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17A-156 (6) 69 FOX FARMS RD BP-2021-0071 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A- 156 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2021-0071 Proiect# JS-2021-000109 Est.Cost:$4000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RCI ROOFING 074334 Lot Size(sg.ft.): 19819.80 Owner: ROWE PETER N Zoning: URA(I00)/ Applicant. RCI ROOFING AT. 69 FOX FARMS RD Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON.712112020 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE GARAGE 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 Sianature: FeeType: Date Paid: Amount: Building 7/21/2020 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1'272 Louis Hasbrouck—Building Commissioner n a r— �� City of NorthamptonWe Building Department CUrti�Ct Dnvaway, rem# 212 Main Street Swerl �tic � �►i- , ! � TF tY Room 100A�tt�ll � fa� �` - . tT nt4 Setpfk trusSm Northampton, MA 01060 hone 413-587-1240 Fax 413-587-1272 F1 �� 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: I Map Lot /b� Unit Cog Foy,Foy, Farms IZd Cg are l�r ` .Zone T_ .T_Overlay District __. F 16'tw cs1 MA — Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: (0 q Fox FA.r m s (Zcl FI o(ev►cQ Me — Pe-"rP( nQwZ Current Mailing Address: Name(Print) �r, L - 5 p Q--1a c h o d Telepho e Signature 2.2 Authorized Agent: Current Mailing Address: Name(Print) G. Telephone Signature SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com leted by permit applicant 1. Building (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) Check Number This Section For Official Use Only Date BuildinfPe mit Numb r: Issued: 721-ZOM Signature: --- Building Commissioner/Inspector of Buildings Date S-R)on-'Ne Son @ rc, .Coo" 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 0 Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [0 Siding [❑] Other[01 Brief Description of Proposed S Qn C�1 [1 Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes _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, Pe+e C � as Owner of the subject property hereby authorize P,�� I to act on my behalf,in all matters relative to wo authorized by this building permit application. Sep 2 4ae bod 7 1 col aC Signature of Owner Date I, M CtrK no 1iJ 12 CJ! /2tT f- , 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. Print Nam bo Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ ` Name of License Holder: lira` i�p I IS IP CS — 00,7 �3q License Number 3a Cilo ► v d5 - 03- -0a Expiration Date Address Signature Telephone 9. Registered Home'lmprovement'Contractor: Not Applicable ❑ �z LL (.0 a,3,5 Company Name Registration Number LI ne 5+ %� - 05 - Q6Q0 U t U'O�3 Expi�ratl�on Date Address 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....... l No...... ❑ RC-1. Roofing Date 6 Line St. Estimate Southampton,Ma.01073 7/1/2020 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location Peter Rowe 69 Fox Farms Rd. Florence, Ma. 01062 Terms Rep Estimate valid for 30 days Angel Description Total Remove existing garage roof. 4,000.00 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 skylight-vented with framing *Add$1500 per skylight-no framing WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $4,000.00 TERMS OF PAYMENT 5%Deposit Customer Signature: Balance upon completion Registration# 126235 Construction License#074334 Date: Insured by Banas&Fickert Ins. Shingle Color Selection: (413)527-2700 a ,. City of Northampton �, itis >rir Massachusetts N1 $r f • A � / ?s DEPARTMENT OF BUILDING INSPECTIONS ?y; 212 Main Street • Municipal Building �ti O' v Northampton, MA 01060 �sa1Y ��y0 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: 04,r 1 i Est. Cost: �y, 000 Address of Work: (Qq FG� F0.Yms !� +►rP t 0 — Date of Permit Application: G/ao 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: q/iU/aC) C I A()o- o L LP / (0 135 Date Contractor Name U 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 � X515 ;.rsl�i Massachusetts '' r V' ./� Itt v 'i DEPARTMENT OF BUILDING INSPECTIONS ! 212 Main Street •Municipal Building J{ �. 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: C0� Fl))( Farms 2d o'62(100 (Please print house number and street name) Is to be disposed of at: �l) S�prn ac�� I i ns r FCcrili L (Please print_ ame a d location of facility) J Or will be disposed of in a dumpster onsite rented or leased from: au" � octCl'�nG (Company Nalyie 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 of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 �.' www mass.gov/dia Workers' CompensatioInsurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO B�FILED WITH THE PERMITTING AUTHORITY. Applicant Information i _Please Print LeEibly Name (Business/Organization/Individual) i Address: _ City/State/Zip: S ! Phone MI" Ja - 05 Are you an employer?Check the appropriate ox: Type of project(required): I.5dI am a employer with_Lemployee (full and/or part-time).* 7. New construction on I am a sole proprietor or partnership and halIe no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurancb required.] 9. Q Demolition 3.a I am a homeowner doing all work myself. I[ Io workers'comp,insurance required.]t 10[]Building addition 4.❑I am a homeowner and will be hiring contr Motors to conduct all work on my property. I will 11.0 Electrical repairs or additions ensure that all contractors either have work rs'compensation insurance or are sole proprietors with no employees. 12.[Plumbing repairs or additions 5.711 am a general contractor and I have hireda sub-contractors listed on the attached sheet. 13.2koof repairs These sub-contractors have employees and have workers'comp.insurance? 6.❑We are a corporation and its officers have ,crcised 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#I must also fill oi it 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 E dditional 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: aJ S t I r-Im t 0 — Policy#or Self-ins.Lic.#: W L I (an a a"7a b 1 q4 Expiration Date: /0- 0,5- Job 0- 05-Job Site Address: tag ro xF City/State/Zip:F el Attach a copy of the workers' compe sation policy declaration page(showing the policy number an expiration date). Failure to secure coverage as required der 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. Ido hereby certify under the pains penalties of perjury that the information provided above is true and correct Si nature: Date: q Phone#: Official use only. Do not write int is 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#: N , SCA t v9'20M•o6117 Offloe oConsumer Aflfair8U3In�1s3/Regulation BIOME IMPROVEMENT CONTRACTOR TYPE,,Partnershlo '`•"'1` 06 06/2020 RCI ROOFING "''' ;N 1 MARK T.DELISL ;��'� ` :��'' �1�� t^ 8 t`r \.�I�.(;' : / ,Q„ Commonwealth of Massachusetts LINE ST �'��+r,•r f� - ""� Division of Professional Licensure SOUTHAMPTON,Mi1ttlJ:Q'7Ct' �� Board of Building Regulations and Standards Underseoretary Const�,ti6t"r <A�S'{��visor CS-074334 :% EXpires: 05/03/2022 Registration valid for Individual use onlyA MARK THOMAS DELC 1"'r'J"'• f• before the expiration date, If found return tol 32 OLD COUNTY Rb'''`. Office of Consumer AHalrs and Business Regulation SOUTHAMPTO MA'q' iL 1000 Washington Street•Suite 710 '1; q Boston,MA 02118 Commissioner da/ Z7 "L4A- Not valid without Signature a 1 115' �: O:M KO Nt1Nr la{L HOME pR c'I .a �'M ,0,�••M: ,�'. �y SIN ( ti,,k;.<% SH'ES1r,<(y� titA��.:•Vi!' 2 „.fit(; ;<, IS.SW S' '• F:1r,; p• �(j SOZ!1, ' ! ', r 01073 ` �xk ffl'k`',rYHa.,; F ,L aVYiN:� _"� �,�;r>a.�;.;t,=,�,.,_„ � i` I ;r�2•,r�,"ti'�.l�,��S•��,'R•U:tJ,,�•�( •�'T'E`0 0V 010fit`; .,• ,,.,,,�;r / , '.,2a�>,�i 'K r''b'S'L IS L'E 4:.srl; Re fslradoo Recd trikk :.� �, .�s•�" � 8xplradon {'t�'1,.,.,i : $',�:; ,2•� a'} HTC,062041, ..6i+w' :. 'Q, , ,,,�� 11/30/2019 E�A'.S' M. i „ �' 2t .0A -4) }� , tti ��r .MNEOw• 'ht'2 4�0{#++' f k,Zt cj 01-12an 0 2 0 •—r-��"-- N W •gym>.,,..., ..�.:: , M0 EALTH 0.i*'�./..IA�1A/hLJ 3 ,y}� �<:;,; M .> A R D i. :<...: SHEET r1 TAL V�l� �{* .ISSUES THE F0LUV!A -`I'x #:fr }� + MA lNG'LLP'` (yyygG ` .-�6.,tv1N�SrREtT ,his �� £ ,.: :;°y��'•�.�'•� •,�\'••. _.. aim:: ,�y�. • '60.1.,�`s': ��.<��• •.I '�•� � >::: .. . .. •.�;, tis` i i . AC"Ra DATE(MM/DD/YYYY) .' CERTIFICATE OF LIABILITY INSURANCE 03/09/20 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 pollcy(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 ::::AA Michael R.Banas eanas&FAgert PHONE Extl: 413.527.2700 NC No; 413-527.0849 Insurance Agency 63 Main Street SS: mb@banasinsurance.com Easthampton,MA 01027 INSURER(S)AFFORDING COVERAGE NAIC p RA: Admiral Insurance Co. 24856 INSURED R B: Safety Insurance Co. 39454 RCI Roofing,LLP R c: Admiral Insurance Co. 24856 6 Line StreetR D Southampton,MA 01073R ER 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 LTR TYPE OF INSURANCE POLICY NUMBER MM/DDS MMIDD� LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE'XOCCUR DAMAGE TO RENTE17- PREMISES Ea occurrence $ 50,000 MED EXP A Cy one erson $ 5,000 A X CA000020963.06 03104/20 03/04/21 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY a PRO-- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO Ea accident BODILY INJURY(Per person) $ OWNED SCHEDULED B AUTOS ONLY AUTOS X 6207761 09/30/19 09/30/20 BODILY INJURY(Per accident) $ X X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ v $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 C EXCESS LIAR CLAIMS-MADE X GX000000385-04 03/04/20 03/04/21 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PE OTH- AND EMPLOYERS'LIABILITY YIN STAT TE ER EXCLUDE ANY PROPRIETOR/PARTNER/EXECUTIVE❑ NIA E.L.EACH ACCIDENT $ _ OFFICER/MEMBER EXCLUDED? (Mandatory In E.L.DISEASE-EA EMPLOYE $ II yas,describe under nd DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I 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 -*—Reference Copy"""""`"""""" ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REP S IVE 15 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 1 I DATE(MMIDD/YYYY) AC"Ra CERTIFICATE OF LIABILITY INSURANCE 10/07/2019 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain polices may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). IOIT PRODUCER NAME; T Michael Banas BANAS & FICKERT INSURANCE AGENCY P"CNE 413 527-2700 AIC No: E-MAIL ADDRESS: mb@banasinsurance.com 63 MAIN ST INSURERS AFFORDING COVERAGE NAIC 0 EASTHAMPTON MA 01027 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER 8: _--- RCI ROOFING LLP INSURERC: — ----- INSURER D: 6 LINE STREET INSURERE: — SOUTHAMPTON MA 01073 INSURER F: COVERAGES CERTIFICATE NUMBER: 457722 REVIS!ON 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 AODLITYPE OF INSURANCE INSO VrVD SUB POLICY NUMBER MMLDD/ YYYY MM DDrYYYY EXP LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $DAMAGE TO RENTED— _ CLAIMS-MADE FJOCCUR PREMISES Ea occurrence $ -- MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- LOC PRODUCTS-COMP/OP AGG $ POLICY"JECT F $ HOTHER: AUTOMOBILE LIABILITY -COMBINED aa acccdeSINGLE LIMIT $ nt ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED N/A BODILY INJURY(Per accident) $ _ AUTOS AUTNONOOWNED PROPERTY OAMA E $ HIRED AUTOS AUTOS (Per accidenl UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I RETENTIONS �/ _ $ WORKERS COMPENSATION X STAT TE ERH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? NIA NIA NIA VVVC10060226472019A 10/05/2019 10/05/2020 (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE $ 1,000,000 If yes,describe under E.L.DISEASE•POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS bAlow �_. N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space 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.gov/lwd/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 ACCORDANCE WITH THE POLICY PROVISIONS. Sample Sample AUTHORIZED REPRESENTATIVE Sample MA 01073 Daniel M.Crgvey,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