Loading...
24C-104 (2) 99 MASSASOIT ST BP-2020-1114 GIS#: COMMONWEALTH OF MASSACHUSETTS Mg.-Block:24C- 104 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2020-1114 Project# JS-2020-001868 Est.Cost: $77300.00 Fee:$500.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: THOMAS DADMUN 107919 Lot Size(sq.ft.): 8668.44 Owner: KNIGHT DEIRDRE Zoning: URB(100)/ Applicant: THOMAS DADMUN AT. 99 MASSASOIT ST Applicant Address: Phone: Insurance: 60 SCHOOL ST (413) 387-7381 HATFIELDMA01038 ISSUED ON.511-212020 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENO 2 BATHS, RE ROOF, INTERIOR RENO 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 5/12/2020 0:00:00 $500.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability .(p Room 100 Waterf Well Availability t 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, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: 9T9�� Me���- `7 Lot C)Cl Unit � to►O 000 �p b� 2 '� Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone / tt Signature 2.2 Authorized Agent: IE�o�tl �tbu -� ( o t4A 01036 Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 5 I Q ov (a) Building Permit Fee 2. Electrical b IZ D (b) Estimated Total Cost of Construction from 6 3. Plumbing I Doc) Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = 0 +2+3 +4 +5) `�� �Jd� , Check Number / 417 Q/J This Section For Official Use Only Building Permit Number: f7Dat ed: Signature: VV �J 0 Building Commissioner/Inspector of Buildings Date f 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 [0] Decks [Q Siding [t]] Other[O] Brief Description of Proposed Work: _F—twbi"u Twc DATA5 440& wpool Top* Wlglix , -pvoiloc' i I&AO&P w Tty-LoR- 0,4jVA-nc-0s Alteration of existing bedroom Yes No Adding new bedroom Yes k No Attached Narrative Renovating unfinished basement Yes _ C No Plans Attached Roll -Sheet 6a. If New house and or addition to existing 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, yF✓1Wk J02 IS V,)t(sb�'i as Owner of the subject property hereby authorize1�;D VfiV" to act on my behalf, in all/matters relative to work authorized by this building per it application. Signature of O er Date Einlni I TL wt It; L , �lkDVAJ0 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. .T0-VAS Print Name , L"_ (I i N1 2-02-o Signature of Owner/Agent Date T SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder: k-, G5 161M. License Number Address C t Expiration Date 415-W-7361 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Companv Name Registration Number (o SG[AODL Sr. b 12 71),,2, Address n" Expiration Date � 1 t r M 1` C J� Telephone 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....... lq No...... ❑ City of Northampton Massachusetts S DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 'r"""••^ �*.:`� 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 la corporation or LLC, that entity must be registered Type of Work: VItl'v l"_owk �nMOrc,I,S 9 FE-Ko-H,- ( Est. Cost: Address of Work: Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 _Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street *Municipal Building �y �~ Northampton, MA 01060 s�bry' i Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name andAddress) Signature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards C o n str-Udt6n'��'$UP4P ry I sOf CS-107919 Expires:09j2412021 THOMAS DAPMUN 60 SCHOOL S7 HATFIELD MA//01038 ? commissioner (,:T) IM fom4xlol dGLN'CW4 a"Ildie Office of Consumer ,affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC 4 Registration: 179682 THE TUCKER GROUP LLC, e9 80 SCHOOL ST Expiration: 08i27l2020 HATFIELD,MA 01038 �.. ` Update Address and Return Card. :CA 1 0 2OM-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 173682 08,127!2020 1000 Washington Street-Suite 710 THE TUCKER GROUP LLC, Boston,MA 02118 THOMAS DADMUI3y/ 60 SCHOOL 8T HATFIELD,MA 01038 `Undersecretary Not valid without Signature R sig CERTIFICATE OF LIABILITY INSURANCE DATE /10/2020 Y) .�1tCC3l2C�► 02/10/2020 THIS CERTIFICATE IS ISSUED ASA 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 NAME: ' Susan Fleury CIC CISR CPIA King&Cushman Inc. PHONE (413)584-5610 (413)584-9322 C n xt: IAC,No P.O.Box 447 ADDRESS: sfleury@kingcushman.com 176 King Street INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01061 INSURERA: Main Street America Assurance Co. 29939 INSURED _ INSURER 8: DADMUN DESIGN&CONSTRUCTION INSURER C: 60 SCHOOL ST INSURER D: INSURER E: HATFIELD MA 01038-9747 INSURERF: COVERAGES CERTIFICATE NUMBER: CL2021003592 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. ADM SUBIR POLICY EFF LTR TYPE OF INSURANCE LNSD WV`D POLICY NUMBER MWDDIYYYY MM10DlYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR PREMISES Ea occurrence $ 500,000 � MED EXP(Any one person) $ 10,000 A MPT4694Q 11/13/2019 11/13/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGRCGATELIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY []jC F-1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: FITRV $ 5,000 AUTOMOBILE LIABILITY COMBINEDSINGLE-LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED -� AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Iyer as dant $ UMBRELLA LIA13 OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION S $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY YIN STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E,I.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE p .I , ..J.......... _...) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Wovkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. 10 BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information "�� Please Print Leeibly Name (Business/Organization/Individual): litt `h cWu &to,)p kj�,(, Address: (O(& ��.L_ St. City/State/Zip: l tX tl A oit)bb Phone#: 413-,59,7­ 701 Are you an employer?Check the appropriate box: Type of project(required): 1.[D I 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 N. Remodeling any capacity.[No workers'comp.insurance required.] 1). El Demolition 3.E]I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 0 Building addition 4.E]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 I I.0 Electrical repairs or additions proprietors with no employees. 12.FJ Plumbing repairs or additions 5.p I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[:]Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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. :Contractors 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: y� IvS. �o1M1'A�11t✓ii I Policy#or Self-ins.Lic.#: P Qj -�!��� �� -1-'7,o Expiration Date: Job Site Address: 11 w1 k-�5*%(T Sl, City/State/Zip: o loG o Attach a copy of the workers'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 cert' under the pains and penalties of perjury that the information provided`above is true and correct. Si ature: Date: 51 k Phone M 15" w - 1 m,1 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#: NOTICE N W NOTICE TO TO a EMPLOYEESW EMPLOYEES Oq M Sv� The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA02111 (617) 727-4900 — www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P .O. BOX 4614 BUFFALO, NY 14240-4614 ADDRESS OF INSURANCE COMPANY (7PJUB-4N82783-2-20) 02-26-20 TO 02-26-21 POLICY NUMBER EFFECTIVE DATES KING & CUSHMAN INC P 0 BOX 447 176 KING ST NORTHAMPTON MA 01060 NAME OF INSURANCE AGENT ADDRESS PHONE # 0 TUCKER GROUP LLC, THE DBA 60 SCHOOL ST DADMUN DESIGN AND CONSTRUCTION HATFIELD MA 01038 EMPLOYER ADDRESS N EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services u.._ provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 001595 W20PIGIS TO BE POSTED BY EMPLOYER DADMUN Design + Construction Prosect Address: SubContractor List 99 Massasoit St. 4-May-20 Northampton, MA 01060 Subcontractor: Has Employees: Yes No Wallace Plumbing and Heating X James Elkins Electrician X Northern Granite X Executive Painting X Dion and Sons Flooring X Cortina Tile X Dubay Bros Roofing X CERTIFICATE OF LIABILITY INSURANCE DATE 03/18/2020YYY) 03/18/2020 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 CONTACT NAME: ENCHARTER INSURANCE LLC AICNNo,Ext: 888 661-3938 A C,No): 877 872-7604 25 UNIVERSITY DR E-MAIL AMHERST, MA 01002 ADDRESS:sOrvice.center@travelers.com (888)661-3938 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:TRAVELERS CASUALTY INSURANCE COMPANY OF AMERICA INSURED INSURER B: JASON WALLACE INSURER C 312 MAIN RD GILL, MA 01354 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 736757415141870 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A 680-3E561935-20 02/27/2020 02/27/2021 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY 75TWAGE TO RENTED CLAIMS-MADEoccurrence,)OCCUR PREMISES Ea $300,000 MED EXP(Any oneperson) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 )( POLICY ❑PRO ❑LOC PRODUCTS-COMP/OP AGG $2,000,000 JECT OTHER: $ BA-9N338515-20 01/22/2020 01/22/2021 COMBINED SINGLE LIMIT $1,000,000 A AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) $100,000 OWNED �( AUTOS AUTOS ONLY BODILY INJURY(Per accident) $300,000 HIRED NON-OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE (Per accident) $250,000 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION N/A STATUTE ERH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICERIMEMBER 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) CERTIFICATE HOLDER CANCELLATION DADMUN DESIGN AND CONSTRUCTION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 60 SCHOOL STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HATFIELD, MA 01038 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 0 ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD A ^�it DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 05104;2020 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.sub)ect 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 Lynn Barry NAME: Goss&McLain Insurance Agency PHONE (413)534-7355 FAX (413)536-9286 -6-AIL IC No A/C No); 1767 Northampton Street No. ADORES 5: INSURER(S)AFFORDING COVERAGE NAIC p Holyoke MA 01041-1128 INSURER A: 9 National Grange Mutual 29939 y INSURED INSURER B! Workers Compensation Insurance 0050 Prestige Granite Inc,DBA:Northern Granite LLC INSURER C: 380 Union Street INSURER 0: INSURER E: West Springfield MA 01089 INSURER F COVERAGES CERTIFICATE NUMBER: CL205406002 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 ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, TYPE OF INSURANCE POLI EFF POLICY EXP LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE ©OCCUR PREMISES Ea occurrence) S 500,000 MED EXP(Any one person) S 10,000 A %'P15382Z 04.'01/2020 04/01/2021 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2'000'000 JECT F7 LOC PRODUCTS-COMP/OP AGG S 2,000,000 POLICY 71 OTHER: $ AUTOMOBILE LIABILITY MBINED SINGLE LIMIT (EaCOalxident S ANYAUTO BODILY INJURY(Per person) S 1,000,000 A OWNED IX SCHEDULED M1T2939W 04/01/2020 04/01/2021 BODILYINJURY(Peraccident) S AUTOS ONLY AUTOS X HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident Underinsured motorist $ a.-,,,. 00,000 X UMBRELLA LIAB ,OCCUR EACH OCCURRENCE $ 1,0 A EXCESS LIAR CUT2939W 04/01/2020 04/01/2021 _ �/ CLAIMS-MADE AGGREGATE S DtD X RETENTIONS 10,000 S WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE ERH Y!N 500,000 B ANY PROPRIETOR'PARTNEWEXECUTIVE � N/A AWC-400.7033443-2019 10/26/2019 10/26/2020 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space,s required) granite installation. Officer of Corp.,Slava Katko.is excluded from workers comp coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Thomas Dadmun ACCORDANCE WITH THE POLICY PROVISIONS. 60 School Street AUTHORIZED REPRESENTATIVE Hatfield MA ��D J 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD l ® 72/12/2020 (MM/DD/YYYY) ACOR" CERTIFICATE OF LIABILITY INSURANCE . llk �' 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 NAME: Andrea Hills IA HOE The Jarrett Agency (PA/CN,No Ext: 8607454222 (A/.C,No): 657 Enfield Street ADDRESS: andreah@koveragegroup.com INSURER(S)AFFORDING COVERAGE NAIC# Enfield CT 06082 INSURER A: UTICA FIRST INS CO 15326 INSURED INSURER B: Executive Painting&Wall Covering LLC INSURER C: 10 SOUTH RD INSURER D: INSURER E ENFIELD CT 06082 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 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. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A ART5139982-00 02/13/2020 02/13/2021 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JE� F—]LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Tenants Liability $ 50,000 AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED $ AUTOS ONLY H AUTOS ONLY (Per accident) UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ LJEXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ ORKERS COMPENSATION STATUTE I ER ND EMPLOYERS'LIABILITY Y/N %NY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ FFICER/MEMBER EXCLUDED? N/A (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 I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Holder as noted is additional insured with written agreement not to exceed the limits,terns or conditions of any policy noted herein. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Dadtnun Design&Construction ACCORDANCE WITH THE POLICY PROVISIONS. 60 School Street AUTHORIZED REPRESENTATIVE Hatfield MA 0 103 8 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AC"R"® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE F10/31/2019 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 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 CONTACT Barbara Grynkiewicz NAME: Webber&Grinnell PHONE (413586-0111 FAX (413)586-6481 AIC.No Ext): ) A/C,No): 8 North King Street ADDRESS: bgrynkiewicz@webberandgrinnell.com INSURER(S)AFFORDING COVERAGE NAIC p Northampton MA 01060 INSURERA: Patrons Mutual Ins.Co.of CT 149235 INSURED INSURER 8: State Auto Property&Casualty Ins.Co. 25127 A.Dion&Son Floor Contractors,LLC INSURER C: Attn:Donald&Daren Dion INSURER D: P.O.BOX 656 INSURER E: Hadley MA 01035 INSURER F COVERAGES CERTIFICATE NUMBER: Exp 7/1/20 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 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. ILICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDY EFF MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTE17-_7 CLAIMS-MADE FX1 OCCUR PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 5,000 A BOP2806463 07/01/2019 07/01/2020 PERSONAL BADV INJURY $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY � PRO ❑ LOC PRODUCTS-COMP/OPAGG $ 4,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANYAUTO BODILY INJURY(Per person) $ A OWNED rx SCHEDULED BAP2406132 07/01/2019 07/01/2020 BODILYINJURY(Peraccident) $ AUTOS ONLY AUTOS XHIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident X 19 PIP-Basic $ 8,000 X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAR HCLAIMS-MADE CXS2125771 07/01/2019 07/01/2020 AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATIONPER AND EMPLOYERS'LIABILITY X STATUTE ER YIN 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ B OFFICER/MEMBERExCLUDED? NIA WCP2227689 07/01/2019 07/01/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I 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 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Dadmun Design&Construction ACCORDANCE WITH THE POLICY PROVISIONS. 60 School Street AUTHORIZED REPRESENTATIVE 1r,1 Hatfield MA 01038 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD CORTTI L-01 LJ U KI C ACRO" DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/06/2020 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(les)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 CONTACT Mary Henderson People's United Insurance Agency,Inc. PHONE 413 735-6545 835 FAx One Monarch Place,10th Fir (A/C,No,Ext):( ) (A/C,No):(844)645-1330 Springfield,MA 01144 AD RIEss:Mary.Henderson@peoples.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Merchants Mutual Insurance Co 23329 INSURED INSURER B: Cortina Tile of West Springfield INSURER C: 1645 Riverdale Street INSURER D: West Springfield,MA 01089 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 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 NUMBER POLICY EFF POLICY EXP LIMITS LTR INSID WVD MMIDD/YYYY MMIDD/YYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR BOP1071849 03/30/2020 03/30/2021 DAMAGE TO RENTED 50p000 P EMI E Ea occurrence $ MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY F]jp&- F] LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY BODILY INJURY Per accident $ AUTOS ONLY ATOS ONLY PROPERTY DAMAGE Per accident $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE CUP9146566 03/30/2020 03/30/2021 AGGREGATE $ 1'000,000 DEC X I RETENTION$ 10,000 $ A WORKERS COMPENSATION X IPER OTH- AND EMPLOYERS'LIABILITY YSTAT T ER 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ CA1033448 03/30/2020 03/30/2021 E.L.EACH ACCIDENT $ OFFICER/MEm MBER EXCLUDED? N N/A 500,000 (Mandatory NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Proof of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DADMUN Design+Construction THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Tom Dadmun 60 School Street Hatfield,MA 01038 AUTHORIZED REPRESENTATIVE r*►ey, 7itG. ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DUBABRO-01 JCHOINIEF CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) __.�. 712fi12019 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 HOES 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 SUBRQGATION 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 I CONTACT' _...._ NATAL- UICClure Insurance Agency,Inc. PHONE FAX 103 Van Deene Ave, (Are,NQ,EXtI.(413)781-8711 _ N ):(413)739-8548 _ .._ Nest Springfield,MA 01089 1-MAIL W�., D INSURERLS�AFFORDINGCOVERAGE�. INSURER,A;Penn-America.... _lnsurance Company32859 lTISUREA INSURER B- Dubay l3rothers Roofing Inc. iNsu; c;. 35 Edendale Street INSllftER D- Springfield,MA 01104 _.._._._....�_ ___._.._....__. INSURER E- INSURER F: iCOVEl2AGES CI;F2TiFICATE NUMI3l=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 REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIE DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PCLAIMS. ILSR ADDLSUBR POLlp EFF FOLIC EXP i __.... .,___LIMITS TYPEOF INSURANCE IVSD I WVA POLICY NUMBER ,A X COVMERCIAL GENERAL LIA8ILITY j FIiCH OCCURREtVC£ g 1,000,0 DAMAGE TO RENTS CLAIMS-3s E X OCCUR PAC7189725 712212fl39 7122/2fl20 �b 100,0 MED,EXP(Any one person) $ 5,0 ____. _,_ __�_ _ PER50NAL8ADVINJURY 'I,IIIlfl,fl GF.N'L AGGRFCATF LIMIT APPL;IFS 1`0-1 GFNFRAL AGGREGATE_,....._. § ..., 2,000,0 x POLICY[ '��l P t 2 000,0 LOC J i PRQDt1CTS CC?MPIOPAGG OTHER: COMBINED SINGLE LIMIT AUTOMCII3ILE LIABILITY (Ea�W_6dent ANY AUTO i BODtLY_INJPRY(PerA OWNED SCHEDULED i AUTOS ONLY AUTOS jj' {I30DIlY aNJURY Per aaidenYj_S,_..� .,, i HOT D NON-OWfJEp ( j PROPERTY DAMAGE S ... AUTOS ONL`f AUTCIS ONLY i 1 S UMBRELLA LIAR OCCUR EACH OCCURRENCE __�$ EXCESS LIAB CLAIMS-MADEAGGREGATE. I S _.._�..... _.__ DED R1 IENTIONS t $ WORKER$COMPENSATION PER OTH- AND EMPLOYERS'LIA13ILFTY Y 1 N T STATr ........... ..__..._.. ANY PROPRIETORIPARTNERIEXECU T IVE I—`1 F.L FALH ACCIDENT $ FFICERIMF,MSFR EXCLUDED? I_ N I A1. andato m NH ---- M ry l E.L_DISEASE�-FA EM?LO 5 II° ,deacrdle timer __.. DESCRIPTION OF OPERATIONS beJoy+ EL_DISEASE-POLICYIL MITI S ' I DESCRIPTION OF OPERATIONS I LOCATIONS 1 VFtitCL£S (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) !RE.375 Holyoke Street,Ludlow,INA _................. CERTIFICATE HOLDER CANCELLATION, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORI THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED It ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE _ ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserv4 -r"- A rn Ort-.........-4 1--- ......�.......4...-.... .........t.._ ..S Al nl1T�T1