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10-023 (9) 441 KENNEDY RD BP-2017-0957 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 10-023 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Deck BUILDING PERMIT Permit 4 BP-2017-0957 Project JS-2017-001645 Est. Cost: $38000.00 Fee: $108.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Grown KEITER BUILDERS 102457 Lot Size(sq. ft.): 375443.64 Owner: SMITH HOWARD Zoning:RR(100)/WSP(100)/WP(13)/ Applicant: KEITER BUILDERS AT: 441 KENNEDY RD Applicant Address: Phone: Insurance: 35 MAIN ST (413) 586-8600 0 WC FLORENCEMA01062 ISSUED ON:2/24/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:TAKE DOWN OLD DECK AND CONSTRUCT NEW DECK 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 ft 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 Occupancy Signature: FeeType: Date Paid: Amount: Building 2/24/2017 0:00:00 $108.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0957 APPLICANT/CONTACT PERSON KEITER BUILDERS �u olt ADDRESS/PHONE 35 MAIN ST FLORENCE (413)586-8600() ®J�s"p,,,"_-- Ayr' of PROPERTY LOCATION 441 KENNEDY RD MAP 10 PARCEL 023 001 ZONE RR(100VWSP(1003/W13(13V THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT /I Fee Paid Ir' l o Building Permit Filled out Fee Paid Typeof Construction: TAKE O D DECK AND CONSTRUCT NEW DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 102457 �/� y. 3 sets of Plans/Plot Plan L / t/li0QN emir Nf THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS' ISAPPLICATION BASED ON INF/{RMATION PRESENTED: (� Approved 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 Demolition Del. ��� /✓ a— Z3— /7 Signature of Building 0 )ci! 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. .. y' • ,` Department use only \11City of Northampton status of PermlC it\ _ Budding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability - Room 100 WaterNVeli Avatiabiity 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 I I Property Address: This section to be completed by office 441 Kennedy Rd Map Lot Unit Zone Overlay District Elm St.District CS District__,,, SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record:Howard Smith 441 Kennedy Rd Leeds, MA Ne tlnbr/� / Current Mailing Address: • , " • / Telephone Sgnature 2.2 Authorized Aaent: Keifer Builders, Inc 35 Main St Florence, .AIA Narinl) Current Mailing address 9_eff("^/Ts7 President, 6t3t #13-5Ya-8 Si ature Telephone SECTION 3-1STIMATFD CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1 Building 38.000 (a)Building Permit Fee 2 Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6 Total=(1 +2 +3.4 'it 5) MC MU Check Number 'ria J This Section FOr Official Use Only Building Permit Number:_ Isste u Dared' Signature' Building Commissioner/Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed, Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning, This column to be filled;n be Buildinn rkpartmem i,ot Size Frontage Setbacks Front Side I: R: Rear Building Height Bldg.Square Footage Open Space Footage 9r IC )I urea minus bldg&pa,ed puking) X of Parking Spaces HI: t ohne&Locationl A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW Q YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document ft B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW a YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES NO O IF YES, describe size, type and Location: E. Will the construction activity disturb(clearing.gradingexcavation,or filling)over I acre or is it pad or a common plan that will disturb over 1 acre'? YES Q NO 0 it YES,then a Northampton Storm Water Management Permit from the DPW is required. Section 4. ZONING all Information Must Be Completed. perms Can Be Denied Due To Incomplete Information fsalrns Proposed Required h i Zonmo This column,a be llTed in e, Bulldmg Department Eat Site I.-tentage Setbacks 'bold Side I : R_ L R_ Rear Building !Richt Bldg Square Rootage `/r Open Space Footage rid tiot dot minus bldg ttanted I uCln 11 of Parking Spaces 1511: A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 10 DONT KNOW (DI YES 10 IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO O DON'T 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 (3 NO O 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 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearinggrading excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES @ NO IF YES_then a Northampton Storm Water Management Permit from the DPW is requaed. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition Replacement Windows Alteration(s) Roofing Or Doors Accessory Bldg. Demolition New Signs I I Decks [♦] Siding I I Other I • Brief work��& Pon of ITO fa�88k as desci bed in attached documents Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Ba. If New house and or addition to existing housing. complete the following: a Use of building One Family Two 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 fl. 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 Howard Smith as Owner of the subject property hereby authorize Keiter Builders, Inc to act nrn m1 n r s relati to work authorized by this building permit application. Signature of O r Date .1111111111111 I, Keiter Builders Inc , 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. Scott Keifer 1'{ey Name , President, Reiter Builders, Inc. 02.20.17 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:Scott Keiter_ CS-102457 License Number 51A Hatfield St Northampton, MA01060 6.20.17 Address Expiration Date ^G'y(t`� ti`!�- President. }Cenci- Builder. Inc 413.586.8600 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Keiter Builders, Inc 175168 Company Name Registration Number 35 Main Street Florence, MA 010_62 _ .4.29.17 Address Expiration Date Telephone 413.586.8600 SECTION 10-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 ❑ 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 1083.5,1. 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 farm 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 Oficial,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 be required from time to time,during and upon completion of the work for which this permit is issued. Also he advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Emplo)crs to Fimplo)ces for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perforin stork for you tinder this permit. The undersigned"homeowner"certifies and assumes responsibiliy 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 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable el Name of License Holder.Scott Keitei CS-102457 0conse Number 51 AHatfield St Northampton, MA 01060 6.20.17 —e--__. name Expiration Date *4 C'-0 1 tont.K,- e, Ihdirtead. In. 413 566 8e06 iiiynalurG I IFiprlUne 9.Registered Home Improvement Contractor: Not Applicable C Keifer Rulltlers,_Inc 175168-. ___.. _ _.. __._. — —e Company Name Registration Number 35 Mao Street Florence, MA 010624.24 17 Address - —.. . . _. .— Expiration Date -. .—.. . -_ Telephone 413_586 8600 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G L C. 152 §25C(8)) Workers Cort pensat o-Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit wig Dion in the denial of the issuance of The budding permit. Signed Addis it Attached Yes q No.. ❑ 11, - Home Owner Exemption T he ma rrcl .e ration for "homeoff ncrs h_esieoded to iodudc owner-occupied Ovelkfigrnt vire(I} rz tnoQ)ISnalic Mid to illlore Such homeorc neo in engage an inchdual for hire mho does not possess a license.provided that the owner acts as supervisor.CM It 780. Sixth Edition Section 18835.1. Definition of Homeowner: Person (s) ho 0011 u parcel of land on frhich he/she resides Of lIends to reside 011rehich there IS or is intended to he.a our or nw [veil) dv clli r. attached or detached structures aeces ry to such use and:or farm s rnetures.A_}xrSOtt 0110 constructs more than our born-in a tommar period shall not he considered a homeowner Suds"hon r u( ffhall ,ahmit to the Building Of Idialfon a f .m n :ccpr.ala to ma the RuildOfficial,that he/she shall be � responsible for all such%torkpeYfunned under the builddnulermit. As acting Construction Supervisor iota presence on the job Sur i.ill he required from tinge to nine.during and upon completion of the work for which this pet mil is issued. Ake he adt cd that with reference to(Ti pier 12(Worked;(-0ntpensatiot0 and Chapw ie3 (I.iabiiite l l:mplocels iu 1-mplofcc for injuries nor r m:fling n Death1H the Ainvesttiffett.Goner l I arcs rinneuded,vounlav be liable l'srper sec hire to perform ff ork for sac+under titin period_ the undersigned "homeoft a rotiGCs and surae.ro;p blllh Hr%onpll' ne schh theSeB ( tate udding Code. .Td nt Sorrhampt n Ordinances. Sr te and I °cal ionindf ] in r and Stale nl hda_ss- -he ns( effeffd Laws Annotated_ Homeowner Signature Williamsburg, MA 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. Address of the work: Mtt Kennedy Rd The debris will be transported by: Keiter Builders, Inc The debris will be received by: Duseau Trucking Building permit number: Name of Permit Applicant Keifer Builders Inc 02.20.170000 President. heifer builders, hie Date Signature of Permit Applicant .\ The Commonwealth of Massachusetts Lt_� Department of Industrial Accidents 1-;v I Office of Investigations ,� 1 Congress Street,Suite 100 Boston,MA 02114-2017 tiy, www.mass.govldia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Keller Builders, Inc Name (Busine,Organizationiindividuap: _ Address; 35 Main Street City/State/Zip: Florence, MA 01062 Ph4418.586.8600 _ one : Are you an employer? Check the appropriate box: Type of project (required): . I am a employer with 18 4. 0 I am a general contractor and I 6. ® New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ® Remodeling 2.0 am a sole proprietor or partner- ship and have no employees 'these sub-contractors have g, ® Demolition for me in workiligca employees and have workers' b any capacity,y 9. 0 Building addition [No workers' comp. insurance comp. insurance.: 5. We are a corporation and its 10.0 Electrical repairs or additions 3. required.] ® P 0 I am a homeowner doing all work officers have exercised their 11.0Plumbing repairs or additions per MGL exemption of ht myself [No workers' comp. right P p 12.0 Roof repairs insurance required.] ' c. 152. §I(4), and we have no Deck employees. INo workers )30 Other comp. insurance required.] 'Any applicant hat checks hoed I must also Pill out the ection below shmsing their workers'comp nsation policy in lbmtat ion. ' I lote,u tierstthnsubmit this affidavit indicating they arc doing all nork and then hire outside contractors must submit a new affidavit indicating such. Kbntracma that check this hoe must attached an additional sheet showing the name ol'the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees they must provide their worker camp.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:Arbella Policy#or Sell-ins. Mc. R 9127440615 Expiration Date:6.11.17_ 441 Kennedy RdLeeds, MA 01053 Job Site Address: City/State/Lip: 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 MCI. c. 152 can lead to the imposition of criminal penalties ofa fine up to $1.500.00 and/or one-year imprisonment. as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to $250,00 a day against the violator. Be advised that a copy of this statement may he forwarded to the Office of Investigations of the DR for insurance coverage verification. I do hereby rtify under the pains and penalties of perjury that the information provided above is true and correct. 02.20.17 President, Metter Builders, Inc. Signature: _..� _ Date: Phone#: 413.586.8600 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License s Issuing Authority (circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone B: The Commonwealth of Massachusetts Department of Inductrud Accidents tun .dig Office of Investigations FY, ,1=7•"— rlsl I Congress Street, Suite 100 /.4-1 Boston,MA 02114-2017 8-T. ts' www.neass.gov(dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciaus/Plumbers Applicant Information Please Print Legibly Keiter Builders, Inc Name iHusiness/Oreanizarion.I ndividuall: Address: 35 Main Street Cltyr5tare%ZI Florence, MA 01062 Phone u: 413 586.8600 Are you an employer' Check the appropriate box Type of project (required): t.� I am a employ unh 1$ . 0 1 on a;enuai contractor ands 6. a New construction rnpl2ves (cull and/or part time) " have hired the sub-contractors am a sole pi opnemr or partner- listed on the attached sheet. 7. 00 Remodeling ship and have no employees I"hese sato-contractors have 8. 0 Demolition Yorks ng for me in any capa_c:ity employees and have Yorkers' 9. 0 Building addition No oorkersf comp. insurance camp. inswnave: required-i c. 0 We are a corporation and its Irl Hitch peal repro is or additions :.07 am a homonym) doing frit cork ou'icers haveexercised their I i.0 Plumbhurt repairs or adrift ions right of exemVonper MGI. nnself iNo workers' comp- p 12.0 Roof eus insurance required.) c 1_.',.51(1) d anye have no 0k employees (No corkers' I 11�Other m comp. Insurance required.] Fry pylar that elided,.ho‘ m ar(dao 1 11 fan the vechion holey sh w'i (heir uo kers comp lmatiou policy i l rmotion. ;Inn vhn abet th is aihdadt indicating the_: eal .t all rtkstdate lire noide eontiaelcollIUSI tiantt a new lid it rdetrng.such. aul ¢ e rhllthis boa anal malted or additional shys slit tau,.the rime el the,rL ueuers ell sate nhether or oro tfinSeontibta lite mplmm. I(arc sal.-c niaemrs have ernplo'ces. rhe' n tut pmddc their rrorkcrs romp-polis) n rather_ I nm an emptorer that ix providing workers'compensation insurance for my employees. Below B the police and job site information. Insurance Cautions Name:Arbella polio 1 or So®-ins Tic lit 9127440615 Expiration on D tic.6.11 .17 441 Kennedy Rd Leeds, MA 01053 Joh Sire Address _ City/State/Zip:, Attach a copy or the workers' compensation policy declaration page(showing the policy number and expiration date). i allure 10 secure coverage as required under ScCuon 25A of MGI. c 152 can lead to the imposition of criminal penalties of a fine up to 51.300 00 and/or one-pear imprisonment, as Yell as civil penalties in the form of a STOP WORK ORDER and a tine of up to 5250.00 a day against the violator. 13e advised that a cope of this statement may he forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby • rtify under the pains and penalties of perjury that the information provided above is true and correct. 02.20 17 President. Reiter Budder~ Inc. en tir .ltwe _ rite..—. . Phone r,- 413.586.8600 Official use only. Do not write in this area,to be completed by city or awn official_ Cite or Town: __—..__ __— ._Pernut/License M_�_ ._—..—.. Issuing Authority (circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector S.Other Contact Person:_....—__ A`oRn CERTIFICATE OF LIABILITY INSURANCE D6/14/2D36 ) 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 IMOMEACT ACynthia Henderson, CISR Webber & Grinnell rat x„ (413)586-0111 _(FAX No),(413)506-6481 e North King StreetADMDAeess:chendersonewebberandgr Innen.cora —MAIL.. _ ._. __._... INSURER(S)AFFORDING COVERAGE MAIC l Northampton MA 01060 IXSVRERA 23L'be118 Protection . 41.360 INSURED INSURER B: Reiter Builders, Inc. INSURER Attn: Scott Reiter _INSURER p; _.._. _. . 35 Main Street INSURER E: Florence MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER Master Exp 2017 REVISION NUMBER: I HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATE D. 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 CONDII IONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSHTYPE OF INSURANCE LSb13P POLICY EP POLICY EXP - - - - i IR wvp POLICY NUMBER IMM4DMYY 1'1 MND/YYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH 000RENTF 5 1,000,000 A CI AIMS-MADE X OCCUR _ DAMAGEI on $ H100,000 - EE ISLC NENTE occurrence) _ -_ _ : 9500069396 6/1/2016 6/1/3017 HEDEXP(Any one person) 5 5,000 PERSONAE S.ADV INJURY 5 1,000,000 OL DI AGGREGATE LIMIT APPLIES PER GENERALAGGREGATE 5 2,000,000 X pOl ICY jFt° .__ LOC PROOVCTS-COMvpP AGG 5 5,000,000 OT HFR S -. AUTOMOBILE I IABIIITY COMBINED SINGLE LIMIT 5 1,000,000 A ANY AUTO . BOOR Y INJURY(PEE person) 5 CUI OSNE) % SCHEDULED 102003939101 6/1/2016 .6/1/2017 BOD INJURY(Per acnlRnt) 5 X HIRED AUTOS . X NON OVMED : PROPERTY DAMAGE 6 AUTOS TPer accident) ___—_. Medd-al Payments $ 5,000 X UMBRELLA LIAR OCCUR I EACH OCCURRENCE 5 5,000 000 •EXCESS LIAR , CLAIMS.MADE A AGGREGATE 5 5,000,000 DED X RETENTIONS 10,00096000b4600064399 6/1/3016 6/I/20II y WORKERS COMPENSATION X SMUTE OTH EMPLOYERS'LIABILITY S .CTE _ _ER .. AND PROPRIETOR EXCLUDED, E.L.EACH ACCIDENT 5 1,000,000 A OFF ICaRIMetBER EXCLUDED YIN NN 912'14 -- -- ItdorylnNHl A 40615 6/11/2016 6/11/201] EL DISEASE MPLOYEE5 1,000,000 yesescnON upper EA IDECRIPTON EF()PERAvoNS below E.L.DISEASE-POLICY LIMIT 5 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,AEbmonal Remarks Schedule,may he apache)It more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Informational Purposes THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE C Henderson, CTSN/CIN -.Sze..'a- s ii ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INSOJS nn,u,n } i y itit4511/4)re , max.; Google DECK LOCATION �a. 111111111111' hili ,�� 11 I li f 111111;1 � , •� ,, ,�� 11111111li1 VIII 111111 u � Litt'it.. tit a r n � lizl �• �(( Top View Store Name 123 Street Rd. 11/16/16 RefDeck 16321 City,ST Scale:To fit (800) 555 1212 I XIS I ING DECK TO BF DEMOLISHED. NEW DEC K 1 BE INSTALLED Al'SAME LOCA3'ION, aiiii + r yam'n `4� • . A\l SIfQf. Sry ' . 7: • MMW. ! i;;si " • vrm++.�rt^ 'T �. } • • I i��i liI � I. III lit E ; Ir y� - rr�rr 1 ex �... .; �.. ms a ._ :___. _..<, 441 KENNEDY ROAD, DECK REPLACEMENT _— r � r_ 20' 1 50' Text 40' RD i > 20' RURAL RESIDENTIAL (RR)