to fumish. dcli%cr and arrange for the installation ( Installation,,. ;�
all materiak de�cribed on Ore below and kin the referenced §p� sheet(b), all of whiciliare incorporated into this Contracl bN fts
reference. along with any applu able State Supplement and Payment Samp a
, Contract')� ulty tiachod creto and any Change Orders (colice6vel�.
Job
Spec Shett(sl ProiectAmount
Siding , 11roduct,': -0
Roofing 7A%Vind.,,, —Inul2,flrr. 7 --
[]Guucr�w Cown OEntry Dcors El 7,?
EIGundrs t CoNers bEntry Dwn,
Ljxoomig LjNlame U lvmdow----� inn ............
0GUMens I Covcr, ClEntry Door, S
—Wi.doNvs 0 J.�—ulation-
EIGuricis Cirver, ElEntryLhors E]
Alinimurn 2517' , Deposit of Contract Xmotmt duL upon execution orthis comracL
�oaa
p- of Total Contract Amount
"lain — '
deposa-Womthnone4hird ofthe ContractAmmult. S
Cubtoiner agTevN thW, immedijic�x upon ;omplcuon of the work $or each Product. castolp"T %V111 Celliflale
fune ibr each Product ii, defined by an ted"Idual Spec Shecti and pay ,my Ndarl�e due A, ipplic-ilik e,;a�h c'ustomcr undcr this
COAlract -jpcs ro N. tolmly dnd.,uvcrJI% obligated and liable hereunder
nic Home Derit'i reserves the right it, Is, U.� .1 Chorge Order oI tc-rimmile this Contract or �aly imfii�Jual Produca- mcjp�je, j)erem. al
its discretion, it The Home Deoi o, if- authorizcd service providet determine, thzit 11 Pertorm ts obliganon, due !o ;, tru"urtj
problem with the home, environmental hatardN mich is tno!d. asbes" or lead pallit other Wet) c4,ifceras Picini, effor% m hck:ause
work requirod to completo djejob v_ 1,)j -licluilvilm the Contr4LL.
Pavincut Summal-N; Th, Payment Summai- oA��A?Z=.
11%luded a% part of Elas Ciartrdvt� el, forth the total
Contravt amount and paymcm, requirml fi,r tnudeposi(s and final payments by Product (a, applicable?.
NOTICE TO CUSTONIER
You are entitled to a completely filled-in copy or life- Contract at the time you sign. Do [lot sig1l a Completion Certificate triote;
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets) before work on that Product
is complete.
fn the event of termination of this Coutracl, Customer agrecs� to pay 'Me Home Depot the coAs of materials, labor, eKitznses
and services provided by The Home Depot or Authorized Service Provider through life date of termination, plus any other
amounts s.et forth in this Agreement or allowed under applicable'law. THE HOME DEPOT INU%Y W11THHOLD AMOUNIS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAY51ENT OR oTHER PAYNNIENTS NIADE, �VMHOLT
LDVJITING THE, HOME DEPOT'S OTHER REMEDIES FOR RECONERIt OF St CH AMOUNjIFS.
Anft,andAuthorization Customer agruva� and mide"tands that dll� A�Qret:nnent is the <nure agreement beivcen Cu.�tomcr
ic D 7
mid Pl with regard to the Products and lostallatiLn services und superbede,, all prior discuN5ion� andaIrcemems. eiffir.-i
oral or written, relating to -mid Products and Install.atioti, 711u, Agreement cannot be assigned or amended except by a writing signed
by Customer and The Home Depot Customer acknowledgcs and agrees that Customer has read. understands. voluntarily accepts the
terms ofand has receii ved a copy of this Agreement.
Acce&d by: Submitted by:
X
'tomler'�s Signaturc Date Sales Con It �c NW:
X -- �T— — Telephone No'.
Custii;les igniturc Date
Sales Consultant License No.
CANCELLATION: CVSTONIE�R MAY CANCEL THIS
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICETOTHE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINKSS
DAY AYfER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRJBED BY LAW IN
CUSTOMER'S STATE.
NOTICE: ADD1110NALTE"15 AND CONDITIONS ARF STATED OMTHE REVERSE, SIDE AND ',RE PART01, THIS CONI RA(T
11-08-13 While- Branch File Yeftow-Cuslomer
HOME IMPROV`EMENT coNTRAp,
PLEASE READ THIS
S old, un
f/iished and Installed by:
Branch Name: Boston North & South Dat(.-U,/Z-q/ THD At -Home Services, Inc.
d/b/a The Horne Depot At-Honic Services
Branch Number: 31 and 33 908 Boston Turnpike, Unit 1. Shrewsbury, MA 0 1545
Toll Free 877-903-3768
Federal TD # 7-5-1-698460: ME Lic # C 02439, RI Cont. Ucft 10427
CT Lic # HIC.0565522:1MA Home Improvement Contractor Rea. # 126893
zq �-/t ' � �4vi/i St 6V
Installation Address*: Vk- k&kv
�e-- z via
City State Zip
1) 11 4v1% AX7 Ph via& Hnnip Phone, Cell Phone;
Home Address:
(It'different ftorn Installation Address)
City
E-mail Address (to receive project communications and Horne Depot updates):
F] I DO NOT wish to receive any rnarl�etjng eniaiis from The Home Depot
Z!�
PrQiect Information. Undersigned ("Customer"). the owners of the property located at the above installation address, agrees to buy.
and THD At-Hoine Services, 1�c. ("khe Home Depot") agrees to furnish- deliver and arrange for the installation ("Installation") of
all materials described on the below and on (he referenced Spec Shcct(s)� all ol ' which ar� incorporated into this Contract by ThiS
reference, along with any applicable State Supplement and Payment Surnmary attached hereto and any Change Orders (collectively.
"Contract"):
State Zip
10b#' 0 -.4 + * S11vt-,ShLet(,-0 #: Proiect Amoont
147Y] 171 -
Home Address:
(It'different ftorn Installation Address)
City
E-mail Address (to receive project communications and Horne Depot updates):
F] I DO NOT wish to receive any rnarl�etjng eniaiis from The Home Depot
Z!�
PrQiect Information. Undersigned ("Customer"). the owners of the property located at the above installation address, agrees to buy.
and THD At-Hoine Services, 1�c. ("khe Home Depot") agrees to furnish- deliver and arrange for the installation ("Installation") of
all materials described on the below and on (he referenced Spec Shcct(s)� all ol ' which ar� incorporated into this Contract by ThiS
reference, along with any applicable State Supplement and Payment Surnmary attached hereto and any Change Orders (collectively.
"Contract"):
State Zip
10b#' 0 -.4 + * S11vt-,ShLet(,-0 #: Proiect Amoont
Cus(orner agrees thaL immediately Upon C0111plttiOn Of the work for each Product. Custoincr execute a ('011111letion CO-tificato
this
(one for each ProdUCt as defined by an individual Spec Sheet) in(] pa� any balance (ILIC. Ns applicable. each CLP�tonler Undel
Contract agrecs to be jointly and severally obligated and liable hereunder.
The Home DcpoL 1-eSel-Vec, tile right to issue U Chan,aC Order or terminate this Contract or anv individual 11�roduct(,) included herein. at
its discretion. if The Home Dep(A 01- its authorized servicL provider deterillities that it cannot perform its ot)[il!at . iO . 11S Ji -le to a Structural
problem with the honie. environinenta! hazards such as inold, asbestos or lead paint. other �,al-ety coilcerns, pricing errors or because
wor� required to coinplete (he job VVaS )lot included in the Contract.
Payment Summary: The Payment Sunu-nar-N. # inCILKIC(l is part of this Contract. -sets fordi the total
Contract amount and palyincnu� required for the dcposits and final pa\ ments b� Product (its applicable).
NOTICE TO cusToNIER
You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate (note:
(here 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, Custouter agrees to pay The Horne Depot the costs of materials, labor, expenses
and services prmided bN The Home Depot or Authorized Service Provider through the date oftermitiation, piws any other
amounts set forth in this Agreement or allowed under applicable llaw. THE HOME DEPOT MAY IVITHHOLD AM61JNTS
OWED TO THE HOME DFPOT FROM T14E DEPOSIT PAYMENT OR OTHER PAYMENTS MADF, WITHOUT
LIMITING T14F HOME DEPOT*S OT1-IER REMEDWS FOR RE-1COVERY OF SUCH AMOUNTS.
Accepuince and Authorization: Custonier ia,ai,ees and undcr,�tands that this A-reci-nent is tile entire agreement (vtween Cusioiner
and The lionic Depot with re-ard to the Products and installation services and supersedes all prior dkcussions and aorcenients. either
oral or written. relatino to said Products and Twtallation. This ALrcerrient cannot be assinned or amended except by it wribilil signed
by Custonier arid The Honic Depot. Customer acknoMcd-es and agrees that Customer has rea(l, underslands. voluntarily accepts the
terms ofand has received a copy of this Ag�reeinent.
i ks
El Windows LJ in sul a ti on
EIGutters/Cover, ElEnLry Doors, 0
DRocifing El 5�i d i —n gEJ Windows 0 Insulation
S
[:]Gutter-,/ Coven, UEntryDoor,� [I—
nizoofing. LMS—i-ding 0 Windorws 0 Insulation
[]Gutters / Covers [3Entry Doors n—
T]Roofin(l SidimT Windows 'Insulation
S
00luerN/Covers ElEntryDoors 1-1
Minimum 2.5% Deposit of Contract.-Wount due upon execution of this contract
Total Contract Amount
$ 6, -z-1 2-
NMaine Pumhasers inay not deposit inore thati one-third of the Contrdct Ani0lint.
/ 1---)
Cus(orner agrees thaL immediately Upon C0111plttiOn Of the work for each Product. Custoincr execute a ('011111letion CO-tificato
this
(one for each ProdUCt as defined by an individual Spec Sheet) in(] pa� any balance (ILIC. Ns applicable. each CLP�tonler Undel
Contract agrecs to be jointly and severally obligated and liable hereunder.
The Home DcpoL 1-eSel-Vec, tile right to issue U Chan,aC Order or terminate this Contract or anv individual 11�roduct(,) included herein. at
its discretion. if The Home Dep(A 01- its authorized servicL provider deterillities that it cannot perform its ot)[il!at . iO . 11S Ji -le to a Structural
problem with the honie. environinenta! hazards such as inold, asbestos or lead paint. other �,al-ety coilcerns, pricing errors or because
wor� required to coinplete (he job VVaS )lot included in the Contract.
Payment Summary: The Payment Sunu-nar-N. # inCILKIC(l is part of this Contract. -sets fordi the total
Contract amount and palyincnu� required for the dcposits and final pa\ ments b� Product (its applicable).
NOTICE TO cusToNIER
You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate (note:
(here 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, Custouter agrees to pay The Horne Depot the costs of materials, labor, expenses
and services prmided bN The Home Depot or Authorized Service Provider through the date oftermitiation, piws any other
amounts set forth in this Agreement or allowed under applicable llaw. THE HOME DEPOT MAY IVITHHOLD AM61JNTS
OWED TO THE HOME DFPOT FROM T14E DEPOSIT PAYMENT OR OTHER PAYMENTS MADF, WITHOUT
LIMITING T14F HOME DEPOT*S OT1-IER REMEDWS FOR RE-1COVERY OF SUCH AMOUNTS.
Accepuince and Authorization: Custonier ia,ai,ees and undcr,�tands that this A-reci-nent is tile entire agreement (vtween Cusioiner
and The lionic Depot with re-ard to the Products and installation services and supersedes all prior dkcussions and aorcenients. either
oral or written. relatino to said Products and Twtallation. This ALrcerrient cannot be assinned or amended except by it wribilil signed
by Custonier arid The Honic Depot. Customer acknoMcd-es and agrees that Customer has rea(l, underslands. voluntarily accepts the
terms ofand has received a copy of this Ag�reeinent.
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CNIO
exn'
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement'Contractor'Registration
THD AT HOME SERVICES, INC -
RICHARD TROIA
2690 CUMBERLAND PARKWAY SUITE 300
ATLANTA, GA 30339
SCA I * MM -05-111
otuct orCussumer Afbirs & Business Regulation
NTRACTOR
Type -
Supplement Card
THD AT HOME SERVICES. INd
THE HOME DEPOT AT HOME SERVICES
RICHARD TROIA
2690 CUMBERLAND PARKWAY S 41�1��
X%.5,M GA 30339 Undersecretary
RegistraWn: 126893
Type. Supplement Card
ExpiraWn: 8/312016
Update Address and return card. Mark reason for change.
Renewal --I Employment 7--1 Lost Card
Address 1 —1
fAcesse or n%istration valid for individul use only
before the expiration date. If found return to:
Office o(Cousumer Affairs and Business Regulation
10 Park Plaza - Suite 5179
Bomony M 4,02114
Nutvalid�r�ou6ig
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I
DATE (MM/DDNYYY)
CERTIFICATE OF LIABILITY INSURANCE 1 02119014
THIS ql�RT!FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPONTHE CERTIFICATE HOLDER. THIS
CERTIFICATE D6tS'N6T AFFIRMATIVELY OR NEGATIVELY AMEND,'EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELIOW.'. - THIS CERTIFICATE- OF.INSURANCE DOES NOT ' CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSU . RER(S), AUTHORIZED
REPFtESENTATIVE OR PRODUCER, AND THE- CERTIFICATE HOLDER.
19—pORTANT: if the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUB ROGATION IS WAIVED, subject to
the terms andconditions of the policy, certain policies may require'an endorsement. A statement'on this certificate does not confer rights to the
certlfiit:�te holder In lieu of such enclorsement(s).
CONTeCT
PRODUCER NAM
MARSH LISA, INC. PII�NE IFAX
TWO ALLIANCE CENTER WC No, Exti, A/C
E-MAIL
3560 LENOX ROAD, SUITE 240D ADDRESS:
ATLANTA, GA 30326 IMqIIRrRfS1 AFFORDING COVERAGE NAIC I
i -- I 0%=%1nrIr%1J NIIMRFR-3
GQVtKAU=
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN. ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOT'WITHSTANDING 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._
'N'R
,T,
A
TYPE OF INSURANCE
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAJMS-MADE M OCCUR
Steadfast Insurance Company
26387
100492-H6meD.GAW-14-15
POLICY EFF
fMMIDDNYYY)
03101/2014 "
INSURERA:
LIMITS
9,000,000
EACH OCCURRENCE
DAMAGE TO 1,000,000
PREMISES (4=11s�
MED EXP (Any one Person) EXCLUDED
.
PERSONAL S, ADV INJURY S 9,000,000
GENERAL AGGREGATE $ 9,000,000
Zurich American Insurance CO
16535
IOSURED
THO AT-HOME SERVICES. INC.
INSURER 0:
New Hampshire Ins Co
23641
DRKTHE HOME DEPOT AT-HOME SERVICES
PRODUCTS - COMP/OP A . GO S 9,000,000
INSUIRE-R' C '
23817
2455 PACES FERRY ROAD
8AP 2938863-11
SELF INSURED AUTO PHY DMG
INSURER D:
1111nols National insurance Company
GEITL AGGREGATE LIMIT APPLIES PER:
7X POLICY[ PEROT F I LOC
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
ATLANTA, GA 30339
BODILY INJURY (Per person) $
B �DILY INJURT(P—.r.c.1d.nt) S
RTYDAMAGE $
PROPERTY DAMAGE
P r nt
UMBRELLA LIAO. 1
EXCESS IJAB
OCCUR
CLAIMS -MADE
i -- I 0%=%1nrIr%1J NIIMRFR-3
GQVtKAU=
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN. ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOT'WITHSTANDING 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._
'N'R
,T,
A
TYPE OF INSURANCE
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAJMS-MADE M OCCUR
ADDL
INSR
SUBRI,
WVD
POLICY NUMBER-
GL04887714-04 -
LIMITS OF POLICY XS
OF SIP, $1 M PER OCC
POLICY EFF
fMMIDDNYYY)
03101/2014 "
POLICY EXP
(MMIDDIYYYYI
03101/2015
LIMITS
9,000,000
EACH OCCURRENCE
DAMAGE TO 1,000,000
PREMISES (4=11s�
MED EXP (Any one Person) EXCLUDED
.
PERSONAL S, ADV INJURY S 9,000,000
GENERAL AGGREGATE $ 9,000,000
PRODUCTS - COMP/OP A . GO S 9,000,000
8
8AP 2938863-11
SELF INSURED AUTO PHY DMG
03/01/2014
GEITL AGGREGATE LIMIT APPLIES PER:
7X POLICY[ PEROT F I LOC
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
COMBINED SINGLE LIMIT 1,000,000
(Ell accident)
BODILY INJURY (Per person) $
B �DILY INJURT(P—.r.c.1d.nt) S
RTYDAMAGE $
PROPERTY DAMAGE
P r nt
UMBRELLA LIAO. 1
EXCESS IJAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
AGGRE ATE $
DEDT _TRETEN71ONS
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNER1EXECUTIVE
OFFICERtMEMBER EXCLUDED? FN
(Mandatory in NH)
If gs, clascriM under
SCRIPITION OF 0 ERATIONS below
WORKERS COMPENSATION
NIA
I
WC049101882 (AOS)
WC049101884 (AK, AZ VA)
WC049101883 (FL)
I
WC049101885 (KY, NC, NH, VT)
0310112014
0310112014
0310112014
03101/2014
0310112015
03101/2015
03101015
03101 015
X OC STATu-��OTH-
RY - T
E.L. EACH ACCIDENT $ 1,00,000
C
C
E.L. DISEASE - EA EMPLOYEE S 000,000
1,000,000
E.L. DISEASE. POUCY LIMIT
(EL) LIMIT 1,000,000
C
C
WC049101886 (NJ)
03101/2014
0310112015
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additlonal Remarks Schedule, If more space is required)
EVIDENCE OF INSURANCE
C F—RI I I- V.; A I t
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 POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Mw-sh USA Inc.
Manashl Mukhedee
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W ivoQ-1.
7L,, A (-f-,Dr) -A 1— —,rl— �f ACORD
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Named
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CP D 1050
nb
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N F R Cj,-,�g Mode
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a/4 Inch GlBzlhg
LOW E
Fill Grille in Air SP;3cB
Ar
WANCE RATINGS
NEaU-y PE
E
solar litzi
1.70
JORAL RERFORMAN�E RATINGS
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0
0.40
ORC
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