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24D-318 (11) B -2023-0029 95 ROUND HILL RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24D-318-001 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-2023-0029 PERMISSION IS HEREBY GRAN ED TO: Project# PORCH REPAIRS/SIDING 2023 Contractor: License Est. Cost: 30274 DANNY LAROCHELLE 069121 Const.Class: Exp.Date: 06/13/2024 Use Group: Owner: CARPENTER KATHRYN M &DAN E TRUSTEES Lot Size (sq.ft.) Zoning: URC Applicant: LAROCHELLE CONSTRUCTION INI Applicant Address Phone: Insurance: 23 COLLEGE ST SUITE 8 (413)781-5651 46-80322S-02 SOUTH HADLEY, MA 01075 ISSUED ON: 01/12/2023 TO PERFORM THE FOLLOWING WORK: REPAIRS TO PORCH/ SIDING 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 VI LATION OF ANY OF ITS RULES AND REGULATIONS. Signature: t: .Y p . ,/ L, I i' Fees Paid: $197.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner The Commonwealth of Massachusetts J A N 1 0) ')073 � r. Board of Building Regulations and Stindarlds FOR (` Massachusetts State Building Code, 780 C1Ik1R F MjjNICIPALITY VY7 FS'i C� RUILhIN IMt oer, in^.I;; USE . Building Permit Application To Construct,Repair,Renovate OtT moil li''a`1''�'?evised Mar 2011 One- or Two-Family Dwelling This Section For Official Use Only Buildin Permit Number: i-Z 3 21 Date Applied: 1 /' Eu 1�1 a.s ///-2I 1 Zdz 3 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1 Prope ty Addr ss: Nor omP 1 1.2 Assess rs Map&Parcel Numb s LIG ha00C) ►'11 'c� mPr 0 3i- 1.1a Is this an accepted street?yes V no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water pply: (M.G.L c.40,§54) 1.7 Flood Zone Information• 1.8 Sewage Disposal System: Zone: Outside Flood Z Public Private 0 Check if yes Municipal On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2 Owner'of Record: .$ VGr' CCC- on-v-el NO(AtNaM ) (t a 1 UtC Name(Print) City,State,ZIP qz, Rojo()() H-,,1k ( () No.and Street Telephone Email Address j SECTION 3:DESCRIPTION OF PROPOSED WORK' (check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 111/1 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief De`cription of Proposed Work': (e��( po rcio) s, Oily,' &� lZ S ?)�'� , {LoL SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ .cp Jtarniarci uilding Permit Fee: $h Indicate how fee is determined: City/Town Application Fee 2.Electrical $ _- _ 0 Total Project Cost3 (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ I Suppression) Total All Fres: *1 3 Check No.g1(4 �o Check Amount: Cash Amount: 6.Total Project Cost: $301 Z ,WI�/\ 0 Paid in Full • e ... : • Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS �f„C11Z` /_/`3)Z_ nn L C.t(C)c\ry\\Q License Number Expiration Date Name of CSL Holder U t3 cc ``epys� U List CSL Type(see below) No.and Street Type Description 1\R , m O\/�V is U Unrestricted(Buildings up to 35,000 cu.ft.) V�`�J{ ' R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding �`2 -9�1- 1 ^Ic%�1 a �_„�. o, SF Solid Fuel Burning Appliances ��J �`(U�`,�-ll�J!�l I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 157A J21/ Zc1 OQ1n "`(vcy,e\ HIC Registration Number Expiration Date HN Company Neme or HIC Registrant ame 3 cw suv\2t) da lca.'neikeConan2en( nVOin and Stree o` , 'n� OI ,��ts1 Email address City/Town, State,ZIP t r 1�1 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 Issuanc the building permit. Signed Affidavit Attached? Yes 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 LffC1 ,\`C Cons ,, Vc`. en to act on my behalf,in all matters relative to work authorized by this building permit application. Coca a- ti I4I?3 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 of my knowledge and understanding. !�cn LorcthQ 11\ I Z3 Print Owner's or Authorized Agent's Name(Elec me Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered con actor (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 fo d 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/potches t Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" DocuSign Envelope ID:812F59E7-6F6C-4662-9EF2-7DD5E85D0945 1 LAROCHELL C O NST RUCTION CO. INC. 23 College St/Suite 8/South Hadley, MA 01075 P: (413) 781-5651 January 4th 2023 To Whom It May Concern, I authorize Larochelle Construction to apply for a building permit at 95 Round Hill Rd for porch repair, siding, gutter and trim replacement on my behalf. LIOG ueipmd by: i"k 1/4/2023 erereeec t.,r live... Customer signature Date Kathy Carpenter Please print legal name for contract documents Eooa,egned by: Visft.1-.�ocllU• 1/4/2023 eoeec57e1Mle... Contractor signature Date Larochelle Construction Inc—Dana & Kathy Carpenter 95 Round Hill Road Northampton, MA 01060 `lig.- The Commonwealth of Massachusetts = le Department of Industrial Accidents t1/4 �h ! Congress Street,Suite 100 ; -,� Boston, MA 02114-2017 -' www.mass.gov/dia otters'('ompcnsation Insurance Affidavit: Builders/('ontractor%/Electrici*ns/I'tutnher$. To BE I ILE1)%%till THE PER%ITTI\(:.U'TNORITV. 1 ) )licant Information ,C� /�� (� (, ��,non Pri ., i.,., Nance(tiusirtrssUrg,nti Organization Individual): s ( 1I ( \� \\C CC)1 , lc. 1-o e Address: 2 J C.(711( SI- So 1)' HctC Phone#:g 13 e— abS e City/Statt:/Zipx1 i�+ / Y 1 T��t � Are yams am i upIIyer?Cheek the appn,I riate hot: Type of project(required): t 1. J tut a employ with 2 employees ltuII and or part-time I..' 7. Q New construction 2.171 1 ant a sole ltrupnvetot or ltmint7thtp and hate no enµ,ltr.ces w orkutg lot me in 8. n Remodeling an!, pa cacity.[No K\Hl.er etanp.ntxorram ren amed.J u 30l am a lateno 1tt1 doing all*tier myself.[No%oriels corm.InwlrautLe v.-Netted"" 9. 0 tkniolition )W 10 0 Building addition A.Q I am a kus meor.1tes and will he hater contrar1txrs to conduct all w!Mk on ray literary_ I will e1Lsute that all emutlaaiurs either Jmue%micas'oara t±misatxm tmutanxz to WIC suit; 1 I.o Electrical repairs or additions gttxoptxta"ts N ith no ctnpluvee... 12.0 Plumbing repairs or altditioris 301 ant a:item al contractor atop 1 have heed the,nth-cuntt:wtnts listed on the atrad ed sheet 13 'r"')l repairsrepairsthese wlh-canna croi v lose.tnployecv and have s utter,craw.ra vut:wce.• 1r'r,:J�" r1 14.Q Other, 6.Q iA c an:a 1:VP pinratlron and 31,tAk-ess h:ri a cast�ised theca n plui ofL'.tL'ritp.lalat t ci NI(at.v. - _ Ice'!'ilt'Yt.and Vte hate no emttelusecs.l'lo tuners comp.nistaunc'Cleguraed.l 'An?:applicant that chocks lea►al must also 611 out the netnni tsdtrw shuatng their woilers'compensation arttley nttuctnatvual.. ' IlonaeoM.eel s who sulvntt this aLTnkatit nutncating they arc dump ail w-nrk and thin Ifni c outside eon-imams mint suttnut a new aL14au it srldicatting much. :t`llrluactuts that cheek this hot must attached an:stIulitionui sheet spurs irip the na:lnc a"ltIt su.ly.ottataiaoes and state whether in not those Rand ice Jtalse employees. lithe sub-contractors I'a.trc eair.10+CO.they ntrlst ptusitIeihcir xtwkcrs tv"trip.moire;. nuonivi 1 aai nh employer that i.prur'iding warberA"compensation insurance far my employees. Below is the policy and job Aire information. InsuirarrLe t_'ewapany Name: 6\f,/`�� t� v ,` � `�j, S"`U �( (�S 1 (1C //,� � I',.r1tL.y ,;or Self--ins.Lice#: A V - �3(,C)_ - `S �� -0 Expiration l?rte: k1(-Z- 1 3 66 Job Site Address: GZ (2C WOO A-) \ R6 _City./StateiZip: 1v(3041) �")t ()IAttach a copy of the Nurkers'compensation policy declaration pate(showing.the policy number and expo Hun date). Failure to secure coverage as required utakr M(it.e. 152. §2SA IN a criminal ti iolattun punishable 1►s ;l fine up to S1.500_0) anti or one-year irnprisonment.as well as civil penalties in the form of a STOP AI)RK()RI)1:R and a fine of up it'S_'5(y.(1()a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the I)IA lot instil mice coverage verification. I do hereby certify under 1/re pains and penalties of perjury that the information pruridal abate is true and correct. r.T Signature: Date: 1 1 > 1 �-- Phone t: '-1'-1 �ca\- sus Official use only: Do not write in 1hiA area.to be completed by city or town officist ('its or Tosco: Permit/License it Issuing:lnthor•ity (circle one): 1. Hoard of Ilealth 2. Building Department 3.('ivy/fawn Clerk 4.l'kctrical Inspector 5. Plumbing Inspector 6.Other ('untact Person: Phone It: __ City of Northampton - S`5 Ste, r Massachusetts `� ( DEPARTMENT OF BUILDING INSPECTIONS a' C.;1 r r� 212 Main Street • Municipal Building r.�ai Northampton, MA 01060 :111/ 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: T , )\ uns The debris will be transported by: Name of Hauler: \. Signature of Applicant: � _--�" Date: 1 (3/ZS THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual DANNY LAROCHELLE 1; _ Registration: 152467 .- 23 COLLEGE ST. SUITE 8 t` 1 Expiration: 08/29/2024 SO. HADLEY, MA 01075 '� • \._\` • 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 dab. If found return to: TYPE:Individual Office of Consumer Affairs and Business Regulation Registration.n Expiration 1000 Washington Street -Suite 710 152467 08,29/2024 Boston, MA 02118 NNY LAROCHELLE NNY S. LAROCHELLE COLLEGE ST. SUITE 8 .d G 4664,04 . HADLEY. MA 01075 I Inriorenr•rolnn, IaF .roliri tin nn1h urn Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Cons IonVSrvisor CS-069121 Ipires:06/13/2024 DANIEL S LA;BOC -41 23 COLLEGEEST.S SOUTH HADL' Y MA e" O • • COnimissiort;.r n r C-;;_;t Construction Supervisor Unrestricted -Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters) of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Forinfnrrr.afinn ab o..f♦his linensc . ... .................. ......... .................. Call(617)727-3200 or visit www.mass.gov/dpl 1 i • MASSACHUSETTS DRIVES !k • ey ISS <t NUMBER 0611512022 S56740480-` , 06113/2027 06/13/1972 b CLASS !:REST END D NONE NONE ;LAROCHELLE DANNY SIMON I+1, 8 BRIAR SPRING LANE S HADLEY,MA 01075.1381 E'Es HAZ - :v _I SEX M .HOT 5'-05'' /� DO 06,1S'IU22 Rev 02122/2011.a, 06/13/j 2 • • • Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/04/2023 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: Applied Risk Insurance Services, Inc. PHONE FAX 10825 Old Mill Rd (A/C,No,Ext): (877)234-4420 (Nc,No): (877 234-4421 Omaha, NE 68154 A-MAIL ADDRESS: PRODUCER (877)234-4420 CUSTOMERID# INSURER(S)AFFORDING COVERAGE NAIC N INSURED INSURERA: Continental Indemnity Co. 28258 INSURER B: Larochelle Construction, Inc. INSURER C: 23 College St Ste. 8 INSURER D: South Hadley, MA 01075-1153 INSURERE: CTL 1273 1722398 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYYI (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence). $ CLAIMS MADE OCCUR MED EXP(any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO- PRODUCTS-COMP/OP AGES $ POLICY JECT LOC $ AUTOMOBILE LIABILITY ANY AUTO (Ea accident)n SINGLE LIMIT ALL OWNED AUTOS BODILY INJURY(Per person) $ SCHEDULED AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS PROPERTY DAMAGE (Per accident) $ NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR _ EACH OCCURRENCE S EXCESS LIAB CLAIMS MADE AGGREGATE DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY X TORY LIMITS F1?i A OFFICER/MEMBER EXCLUDED?ANY PROPRIETOR/PARTNER/EXECUTIVE y J N/A 4 6-8 0 3 2 2 5-0 2-2 0 06/02/2022 06/02/2023 E.L.EACH ACCIDENT $ 1,000 r 000 (Mandatory in NH) E.L,DISEASE-EA EMPLOYEE $ 1,0 00,00 0 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach Acord 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Dana& kathy Carpenter SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 92 Round Hill Rd. BEFORE THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED Northampton, MA 01060 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIV�� 1 / 111 1783118 ACORD 25 (2009/09) G1988-2009 ACORD CORPORATION. All rights reserved DATE(MM/DD/YYYY) ACORN® CERTIFICATE OF LIABILITY INSURANCE 1/4/2023 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 The Dowd Agencies, LLC PHONE Diane 437- 0 CISR FAX 14 Bobala Road (ac.No.Ext): 413 437-1062 (A/c,No):413-437-1462 Holyoke MA 01040 ADDRESS: dlafleche©dowd.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Selective Insurance Company of the Southeast. 39926 INSURED LAROCON-01 INSURER B:Selective Insurance of South Carolina 19259 Larochelle Construction, Inc. 23 College St. Suite 8 INSURERC: South Hadley MA 01075 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2028416867 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 SUBR POLICY EFF POLICY EXP LIMITS LTRINSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY S 2438601 10/1/2022 10/1/2023 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $1,000,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X jE X LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY A 9108364 10/1/2022 10/1/2023 COMBIaaccidNEDent)SINGLE LIMIT $1,000,000 (E ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED Xy NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) A X UMBRELLA LIAB X OCCUR S 2438601 10/1/2022 10/1/2023 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 • DED X RETENTION$n $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LI IIT $ A Installation Floater S 2438601 10/1/2022 10/1/2023 Limit $150,000 Deductible $1,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re; Dana&Kathy Carpenter Certificate Holder is Additional Insured per written contract 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. Dana & Kathy Carpenter 92 Round Hill Rd. Northampton MA 01060 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD