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24B-078 (2) 293 KING ST-LIA HONDA BP-2017-0630 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block:24B-078 CITY OF NORTHAMPTON Lot: -00I PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2017-0630 Project# JS-2017-001016 Est.Cost: $29035.00 Fee: $210.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groun FORISH CONSTRUCTION CO INC 027190 Lot Size(su. ft.): 135907.20 Owner: 293 NORTHAMPTON REALTY LLC CIO WILLIAM LIA Zoning:HB(100)/GI(0)/ Applicant: FORISH CONSTRUCTION CO INC AT: 293 KING ST- LIA HONDA Applicant Address: Phone: Insurance: P O BOX358 (413) 568-8624 Workers Compensation WESTFIELDMA01086 ISSUED ON:1114/2016 0:00:00 TO PERFORM THE FOLLOWING WORK RENOVATE 2ND FLOOR TO CREATE LARGER GENERAL OFFICE & RELOCATE BREAK ROOM 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 Occu a anc Si•nature: FeeTvpe: Date Paid: Amount: Building 11/4/20160:00:00 $210.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0630 APPLICANT/CONTACT PERSON FORISH CONSTRUCTION CO INC ADDRESS/PHONE P O BOX358 WESTFIELD (413)568-8624 PROPERTY LOCATION 293 KING ST-LIA HONDA MAP 24B PARCEL 078 001 ZONE HB(lOOVGI(O/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled outFee PaidTypeof Construction: RENOVATE 2ND(02 EATE LARGER GENERAL OFFICE&RELOCATE BREAK ROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 027190 � 3 sets of Plans/Plot Plan 1 ild '/ w-�e '"`vK/rC THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: pproved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR _ Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management D Si o i din O ml Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. :" '7,... 6ki. f(des Version!.?Commercial Building Permit May 15,2000 Department use only / \ City of Northampton Status of Permit: 5 wilding Department Curb Cut/Driveway Permit �p i :`% 212 Main Street Sewer/Septic Availability 434 ' Room 100 WaterNVell Availability Northampton, MA 01060 Two Sets of Structural Plans c .g" phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans & `' Other Specify APPL TION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Lia Honda Map Lot Unit 293 King Street Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 2(1 A l i D.,.dn I.1.( 125k C;n vv. _. . . A1( "05 Name(Print) Current Mailing Address: 1111 NI-addl CIA'-4W Signature Telephone 2.2 Authorized Agent: Forish Construction Co., Inc. P.O. Box 358, Westfield, MA 01086 Name(Print) Current Mailing Address: _ i ' (413) 568-8624 0Signature . • ' Telephone SECTION 3-ESTI ATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $23,535.00 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of $2,000.00 Construction from(6) 3. Plumbing 53.000.00 Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 5500.00 6. Total=(1 +2+3 +4+5) ]_`);:i s n1) Check Number QOCIOS lir ova This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs El Demolition 0 Repairs 171 Additions ❑ Accessory Building CI Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing 0 Change of Use❑ Other ❑ Brief Description Renovate second floor to create larger General Office &relocate Break Room. Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 EJ1A I ❑ A-4 0 A-5 0 18 ❑ B Business 0 2A 1 0 E Educational ❑ 2B I ❑i F Factory ❑ F-1 0 F-2 ❑ 2CI ❑ H High Hazard ❑ 3A 0 I Institutional ❑ I-1 0 1-2 0 1-3 ❑ 3B ❑ M Mercantile 0 4 0 R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage 0 S-1 0 S-2 ❑ 5B I ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1 1° :r rd 2nd 3rd 3rd 4th 4th Total Area(sf) Total Proposed New Construction(sf) No Chonee Total Height(ft) Total Height ft No Chanute 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public 0 Private 01 Zone Outside Flood Zone El Municipal ❑+ On site disposal system Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size No Changes Frontage No Changes Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage Open Space Footage (Lot area minus bldg&paved patting) #of Parking Spaces Fill: (wlumc&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW Q YES Q IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: Existing building &pylon signs D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O IF YES, describe size, type and Location: E. INN the construction activity disturb(clearing, grading, excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. 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 Q No 0 SECTION 11 -OWNER AUTHORIZATION•TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I \lichacl Lia , as Owner of the subject property hereby authorize I orikh Cucbtructiou Lu., Inc, to act on my behalf,� in all matters relative to work authorized by this building permit application. Signature of Owner Date Michael 1_1;+ 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. Michael Lia Print Name Wita q Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: me Iurl'h CS 02 100 License Number P.O. BBuv ;_5k. 2A 2>indrL u NIA Inn(,, ( IS Jzo /6 Address Expiration Date 11 :_ii"OP-N8'a Signature /1Telephone SECTION 13 RS'COMPE SATION 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 Q No Q V'er.ion 1 7 CL.n!ncr tial Building Penni;Vas 15.:000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 750 CMR 116(CONTAINING MORE THAN 35,000 C.F.CF ENCLOSED SPACE) 9.1 Registered Architect: Not Appbcatle 0/' / y Name Regisn6 ane (O / Address /' / 7 � e ji LLL --d-c i Telephone 9.2 Registered P-.fessional Engineer(s): Name Area of Respcnsibility Address Registration Number Signature Te!ephore Expiration Da!? Name Area of Resporeibilily AU:re as_ Reg islralion Number Signature Telephone Expiration Date Name Area of Resporsibiaty Aodress Reg1stra5on Number Signature -._ Teep :ne Expiration Date Name Area of Re soonsibiily Auiress RRegs!ral.o0 pother Signature Telephone Experti on Date 9.3 General Contractor Forish Construclull Co.. Inc. No;Atop cote ❑ Company Name' Eric Forish Responsible In Charge of Corsair ction P.O. Box 358. AA'estiield. NIA 01036 Adders 7 PAW- ` -cP 1 ?i2-65 (413) 568-8624 sid-arrre re:epnone 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. 29; Khu Sv:ei Address of the work: The debris will be transported by: I lucking The debris will be received by: v 124L ding. 24 I_u.dmmpion SunWampum. 111 Building permit number: Name of Permit Applicant r0[1.11 ( oli t uc11on ( „- Inc Date Signature of Permit Applicant The Commonwealth of Massachusetts - E Department of Industrial Accidents 47 = �= 1 Congress Street, Suite 100 r . lf Boston, MA 02114-2017 '' „ www.nmss.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):POPISH CONSTRUCTION COMPANY, INC. Address:21 MAINLINE DRIVE, PO BOX 358 City/State/Zip:WESTFIELD, MA 01086 Phone#:413-568-8624 Are you an employer?Check the appropriate box: Type of project(required): LQ I am a employer with 20 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. 9 Remodeling any capacity.INo workers'comp.insurance required.] 3.9 l am a homeowner doing all work myself(No workers'comp.insurance required.]f 9. ❑Demolition 1toconductallworkon0❑ Building addition 4.91 am a homeowner and will be hiring contractorsmy propenY l will ensure that all contractors either have workers'compensation insurance or are sole 11.9 Electrical repairs or additions proprietors with no employees. 12.9 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof repairs These sub-contractors have employees and have workers'comp.]nsurancd 6.9We arc a corporation and its officers have exercised their right of exemption per MGL c. 14.❑l Other Comm'I Construction 152,41(44 and we have no employees. No workers'comp.insurance required 1 *Any applicant that checks box kl 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:ABC Massachusetts Workers Compensation Self Insurance Group Policy#or Self-ins.Lic.#:ABC MA 005010-16 Expiration Date: 1/1/2017 Job Site Address:Northampton Honda, 293 King Street City/State/Zip: Northampton MAW 060 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 DR for insurance coverage verification. I do hereby certify under the ains nd penalties of perjury that the information provided above is true and correct. Signature: j Eric J. Forish, President Date: November 3, 2016 Phone#: 413-56 -8624 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License N 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 H: . a �� /INSURER'S�/ / AFFIDAVIT AS TO WORKERS' COMPENSATION INSURANCE 1,gi-h k /J/7-/ oc /02,3 -kfi I ��� �g]Name,�ddAddress]am: jfar�(a�,u, thp rized✓representative of% Y i At , • ni/>i _e nsurance Company S(affl ZSt7 rOnC a Gra✓ffl2 company Name] (a producer' in the voluntary market)' ❑ an authorized agent of , Insurance Company(an agent [Company Name] in the voluntary market, authorized to sign on behalf of a producer)' ❑ an authorized signatory of the ,the Prime Contractor [Company Name] (an insured of a producer in the involuntary market pool)] ❑ an authorized signatory of ,the Sub-Contractor(an insured of [Company Name] a producer in the involuntary market pool, group,or otherwise insured)] and do hereby aver that effective /-i [Date], r/ish il/1S71///C7icO CO , Dl C - [the Prime or Sub-Contractor], is insured for Workers' Compensation insurance with W/ C,�fo5SrarkceftG/l.�-I✓ vi- Insurance Company under Policy No[s]. ig,�[,/f/RQ(J�r�/(1/�iJ rn/c` ua�i4b[He a ac teTCertiTi�a/ ilffisurance,and in accordance with Massachusetts General Laws, Chapter 152 and Subsection 7.05A of the Standard Specifications for Highways and Bridges of the Highway Division of the Massachusetts Department of Transportation. 7Id& Alf PI/L. S lure ��c�F��� rtle COMMONWEALTH OF MASSACHUSETTS Ont is d Is"- i� , 20/4 before me,the undersigned notary public,personally appeared Rad,'* document signer],proved to me through satisfactory evidence of identification,which was/were /r'n-/i.S ,to be the person who signed the preceding or attached document in my presence,and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of their knowledge and belief. p `1) (e�i.2 �_ -Pail -- ,Notary J[CcJi ' e. cu ((a ,Ly � IErintedhiamel MARIA C. SULLIVAN °A r Notary Pane]' ' COM..DNWEALTH OF MASSAC.- ,B o : • q 1Av Commi sion Exp'ies s A producer is an insurance company that provides insurance policies directly,not an insurance, August 20 205. t For Prime or Sub-Contractor companies insured through the voluntary market,this Affidavit must be comp ete by ti a usurer e A or an authorized agent of the insurer. 1 If the Prime or Sub-Contractor is insured through the involuntary insurance market,a pool,such as the Worker's Compensation Inspection and Rating Bureau,or is otherwise insured they may provide a Certificate of Insurance and this Affidavit which may be signed by an authorized signatory(company officer)of the Prime or the Sub-Contractor. Effective 10-May-10 a Client#:10605 FORGO ACORD.. CERTIFICATE OF LIABILITY INSURANCE DATE IMWDDIYWYI 11/03/2016 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 INSUREft15),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 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 endorsementls). PRODUCER CONTACT Jane Eitel T.P.Daley Insurance Agency,Inc PHONE413 FAX IA/C,No: j ee 788-0971 1Aq LINA:413 739-2645 1381 Westfield St. EMAIL aneeitel t dale msurance.com ADOREsO. I INP Y P.O.Box 1150 INSURER(S)AFFORDING COVERAGE TuTiCr West Springfield,MA 01090 INSURERA:Transportation Insurance Co. I INSURED INSURER a:Continental Insurance Co. Forish Construction Co.,Inc. INSURERc 21 Mainline Drive INSURER O: P.O.Box 358 INSURER E: Westfield,MA 01086 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. NOTYNTHSTANDING 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. LTRR TYPE OF INSURANCE INSRL WVD POLICY NUMBER M/DDSUBR YEFF POLICY EU LIMITS IMWDCIYEFF POLICYEYY ' B GENERAL LIABILITY 6016132053 12/31/2015 12/31/2016 EACH $1,000,000 X COMMERCIAL GENERAL LIABILITY BRAEMYEeo"wF,Penrel $500,000 CLAIMS- DE I OCCUR MED EXP{Any one person} $15,000 X _ PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GENT AGGREGATE LIMIT APPLIES PER vxooucs-couvroP ADG $2,000,000 POLICY f ^ °E° LOC _ $ C°ManEeD SINGLE LIMIT B Au.OMOBILE UABIUTY 6016132019 12/31/201512/31/2016 Lagwdegy_. _ _._. $1_,000,000_ X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS _ _ WNEO PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS_ AUT (Per acudentl X Drive Dm Car $ B X UMBRELLA LMB X I OCCUR 6016132036 12/31/2015 12/31/2016 EACH OCCURRENCE $5,000,000 EXCESS LMB i CLAIMS-MADE AGGREGATE $5,000,000 DEO X1 RETENTION 610,000 $ A WORKERS COMPENSATION WC616131999 12/31/2015 12/31/2016 X WCSTAM- OTH- AND EMPLOYERS'LIABILITY /TORY LIMIT$ F8 AFFICEOMEIMTOER/PARTNDEOXECUTIVE Y NN NIA E.L.EACH ACCIDENT $500,000 (Manmm,Y In NH) I EL.DISEASE.EA EMPLOYEE $500,000 DESCRIPTION OF OPERATIONS below E L.DISEASE.POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach AGGRO 101.AddRIonal Remarks Schedule.K mare space Is required) Project: Lia Honda Northampton second floor renovation CERTIFICATE HOLDER CANCELLATION Lia Honda of Northampton SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 293 King Street ACCORDANCE WITH THE POLICY PROVISIONS. Northampton,MA 01060 AUTHORIZEDREPPREESENTATWE / ) /J ©1968.2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #5133039/M126019 JXE Client#:975285 FORISCON ACORD.. CERTIFICATE OF LIABILITY INSURANCE °PiE(MMI°0/Y' 12/15/2015 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 INSURERl51,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 terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer fights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Kathy Wagner USI Insurance Solutions,LLC PHONE we N.,Esq.,BSS 874-0123 FAx IWC,No).. 610 537 9481 123 Interstate Drive EMAIL Kathy.Wagner@usi.biz West Springfield,MA 01089-3600 INSURER(S)AFFORDING COVERAGE NA1Cs 855874-0123 NSURER A:ABC Mass Workers Comp Self-Insu 99999 INSURED NSURERS: Forish Construction Co.,Inc. PO Box 358,21 Mainline Drive NSURER c: NOURERO: Westfield,MA 01086 NSURERE: NBURER 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. IEXP LTR TYPE OF INSURANCE INSR WV!, IMOLIPOLICY NUMBER Awn.SUERPOCYEF£C/YEFI'I I POC/ LIYVYYEXP) LIMITS COMMEROAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE OCCUR PREMISES Fet oxu ence) MED ESP(Any one person) PERSONAL B ADV INJURY GE N'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE PRO POLICY JECT LOC PRODUCTS-COMP/OP AGG OTHER _ AUTOMOBILE LIABILITY (COMBodepSINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEOULED BODILY INJURY(Per accident) S AUTOS NUTOS ON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) S UMBRELLA LAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE S DED RETENTIONS $ A WORKERS COMPENSATION ABCMAOOS501016 01/01/2016 01/01/2017 X MOOS O " FR AND EMPLOYERS'LIABILITY OFFI PROPRIETOR/PARTNER/EEXCLUDEXECUTIVE YNx NIAI EL.EACH ACCIDENT $1,000,000 (Mandatory In NFO E.L.DISEASE-EA EMPLOYEE 0,000,000 to ..eeacnhe ender ESCRIPTION OF OPERATIONS below EL.DISEASE.POLICY LIMIT 1.1.000,000 ESCRIPRON OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddNmal Remarks Schedule,may be attached Il man space Is required) Evidence of Massachusetts Worker's Compensation Insurance. 2015 Experience Mod is 0.96 CERTIFICATE HOLDER CANCELLATION For Insurance Verification SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Purposes ACCORDANCE WITH THE POLICY PROVISIONS. 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