17A-253 (6) 149 OAK ST BP-2017-0355
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 17A-253 CITY OF NORTHAMPTON
lei:-001PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category;...INSULATION BUILDING PERMIT
Permit# BP-2017-0355
Project# JS-2017-000583
Ey4,Cost;$1909 00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(su.ft.): 16291.44 Owner: BOYLE CHRISTOPHER 1
Zoning: URB(100)/ Applicant: IDEAL HOME IMPROVEMENT INC
AT: 149 OAK ST
Applicant Address: Phone: Insurance:
142 BOYLE RD (413) 863-2128 Liability
GI LLMA01354 ISSUED ON:9/14/20160:00:00
TO PERFORM THE FOLLOWING WORK:INSULATION -494 SF CELLULOSE OPEN ATTIC,
741 F FBG SILLS, AIR SEALING
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 if Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: ¢il; Insulation:
Final: Smokes 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 9/14/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit
i Building Department Curb Cut/Driveway Pernit
212 Main Street Sewer/SepticAvailability
! Room 100 Water/Wei Availability
DEPNOR I VAMP ,T°r nu— (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 prPropertyy A�d+dress: ,�,,rThis section to be completed by office
$i L.N.4---S t T e.t- Map Lot Unit
F.t Orcn`c ;;r'�Sy n, Zone Overlay District
1 1 ' ' Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
C Withlr E" A.J19 IL}cV OGLSt N' OY'e,^nCC_ a
Current Mailing AEtlmss' 1 \ J'~J G y- �..1L I -I
Telephone
Signature
2.2 Authorized Agent:
�CI A YLS�� y 11'- \40). &AI bIZSK. 6( I k ailk
me1r'r+•H Current Mailing Addre s
S' ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COST
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Pend Fee
2. Electrical (b)Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee D'
4. Mechanical(HVAC)
5.Fire Protection r��� __
6. Total-(1 +2+3+4+5) 0•CC Check Number 3407v
9
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: �r.r/ / i..,/ 9-7r-/Of.
CIPPor
Budding Commissioneritnspector of&aldngs Date
Section 4. ZONING Att Information Must Be Completed_Permit can Be Denied oue To Incomplete Information
Existing Proposed Required by Zoning
ms column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage m
Open Space Footage
(tau arw minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Lebanon)
A. Has a Special Permit/Variance/Finding ver been issued for/on the site?
NO O DONT KNOW YES 0
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 0/YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained O , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0'
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. VW the construction activity disturb(clearing,grading,ex ion,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O 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 ❑ Replacement Windows Alteration(s) in Rooting ❑
Or Doors D i
Accessory Bldg. El Demolition 0 New Signs [MI Decks ID SidingICI Other It�
Tl . a s
Brief
° Y°c-C4P1 a°1c&cvpcn a-Vy e 1 '1(41 c' ..Pb() 'AI tarso:)k r ,eS AR i rlei
Alteration of existing bedroom Yes fNo Adding new bedroom Yes ‘/No
Attached Narrative Renovating unfinished basement _Yes Y
Plans Attached Roll -Sheet
aa.If New house and or addition to existing housing,complete the following:
a. Use of building: One Family %. toTwo 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, `\✓hY 1St iSity ik 4-J\J Y..7�. - as Owner of the subject
property ,'(` vin n
hereby authonze `ice+ 7 v..5 \ 1 1 '
ton my behaf, nn all matters elative to work authorized by this building permit application.
(^�i 1 moi ' / 7t0
Signature"off Owner
/ Date
I, }VvY 4iS l/7 { k I S_.,. __,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.
James 1ilIS _..
Sign re of Owner/Agent Date
•
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
ter—
Name of License Holder: CA Com . 2. jI S 9 ) , C?
License Number
, tt1 YVUA1/4. Q S I its f`
Address Expiration Date
Via., (' 111`/A -� i N d)Ae
gnature Telephone
9-Reinstated Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
�-1�i Li{ Lt
Address
p �'7 (it '- Expiration Date
O1 J Telephone�12) W 4
24
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidav must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the build' g permit.
Signed Affidavit Attached Yes__ No ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and(or fann
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be
responsible for all such work performed under the building permit
As acting Construction Supervisor your presence on the job site will he required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,You may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature ,
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
i
Address of the work: Iu1 LGC &t -f-i 1'� f C<
The debris will be transported by: n
The debris will be received by: A-
Building permit number: 1 31, 1 ( S
Name of Permit Applicant C I OlJy L\
q� gli vti a �
Date Signature of Permit Applicant
City of Northampton
N
4,----%
j, Massachusetts (
x
Rr 124
t�, DEPARS'NT OF WI WING INSPECTIONS 1. jS
y077-1* 212 Main Street • Municipal Building xs tiy ye
11t 6 ,f Northampton, Ma 01060 sr",
'Y>i
Property Address: I4Cl Oct0 �..,-
r
k , 11(ly-C, )CC
Contractor ('� -
Name: t_ia ,L-S c J(I S
Address: 4)-,�r,c \,. Y_-kd
City, State: el I ( culy & 0 v 3
tt t
Phone: LA \"3 .r5 - c)-{
Name: C
Property Owner '^ yt C
4s I tcv C ....),4 Lc
Address: l
{�\LrkCI Oat_ c*-•
1
City, State: I min et_ ,rr iU
I, l J.�,{Y 2S IA t t S (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
Date , lc,{\ t
The Commonwealth of Massachusetts
--r.—_— Department ofIndustrialAccidents
of — t
e.�lip=E' Office ofInvestigations
'Elie" 1 Congress Street,Suite 100
'' = I'I= Boston,MA 0211 4-2 01 7
•.: www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please P
rint Legibly
Name(Business/organization/Individual): I kp� i�J , I nip rm aplrt+
_
Address: Mo-- >bQy
yte/Zip: el (I f,U OF) Phone#: LI Vj'�I 3 ' czi 31?
An employer?ChedSthe appropriate box: Type of project(required):
I. a employer with (X 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers'
insurance.. 9. ❑ Building addition
comp.[No workers' comp.insurance
required.] 5. ❑ We are a corporation and its 10.1:1 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 L❑ Plumbing repairs or additions
myself [No workerscomp. right of exemption per MGL
Y 12.❑ of repairs
' n, a,
insurance required.]t c. 152,e 1(4),and we have no 13 er'i t�(�,[},�,7 (.l�
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information.
'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. if �'
Insurance Company Name: ,/ [�itL .,fti I f\(A.r6 i l..l Co .
#:m 11Y
Policy#or Self-ins. Lic. 1 501 I 1 0 Expiration Date: I IT1 LO 117•
Job Site Address: \ —I Ci 0ckx ST• City/State/Zip: . ii 4
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereb under the ns and penalties of perjury that the information providedabove is true and correct
Signatm'e: + J�11,r icA-/\, Date: (—1 ) "[e� k ) k0
Phone#: 415 O _J
.cL - 3.1awl
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-091207
Oonsrucon Supervise[
JAMES P ELUS
142 BOYLE RD
GILL MA 01364
Expiration:
Commissioner 10/1612018
mn/Rain B Regpb'e
▪. �.r_-dOME IMPROVEMENT CONTRACTOR
'.. a• NegistrNon: 146402 Type
v:>Ez)ImIjoa 42212017 Prale CWPoralar
IDEAL HOME IMPROVEMENT INC.
JAMES ELLIS
142 BOYLE RD
GILL MA 01354 J�
Ve der eercory
A�•
CERTIFICATE OF LIABILITY INSURANCE DAOVD nD1�s
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terns and conditions of the policy,certain policies may require an endorsement, A statement on this certificate don not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER tams Dakota Coughlin
A. H. RIST INSURANCE AGENCY INC. PHONE
(4131563-4a73 I I;Cwe_,,,,,
iooREas: dakotaCahnstcom
P.0 SOX 391 INSURER(S)AFFOROINGCOVERAGE HNC4
TURNER FALLS _ MA 01376 INSURER A: ACADIA INS CO 31325
INSURED INSURER B:
IDEAL HOME IMPROVEMENT INC wsuRERc:
INSURER 0:
142 BOYLE ROAD PPM/MERE:
GILL MA 01354 . wsueERF:
COVERAGES CERTIFICATE NUMBER: 27952 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 WIN 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.OMITS SHOWN MAY HAVE PFFN REDUCED BY PMD CLAIMS
(NSR I TYPEOF INSURANCE r1DBL-W— W you&Y EFF Pol1CY LpY DMS.
ITRIWED min POLICY NUMBER eMNGMYYI (MMNOfl VYY�
I COMMERCIAL GENERALLKBitlrr EACH OCCURRENCE $
MAWBEIPMENTED
—..I_�CLAIMS-MADE OCCUR PREMISES IF.-anrtaue 4 _
_._ MED EXP IND are Remo) S
_ N/A PERSONAL RAWIJURY $ _
[GEN).AGGREGATE LqIIMpIIT APPLIES PER. GENERAL AGGREGATE $
iPOLICY jJECT LOC PRODUCTS-COMP/OP AGG Y _
OTHER: $
AUtOMDEPLEUABILIwv 1 COMBINED ENGLE LIMIT S
�-
ANYi woofing
• poem)BODILY INJURY(Per em) S
—
ALLLGAMED
IEO SCHEDULED
AUTOS WA aGDuvfNR9Ea(Dec acGna)Ii
HIRED
AUWotM1HEP P ME110 GE IS
MIRED AUTOS AUTOS IPV!��NII. a ^---
of
I [UMBRELLA LIAOI Y — —OCCUR [ EACH OCCURRENCE f.$
EXCESS UABCLAIMS-MADE
l CLAIMS-MADE
N/A AGGREGATE IS
I DED RETENTIONS �/ �} $
WORMERS COMPENSATION X STATUTE ER
AND EMPLOYERS'UAB(L.ITYPt
_. .-
`ANYPAOPWETORtPn4iNEFiEXECUtNE T'/N Et.EAC#IACCIDENT
$ x,000
A iDFPDEWetEro eckeet m tun WA WA MAARP301170 01/262016)01/26/2017 -- —
INanGlayinNH) EL DISEASE(EA EMPLOYEE $ 500,000
itty VTIONuMAr
OESCRwrON OF DPERAT'APR Woof I EL.DISEASE-ma rYLaMT 5 500,000
1
N/A
1
DESCRIPTION OF OPERATIONSI LOCATIONS/VEHICLES(ACORD 101,AOdtloYW Rena*.SehMWa,may a atbcM1N1If mate Apace"inquired)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 0306 3,00 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 form 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.govewd/workers-compensationrinvestigationte
CERTIFICATE HOLDER CANCELLATION
1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Ideal Home Improvement, Inc. ACCORDANCE WITH TFMPOUCY PROVISIONS.
142 Boyle Rd. AUTHORIZED REPRESENT/GSM
Gill, MA 01354 �?
DanielM.Croy.CPCU,Vice Resident-Residual Market-WCRIBMA
€'tette-2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD
A CERTIFICATE OF LIABILITY INSURANCE 1/24/29 5
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
I 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 INSURERIS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policylies)must be endorsed. If SUBROGATION IS WAIVED, sub ect to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to Iha
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Tracey Kukles
A.H. Rist Insurance Agency, Inc. IAF un A.�,- t4'-3)863—a 373r....� inlc ewl l"sl esF-^s'e
159 Avenue A gu
, As
P.0. Box 391 INSURER(SI AFFOR.INO COVERAGE NAICN
Turners Falls MA 01376 INSURERANautilus Insurance Company
INSURES INsUR€NB:Comnerce Insurance Company
Ideal Home Improvement, Inc. INSURER C:
142 Boyle Road INSURER o:
INSURER F'.
Gill MA 01354 INSURER A: '
COVERAGES CERTIFICATE NUMBER:Nov 15 flab REVISION NUMBER:
THIS tS TO CERTIFY THAT THE POICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED'10 THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDIGATED. 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.
T
IL9n0. TYPE 0p INSURANCE LNSRIWVll POLICY NUMBE0. MIDDNYEFF O/DDYESP LIMITS
tMMIDMYY"v1
LoENERA[tWmLTY
EACH O C Ra[n E S 1,000,000
15N HOE[o iiriMII
LX COMMERCIAL.bfiNE1L0[L18I1.1I1 100,000
PREMISES S C
A f.pmSMFOE X OCCUR NN6344B2 ft1/19/201v 11/19'2016 MEn VP f'sr'n 5,000,
I easnw.Ll ADv wruav rv. _ 1,000,000
�j_ l GENERAL I+4.nTF I C. 2.000,000
uz,}L;,uk,t.t‘.,,/L
UMPROU,u-ric E,+ j Vaca c ' r. . 2.000,000
F-1 POLICY I , 011 LOC (
AUTOMOBILE LIAa IITY •y1 —a 0
COMBINED SII r. x 000 00
III
B ANT AUTO l 'AGONY INJURY U S
LL OVNEUI SCFIEDO ED SDLRBV L11117,2015 It/172016
lTOS `YAUTOS imply pejuRv P
`• I AUI ' t it rR )
1 X . ,
:RFD Horns t AUroS F. H
IMHREL UAB j OCCUR EACHOCCURRENCr
„CESS LwB C.AIA,-MAGE . I bG CS Pi'J 0T4
) r RRETENTIONI T �—
1 V1NRKER5QY PELIAuoN ( 1' I
AND EMPLOYERS'LIABILITY N L T19Y IM LD fl
'N . IvEM OPPf9Y ,EXECUTIVE Y 61 EACH ACCIDENT
I.. '.Cabe BEPEXCUDED', /NIA - , '
IImO lnNtO E.LDISEASE-rA EMPLOYEi! I
I RV .(IIPcrT0N Odor I — --
'DESCRIPTION Of OPERATIONS tube E E L OY5IAa=-PPOI[CY I MT,E
1 1
I L
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IAnaml ACQRD.N.,Aaulvcnal Ram., ,sort I :if more space Is rt9NIrrod1
Classification: Insolation
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Ideal HOBO Improvement, Inc. ACCORDANCE WITH THE POLICY PROVISIONS,
142 Boyle Road AUTIIORREO REPRESENTATIVE
Gill, MA 01354
Tracey Ifukletei CEPTTR
ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved,
INS025 sons/:m The ACORD name and logo are registered marks of ACORD