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24C-109 (2) 119 MASSASOIT ST BP-2020-0302 GIS#: COMMONWEALTH OF MASSACHUSETTS Map Block:24C- 109 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ROOF BUILDING ILDING PERMIT Permit# BP-2020-0302 Proiect# JS-2020-00050$ Est.Cost: $18400.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RCI ROOFING 074334 Lot Size(sg.ft.): 5009.40 Owner: MIDDLETON ARTHUR Zoning:URB000)/ Ag2licant. RCI ROOFING AT. 119 MASSASOIT ST Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 _ Workers Compensation SOUTHAMPTONMA01073 ISSUED ON.9/6/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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: FeeTyae: Date Paid: Amount: Building 9/6/2019 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1,272 Louis Hasbrouck—Building Commissioner E C E I V . gg Department use only City of NorthrA0 Outs of Permit: Building g Dept Curb;Cut/D.riveway Permit 1 tirr, 212 Main SEP 6 2� Sewer/Sep'lic Availability Room 1 Water/WelliAvailability Northampton, 60 TwQ bets oStructural Plans phone 413-587-1240 F x 4r1�`3��69F4�29f2i�I��`F Pl�jtY5ile Plns — NORTHAM010N,MA r {��� Othe"r'S`pecify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION -!>o 0, 1.1 Property Address: This section to be completed by office � I maS�Cv$Ot-� Map G Lot Unit NO('FI�C�XYlV1 I m Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: A mut- m, l e- h I19 rrlcssGsc�l+ for+fit x rr r}Mn��w Name(Print) Current Mailing Address: It (�IUi )'��,.3 — G953 (]*I t r h o j Telepho e Signature 2.2 Authorized Acient: C to LI n e 34- , Sr)u±kct min a)Iq U10`7� Name(Print) / Current Mailing Addr ss: ��113� 5Q - y�� 5 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building P)��i 1 (a)Building Permit fee 1 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) 1 y 00 Check Number This Section For Official Use Only Building Permit Number: DateIssued: Signature: Building Commissioner/Inspector of Buildings Date S-}-home Son @ r c,'i roo-k*1-19 ,com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [[] Siding [❑) Other[❑] Brief Work:Description of Proposed See 4ahPd 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 Muse ah&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 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , as Owner of the subject property hereby authorize Pl L f'1[y}f I i 1G to act on my behalf,in all matters relative to wo authorized by this building permit application. Se o f br hod C q -©y — Q m Signature of Owner Date I.irK ndi-s ho _ a5 (1114hDrfZecl [! � as Owner/Authorized Agent hereby declare that the statements and information on the fo a oing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Nam (^A -�y� a019 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: J Mar L IJP_I i'sII,.- C S — (0? y ?2 License Number rI E 3 OIGa 05 - 03- ao Q 0 Address Expiration Date Signature Telephone 9. Registered HomeImprovement Contractor: Not Applicable ❑ I� C rsCOA0 LLP /a(oa3s Company Name U IRegistration Number LI n 3+ _ .S)u- skarn In CSS - 05 - a0a0 Expiration Date Telephone 413'S�?7-1/795 —7 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....... d No...... ❑ RC.I. Roofing6Line St. Date Estimate Southampton, Ma. 01073 6/24/2019 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location Art Middleton 119 Massasoit St Northampton, MA 01060 Terms Rep Estimate valid for 45 days Chris Description Total Remove existing roofs. t„tir y#,j\ Lt`� 18,400.00 Furnish&install 1/2" plywood over existing decking. w1 G\"^V A Furnish&install aluminum drip edge,pipe flashings,chimney flashings(if needed)and step flashings. Furnish& install CertainTeed Winterguard ice&water barrier along eaves and valleys. Furnish and install synthetic underlayment. Furnish and install Lifetime CertainTeed Landmark Series shingle. Furnish and install CertainTeed approved ridge vent. All exterior roofing related debris to be removed by R.C.I.Roofing. All work will be performed according to manufacturers'specifications. Lifetime CertainTeed material warranty included. All related permits will be obtained by R.C.I. Roofing. Add$2000 to replace large skylight Add$1500 to repalce small skylight (no interior work included for skylights) WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $18,400.00 TERMS OF PAYMENT 5%Deposit Customer Signature: Balance upon completion Registration# 126235 Date: $13 U 1 Construction License#074334 Insured by Banas&Fickert Ins. Shingle Color Selection: t E MAt L{p S kE Li E4 A66VT Tull (413)527-2700 City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building yJA�. iia Northampton, MA 01060ss..... j11b 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. Vie:V the homeowner has contracted with a corporation or LLC, that entity must be registered. Type of Work: 041 nQ t1Est. Cost: 4 R, y00 Address of Work: I I q M SS a 531+ rSJ Ah rlfVi&-kh 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: 09-6,, - QC, 6 .C . 1. A noA'nq L LP (v 13 5 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: _ - See c4o, l,F . Date Owner Name and Signature City of Northampton Massachusetts ties _°•.c,�� is 1 DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Northampton, MA 01060 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: II I M(&StaS�"i f s+ (Please print house number and street name) Is to be disposed of at: (Please prin ame a d location of facility) Or will be disposed of in a dumpster onsite rented or leased from: Usm aulinu d K0Cfrj1n4 (Company Na(fie and Address) Signature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicaWd, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/(:ontractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): I (YT�no , LLP Address: b Ll nP S+rpe+ City/State/Zip: ()109a Phone#: 5D3- V'705 Are you an employer?Check the appropriate box: Type of protect(required): I.BdI am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E] Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F;Jf�oof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: [�, �`r�uoi �In.5 104 to Policy#or Self-ins.Lic.#: V W C n o(a A a a�V 7a d I�' A _ Expiration Date: /U- 0 5 - a Q I c/ Job Site Address: I Int S+. City/State/Zip:Nf)(4 tC-Mak n M A OI OIDO 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains d penalties of perjury that the information provided above is true and correct. Signature: / Date: G -04 - a O 1 Phone#: L13) 5Q7- 9775 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SCA 1 0 20MM-05117 //l p / GRO Office of Consumer Affalrd&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE.:PartnershlD �' ExnlCation 126g?; 05/05/2020 RCI ROOFING 1s(-.f, N111 r r . _ t' Commonwealth of Massachuselt'§ MARK T.DELISL ``1 t; 6 LINE ST +?�r:�:`.; rye �� / DIVlsion of Professional Licensure Board of Building Re ulallons and Slandards SOUTHAMPTON,M/fi't1'f:°A 0' Undersecretary Cons, 'fli - -4-1 rvisor CS.074334 � I�l, f fKkplres; 05l03/202c r..t:, 11 , Registration valid for Individual use only j '`t T." before the expiration date, If found return to: MARK THOMf1S Dr; Office of Consumer Affairs and Business Regulation 69 BRIGGs sT v .A. 1000 Washington Street• Suite 710 EASTHAMPTO n, Boston,MA 02118A 0t1a Commissioner / Not valid without signature ' 1 t , it � � & Ant � n ,$r�•ti,.....,.._.,_._,,.,,-•....,.••,,.,...., . , OMM:ONINEALTH;0•F r ' HOME IMPRIgVfFj ' N )) ONTRACTOR s a a S G �R G��'� O •T =ISP cr, Rt} r,'sx SHEETtfY[E>tfA�L:Vu( RK: R�: ;�•;�rX:; t i,IN f 4110 'ar IS.SI E �3�<. :a4 .. <?5;,�HE'FO�LLOUVIIV:G�I,;�l'�� .::. T� t�• ,Z2I->' 01073 lJ:1J SSD ..:<:: ,rsz,.'�: Registration'!#""' '" F ffecti.b-'V 4t�' Ex itadon Ti ; EASTf{ 4IIfa�jIA . HIC.0G2474i' �c�ui Q.1:$,, ``•.• 11/30/2019 2. :' AlGtLED • � .� ""_' 1327% r•'s«,£ <�`„>3 ,��„ag•4' f. Y2 Q, Oa: ° 466498 : r __. nM l'• ti u'i'i ` I h” "i i.n,l�'Pn ,'YIRJ"j"• , '•,t',47 d<,i A:ff:,{q,.;, fV1.0N1IVEAL Mk,O<F fV1-A5: C40 E=r' � l.. COM �q £ + 41"'aGrv�`S': •orb;'�r:i?<c'.;El:'3.a „ .. Is:s:u.�s` Ia :Fa°�trowl:nlf;.• «ll'� ssly}' : W A NCS a 'j_y,V 1r j cr l3a �'oi�• Iv1A• rt??I�:I�°LISL�,�:t;�,,l�.�•,.� •��� Ikl:• :tip. .: 'EA: !Itrd� `>. i< I r '''^ f. f••• ,�i•r\1.;w(�•'i4' ,;�.' ' �,' r�:�+•"kis? .t::�:i3>,•' ''`�� .• . . 0' 0 .Z910'9['201 4 9 : " ! ACC OR ® CERTIFICATE OF LIABILITY INSURANCE r ATE(MM/DD/YYYY) 03/19/19 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 have ADDITIONAL INSURED provisions or 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 NAME: Michael R.Banas Banas 8:Fickert A/CNNo Exit: 413-527-2700 we No): 413-527-0849 Insurance Agency E-MAIL 63 Main Street ADDRESS: mb@banasinsurance,com Easthampton,MA 01027 INSURER(S)AFFORDING COVERAGE NAIC r INSURERA: Admiral Insurance Co. 24856 INSURED INSURER 13: Safety Insurance Co. 39454 RCI Roofing,LLP INSURERC: Admiral Insurance Co. 24856 6 Line Street INSURER D: Southampton,MA 01073 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MMID/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FRI OCCUR PREIN SES Ea occurrence) $ 50,000 MED EXP(Any oneperson) $ 5,000 A X CA000020963-05 03/04/19 03/04/20 -PERSONAL BADV INJURY $ 1,000,000 GEMLAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY[X PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER. $ AUTOMOBILE LIABILITY EOMaBI UeDtSINGLE LIMIT $ 1,000,000 ANYAUTO BODILY INJURY(Per person) $ B OWNED X SCHEDULED X 6207761 09/30/18 09/30/19 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 CEXCESS LIAR HCLAIMS-MADE X GX000000385-03 03/04/19 03/04/20 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N OFFICER/MEMBER EXCLUDED? /A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ROOFING CONTRACTOR. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ask THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REP S IVE 15 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ACCW" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDO/VYVY) lk � 1 03/19/2019 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: Michael Banas BANAS & FICKERT INSURANCE AGENCY p"C"N Ext. 413)527-2700 FAX No: E-MAIL ADDRESS: al@banasinsurance.com 63 MAIN ST INSURERS AFFORDING COVERAGE NAIC N EASTHAMPTON MA 01027 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: RCI ROOFING LLP INSURERC: INSURER D: 6 LINE STREET INSURER E: SOUTHAMPTON MA 01073 INSURER F: COVERAGES CERTIFICATE NUMBER: 379588 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, INSR LTR TYPE OF INSURANCE ADDL 5 BR POLICY NUMBER MM DDPOLICY EFF MM/DDPOLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F]OCCUR DAMA ET RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL b ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S JECT -]LOC PRODUCTS-COMP/OP AGG $ POLICY❑ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED -- AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE N/A AGGREGATE $ DEDRETENTION$ I I $ WORKERS COMPENSATION X STATUTE EORH AND EMPLOYERS'LIABILITY Y 1 N ANYPROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXC--f ., N/A N/A VWC10060226472018A 10/05/2018 10/05/2019 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If mora space 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 benefits 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 above 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 tool at www.mass.govAwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Is n THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Reference Copy I ACCORDANCE WITH THE POLICY PROVISIONS. Reference Copy AUTHORIZED REPRESENTATIVE ` $ Reference Copy Daniel M.Cri��ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD