16A-004 (2) 87 CHESTERFIELD RD BP-2019-0746
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 16A-004 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:INSULATION BUILDING PERMIT
Permit# BP-2019-0746
Proiect# JS-2019-001229
Est.Cost: $5916.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AMERICAN INSTALLATIONS LLC 106178
Lot Size(sg.ft.): 47916.00 Owner: Melissa Fowler
Zoning:URA(100)/ Applicant. AMERICAN INSTALLATIONS LLC
AT. 87 CHESTERFIELD RD
Applicant Address: Phone: Insurance:
130 COLLEGE ST (413) 552-0200 WC
SOUTH HADLEYMA01075 ISSUED ON:12/26/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.-ATTIC AND BASEMENT INSULATIONA AND AIR
SEALING THROUGHOUT
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 12/26/2018 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
/VS.0(AT Q 4/
Department'use only;'
R E C E I V E D C ty of Northampton Status di Permit._
Bi jilding Department Curb Cut/Dnvewll-
ay Permit
212 Main Street Sewer/Septic Ayailabilitiy
DEC 2 6 2018 Room 100 WaterNVeil'AvarlabrUty
No hampton, MA 01060 Two Sets of Structural Plans
DEPT.of cun_DING INN 13- 87-1240 Fax 413-587-1272 P1698te Plans>
NORTHAMPTON,MA 01060 Otiler'Specify.
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY(,jDW�ELLING
SECTION 1 -SITE INFORMATION 6p (q -� G VD
1.1 ProaertvAddress: This section to be completed by office
Map JCj Lot Unit.
87 Chesterfield Road
Zone Overlay District
Elm St.District.. CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Melissa Fowler 87 Chesterfield Road
Name(Print) Cu n �" T`9�' s:
(i
See attached Telephone
Signature
2.2 Authorized Agent:
American Installations 130 College St., Ste 100 South Hadley, MA 01075
Name(Print) Current Mailing Address:
W&i - ,,1.1,Ey. yL1Q 413-552-0200
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 5916.00 (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+5) 5916.00Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
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 in by
Building Dvariment
Lot Size
Frontage
Setbacks Front Q U
Side L:= R:= L-.= R. J
Rear
Building Height
Bldg.Square Footage C� %
Open Space Footage J
(Lot area minus bldg 8c paved
parking)
#of Parking Spaces
Fill:
volume&Location) �-- ------ f� ----------`�---------------�
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES Q
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 f Page and/or Documents_ }
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 O
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 O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing E]
Or Doors 13
Accessory Bldg. ❑ Demolition ❑ New Signs 10] Decks M Siding[O] Other
Brief Description of Proposed
Work: Attic insulation and air sealing throughout
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Pians Attached Roll -Sheet
6a.It New house and oc addition.to,existing houstna,.comOle te the fol iOwing-
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 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, as Owner of the subject
property
hereby authorize American Installations
to act on my behalf,in all matters relative to work authorized by this building permit application.
See attached
Signature of Owner Date 121 4/201
I, American Installations 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.
American Installations
Print Name
Signature of r/Agent Date 2/14201
1 .
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder: Wesley K. Couture 106178
License Number
130 College St., Ste 100 South Hadley, MA 01075 9/29/19
Address Expiration Date
�
�-D uai_�,in 1L. Gu 413-552-0200
gnature Telephone
9.Registered Horne lm6rotremerit Contractor:__ Not Applicable ❑
Wesley Couture 175982
Company Name Registration Number
American Installations 6/26/19
Address Expiration Date
130 College St., Ste 100 South Hadley, MA 01075 Telephone 413-552-0200
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8)j
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....... 11 No...... ❑
H6me OwnerEzemAtion
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) 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 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.
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 Massachusetts General Laws Annotated.
Homeowner Signature
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Strout • Municipal Building
Northaton, MA 01060 `8��^
Property Address:
87 Chesterfield Road
Contractor
Name: American Installations
Address: 130 College Street Ste. 100
City, State: South Hadley, MA
Phone: 43-552-0200
Property owner
Name: Melissa Fowler
Address: 87 Chesterfield Road
City, State: Leeds, MA 01053
1, American Installations (contractor)attest and affirm that the building I intend to
insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
V-
Date 12/14/2018
l
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: 87 Chesterfield Road
The debris will be transported by: American Installations
The debris will be received by: Waste Management of New England
Building permit number:
Name of Permit Applicant Wesley Couture
Date Signature of Permit Applicant
mass save
Ucensed&insured PARTNER
ql�t
MA CS!#:1(X 178 61.
MA Regrstroaon#175982 American Installations www-AmericanInstallations.com
130 College Street Suite 100,South Hadley,MA 01075• Office;(013)SSZ-0200 Fax:(413)552.0202• EmEI supports@Americanlnstallations.com
Customer Name:Melissa Fowler
Email:Not provided
Phone:413-977-0455
Premise Address:87 Chesterfield Rd,Northampton,MA 01053
Project ID:3612293
Date:Dec. 10,2018
Job Description
z-.�.8,,....-..34., ,Tl�' k' _.. ;° {
Air Sealing at Estimated 62.5 CFM50 Per Hour Living 18 hr $1,666.44 $0.00
Space
Exterior Door Weather Stripping (with AS hrs) Living 5 each $150.35 $0.00
Space
Door Sweep (with AS hrs) Living 5 each $126.55 $0.00
Space
Attic Stair Cover w/Carpentry (with AS hrs) Living 1 each $289.31 $0.00
Space
Whole House Fan Box -2"Thermal Barrier Polyiso (with Living 1 each $187.70 $0.00
AS hrs) Space
Attic Floor- 6" Open Blow Cellulose Living 1500 SF $2,430.00 $607.50
Space
Propavent Living 213 each $886.08 $221.52
Space
Damming Living 64 each $152.96 $38.24
Space
Bath Fan Hose Living 1 each $26.20 $6.55
Space
WARRANTY:American Installations,LLC will provide the above stated homeowner with a 1-year workmanship warranty.
American installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with the above specifications and all local and state
building regulations for the Total Contract Value as stated herein.
ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are TOTAL CONTRACT VALUE=5
satisfactory and are hereby accepted.You are authorized to do work as specified.Payment
Down Payment=S ❑
will be 1/3 down prior to start of work,and balance due upon Completion. PAID
Balance Due Upon Completion= 5
Signature Date
Page 1 of 2
Property Owner(Print) (Sign) Date
Representative:(Print) (Sign) Date
THIS AGREEMENT IS COMPOSED OF THIS PAGE AND THE REVERSE SIDE OF THIS PAGE AND SHALL BE CONSIDERED THE ENTIRE AGREEMENT BY THE-70 INVOLVED THIS AGREEMENT IS BETWEEN AMERICAN INS7ALUSTIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY',
ANOTHE W STOMER)S)NAMED ABOVE,HEREINAFTER REFER REO 10 AS-QIENT'.AND WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REGULATIONS AN D OROINANCES OF THE STATE OF MASSACHUSETTS OR CONNEC71CUT RESPECTIVELY,AS WELL AS ALL LOCAL JU RISDICTION5
mass save
-icensed&Insured
PARTNER
MA Ca#:106178 ,
MA Registration#175982 American Installations www-Americaninstallations.com
130 College Street Suite 100,South Hadley,MA 01075• Office:(013)552-0200 Fax:(413)552.0202• Emailk support@Amerlcanlnstallations.com
Customer Name:Melissa Fowler
Email:Not provided
Phone:413-977-0455
Premise Address:87 Chesterfield Rd,Northampton,MA 01053
Project ID:3612293
Date: Dec. 10,2018
Project Total $5,915.59
Weatherization incentive ($2,621.43)
Air sealing incentive ($2,420.35)
Total Program Incentive -$5,041.78
Customer Total $873.81
WARRANTY:American installations,LLC will provide the above stated homeowner with a 1-year workmanship warranty.
American installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with the above specifications and all local and state
building regulations for the Total Contract Value as stated herein.
ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are TOTAL CONTRACT VALUE=S 873.81
satisfactory and are hereby accepted.You are authorizedto dowork as specified.Payment Down payment=S 200.00
will be 1/3 down prior to start of work,and balance due upon Completion. PAID
Balance Due Upon Completion= S 673.81
Relzhil 7�1414e-
Signature Melissa Fowler(Dec 14,2018) Date 12-10-18
Property owner(Print)Fowler,Melllsa (Sign) Page 2 of 2 Date
Representative:(Print) Jason Bhajan (Sign) J�—"44"' Date 12-10-18
THIS AGREEME'1T IS COMPOSED Of THIS PAGE ANO THE REVERSE SIDE OF THIS PAGE ANO SHALL SE CONSIDERED THE ENTIRE AGREEMENT BY THE PARTIES INVOLVED'NIS AGREEMENT 15 BETWEEN AMERICAN 1 NST ALLATIONS,LLC HEREINAFTER REFERRED TO AS"COMPANY•.
ANDTHE CUSTOMER(S)NAMM MOVE.HEREINAFTER REFERRED TC AS'CLIENT.AND WILL BE SUBIECTTOALI APPROPRIATE LAWS,REGULATION5 AND ORDINANCES OF THESTATE Of MASSACHUSETTS 09 CONNECTICUT RESPECTIVELY,AS WELL AS Al LOCAL JURISDICTIONS
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
wi 600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leizibly
Name(Business/Organirsttion/Individual): American Installations,LLC
Address: 130 College Street,Suite 100
City/State/Zip: South Hadley,MA 01075 Phone#: 413-552-0200
Are you an employer?Check the appropriate box: Type of project(required):
1.[A I am a employer with 60 _ 4. ❑ 1 am a general contractor and l 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet.t E] 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
required.] officers have exercised their 10.❑ Electrical repairs or additions
3_❑ 1 am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.] 13.®Other Insulation
*Any applicant that checks box#1 must also rill out the section below showing their workers'compensation policy information.
t Homeowners who submit this afdavil 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 their workers'comp,policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site
information.
Insurance Company Name: Guard Insurance Companies
Policy#or Self-ins. Lic.#: URWC609917 Expiration Date: 09/04/2019
g-4 Ches4 itW Road ty p: Mfi- MO+nn,
Job Site Address• tCi /State/Zi MH bin
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 certify under the pains and penalties of perjury that Ike information provided above
is true and correct
Si nat r : 6Date:
Phone#: 413-55f-0200
Oficial use only. Do not write in this area,to be completed by city or town ofciaL
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#:
Commonwealth of Massachusetts Construction Supervisor
®4 Division of Professional Licensure Unrestricted-Buildings of any use group which contain
Board of Building Regulations and Standards less than 35,000 cubic feet(981 cubic meters)of enclosed
Construction'Stlpervisor space.
CS-106178 Expires:09/29/2019
s
WESLEY COUTURE
218 LATHROP OTREET
SOUTH HADLE16i111A 01075
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
n Q For information about this license
Commissioner ��fi~• Call(617)727-3200 or visit wwwmass.gov/dpl
Uzi
s; Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement-Contractor Registration
Type: LLC
AMERICAN INSTALLATIONS,LLC. Registration: 175982
130 COLLEGE STREET SUITE 100 Expiration: 06/26/2019
SOUTH HADLEY,MA 01075
Update Address and return card. Mark reason for change.
SCA 1 0 2OM-05111
lyl Add---- 0ClEmplQymet]f 0 LoidrtArSi<
�/lam if r:»r»rnnuarvr�/fi ref^ft<rttrr�fa.u•/r.
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the expiration date. B found return to:
l Registration Exoi on Office of Consumer Affairs and Business Regulation
175982 06/26/2019 10 Park Plaza-Suite 5170
AMERICAN INSTALLATIONS,LLC. Boston,MA 02116
WESLEY COUTURE
130 COLLEGE STREET SUITE 100 (� -7;/4 -
SOUTH HADLEY,MA 01075 Undersecretary Valid without signature
ACV DATE(1eAlD01VYYY)
as•V CERTIFICATE OF LIABILITY INSURANCE
l 9/4/2018
THIS CERTIFICATE 19 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. If SUBROGATION IS WANED,subject to
the terms and conditions of the policy,csrta(n poples may require an endorsement A statement on this certificate does not confer rights to the
cerdflosts holder In lieu of such s.
PRODUCER Linda Powers
Webber & Grinnell E (413)586-0111 FAx t41315ec-4as1
8 DTorth acing Street "AIL .1Dovere9llrsbberandgrinnell.com
WSU AFFORDING COVERAGE NAIL e
Morthampton UK 01060 INSURER MMIOYOrS Mutual Casualty
INSURED INSURER B:Herkshire Hathaway GUARD Int. Co.
American Installations, LLC WSURERC:
Attne Wes & Susanne Couture INSURER D:
130 College Street, Suits 100 INSURER E:
South Hadley MA 01075 INSURER F•
COVERAGES CERTIFICATE NUMBER:Naster Mxv 9-2019 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.
B6R IRMAPOLICY OF W TYPE DANCE POLICY NUMBER IMMIDOrrfm W LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO R1?rw_
A Z CLAIMS-MADE F7 OCCUR PREMISES(Ea oemmme) $ 300,000
5D3535217 9/4/2018 9/4/2019 MED EXP One raon $ 10,000
PERSONAL&ADV INJURY S 1,000,000
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
Z POIJCY 0 JECT ❑LOC PRODUCTS-COMPAOP AGO $ 2,000,000
$
AUTOMOBILE LIABILITY POOLE LIMIT S 1,000,000
A ANY AUTO BODILY INJURY(Per person) S
ALL OWNED Z SCHEDULED 523535217 9/4/2018 9/4/2019 BODILY INJURY(Perac&W) S
AUTOS AUT�ED PROPERTY DAMAGE S
Z HIRED AUTOS z AUTOS Mw acdderM
x
Coll$2.000 Z comp$4000 PIP-Seel- $ 8,000
Z UMBRELLA UAB OCCUR EACH OCCURRENCE $ 11000,000
A EXCESS UAB CLAIMS-MADE AGGREGATE $ 11000,000
DED I Z I R 5J3535217 9/4/2018 9/4/2019 $
WORKERS COMPENSATION x
AND EMPLOYED'LIABILITY --
ANY PROPRIETORIPARTNER�EXECUTIVE Y/❑N NIA E.L.EACH ACCIDENT S S S00,000
B OFFICERIMEMBER EXCLUDED?
yORN0609917 9/4/2018 9/4/2Pnd�Y In NH) 019
E.L.DISEASE-EA EMPLOYEE $ 500,000
If deecdba'Off MPEnATIONS below E.L.DISEASE•POLICY LIMIT S 500,000
A Commercial Property 5A3535217 9/4/2018 9/4/2019 deduoeble$1,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO 101,AddlBaut RemerMB Schedule,mry be elNchad 8 mon epee Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCR03ED POLICIES BE CANCELLED BEFORE
Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
W Grinnell, CPCU, CIC ���
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INS025(2014o1)