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32A-227 (15) BP-► 022-0973 58 POMEROY TERR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 32A-227-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-0973 PERMISSIONIS HEREBY GRANTE I TO: Project# -ROOF Contractor: License: Est. Cost: 44600 RCI ROOFING LLP 074334 Const.Class: Exp.Date:05/03/2024 Use Group: Owner: COLLEGE CHURCH INC THE Lot Size (sq.ft.) Zoning: URC Applicant: RCI ROOFING LLP Applicant Address Phone: Insurance: 6 LINE ST (413)527-4775 VWC10060226472021 SOUTHAMPTON, MA 01073 ISSUED ON:08/12/2022 TO PERFORM THE FOLLOWING WORK: STRIP and RE-SHINGLE 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOL TION OF ANY OF ITS RULES AND REGULATIONS. Signature: ei • it .5? - ?DV Fees Paid: $315.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Buildinc Commissioner RECEIVED A U G 1 1 2022 e Commonwealth of Massachusetts .,'P�'.fi NOt�THAMPTON A Office of Public Safety and Inspections I�1 / .OF BUILDING INSPECTIONS Massachusetts State Building Code(780 CMR) i.0 • . . • •plication for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number:a d• q 73 Date Applied: Building Official: SECTION 1:LOCATION 58 Pomeroy Terrace Northampton 01060 College Church-Gymnasium No.and Street City 2Tow Zip Code Name of Building(if applicable) 32A Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building ISX Repair 0 Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other ©c Specify: roof replacement Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No Is an Independent Structural Engineering Peer Review required? Yes 0 No Brief Description of Proposed Work: remove existing shingle roof down to decking and install new shingle roof SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4❑ A-5❑ B: Business 0 E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2❑ H-3 0 H-4 0 H-5 0 I: Institutional I-i 0 I-2❑ I-3❑ I-4❑ M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility❑ Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA CI IB ❑ HA IIB 0 IRA IIIB ❑ IV 0 VA VB 0 SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:o Site Public 0 Check if outside Flood Zone El Indicate municipal CIA trench will not be Licensed Disposal Rd 0 required❑or trench or specify:_ Private 0 or indentify Zone: or on site system 0 permit is enclosed 0 E Windsor CT-USA Waste Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner The College Church Inc 48 Pomeroy Terrace Northampton 01060 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Kenneth Strong _ _ 413. 320 _ 8090 klstrong@comcast.net Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: RCI Roofing LLP 6 Line Street Southampton MA 01073 Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit apblication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control (the professional coordinating document submittals) ; Mark Delisle 413_204 _3207 _ mdelisle@rciroofing.com CS-074334 Name(Registrant) Telephone No. e-mail address Registration Number 32 Old County Road Southampton MA 01073 5/3/202 Street Address City/Town State Zip Discipline Expir tion Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildini,permit. Is a signed Affidavit submitted with this application? Yes® No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)_$ 44,600 1.Building roofing $44,600 Building Permit Fee=Total Construction 7 (Insert here 2.Electrical $ appropriate municipal factor) . 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$100 (contact municipality) 5.Mechanical (Other) $ Enclose check payable to City of Northampton 6.Total Cost $44,600 (contact municipality)and write check number here 3, I Z— SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attes der the pains and penalties of perjury that all of the information contained in this application is true and accurate to t of knowledge and understanding. Mark Delisle Partner 413 204 3207 8/8/2022 Please print and sign name Title Telephone No. Date 6 Line Street Southampton MA 01073 mdelisle@rciroofing.com Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: J/772 8'1 Z ZQZ Z Name Date City of Northampton Massachusetts adz .t1.. 4'� DEPARTMENT OF BUILDING INSPECTIONS 3t ' ' 212 Main Street • Municipal Building ilh., Northampton, MA 01060 rsph °"kIt 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: Shoham Road,E Windsor CT The debris will be transported by: Name of Hauler: USA Hauling&Recycling Inc Signature of Applicant: Date: 8/8/2022 The Commonwealth of Massachusetts Department of Industrial Accidents V� al� Office of Investigations ' _ 1-. Lafayette City Center.1.11 MOM j 2 Avenue de Lafayette, Boston,MA 02111-1750 "^ 'l www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RCI Roofing LLP Address:6 Line Street City/State/Zip:Southampton MA 01073 Phone #:413-527-4775 Are you an employer? Check the appropriate box: Type of project(required): 1.❑IIIII I am a employer with 13 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. El Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ 9. [' Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑■ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:AIM Mutual Insurance Co Policy#or Self-ins. Lic. #:VWC 10060226472021 A Expiration Date: 10/05/2022 Job Site Address: 58 Pomeroy Terr City/State/Zip: Northampton MA 01060 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 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 rjury that the information provided above is true and correct. Signature: Date: 08/08/2022 Phone#: 413-527-4775 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): 10Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 50Plu%nbing Inspector 6.❑Other Contact Person: Phone#: • R.C. I. RoofingT t..r 6 Line Street,Southampton,MA 01073 Phone: 413-527-4775 Fax:413-527-8469 July 14,2022 Mr. Ken Strong College Church 48 Pomeroy Terrace Northampton, MA Re: Roof Replacement- Gymnasium (Backside Only) 48 Pomeroy Terrace Northampton, MA Dear Ken; Thank you for the opportunity to provide the following estimate to remove and replace the roofing on the back portion of the gymnasium building at the above referenceld property. Our scope of work is outlined below. Scope of Work: Remove existing shingles and underlayments down to plywood decking and properly dispose Replace wet or damaged 'W' plywood and 2" insulation as needed Furnish & install Ice & Water barrier on entire roof surface Furnish& install Certainteed 30-year shingles color Pewterwood Furnish & install continuous ridge vent Furnish& install hip & ridge shingles Furnish & install all necessary flashings Remove and dispose of all roofing related debris Price: $39,800.00 Alternate 1: Change Certainteed 30-year shingle to 50-year(Landmark Pro) Alternate 1 Price: $4,800.00 (2) Notes: 1/2" plywood to be replaced at$3.50 SF 2" polyiso insulation to be replaced at$2.70 SF RCI Roofing will provide crane as needed All work installed to manufacturers standards RCI Roofing employees are OSHA 10 certified. Terms: A 50% payment will be due at time of material delivery. Balance will be due upon completion. References and insurance certificates will be provided upon request. We hope that you select R.C.I. Roofing to do this work for you. To accept this proposal, please sign and return a copy to us. We will obtain required permits and notify ycu when we plan to schedule the work. Dana Painchaud Estimator, Commercial Accounts Accepted by Date cam-- — d"t c H c 14 •AK WiYI-i ,qLi r/C NA`T�c- J Commonwealth of Massachusetts s iii Division of Occupational Licensure construction Supervisor Board of Building Regulations and Standards Unrestricted -Buildings of any use droop which contain tol t less than 35.f%:)cubic feet(991 cubic meters)of enclosed Coast{ �CIC SI1' isor .ry ;pace. CS-074334 v' f tpires:05/03/2024 MARK THOfv} S DELISLE 32 OLD COUNTY RD -r 2.SOUTHAP TON M 373 :% 6 r _ t0 r: ii �r.1 vatl' Failure to possess a cure a edlti. he Massachusetts .�,p n State Building Code is cause for r, >tion of this license. Commisstoe r GddAAr' /, Cs •c.. For information about. .i,cense Call(617)727-3200 or visit m rnass.govldpl THE COMMONWEALTH OF MASSACHUSETTS Registration valid for individual use only before the Office of Consumer Affairs&Business Regulation expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation TYPE:LLP 1000 Washington Street -Suite 710 Registration - Expiration Boston,MA 02118 126235 06/17/2024 RCI ROOFING,LLP MARK T.DELISLE 0 LINE ST ilun..t LC.+/: • „ `-- - SOUTHAMPTON,MA 01073,. f _ Undersecretary Not valid without signature Foid,1nn 0cloO,Along At Pr1uratIons r. . M 0>, ALTH OF MI. ..., q1l DIVISION OF OCCUPATIONAL LICENSURE BOARD OF SHEET METAL WORKERS ISSUES THE FOLLOWING LICENSE MASTER-UNRESTRICTED MARK T DELISLE 32 OLD COUNTY RD iw�t SOUTHAMPTON,MA 01073-9601 W A' 13276 05128/2024 214006 LICENSE NUMBER BER EXPIRATION DATE SERIAL NUMBER C ,J MONWEALTIH OF MA S STATE OF CONNECTICUT '' :' °•' ' �W' s} DEPARTMENT OPCONSUMER PROTECTION. '' .,�:; fwJARD Oi HOME IMPROVEMENT CONTRACTOR SNIEET MEFAL h 3R$ERSS It C I ROOFING 1.1.P ISSUES TKE FOLL.OWNG uCE E \\,6 LINE STBUSIMtE55 i SOUTHAMPTON,MA 01073 MARA T OEL1SLE Rd I ROOFING LLP • d LINE STREET 2 g'st.taian Al � _....Fife n- ._.-- __.1;xpuad nii I-IIC.0624741 12 02 03/31/2023 EASTHAMPT N,MA 01073 SIGNED 401 pW13*..,2023 $4510 et DATE(MM/DD/YYYY) Acc uzo CERTIFICATE OF LIABILITY INSURANCE �...�' 03/04/22 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 CON(AC( NAME: Michael R.Banas Banas&Fickert PHO(A/QNNo,Extl: 413-527-2700 FAX No): 413-527-0849 Insurance Agency E-MAIL 63 Main Street ADDRESS: mb@banasinsurance.com Easthampton,MA 01027 INSURER(S)AFFORDING COVERAGE NAIC it INSURER A: Admiral Insurance Co. 24856 INSURED INSURER B: Safety Insurance Co. 39454 RCI Roofing,LLP INSURER C: Admiral Insurance Co. 24856 6 Line Street INSURER D: Southampton,MA 01073 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE I XI OCCUR OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A X CA000020963-08 03/04/22 03/04/23 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PE& LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B AWNED X SCHEDULED X 6207761 09/30/21 09/30/22 (Per )�' $ , AUTOS ONLY , AUTOS BODILY INJURY accident X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE X GX000000385-06 03/04/22 03/04/23 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N!A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ROOFING CONTRACTOR. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ""�" Reference Copy ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REP -SI IVE 15 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD CORD®A CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 03/04/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Michael Banas BANAS & FICKERT INSURANCE AGENCY (locc.NNc Ext): (413)527-2700 A No): E-MAIL ADDRESS: so@banasinsurance.com 63 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC# EASTHAMPTON MA 01027 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: RCI ROOFING LLP INSURERC: INSURER D: 6 LINE STREET INSURERE: SOUTHAMPTON MA 01073 INSURERF: COVERAGES CERTIFICATE NUMBER: 750332 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 SUER LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY POLICY EXP (MM/DD/YYY`/) (MM/DDIYYI'Y) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE _ AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OOTH X PEATUTE AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICERJMEMBEREXCLUDED? N/A N/A N/A VWC10060226472021A 10/05/2021 10/05/2022 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 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/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Reference Copy ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Daniel M.Crq(,vfey,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