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18C-141 680 BRIDGE RD-51 FIRETHORN LANE BP-2020-0845 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C- 141 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-2020-0845 Proiect# JS-2020-001454 Est.Cost: $12000.00 Fee: $78.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MARK JODOIN 49918 Lot Size(sa.ft.): 1497897.72 Owner: LATHROP COMMUNITY INC zonine: Applicant: MARK JODOIN AT. 680 BRIDGE RD - 51 FIRETHORN LANE Applicant Address: Phone: Insurance: 15 JONES DR (413) 885-7361 WC EASTHAMPTON MAO 1027 ISSUED ON.112412020 0:00:00 TO PERFORM THE FOLLOWING WORK.PORCH, KITCH, BATH RENO 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 1/24/2020 0:00:00 $78.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only -r>tsrr� City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans .� phone 413-587-1240 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 RECEIVED— histi section tion to be completed by office �/ f--Ire'7f/A'« v l of t Z-� Unit A/OIAN j✓lq ��6(w e Overlay District JAN 2 3 2 ;' Elm St. istric CB District SECTION 2-PROPERTY OWNERSHIP/AU INSPECTIONS NORTHAMPTON,MA 01 60 2.1 Owner of Record: ,�� 4,-fih4o Name(Print) Curr t Maili g Addre Telephone Signature 2.2 Authorized Agent: Name(Print) 00, Current Mailing Address: (21117) nature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS —F— Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building r o QpU (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 = 0 +2 + 3+4+ 5) QUA: Check Number This Section For Official Use Only -��i .� Building Permit Number: DateIssued: Signature: i z d(ql ab Building Commissioner/Inspector of Buildings Date � a�dome I1��1PRoye�n� SL 6141 ML t @ 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 This column to be filled in by Building Department Lot Size Frontage Setbacks Front " Side L: RL.....w.... 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 aSp cial Permit/Variance/Finding ever been issued for/on the site? NO 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 0 YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO k�4 DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained I Obtained I , 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 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, exc ion, 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 ❑ Replacementrdows Alteration(s) Roofing Or Doors Accessory Bldg. ❑ Demolition © New Signs [0] Decks [M Siding [0] Other[0] Brief Description of Proposed Work: �y eGc1 Pc7u4 �16Y-� �1/N STS/ 6--"K. / ��5 1"L�(Gc1 391�CS Alteration of existing bedroom Yes ! No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes f 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. '711 S� Dimensions (2- e. ye. Number of stories? f. Method of heating? Fireplaces or Woodstoves /�`, Number of each No g. Energy Conservation Compliance. Ado- Masscheck Energy Compliance form attached? -� h. Type of construction J�A/OUr)' 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 OWNEERSSf AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, / ' 1 K1,A,4 Z as Owner of the subject property 9 n hereby authorize �lYX6/� to act on y behalf, in all matters relative to work authorized by this building permit application. S gnature of Owner Date 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. Print Name f l ignature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES , 8.1 Licensed Construction Supervisor: / Not Applicaabrllee ❑ Name of License Holder: !� Glc�.t�'`J Q /L License Number Z220 Address Expiration Date Signature Telephone 9.Re istered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number /5- --J-60veJ o1,'5PZ y�� �o Address Expiration Date Telephone W- 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....... 0`�— No...... ❑ City of Northampton Massachusetts • �•' ,VAC f; DEPARTMENT OF BUILDING INSPECTIONS "a 212 Main Street • Municipal Building 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: keel c:�?`el 41( Est.Cost: /oar 000 Address of Work: F-t Date of Permit Application: //a3/vim o 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�Zk -TD6 AJ Date Contractor Name HIC Registration No. OR: Notwithstandin -he above tice, I hereby apply for a building permit as the owner of the above property: i Date / wner Name and gignature e 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 bum 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-MASSA-FE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia City of Northampton • 4 Massachusetts =� DEPARTMENT OF BUILDING INSPECTIONS �, w T 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: (Please print house number and street name) Is to be disposed of at: (Please print name an location offacility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Permit Ap 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. The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia «'orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le«ibly Name(Business/Organization/Individual): /4014/J f IyJ/17 " / f Address: .o ,me t City/State/Zip: /7�/ �i /�An+6 &one#: 65(t 7W 537�? 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 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. RrRemodeling any capacity.[No workers'comp.insurance required.] 3.F1I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 9. [Demolition 4.E]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 ❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[:]Roof❑ p Roof re airs These sub-contractors have employees and have workers'comp.insurance.: 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. xContractors 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:g 0� e 5� -2 X��%l, L Policy#or Self-ins.Lie.M x9080377 Expiration Date: 1111911 Job Site Address: �� lk-OI.'-/ /–A','e City/State/Zip:NV)?AdWe'J,#U- 0/d() 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. Ido hereby certify under the Rains and penalties of perjury that the information provided above is true and correct Si ature: ` ! _.. Date: Phone#: 7/3 913 —'96,0r 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#: ��® DATE(MM/DDIYYYY) A CCERTIFICATE OF LIABILITY INSURANCE111 1 01/23/2020 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 CNTNAME: T Rich Kouvo _. ---. - HUB INTERNATIONAL NEW ENGLAND LLC f'HONN (413)750-7106I ac No: ADDRESS: rich.kouvo@hubinternational.com 600 LONGWATER DRIVE INSURER(S)AFFORDING COVERAGE NAIC0 NORWE_LL MA 02061 INSURER A: AIM MUTUAL INS CO 33758 NSURED INSURER B: MARK JODOIN INSURER C: JODOIN HOME IMPROVEMENT INSURER D: 15 JONES DRIVE INSURERE: EASTHAMPTON MA 01027 INSURER F: COVERAGES CERTIFICATE NUMBER: 496956 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 TYPE OF INSURANCE ADDL SUBR POLICPOLICY NUMBER MMIDDY EFF POLI EXP LIMITS LTR VGEWLA RCIAL GENERAL LIABILITY EACH OCCURRENCE $ NTED AIMS-MADE OCCUR PREMISES EaEoccurrence) MED EXP(Any one person) S N/A PERSONAL&ADV INJURY $ EGATE LIMIT APPLIES PER: GENERAL AGGREGATE E E]JETFILOC PRODUCTS-COMP/OP AGG S CO BINED $ AUTOMOBILE LIABILITY Ea accident)SINGLE LIMIT t ANY AUTO BODILY INJURY(Per person) tS ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTYDAMAGE $ HIRED AUTOSAUTOS Per accident) a UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE NIA AGGREGATE E DED RETENTION E WORKERS COMPENSATION X STA ER AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N EL.EACH ACCIDENT S 500,000 A OFFICER/MEMBER EXCLUDED? NIA NIA NIA AWC40070296132019A 08/31/2019 08/31/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE s 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT s 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more 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 gov/lwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Lathrop Retirement Community ACCORDANCE WITH THE POLICY PROVISIONS. 100 Bassett Brook Drive AUTHORIZED REPRESENTATIVE Easthampton MA 01027 7)J1 C�(x Daniel M.CroWJey,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 JODOHOM-01 KO R11 ACORO CERTIFICATE OF LIABILITY INSURANCE FDATD/YYYY) 1/123/223/2 020 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 CONTACT HUB International NE formerly ICNE,Inc. PHONE :(800)243-8134 (FAXAfC,No):(413)731-9539 1070 Suffield Street Agawam,MA 01001 EMAA DD IL INSURERS AFFORDING COVERAGE NAIC k INSURER A:Nautilus Insurance CO 17370 INSURED INSURERS:Commerce Insurance Company 34754 Jodoin Home Improvement INSURER C: c/o Mark S Jodoin 15 Jones Drive INSURER D: Easthampton,MA 01027 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 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 TYPE OF INSURANCEAIDDL SUBSD DR POLICY NUMBER MOLIC EFF POLICY EXP LIMITS A X COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADEnCe OCCUR NC863543 6/26/2019 6/26/2020 DAMAGE TO RENTED $ 100,000 XI PREMISES(Ea MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑PRO ❑LOC 2,000,000 JECT PRODUCTS $ OTHER: $ B AUTOMOBILE LIABILITY CO eCBIGNED 6etJSINGLE LIMIT $ 1,000,000 ANY AUTO RPJ989 3/26/2019 3/26/2020 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS AUTOS ONLY AUTOS BODILY INJURY Per accident $ X HIREDX NON-0WNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Peracadent $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LJAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION I PER ETH- AND EMPLOYERS'LIABILITY Y/N TUTF— TER ANY PROPRIETOR/PARTNERIEXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDE — (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E,L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Lathrop Retirement Community THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 100 Bassett Brook Drive Easthampton,MA 01027 AUTHORIZED REPRESENTATIVE f17-6 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD