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32A-051 (4) BP-2022-1625 49 MARKET ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 32A-051-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-1625 PERMISSION IS HEREBY GRANTED TO: Project# add bath 2022 Contractor: License: ANTHONY STOKESSTOKES Est. Cost: 34977 CONSTRUCTION LLC Const.Class: Exp.Date: MARKET STREET NORTHAMPTON PROPERTIES Use Group: Owner: LLC Lot Size (sq.ft.) Zoning: URC Applicant: STOKES CONSTRUCTION LLC Applicant Address Phone: Insurance: 223 STATE RD (413)834-1170 2001W9265 WHATELY, MA 01093 ISSUED ON: 12/16/2022 TO PERFORM THE FOLLOWING WORK: INTERIOR RENO FOR GOLF SIMUALATOR ADD ABA BATH 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: t,cpNAILA.CY1 is Fees Paid: $244.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner 11: !* ! 1DIL The Commonwealth of Massachusetts krt._ \ s"11�'\�c SA, 1ovs Office of Public Safety and Inspections .,-r a 1nr:. Massachusetts State Building Code(780 CMR) . ^ BuTiding Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number:idi ' /('ads Date Applied: Building Official: SECTION 1:LOCATION 142 447 (via(Key S 4 rJol-FKnwi f W-. AN blob() No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2•PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Buildingg Repair❑ Alteration 0 Addition 0 Demolition ❑ (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No 0 Brief Description of Proposed Work: aeltvt8 c`i t1all +of w,r%Vv5 + I'\S OA L ov• . 610►18 0-4-Ln(DO4n D(.lUJCLI , 14.SO A C % oo r oe (1c+.. A/} SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) 375— 2- $_?s Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business& E: Educational ❑ F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4❑ H-5 0 I: Institutional 1-1 0 I-2❑ I-3 0 1-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2❑ U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA0 IIB ❑ IIIA ❑ IIIB 0 IV 0 VA 0 VB 0 SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal: Public' Check if outside Flood Zone 0 Indicate municipal A trench will not be Licensed Disposal Site 0 Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify: affzrczk.b lR permit is enclosed 0 00v,k9 51-d s-• Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes❑ or No 0 Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: 0 A (l<� 0 �L�G� -�u i i i✓t I. n vg`i f'9 a f ll-/e fie�p wUnz� -- SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner (6.e.lei CtiAAM u �,ki)tS 113c yer5+ -PI,orekcL otoco2- Name(Print) No.and Street City/Town Zip Property Owner Contact Information azL- 9571 4t -,O,L- 1-{tog 141.54rt!.1 manly wtelAtirtkookcowk Title Telephone No.(business) Telephone No. (cell) e-mail address si If applicable,the property owner hereby authorizes: Avt+4toA -S () 9,a3 5-k U' t-k1 LMc 01013 Namt Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here D. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control (the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor S-b Yu2 S Cv AS t-rO CIAO," l_ .C Company Name I-},act*to t S+0 lc e,S c S o g M 6 e)9 IA Name of Person Responsible for Construction License No. and Type if Applicable 0-a-3 S-i-.4.e.. i v61 , 1 d mo, o lb q'3 Street Address City/Town State Zip - 413 - Say- 1170 an+taontfSi cS fa@ 5r/*) .(bIt Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 3H,9 7 7• (.1 1.Building $ MO 7-7.(07 Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ 10,000 appropriate municipal factor)=$ . 3.Plumbing $ 5t O00 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ 3►t 9 7 7, Co-) (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. k o IA- c h 1-e. \ fo jee c-f d uLs B 3 -R 34- ( (I v adz, Please print and sign name Title Telephone No. Date a D 5+4-j-z le-4 w t.,y (HA o i o rtfh`l 3 aor►j 5146 ea5i u I.c;owt Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: i PA`'/G�a- Name Date City of Northampton . 4IC Massachusetts `ti ! •w • DEPARTMENT OF BUILDING INSPECTIONS yr, 212 Main Street • Municipal Building yvj :Cs .+� Northampton, MA 01060 .• ,10 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, 554, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: 11}f-iv D ,nikl?S,1-ci'S . Location of Facility: GI t eizv` (Akek_ LS The debris will be transported by: Name of Hauler: 1 JC.-v Signature of Applicant: Date: , The (-onunottweulih of.1lassachtcsetts Deportment of Industrial Accidents 1 Congress Street, Suite 100 Berstnn, .11.-1 0 114-2017 is to it•-nt ass.got/din 1lutkrrs' ('onrprnsatiun Insurance %ftidasit: Builders Contractors/Electricians Plumbers. to Bt. I ll Et)vs 11 11 Mt PF K\II I I INC;Al l lIOkI11..•nulirant Information Please Print Leitibls Name tBusines,thtaniraiion Ind itidu.sii StvK eS CQ,„S*_ca,V,^ :- Address: t3-'a 3 _.S City/State/Zip: ui , e 1 ut,ls, p to 9 3 Phone #: c 11Z .- g 3 '.( - l 1 Z d ter y..wr rmpluy re?('kek r!r appriprtai,brit: Type of project(required): I -1 am 4 engskoycs with 3 crnpiosees t tali anti a part-timei.• 7. New construction :0 I am a sole proprietor ur purtnc-tshup arid have no employees%orlon; for nic iti 8. .Remodelrng any capacity (flu%taken'comp.insurance re uuu l.) 30 I am a lionaxiwner doing all work myself (No%areas comp insinuaten�uueal I' 9. ❑Demolition 10 0 Building addition 4.(,I am a bona-vwne.and will b hiring contraturs to cuiduci all work on my pnrprtty I will t4__Ji as urr that all c.ngrs un either Irate winters'ionmensation insurance tr;ur sole 11.0 Electrical repairs r addition, pnipnstors with no employees 12.0 Plumbing repairs it addition. I am a general contractor and I base hued the sub-cairn/actors listed on the attached sheet 13 Root repairs thewIhe suh-euttri.tots fuse entpluycc.and lose workers'comp unuram'c 6.0 we are a corporation and its officers has e exercised then right of et mpuon per l K L I.:. 1 .Q Otht 1 15:2.0141.and we has nu employees.Pilo woken'camp.insurance required.( •Any applicant that checks h os at must also till out the see-tum below shMowmg then workers'compensation policy mfurmatiun Mimeos*tiers w hi)submit this affidas it indicating they are doing all wink and then hue outside eamtraclee.must submit a new atfidas it milmaing such. :t ontractors that check this h,<iti must attached an additional sheet show mg the name of the sob-eaaitractees and state w he-ther or not those minim hale emldos rc-. I1 the sub-contractori base crop loy cis.they must pro,idc'her worl.cr,'.:oinp is lies nwtih er I am an employer that is providing►writers'compensation insurance for my employees. Below is the policy and job site inlornurtion. In,ur.in.c - ompan.. \ant:. a_MiLifs4 Policy r or Self-kiss. Lei.. : 9,6UtVJci a by Lxpiralion bate: It `(Of 2-3 Job Site Address: L-r? C'ityState'7.ip. VAb(hNc,,Imptl)►- - O10I) Attach a copy of the workers'compensation polity declaration page(shining the polies number and kpiration date). Failure to secure coverage as required under MGL c. 151 *25A is a criminal violation punishable by a tine up to S 1,500.00 and or one-year imprisonment,as well as civil penalties in the form old STOP WORK ORDER and a tine of up to S250.00 a day against the s rotator.A copy of this statement may be forwarded to the Office of Ins estigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above i.s true and cur cL Si n.tluic - - Date /a/fs/2Os?. Phone» C/f - 83(-1--i/70 Official use only. Do not trrite in this area.to hr t o,npleted hi•city or town official (•its or'ton n: Permiet.icense a Issuing.tuthorits (circle"net: 1. Board of Health 2. Building Department 3.( its'Iossn(perk 4. I•:kctr1cal Inspector 5. Plumbing Inspector 6.Other ( intact Person: Phone tt: .. v From: 14-vc-ViAC n`l Sin a C E 094 ho`7 o 2 ? 3 s ,-fie Sla�ccs C 5frUCAUA., NorikavtA oto6 To: Jonathan Flagg Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 The Massachusetts Building Code, section 107.1 allows for an exclusion from requirements for construction control in certain situations. In accordance with code section 104.10, I request that you grant a modification to waive the requirement for construction control of the project at (1-) nko.,( c 5+ (Act o k oo 0 because the work is of a minor nature, will not affect structural elements, health, accessibility, life or fire safety, and will be done in accordance with the prescriptive requirements of the code. Thank you for your consideration. ol& Respectfully, CZ Stokes Construction LLC. 223 State Rd Whately,MA.01093 Date Invoice# 12/14/2022 4 Phone# 413-522-6975 jeremystokes1990@gmail.com Bill To Cameron Carswell 47 Market St Northampton MA,01060 P.O. No. Terms Project Quantity Description Rate Amount Bathroom- 8,640.00 8,640.00 Labor to frame,insulate,drywall, tape,mud, prime, paint, Install trim,install door, install cabinets,install flooring. Labor to Install flooring on bay window floors. 300.00 300.00 Labor to Install drywall, tape,mud,sand, prime,and paint ceiling approx 800sq ft 6,480.00 6,480.00 materials to complete above projects 3,657.67 3,657.67 Permit fee 600.00 600.00 Dump fee 300.00 300.00 Customer to provide: Plumber Electrician Toilet Cabinets Sink Faucet Lighting Spray foam insulation Labor and materials to install spray foam insulation approx 5.5' (R-38)$6500 Total $19,977.67 Stoked Conatruction1c. CONTRACT FOR SERVICES This Contract for Services ("Contract") is entered into on this 14th day of December, 2022 ("Effective Date") by and between Stokes Construction LLC. (License CS094609) of 223 State Rd. S. Deerfield, MA 01373 ("Stokes Construction LLC."), and Benjamin Lewis of 113 Whittier St. Florence, MA. 01062 ("Property Owner") (collectively "Parties"), for certain construction and/or renovation work at the property located at 47 Market St. Northampton MA. 01060 ("Worksite"). WHEREFORE, in consideration of the mutual promises set forth below, the sufficiency of which is hereby acknowledged, the Parties hereby agree as follows: 1. SERVICES AND TERM OF CONTRACT Beginning on or about December 21, 2022 ("Commencement Date"), Stokes Construction LLC. shall provide to Property Owner the services described in the attached Exhibit A ("Services" or "Work"), which is herein incorporated as though fully set forth, verbatim. Stokes Construction LLC. anticipates that the Work will be completed on or about January 20, 2023, ("Completion Date"), though there may be unanticipated variables that could expedite or delay the Commencement Date and/or Completion Date, including without limitation inclement weather, delivery of materials, scheduling issues, acts of god, boycotts, accidents, permit issues, forces majeure, and other such unforeseen circumstances. Stokes Construction LLC. will use reasonable efforts to commence and complete the work on or by the stated dates, but bears no liability for delays unless there is clear and convincing evidence that Stokes Construction LLC. failed to act reasonably under the circumstances. 2. PAYMENT/S FOR WORK, LABOR, MATERIALS,AND SERVICES The total cost to the Property Owner for the work, labor, services, and materials called for hereunder is $19,977.67 ("Contract Price"), which shall be due and payable as follows: $600.00 Due upon execution of this Contract (this deposit does not exceed the greater of one-third of the total price or the cost of custom materials) $8,897.67 Due upon/by Wednesday, December 21, 2021 $5,240.00 Due upon/by Passed insulation inspection (approx. Jan 7, 2023) $5,240.00 Due upon completion of the work called for herein In the event that any payment called for hereunder is late in any respect, Stokes Construction LLC., in its sole election and discretion, may immediately suspend any and all Work unless and until Property Owner comes current on all payments owed. If Property Owner comes current on all payments owed within thirty (30) calendar days of the applicable due date set forth above, then Stokes Construction LLC. shall resume the work. If the Property Owner fails to come current within thirty (30) days of the applicable due date set forth above, Stokes Construction LLC. may treat the failure to timely pay as a material breach of this Contract, may terminate the Contract without liability, may immediately begin applying interest at the rate of twelve percent (12%)per annum, and may seek any and all legal remedies available to Stokes Construction LLC.. Payments shall not be contingent upon acceptance of any work done by third-parties, and Stokes Construction LLC. shall have no responsibility or liability for any work performed or materials provided by third-parties. 3. MATERIALS Stokes Construction LLC. has provided Property Owner with a list of anticipated materials needed for the Work, as well as the associated costs. These anticipated costs are set forth in Exhibit B hereto, and are included in the Contract Price set forth above. Stokes Construction LLC. may make reasonable substitutions of materials without penalty, offset, or credit, so long as such substitutions, in Stokes Construction LLC.'s business judgment, are similar in quality to those listed in Exhibit B Page 1 of 5 (g) Headings: The headings in this document are not intended to hold legal significance, but instead are for organizational purposes only. YOU MAY CANCEL THIS AGREEMENT IF IT HAS BEEN SIGNED BY A PARTY THERETO AT A PLACE OTHER THAN AN ADDRESS OF THE SELLER, WHICH MAY BE HIS MAIN OFFICE OR BRANCH THEREOF, PROVIDED YOU NOTIFY THE SELLER IN WRITING AT HIS MAIN OFFICE OR BRANCH BY ORDINARY MAIL POSTED, BY TELEGRAM SENT OR BY DELIVERY, NOT LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS AGREEMENT. PLEASE SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. By signing below, I affirm that I (i) have read this agreement, (ii) understand every term, (iii) agree to be bound by the same, (iv) have sought the advice of legal counsel or have knowingly declined to do so, (v) am authorized t nter intohis contract; and (vi) do so willingly and without any pressure or influence. DO NOT,SIG THI CONTRACT IF THERE ARE ANY BLANK SPACES Pr e Owner's nature J D to Printed Name: Ltl1AN),c 1 4 S 'x\ 1 Stokes Construction LLC. Date By and through Anthony A. Stokes Property Owne, i reby a Howled es receiving a copy of this contract, fully executed by all parties. j Z/1<-t Z_Z Pr erty Owner s Signature (D to NOTICE OF CANCELLATION Page 4 of 5 Date of Transaction: You may cancel this transaction, without any penalty or obligation, within three business days from the above date. If you cancel, any property traded in, any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the seller of your cancellation notice, and any security interest arising out of the transaction will be cancelled. If you cancel, you must make available to the seller at your residence, in substantially as good condition as when received, any goods delivered to you under this agreement; or you may if you wish, comply with the instructions of the seller regarding the return shipment of the goods at the seller's expense and risk. If you do make the goods available to the seller and the seller does not pick them up within twenty days of the date of your notice of cancellation, you may retain or dispose of the goods without any further obligation. If you fail to make the goods available to the seller, or if you agree to return the goods to the seller and fail to do so, then you remain liable for performance of all obligations under the contract. To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice, or send a telegram to Anthony Stokes, Stokes Construction LLC., 223 State Rd. South Deerfield, MA 01373, not later than midnight of the third day after this contract. I hereby cancel this transaction. (Property Owner's signature) Date Page 5 of 5 L. Commonwealth of Massachusetts IP Division of Occupational Licensure Board of Building Regulations and Standards CiOflSteAoniJr rV1SOr CS-094609 sitpires:05/17/2024 ANTHONY A. TO 223 B STATD" WHATELY Pat 0 4 r �O ttttttt Construction Supervisor 1 Unrestricted -Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. ,' For information about this!icense Call(617)727-3200 or visit www.mass.gov/dpl i 141"x 72f" /f 181;" t: 4 \ .. 1 N 'L * .-h 0 e- N ZD fJ 7 O N. / 43}" 43+" / 87" 1 I I a W N. I 1 I _, 1 M M i I j i 1 1 1 73-__--__ _ 1 1 e N; 135; _ \/% A 75" -----1 All dimensions size designations This is an original design and must Designed: 12/15/2022 given are subject to verification on not be released or copied unless Printed: 12/15/2022 job site and adjustment to fit job AOAO applicable fee has been paid or job conditions. 2020 order placed. 1 ... "--'- AFRO INSURANCE BINDER DATE(MM/DD/YYYY) 11/10/2022 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT,SUBJECT TO THE CONDITIONS SHOWN ON PAGE 2 OF THIS FORM. AGENCY COMPANY BINDER R Marcia Hawkins Agency American National/Farm Family Cas Ins Co 22012 115 Wate Street DATE EFFECTIVE TIME DATE EXPIRATION T E Williamstown,MA 01267 I AM 12:01 AM 11/10/2022 L PM 01/10/2023 NOON PHONE 413-458-5584 - WC,No,ExD: (FA/At‘No):413-458-9353 THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE'NAMED COMPANY CODE:4447f SUB CODE: J‘ PER EXPIRING POLICY S. 2001W9265 and 2001X3017 AGENCY CUSTOMER ID: DESCRIPTION OF OPERATIONS/VEHICLES/PROPERTY(Including Location) INSURED AND MAILING ADDRESS Carpentry-Renovations Stokes Construction LLC 223 B State Rd Whately,Ma 01093 COVERAGES LIMITS TYPE OF INSURANCE COVERAGE/FORMS DEDUCTIBLE COINS%j AMOUNT PROPERTY CAUSES OF LOSS BASIC BROAD SPEC GENERAL LIABILITY 2001X3017 11/10/2022 - 11/10/2023 EACH OCCURRENCE f 500,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES $ CLAIMS MADE I X OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 RETRO DATE FOR CLAIMS MADE PRODUCTS-COMP/OP AGG $ 1,000,000 VEHICLE LIABILITY _ COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED AUTOS ONLY BODILY INJURY(Per accident) $ - SCHEDULEDAUTOS PROPERTY DAMAGE $ HIRED AUTOS ONLY MEDICAL PAYMENTS $ _ NON-OWNED AUTOS ONLY PERSONAL INJURY PROT $ UNINSURED MOTORIST $ VEHICLE PHYSICAL DAMAGE DED ALL VEHICLES I SCHEDULED VEHICLES ACTUAL CASH VALUE COLLISIONS. STATED AMOUNT f OTHER THAN COL- GARAGE LIABILITY AUTO ONLY-EA ACCIDENT f ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE SELF-INSURED RETENTION $ 2001 W9265 11/10/2022 - 11/10/2023 PER STATUTE WORKER'S COMPENSATION E.L EACH ACCIDENT $ 500,000 AND EMPLOYER'S LIABILITY E.L DISEASE-EA EMPLOYEE $ 500,000 E.L DISEASE-POLICY UMIT $ 500.000 SPECIAL FEES $ CONDITIONS I OTHER TAXES $ COVERAGES — — --- ESTIMATED TOTAL PREMIUM $ NAME&ADDRESS ADDITIONAL INSURED LOSS PAYEE I I MORTGAGEE LENDER'S LOSS PAYABLE LOAN 0: _ AUTHORIZED RFPRESFNTATIVF Marcia Hawkins ms Page 1 of 2 ©1993-2016 ACORD CORPORATION. All rights reserved. ACORD 75(2016/03) The ACORD name and logo are registered marks of ACORD