17A-264 (3) BP-' 022-1566
72 OAK ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17A-264-001 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-2022-1566 PERMISSION IS HEREBY GRANT D TO:
Project# ROOF Contractor: License:
PREMIER EXTERIORS & DESIGN
Est. Cost: 19900 LLC 110285
Const.Class: Exp.Date: 01/09/2024
Use Group: Owner: GREENE WILFRID R
Lot Size (sq.ft.)
Zoning: URB Applicant: PREMIER EXTERIORS &DESIGN LL
Applicant Address Phone: Insurance:
500 MAIN ST (413)207-6074 WC2335B211 B8012
FISKDALE, MA 01518
ISSUED ON: 12/06/2022
TO PERFORM THE FOLLOWING WORK:
STRIP AND RE-ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: Footings:
Rough: Rough: House# Foundation:
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 VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:g '1I .)
1 '
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
r `
,iw �° The Commonwealth of Massachusetts
NO V 2 3 2022 Ij and of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
''` Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
,7r-+...0. 0 "AA O10n0 ��S One-or Two-Family Dwelling
This Section For Official Use Only
Buildin Permit Number:&0•55
/4 �,,' 5- Date Applied:
1. au Di 1/& 1I- 36-2021.
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assesso ap&Parcel Nu e s
'10 00Y-- Sk-• 11/144/
1.1 a Is this an accepted street?yes no Map Number Parcel Number
13 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 0 Private 0 Zone: _ Outside Flood Zone? Municipal❑ On site disposal.ystem ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wn 'of Record:
v3wn o Elfeev\e_ FI ice, M 01 do
Name(Pri t) City,State,ZIP
'7 a 0 a1c S-*. 4 t 3(oRs'Ng 9 cG s+,ne--
No.and Street Telephone B5fil Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building FP Owner-Occupied W Repairs(s) * Alteration(s) ❑ Addition ❑
Demolition 0 Accessory Bldg.❑ Number of Units I Other 0 Specify:
Brief Description of Proposed Work (Z-QwaQ_ �('(x I fetka Q e0til 3)1�QOle Q
a-5 v�Pedect. *1.1 I J
4 n,, Ao av x ec c I ace e_S '-e (` `(cishi'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1 `q on 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 1 ElStandard City/Town Application Fee
0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fel:4
(,�
Check No.[� I Check Amount:
6
6.Total Project Cost: $
k c 1 q d U 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
��, J. CS-t�oag�
\'n License Number Ex iration Date
Name of CSL Holder
313L1 Mcl\\—OU ^ • List CSL Type(see below) (A.
No.and Street 1-�(� Type Description
Wise `_ -cc e1\ot, O\OlJ"1�,3 Unrestricted(Buildings up to 35,000 Cu.ft.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
G � SF Solid Fuel Burning Appliances
�100 p 3vO u l`'t t pXOCt uc'�Q(6a 0-top(e.yvi 1 er I Insulation
Telephone Emai ddress e.X}!'r jc 5,Co H D Demolition
5.2 Registered Home Improvement Contractor(HIC) Po38'6'13' Qg a3
&V1 i '---)oce.rici5 HIC Registration Number E pirati n Date
HIC Company Name or HIC Registr�cit Name '
}'�OLit(1 51- . 9 1 jai a� .
N Street (���� 1 dress `�
Oisl 413202c007�f $�c+e�icXS•
City/Town, State,ZIP Telephone COW%
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 of the building permit.
Signed Affidavit Attached? Yes )62 No 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Ka VW) `fix in
to act on my behalf,in all matters relative to work authorized by this building permit application.
See c 'K'cac-st- c.'--ckc.�•ed
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
copained in this application is true and accurate to the best of my knowledge and understanding.
. ft/16
Print Owner's or Authorized Agent's Name(Electronic 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(HIC)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"
_ .\. The Commonwealth of Massachusetts
Department of Industrial:Accidents
1 Congress Street,Suite 100
• tI ' Boston,MA 02114-2017
1.t> :` www.mass.goridia
II urkrr+Compensation Insurance Aftidas it:fluBuildersiContractorstElectriciansfPlumbers.
10 BE FILED N 1111 THE PERMl'Uil (;AI''fIIORI"t i.
Applicant Information {� Please Print(Ltrlibh
Name(HusanessY Organization hub%rdu*dual l' `�rew,r�r n'ors 1 ( ' S t {
Address: 5OC) Nato o S T .J-
, AIn � p
CityiState;''Zip: F a e, 1vV �I 3Iz5 Phone#:` 13__.t O ' (or? q
'ire sea an employee tie&the appropriate bob:
Type of project(required):
I A i am a enirbyer with g°ei ptu}te (full neuter port-roes►• 7. 0 New construction
20 I am a role proprietor or minnership and have no eatpkryeies oinking forme in $. 0 Remodeling
any capacity.(1No wortmi7 comp.insurance nce rued.]
301 am a homeowner doing all work my elf.[into workers'Burr;,. rmairmee ramrod]" S1. Ikinwlition
4.01 am a homeownerand v.ell be hiring aialxmkxs to conduct work tin my property. 1 w ill 100 Budding addition
ensure diet all contractors either have rs+orleers'Compensatrust ntnurancr to arts sole 1 1.Q Electrical repairs or additions
pruiniri Ors with um earployfier. 12.0 Plumbing repairs or additions
50 I am a general coaaraeterr and 1 have hired the aob.ea l,aetou lasted on the attachcat sheet 13 tglltoof repairs
Thew yteb,c tintrx'km ham ha employees and hav w e alkers'rump.tnaurarrce.
6.0 We area corporation and its ueff►cerr bane mourned reed deer right ut c♦corium tart Wit.iL c. 1$.❑other
152.9<1(4).and we hair no eoaiduytees. No workers'wimp.insurance required..I
*Any applicant dial chocks boat ai mini also fill out the section below shooing then w urkcts'eumprmaawn p ahe arfurmateun.
*Bern ietioners who submit does affidavit indicating this:are doing all wink and then lute outside contractors mini submit a new at7ida%a indicating such
;Contractors that 4'heci.tins box moors attached an Aid:Moral nal sheet show rug the name of the su(►euttt:rctursand state whc-ihet or not those entittcb!Laic
t+nplotiec,. It the sub-...nuactots bate curioti eeo.the_r trtust pros ode then %tinker:camrp polecaa number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Nance: - Rig I � ....._
Pokey#or Self-ins.Lice tt: S' °'11:-8-( AOro' Expiration Date:
Job Site Address: 3 ( )U Sr . City/StateiZip: Fills( ' i O 1 O(0 P
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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
andior one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereb•certify a er pains and penalties of perjury that the information provided above is tree mad correct
Signature: Date. << 1 I5-/aa
Phone z Vo 0"5c 7)0" I I'J I
OlfiLirel use only. Do not write in this area.to be completed by city or town officiaL
( its or I ow n: Permit/License p
Issuing,tuthorits (circle one):
1. Board of health 2. Buildine I)epartntaul 3.( its A own Clerk 4.Electrical Inspector S.Plumbing Inspector
b.Other
( ontaet Person: Phone(1:
City of Northampton
Massachusetts 4G x r'<it <
,r c
. 1 � �� . 4 DEPARTMENT OF BUILDING INSPECTIONS ; j�
s� a`
212 Main Street • Municipal Building ti O
,._.� Northampton, MA 01060 -:frig, .�')CN-
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: �,� (�('Lt A i�C !"l (,� P.�1 I�C� (r n pod, CT-
The debris will be transported by:
Name of Hauler:L5 [kit U Ic'4
6,{—
Signature of Applicant si Date: i( i5 or _a2
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Regulations and Standards
lr
Constteit}ion Srvlsor
CS-110285 cpires:01/09/2024
KEITH W DE1(IN
3134 MOUNTAIN ROAD
WEST SUFFIECj.D CT 06093 i
Commissioner
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
1000 WashingtoQ $jrept- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
4.
Type: Supplement Card
•
Registration: 203808
PREMIER EXTERIORS AND DESIGN,LLC ' Expiration: 11/28/2023
500 MAIN ST \ r '
FISKDALE, MA 01518
Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration date. If found return to:
TYPE:Supplement Card Office of Consumer Affairs and Business Regulation
Registration Expiration 1000 Washington Street -Suite 710
203808 - 11/28/2023 .Boston,MA 02118
PREMIER EXTERIORS AND DESIGN,LLC
NICKOLAS E.KORTESIS
500 MAIN ST .K�•�
FISKDALE,MA 01518
Undersecretary u s gnature
PREMEXT-01 DROSE
,4coRo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)
46.....------- 9/2/2022
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 pollcy(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CA�NN CT Deborah Rose
NAM _--- _ _
O'Connor&Co.Insurance Agency Inc. I PHONE F
135 Thompson Road t,c,No, � Mb
P.O.Box 1090 I{ ss: — —
Webster,MA 01570 !
INSURERS)AFFORD/NG COVERAGE_-_- NASD*
INSURER A:Western World Ins.Co.
INSURED j INSURER 6_MAPFRE Citation 40274_
Premier Exterior 8,Design LLC INSURER c:
500 Main Street
Fiskdale,MA 01518 INSURER u c — _
II INSURERE'--- - I
_1
j INSURER F: I
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.
MISR IADDUSUBR POLICY EFF : POLICY EXP
TYPE OF INSURANCE
LTR 'INSD MD 1 POLICY NUMBER (MM/D0/YYYYI,(MM/DD/YYYY) LIMITS
A X COMMERCIAL GENERAL LIABILnY I 1,000 000
__i EACH OCCURRENCE s
CLAIMS-MADE ' X,OCCUR INPP8623081 8/30/2022 : 8/30/2023 DAMwGE To RENTED 300,000
i i_- 1 X x i PREMISS$(Ed4�SlQeROet ;
1 i MED EXP(Any one person// S 5,000
—�.-_-- I PERSONAL&ADV INJUR+ :$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER 'GENERAL AGGREGATE $ 2,000,000
X POLICY -: PRCOT- LOC I 1 PRODUCTS-COMP/OPAGG $ 2,000,000
OTHER. E I I
B AUTOMOBILE LIABILITY I i �M�INEEDDt3MGLE LIMIT ;e 1,000,000
ANY AUTO ({fan c X X !'BCYH58 9/15/2022 9/15/2023 I BODILY INJURY(Per Pen an— $ _--AUTOS ONLY ONLY,OWNED ,"AUUTNOpSW�D I j BODILYBR INJURY(Per accident)I$
X AUTOS ONLY hX AUTOg ONLY I(Per accident)AGE +i$
' I I I .s
UMBRELLA LIAR I I OCCUR I EACH OCCURRENCE i$
EXCESS LIAB El CLAIMS-MADE, AGGREGATE $
I DED 1 !RETENTIONS j S —_
WORKERS COMPENSATION _ -
PER QT►�
AND EMPLOYERS'LIABILITY YIN STATUTE I ER
ANY PROPRIETOR/PARTNER/EXECUTNE I ' EL EACH ACCIDENT 1 S
OqFFICER M MBER EXCLUDED? I NIA •
(Mandatory In NH) EL DISEASE-EA EMPLOYE$
If E descN under EL DISEASE-POLICY LIMIT'$
DESCRIPTION OF OPERATIONS below _,
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES ACORD 101,Additional Remarks Schedule,may be attached if more space Is required)
WORKERS COMPENSATION CERTIFICATE ISSUED SEPARATELY.
EASTERN STATES EXPOSITION IS INCLUDED AS ADDITIONAL INSURED ON GENERAL AND AUTOMOBILE LIABILITY POLICIES-WAIVER OF
SUBROGATION APPLIES. WORKERS COMPENSATION APPLIES IN THE STATE OF MASSACHUSETTS '
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
i h)11
ACORD 25(2016/03) CO 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
.1‘‘ PREMIER EXTERIORS AND DESIGN LLC.
MA License#203808 CT License#0664680
PREMIER EXTERIORS 500 Main St. Suite 1 Sturbridge MA 01518
AND DESIGN 413-207-6074
W W W.PREM I EREXTERIORANDDESIGN.COM
Submitted
To: kA} l\ hd G(ew-
k*'eu 32- Oa 4.
MA. 01002- JOB NAME
JOB LOCATION
PHONEgl3„SC)4r 52..z(3 DATE Ir I fLZ ESTIMATOR
We Hereby submit s.ecifications and estimates for work to be performed and materials to b sect' if
5.1 Ia box, 6. . ��'� {
611 ' 401,10t dr\iip ( nor DOfh n 1 dec vt —
210/F.414.:;1/461it,e_ci, v ��� CoE,, �2c L(, ,fir-_
,... ..d. AZ/ti el '' de tf,
n t( 9e� Thy) tgik Ett76- 6
usi er.
Do not do: Construction related permits:
WORK SCHEDULE
Contra or ill not begin the work or order the materials before the third day following the signing of this Agreement,unless specifie h rein,Contractor will begin the work on or about
127%T23— (Date). Barring delay caused by circumstances beyond Contractor's control,the work will be completed by I �( 27 (date). The Owner hereby acknowledges
And agrees that the scheduling dates are approximate and that such delays that are not avoidable by Contractor including,but not mited to strikes,Act of God,Shortages of materials,
accidents,and all other delays beyond its control,shall not be considered as violations of this agreement.
WARRANTY
The Contractor warrants that the work furnished hereunder shall be free from defects in material and workmanship for a period of following completion and shall comply
with the requirements of this Agreement. In the event any defect in workmanship or materials,or damage caused by the contractor,its subcontractors,employees or agents,is discovered
After completion of any job,including cleanup,the Contractor shall,at its own expense,forthwith remedy,repair,correct,replace,or cause to be remedied,repaired or replaced,such
We Propose hereby to furnish mat rial and labor—completejn accordanc with the above specification,for the sum of: > CX"
W `Y .� ��f: G�fi1i1 J . 'V't- '(�i�}�!� dollars($ (C/, C � �-- .
Payment to be made as follows: (e?..
PREMIER EXTERIORS AND DESIGN LLC
% ($ �00 )upon signed contract: — Name of Contractor/Designated Registrant
500 MAIN ST.Suite 1
_%($ I upon completion of h `LA u ra o-e Street Address
STURBRIDGE,MA 01518 413-207-6074
% ($ I upon completion of City/State Phone
% ($ )shall be made forthwith upon Registration No. �j l r
completion of work under this contract.
�(T J�tvfk f.
Name of Salesman
4
Authorized Sign e
elitt , ifl ,(_—_____.—
Acceptance of Proposal: I have read both sides of this document and accept the prices,specifications and conditions stated.I understand that upon signing,this proposal
becomes a binding contract.You are authorized to do the work as specified.Payment will be made as outlined above.You may cancel this agreement if it has been signed by a
party thereto at a place other than an address of the seller,which may be his main office or branch thereof,provided you notify the seller in writing at his main office branch by
ordinary mail posted,by telegram sent or by deliver,not later than midnight of the third business day following the signing of this agreement. Please refer to the Notice of
Cancelation
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY ANK SPACES.
7
1/� 4' ! — zz
Signature t -�E'�"� Date !!/ '`� ��y�Signature Date l/ 1
Owner(s) Salesman
Signature Date
Contractor
12/6/22,2:08 PM Workers Comp Ins-Premier Exteriors.jpg
AtC u®
CERTIFICATE OF LIABILITY INSURANCE PATE`"antony`"
il
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFE oLDEFF,TIPS.
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTERf1HE COVERAGE AFFORDED ABY THE POLICIES
BELOW. THIS CERTIFICATE Of INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERISI,AUTHORIZED
REPRESENTATIVE OR PROOUC@R,AND THE CERTIFICATE HOLDER.__. --... _.... --_. .__.. .__.__ ..._ _._
-" - IMPORTANT: If the certificate bolder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION lS WANED,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 endorsementts).
PRODUCER '- —
NAME:C SWOP Tre)Pears
O'CONNOR 8 COMPANY INSURANCE AGENCY INC 700"E rAX
-wio E.cS, l 9At 9a9 1 IP. (VC.Ws)
PU Boo 10110 "ARE. suu U.oconnU 'ur..olr:.
Webster INSURE, ePe ATFORDING POPERAor TIME et
-__ . _ MA 015711 a ortcs A I IRFRTY MUTUAL EIRE INS CO 218 r;5
INSURED
_. __...
INSURER n,.
PREMIER EXTERIOR&DESIGN LLC msam e
MAURER O S i3ARWETT STREET m4T1ER Es.
BERRYVILLE VA 22611 INSURER r:
COVERAGES CERTIFICATE NUMBER: 717245 REVISION NUMBER:
`HIS IS TO C,ERTII'Y THAT THE PE7t ICIES of INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI00
INDICATED. NolVEITHSTANDING ANY RFOUIREMENT,TERM OR CONDITION OF ANY CONTRAI.e I OR OTHER DOCUMENT WITH RESPECT TO WHICH I HIS
CERTIFICATE MAY.RE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS ANO 1,ONDTIONS OF SUCH Pot LIMITS SHOWN MAY HAVE BEEN REDUCED BY RAID CLAIMS.
Arun Strap _. —— PALtCY Eft POLICY Eel
TYPE OF INSURANCE a WED IND POOCYRVMOER MID IMO,YYYYl fMM/DO/YYYYI) EMITS -....
COMMERCIAL GENERAL LOMA/TY I FAD/QC, ODD/CE $
ao
1 cLANisAtAbr Ili JR i _ _PREEMMISES(E Gtei 1..5_ _...
nI NIA i, pirSON LL Altv lo/ere I$ _
E ENT,AGGREGATE LIMIT APPLIES PER: I GENE11A1 APORTGA IS $
s
I PR09tX„TS LAND:on PL�ttCYL �JEST [.�,�LOG 1 ._� � �'c.
S
/ (OTNEA } COMBINED swat EEMIT ,f
AUTOMOBIt f LNali In lEa OYr?er'1 -t-
A}r'5 AUTO ( I ROM,IuR]RY Ow tan oe,l $
I {
AUlOSJ+/EL' SCHEDULED _N/A ROSILY INJURY tFer BLtYderSi�$
!DI ED AUTOS AUTOS'NFO i r PA°PERTS,DAMAGE f —.—
1��`EII {
�� �AUTOS t
uMexELLAuae 1 cr l;a I 1 t EAe QCTunrastroc IS
EXCESS LAID P•/LeADE1 NIA T , 1 AGGREGATE __...
DEE I RETENTION T I I I
,woRREAsc0MPENSATION I tt '1 I
AND ErAP DYERS L/ASIWTY i `I STATUTE 1 LA
ANYPftLWRiETORPAitTFMRrFXF6]111VE Utz I E L.EAGN ACCIDENT 1 S 1,000,000
A JFEICERIMEMBEREX.q,UDES' WA NIA MA: WC233SB21106011 '09Wt2U2 I i 09/0112022 I T( 1,9Mandatory In NH) EL.Ot0EASE-EA EMPLOYP1$ 1,000,000
Iit yyeg'UnmAAundm I II
SESOPIPTIONOFOPERATIONSSALM DISEASE POLICY LIRE I $ 1,000,000
i
W/A
I
1 I
DE$CRIPOON OF OPERATIONS/LOCATORS a PERICLE$IACOW 1D1.Ada0Nrnsl nonaPA&:MdW,nos It•Meshed 4 n om A0Au is oequMdi
Workers"Compensation benefits will be paid to MassadIusettS employees only PLrsulTIt to Endorsement WC 20 03 O6 B,no authorizabon Is given to pay
aimms for benefits to employees in states other than Massachusetts if the insured hires,or has hired those ompiaYee0 outside of Massachusetts.
This rerbficate of insurance straws the policy in force on the dote that this Certificate was issued(unless the expRatlon date on the above policy precedes the
Issue date of this certificate al insurance). The status of fhis coverage ram by monitored daily by as-OSsrig the Proof of Coverage-Coverage Verlficalion
Search tool at MOW,mass gavfvaftworkefs-cernponsaliontillvssii(stone.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
ALIT HeTRIZFD REPRESENTATIVE
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ID 1988-2014 ACORD CORPORATION, All rights reserved
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