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25A-085 (5) BP-2022-1170 359BRIDGE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 25A-085-001 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-2022-1170 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 4231 AMERICAN INSTALLATIONS LLC 106178 Const.Class: Exp.Date:09/29/2023 Use Group: Owner: J. CUNNINGHAM, MICHAEL Lot Size (sq.ft.) Zoning: SC/URB Applicant: AMERICAN INSTALLATIONS LLC Applicant Address Phone: Insurance: 130 COLLEGE ST SUITE 100 (413)552-0200 AMWC262555 SOUTH HADLEY, MA 01075 ISSUED ON:09/19/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATION 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: Q Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner 22-2294-A8�B ill l[.T 065 Dep City of Northampton ��� ` `` „ " �"' Building Departtnent sEP NS 21Main 62 ` ULA TION �1 Northampton, &OliOtib� phone 413-587-1240 Fax 41 - 4 /1h ONLY N Mq o r)pNS APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING dNLY SECTION 1 -SITE INFORMATION INS ULA TION PERMIT 1.1 Property Address: 359 Bridge Street This section to be comp tee by office Map 6- Lot L" `� Unit Northampton MA 01060 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: vlichael Cunningham 359 Bridge Street Name(Print) CurrArltTul9 g/�ddrgs: See attached Telephone // ll))44LL Signature 2.2 Authorized Agent: American Installations 130 College Street Ste. 100, South Hadley, MA 01075 Name(Print) Current Mailing Address: • (413)552-0200 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 4231.19 (a)Building Permit Fee 2. Electrical 0 (b)Estimated Total Cost of Construction from(6) 3. Plumbing 0 Building Permit Fee 4. Mechanical(HVAC) 0 4! 5. Fire Protection V" 6. Total=(1 +2+3+4+5) 4231.19 Check Number ai"q 2� ,�q This Section For Official Use Only Building Permit Number: (311 oI a'� I•t=7V IIsssued: Signature: ///1Z q."it-ZOZ Z Building Commissioner/Inspector of Buildings Date permits@AmericanInstallations.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: Wesley K. Couture 106178 License Number 130 College Street Ste. 100, South Hadley MA 01075 9/29/2023 Address Expiration Date A,/e.. /5 (413)552-0200 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 American Installations 175982 Company Name Registration Number 130 College Street Ste. 100, South Hadley MA 01075 6/26/2023 AddG Expiration Date �� -�G ..,— Telephone (413)552-0200 SECTION 5-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 X No 0 Brief Description of Proposed Work NOTE: INSULATION ONL Y Attic and basement insulation and air sealing throughout. I, American Installations - Wesley Couture , 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. Wesley K. Couture Print Name 8—C7--- 9/7/22 *Pattie of 07,Agent Date I, Michael Cunningham ,as Owner of the subject property hereby authorize American Installations to act on my behalf,in all matters relative to work authorized by this building permit application. See attached 9/7/22 Signature of Owner Date i City of Northampton f,?✓ Massachusetts 5. ''•(e r. r a ,. 4., , , DEPARTMENT OF BUILDING INSPECTIONS 'a'. , : 212 Main Street • Municipal Building d,, 4a, ..,." � Northampton, MA 01060 r tY 3'''. - 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: Insulation Est Cost, 4231.19 Address359 Bridge Stret of Work Date of Permit Application: 9/7/22 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 x Other(specify): Contractor pulling permit for homeowner 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: 9/7/22 American Installations 175982 Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton O.. M ,, 3, tj 'A- 4 . Massachusetts �a?y� ,.!�'{ca 4 l DEPARTMENT OF BUILDING INSPECTIONS a'. c M' f'": it;01/ 212 Main Street •Municipal Building Z��s 4�pa .›P""'' Northampton, MA 01060 sN .i%D% 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: 359 Bridge Street (Please print house number and street name) Is to be disposed of at: K& W Materials &Recycling, 138 Palmer Ave, West Springfield, MA 01089 (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 9/7/22 Sig ature of P rrnit 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. City of Northampton r4,, gas. sip it Massachusetts mow. flk } �'�, �P DEPARTI NT OF BUILDING INSPECTIONS 9-. '. '' ,�"" '• 212 Main Street • Municipal Building Jy'Pi"' yob � - Northampton, MA 01060 �Pll 11 MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: 359 Bridge Street Contractor Name: American Installations Address: 130 College Street Ste. 100 City, State: South Hadley MA Phone: (413)552-0200 Property Owner Name: Michael Cunningham Address: 359 Bridge Street City, State: Northampton MA 01060 I, Wesley K. Couture (contractor) attest and affirm that the building I intend to insulate does not have any open air (knob and tube)wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature Date 9/7/22 Page 1 of 1 • ma-s save Licensed&insured 41Ik PARTNER MA CA*:106178 kVA- MARegrstrntion#175982 American Installations www.Americanlnstallations.com 130 College Street Suite 100,South Hadley,MA 01075•Office:(413)552-0200 Fax:(413)552-0202• Email:supports AmericanlnstaUetions.com Customer Name:Michael Cunningham Email:Not provided Phone:617-957-0428 Premise Address:359 Bridge St,Fl 1,Northampton,MA 01060 Mailing Address:359 Bridge St,Fl 1,Northampton,MA 01060 Project ID:4557128 Date:Aug.8,2022 Job Description ax Door Sweep (with AS hrs) 2 each $52.22 $0.00 Exterior Door Weather Stripping (with AS hrs) 2 each $63.62 $0.00 Air Sealing at Estimated 62.5 CFM50 Per Hour 1 hr $94.33 $0.00 Rim Joist-6" Fiberglass Batting 48 SF $129.12 $0.00 Project Total $339.29 Weatherization incentive ($129.12) Air sealing incentive ($210.17) Total Program Incentive -$339.29 Customer Total $0.00 WARRANTY:American Installations,LLC will provide the above stated homeowner with a 1-year workmanship warranty. American nstallations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with the above specifications and all local and state building regulations for the Total Contract Value as stated herein. ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are TOTAL CONTRACT VALUE=S satisfactory and are hereby accepted.You are authorized to do work as specified.Payment wilt be 1/3 down prior to start of work,and balance due upon Completion. Down Payment r S ❑ PAID ala a Due Upon Completion= Signature Date Z Property Owner(Print) (Sign) D Representative:(Print) (Sign) Date THIS AGREEMENT IS COMPOSED OF/HIS PACK AND THE REVERSE SRffi OF THIS PAGE AND SHALL 8E CONSIDERED THE ENTIRE AGREEMENT ar TNePARTIES INVOCVED.THIS AGREEMENT a BETWEEN AMERICAN INsTALLAIWNS,LLC HEREINAFTER yErETRED TO AS'COMPANY, ANDTME CUSTOMERG1 NAMED AGOVE,MERDNAFTER REFEvato TO AS'LIAM',ASS W RL aE SUBJECT TOA4APPEAPRMTE LAWS,REGULATIONS AND ORDNNANQS OF THE STATE OF MASSACHUSETTS ORCONNCOMM RESPECTIVELY,AS WELL AS AU.LOCAL JURISDICTIONS. Page 1 of 2 4 mass save Licensed&Insured PARTNER MA CSL k:106175 MA Registration#1759ffi In stallation nstal at10n www.Americanlnstallations.com s 130 College Street Suite 100,South Hadley,MA 01075•Office:(413)552-0200 Fax:(413)552-0202•Entail:supportlAmericenlnstallations.corn Customer Name:Michael Cunningham Email:Not provided Phone:617-957-0428 Premise Address:359 Bridge St,Fl 2,Northampton,MA 01060 Mailing Address:359 Bridge St,Fl 2,Northampton,MA 01060 Project ID:4557134 Date:Aug.8,2022 Job Description Air Sealing at Estimated 62.5 CFM50 Per Hour 8 hr $754.64 $0.00 Exterior Door Weather Stripping (with AS hrs) 1 each $31.81 $0.00 Door Sweep(with AS hrs) 1 each $26.11 $0.00 Vent Bath Fan to Roof or Other 1 each $146.78 $0.00 Hatch -2"Thermal Barrier Polyiso 1 each $47.37 $0.00 Attic Floor- 13"Open Blow Cellulose 1092 SF $2,566.20 $0.00 Damming 24 each $58.80 $0.00 Propavent 63 each $260.19 $0.00 Project Total $3,891.90 WARRANTY:American Installations,LLC will provide the above stated homeowner with a 1-year workmanship warranty. American Installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with the above specifications and all local and state braiding regulations for the Total Contract value as stated herein. ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are TOTAL CONTRACT VALUE=,S satisfactory and are hereby accepted.You are authoritedto do work as specified.Payment Down Payment=S ❑ will be 1/3 down prior to start of work,and balance due upon Completion. Balance Due Upon Completion= S Signature Date. Property Owner(Print) (Sign) Date Representative:(Print) (Sign) Date TNIS AGREEMENT IS COMPOSED OF1NI5 PAGE AND THE REaFRSE DOE P The PAGE AND SNALL Es CONSIDERED THE ENTIRE AGREEMENTBV TNE PARTIES RNCRYED.TNS AGREEMENT a BETWEEN AMERICAN INSTALLATIONS,LLc HOIEINAFTER REFERRED TO AS'COMPbIM, AMNIA CUSTOMERISi NAMED wow NEREMAPTER REFERRED TO AS`0.1EM',AND WILL ILL SLIEJECT TOME,APPROPNV TE LAVA REGOIATIONS ONO ORDINANCES Of THE STATE OF MASSACNUSE7TS.OR CONNECTICUT RESPECt:yELV,AS WELL AS ALL LOCAL jURpWRIpNS. Page 2 of 2 mass save Licensed&Insured PARTNER MA CSt st:106178 ` MA Registration#1 759132 American Installations www.Americanlnstallations.com 130 College Street Suite 100,South Hadley,MA 01075•Office:(413)552-0200 Fax:(413)5S2.0202• Email supporteAmericanlnstallations.com Customer Name:Michael Cunningham Email:Not provided Phone:617-957-0428 Premise Address:359 Bridge St,Fl 2,Northampton,MA 01060 Mailing Address:359 Bridge St,Fl 2,Northampton,MA 01060 Project ID:4557134 Date:Aug.8,2022 Weatherization incentive ($3,079.34) Air sealing incentive ($812.56) Total Program Incentive -$3,891.90 Customer Total $0.00 WARRANTY:American Installations,LLC will provide the above stated homeowner with a 1-year workmanship warranty. American Installations,LLC hereby proposes to furnish all material and labor to complete the above scope of work in accordance with the above specifications and all local and state bolding regulations for the Total Contract Value as stated herein. ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are TOTAL CONTRACT VALUE=S satisfactory and are hereby accepted.You are authorized to do work as specified.Payment Down Payment=S ❑ will be 1/3 down prior to start of work,and balanced upon Completion, PAD Balance Due Upon Completion= S 8/8/22 Signature Date Property Owner(Print) (Sign) Date Representative:(Print) (Sign) Date THIS AGREEMENT IS COMPOSLD Or THIS PAGE AND THE REVERSE 510E Of THIS PAGE AND SHALL BE CONDO °THE ENTIRE AGREEMENT Br THE PARTIES I*VCtVED.THIS AGREEMENT IS BETWEEN.AMERICAN INSTALLATIONS,LLC HEREINAFTER REFERRED 70 AS'COMPANY', ANDTHE CUSTOMERS)NAMED ABOVE,HEREINAFTER REFERRED 70 AS"CLIENT',AND WILL BE SUBJECT TO ALL APPROPRIATE LAWS,REDUUTIONS ANO ORDINANCES OF ONE STATE OP MASSACHUSETTS OR CONNECTICUT RESPECTIVELY,AS WELL AS ALL LOCALIURISDICI IONS. The Commonwealth of Massachusetts Department of Industrial Accidents -:.' Office of Investigations IMsic lr w Lafayette City Center .. . 2Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):American Installations LLC Address:130 College St, Suite 100 City/State/Zip:South Hadley, MA 01075 Phone #:413-552-0200 Are you an employer? Check the appropriate box: Type of project (required): 1.❑■ I am a employer with 43 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: 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 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no Insulation 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. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those eantities 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: Berkshire Hathaway GUARD Insurance Policy#or Self-ins. Lic. #:AMWC332951 Expiration Date:09/04/2023 Job Site Address: 359 Bridge Street 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 9/7/22 Phone#: 413-552-0 00 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 3E1City/Town Clerk 4.0 Electrical Inspector 5EIPlumbing Inspector 6.0Other Contact Person: Phone#: mm Massachusetts Divisionsession Licensure ofi q� � a Cam. I" CS- 1 2�23 WE LEY C 139 PAC ' ` I c PELHAM MA 0,'1002 , ,, , _ ..44 404.41( ,,,,-.'-i-},-7., il lc tle-en44,40,-.., , „....„. Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts Home Improvement Contractor Registration Type: LLC istration: 175982 AMERICAN INSTALLATIONS,LLC. faei} Expiration: 06/26/2023 130 COLLEGE STREET Stifl E 100 SOUTH HADLEY,MA 01075 ttpdats Address end Return Card. Oflios of C Affairs it eusksss t$n HOME IMPROVEMENT CONTRACTOR for Ind' if use oniq TYPE:LI C rice neg"thm iste. R found return ta: OhNs of Consumer Affairs and Business fiequiet+on 175982 0612BI 8 1000 Wsihini ton 9tnoet -Suite 710 AMERICAN INSTALLATIONS,LLC. Boston,MA 02118 r 4YESLEY COUTURE ) V. ,, 130 COLLEGE STREET SUITE 1 OO poronN ee6-a Q#valid without signature 1Hf'tit I$ SOUTH HADLEY,MA 01075 undersecretary , AC RU® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) O8/30/2022 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Barbara Grynkiewicz NAME: Webber&Grinnell PHONE (413)586-0111 FAX (413)586-6481 (A/C No,Ext): (AIC,No); 8 North King Street gDDRIESS: bgrynkiewicz®webberandgrinnell.com INSURER(S)AFFORDING COVERAGE 1 NAIC p Northampton MA 01060 INSURER A: Employers Mutual Casualty Company i 21415 INSURED INSURER B: AmGUARD/BH GUARD 43290 American Installations,LLC INSURER C: Attn:Wes&Suzanne Couture INSURER D: 130 College Street,Suite 100 INSURER E: South Hadley MA 01075 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 9/4/23 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR .INSD WVD POLICY NUMBER (MMIDDIYYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENI1D X CLAIMS-MADE OCCUR I PREMISES(Ea occurrence) $ 500,000 X Liquor Liability MED EXP(My one person) $ 10,000 A 5D3535223 09/04/2022 09/04/2023 PERSONAL 8.ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n JE Q n 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) $ A OWNED X SCHEDULED 5Z3535223 09/04/2022 09/04/2023 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS _ HIRED �/ NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY AUTOS ONLY (Per accident) PIP-Basic $ 8,000 X UMBRELLAUAB _ OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS UAB CLAIMS-MADE 5J3535223 09/04/2022 09/04/2023 AGGREGATE $ 1,000,000 I DED X RETENTION $ 10,000 $ WORKERS COMPENSATION X STATUTE EORH AND EMPLOYERS'UABIUTY YIN 500 000 B ANY PROPRIETOR/PARTNER/EXECUTIVE Y NIA AMWC332951 09/04/2022 09I04/2023 E.L.EACH ACCIDENT $ , OFFICER/MEMBER EXCLUDED? SOO,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500, I000 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) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD