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32A-080 (2) • KESU ,acoRO° CERTIFICATE OF LIABILITY INSURANCE DATE 7 /7 /2 D /YYYY) � 7/7/2011 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 (413) 733 -3131 CONTACT Mary Lou Rosner FieldEddy Insurance 4 (AIC NNo, Est): ( 13) 233 -2122 FAX No): (413) 733 -3191 96 Shaker Road E-MAIL ADDRESS: mrosner @fieldeddy.com P.O. Box 709 PRODUCER East Longmeadow, MA 01028 -0709 CUSTOMER ID # -01 _ _ INSURER(S) AFFORDING COVERAGE NAIC INSURED Gandara Mental Health Center Inc INSURER A : Philadelphia Indemnity Insurance Com.an 147 Norman Street INSURER B :Atlantic Charter Insurance Company West Springfield, MA 01089 INSURER C : INSURER D : 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. I LTR TYPE OF INSURANCE INSR SUBR r POLICY EFF POLICY EXP WVD POLICY NUMBER LIMITS (MMIDDIYYYY) (MMIDD /YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY PHPK741925 7/1/2011 7/1/2012 DAM T• - E ED 100,000 PREMISES Ea occurrence) $ CLAIMS -MADE X, OCCUR - MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS - COMP/OP AGG $ 3,000,000 X1 POLICY PECOT- LOC $ — AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO - - BODILY INJURY (Per person) $ ALL OWNED AUTOS — BODILY INJURY (Per accident) $ SCHEDULED AUTOS – - - -_ PROPERTY DAMAGE $ HIRED AUTOS (Per accident) I NON -OWNED AUTOS $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $ 3,000,000 A PHUB351211 7/1/2011 7/1/2012 — DEDUCTIBLE $ X RETENTION $ 10,000 I $ WORKERS COMPENSATION X WC STATU- OTH _ AND EMPLOYERS' LIABILITY _ TORY LIMITS ER Y / N B ANY PROPRIETOR /PARTNER/EXECUTIVE _ WCV00968000 7/1/2011 7/1/2012 E.L. EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 A Misc.Professional Liability IPHPK741925 7/1/2011 7/1/2012 Occurrence /Aggregate 1,000,00013,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Proof of insurance coverage issued per request. with regards to location: 25 Graves Ave. Northampton MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ty p ACCORDANCE WITH THE POLICY PROVISIONS. Northampton, MA 01060 - AUTHORIZED REPRESENTATIVE © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Fat 600 Washington Street Boston, MA 02111 www. mass.gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Bus iness /Organization/Individual): Gandara Mental Health Center, Inc. Address: 147 Norman Street, City /State /Zip: Northampton, MA 01089 Phone #: 413 - 736 -8329 ext 204 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. New construction listed on the attached sheet. 7. ❑ Remodeling 2. El I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. ['Demolition capacity. employees and have workers' working for me in any P ty $ 9. ❑ Building addition [No workers' comp. insurance comp. insurance. re uired. 5. ❑ We are a corporation and its 10. El Electrical repairs or additions q ] 3. officers have exercised their 11. Plumbing re ❑ I am a homeowner doing all work g pairs or additions myself. [No workers' com right of exemption per MGL m Y comp. 12. ❑ Roof re airs insurance required.] t c. 152, § 1(4), and we have no 1� employees. [No workers' 13. Other are- /L r 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /State /Zip: 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 an penalties of perjury that the information provided above true and correct. Signature: ,./41.1111r ' Date: — Phone #: 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 #: • Versionl.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes 0 No eJ SECTION 11 - OWNER AUTHORIZATION -'TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 1 0 .. it� .. . � . , ®Aferi/. .1 0 _ . . as Owner of the subject property hereby authorized -.p ,� act on my behalf, in all matters relative to work authorized by this building permit application Signature of Own 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 Signature of Owner /Agent Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder:'.._ P Qf L 'r d -� Addre Number Address _ ) i° Td j ill_ /44A Expiration Date gnature ` ' / fi , Telephone VAOL' SECTION 13 - 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 0