10B-092 (11) LE ebs BP-2022-0343
191 MAIN STPARCEL B COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
10B-092-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2022-0343 PERMISSIONISHEREBYGRANTED TO:
Project# WINDOWS Contractor: License:
Est. Cost: 28586 WINDOW NATION LLC 116396
Const.Class: Exp.Date:05/20/2025
Use Group: Owner: A ROBERTS CYNTHIA
Lot Size (sq.ft.)
Zoning: URB/WP Applicant: WINDOW NATION LLC
Applicant Address Phone: Insurance:
575 UNIVERSITY AVE (866)217-9582 WC9064617
NORWOOD, MA
ISSUED ON:04/07/2022
TO PERFORM THE FOLLOWING WORK:
INSTALL 21 REPLACEMENT WINDOWS
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:
Gas: Final: Final: Rough Frame:
Rough: Fire Department Driveway Final: Fireplace/Chimney:
Final: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: • Q
CP1 •
Fees Paid: $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
1, The Commonwealth of Massachusetts _. - '1,..i..
_� t_..
Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR FUSE MUCIPALITY ^.o no l I
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 7.n �, f
One-or Two-Family Dwelling z v' t
This Section For Official Use Only
N
Building P rmit Number: S P ).)-— ?�e f Da Applied: o m N `
huit.)/Z5
. .70
Building Official(Print Name) �� Signature Date 0
SECTION 1:SITE INFORMATION
1.1 Property Address 1.2 Assessors Map&Parcel Numbers
sivii
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public El Private CI _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP1y y�
2.1 dp p)of Record: p, / '/�,.- of V Lc
Name(Print) ���� � City, (tate�,ZIP__
I v 1"-9 9211
No.and Street Telephone mail Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. ❑ Num f Other 0 S city:
Brief Description of Proposed Work2: /A) ? Y2 2:4 e_AT 7
1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $Z0 4 20 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ f ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
Suppression)5 Mechanical (Fire $ Total All Fees:V ,�( L
�/'•`
�( Check No. eck Amount: Cash Amount:
6.Total Project Cost: 0404• 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
6 5.1 Construction Supervisor License CSL) /7 ,,. )Z3g �,2.02j
FE ''PpV € (License Number 7F� Expiration Date
Name of C L?older A bb EST j)/�
/1 LP— �_GJ List CSL Type(see below)
No.and Street T e Description
0,i) 911i9y7dbo,u kr.&12.6 L� �'�U) Unrestricted(Buildings up to 35,000 cu.ft.)
/ -� Restricted 1&2 Family Dwelling
Cit State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
/ j —2//—7_/J 7^-Z SF Solid Fuel Burning Appliances
!(� j I Insulation
Telephone Email address D Demolition
5.2 Registered Home Im o e nt Contractor(HIC)
�9 �`] hegrauonNurnber Expiration Date
HIC Tr
/7!4 , �
ip�}�G� t b J„� / —2) Email address
City/Town,/ State,ZIP ,� Telephone
SECTION 6: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 f the building permit.
Signed Affidavit Attached? Yes No .0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR yB�JUILDING PERMIT
I,as Owner of the subject property,hereby authorize ge-e 7JLDD" Z
to act on my behalf,in all matters relative to work authorized by this building permit applion.
Si D) 207f— 6 //2 :2-2P22
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best y kno ledge and un rstanding.
',_471)Dm 1 - -2'
Print Owner's or Authorized ent's Name ectronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(MC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
•
City of Northampton
a �,s:� „ cf
Massachusetts ��.
VA
44' DEPART1 NT OF BUILDING INSPECTIONS w.
a'• j;
.'L 212 Main Street • Municipal Building
Northampton, MA 01060 spN .• ��o
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: //L I) "))i
The debris will be transported by:
Name of Hauler: Y/Signature of Applican . Date:
. r
1070 North Farms RoadTur•Anf
Date of Agreement:
Wallingford,CT 06492 February 28,2022
WINDOW NATION Sales: 866-446-2846
License#: 197968 WINDOWS • SWING • DOORS Service: 866-217-9582
PRODUCT SPECIFICATIONS
Buyer's Information and Buyer Contact Information: Buyer Email Information:
Description of Property: (413)923-1924 Primary Mobile jlacoff@gmail.com
Jodi Lacoff (413)387-9369 Primary Mobile
Cynthia Roberts
191 Main .S I
Leeds,MA 01053
Buyer(s) listed above hereby jointly and severally agrees to purchase the goods and/or services
listed on the accompanying specification sheets, in accordance with the prices and terms
described in the Custom Remodeling and Improvement and the Product Specifications
(collectively,this"Agreement").
Windows-Belle Vue inclusions:Beveled exterior frame with drip-cap,Fusion welded frame and sashes,Limit lock
on double hung windows, Multi-Layer weatherstripping , Defense-Tek Cam-action lock, Special formula uPVC,
Constant force balance system on double hung window,Integral lift rail,Super Spacer,CoreFX reinforced meeting
rail, Forecaster sloped sill, Gatekeeper sash-to-sill interlock, exterior custom capping, installation by factory
certified crew,clean up and haul away of all job related debris.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
It is agreed and understood by and between parties that the Product Specifications, along with the
Custom Remodeling and Improvement Agreement,constitutes the entire understanding between
the parties,and replaces any and all prior negotiations,representations,or agreements,either
written or oral. The Product Specifications may not be changed,modified,or varied in any way
(with exception that installation materials may be substituted with similar products when
inventory shortages exist)unless such changes are in writing and signed by both Buyer(s)and
Window Nation,LLC. Buyer(s)hereby acknowledge that Buyer(s)has read the Product
Specifications.
I have read and received each page of this 3 page Product Specification.
Window Nation Buyer(s)
Signature Signature of Exterior Design Consultant Signature
Paul Cangialosi-License#On File ,
YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY
AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION
OF THIS RIGHT.
February 28,2022 www.windownation.com Page 1 of 3
TAVA94r
• 1070 North Farms Road Date of Agreement:
Wallingford,CT 06492 February 28,2022
WINDOW NATION Sales: 866-446-2846
License#: 197968 WINDOWS • SIDING • DOORS Service: 866-217-9582
PRODUCT SPECIFICATIONS
Buyer's Information and Buyer Contact Information: Buyer Email Information:
Description of Property: (413)923-1924 Primary Mobile jlacoff@gmail.com
Jodi Lacoff (413)387-9369 Primary Mobile
Cynthia Roberts
191 Main
Leeds,MA 01053
Work Order Details:
Model:Belle Vue W:36"H:54" Location:Level I,Bedroom(master) ' 1
1 Quantity:3
• Style:Double Hung • Configuration:Equal Sashes
• Grids:None • Glass:Extreme 2 Pane/Low-E&Argon
• Screen:Half Screen
• Color:Interior White/Exterior White
Model:Belle Vue W:35" H:53" Location:Level 1,Bathroom
2 Quantity: 1
• Style:Double Hung • Configuration:Equal Sashes
• Grids:None • Glass:Extreme 2 Pane/Low-E&
• Screen:Half Screen Argon/Tempered Full F
• Color:Interior White/Exterior White
Model:Belle Vue W:36"H:53" Location:Level 1,Kitchen
3 Quantity:1 '
• Style:Double Hung • Configuration:Equal Sashes
• Grids:None • Glass:Extreme 2 Panc/Low-E&Argon
• Screen:Half Screen
• Color:Interior White/Exterior White
•
Model:Belle Vue W:36"H:54" Location:Level 1,apartment living room
4 Quantity:10
• Style:Double Hung • Configuration:Equal Sashes
• Grids:None • Glass:Extreme 2 Pane/Low-E&Argon
• Screen:Half Screen
• Color:Interior White/Exterior White
February 28,2022 www.windownation.com Page 2 of 3
1070 North Farms RoadVU‘lfr Date of Agreement:
Wallingford,CT 06492 February 28,2022
WINDOW NATION Sales: 866-446-2846
License#: 197968 WINDOWS • SIDING • DOORS Service: 866-217-9582
PRODUCT SPECIFICATIONS
Buyer's Information and Buyer Contact Information: Buyer Email Information:
Description of Property: (413)923-1924 Primary Mobile jlacoff@gmail.com
Jodi Lacoff (413)387-9369 Primary Mobile
Cynthia Roberts
191 Main
Leeds,MA 01053
Work Order Details(cont.)
Model:Belle Vue W:36"H:53" Location:Level 1,Family Room
5 Quantity:3
• Style:Double Hung • Configuration:Equal Sashes
• Grids:None • Glass:Extreme 2 Pane/Low-E&Argon
• Screen:Half Screen
• Color:Interior White/Exterior White
Model:Belle Vue W:36" H:53" Location:Level I,Dining Room
6 Quantity:3
• Style:Double Hung • Configuration:Equal Sashes
• Grids:None • Glass:Extreme 2 Pane/Low-E&Argon
• Screen:Half Screen
• Color:Interior White/Exterior White
Additional Items
21 -EPA Lead Containment Install-Window(Per Opening)
Special instructions:
Told to remove blinds
Installation Details:
Window Removal Type:Wood Additional products needed in the future:No
Exterior Trim:G8
Exterior Trim Color:White Customer agrees to allow Window Nation to post a yard
Sealant:OSI Quad Max sign until 30 days after install:Yes
Insulation Around Window:OSI Quad Foam Year house was built: 1965
Clean Up and Haul Away:Yes EPA Lead Containment Required:Yes
EPA Lead Testing Required:Yes
HOA Approval Required:No
February 28,2022 www.windownation.com Page 3 of 3
• 1070 North Farms RoadAAA/ Date of Agreement:
Wallingford,CT 06492 February 28,2022
WI N DOW NATION Sales: 866-446-2846
License#: 197968 WINDOWS • SIDING • DOORS Service: 866-217-9582
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Buyer's Information and Buyer Contact Information: Buyer Email Information:
Description of Property: (413)923-1924 Primary Mobile jlacoff@gmail.com
Jodi Lacoff (413)387-9369 Primary Mobile
Cynthia Roberts
191 Main
Leeds, MA 01053 _
All home improvement contractors and subcontractors shall be registered. Inquiries about a
registered home improvement contractor should be directed to the Office of Consumer Affairs and
Business Regulation Home Improvement Contractor Program, 1000 Washington Street, Suite 710,
Boston,MA, 02118, 617-973-8787
Buyer(s)listed above hereby jointly and severally agrees to purchase the goods and/or services of Window Nation,LLC.
("Contractor")in accordance with the prices and terms described in this 6 page document and the Product Specifications,which
are incorporated as part of the Agreement(collectively,this"Agreement"). This Agreement represents a cash sale of goods and
services. Buyer(s)agrees to pay the cost of the goods and services purchased as described herein,regardless of timing or
approval of any financing Buyer(s)may seek for their purchase.
Sale Total $28,337.00
Setup&Disposal Fee $249.00 Estimate Project Start:14-16 weeks
Permit Sale Price $28,586.00 Fee 86.00
TotaEstimate Project Finish:1 to 3 days after start
Total
Sales Tax(0%) $0.00
Total Amount Due $28,586.00 Buyer(s)acknowledge that definite start and completion
Down payment-Check 158 $1,000.00 dates are NOT of the essence. Delays beyond Contractor's
Balance Due $27,586.00 control not included in calculating timeframes. See
COD(Payable at time of install) $2,086.00 Section 5 of the Terms and Conditions.
Amount Financed $25,500.00
This Agreement constitutes the entire agreement and understanding between the parties,and this Agreement replaces any and all
prior negotiations,representations,or agreements,either written or oral. No amendment,modification or waiver of this
Agreement shall be valid or effective unless in writing and signed by both parties. Buyer(s)hereby acknowledge that Buyer(s)
1)has read the entire Agreement and has received a completed,signed,and dated copy of this Agreement,including the two
accompanying Notice of Cancellation forms,on the date first written above and 2)was orally informed of his/her right to cancel
this transaction.
Buyer(s)also agrees and understands that if Buyer(s)finance the work with a third-party,the terms of that financing will be
contained on separate documents,including any finance charge.
Price includes all discounts and promotions.
1 have read and received each page of this 5 page Agreement.
Window Nation Buyer(s)
Signature of Exterior Design Consultant Signature
Paul Cangialosi-License#On File
YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY
AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION
OF THIS RIGHT.
February 28,2022 www.windownation.com Page 1 of 5
1070 North Farms Road Date of Agreement:
Wallingford,CT 06492 February 28,2022
WINDOW NATION Sales: 866-446-2846
License#: 197968 WINDOWS • SIDING • DOORS Service: 866-217-9582
PRODUCT SPECIFICATIONS
Buyer's Information and Buyer Contact Information: Buyer Email Information:
Description of Property: (413)923-1924 Primary Mobile jlacoff@gmail.com
Jodi Lacoff (413)387-9369 Primary Mobile
Cynthia Roberts
191 Main
Leeds,MA 01053
Order Summary:
Belle Vue Belle Vue
20 Double Hung 1 Double Hung
Configuration:Equal Sashes Configuration:Equal Sashes
Grids:None Grids:None
Glass:Extreme 2 Pane/Low-E&Argon Glass:Extreme 2 Pane/Low-E&Argon/Tempered Full
Screen:Half Screen Screen:Half Screen
Color:Interior White/Exterior White Color:Interior White/Exterior White
Total Order Summary of Units 21
Additional Items
21 -EPA Lead Containment Install-Window(Per Opening)
Special instructions:
Told to remove blinds
Installation Details:
Window Removal Type: Wood Additional products needed in the future:No
Exterior Trim:G8
Exterior Trim Color:White Customer agrees to allow Window Nation to post a yard
Sealant:OSI Quad Max sign until 30 days after install:Yes
Insulation Around Window:OSI Quad Foam Year house was built: 1965
Clean Up and Haul Away:Yes EPA Lead Containment Required:Yes
EPA Lead Testing Required:Yes
HOA Approval Required:No
February 28,2022 www.windownation.com Page 1 of 1
The Commonwealth of Massachusetts
' t Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
. www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERIVII'I'I'ING AUTHORITY.
Applicant Information ,^ Please Print Legibly
Name1--(Business/Organization/individual): L//�1I1//) 0 1.,/, - /0/1
Address: � �, ) am% 4L'�:
�l /2 j y� ( j
City/State/Zip: 4'/�, b�'� d J%/7" lG' Plione#: C-� 726
Are you an employer?Check the npproprinte box: Type of project(required):
• I.hl'I t nm a employer withZU employees(lull and/or part-time). 7. ❑New construction
,i2..❑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. ❑Demolition
3.0 I tuna homeowner doing all work myself.[No workers'cotup.insurance required.]r
4.01 am a homeowner and will be hiring contractors to conduct all watt on my property. 1 will
10[]Building addition
ensure that all contractors either have workers'compensation insurance or are sole I I.[]Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
S. I ant a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13.QR repairs
These sub-contractors have employees and have milkers'conip.insurance.; fiA/�,r71i�L
6,0 We are a corporation and its officers have exercised theirri right of exemption l4• that• �/ l� �"7
p g p' perMCLc.
(52,g 1(4),and we have no employees.[No workers'comp:insurance required.]
"Any applicant that checks box in must also fill out the section below showing their workers'compensation policy information.
7 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 or cite sub-contractors and state whether or not those entities have
. trttiployecs. If the sub-contractors have employees,they must provide their workers'cdmp.policy number.
'I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
in ormation. ' '
•
Insurance Company Name:
C` I ((""� 4' Expiation Date:
Policy#or Self-ins.Lic.#: /5)6" v 7 r
Job Site Address: / i 7' City/State/Zip: in 6210j
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expliation 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 tine 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 cer ' nder th'e p2t'ns and penalties of perjwy that the information provided above is true and correct.
Signature:`. � '.. ' Date:
Phone#:
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 ft:
w Division of Occupational Licensure
Board of Building Rel lations and Standards
Can`tl 'wn Svrsor
.y
CS-116396 ,. i plres:0512012025
BRANDON L. OYLE
142 RHODE ISLAND AX y',
CUMBERLANt) RI 02864 " i
.iI• . �J
"of.f.V�1J
„t:
Commissioner ortQa K biFmdo—
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affai and Business Regulation
1000 Washingtge=Street-Suite 710
Boston,Massachusetts 02118
Home Im royementrfpntractorRegistration
rn .._�..
L .�.�..1... "`.3 w
rR `k �iy . - - Type: Supplement Card
emniry aeon: 197968
WINDOW NATION LLC pation: 02/12/2024
8110 MAPLE LAWN BLVD,#335 \FA t
FULTON,MD 20759 " ` ` > ,
-o
l ...,.... ..
y 4/
!,1 SN,
Illi Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affair+_s&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMEK+CONTRACTOR expiration date. If found return to:
TYPE:Sup'pierrent Card Office of Consumer Affairs and Business Regulation
Registration Expiratiolt 1000 Washington Street -Suite 710
197988 02112J2024 Boston,MA 02118
WINDOW NATION LLC ._ t
BRANDON BOYLE `� . f
575 UNIVERSITY AVE r, � tLLr�i f"--"F'"" df*s.----- Z
NORWOOD,MA 02062 '7 'f ����'
' Undersecretary Not valid without signature
-=v '/1?f00-t • OP.'_: .1 A.'.
L.„--- CERTIFICATE OF LIABILITY INSURANCE I V080;4;2021 I
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE 00E3 NOT AFFIRMATIVELY-OR NEGATIVELY.AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURArNC, DOES NOT CONSTITUTE ITtUT= 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
I this certificate does not confer rights to the certificate holder in lieu of such andorsementls)-
P.aooucsa 440-461-1101 )CONTACT Tim Fitzpatrick
.EaYJc:
Todd Associates,Inc. PHONE 4}0.461-1101 I sAx 44Q-j46-D132
23825 Commerce Park,Suite A t uc,No.Eai: :;ac.)Iol:
Beachwood,OH 44122 f;��R�ss,jrusso@toddassociates.com
toddassociates.com
Timothy P.Fipatrick •
:NSURER(SIAFFORDING00VERAG=_ vivo i tnsuRERA:Selective Ins.Co-of America 125T2
:NSUREB i INSURER a:Selective Ins.Co.of the SE i39926
'Mildew Nation Holding,LLC i.
gootndo:v Nat on LLC ::M3URER C:
•l9intltl tiplz LQC 1neyL
alto.,ladle igi 31vd„-.+3 i INSURER Fulton,.51D:0759
(INSURER E:
INSURER F: '
_COVERAGES CERTIFICATE NUMBER: REVISION NUMBER*
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEC 3ELCW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POL:CY FERICO
INDICATED. NOTWITHSTANDING ANY REQUIREMENT TERM OR CoNG17'CN OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WI ICH ThIS
CERTIFICATE MAY 3E ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED 3Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TiE TERMS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IMSRI 'aD01 ISUBRi i POLICYEEPP I POLICYEYP I
t TYPE OF INSURANCE I t� 1-1'f to POLICY NUMBER :r„im m .11 t, It re-re-el f LIMITS
A I X I COMMERCIAL GENERAL LIABILITY ( ii II i H_CCI:P.RENCE I_ 1,000,000
1 1 1 C ; - I S24 108/04/20211 O8/04/20221 in5E50_n cclsmresI i 5 BOO 000
L41t.(S-5(Arr_ OCCUR 23575
15,000
1� 1 1 i 1 I.uso c?.inv'na aeroon, t 1,000,000
1 i i j i PERSONAL 3 AGV INJUR'! ! 3
I i 2,300.000
r,.,vGR=3�5..LI'Jr.APP_IES F_3 1 ; ..ENEAM.-u3RE•.ATE : 000.300
1 I PCL'c'Y 1 X i=cfi 1 X 1.00 1 i ..C-3- CMP.CP Ac:O 13
I i -�Ea' 1 1 I I •
I
A i AUTOMOBILE LIABILITY 1 I I I :CLONED JSi?IGL❑=:�H- y 1,000.000 I
Xi ANV l-C I s:a23573.32359s:3 108/04/2021 08/04/2022 1i soc••autR•" P,er arsem
iI--jI ';lNe7 ''1 SCH=0uLED 1 iI i ) _Out 9,P+UP.• Pr acccan 13
AUTOS-.mt.!' L___)AUTOS
i
: IPROP ERTY C AMAGEi ..fg00?LY 1171
1 1NO 'aL-7j i j ,Pere=damn
I I i , n
A ! X U JBRELLO uaa I X i cccuR I i 'EACH OCCURRENCE
; ; 10,300.000
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3ESCRIP iTON OF OPERATIONS!LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
Waiver of Subrogation is provided where required by written contract and as
permitted by law.
CERTIFICATE HOLDER CANCELLATION
BOSTBO4
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
ACORD 25(2016/03) 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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