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44-010 409 ROCKY HILL RD ' BP- 2011 -0708 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 44 - 010 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: RENO WIRING BUILDING PERMIT Permit # BP- 2011 -0708 Project# JS- 2011 - 001163 Est. Cost: $9374.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RONALD W HASKELL 82630 Lot Size(sq. ft.): 85377.60 Owner: SCHUSTER NICK A & MARY & SUZANNE SCHUSTER Zoning: SR(100)/ Applicant: RONALD W HASKELL AT: 409 ROCKY HILL RD Applicant Address: Phone: Insurance: 1406 MAIN RD (413) 202 -7209 WC GRANVILLEMA01034 ISSUED ON:3/3/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: ENLARGE BEDROOM CLOSET & CHANGE BATHROOM ENTRANCE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 3/3/2011 0:00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner ` . t __��.._.._ ...,.._ Department use only RECEIVED City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit MAR 3 2011 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability DEPT. OF BUILDING INSPECTIONS Northampton, MA 01060 Two Sets of Structural Plans NORTHAMPTON,MA0 587 -1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office O � �� / / /� �� , Map Lot Unit y Y Zone Overlay District r Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: .� U i AV�nx2 Cr .iT�...g- v' Name (Pj nt) Current Mailing Address: LI i 3 J J 1 et - -3001-t Telephone . ur- 2.2 Authorized Agent: i r / cM,,.�li`� W - LY1■S <i � ) 40C - r*Ahustl / tAAA, 011)34 ti P.rint), Current Mailing Address: AMI111■... (4 I '1) Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 7-173- GS (a) Building Permit Fee 2. Electrical -� (b) Estimated Total Cost of Construction from (6) 3. Plumbing �, .. Building Permit Fee / - � 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) 9 373 , •' Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature Building Commissioner /Inspector of Buildings Date Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW I@ YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW V, YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES Q NO (► IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO IF YES, describe size, type and location: l E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® N O Ito IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0] Other [d] Work: Descripti1 L Pr �posd � � � i � l �T �ik � �� �D,�v Work: j`�i.l : ) l� `'irk- 2F.'�/ \ 'i \� Alteration of existing bedroom t&. Yes No Adding new bedroom Yes l7L No Attached Narrative Renovating unfinished basement Yes oc No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS GENT OR CONTRACTOR APP IES FOR BUILD NG PERMIT A t 1. _ , as Owner of the subject pie , • ?4 �k � hereby autho l�r Nt � �., r�, »vg�., � 7 r - i — ��'r4 CAviA ; , to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date CPYL9 4 . N YS k4- /1 , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ,. </yt p.> / f) [ J , /44.s 7Ce, ' 1 Print Name /A 212;3/ 1 1 Signature of Owner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: �� Not Applicable ❑ Name of License Holder : (AN" t W - `n? ia. I \ e -3 0 License Number A t Expiration Date G /), �— 7 ? . 61 'R) Sign ture Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ � 3 4O - 7 Company Name ^ c _ Registration Number Address �� '� ` � U ess l Expiration Date I (4 1 &A ( ) f � t V Telephonell3 j 7 0 iU3 9 SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit 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. Signed Affidavit Attached Yes No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature The Commonwealth of Massachusetts Department of Industrial Accidents 1, _ I Office of Investigations ' „;�1 ®' _ » 600 Washington Street e 1, Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): '--" , a , +S t Address: 1 t1, DJ t J v 1 City /State /Zip: GIA\Aui t (Q, \ANV 01 0 3 1 1 Phone #: "11` 5 0R ` ' Are you an employer? Check the appropriate box: Type of project (required): 1.E1_ I am a employer with 1.1 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction listed on the attached sheet. 7. ®.Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 3. ❑ I am a homeowner doing all work 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 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 is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: - rte 7r..Q ___Ly;, Q, Q,"„\ f ( , 1 Policy # or Self -ins. Lic. #: L 4 ei - e065 6( . 03 Expiration Date: 10 1 'LS - ( Job Site Address: Li c . �r _ut `' t l ] City/State /Zip: Ab ,r p7a� 1MA. (,7/66 - f 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 hereeb • u der t e pains ! nd penalties of perjury that the information provided above is true and correct Si. ature: ■ DA A Date: -7, ---/2--.3/ 1 / Phone #: L/ / ') ? - L — 2 0- 6 % Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # 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 #: R.H. & SONS CONSTRUCTION RON HASKELL OWNER 1406 MAIN ROAD GRANVILLE MA. 01034 PHONE: 413 - 357 -9929 FAX: 413 - 357 -9991 MA REGISTRATION NO. 136407 MA LICENSE NO. 082630 Ron_haskell @rhandsons.net Suzanne Schuster 409 Rocky Hill Rd Northampton, Ma. 01062 413 - 584 -3004 Master Closet/Bathroom: 1. Build wall approx 11' high x 8' long at designated location. In this wall there will be two doorways one for the new bathroom entry and a door for the new walk in closet entry. 2. The bathroom door will be a 24" right hand in swing door the closet door will be a 24" bi -fold unit. 3. The old bathroom entry will be framed in and sheet rocked on both sides. 4. The old closet wall will be removed and the sheet rock on the ceiling will be patched. 5. We will be removing the old vanity and the wall that it is on. We will also be removing the existing tile in the entire bathroom and installing cement board on the floor. The existing vanity will be re- installed. 6. All the plumbing will be re- directed to a new location where a double bowl vanity will be installed eventually. 7. All electrical will also be moved and re- directed, there will be a new GFCI plug for the double bowl sink, a new vanity light or some other type of light for the new sink area will be installed, there will be a new fixture in the closet installed and there will be two new outlets installed on the bedroom side of the closet wall and on the wall where we close up the bathroom door. 8. All sheet rock work joint compound sanding and priming of all new rock and patches are included. 9. The floor will be removed in the closet area as we will need to cut in two new walls. We will also need to tear up some of the subfloor in different spots to run wiring and re- configure the plumbing. All these areas will be patched I with plywood. ' f F �� 1 � 'co) ' c, S b `t'r i S i C� i ) t „ y Gam"-"' 15� T1' fs 10. We will provide and install the new trim work and the two new doors. Trim work style to be determined at later date. 'i •'" f y • 11. When our job is complete customer will have the old vanity installed in new location where the double bowl vanity will be installed eventually. All walls that we work on will be primed, all trim work and doors will be installed but not stained or painted. Cement board will be installed on bathroom floor and closet will be ready for the customer to install there shelving system and flooring. 12. We will provide the trash removal and all the construction material including the trim. 13. Customer is responsible for purchasing the double bowl sink and vanity and faucets finish lights for closet and bathroom. Total price is $9373.65 $500.00 deposit $3500.00 the day we start $4500.00 after rough plumbing and rough electrical are complete. $873.65 due upon completion ir co r IN 0 I6 1;\ 1 i �� + Any alteration or deviation from above specifications involving extra charges will be executed only upon written order, and will become an extra charge over and above the estimate. All workmanship will be warrantied for 1 year from the date of completion. Any unforeseen damage or any unforeseen situations caused by previous remodel projects that are out of our control will be charged at a time and material rate of $65.00 per hour to repair before we can proceed with our portion of the project. Customer right of cancellation is 3 business days from the day the contract is signed. ZA-/ lbedie Contractor's signature d• t / / t Custo ignature t date \iaa. tchusett. - Department of Public Safct. 9 B(tard of B uildin1 Re_ an d Sta ndards Construction Supervisor License License: CS 82630 Restricted to: 00 RONALD W HASKELL " 44. 4 ,,fi 1406 MAIN ROAD GRANVILLE, MA 01034 �"G"- -��. Expiration: 1/18/2012 ( "mill i...i,4n Tr 13509 -6 , or Office of Consumer Affairs & B siness Regulation * y - / HOME IMPROVEMENT CONTRACTOR - Registration: 136407 Type: 14— Expiration: 7/23/2012 DBA R.�'. & SONS CONSTRUCTION RONALD HASKELL 1406 MAIN RD. GRANVILLE, MA 01034 Undersecretary ACORD CERTIFICATE OF LIABILITY INSURANCE 06/21/ 0 PRODUCER 413 .737.3539 • FAX 413 .731.8255 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Bombard Insurance Agency, Inc /Bates Full am Ins Agcy ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 110 Elm Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. West Springfield, MA 01089 INSURERS AFFORDING COVERAGE NAIC # INSURED Ronald W. Haskell INSURER A: National Grange Mutual 14788 DBA: R H & Sons Construction INSURER B: 1406 MAIN Rd INSURER C: GRANVILLE, MA 01034 INSURER D: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSRp DATE (MM /DD/YYI DATE IMM/DD/YY1 GENERAL LIABILITY MPS70626 03/29/2010 03/29/2011 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 500,000 PRFMISFS (Fa nnnurenca) CLAIMS MADE X OCCUR MED EXP (Any one person) $ 10,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ 2,000,000 7 POLICY X PRO LOC JECT AUTOMOBILE LIABILITY M9S70626 06/20/2010 06/20/2011 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) A X HIRED AUTOS BODILY INJURY — X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ _ AUTO ONLY: AGG $ EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TO BE ISSUED BY WC STATU- OTH- TORY LIMITS _ FR EMPLOYERS' LIABILITY CARRIER DIRECTLY E.L. EACH ACCIDENT $ ANY PROPRIETOR /PARTNER/EXECUTIVE OFFICER /MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Interior Carpentry It is agreed and understood Home Depot USA, Inc Its parent, affiliates and subsidiaries are listed as additional insured with respects to liability caused by operations performed by the named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Ernest Bates, Jr./BATSC1 ACORD 25 (2001/08) FAX: 877.885.0694 © ACORD CORPORATION 1988 I 10/11/2010 PRODUCER 1 THIS CERTIFICATE E5 ISSUED AS A MATTER OF INFORMATION ONLY AND Applied Risk Insurance Services, Inc. ' CONFERS NO PI�:.r0'S UPON THE DEE:IFICAiE HOLDER. THS 10825 Applied R Mill Rd CERTIFICATE DOES NOT AMEND, EXTEND 'END OR ALTER COVERAGE TER THE COVERE AFFORDED BY THE POLICES S BELOdv. Omaha, NE 68154 -0646 (877)234-4420 l I NSURERS AFFORDS .C'' COVERAGE ?DMC INSURED ; NSURER A: Continental Indemnity Co. I 2825 8 Haskell, Ronald W. INSURER B' ____ dba R H & Sons Construction I IP':SurER C 1406 Main Rd - - - -- �i Granville, MA 01034 -9722 NSURERC: I CTL 1273 5271 I I INSURER E COVERAGES 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 CF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCR;BED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS. INSRADD'L I POLICY EFFECTIVE (POLICY EXPIRATION(. LTR INSR TYPE OF INSURANCE POLICY NUMBER I DATE IMM/DD/YY) I DATE (N''V /ODIVYI ' LIM :TS GENERAL LIABILITY i I EACH OCCO'.RPENCE I DAMAGE r,_ ° iE_E TO COMMERCIAL GENERA LIABILITY _ -.rem _ F• r 4 CLAIMS MADE j OCCUR I MED EXP (Any one cers $ _RSOLA_ & AD 'V INJ.,R1' I 5 I I I T G v R.,,L AGGREGATE ' S GENT AGGREGATE LIMIT APPLIES PER. ?TODOC i S - 00 . ? A G _-I PRO- rte,, _.. --_ _ _ POLICY iJECT I LOC • • AUTOMOBILE LIABILITY COGS VETSti ELM -T ANY AUTO !Ea accid�or'; ALL OWNED AUTOS EO v ti ; ::.Y SCHEDULED AUTOS - H t, - HIRED AUTOS ., �„ I NON -OWNED AUTOS - - - - - - - S I — PROPERTY DAMAGE i y I i GARAGE LIABILITY I AUTO N AVC.JE JT F $ LTTI E ANY AUTO l 1 OTHER T, IAN E„ AG AUTO ONLY: 0 (EXCESS /UMBRELLA LIABILITY I I EACH OCCURRENCE I s _.___ ` __- i I I OCCUR I I CLAIMS MADE I AGGREGATE ._ - i D EDUCTIBLE i 7 - RETENTION $ ! WORKERS COMPENSATION AND I I BC STATU- 1 1C7H -1 EMPLOYERS' LIABILITY I X i TORY LIMITS - E AANY PROPRIETOR /PARTNER/EXECUTIVE 46- 806566 -01 -03 10/25/10 10/25/11I E.L. EACH ACCIDENT : $ 100,000 OFFICER/MEMBER EXCLUDED? If yes, describe under I E.L . D'SEASE - EA EMPLOYEE $ 100,000 SPECIAL PROVISIONS below l E L. DISEASE - POLICY LIMIT 1$ 500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT; SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION - I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES S SE CANCEL' BEFORE B F 'RE THE ': R H & Sons Construction EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDE ./OR TO IAL qn I DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER N G THF i EFT BUT : . 1406 Main Rd I FAILURE TO DO SO SHALL IMPOSE NO OBLIGATON OR LI.f.L'ELiTY OP ANY ',CND UPON Granville, MA 01034-9722 THE INSURER, ITS AGENTS OR REPRESS TATIVES. 1 U"THOREZED REPRESENT Attn:l Project Manager I J . 1783118 -- ACORD 25 (2001/08) �/ ; A C3FiO "'r :::P RMION :" . , , \ ,., •,., ' - . t rt)ti ,..,‘ -o> f3 ,:.- A •4, -,\,.`.. ,..1‘› .15 ti ° C _._._..._____..,, (-L------ ... ........" ..,„, Ni 1.- , b 7 \ i0 ID 9 . 0 ..... :_ac • P 6 ......--Np . . • . r j 1 - , ! , • . cl r- 4 4 ) • , ; t-• 1 N /1\ ! ____ hi C 4,,..________ e i ---------- I i i A 3 1 -ce NI ;Fs , r- I ) ..k , c). iii \it 0 0 / b • I I .......... ,.....X. 4.-------..,