Loading...
32A-006 (4) BP-2022-1648 24 WALNUT ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 32A-006-001 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-2022-1648 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2022 Contractor: License: Est. Cost: 2950 AMERICAN INSTALLATIONS LLC 106178 Const.Class: Exp.Date: 09/29/2023 Use Group: Owner: Lot Size (sq.ft.) Zoning: URC Applicant: AMERICAN INSTALLATIONS LLC Applicant Address Phone: Insurance: 130 COLLEGE ST SUITE 100 (413)552-0200 AMWC262555 SOUTH HADLEY, MA 01075 ISSUED ON: 12/27/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ERI ZATI ON 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: f - TAIT Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner )1:16..iir 22-3012 A&B 0 LM•,. City of Northampton j / ' Building Department ��` 2 212 Main Street i 4' �� INS ULA TION Room 100 ( ...- Or ter. Northampton, MA 01060 • phone 413-587-1240 Fax 413-587-1272 Fh4 QfJL., Yx ' ao Av APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INS ULA TION PERMIT 1.1 Property Address: This section to be completed by office 24 Walnut St Map Lot Unit Northampton MA 01060 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: tii1L°`'!n 24 Walnut St Apt 1 Name(Print) Current Mailing Address: 802-254-5692 See attached Telephone Signature 2.2 Authorized Agent: American Installations 130 College Street Ste. 100, South Hadley, MA 01075 Name(Print) Current Mailing Address: (413) 552-0200 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 2950.45 (a)Building Permit Fee 2. Electrical 0 (b)Estimated Total Cost of Construction from(6) 3. Plumbing 0 Building Permit Fee 4. Mechanical(HVAC) 0 5. Fire Protection 6. Total=(1 +2+3+4+5) 2950.45 Check Number a2,7 /�,,/n�-11 This Section For Official Use Only Building Permit Number: ilro)A- Date Issued: /7:47 Signature: 12-27- ZOZZ Building Commissioner/Inspector of Buildings Date permits@AmericanInstallations.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: Wesley K. Couture 106178 License Number 130 College Street Ste. 100, South Hadley MA 01075 9/29/2023 Address Expiration Date (413) 552-0200 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 American Installations 175982 Company Name Registration Number 130 College Street Ste. 100, South Hadley MA 01075 6/26/2023 Address Expiration Date Telephone (413) 552-0200 SECTION 5-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 ❑ Brief Description of Proposed Work NOTE: INSULATION ONL Y Attic and basement insulation and air sealing throughout. American Installations - Wesley Couture , 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. Wesley K. Couture Print Name 12/9/22 Signature of / Date Dalia Shevin I, , as OwneF of the subject property hereby authorize American Installations to act on my behalf, in all matters relative to work authorized by this building permit application. See attached 12/5/22 Signature of Owner Date City of Northampton Massachusetts tr; * DEPARTMENT OF BUILDING INSPECTIONS11 I 212 Main Street • Municipal Building Northampton, MA 01060 Pr j' 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: Insulation Est.Cost: 2950.45 Address of Work: 24 Walnut St Date of Permit Application: 12/9/22 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 x Other(specify): Contractor pulling permit for homeowner 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: 12/9/22 American Installations 175982 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 s Massachusetts? sJi R G A c 4 a DEPARTMENT OF BUILDING INSPECTIONS 1 212 Main Street *Municipal Building ,��� Northampton, MA 01060 st �� 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: 24 Walnut St (Please print house number and street name) Is to be disposed of at: K e'r W Materials e'r Recycling, 138 Palmer Ave, West Springfield, MA 01089 (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 12/9/22 Signature Permit Applicant 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. T,0. Yj�r City of Northampton �5 , k �5;. ,..c t xMassachusettsw%` ` DEPARTMENT OF BUILDING INSPECTIONS 2. �1Y J ` 212 Main Street • Municipal Building �sr. �j. -" Northampton, MA 01060 MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: 24 Walnut St Contractor Name: American Installations Address: 130 College Street Ste. 100 City, State: South Hadley MA Phone: (413) 552-0200 Property Owner Name: Dalia Shevin Address: 24 Walnut St City, State: Northampton MA 01060 I, Wesley K. Couture (contractor) attest and affirm that the building I intend to insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature r L/r Date 12/9/22 Page 1 of 1 mass save Licensed&Insured 11011111111 PARTNER MA CS!.#.106173 MARegi.Rtmnnnu175982 American Installations www.Americanlnstallations.com 130 College Street Suite 100,South Hadley,MA 01075* Office:(413)S52-0200 Fax:(413)552-0202• Email:supporteAmericanInstallations.com Customer Name:Daniel Papasian Email:Not provided Phone:802-254-5692 Premise Address:24 Walnut St,Northampton,MA 01060 Mailing Address:24 Walnut St, Northampton,MA 01060 Project ID:4670960 Date:Dec.5,2022 Job Description Measure Description Location Quantity Unit Total Cost Customer Cost Propavent 40 each $165.20 $0.00 Attic Floor- 15"Open Blow Cellulose 784 SF $1,983.52 $0.00 Air Sealing at Estimated 62.5 CFM50 Per Hour 6 hr $565.98 $0.00 Project Total $2,714.70 Weatherization incentive ($2,148.72) Air sealing incentive 1($565.98) Total Program Incentive -$2,714.70 Customer Total $0.00 WARRANTY:American installations,LLC will provide the above stated homeowner with a 1-year workmanship warranty. American Installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with the above specifications and all local and state building regulations for the Total Contract Value as stated herein. ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are TOTAL CONTRACT VALUE $ satisfactory and are hereby accepted.You are authorized to do work as specified.Payment will be 1/3 down prior to start of work,and balance due upon Completion. Down Payment=S ❑ PAID Balance Due Upon Completion= S Signature Date Property Owner(Print) (Sign) Date Representative:(Print)ida /���7771�6 aT‘ (Sign) Date THIS AGREEMENT IS UOMPOSED Of THIS PAGE ANO THE REVERSE SIDE OF THIS PAGE ANC SHALL BE CCNSIOEREO THE ENTIRE AGREEMENT R1 THE PARTIES INVeyE0.THIS AGREEMENT 15 BETWEEN AMERICAN INSTALLATIONS,UC HEREINAFTER,REFERRED TO AS-COMPANY, ANDTIE CUSTOMERIS)NAMES ABOVE,HEREINAFTER REFERRED TO AS`CLIENT',AND W ILL tlE SUMO TO AU.APPROPRIATE to WS,REGULATIONS AND ORDINANCES OF THE 5TAlE OF MASSACH USE:1S OR CONNECTICUT RESPECT IVEOr,AS WEII.As ALL LOCAL 1URISDICII0NS. Page 1 of 2 J ma s save Licensed&Insured PARTNER MA at it:206278 1111111%. MARoyefrotlon#275982 American Installations www.Americaninstallations.com 130 College Street Suite 100,South Hadley,MA 01075•Office:(413)552-0200 Fax:(413)552-0202• Emaik cupporteAmericanlnstallations.com Customer Name:Daniel Papasian Email:Not provided Phone:802-254-5692 Premise Address:24 Walnut St, Northampton,MA 01060 Mailing Address:24 Walnut St,Northampton,MA 01060 Project ID:4670989 Date:Dec.5,2022 Job Description Measure Description Location Quantity Unit Total Cost Customer Cost Door- 2"Thermal Barrier Polyiso 1 each $90.61 $0.00 Attic Floor- 15"Open Blow Cellulose 768 SF $1,943.04 $0.00 Hatch -2"Thermal Barrier Polyiso 1 each $47.37 $0.00 Damming 48 each $117.60 $0.00 Propavent 45 each $185.85 $0.00 Air Sealing at Estimated 62.5 CFM50 Per Hour 6 hr $565.98 $0.00 Project Total $2,950.45 Weatherization incentive ($2,384.47) Air sealing incentive ($565.98) WARRANTY:American Installations,LLC will provide the above stated homeowner with a 1-year workmanship warranty. American Installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with the above specifications and all local and state building regulations for the Total Contract Value as stated herein. ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are TOTAL CONTRACT VALUE $ satisfactory and are hereby accepted,You are authorized to do work as Specified.Payment Down Payment=$ ❑ will be 1/3 down prior to start of work,and balance due upon Completion. PAID Balance Due Jpnn Completion= Signature Date Property Owner(Print) (Sign) Date Representative:(Print) (Sign) Date THIS AGREEMENT IS COMPOSED OF THIS PAGE AND TNEREN:RSE SIOE OF THIS PAGE AND SHALL BE CONSIDERED THE ENT IRE AGREEMENT RN THE PARTIES INVOLVED.THIS AGREEMEN115 BETWEEN AMERICAN INSTALLATIONS,UC HEREIN AFTER REFERRED TO AS'COMPANY.. AND THE CUSTOMERS)DANIEL ARENE,HEREINAF1 ER REFERRED TO AS"CLIENT AID)WILL BE SUBJECT TOAD APPROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE STATE Of MASSACH U5EI IS OR CONNECTICUT RESPECTIVELY,A5 WED AS AU LOCAL IUNISSIICT IONS. Page 2 of 2 mass save licensed&insured MACSC#:206173 PARTNER MA Regittmtlon#2759R2 American Installations www.Americaninstaliations.com 130 College Street Suite 100,South Iledey,MA 01075•Office:(413)552-0200 Fax:(413)552-0202• Email:support4Americanlnstallations,com Customer Name:Daniel Papasian Email:Not provided Phone:802-254-5692 Premise Address:24 Walnut St,Northampton,MA 01060 Mailing Address:24 Walnut St,Northampton,MA 01060 Project ID:4670989 Date:Dec.5,2022 Total Program Incentive - 2,950.45 Customer Total $0.00 WARRANTY:American Installations,LLC will provide the above stated homeowner with a 1-year workmanship warranty. American Installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with the above specifications and all logal and state brilding regulations for the Total Contract Value as stated herein. ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are TOTAL CONTRACT VALUE= satisfactory and are hereby accepted.You are authorized to do work as specified.Payment Down payment=S ❑ will be 1/3 down prior to start of work,and balance due upon Completion. PAID Balance Due Upon Completion• S P 4. /Or � Signature Date Property Owner(Print) (Sign) Date Representative:(Print) ,4Y I_I 144Kc.4 (Sign) Date THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THERMSE SIDE OP TINS PAGE AND SHALL RE CONHOEREO THE ENTREAaRQMERT Rr THE PARTIES INVOLVED.TINS AGREEMENT IS BETWEEN AMERICAN INSTALLATIONS,LLCHagINAFT REFERRED ID AS'COMPANY, MOTHS CUSTOMERIs)NAMED ABOVE,HEREINAFTER REFERRED TO AS'CLIENT,AND Will RE SMELT'MALL AFFROPRIATE LAWS,REGULATIONS AND ORDINANCES OF THE S TATE OF MASSAO4US 1TS OR connon trr RESPECTIVELY,AS AS ALL LOCAL AA ROD CTIONS. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations =aB= Lafayette City Center .::f ��. 2Avenue de Lafayette, Boston,MA 02111-1750 "�..��' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):American Installations LLC Address:130 College St, Suite 100 City/State/Zip:South Hadley, MA 01075 Phone#:413-552-0200 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 43 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. n Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' p Ty 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.f] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 1.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13 ❑■ Other Insulation 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: Berkshire Hathaway GUARD Insurance Policy#or Self-ins. Lic. #:AMWC332951 Expiration Date:09/04/2023 Job Site Address: 24 Walnut St City/State/Zip: Northamptdn MA 01060 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 9. ( b.tZ Date: 12/9/22 Phone#: 413-552-0 00 Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 3.0City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: Commonwealth of Massachusetts , Division of Professional Licensure Board of Building Regulations and Standards ‘. . Consts,: , z *„ , s„ , iisior , CS-106178 .I4 , ELDires 09/29/2023 - , WESLEY COUTURE -,-,139 PACKAROVILLE RO,itt- PELHAM MA 01002 .. , .._ 1 , I) in Commissioner .1- ,---')o“,44/44 IS tIC,dirciti,A,_, i (,) --,..-• ...11.114•110.-,, ,,TtSrl,PT Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC Regibticition: 175982 AMERICAN INSTALLATIONS,LLC. Expiration: 06/26/2023 130 COLLEGE STREET SUITE 100 SOUTH HADLEY,MA 01075 Update Address and Reture Card. Office of Consumer Attain&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. ff found return to: liseistastIstn Exakelien Office of Consumer Affairs and Business Regulation 175982 08/28/2023 1000 Washington Street -Suite 710 Boston,MA 02118 AMERICAN INSTALLATIONS,LLC. , / / ,i,._ WESLEY COUTURE /2 - /1./, n - 130 COLLEGE STREET surrE 100 fie,.40.(a(ma/sof Not valid without signature SOUTH HADLEY,MA 01075 Undersecretary AC R® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) L...../ 08/30/2022 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 Barbara Grynkiewicz Webber&Grinnell PHONE (413)586-0111 FAX (413)586-6481 (A/C E-MAIL Extl: 9 (NC,NO): 8 North King Street ADDRESS: bgrynkiewicz webberand nnnell.com INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURERA: Employers Mutual Casualty Company 21415 INSURED INSURER B: AmGUARD/BH GUARD 43290 American Installations,LLC INSURER C: Attn:Wes&Suzanne Couture INSURER D: 130 College Street,Suite 100 INSURER E: South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 9/4/23 REVISION NUMBER: I 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE iORENrho CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ 500,000 x Liquor Liability MED EXP(Any one person) $ 10,000 A 5D3535223 09/04/2022 09/04/2023 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JEC7 LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE UABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED ts/ SCHEDULED 5Z3535223 09/04/2022 09/04/2023 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED v NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) PIP-Basic . $ 8,000 X UMBRELLA UAB OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS UAB CLAIMS-MADE 5J3535223 09/04/2022 09/04/2023 AGGREGATE $ 1,000,000 DED X RETENTION $ 10,000 $ WORKERS COMPENSATION X STATUTE EORH AND EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE YYN NIA AMWC332951 09/04/2022 09/04/2023 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under — DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD