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36-276 (2) 16 SPRUCE LN BP-2019-0522 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36-276 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2019-0522 Project# JS-2019-000846 Est.Cost: $10400.00 F e: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RCI ROOFING 74334 Lot Size(sa.ftp: 36895.32 Owner: SLOAN INGE B Zoning: Applicant: RCI ROOFING AT. 16 SPRUCE LN Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON.1013012018 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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: 21 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 10/30/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner o x77 '::;;•` "' &U"!d., uge'' 0Ty' 71 CIty of Northampton ' ;la'l;�lsiof!i?3fcijlt:: ' ` Bullding Department T oC*-.) ^ 212 Maln Streeta;tij�, . hic;,Av; Room 100 !,w' ;tiiR;Nwell; u:�a'ttab.ilrt,,y y, o� Morthampton, MA 01060 Tyra`3;8'ts`oaS.t(r:wgtan:a .Plians: l Z _ pho T13 X87-1?_40 Fax 413-587.1272 ) a'bUfhi, lais;':' o v _ LIGATION TC STRUCT, ALTER, REPAIR, RENOVATE OR DEM01.18H A ONE OR TWO FAMILY DWELLING gyp' L q�5 �" a EC1`I N 1 :S'IT:E INFORMA.TI' :N: �.� !?ro er AIdr3'ss; r �. '7�1I,�':I'aTs;ecltlull`t'o'+b:e c:o:m:pa:e;t`e:d`'b:ya.tfl'ce it %lo/SP,-u de- LI-) . ap— �l Of�2C1, l'j'Jl� �'o.n,e.�.•,,..•__-__,.. _'O;v�e:nlay�'D't'st�rdc�t_�, __ _. +Elrn�.t: ora.tr�Pet--•� � �;e'�oas.t'rler„^.,� tCT1oN 2 - PROPERTY OWN:hR'f3l-MIP•I.AUT'H'O;R.IZED'.AGENT >,I owner of Record acne (P/nq Current MAng)\ddr.ass; Telephone ,,ionalure 2 Authorized Aaerll; Larne (Priv) ;✓,.� Current Malling Address; ignature Telephone ;GCTIO_N 3 • ESZfY�AT.E.p_(%;0.NS':TFtU:C.TI'. N 00..ST:S- len, Estimated Cost(Dollars) to be Ufflcial-Use-only com leted by permit applicant, I Building (a')'Bull.d9n.g:P.0r.mbl:Pee fir .. I o yoa. - _ _ c:iedrical (ps):Esllmaha.d Toaal Cost o.f C.ans'truatiola:from.(6) 3 Plumbing :6u'liclln;g Pe:erreLt:Fee• i Mechanical (HVAC) _ ► —1 " ire Protection Total + 2 + 3 + 4 + 5) _�. --„e,�._ •T�:h.�'8'e.�.tlon�F�or`pffl.ca.a'I;tJse Only_ .._ )uilrling Permit N.Umbe.r;: __ Issued,.--.__ >ignalure, i '''I"�^�r�V'� !o/ 7-9 Building.Com.ml:rslon.er1l'nspector:o.f•B.wlldings: Data: S.ECT:ION 6• DIS.CRIP•: IO OF P�R.I'J.PQS• D"VJ:O. K (che:k:aal ar�nl.lr:ah�.)� New Nouse Addltlon- Replacement windowste.ration(s) ❑ Roofing [�— Or Doors D i Accessory Bldg. Demolition ❑ New Signs (CM) Deoki; (q Siding (o) Other(❑) Brief Description of Proposed Alteration of existing bedroom _Yes, No Adding new bedroom-- Yes No Attached Narralivr: Renovating unfinished basomerlt Yes _No Plans Attached Roll - Sheet �" -- I sa I:f:New.:hcous(xa:a' ''(aar �i;>�Jontt,o �x'fs;llitl ';fit, I a 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? _ cl. Proposed Square footage of new-construction, Dimensiomi I e. Number of stories? — — 1 f. Method of healing? Fireplaces or Woodstoves Number of each_ i g Energy Conservation Compliance, Masscheck Energy Compliance form attached? Type of construction Is construction within 100 fl. of wetlands? Yes _ No, Is constructi(,n within 100 yr, floodplain _Yes No i I Depth of basement or collar floor below finished grade !K. Will building conform to the Building and Zoning regulations? Yes No , . Septic Tank City Sewer Private well City water Supply SECTION 7.a •-OWNER AU-1'FfOR1ZAT-10N.• OWN ERS-AG'EN.-T.U.R E'.QNTR-A.CTQR.APPi:JE:$ F•O:R'R.IJ:LhfJLN.Q PBf2.(VIIT as Owner of the subject propeaiy I j hereby authorize 7 1 n o _ to act on my behalf, in all matters relative to work authorized by this building permit aRtlicatlon, Signature of Owner Dale A ' as Owner/Authorize:d Agent hereby declare that tho statements and Information on e foregoing application are true and accurate, to the best of my knor,ledge and belief. Signed under the pains..and•penalties of perjury, Print Name Signature of Owner/Agonl �`— "TION 8 • C 0 N 87 RUCTI 0.N'8:A RVI 01E.'s: Not Applicable 0 )_�Lof ULcerjspjjqld�u:_ffi o�_r a 0 y '?) License Number ess Expiration Date Telephone _0'r Not Applicable 0 M,any Na mq Registration Number Expiration Date TelophoneLqi�LrL� '� j CTION 10.W-ORF(E.,Ra',CC)MP'.E.-NS,AT.I,O.N INS'UR'ANCE APFI.'OA-..V.IT (W.G.L. c. 162, § 260:(6)) .vers Compensation Insurance affidavit must be completed and submitted with thN application, Fallure to provide this affidavit will result !ie denial Of the issuance of the building permit, ped Affidavit Atla(,,hed Yos...... CI No,,,,,, 0 The current exemption for"homeowners" was extended to Include a_w_rLaL..j(Lci,tpIed Dwellings of one(1) or two(2).fan-fliles and to allow such homcowner to engage an Individual for hire who does not possess i license, pvovlded that the owneracts as Lap i Ylsov. Q VIR X80, Sixth Edition Section j)eflL,Lt.LoiiofHomeowner,; Pei-son (s) who own a parcel of land on which he/she resides or intends to reside, on which there tS' or is intended to be, a one or two family dwelling, attached or detached iltruc.tures accessory to such use and/or farm structures,A.AWon who constructs one home In a �Leawpetlod shall got be considei,ed a lip_inemyner, Such "homeowner"shall stibmilt to the Building Official,on a form acceptable to the Building Official, thathe she shall be LesL3gnsjble for ail suc oOt performed under the building nel-mit, As acting Construction Sitnerylsor Your presence on the job site will be rquived ftom time to time, during and upon completion of the work for-which this permit Is Issued, Also be advised that with reference to Chapter 1 S (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 llnblt for Pei-sol)(8) you hire to perform work for you under this permit, The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Mmsachwetts General Laws Annotated, Horneowliel.Signature RC,1- Roofing Date I 6 Line St. Estimate Southampton,Ma.01073 9/4/2018 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location Inge Sloan 16 Spnlce Ln. Florence, MA 01062 Terms Rep Estimate valid for 30 days Chris Description Total Remove existing roofs. 10,400.00 Furnish&install aluminum drip edge,pipe flashings,chimney flashings(if needed)and step flashings. Furnish&install CertainTeed Winterguard ice&water barrier, 6 feet along eaves. Furnish and install synthetic underlayment over existing deck. Furnish and install Lifetime CertainTeed Landmark Series shingle. Furnish and install CertainTeed approved ridge vent. All exterior roofing related debris to be removed by R.C.I.Roofing. All work will be performed according to manufacturers'specifications. Lifetime CertainTeed material warranty included. All related permits will be obtained by R.C.I.Roofing. Add$2.50 per sq. ft. for wood decking replacement if needed. WE LOOK FORWARD TO DOING BUSINESS WITH YOU THIS WINTER. Total $10,400.00 TERMS OF PAYMENT Ay 5%Deposit Customer Signature: ,�✓ Balance upon completion Registration# 126235 Construction License#074334 Date: J Q Z_ Insured by Banas&Fickert Ins. (413)527-2700 FShTinleolor Selection: The Commonwealth of Massachusetts Department of Industrial Accidents -- 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Please Print Leeibly Name (Business/Organization/Individual); R C• 1 /Ppp•10/,�q _ ,(._L_/0 Address; ,L//18- City/State/Zip: / 8-City/State/Zip; , ufh�r>7_ h IVH 0/U�73 Phone #; ('f/3) Are you an employer?Check the appropriate box; Type of project(required); 1. 17 1 am a employer with 12U 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 $, ❑Remodeling any capacity.(No workers'comp,insurance required.] 9, ❑Demolition 3.❑I am a homeowner doing all work myself.(No workers'comp.insurance required.)t 10 E] Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 1 1•❑ Electrical repairs or additions proprietors with no employees. 12,❑Plumbing repairs or additions 5.7 1 am a general contractor and I have hired the subcontractors listed on the attached sheet. 13•©'Roof repairs These subcontractors have employees and have workers'comp.insurance., 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other _ 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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 subcontractors and state whether or not those entities have employees. If the subcontractors 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; Surd<��re- (,o _ Policy#or Self-ins, Lic, #: U-)UAf,-./(1d Expiration Date; /D Job Site Address; A, i 4LLCL L/) . City/State/Zip; riff ,I e/YA el, (r,Z Attach a copy of the wor ters' 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 DIA for insurance coverage verification, I do hereby certify under tit. a. s a d penalties of perjury that the information provided above is true and correct. i Signature; -: °'J Date: /0 Phone#: �''�/.3y� 6 2-'7 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#: 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: The debris will be transported by: f' I Gttc/ih 41i/7�f w2_t'�rc�in�i The debris will be received by: 6()e6t�rn Reurc%�17 %rahs��r c61ch Building permit number: I 27 Name of Permit A ppI'cant (LC/ �)vj Date A9 -a� -�� Signature of Permit Applicant SCA 1 0 20M•05/17 d5-11. 071J)tN)ttls2Ct�L1bO ��/pAJCtc7tttdP Office of Consumer Affaird&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE-,Partnership Exairation 05/05/2020 RCI ROOFING,{ L .z_�=_.l i Commonwealth of Massachusetts 1 MARKT.DELISL 1};_ CP—Cc Division of Professional Licensure \, 4F� � 6 LINE ST Board of Building Regulations and Standards �,.`�i�,-�./:� SOUTHAMPTON,MA`x1073` Undersecretary Cons�rt�. ti�t�ls�l1' rvisor !r• CS•074334 .r 1 ,;,; SNpires: 05/03/2020 Registration valid for individual use only �` � before the expiration date. If found return to: MARK THOM/aS DEIJj fid �• , 69BRIGGS ST• EET , �I' ; ti' ^. - .,z ,f• Office of Consumer Affairs and Business Regulation EASTHAMPTO 1000 Washington Street•Suite 710 A',.01625•;. "i.= "-"??` Boston,MA 02118 i7C) 1115 h° ' Commissioner • I, Not valid without signatureMOM 'a ,X, X M' 11 -- ::� :CO EALTFi OF MM.ON•W M` SSACHUSIcTTS 0 0 0 0 HOME IMPRQVEMPENT•'CONTRACTOR .,,•£�,;�'�I�� ;E}oAR;a�pp RCfR.. biI 1GLyLP 6: :IN :ST , SHEET MT,AL IWiRK :RS; SOU TITAIvT�?.TOfta::Iv(�A 01073 £:?3F ISSUES-1F{E'FO.L'G0.1!iIIN:G L(C 'hISE ff f..; :F " ';.MAST' w. l R•IJ:N.{;�:S.T'.I::GTED is ,;i1 :FSK T'DELISLE :; z LIC,/RE NQ, ... E;F •TI , ;, X IR ___ g9''SR IGG.S.. -ST :.::x. ". HIC.0624741 12/01120T7 11/30/2018 EASTHQ;"' aN� MA .Q1',0,2 ; 39' 1 7 r f j JIUIvt_v __.___.____•._._.�... .. __._., <:.>. ..... 1347 "::.:. --___-- G;<"> ''0;5/2872020, 466498 • , nbvi;Kid"idij?§ .. .. • I ' €'. y O'0MM NWA t MAS. , '. ;G I RS> 0:WI.N *11St?.• qx NESS- 'MA��;Ki'1':D:ELI.S�I:}f�;« :;;��`s: :<. ;v, "'a:_ �'� � '4• IN 097091201.9 34'2236 , .,... -:.:-n-•vax»sr.r:-:.nt.u s>..�..w,:H:A•.rrtw-•t"-y"rynw� t,��ia�''"�°---• M Oct. 4. 2018 4: 39PM No, 3123 P. 1 Act® CERTIFICATE OF LI�BILITY INSURANCE DATE(MMIDOITTYY) �� I 10104/18 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMP-NO,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW: THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTL A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER] IMPORTANT. If the certifleate holder is an ADDITI NAL INSURED,th poiicy(ies)must have ADDITIONAL.INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of t� a policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER UUN CT NAME: Michael R.Sanas Sanas 8 Fickert PHC N Ex:: 413527.2700 Fac Na): 413-527.0849 MAIL 63 Main Street Insurance Agency ADDRESS: mb@_banasinsurence.com Easthampton,MA 01027 INSURERS AFFORDING COVERAGE NAIC A INSURERA: Admiral Insurance Co. 24856 INSURED INSURER B: Safety insurance Co. 39454 RCI Roofing,LLP INSURERC: Admiral Insurance Co. 24856 6 Line Street Southampton,MA 01073 INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAM 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 SE 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, SYR TYPE OP INSURANCE INSO VND POLICY NUMBER] MMMQ MWDD OLICY P LIMITS X COMM ERCIALGFNGAALLIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE OCCUR PREMISES Es occurrence $ 50,000 MED EXP(Any one Orson S 10,000 A X CA000020963.04 03/04/18 03/04/19 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATELIMIT APPLIES PGR; GGNERALAG3RE0ATE S 2,000,000 PpLICY Z ECT ❑LOC PRODUCTS.COMP/OP AGG $ 2,000,000 OTHER: S AUTOMOBILE LIABILITY L SI:yEO INGLE LIMIT Eaaceldent $ 1,000,000 ANYAUTO BODILY INJURY(Per person) $ OWNED B AUTOS ONLY X AUTOSULED X 6207761 09/30/18 09/30/19 BODILY INJURY(Per acddenl) $ X HIRED X NON-OWNED PRO GRTY AMA $ AUTOS ONLY AUTOS ONLY Per accident g UMBRELLA UA8 OCCUR EACH OCCURRENCE g $,000,000 C EXCESS LIA9 CLAIMS-MADE X GX000000385.02 03/04/18 03/04/19 AGGREGATE g 5,000,000 DEO I X I RETENTIONS 10,000 w\'ORKERS COMPENSATION PERTUTE - ER 0 - AND EMPLOYERS LIABILITY Y 1 N STA ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACHAGGIDEn1T 5 OFFICER/MEMBER ExCLUDE07 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE II Yes,describe under DESCRIPTION OF OPERATIONS belew E.L.DISEASE-POLICY LIMNS DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Addltlonal Remarks S(hedule,may bo attached If more space Is required) ROOFING CONTRACTOR. The General Liability policy includes an Additional Insured endorseme t that provides Additional Insured status to the certificate holder,only when there is a dvritten contract that requires Such status,and only with regard to work performed on behal of the named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL SE DELIVERED IN ""'"'*'Reference Copy"""* ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR.95 IVE iSAC D CORPORATION. All rights reserved. ACORD 2$(2016/03) The ACORD name and loco are realstered marks of ACORD Oct, 4. 2018 4: 39PM No, 3123 P. 2 �►C© CERTIFICATE OF LIABILITY INSURANCE DAr9(MMroDfrMri �-� 1 10/04/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION OLY 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDEF, IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,t11e policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and Conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsoment(s). PRODUCER CON AOT NAME: Michaol Series BANAS & FICKEONERT INSURANCE AGENCY PHextil 413 527-2700 1is No: EMAIL Q ADDRESS: mD banasinsvrance•COm ' 63 MAIN$T INSURERS AFFORDING COVERAGE NA1C N EASTHAMPTON MA 01027 INnURERA: AIM MUTUAL INS CO . 33758 INSURED INSURER B RCI ROOFING LLP INsuRERCI INSURER 0: 6 LINE STREET INSURER E: SOUTHAMPTON MA 01073 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 322172 1 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 R£QUIREMENY,TQRM OR CONDITI DN OP ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFF RUED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE SEEN RE,OUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE A f 0 P I POLICYEFF POLICY LTR OLCYNUMBER MM MM/DD LIMITS COMMERCIALGENERAL LIAWLrry EACH OCCURRENCE S CLAIMS-MADE OCCUR PA - 1015 5 Ea omireenee S MED EXP(Any one pe=n) S N/A PERSONALdADVINJURY s GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 3 PRO• POLICY JECT LOC PRODUCTS•COMP/OP AGG S OTHER!, S AUTOMOBILE LIABILITY Coll BINEDSINGLE IMI S IF.accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per 5 AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE S AUTOS Per accide 5 UMBRELLAL1AA OCCUR EACH OCCURRENCE s EXCES$LIAO CLAIMS-MADE N/A AGGREGATE $ OED RETENTION$ S WORKERS COMPENSATION X TT UTE ERH AND EMPLOYERS'LIABILITY Y/N A OFF CEORN ASeR2XCLUOEG,EC�tVE NIA NIA NIA VWG10060226472018A 10/05/2018 10/05/2019 E.L.EACH ACCIDENT $ 1 000,000 (Mandatory in NMI E,L.DISEASE-EA EMPLOYEE 5 1,000,000 If yae,describe under DESCRIPTION OF OPERATI NS below E.L.DISEASE.POLICY LIMIT S 1,000,ODO N/A DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORO 101,Additional Remarks Bat adule,may be attached If more space is required) Workers'Compensation benefits will be paid to Massachusetts employees oily.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in States other than Massachusetts if the in iured hires,or has hired those employees outside of Massachusetts, This certificate of insurance shows the policy in force on the data that this ce ificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage•Coverage Verification Search tool at www.mass,gov/Wd/workers-compensatiorYnvostig2dons/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE OESCRISED POLICIES BE CANCELLED BEFORE. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Proof of Coverage ACCORDANCE WITH THE POLICY PROVISIONS. 00000 AUTHORIZED REPRESENTATNE 00000 MA 00000 n"{ �� Daniel M.Crow y,CPCU,Vice President-Residual Market_WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and log I are registered marks of ACORD