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23B-046
30 LOCUST ST BP-2021-0923 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23B-046 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-2021-0923 Project# JS-2021-001578 Est.Cost: $451659.00 Fee: $3164.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RAYMOND R HOULE CONST INC 066227 Lot Size(sq. ft.): 1325051.64 Owner: COOLEY DICKINSON HOSPITAL INC Zoning: M(99)/WP(21)/URB(1)/ Applicant: RAYMOND R HOULE CONST INC AT: 30 LOCUST ST Applicant Address: Phone: Insurance: 5 MILLER ST (413) 547-2500 () WC LUDLOWMA01056 ISSUED ON:2/26/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:RENO THE MRI SPACE 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 signa� .` yg TAIT FeeType: Date Paid: Amount: Building 2/26/2021 0:00:00 $3164.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File# BP-2021-0923 APPLICANT/CONTACT PERSON RAYMOND R HOULE CONST INC ADDRESS/PHONE 5 MILLER ST LUDLOW (413)547-2500 Q PROPERTY LOCATION 30 LOCUST ST MAP 23B PARCEL 046 001 ZONE M(99)/WP(21)/URB(1)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: RENO THE MRI SPACE /) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 066227 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: X Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW _ _Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay 2-aaZa.l Sign.1 re of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. RECEIVED I Version1.7 Commercial Building Permit May 15,2000 Department use only F E B 1 9 2021 of Northampton Status of Permit: Su'ding Department Curb Cut/Driveway Permit - I _ 2 2 Main Street Sewer/Septic Availability 1'if PT.OF r unnin ;1NSPECTIoNSRooip 100 Water/Well Availability NOF�THAn4F TnN.rnr s On, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOUSH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 30 Locust St. Map c; 3& Lot d ce Unit Northampton, MA 01060 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT $.1 Owner of Record: Cooley Dickinson Hospital 30 Locust St. P.O. Box 5001 Name(Print) Current Mailing Address: Signature a lent. t< c ' 113-582-2313 ep 22 Auth Asnt:Timothy S Pelletier 5 Miller St. Ludlow, MA 01056 Name(Print) Current Meiling Address: 1-413-547-2500 Signature �C�',,cc f' l` Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 297,874.00 (a)Building Permit Fee 2. Electrical 62'QOO oo (b)Estimated Total Cost of Construction from(6) 3. Plumbing 00 Building Permit Fee �-ll / Ct, 4. Mechanical(HVAC) 83,450.00 �f/� (,/ 5.Fire Protection f1335 00 B. Total=(1+2+3+4+5) 451659.00 Check Number if /5 Ff This Section For Official Use Only Building Permit Number Date 60, a' ' q�� Issued S re: r. �I 1'4 I 1 Buiidl Commissioner Inspector of Building / Date VersionI.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 36,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations 0 Existing Wall Signs 0 Demolition 0 Repairs 0 Additions 0 Accessory Building 0 Exterior Alteration 0 Existing Ground Sign 0 New Signs 0 Roofing 0 Change of Use❑ Other 0 Brief Description Enter a brief description here. Of Proposed Work: Renovate the MRI space for installation of a new MRI unit SECTION 6-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ElA-2 ❑ A 3 ❑ 1A I 0 A-4 0 A-5 ❑ 1B I 0 B Business 0 2A If 0 E Educational 0 28 ( ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ SA ❑ I Institutional © 1-1 ❑ I-2 ® 1-3 0 38 ❑ M Mercantile ❑ 4 ❑ R Residential 0 R-1 0 R-2 0 R-3 0 5A ❑ S Storage ❑ S-1 0 S-2 ❑ 58 1 ❑ U Utility ❑ Specify: M Mixed Use 0 Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Institutional Proposed Use Group: Institutional Existing Hazard Index 780 CMR 34): 4 Proposed Hazard Index 780 CMR 34): 4 SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1st 1rt 2nd 2nd 3`d 3.e 4s 4m Total Area(sf) Total Proposed New Construction(sf) Total Height(ft) Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private 13 Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled is by Building Department Lot size 969,427.8 969,427.8 Frontage 2658' 2658' Setbacks Front 102' 102' Sigt L:.S8' R: 42' L: 88' R:.42' EMI 18' 18' Building Height 64.5' 64.5' Bldg.Square Footage 402,861 x' 402,861 Open Space Footage Xe (Lot area minus tads a paved 40.6 40.6 puking) #of Parking Spaces 761 761 Fill: N/A N/A (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? N0 0 DONT KNOW 0 YES IF YES,date issued: Dec 13,2001 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW O YES 0 IF YES: enter Book 6504 Page 239 and/or Document# B. Does the site contain a brook,body of water or wetlands? NO O DONT KNOW O YES O IF YES,has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES ® NO lO IF YES,describe size, type and location: Various D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO IF YES,describe size,type and location: E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW Is required. Version 1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: HAI Architecture Not Applicable 0 Name(Registrant): 60 Gothic St. Northampton, MA 01060 Registration Number Address 8951 See affidavit attached 1-413-584-7224n�� Signature Telephone 8-31-2021 9.2 Registered Professional Engineer(s): Jeffrey S. Cichonski Fire Protection-Mechanical-Electrical Name Area of Rsapo eblity 50 Griffin Road South Bloomfield, CT 06002 1.49384 Address Registration Number See affidavit attached 1;860-286-9171 6-30-2022 Signature Telephone Expiration Date Bernard J. Hunt Structural Name Area of Reeponsiday 32432 Address Registration Manbsr See affidavit attached t-413-464-2522 6-30-2021 Signature Telephone Expkadon Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Raymond R. Houle Construction Inc. Not Applicable 0 Company Name: Timothy S. Pelletier Responsible In Charge of Construction 5 Miller St. Ludlow, M//A��01056 �Address /G�� '" l�/ ��'�r 1-413-547-2500 Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) 1 Independent Structural Engineering Structural Peer Review Required Yes 0 No e SECTION 11-OWNER AUTHORIZATION-TO BE COMPLETED WHEN l OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Cooley Dickinson Hospital I, ,as Owner of the subject property hereby authorize Raymond R. Houle Construction Inc. to act on my behalf,In all matters relative to work authorized by this building permit application. 29.frtia-47-/(ta K c5�ZZ402/18/2021 Signaturwner Date Raymond R. Houle Construction Inc. as Owner/Authorized Illnlereby 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. Timothy S. Pelletier Print Name G� 2--/6 Z 2/ Signature of OwneNAgent Date SECTION 12-CONSTRUCTION SERVICES T 10.1 Licensed Construction SuoeMsor. Not Applicable 0 Name of License Holder:i Timothy S. Pelletier 066227 License Number 5 Miller St. Ludlow, MA 010.5.6 07-07-2021 Address Expireron Date 1-413-547-2500 Signature Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§2SC(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 0 No 0 City of Northampton 212 Main Street,Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: 30 Locust St. Northampton, MA The debris will be transported by: USA Hauling The debris will be received by: USA Hauling Building permit number: Pending Name of Permit Applicant Raymond R. Houle Construction Inc. 7//2-Zo2r �f Date Signature of Permit Applicant Initial Construction Control Document To be submitted with the building permit application by a 1 1 Registered Design Professional for work per the 9th edition of the Massachusetts State Building Code, 780 CMR, Section 107.6.2 Project Title: Cooley Dickinson Hospital MRI Replacement Date: 2/12/2021 Property Address: 30 Locust Street,Northampton,MA Project: Check(x)one or both as applicable: New construction I X Existing Construction Project description: Replacement of existing MRI with new equipment and associated mechanical and electrical upgrades required to support the new equipment. I,Jeffrey S.Cichonski,MA Registration Number: 49384,Expiration date:6/30/2022,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': Architectural Structural X Mechanical X Fire Protection X Electrical Other: for the above named project and that to the best of my knowledge,information,and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official,I shall submit field/progress reports(see item 3)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work,I shall submit to the building official a `Final Construction Control Document'. Enter in the space to the right a"wet"or �E ' • . electronic signature and seal: 't N :KI ir Phone number: 860-286-9171 Email:jeffc@bvhis.com •. ,sae Building Official Use Only Building Official Name: Permit No.: Date: Note 1.Indicate with an`x'project design plans.computations and specifications that you prepared or directly supervised.If'other' is chosen, provide a description. Version 06 I 1 2013 Initial Construction Control Document 4 � To be submitted with the building permit application by a }mil § Registered Design Professional I for work per the 9th edition of the r.�, Massachusetts State Building Code, 780 CMR Project Title: Cooley Dickinson Hospital MRI Replacment Date: February 17,2021 Property Address:30 Locust St,Northampton,MA Project: Check(x)one or both as applicable: New construction XX Existing Construction Project description: Remove existing MRI and interior finishes and install new MR1 and shielding and new rooftop chiller. I, Bernard J.Hunt,MA Registration Number:32432 Expiration date: 06/30/2021 ,am a registered design professional, and hereby certify that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': Entire Project Architectural xx Structural Mechanical Fire Protection Electrical Other: for the above named project and that such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'. Enter in the space to the right a"wet"or �r�zH°F Lc 41 electronic signature and seal: a?. rigs *p S, BERNARD J. n 3 V STRUCtUHUNTRAL �^ No.32432 Phone number: 413 464 2522 Email: bhuntsr@gmail.com 44, N'aisire ° �Q NALE Building Official Use Only Building Official Name: Permit No.: Date: Note 1.Indicate with an`a'project design plans,computations and specifications that you prepared or directly supervised.If`other' is chosen, provide a description. Trial Version I0 09 2012 Initial Construction Control Document l!rt To be submitted with the building permit application by a Registered Design Professional • ` for work per the ninth edition of the Aye Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Renovations for MRI Replacement Date:02/15/2021 Property Address: Cooley Dickinson Hospital, 30 Locust Street, Northampton, MA 01060 Project: Check(x) one or both as applicable: New construction X Existing Construction Project description: Replacement of existing MRI Unit and minor renovations to a limited area of Radiology — Basement Floor Level. I Donald J. Hafner, MA Registration Number: 8951 Expiration date: August 31, 2021 , am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerningl: X Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that to the best of my knowledge, information, and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent comments,in a form acceptable to the building official. Upon completion of the work,I shall submit to the building official a'Final Construction . - ,r`A •nt'. Digitally signed by Don s o J. ti/ Enter in the space to the right a "wet" or Don Hafner,Hafner,AIA,NCARB 4- ova haft,l�C'� electronic signature and seal: AIA NCARB Date:2021.0,2.16 S i 18:16:22-05'00' Amherst \ Massachusetts Phone number:413.585.1512 Email: don.hafner@haiarchitecture.com / Building Official Use Only 1Z41 of MPSgP Building Official Name: Permit No.: Date: Note 1.Indicate with an'x' project design plans,computations and specifications that you prepared or directly supervised. If'other'is chosen,provide a description. Version 01 01 2018 The Commonwealth of Massachusetts .=-.../. Department of Industrial Accidents Office of Investigations 9., :, Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 y', www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legib1% Business/Organization Name: Raymond R. Houle Construction, Inc Address: 5 Miller St. City/State/Zip: Ludlow,MA 01056 Phone#: 413-547-2500 Are you an employer?Check the appropriate box: Business Type(required): 1.® I am a employer with employees(full and! 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. Q Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.0 Other_ *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. "If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: AIM Mutual Insurance Insurer's Address: P.O.B 4070 City/State/Zip: Burlington,MA 01803 Policy#or Self-ins. Lic.# MCC-200-2000566-2020A Expiration Date: 12/31/2021 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under§25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. Si.mnature: /41 �� Date: 2-19-2021 Phone#: 413-547-2 00 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 1 f Board of Health 2.0 Building Department 3.0City/Town Clerk 4.0Licensing Board 5E1 Selectmen's Office 6.DOther Contact Person: Phone#: www.mass.gov/dia i"w"1 RAYMRHO-01 AWA LA ,4�Ro• CERTIFICATE OF LIABILITY INSURANCE DATE/15120YYYY) 12/15@0?A 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 POUCIES 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. It 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 Ileu of such endorsement(s1. PRODUCER ...._ CONTACT Angela IAupustino Phillips Insurance Agency,Inc. PRONE PAIN 97 Center Street ANC,No,Exe::(413)904-&Yt4 Nn:(413)592-0409 Chicopee,MA 01013 ifliCa.angelaaphIllipsInsurance.ocen INsURE71ta1 AMNIONS CON RAN( NAICIF imam A:Selective Insurance 12572 INSURED !Fiume e:A.I.M.Mutual Ins.Co. 33768 Raymond R.Houle Construction Inc INSURERC: 6 Miller St - — Ludlow,MA 0106E INSURER a: IENSURER _ ._ NSURER 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 PAD CLAIMS. MLVI R — T71 T. EMI POLICY EXII TYPE OF INSURANCEr�' ti1l , POLICY NUMBER II/I l NMlif➢DK1�Y1EACH OCCURRENCE LIMITS X COMMERCIAL OENtRAL LY1dLIrY 1,000,00� CLAIMS-MADE n OCCUR ' As. DMM(iEnlsFRRENTE1 - 6680 1213112020 1213112021 PRFascE.ousarenul i 500,000 ,--- — ME()E>P(Any one paw) $ 15,000 - - _ PERSONAL ILADV INJURY $ 1 r060,000 „ggN L.AGGREAA UMIT AP use PER: � TE $ 2,000,000 POLICY UX LOC PRODUCTS.co.PIOPAee $ 2,000,000 OTHER. ,000 AUTO/SCREE LIABILITY A COMBINED Lahr $ 1,� _ ANY AUTO II_apt® 10741111 1212112020 12131/2021 sooaY swum Par wawa $ AUTOSDONLY X NMplr�0p8 M _BODILY NJURY Pr ,.X j AUTOS ONLY X AU705 ONLY spar Lam_�PAMAGE I E A'X uuumaUAu*a X,OCCUR EACH OCCURRENCE $ 5,000,000 'amass use lCLASIBIAADE 2396590 12/31/2020 12/31/2021 AGGREGA� r 5,000,000 DED X I RETENTION$ 10,1 10 $ B 'WORKERS COMPEt1SAT1ON AND EMPLOYERS'UABILnti C�00.200060ti-2020A 1?J3112020 12/31/2021 X STATUTE 1000,000 ANY PROPRIETORlPA. UTIVE EL EACH ACCIDENT j �IFmNnl EXCLUDED? N NIA 1,000,000 e gyeaee,describe under E L DISEASE-EA FJIPIAYEE $ DESCRIPTION OF OPERATIONS trim EL A Equipment FloaterEL DISEASE-POUCYLIMIT alas° 12/3112020 12/31/2021'limit 100,000 OEICIIIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD 101,Adam ontl Remarks schsd.as,may es attached Y mom sped Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE Proof of Coverage THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1" '74' 1'1'1,4 I ACORD 25(2010/03) ©190B-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD