24B-066 (22) 243 KING ST BP-2017-1520
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24B-066 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:demolition BUILDING PERMIT
Permit# BP-2017-1520
Project# JS-2017-002539
Est.Cost: $20000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const,Class: Contractor: License:
use Group: TYLER BERGERON 080274
Lot Size(sq. ft.): 182342.16 Owner: COOLIDGE NORTHAMPTON LLC C/O HOULIHAN-PARNES/ICAP
REALTY
Zoning: HB(98)/GI(2)/ Applicant: TYLER BERGERON
AT: 243 KING ST
Applicant Address: Phone: Insurance:
730 GULF RD (413)427-8034 O WC
BELCH ERTOW NMA01007 ISSUED ON:6/30/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMOLISH AND REMOVE DRIVE UP CANOPY
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 ti 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 6/30/2017 0:00:00 $50.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1520
APPLICANT/CONTACT PERSON TYLER BERGERON
ADDRESS/PHONE 730 GULF RD BELCHERTOWN (413)427-8034 p
PROPERTY LOCATION 243 KING ST
MAP 24B PARCEL 066 001 ZONE HB(98)/GI(2)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Pennit Filled out
Fee Paid
Tvpeof Construction: DEMOLISH AND OV RIVE UP CANOPY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 080274
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
,.approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Man
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 Delay
a� L 6/2-9(17
Signature of Building Official 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.
---31
-
JUN 2 T
Versionl.7 Commercial Buil in&'cued Ma IS 2000
rr.':' ent se only
.-
City of Northampton �tNSM ".cco
Building Department -C176Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 WateoWell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION 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
This section to be completed by office
1.1 Property Address:
)1/3 Yin-' $I;5):-<-1- Map 7 1�./6 Lot 000 Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 1 I I
L-oce:clya N+^ILe.o lo,d LLL IC /^, )t 5ireF b
t5..:]r /CS5 2r, ,' Ni
Name(Punt) Current Mailing Address:
Signature Telephone
2.2 Authorized Anent: p /
-rriI. - Bpt-,eE,1 730 (�.siF Rd OCtf[Wrlo,.,nM4
Name(Print) Current Mailing Address:
/////AJ,, t//3- 9) 7- 90.3y
Signature I'!N/�_ Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (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 r.r-y� !` ,p ,�-yt
6. Total=(1 +2+3+4+5) &Oi {/ tD Check Number 7 gy3 so
V
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
ii ter
`R'f-t`7 730 20 ane :t . for l
Version!.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR
CONTRACTOR APPLIESFORBUILDING PERMIT
I, l �t Cc II�Sc ��'` �I r'��'1 ,as Owner of the subject property
hereby authorize Q
nJL t 'I tZ1 to
act on my behalf,in all matters relative to work authorized by this building permit application.
/ V( (cif;r
Signature of Owner Date
I. ')IC ,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 andh^[ penalties of periurv.
Ty)lrA.^ VPV;y V.1
Print Name /K
Signatureof JOxmer/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction SupervisornNot
Applicable 0
Deena, �/ t' ID
Name of Lee ,Helder: � s aron C5- I200)71/
License Number
730 b„I( Rol $AtLe: L ,. A4 oroc)7 7- ) '7
mikes_ Expiration Date
Oe'sLr
Sgnatu Telephone
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 !,J No
Version l.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations 0 Existing Wall Signs ❑ DemolitionRepairs❑ Additions 0 Accessory Building 0
Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing 0 Change of Use Other 0
Brief Description Enter a brief description here.
Of Proposed Work: Qe MGI;4 c-41tenovt d i,Je Up ctkrtcpy
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 0 A-2 ❑ A-3 0 1A I 0
A-4 ❑ A-5 0 1B 0
B Business 0 2A 0
E Educational ❑ 2B I ❑
F Factory 0 F-1 0 F-2 ❑ 2C
0
H High Hazard 0 3A ❑
I Institutional 0 I-1 0 1-2 0 1-3 ❑ 3B 0
M Mercantile 0 4 0
R Residential 0 R-1 ❑ R-2 0 R-3 0 5A ❑
s Storage 0 5-1 0 S-2 0 5B l 0
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°
2nd 2
dd
3.e 3'd
4m 4m
Total Area(sf) Total Proposed New Construction(sf)
Total Height(0)
Total Height ft
7.Water Supply(M.G.L.C.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public 0 Private 0 Zone Outside Flood Zone❑ Municipal 0 On site disposal system❑
Version!.?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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage •
Open Space Footage
(lot area minus bldg&paved
parking)
it of Parking Spaces
Fill:
(volume&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 0 DONT KNOW 0 YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O 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:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO ler
IF YES, describe size, type and location:
E. Will 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 �l
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version!.?Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable 0
Name(Registrant)^,
Registration Number
Address
\\\\\\ Expiration Date
Signature \ Telephone
9.2 Registered Professional E i 'neer(s):
Name Area of Responsibility
•
Address \ Registration Number
Signature \', - Telephone Expiration Date
Name Area of Responsibility
i
Address '� Registration Number
Signature Tele a Expiration Date
Name \Area of Responsibility
Address Reg(Stralion Number
•
Signature Telephone Expiration e
•
Name Area of Responsibility
Address ; Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
5 •
'tDs''bq �:�rr5 TNG Not Applicable ❑
Company Name:
Tyler & y'toi
Responsible In Charge of Construction
73D c,,l( kc( 3eI7tvr4. ,, tWA 0/007
Address
913-07-0031
Signat / Telephone
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: 2 1f3 k,, sirec b /1/r {Lf L„, /tlas 3
The debris will be transported by: DAJc L,'.L HY5
The debris will be received by:
Building permit number:
Name of Permit Applicant 7/10- ic; ro:,
/5-1) e4 ;----
Date Signature of Permit Applicant
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The Commonwealth of Massachusetts
trim= Department of Industrial Accidents
Office of Investigations
E_Irl=qq� Congress Street,Suite 100
1-1.419--= Boston,MA 02114-2017
Vt.
+' www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information a p Please Print Legibly
Name(Business/Organization/Individual): p/.2B
,y
Jr ,I ,:Ver-5 L
Address: 73c b„(C X20.-01
City/State/Zip: 6c)CLryo.^,.n /fitl Gl'oo7 Phone#: 913' `/)7-e5034
Are you an employer?Check the appropriate box:
I.(r,am a employer with 3 4. ❑ I am a general contractor and I Type of project tr coon ):
employees(full and/or part-time).' have hired the sub-contractors 6. New❑ consconstruction
listed on the attached sheet. 7. ❑Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. [demolition
working for me in any rapacity. employees and have workers'
insurance.: 9. El Building addition
comp.[No workers' comp.insurance
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ lam a homeowner doing all work officers have exercised their I1.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.]' c. 152,§I(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box#I 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 sob-contmeton 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: /77tyL' f
IJMA)
Policy N or Self-ins. Tic,#: L �L 74.030 L' Expiration Date:V• 7-)3-)2
^^� A
Job Site Address: �4.) ••:j �+.r Wo[" � ] �.+n City/State/Zip: /✓' 0/CC 0
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 ofa
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 cera under the pains and penalties of pedury that the information providedabove is true and correct.
Signature: h Date: G-ls ,l
Phone g: / IP3-p 07'f 73LJ
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#:
i-....1 BERGBUI-01 LLANDRY
A�R� CERTIFICATE OF LIABILITY INSURANCE DATE(MMODNY"I
5/26/2017
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(les)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 License a 1780862 kakisci Linda Landry
HUB International New England PHONEFox
79 Lyman Street
(NC.no,Exp(413)2754642 (A/C,NeL(413)5384010
South Hadley,MA 01075 kafiss,linda.landry@hubintemational.com
INSURERIS)AFFORDING COVERAGE HMG
INSURER A:Ohio Security Insurance Company 24082
INSURED INSURER a:Allmerlca Financial Benefit Insurance Company 41840
Bergeron Builders Inc
INSURER C:
Tyler Bergeron
730 Gulf Rd. INSURER 0;
Belchertown,MA 01007 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 HATH RESPECT TO WIICH 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 BEEN REDUCED BY PAID CLAIMS.
INS0. TYPE OF INSURANCE ADOL SURR POLICY NUMBER POLICY EFF POLICY EXP
LTR INSD MD IMMIODM'YYI INeONYYYYI LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 500,000
CLAIMS-MADE X OCCUR BKS56149725 09/12/2018 09/12/2017 pparpns°rF.RENT:rel 300,000
1 MED EXP(Any ane pecan) 16,000
I PERSONAL S AIN INJURY 500,000
GENL AGGREGATE PLqNpn�T APPLIES PER GENERAL AGGREGATE 1,000,000
POLICY X JEGX LOC ! PRODUCTS-COMP/OP AGG 1.000,000
OTHER:
-B AUTOM0aILE UAONnY I IEeacci E�OIaNGLE UNIT
ANY AUTO _ AWN9157929 07/14/2016 07/14/2017 sooty POUR?(Prpv.m) 250,000
AUTOSDINNED ONLY X SCHEDULEDTBODILY INJURY(Per accident)
600,000
X NAIWR°S ONLY X nL8cd Nk rrr« N�AGE 100,000
UMBRELLA LIAB 1 OCCUR 1 EACH OCCURRENCE
EXCESS LIAB CLAIMS-MADE 1 AGGREGATE
DEO RETENTIONS I
WORKERS COMPENSATION1 . GTN-
ANDEMPLOYERS'LABILITY 1,/N STATIFW ER
fA�N�YIPROPP1REIEETTCFRpRARTNEFUEE�NE N/A EL EACH ACCIDENT
`M.ntlM°rY In NN) EL DISEASE-EA EMPLOYEE
Il ynE L.under
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY MIT
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 1e1,Addllpml Remarks Schedule,maybe attached Il more space Is require)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
UMass Five College Federal Credit Union ACCORHE DANCE WITH THE POLCYP THEREOF,PIRATION DATE ISIONS.E WILL BE DELBIEREO IN
200 Westgate Center Drive
PO BOX 1060
Hadley,MA 01035 AUTHORIZED REPRESENTATIVE
ACORD 26(2016/03) ID 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
CERTIFICATE OF LIABILITY INSURANCE op2g"""°"""Y"
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 les)must be endorsed. N 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).
IDUCER CONTACT Paychex Insurance Agency Inc
PAYCHEX INSURANCE AGENCY,INC. IA FAX
150 SAWGRASS DRIVE iuCNN 77
Fkn• 8 -266-6850 /Ar Nps. 585-389-7426
ROCHESTER, NY 14620 E-MAIL Certs@paychex.com
ADDRERA
INSURER(S)AFFORDING COVERAGE NAIC f
JRED INSURER A: NorGUARD Insurance Company 31470
BERGERON BUILDERS INC INSURER B:
730 GULF ROAD
BELCHERTOW N,MA 01007 INSURER C:
INSURER D:
INSURER E:
INSURER F: I
OVERAGES 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 SUCHIPOLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE DOL SUBR POLICY NUMBER POLICY EFF I POLICY EXP LIMITS
NSR WVD (MIPODYYYY)I(MMVDfYVY)
GENERAL LIABILITY � ,EACH OCCURRENCE 1 S
COMMERCIAL GENERAL LIABILITY I I I DAMAGE TO RENTED
I PREMISFS(Feno`IImmcAI $
CLAIMS-MADE!-- CCUR I I MED EPP(Any one person) $
I PERSONAL B ADP AWRY $
GENERAL AGGREGATE $
GENL AGGREGATE LIMIT APPLIES PER I
PoUCv PROJECT J'Sr I PflODUCTS-COMPgP AUG $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S
Y
AN (Ea accident/
AUTO
BODILY INJURY $
--J ALTOS rvEo J AIJrNOSSCEDOLEo (Per RY9n)
--_-- ED AUTOS i1UTOSW" BODILY INJURY $
FINED IPerPERTY
• PROPERTY DAMAGE $
(Per alt)
$
UMBREwB OCCUR EACH OCCURRENCE $
EXCESSUAB P_--
MSMADE AGGREGATE S
DED RETENTION $
WORKERS
EMPLOYERS ABIlITY AxD BEWC760306 07/23/2016 07/23/2017 X -METT,MT OH-
E L EACH ACCIDENT S 100,000.00
ANY 4FOPRIETORFAATNEP,ExECOrIE
EL DISEASE-EA EMPLOYEE $ 100,000.00
(Mm
lseryInNH) EXCLUDED? FI UN •GI N/A I EL DISEASE-POLICY LIMIT $ 500,000 00
II yea.yesyyLH way.
fF CThPTE N nF npERATInNR L..
I
DRIPTXIN OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD let A44XbnBl Remarks Schedule,Il mom space Is meulrmi)
RTIFICATE HOLDER CANCELLATION
The Town of Princeton Mass. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF.HOTCE WILL BE DELNERED IN ACCORDANCE WIm THE POLICY
PROVISIONS.BUT FAILURE TO MAC SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATNES.
AUTHORIZED REPRESENTATIVE 03t` ?
-
ORD 25(2010/05) 1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD