The URL can be used to link to this page

B-19-960 - 0008 BENGAL LANE - Building Permit' I �00 konAn� The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling O (This Section For Official Use Only).. Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#,for locations forwhich a street address is not available) t 0 No.and`itreet j City/Town Zip Code - Name of Building(if applicable) t SECTION 2:PROPOSED WORK. Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendixl) ' Change of Use ❑ Change of Occupancy ❑ r _ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: r SECT'ION.3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING.RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING I4EIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto' F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ f, I: Institutional I-1❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1❑ S-2❑ U: Utility❑' Special Use O and please describe below: Special Use: SECTION 6.CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Debris Removal•it Perm : Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p required❑or trench or specify: PrN ate❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: �I:�t Listi rig:Cununaion Il r,cy.I,'n,:cs: -......_....._........__-............--- - .. .. Not Applicable❑ Is Structure within airport approach area? is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?:- �' - Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property;Owner Name(Print) No.and Sttr et City/Town Zip Property Owner Contact Information: OunR r C��,�o 6. 6�®� OcAkA 361 0-)arn lco Title Telephone No.(business) Telephone No. (cell) •-mail ackidss If applicable,the proper gner�ereby authorizes a Name Street Address City/Town State, ,Zip, to act on the property owner's behalf,in all matters relative to work authorized by this build ing permit a , lication SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If budding.is less than 35,000.cu.ft.of enclosed s ace and or not tinder Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control R,06 c ��l ��r3 y1�3yDau\0 04VOy Na (Registrant) Teleph a o. e-mail address Registration Numbe a Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor PDyrC . 7Lnta Name of Person Responsi le for Construction License No. and Type if Applicable I % �J�hG\tc� Lc\n Q- Mpr Q Street Address City/Town State Zi Telephone No. business Telephone No. cell mail address SECTION 11:1•V0RKfa;6'C OMPF.aSATION INSURANCY AF.F1T.)r\VH M.G.L:.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ 00U Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minunum fee=$ (contact municipality) 5. Ntechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this pl'cat' �n ' true a ur a to he b st of my knowledge and understanding. gk3 10 g- 'fl Please rmt and sign n nie , Title Telephone No. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: . Name Date �. The Commonwealth of Massachusetts Department of Industrial Accidents `~�Ic Office of Investigations - I 600 Washington Street Jr•'! Boston, MA 02111 y www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Hanle (Business/Organization/Individual): ("��i C c o . Address:—! 'TZ City/State/Zip: - 51 Vt phone #: [—Are van an employer? Cheek the appropriate box: 1. I atn a employer with— 4, ❑ I am a general contractor and I Type of project(required): employees (full.and/or part-time).* have hired the sub-contractors '; 6. Q-Ne construction 2.❑ I`am'a sole proprietor or partner- listed on the attached sheet. 7. emod ning ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' g' ❑ Demolition [No workers' comp.insurance comp. insurance.$ 9. ❑ Building addition required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, §1(4),and we have no 12.[] Roof repairs employees. [No workers' 13.❑ Other 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. #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. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: 1- Expiration Date: Job Site Address: _Ci /State/Zi ty Attach a copy of the workers' comp ation policy declaration page(showing the Policynumber 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 it day against the violator. Be advised that a co of this Investigations of the for insurance coverage verification.copy statement may be forwarded to the Office of I do hereby certijy u e the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# L thority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector rson: Phone#: CITY OF S.M.E121, 1NhXSSACHtJSETTS BL'ILDIING DEP.kRT.\MNT `\ 3.0 120 W ASHINGTON STREET, 3*0 FLOOR T .L. (978) 745-9595 FAX(978) 740-9846 KIMBERt FY TAUSCOLL MAYOR THoNtAs ST.Pmm DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMOSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris,and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : (name of facility) (address of facility) QUA signature of permit applicant date debrisatT.doc t Sanctuary Condominium Trust c% Crowninshield Management Corp.. 18 Crowninshield Street Peabody, MA 01960 (978)532-4800 August 20, 2019 i Ms: Lisa Ghiozzi 8 Bengal Lane Salem, MA 01970 RE: Replacement Windows and/or Sliders—Sanctuary Condominiums Dear Ms. Ghiozzi: Thank you for your inquiry regarding window/slider replacements at your unit. Please be advised that the Board of Trustees for the Sanctuary Condominiums does not object to the replacement of these sliders so long as they match in appearance from the existing, they must fit in the existing opening, molding size and glass size must remain the same they will not allow grids and they will not:allow French doors. We.require the permits be pulled in advance;-and that a;copy of the final approved;permit once completed is also submitted to our office. We also require that you hire only a licensed contractor, with adequate insurance. Please be sure that new sliders are properly flashed and that a pan is used to protect:against leaks. # You will most:likely need to show a copy of this letter to the Building Department.in order to.obtain your permit. Should you have an questions or.require additional information please Y Y q _ q ,p s feel free.to call , me, directly at (978)532-4800 ext 9.23.2, Sincerely, Jill Fama, CMCA Regional Property Manager Crowninshield Management Corp. Managing Agent for the Sanctuary Condominiums cc: File f f f t i Job Contacts Link Leads i A 06 WO Mo ay, Z. ,August 19,2010 __ � 9A 4 (r Comments Lead: 1091841 Go Advanced Search 1:56 PM foltJpdates,; ! a Homeownertnformation h _ _ information a Homeown Per M!M Lisa Ghiozzi Commissions Sale Amount - $4,760.00 Balance Due $3,570.00 l..,,�...— Homeowner2 M/M Product 6500/6100 Series Windows(8%) Documents Job Slte Address_ 8 Bengal Lane t Status Sale/Order Received=PSG ' -- Salem,MA 01970'. - Job Issues Branch New England North I _ f `Siebel Lead lD SiebelOrder# Measure# Order Detail County ESSEX 1 MIL6XL1 1-49013197957 587051 89819164 Esirlhng Address 8 Bengal Lane is =2 Payments Lo�._. - . �w- 9 _ _ . xSa - Salem MA 01970 Commission _ Rate i Permits Consultant Name Term Date Split Coma Plan PO Primary Phone (781)526-6702 J mmesBurke ' 0%Stra g thth C'm i ss ionj ,W,ork Phone E 100 O. t ,E Ext., 0 Result Combo Cell Phone Dates, NWork� Ph'�o ei 2 —'� """r ;Sate Date 8%7/2019 FUP Services �- .�.....,a, � .a � t r : . �_ Cell Phone 2 Credit Date W7/2019 FPD-Customer Show Map Emai�11 a1361 t 1;y@9mail comw iRTP Date8/9/2019:, Post lnstalt'Datea,; a -- -�^-�`•�`--- --� Start Date i FPD-Home Depot TouchPoints Cross Street p Ins e�""'�cfio r . ._ : -1Vlarketing p B-Back 'No—._-%w�- Update Job Referral Store.,','-, `2686-SALEM MA ., � _, Joti lntlicators , Work Orders Base Store 2686-SALEM,MA Lead Paint.No Test-LSWP Not Req y F p leatl Source . = 0250 Store Associate-Siebel a S 2 P•s�� Sf(Aers User£ Date Time Status Corr�,Appt�Date Appt Time;'Consultant 9 *�,�f ROBERT POCZOB 8/11/2019 6:30 AM Order Received-PSG No 8/7/2019 9:30 AM James Burke ROBERT POCZOB 8/11/2019 6:30 AM Measure Complete No 8/7/201.9 9:30 AM James Burke ANGELA MCREYN 8/9/2019 1:52 PM Released to Production No 8/7/2.019 9:30 AM James Burke ANGELA MCREY 8/9/2019 1:48 PM Order Entry. No 8/7/2019 9:30 AM James Burke James Burke 8/7/2019 10:16 AM Credit Pending_ No 8/7/2019 ::30 AM James Burke James Burke 8/7/2019 10:16 AM Sale Pending No 8/7/2019 9:30 AM James Burke II James Burke. 8/7/2019 10:16 AM Sent to the Field No 817/2019 9:30 AM James Burke 1 James Burke 8/7/2019 :16 AM Lead Entered No r Ctose _ Print Y t Home Improvement Agreement: Pagel Home Depot License#'s For the most current listing www.Homedepot.com/LicenseNumbers MA: 107774, 112785 i i 1 i r i James Burke Salesperson Name: p Registration No. (if applicable): Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named:below will furnish, install and/ or service the equipment listed below at the price, terms and conditions as outlined on this form. Ghiozzi Lisa New England North 1-MIL6XL1 -� Customer Last Name Customer First Name Store #L Branch Name Customer Lead/ PO# ' 8 Bengal Lane Salem MA 01970 Customer Address City State Zip (781� 526-670� l ja1y361@gmail.corli i Home Phon6# Work Phone# Cell Phone# Customer Email Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury. . 01545 Address city State Zip r Or Email: C:ustomercancellationnortheast@homedepot.com Service Provider Email Address BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A DIFFERENT CANCELLATION PERIOD.THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME j DEPOT OR SERVICE PROVIDER, AT YOUR SERVICE.ADDRESS, AND IN SUBSTANTIALLY THE I SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OFF YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING YOUR RIGHT l TO CANCEL... PLEASE 1 BEL TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTI OF GHT TO CANCEL. I i Acknowledged by: 08/07/2019 er gn Date 1 Contract Price an Pa t Sche le :Payment of the Contract Price is due upon signing unless a .different payment chedule is require by law, specified below or in a payment addendum. Contract Price: $ 4760.0o Includes all applicable taxes. Excludes finance charges."` Sales Tax: $ o.00 (If applicable) z *Maximum deposit ONL Y applicable in MD, MA, ME 33 11, NJ, Wl 99% I Dep. 25.0 % Deposit Amount $ 1190 Remaining Balance $ a570.00 The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-customer Care: 1-800-466-3337 460FI HDE Customer Agreement(24 Jul.18) v 0.1.8 I S Home Improvement Aoreement:.PagQ Id Finance Charges: "Any interest.payments or other finance charges will be determined by Customer's separate cardholder or loan agreernent,.to which The Home Depot is NOT a party, and will.be in addition to Customer's 1 payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to Service Provider; however, Service Provider may collect Customer's payment(s) made payable to The Home Depot. Insurance proceeds will will not be used to pay some or all .of the total amount of sale. i Description of Work to be Performed- Installation of 1windows 1 , A more detailed description of the work to be performed is included in the section entitled Scope o Work which appears on page 0 of this.Agreement. Anticipated Delivery Date/Installation Schedule Approximate Start Date: 1o/oz/zola Approximate Finish Date; 10/3o/2o1s. All dates are ,approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if applicable. i } Electronic Records Authorization: i You are entitled to a paper copy of this Agreement if you choose. if you consent to an e-mailed copy,your consent applies to this Agreement and all subsequent documents and.written communications related:to this agreement. By contacting your Service Provider, you may update your email address; withdraw your consent, or obtain a paper copy of the Agreementor related documents at.no charge. By providing your consent and verifying your email address above, you confirm that you have access to a computer that can eceive and open emails and PDF documents. ELV initi ing this paragraph, I consent to receive only electronic records related to this transaction. itial Acceptance and Authorization: y signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation and/or (b) order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this.Agreement. Do not sign if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.). By signing, you acknowledge that you have read, understand, and accept this Agreement in its:entirety, including the General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a co plate copy of this Agreement. Keep.it to protect your legal rights. f 08/07/2019 The Home Depot to s ig a e Date Service Provider Name f( i X. 08/07/2019 1900 Boston Turnpike Unit 1 I Co-Si r applica le Date Service Provider Address X 08/07/2019 Shrewsbury MA 01545 at a On Beh If of Home Depot Date City State zip _ R-1=073-13-00031 Service Provider Phone umber Service Provider License Number The Horne Depot-2455 Paces Ferry Road,N.W.Bldg.9-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337 460FI HDE Customer Agreement(24 Jul.18) v 0:1.8 r Commonwealth of MassaCKUSetts Division of Professional L.icensure Board of Building Regulations and Standards .v Ex 172 WHALERS="L NE SALEM MA' 01 70 Commissioner Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement"Cotractor Registration l Type: Corporation ' Registration: 1479M ROSICCO INC212021 172 WHALERS LANE j Expiration: 08l2 4 . SALEM, MA 01970 t$ r n 1 y : Update Address and Return Card, Moir .w. oire'f3u�tin��dgu��oion "O#AP- IMPAMP-MENT CONTRACTOR Regishatlon valid for Individual use only TYgO;,Ce<t9rr1ucxl before the expiration date. If found return to: �AllftC�!l1t- � 0u0 Office of Consumer Affairs and Business Regulation 147` 001 /2na1 1000 Washington Street -Suite 710 RO�3ICC0 INC Boston,AAA 02118 > gal inn.MA 01970 Not valid wit Sout signature andersocretary . ; .777 777777 --- DATE(MM/ODIYYYY) CERTIFICATE OF LIABILITY INSURANCE 0711 212 0 1s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY.AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE:A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED -REPRESENTATIVE OR PRODUCER,AND THE.CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the-terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such:.endorsement(s). PRODUCER CONTACT NAME: Maryellen Goodwin DAVID E ZELLE_R INSURANCE AGENCY INC PHONE (781)595-2071 ADDREss: maryellen@davidzeller.com 370 LYNNINAY INSURERS AFFORDING COVERAGE NAIC q LYNN MA 01901 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER 6: - j RQBICCO INC INSURERC: 1 INSURER D: " 172 WHALERS-LANE INSURER E: SALEM MA 01970 INSURERF: COVERAGES CERTIFICATE-NUMBER: 424735 REVISION:NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR-THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I�TRR TYPE OF INSURANCE �ADOUSUBRj POLICY EFF POLICY EXP POLICY NUMBER I MMIDD i MMIDD I LIMITS I COMMERCIAL GENERAL LIABILITY I I EACH OCCURRENCE is CLAIMSMADE ! `i'OCCUR i D R I J I I PREMISES rEa"oavrrente is MED EXP(Any one person) is N/A i i I PERSONAL&AOV INJURY 1 S I GEN'L AGGREGATE LIMIT APPLIES PER: i 1 i i GENERALAGGREGATE is POLICY 1 ?ECT LOC t ? PRODUCTS-COMP/OPAGG 4 S I OTHER: i i S I AUTOMOBILE LIABILITY j I I COMBINED SINGLE LIMIT S I- i LEa acaoernl- - --_-i —-- I ANY AUTO I IBODILY INJURY(Per person) S ALL OWNED (—'SCHEDULED ij AUTOS AUTOS I NIA I i BODILY INJURY(Per scatlent) S i NON-0V4tJED t I I ; PROPERTY DAMAG£ HIRED AUTOS 1 I AUTOS l I Peracddent S !1 i S j 'UMBRELLALIAB i OCCUR EACH OCCURRENCE is EXCESSUAB ^CLAIMS-MADE! NIA I j AGGREGATE i S i i DED i i RETENTIONS i i 1 is WORKERS COMPENSATION ( X I i STATUEEAND EMPLOYERS'LIABILITY RH IANYPROPRIETORIPARTNER/EXECUTIVE E;L EACH ACCIDENT 1,000,000A OFFICERIMEMBEREXCLUDED? NA I NA 1 6HUB5B37400219 i 07/2312019 f 07l23QUO (Mandatory 1n NH) i i I E.L.DISEASE-EA EMPLOYEEi S 1,000,000 If yes.describe under 1�DESCRIPTIONOFOPERATIONSbelow ELD1sEASE-POLICYISMIT I S 1,000,000 I � I I 4 ! N/A i DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more apace Is required) Workers'Compensation benefits Will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefit,to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the ahove.policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search toot at wvwY.mass.9cuAwd(wotkem-compensauanfinvesttgationsf. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN THD At-Home Services Inc and The Home Depot ACCORDANCE WITH THE POLICY PROVISIONS. 269 Cumberland Parkway AUTHORIZED REPRESENTATIVE I Atlanta GA 30339 Daniel M.Crowley.CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(20`14/01) The ACORD name and logo are registered marks of ACORD