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24A-232 35 PILGRIM DR BP-2018-0146 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block:24A-232 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit# BP-2018-0146 Project# JS-2018-000261 Est. Cost: $9600.00 Fee: $75.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOSEPH KENNEDY 055440 Lot Size(sq. ft.): 10759.32 Owner: DICE DEE Zoning: URA(100)7 Applicant: JOSEPH KENNEDY AT: 35 PILGRIM DR Applicant Address: Phone: Insurance: 38 HARKNESS AVE (413) 525-1735 () Workers Compensation EAST LONGMEADOWMA01028 ISSUED ON:8/31/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 7 VINYL WINDOWS, 1 BAY WINDOW & ONE ENTRANCE DOOR 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 Occupancy Signature: FeeType: Date Paid: Amount: Building 8/31/2017 0:00:00 $75.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner . fDP-IS.-114Lo. 0 . r‘ciovuls Department use only ,---,-cr„,_,•14P,,-. City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit 14 1.- .4 '' 212 Main Street Sewer/Septic Availability li 1 1 ' di4 Room 100 Water/Well Availability \iiii* i,) ....,,,. ii,.. -- ,,, / . 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,REPAIF,RENOVATE OR r3Empu-H A ONE OR TWO FAMILY DWELLING I SECTION 1 -SITE INFORMATION 2. I 1.1 Property Address: i Thl ,section to be completed by office .,. 2 5 ?cAvo, r • __ _ Map , IP 1\- Lot C- )— Unit Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2 1 Owner of Record: Lee rce l 'V C Lin r. ?C. ? 1..i 'D )00 ft 4e ctgt Ai Cu ,,, ,.iling mudress: *1— 5—‘6. - q 5-6_S- ( - eP(Prir*5---Ytjp__r Telephone Signature 2.2 Authorized Agent 0(C )y ('-)C-P 0(1 (\ ,ok774 P c 3S ktiLp 5-I I'\-kl-e Fo4 /-. ) llyjily_,“t? Nam (Print) Current Mailing Address: 91? s- ac - ( 7?r Sign re Telephone _.-- SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building -' 'es,.V 0 0 (a)Building Permit Fee 2. Electrical V ( 6°0 (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) cN, 5.Fire Protection et W 6. Total=(1 +2+3+4+5) '�j6 © 0 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: e;P -----_- 4-,--.• -1 611WW-U-e?-1-v 9/30 i L,7 Building Commissioner/Inspector of Buildings Date at EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 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) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 • DONT KNOW 41 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW a YES 0 IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO la DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q Date Issued: C. Do any signs exist on the property? YES Q NO 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. Will the construction activity disturb(clearing,gradin.,excay.tion,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO "No 1111 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. .• SECTION 5-DESCRIPTION OF PROPOSED WORK(check all atoneable) New House D Addition E: ReplacementApi dows Alteration(s) 0 Roofing 1::1 Or Doors Accessory Bldg. El Demolition El New Signs [0] Decks [C] Siding RD] Other[0] Brief Descripitionof,er' oposgd Work:It/K-4AL t of 0 (L4-il "-& l l,Oti t (0 C7 W k'1., e'(-%.;/ I .e(-AA-((1( -P ?)(Lar Alteration of existing bedroom Yes ><- No Adding new bedroom Yes .X" No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building :One Family S'.....-- 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 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\ I, Q 4 4) , ,as Owner of the subject property (_ • i, , \r‘ hereby authorize '72-6 5riA. Z k tnr .w---4-- -co-'?' . t on aif,in all matte p relative to work authoriz by this building permit application. te-rE --e'e C-4) Signature of Owner Date _ I, °=1-0 ) I \ i w/tLo c ,as Owner/Authorized Agent hereby declare that the statements an formation on the foregoing application are true and accurate,to the best of my knowledge and belief. Siged under thepains and penalties of perjury. 0 p(0 1 _ /e Print ame 4.. ' Sign.; re of' - /Agent Date R -Jt -1 7 , SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: _. Not Applicable ! Name of License Holder: (5 CP r 4 Lttn 0(7 O s-5-1mof (( �- License Number kti4 rs e.4-u e t-_--ct c-T- 1,___0 , i. - C Address Expiration Date ' (? (V) 7- 7? ? c-e11 Sig, ure {1, ' Telephone i 9. eaiste ; e Improvement Contractor:\ Not Applicable�>! �, Cavy CO Lk -v-c^c -sC(-11 7 I rq d Company Name 1-tlutt Registration Number E --“'. 4tKA-Lwrr kt,40 c,c(cA- Address Expiration Date 0 ( C 9 Telephone t 1 ? '' 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&-.' No ! City of Northampton ,.oasHiM�i 4. Massachusetts wS'S I- * �a { s < ` DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 Js� o14`, AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units...,or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeownereP �� has contracted with a corporation or LLC,that entity must be registered An Type of Work: v�C10 Ct.'5 4 ( (9f Est. Cost: 7 W 6 Address of Work: ?c ( (/t( �,(/� c • Date of Permit Application: (— 17 I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: / Date Corftractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton o ' Massachusetts ��S* t ( ' DEPARTMENT OF BUILDING INSPECTIONS iti 212 Main Street • Municipal Building " y'e. Northampton, MA 01060 Massachusetts Residential Building Code Section 110.R5.1.2 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. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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 be 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. City of Northampton .4„ /?.-- Massachusetts - , fr , t DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building 'wilP.1410 Northampton, MA 01060 441if 3,0% Debri s Disposal Affi davi t In accordance of the provisions of MGL c 40, 554, 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 150k The debris from construction work being performed at: 75- Ur . pi I (Please print hodse number and street name) Is to be disposed of at: crA--e V-P y (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: 0 - t\ Loct. c-- * CCLp (Company Name and Address) 5447 I— I Signa re of Per, it App - t or er Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations — 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Legibly Name(Business/Organization/Individual): CL1 S Address: ? ? `C1 r`k <5' t--C.“ Fcts LeiA (A......6.. 0(.0 City/State/Zip: Vk-C11/4 V ( 0 4q--- Phone#: Lilt? ` c5 d-5 j 7 Are you an employer?Check tte appropriate box: Type of project(required): 1. -I am a employer with 4. ❑ I am a general contractor and I 6. I=1 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 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.111 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. T ` r Insurance Company Name: r k 5'1.(,1 l 1 u1 -1't-(‘-eLig WPolicy#or Self-ins.Lic.#: C c) `) 5' 7 Expiration Date: 4 ` — 1 Zs Job Site Address: ? Pl l��`((� 0Ciry/State/Zip: L)Ca (Au ((� +t ( U"` 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 c ify under he p ' and penalties of perjury that the information provided above is�truepct and corre Signature: ,Q t-Date: iJ l — ( 7 Phone#: l - c 17' I 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia '1'. \ \ \ \ \ o V ` C4o 0 ' N uG C6 y 0. t ' G V"' y s t" \ \ ' .. Ilk NN u o 0 N \ \ 0 cf) -0 .--- : \ t. 1:1; c' G c' N d i 0 Co 4 •� to w ' 23 y m d ,. r''n ��y d ek Q O -6 5 cin1.-..t..,: o � oo � 0 e 0 o U \\3'. C) ui,.....,-I, w> W��Z za00c° CC1 c?O N M'iiuiiii " "° sr 1 (...) i c 0 I ; — o 0 co co 4-. I 0• o L.. e . . co oo; o OS Ct.c, 1.___. 0 1 CO ••• ''-' 41; 0 a I , .... 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C° "-- fY CO 0) 0 i 20 ---,..-; ,... , to; ‘-- -c- Z 3 <1--Z Z 7-• v > is3 0 < 1—UJ 0 _.'• 1 i 2 60 E lij 0 — •'-' I- t---4 > 0 . n 1-3) a Z 111 m Lii i< 0 CD Eij o 0.,al - 1'.:•' :7___712ti, ..-'. l'atTr-7:, !), 1-Lii< 1 c ct ct cyrdc c•tic,", CLI •,I ..fsig,rp ,_ co 7.115 % > 7 t /\\ • ( k . 5 � « o o : c, \ \ ?� ƒ of ) v*" \s'tste, 0,1 � $_ '' ■- 7 k. ktkg % 0 �� aV • AC R® DATE(MWDD(YYYY) `� CERTIFICATE OF LIABILITY INSURANCE 6/9/2017 THIS CERTIFICATE IS ISSUED AS A MA I i tR 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 CONTACT Marion Lentes NAME: Berkshire Insurance Group, Inc. __WC_PHONE Exry: (413)935-1200 — _ I(A/�C No :(413)567-5300 138 Longmeadow St. E-MAIL ADDRESS: INSURERS)AFFORDING COVERAGE NAIC N Longmeadow MA 01106 INSURER A Associated Industries Insurance 23140 _ INSURED INSURER B:Safety Indemnity Co. 33618 Charista Construction Services, Inc. INSURERC:Savers Property & Casualty 38 Harkness Avenue INSURER D: INSURER E: East Longmeadow MA 01028 INSURERF: COVERAGES CERTIFICATE NUMBERCL1752248862 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. INSR TYPE OF INSURANCE ADOL SU13k —' --- . __- POUCY EFF POLICY EXP WATTS LTR INSD WVDM) POUCY NUMBER (MMIDDIYYYY) (MDDJYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300,000 A CLAIMS-MADE _X OCCUR PREMISES Ra ocaIIrencel $ AES102641704 5/6/2017 5/6/2018 MED EXP(Any one person) $ Excluded PERSONAL.&ADV INJURY $ 1,000,000 GE AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY J JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: Property Damage Deductible $ 1,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _.(Ea accident) B I ANY AUTO BODILY INJURY(Per person) $ 250,000 ALL OWNED 'SCHEDULED AUTOS X AUTOS 5021567 6/2/2017 6/2/2018 BODILY INJURY(Per accident) $ 500,000 NON-OWNED PROPERTY DAMAGE $ 100,000 X HIRED AUTOS X_... AUTOS _Ter accident) _ _ $ UMBRELLA UABOCCUR EACH OCCURRENCE $ _ EXCESS LIAR CLAIMS-MADE AGGREGATE S DED I RETENTION S $ WORKERS COMPENSATION PERI OTH- AND EMPLOYERS'UABIUTY STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE i/NI E L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBERdoryin NH)EXCLUDED? /A 1700002577 6/8/2017 6/8/2018 E.L.DISEASE-FA EMPLOYEE $ 1,000,000 C (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Proof of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE Marion Lentes/MLENTE %�,J l 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 Gntann