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24D-225 (2) 244 PROSPECT ST BP-2020-0301 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24D-225 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND PERMIT (MGL c.142A) Category: ROOF BUILDING 1 E RM I T Permit# BP-2020-0301 Project# JS-2020-000507 Est.Cost: $16600.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RCI ROOFING 074334 Lot Size(sa.ft.): 8407.08 Owner: PAYNTER ROBERT W& Zoning: URB(100)/ Applicant: RCI ROOFING AT: 244 PROSPECT ST Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:9/6/2019 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: 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 9/6/2019 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner CC. City p E C E� ' Department use only Cit Of North m t vvV a s of ermit: i :• Building Dep rtm nt Cur Cut/ riveway Permit i 212 Main tree SEP Se er/Se tic Availability ROOm 00 ��"r Wa r/W I Availability Northampton, A 1060 Tw Sets f Structural Plans phone 413-587-1240 ax t;i PF.. tSite lans --- r )RTHAMrTorv.rnA ©therSp cify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 8 P' a� 30 1.1 Property Address: This section to be completedbyoffice a yy pia c-� s+. Map Lot C Unit \IQ 30 h t M A Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: V)c, e (+ P&14 n+P-r `�`I Pf-��o�c� S-i �!f,r-t hr�r�,o-�a Names(Print) Current Mailing Addr ss: T `)CSP d�4arhA Telephone 5?1, — 6I�7 P Signature 2.2 Authorized Acient: C to Li134- , Sr)u±kcrn r1n M A 0109-s Name(Print) Current Mailing Address: �yi2,> 5Q-7 - y�� 5 Signature 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 �btr��n 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) (; Check Number This Section For Official Use Only Building Permit Number: DateIssued: Signature: 2&A 9 Building Commissioner/Inspector of Buildings Date S-H)ornpSoh @ rc,I roo+6-)q .corn EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [❑ Siding [❑] Other[01 Brief Work:Description of Proposed S 2 e Q.4a ched Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If Newhouse and or-addition to existinq 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 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 P�CI f 1lY}t l i 1G to act on my behalf, in all matters relative to wo authorized by this building permit application. ` P ailorbod Oq-ou -a(M Signature of Owner Date I, Mo_rK n0jiS I2 — (j,S 0 Lt4J7Dr 1 ZeC .l ter,+ as Owner/Authorized Agent hereby declare that the statements and information on the foa oing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Nam / C)q 19 Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: (Ar K (JP_1 151e. C S (0`7 V1 l License Number r► E OIQ 05 - 03- aQ Q 0 Address � Expiration Date Lq1, ) 5a7-L4 Signature Telephone 9. Registered HomeImprovement Contractor: Not Applicable ❑ 1, C-1 LLP /a to a 3,5 Company Name Registration Number Lp Line a� amrA o MA C)10`13 0S - 05 - a6a0 Address 7 Expiration Date Telephone 413-,Sa?7-Y?95 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....... ls� No...... ❑ RC-1. RDate 6Line St. Estimate Southampton,Ma. 01073 8/14/2019 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location Robert Paynter' 244 Prospect St Northampton, MA 01060 Terms Rep Estimate valid for 30 days Chris Description Total Remove existing roofs. 16,600.00 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 and 3 feet in valleys. 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. Add$2000 per venting skylight for replacement *price does not include any interior work on skylights WE LOOK FORWARD TO DOING BUSINESS WITH YOU, Total $16,600.00 TERMS OF PAYMENT 5%Deposit Customer Signature: �GW v Balance upon completion Registration# 126235 Construction License#074334 Date; a Insured by Banas&Fickert Ins. (413)527-2700 Shingle Color Selection: c G11S1 C\C'J t d a VL U •i C. V 0 CIQ r tuto00f City of Northampton Massachusettsw?S,$ = J-1 ! DEPARTMENT OF BUILDING INSPECTIONS ?S 212 Main Street • Municipal Building v�4, Northampton, 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("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 homeowner has contracted with a corporation or LLC, that entity must be registered. Type of Work: �j 041 n Q Est. Cost: 1( to 0o Address of Work: l.( ea)soe C4 64 . NOCA ra N'-Qj:m Date of Permit Application: 09 -Off— aQ dol 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: C , T. L LP / 60/35 Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: (S e e O Aa&,ed Date Owner Name and Signature City of Northampton Massachusetts ti����� x_:•.J��'t� w+ S � 1 DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Fluilding Northampton, MA 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 properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: ag g PCc�,nec+ (Please print ho se number and street name) Is to be disposed of at: Wts+prn 6erudinn Tans-fir- F,-Ti h (Please prin ame a d location of facility) Or will be disposed of in a dumpster onsite rented or leased from: USM t exldlrlU Gnd koccdin4 (Company Na0e and Address) Signature of Permit Applicant or Owner 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 oflndustrialAccidents 1 Congress Street, Suite 100 c` Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/(,ontractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):_ LC' .I (rAnq LLP Address: D 1 S+roe+ City/State/Zip: Q:J�n, e)1091 Phone#: 5D]- 0,5 Are you an employer?Check the appropriate box: Type of project(required): 1.Bd1 am a employer with 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 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.71 am a homeowner doing all work myself.[No workers'comp,insurance required.]t 10E] Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. 2�_oof repairs These sub-contractors have employees and have workers'comp.insurance.t 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#1 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors 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:_f-1 T. /}�_ffl 4k j L'wn_S u al-n 0 Policy#or Self-ins.Lic.#: y W C 1 n 0(n n a a to V'7a 6 d A _ Expiration Date: 10- 0 5 - 4 0 19 Job Site Address: : qq P(nSOPC+ S+ City/State/Zip: N,,(+k krnih MA 61W,0 Attach a copy of the workers' coAipensation policy declaration page(showing the policy number and kpirailon 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains d penalties of perjury that the information provided above is true and correct. Si nature• l Date: Oq -CN - :gym Phone#• ���1 �a7' L129 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SCA 1 20MM-05/1Q7� V/LB (Q097N7td/tW6000C/G r„���JtZCJLICJPrt� Office of Consumer Affalyd&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Partnership Realstrall6n, Expiration 1 ::>_ 05/05/2020 RCI ROOFING, 1 ' Commonwealth of Massachusetll .. Division of Professional Licensure MARK T.DELISI 6 LINE ST tit '4yM1. �� Board of Building Re ulatlons and Slandards SOUTHAMPTON,M�'Q1073' Undersecretary Cons�rt+,Ctir�l�{Ijrvisor _. CS •074334 ; x Tres; 05/03/2020 Registration valid for individual use only � � A, , before the expiration date, If found return to: MARK THOMAS D �.,•� _ Y / Office of Consumer Affairs and Business Regulation 69 BRIGGS ST EEY 1000 Washington Street•Suite 710 Boston,MA 02118 EASTHAMPTO ►A',,.01d: ,•. �-� Commissioner CZ Not valid without signature , e fi<1GOIV9M:ON WEA LTH.p e F MAS SAC HOME IMPR,qVN fONTRACTOR HU SE:T.TS. tR P IN SHEET IVlEs1AL:W. ��" t:< IS.S 's gs 1MfV:0�;�f� �� <'a. f :4 SOT1J,lb 01073 <"< �`<•$N( S R•U:IV , Re istradon't#""" - ffecti ki Y ,•- Expiration A x?eY RfGf3.S,STa ,., HIC.0624741. .. c - A THA 'a�. 1 ' .; . �C�U/ Q•11$ >` 11/30/2019 w�ss QktOt � ��.0..0: i SIGNED � .. •€ •.y.�};>• .}., .� s<« � t<. _ 132 t 3 W. g. a>>f'b! /28'/2020 yes 466498 { _cif --- 'rot• "'" ` 1-!1' nu'ot�5in 'R1RN'i ,, 1Nvp+`,K..i 'Y, , :. `ON1fVI0N11VEL 'H .O'F;<Nt':' ZYif , R W.s?f3'3':erq �::, :.z 1.16M. 18 SUE'S hiRQLIOWI.1G',f .�1 s$I"•"�a; } �,. a c `x'3.3^`'€;''•�.: , � ���:��y:a utt• ,!•,�'�;_.�' •i A"•,r`,,>• S` }ifs > �E '"E F$> 3, as 4ia,•sr„.. f=ffb9109/2'019 34422364 3 ” s.e. l,.,t...: ... n , :r. :, .-�..a v>',R•?r:•}�e�lt4'MM ,�., r ' , 1 , M q�Rte® CERTIFICATE OF LIABILITY INSURANCE F_DATE(MM/DD/(YYY) 03/19/19 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(ies)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 UUNTACT NAME: Michael R.BanaS Banas&Fickert acNN EXt, 413-527-2700 tAAiC No): 413-527-0849 Insurance Agency ADDRESS:63 Main Street ESS: mb@banasinsurance.com Easthampton,MA 01027 INSURER(S)AFFORDING COVERAGE NAIC r INSURERA: Admiral Insurance Co. 24856 INSURED INSURER B: Safety Insurance Co. 39454 RCI Roofing,LLP INSURER C: 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 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. POLICY F POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE Fx_]OCCUR PREMISES Ea occurrence $ 50,000 MED EXP IAny oneperson) $ 5,000 A X CA000020963-05 03/04/19 03/04/20 PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMITAPPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B OWNED X SCHEDULED X 6207761 09/30/18 09/30/19 BODILY INJURY(Per accident $ AUTOS ONLY AUTOS ) X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 C EXCESS LIAR CLAIMS-MADE X GX000000385-03 03/04/19 03/04/20 AGGREGATE $ 5,000,000 DED I X I RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVENIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ROOFING CONTRACTOR. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Agsk ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REP S IIVE 15 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ,d►coRo® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDlYYYY) �.� 03/19/2019 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(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 NAME: Michael BanaS BANAS & FICKERT INSURANCE AGENCY PHONE Exry. (413)527-2700 fA No, E-MAIL ADDRESS: al@banasinsurance.com 63 MAIN ST INSURERS AFFORDING COVERAGE NAIC• EASTHAMPTON MA 01027 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: RCI ROOFING LLP INSURER C: INSURER D: _ 6 LINE STREET INSURER E: SOUTHAMPTON MA 01073 INSURER F: COVERAGES CERTIFICATE NUMBER: 379588 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 ADDL SUER POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD MM/DD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ TED CLAIMS-MADE ElPRREMIEMI OCCUR —ffT RENSES Ea occurrence) S MED EXP(Any one emon $ N/A PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY D JECP'0.T F—]LOC PRODUCTS-COMPlOP AGG $ OTHER: I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY Per accident $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION X STATUTE ETH- AND EMPLOYERS'LIABILITY YIN ­ ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 1,000,000 A OFFICER/MEMBEREXCLUDED? NIA N/A WA VWC10060226472018A 10/05/2018 10/05/2019 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEEI$ 1,000,000 If as,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may b•attached If more spat.Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.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 insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate 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.govAwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Reference Copy ACCORDANCE WITH THE POLICY PROVISIONS. Reference Copy AUTHORIZED REPRESENTATIVE 1 r` r Reference Copy �'" Daniel M.C14y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD