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29-350 (2) 48 AUSTIN CIR BP-2020-0147 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-350 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2020-0147 Proiect# JS-2020-000241 Est.Cost:$16400.00 Fee: $264.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MIKE KRASNOV 102047 Lot Size(sg.ft.): 13852.08 Owner: VILKHOROY ALEX zoning: Applicant: MIKE KRASNOV AT. 48 AUSTIN CIR Applicant Address: Phone: Insurance: PO BOX 491 (413) 328-1778 WC WEST SPRINGFIELDMA01090 ISSUED 0,�V:8/5/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF, DECK, KITCH RENO, REMOVE DRYWALL FROM BASEMT 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: FeeTvpe: Date Paid: Amount: Building 8/5/2019 0:00:00 $264.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0147 APPLICANT/CONTACT PERSON MIKE KRASNOV ADDRESS/PHONE 32 MERWIN ST SPRINGFIELD (413)328-1778 PROPERTY LOCATION 48 AUSTIN CIR MAP 29 PARCEL 350 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATIONet=KLIST CLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: STRIP&SHINGLE ROOF, DECK,K H RENO,REMOVE DRYWALL FROM BASEMT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 102047 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO)MATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay <� 8 - 5-2oig Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all Zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. Department use only City of Northa pto — E' Uof Pe-, it: Building Depa men Curb uttDri eway Permit 212 Main St eet AVG _� ewe Septi Availability Room 10 �� ate ell vailability Northampton, M 01 Two ets o Structural Plans phone 413-587-1240 F x 4 fSfMx;injsF Pip e PI ns THAMPTON.M ;. ec 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 C\qc 1 e Map_�_C� Lot , 7M unit No •�.�,_ y P�}j�' /\,v itk Zone Overlay District ' •`�'� Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Oe.x V; I kke,•Dy Name(Print) Current Mailing Add ss:— 'A I I Q0 It s:'Q0It` y Telephone Signature A\e—, V, I 2.2 Authorized Agent: d I �� SAG G- 0• eox Lig(. W 5P12�rnq H-e Na a(Print Current Mailing Address: Signature Telephone SECTIOd3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building gC)o (a) Building Permit Fee L 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) (� 5. Fire Protection r� 6. Total =0 +2+3 +4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date V@ EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning N ^ This column to be filled in by '►11 Building Department Lot Size Frontage Setbacks Front r _ r Side L: R: _. L:�.' R: Rear ®g Building Height Bldg. Square Footage % � Open Space Footage % (Lot area minus bldg&pavedi arkin --� -� #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ku DON'T KNOW 0 YES 0 ....... ..... _. ............... IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW ® YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW `, N YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained 0 , Date Issued: C. ` Do any signs exist on the property? YES 0 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: Y 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 0 NO 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 ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [1:3] Decks [❑ Siding[0] Other[of Brief Descripti p n of Propose Rk wllck" PtN r nR fm A, , m(xK-\- . 1,,, Work: R O� Q,(�Q sl�jr}1k� yX5 QRC��Vl9. ���U 1�1 �.Qv�Cf��( �wu yA�Vvv Alteration of existing bedroom Yes--�—No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building: One Family_A Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? PC) d. Proposed Square footage of new construction. ''�/'r Dimensions e. Number of stories? I f. Method of heating? k l___ Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. NIA 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 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 1 V t� /�k� �y as Owner of the subject property hereby authorize /"1` k e t`o•S A O v to act on m behalf, in all ma rs relative to work authorized by this building permit application. - 9 Signature of Owner Date I, iM I ��' �QSAJD&"- as Owner/Authorized Agent hereby declare that the states 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. Print Na Sign o n /Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction�Supervisor: Not Applicable 0 Name of License Holder: I ► \1 yl� ooy I C)!i0 License Number 'v e cLl U3. S '\ R l rn [011D-2, Z.,0 . Address I j Expiration IDate 1l - 32-9- 7 7 . Sign e Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ � u-1U�Ex Curls -c�-� C�iQv� , l--C�- � 7 q5g Company Name Registration umber Env P-i�e a n �-�(,e� ►'n 1 �IL2_1 AdcTress Expiration ate �Jephone �r13-3Z8`l�� 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...... ❑ l City of Northampton Massachusetts c DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building �� rb Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered. Type of Work: Aq_,yt a,&e \ Est. Cost: 1 �, co Address of Work: �s�-;r` C,cc le- Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s)- Work excluded by law(explain): Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: A A4 M 1 rJ S. Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS , ,r .. 212 Main Street • Municipal Building Northampton, MA 01060 � 1L� Massachusetts Residential Building Code Section 110.R5.1.2 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. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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. City of Northampton s' Massachusetts G DEPARTMNT OF BUILDING INSPECTIONS , ✓ 212 Main Street a Municipal Building Northampton, MA 01060 +4r'y �nw Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signatj//,Fs6rrRf Appli nt or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. i The Commonwealth of Massachusetts Department of Industrial Accidents I 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 C Please Print Legibly Name (Business/Organization/Individual): (lj�At EX � J� ��rff�,(�✓� l�l�� Address: l7)C y0� City/State/Zip: �- �+Q, m 1� Phone#: q t3 Are you an employer?Check the appropriate box: Type of project(required): 1.[�I am a employer with_employees(full and/or part-time).* 7. ❑New construction In I am a sole proprietor or partnership and have no employees working for me in 8. LrVl Remodeling any capacity.[No workers'comp.insurance required.] 3.O I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 9. Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.M 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: p 6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other 152,$1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t 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: &2'c> ��til�`ZOL� C Policy#or Self-ins.Lic.#: Y2LA WC-610 G 7Zq 1 1 Expiration Date: 1 Job Site Address: 14R � Irl G cd e- t �1�a�, C^ty/Sttaa1te/ip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is 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 and r of perjury that the information provided above is true nd correct Si nature: Date: Phone#: o(Ir2 6 I 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#: f Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: LLC Registration i i n 187455 04/11/2021 BUILDEX CONSTRUCTION,LLC MIKE KRASNOV 900 RIVERDALE ST #224 WEST SPRINGFIELD,MA 01089 Undersecretary lauolssiwwo- 690L0 VIN(113HON18dS 1S3M l+Z Z# 1S 31V ON3ARI 006 AONSV-dA 3NIW ADELr OZOUEO/OL 'sarld�j LVOZOI-SO r josinjadn!�UPklorlilsuoC spjepuelS pup suogeln6a8 6uiplin8 to pipo9 ainsuaai-I IeuVssalWd 10 uoIsinlo 7 sllasn4:)essey4 to Wleamuowiuo� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) 06117/2019 THIS CERTIFICATE IS ISSUED ASA 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 AFFO RIDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING Ih SURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSUR D provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an ei idorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Marion Lentes,Ext 103 Foley Insurance Group Inc. PHONE (413)214-7474 FaX (413)214-7447 ac No Ext: arc,No):37 Elm Street ADDRESS: mlentes@foleyinsurancegrou Corn INSURERS)AFFORDING<OVERAGE MAIC y West Springfield MA 01089-2703 INSURERA: Patrons Mutual Insurance Co of CT 20028 INSURED INSURER 5: Patrons Mutual Ins Co of CT 14923 Buildex Construction LLC INSURER C: State Automobile Mutual Insu ce Co 25135 PO Box 491 INSURER C; NorGUARD Insurance Complury INSURER E: 'Nest Springfield MA D1090-0491 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1932712054 REVI ON NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE 7OR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH F ESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCt_USIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MIpD E C LIMITS COMMERCIAL GENERAL LIABfUTY 1,OOD,000 EACH .CURRFNCF S CLAMS-MATE ©OCCUR °•M RENTED 300,000 PREM 3E5 Ea occurrence S MED (Any one pensanl 5,000 A Y BOP2838326 03!2312019 03/23/2020 PER NAL BADV INJ:IRY $ 1.000.000 GEN'L AGGREGATE LIMIT APPLIES PER GENE AGGREGATE $ 2'000.000 POLICY J� F-1 LOC PRODICTS-CCMP/OPAGG $ 2.000.000 OTHER a AUTOMOBILE LIABILITY COMEM qED SINGLE LIMIT $ 1,000,000 ANY AUTO Ea ac dnnt BODIL INJURY(Per person) $ OWNED Y BAP2456688 03123/2019 03/23/2020 800112 INJURY(Par acddent) $ B AU70S ONLY q�OSULED X HIRED NON-OWNED PROP TY DAMAGE AUTOS ONLY AUTOS ONLY Per wide ) $ i9 WaN4 r of collision $ XqCE LA LIAB OCCUR 2,000,000 EACH CCURRENCE $ C UAB CLAIMS-MADE CXS2141619 0312312019 03/23/2020 AGGR GATE $ 2.000.000 X, RETENTION$ 10.000 $ WORK ERS COMPENSATION AND EMPLOYERS'UABIUTY ,11 N X S AR ETH, D ANYPROPRIETOR,'PARTNERlEXECUTlVE NIA BUWC906727 10/10/2018 10110(2019 EL 1AACCIDFNT $ (Mandatory n N1.000.000 OFRCEry in N ) EXCLUDED? H) 1,000,000 ry If yes,describe under E.L.DI EASE-EA EMP_OY EE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1.000.000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached H more space is requiredl CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROW 5IONS. AUTHORIZED REPRESENTATIVE MA 01033 @1988-2015AGORE CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD