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38B-232 (3) 60 OLIVE ST BP-2019.1259 GIS 0: COMMONWEALTH OF MASSACHUSETTS MU;MRck:38B.232 CITY OF NORTHAMPTON Lot,A01 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Bulldlna DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Catacorv' REPLACEMENT WINDOWS/DOORS BUILDING PERMIT EMIIN BP•2019.1259 Project# JS-2019.002037 Esj,,0.gst S2S600,0 Ecg 10 44 PERMISSIONIS HEREBY GRANTED TO: C20gyOAyg; Contractor: k1cense: Use Grouo: JOSEPH KENNEDY 058440 Lot Size(sa,R.), 24785.64 Owner. MCGOVERN KATHLEEN D Zoning: URB(100V ApPlicant, JOSEPH KENNEDY AT. 60 OLIVE ST ApplicantAddress: Phone: Insurance: 38 HARKNESS AVE (413) 525.1735 0 Workers Compensation EAST LONGMEADOWMA01028 ISSUED ON.512112019 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 17 REPLACEMENT WINDOWS, DOOR AND ROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector or Plumbing Inspector of Wiring D.P.W. Building Inspector Undorgnundt gorvica; Helen Footinge: Rough; Rought House# Foundation Driveway Final: Final: Final: Rough Frame; Gas: Ff�S„Q;pprMmeut Finplace/Chimney; Rough: 01L Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certitieete of Qcc ply Signature: F jgTvR j; pill PAW Amounts Building 3/21!20190;00;00 $80,00 212 Main$treat,Phone(413)937.1240,Fax: (413)387.1292 Louis Hasbrouck r Building Commissioner wmwowj, dcor- MT Department use only City of North mpt n 1--cu s of ermit: Building Dep rtm nt MAY 8 201 a Driveway Pemrit 212 Main r/S ptic AvailabilityRoom 1 0 r/W Il Availability Northampton, D1880=°uii or:=.r."' Sets of Structural Plans phone 413587-1240 Fax-413.587-4272 lane Other specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A/O'NE OR TWO FAMILY DWELLING SECTION 1 -SDE NIFORMATION �7 �m`Ji y 1.1 P : This section to be completed by office OD `u n Map Lot '--3� Unit LLL C Zone Overlay District Elm SL District CS District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT .1 nr f or MC 0 -0Lwm XD 0 iUf S Kle(slCl y" h 0 (06 Name(Pnn Cwrent Mailing Address: / 1 ` Telephone, Signetu 23 A rtho o rep(-, . JAWr` 3 S' J�e,,I. jr-5' 4 f - y o ( o) Na (Print) Current Malang Address: Li sae- 1�3r signs Telephare SECTION 3-ESTIMATED CONAMCTION COSTS Item Estimated Estimated Cost(Dollars)to be Official Use Only completed by rmil applicant 1. Building !^ 0 0 (a)Building Permit Fee 2. Electrical woo O (b)Estimated Total Cost of W Construction from 8 3. Plumbing ot.'f Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official U"Only Date Building Permit Num Issued: Signature: Lz 5-2l'2019 Building Canmissioner/Inspector of Buildings tate EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Infomw[bn Most Be Completed.PermR Can Be Dented Due To Incomplete Information , Existing Proposed Required by Zoning Thi.column to be filled in by Building Depanmenr Lot Size Frontage Setbacks Front Side L R: U R: Rear Building Height Bldg. Square Footage _ % Open Space Footage % (Loi vee minus bldg&paved erku #of Parking Spaces Fill: volume&Lucnian A. Has a Special Permit/Variance/Findi ever been issued for/on the site? NO O DONT KNOW YES O IF YES, date issued: VVV IF YES: Was the permit recorded at the R ry of Deeds? NO O DONT KNOW 99 YES O IF YES: enter Book Page. and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW O YES O IF YES, has a permit been or(teed 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 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 X L IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,ex abon,or filling)over 1 acre or is it part of a common plan that will disturbover 1 aae9 YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5•DESCRIPTION OF PROPOSED WORK Icheck all applicable) New House ❑ Addition ❑ Replacement Wlpdows Alter loci ❑ Roofing Or Doors lS Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [D Siding 0=31 Other[17I Brief Descdpbon of Proposed g 1'7 � Work: ��1 �4CP � W � oc,.rt 4 2kC (I t fI0Or, w rorr�o�j Alteration of existing bedroom_Yea No Adding new bedroom Yea No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Ga.If New house and or addition to existina 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 adached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? I. 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 I. Depth of basement or cellar floor below finished grade k. Wig building conform to the Building and Zoning regulations? Yes No. I. Septic Tank_ CgySei Private well City water Supply SECTION 7a•OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR �APPLIES FOR BUILDING PERMIT I, a � VC t 11 I(k C 6- 0 `k-lz/t"k ,as Owner of the subject property I Ib hereby authorize 7-X �t d to act on y behag, wall mexen ive o work a odzed this building permit application. Signaturetof OvAork Date I, 'Tou kV& ,as Owner/Authorized Agent hereby declarb Met the statements a iMan iatinn on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under gra pain and pe alties of peq'\]rry. 71Td� (A7 Pant Nemo Q of Ager Date SECTION 8.CONSTRUCTION SERVICES 8.1 Licensed Construction Suoervis Not Appikable, ❑ Name of U"nse Holder: �C'P V.X )/1Q 05 ) ,?Q e) Worse Number ,Wd EtQlkatlom Dau sig Telephone C redcma tnaScrvC'c}II Boc� Not Applicable ❑ CVH5 l '? 14 �—a Comtunv Nams Registration Number ? � � �st � 5 mus. oco S — g Address [ x E Omtion Date Telephona SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,f ZSC(6)) Workers Compensation Insurance affidavit must be completed and Submitted vdth this application.Failure to provide this affidavit will result in the denial of the issuance of thebuildin mtit. Signed Affidavit Attached Yes...... No...... ❑ City of Northampton Massachusetts `W a ffiPAalrarrr or sozaoznc zaaracrzons 312 Main etrwt • rbniciral Building i� •-\Y cs aorthsm n, Ma 01060 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 CHIC"). M.G.L.Chapter 142A requires that the"reconshucdon,atemtion, renovation, repair,modemizaa'on, conversion, improvement, removal, demolition, or consWcgon of an addition to any prewxdsdng owner-occupied buiMing containing at least one bud not more Man four dweNng unda....orto structures which are adjacent to such residence orbudd ngr be done by registered contractors. Note.Ijthe homeowner\\has contracted\\with a corporation((oa�r LLC,that entity must be rregistered Type of Work: \l tC�o-u-''���JOfI/' i tr`-O0i Est.Cost d S 000 Address of Work: 6 ii^O ( UQ S r�- �Q/' 4 Date of Permit Application: 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 RESPONSIBR.ITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: 1 hereby apply for a building permit as the agent of the owner: � C �� (-1 Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I he apply for a building permit the owner of the roperty: Date Owne Name and Signa City of Northampton _ 9-' - Massachusetts / e l` A s DEPAR4r@IT OF BOILDZNG SNSPSCTZONS 314 Main Strwt • Municipal Building Northam biu, NA 01060 rsY .y7��a Massachusetts Residential Building Code Section 110.115.1.2 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 Massachusetts DBPAR]faiMl OF BUILDING INSPECTIONS 212 Win Stz t •Municipal Suilainq0 pC� aortha ton, W 01060 Debris 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at K 0 ( (tue s �- (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite'rented or leased from: �.p� ()LI �C k) L!ti� l C�- (Company Name an Address) i s- 0C azure Uf Pe 1 plica or Owner Date If, for any reason, thedebris 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 Departmentoflndu..ctrialAccidents I Congress Street,Suite 100 Boston,MA 01114-2017 www.massgov/dia \Corkers'Compensation Insurance Affidavit: Builders/Contractors/Eleclricians/Plumbers. TO HE FILED WITH THE PERMITTING AUTHORITY. Applicant Infmatronse Print Letzibly Name(Bminessiorganiaooe/itldividualy C-!\"At L, f-- @(^� ( opt. Address: 8 t<j ? w/lk� ,f rr let Ne G a 4 4 U..t r�o(,j City/State/zip: Ike. ©( CD a Phone a: til ? -Sar (7�s Ase you m astoeyeR clack)ro\e appor,wha a lax: 'Tw ype of project(n9aired): t. amaemploya with ICU emPloy«slfull eial/«pact-time).' 7. []NeConstruction 2. I am a sole proprietor or permenhip and have no employees working for me in 8. Wemodeling my capacity.[No workers'comp.insonce required.] 3.[][am a homeowner ming all work myself.[No workcia'cosop.insumn«sryui red.]t 9. Demolition 4.[]1 an aho.er anal will be hinngcontractors so conductall work on my property. 1 will 10 Building addition ensure that all coahw:mr curer have workers,commis non insurance or arc sole I1.[3 Electrical repairs or additions plosers.with no employees. 12.n Plumbing repairs or additions 6C]1 arae general contrmor vial shave es a the have workers'co listed an the atbchW ah«I. 13JERoof repairs Ibex subcantrctors have engloy«a ural have workers'tong.ireusance 6.❑We are a corporation and its omcer have exercised Meir right ofexerroon per MGL c. 14.❑Other 152,§I(4),and we have ins enrplayees.[No workers'comp.imurmce required.] *Any applicant that checks box#1 inner also fill not the rutins below showing Meir workers'wmpcnution policy infnmiation. I Hontenvorient who submit this affidavit indicating they arc doing all work and thin him outside contractor must submit a ocw affidavit ins iestiag ouch. lCon rmtor Mat chock this box most anached an additional shcel showing the name of the sub<ontratton and state whedor or not those,miinn have cmploy«s. If the subci ntracmn have employ«s,thry must provide Meir workers comp.policy number. 1 am on employer that Is providing workers'rompensadon insurance for my employees. Below is the policy and job site information. II Insurance Company Name: pini, kve'' -1-"`5-Uret Lice CO ccl/la� a Policy#or Self-ins.Liifc.8: Ui C 0 0 0 A S Expiration Date: I I Job Site Address: ltl V l I l`Cf`P cityrceWZip: ( I�Caaw°�t'I Attach a copy of the workers'eompe tion policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required trader MGL c. 152,§25A is a criminal violation punishable by a fine up in S 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 tray be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby a fy under penaaies ofpindiny don the Information provided above is true and eonea Signature: S Date: Phone#: l - !L2s':177r' Official use only. Do not write in this area,ro be completed by city or town official. City or Town: Permit/License g 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for thew employces. Pursuant to this statute,an employee is defined as"...every person in the service of another under my convect of him, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or my two or mom 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 mother 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 my of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of complianoe 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-contractors)minimal,address(m)and phone numbers)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 my questions regarding the law or if you arc 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 sive 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 acre to fill in the permit(license number which will be used as a reference number. In addition,an applicant that most submit multiple perrniHliceme applications in my given year,need only submit me affidavit indicating current policy information(if necessary)and under"lob 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 curb year. Where a home owner or citizen is obtaining a license or permit not related to my 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 Department's address,telephone and fsx number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmmm.gov/dia 01 i IiT , I'll. 1 fill f fi il �'J! fill i"I ­ilil,, l fit It it "It - ;. I - , ,. I)'.i, t'l .1.111 11"1 'a" ill Jifn if t, It Ic PI Ull of collIhIpwli ,it a, ....... .... p'lli,lioll 1. +a _enet2 nary o1.lo":If qvilq fill :,_ rmp Pit np Fo lii F T, ICAnn .�lj I'li Wil lit, JuLomint!ou uuq ju;o.( i.ficjjou? fie �o�zo�rocaea�i o�C��aQa¢c,<ivae� Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration I ype: Corporation 71982 CHARISTA CONSTRUCTION SERVICES,INC. Registration: 5/09 PO BOX 706138 HARKNESS AVE Expiration: 0 05/09!2020 E.LONGMEADOW.MA 01028 UPtlafe Atlemas and Rewm Cad. oinie ME IMPPROVEfai]EW Birrsma"'Ap u ion HONF INF TYPE:C= Regist virauo rtrdi.It taund Only TYPE:CoroaaGm befere Incfie onsim er tlafe. q found mwrn fn: Rv171982an F�Imm One Aof Consumer Affairs and Business ge9ulafion 1]1982 O6ro9I2020 One Ashburton Race-SORe 1301 CHARISTA CONSTRUCTION SERVICES.INC. Bosmn.MA 02106 JOSEPH KENNEDY BOX ' r PO ]06/38DARKNESS AVE r E.LONGMEADOW,MA 01026 Undersecretary pt Val Ith Deture Commonwealth of Massachusetts. Division of P,.Ief Sional LKensnre Board of Building Regulations and Standards ConstrAWion Supervisor CS-055440 Expires: 07/22/2020 JOSEPH ANENNEDY 18 FOREST ST POBOX 1]68 - BON0.5VILLE MA 0100p �2�> Commissioner �/"— fi. ACOROY CERTIFICATE OF LIABILITY INSURANCE MTE'.�dY,YY, anenolR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND,E"END OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHOWED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT. N the cerSlicale holder H an ADDITIONAL INSURED,UN policylieai must have ADDITIONAL INSURED provisions or be endorsed. N SUBROGATION IS WANED,subject to the terms and conditions of the polity,certain policies may require an endoreemant A atslement on this certificate does not confer rights to Me cenificab holder In lieu of such endomement(s). PRODUCER HAMF T MaMn Lente5 Befthire Insurance Group.Im PHONE (113)935.1200 uc (413)557d.00 138 Ldlg.06DA St A. Ebs: mienws1PwmsnIRi11 umR mUp.Cd11 INYWERISIAFFOROWGCOVBUOE rUk• LonymeadoN MA 01105 snake, Sar bsumnce COmpanY IN23 ucunLO W WRERB: Cuuma ConsWCNSO SNMCRL In.. WSWERC: 38 Harmess ANenue mMrRmo INSURER E: East Longmeadow MA 01028 IN.RERI COVERAGES CERTIFJCATENUMBER: CL1882851112 REVISION NUMBER: THIS IS TO CERFIFY 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. E%CLUSIONSNID CONDMONS OF SUCH POUCIES.LIMITS SHOWN MY HAVE BEEN REDUCED BY MID CLAIMS. LTR W EMNSVMXCE No neuWDDA,YIUsers COY HTNaALGENEMLLMYUW M�L .'T RRENCE s CWNSM.tCe �OCda1 a ax {ADV-URY {GELATE {CCMPOPMp {sAVIONOaNEL4ilry L IlYli iANYAUT3 RYIPN.I {I,OSONLY AVn]$ �O RYNMIoM. II i VTO"RedSONI AVTD$0NLY E 5 s UMBRFLAL1Fa � EAGHOCCURRNICE S u.mag"UAB CWMBIMGE ASCREAATE s CEO I I RETENTION S s MAN.CONPEN.0A OTH AND cmRmTRS'LuMUTY 1.rN A ER Y PRO%aETOIIINMERIFXEUIINE 1,DDD.DDD A OFRCEANEMBON ExcLUCEm NIA WC0002537 OBmYN16 OBmBR018 EL FALX McxNRi S mF^aFM'III XMI EL dsFASE.FAEMFLOYEE S 1'OND00 nya aMw ua.. 1,000,000 CfSCRIPINMGFfPEAATRML4EXtw' ELd8FA4E-PoLICYUYIi S G6CNPIYN CP Ce[IIAlId15/LOCAlId15lY94C1E$IACOIIOIm.AGYabN Pmlulb StlygN,mq bYb[MemWRpEbIXnMWa5) CERTIFICATE HOLDER CANCELLATION SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Cluu.a COnffiKIbr Baru..m0. ACCORDANCE WITH THE POLICY PROVISIONS. AUINNIITFO REPRE4ENTmvE O 19884076 ACORD CORPORATION. All lights ne eTved. ACORD 25(2016103) The ACORD name and logo a re registered marks of ACORD _-In F---_ CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMIATIVELY OR NEGATIVELY AMEND.EMIND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES SELOVI. THIS CERTIFICATE OF INSURANCE WES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. If the holder is on ADDITIONAL INSURED,Ott,polky0r,l)noret In.ADDITIONAL INSURED pmerislan,or M andeareapd. It SUBROGATION IS WAIVED.ruableat to tY.loners and andMom aftlem policy,"Min polithe rhur,nequirs an ndonnumant A .1 Has carfifficale does not eande,nighile to Bear cordiflesto holder In lieu of such ondlarainnit"s) PRODUCER 1-hreeen L Leahy Leahy&Bronne Insucance+Reafty,Inc, I—E eao� (413)708 8393 Bux (413)n�U 535 Man Steen,Saft I ro.OrMWhyan�.� s"'glew FAA 0111&201311 ATLANTIC CASUALTY 21M ARSEULA�PROTECTION Charot.con.ouction S. �o; --- ---- -- 38 Han,res�A.. East Longenentov MIA COVERAGES CERTIFICATE NUMBER: REVISION NUMBER, THIS IS TO CGffTFYTMTTHE POLICIES OF INSURAOIDE LIE'ED SEILOINHAVE BEEN 15SUEDTOTHE INSURED NAMED ABOW FOR THE POLICY PERIOD NM�TED. �STMMNGAWWOUIREMEW.WM�C�MMOFAWM�CTORO��EW��CTTOMICHMS CERTIFICATE MY ME ISSUED OR MY PERTAIN.THE INSURAHICE AFFOROG)BYTHE POLICIES DESCRIKD HEREIN IS SUBAECT TO ALL THE TERMS. �M���C�MNSOFS�POUCIES.UMIn�OMWY��WM��EDVKD�IMS Fc,Lc element LiJuBaLrYI OA�m 0 OCCUR to.= A m1O(D3(0 04AM12019 04001,21GO 1.000m s 711100,001) El r, 0 LOC I Z00BO0(p Employee Gainers I ANYAU"o 250,1100 B (Aarffl) AUTOS =20 EE.ppf; HIRED AuffOSOHLY AlIKSONLY, "c"B"A'aa 'B`Bf`� t'it-414181C Is 11.000 a H AGGREGAW s afTeurces YIN E.LWIA41R!.� a Oc�,KaGueee CERnFVA' TE HOLDER CANCELLATION SHCULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANC1J.I-ED BEFORE THE IDIFIRATION MTE THEIREOFF,NOTICE MI BE DEURIEMD IN AC�NCE���CYPRMSIOW. I @1988-201SACORDCORPORAMM ANBgIft,,,,W,, ACORD26(2016103) The ACORD nam and logo 0.191.1amed Marks of ACIRD