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38A-025 (2) BP-2023-1429 34 RUST AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 38A-025-001 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-2023-1429 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2023 Contractor: License: Est. Cost: 3500 BRIAN MITCHELL 115753 Const.Class: Exp.Date: 12/20/2024 Use Group: Owner: PITTORE CLIVIA Lot Size(sq.ft.) Zoning: URB Applicant: BRIAN MITCHELL Applicant Address Phone: Insurance: 316 BROOKSIDE CIRCLE (413)949-2300 WCC50050247022023 FLORENCE, MA 01062 ISSUED ON: 10/16/2023 TO PERFORM THE FOLLOWING WORK: STRIP AND REROOF 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: , r Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner t The Commonwealth of Massachusetts - • - yf Board of Building Regulations and Standards ` FOR MLJNICIPALLIY Massachusetts Stye Building Code, 780 CMR -us _ - Building Permit Application To Contract,Repair,Renovate Or Demolish a R edk�-`- +€E I V E i_) One-or Two-Forruly Dwelling. • -. This Section For Official Use Only QG� 1 3 2023 . Building Penh t Number. (jP.2 3- I`"12� _ Date Applied: . . . ,_ ,/ ' e -1 k zMir;INSPECTIONS rJr,,J 1<��75 i O ,rr,� r N..AA,- i Building Official,(PtntName) Sign alTire Date-_.. SEC'1`lON 1: SL'1'H,INFORMATION 1:1 Pt e drlr-ess: 1.2 Assessors Map &Parcel Numbers' •- 1.1a Is this an accepted sllcet?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.GL c.40,§54) 1.7 Flood Zone Tnformation: 1.8 Sewage Disposal System: Public Private❑ Zone: _ Outside Flood Zone?Chcck if yes❑ Municipal 0 On site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: aii'v1a /i'fi70 re - "10{TA c? �1ck, , 44/9 v106c> Name(Print) City,State,tiP . y /)S'i Ave .9/3-5eN-i721 cli y 6eeL QG J�oio�n, No. and Street Telephone Email Addre ' SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply) New Construction❑ Existing Building El'/ Owner-Occupied 0 Repairs(s) 0 Alteration(s) ❑ Addition 0 Demolition 0 Accessory Bldg. 0 NiTmber of,Units Other 0 .Specify: .. . Brief Description of Proposed Work 2: n f2 4'?c v e. A /OGe £.r.4` S f-tsd9' A yin--/f 511,,yr frc; - SECTION 4: ESTIMATED CONSTRUCTION COSTS . Item . Estimated Costs: _ Official_ lse_anly_____ ._ . -- -. . -- abor and PMMend-) `1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2.Electrical $ • 0 Total Project Cost'(Item 6)x multiplier 'x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List . 5.Mechanical (Fire $ Suppression) Total All Fees: • ' )4i). . Check No. �eck Amount ` Cash Amount 6.Total Project Cost: $ 1'J ❑Paid in Full ❑ Outstanding Balance Due: • MA Historic Commission Review Process: • Is their review completed? ' Yes No . SEL TION 5: CONSTRUCTION SERVICES- • 5.1 Construction'Supervisor License(CSL) ? c:5 /iS 7$3 ! 'a.v 2 UZ�/ /rl n ✓J'I, •e,/I License Number Exp' on ate • Name of CSL Holder . !� A ' List CSL Type(see below) VC - . 37A /3'arifrs C•`c'& . No.and Street • Type - Description /rim >1C-2 I!'� C�I(� 6 - U1✓ • Unrestdctad(BudrTmg up to 35,000 cu. it) f` 4 R. Restricted 1&2 Family Dwelling - City/Town,State, ZIP _ M M • asonry RC Roofing Covering - WS Window and Siding L j • SF Solid Fuel Burning Appliances 1/13 9LI7 GG" 23UU kA.,Nc/1 jy,(yi•j(,GGir, I Insuiaiien Telephone F.anail addM.s D Demolition 5.2 Registered Home Improvement Contractor CHIC) t//9—r✓` 1°Iri�` re./l • 1, 7( .27 7 i, 1! HIC Registration Number iration Date HIC Company Name or HIC Rees-Of-ant iant Name - - 3/ A90 cd�S.G"cA' Cry-c- �, No. and Street • T', C.1 N e' 1"1EI�C�i cam . . . P i&,-e."74-P, i4 (�iDe z 1/1.3` M 9-23e 1 ess City/Town, State,ZIP Telephone K D C.i n C- PI • • - 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 Ca No ❑ ' SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S.AGENT OR CONTRACTOR APPT,IFS_FOR BUbDING PERMIT' I,as Owner of the subject property,hereby authorize sjrr,ff-r✓ /27, �./ to act on my behalf in all matters relative to work authorized by this building permit application. &//L. q- /21t ,r? - - • /0/i3/ Z023 • Print Owner's Name(Electronic Signature) Prate • SECTION 7b:-OWIIER1.OR AIITFORIZED AGENT DECLARATION . . • . • By entering my name below,I.hereby atest snider 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. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NO L'LS: 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 . _ _ _ __ • •l• ••program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at • WWW.m ass.Pov/oca Information on the Construction Supervisor License can be found at www.mass.auv/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 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: c3V S/ A--ts'•a The debris will be transported by: 05A Po divj The debris will be received by: U5/ Building permit number: Name of Permit Applicant n al Ki/. Ail, - // // /h? 3 .- Date Signature of Permit Applicant I HIV .uininunweuun uj lr:ussus.reu3eii3 Department of Industrial Accidents Office of Investigations Lafayette City Center 2 Avenue 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): / ,r 9(,�G Ph / 1 i 11�/ / ��ley 1 t C A}1 ) ,.i1-7 J Address: I/ "�; h 4 // 5,1 .5fr-2 -l��< <�sg. CJ1jUzi City/State/Zip: 5 {-7 ✓vi.yg; rJ/iv LJ Phone #: 9/3— l/9- 2,3oci Are you an employer? Check the appropriate box: T)pe of project (required): 1.❑ I am a employer with 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. El Demolition working for me in any capacity. employees and have workers' q Building addition [No workers' comp. insurance comp. insurance.* required.] 5. aWe are a corporation and its 10. Electrical repairs or additions officers have exercised their 1 1. iumbing repairs or additions 3.El I am a homeowner doing all work 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' 13.0 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 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: Lt\j-cil-ti r t L,pi npito// (�-,�a 6,rev? ,7-,r) ' Policy#or Self-ins. Lic.#: htJ C.C rO 0 S Q 2 tr7 0 Z 2 u 2.3A Expiration Date: 372 rl2 G Z L! Job Site Address: 39 /Z/yf AV' . City/State/Zip: /VC flJit/,-t J MA- . 0 //)Se 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 unddeerr t rtthepains and penalties ofperjury that the information provided above is true and correct. Signature: _�` Date: A'//.�l ZG Z Phone#: /f 3 -- 9 -/' �L.Jao / 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 3fCity/Town Clerk 4.0 Electrical Inspector 51:IPlumbing Inspector 6.0Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s) name(s), address(es)andphone number(s) along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111-1750 Tel. (617) 727-4900 or 1-877-MASSAFE Revised 7-2019 Fax (617) 727-7749 www.mass.gov/dia 4C IJ? CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYV) 06/30/2023 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 poliey(iss)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). RODUCER CONTACT Samantha Babilonia NAME: Slera Group,Inc. PHONE (413)586-0111 FAX (A/C,No,EX1): (A/C,No): (413)5t36-6481 Nebber&Grinnell Divls!on ADD ESS: sbabilonia@webberandgrinneli.com North King Street JNSURER(S)AFFORDING COVERAGE NAIC a7 Vorthampton MA 01060 INSURERA: Associated Employers Insurance 11104 NSURED INSURER B: Kingdom Building and Contracting,Inc. INSURER C 318 Brookside Circle INSURER 0 INSURER E: Florence MA 01062 INSURER F: OVERAGES CERTIFICATE NUMBER: Master:2023-2024 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. VSR ADM MAR POLICY EFF POLICY EXP _TR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE + OCCUR DAMAGETORENTED PREMISES lEa occurrence) $ MED EXP(Any one person) S PERSONAL&ADV INJURY $ AGGREGATE LIMITAPPUES PER. GENERAL AGGREGATE $ _^ POLICY 7 PRO- JECT LOC PRODUCTS•COMP/OP AGG S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea acvdent) ANY AUTO BODILY INJURY(Per person) S OWNED ^ SCHEDULED BODILY INJURY(Peracc'denll $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accdent) UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION S WORKERS COMPENSATION PER OTN- AND EMPLOYERS'LIABILITY STATUTE ER Y/N 100000 A ANY PROPRIETOR/PARTNER/EXECUTIVE N NIA WCC50050247022023A 03/25/2023 03)25I2024 E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 100,000 It yes,descr,be under 500000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S , DESCRIPTION OF OPERATIONS/LOCATIONS/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 Afj ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Ccrnrr.or�t+eaith of Massachusetts Division of Professional Licensura Beard of Building Regulations and Standards ? "!str::c.tJ . Ss:tk*r✓is r C S-115733 Expints: 12'2O/2D24 BRlAli L *11 ChELI. 31S SA�rDKSIDE CHICLE FL:IRE r E kisAt I i62 Commissioner s._ ._-- a►rest-14es! -£i#izifugs of any use group which tontein ;ass lien 3°.. :able fret t9S1 zui is rfeters' of entdesed spare, Failure to P:.ssess a Z.;irrertt edition of the >gassachusette State Building Codt is cause for revocation of ih►s li:.ense. For in#cr ation about this stem Call f'.r',•72?-3231? or visit wsrw : ese,govidpl 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 Registration: 187134 BRIAN MITCHELL D/B/A KINGDOM BUILDING&CONTRACTING Expiration: 04/04/2025 316 BROOKSIDE CIRCLE FLORENCE, MA 01062 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: Individual Office of Consumer Affairs and Business Regulation Registration Expiration_ 1000 Washington Street -Suite 710 187134 04/04/2025 Boston,MA 02118 RIAN MITCHELL /B/A KINGDOM BUILDING 8 CONTRACTING RIAN MITCHELL 4 TURNBULL ST / % <(//; PRINGFIELD.MA 01104 C� . . . . DATE(MM/DD/YYYY) Ro® CERTIFICATE OF LIABILITY INSURANCE 07/07/2023 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 I 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 Elizabeth Carballo,CISR,CPIA NAME: Finck&Perras Insurance Agency Inc. PHONE (413)527-5520 FAX (413)527-5970 (A/C,No,Ext); (A/C,No): 6 Campus Lane E-MAIL bcarballo@finckandperras.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Easthampton MA 01027 INSURER A: Main Street America Assr Co 29939 INSURED INSURER B: KINGDOM BUILDING&CONTRACTING INSURER C: 316 BROOKSIDE CIR INSURER D: INSURER E: FLORENCE MA 01062-3552 INSURER F: COVERAGES CERTIFICATE NUMBER: CL237707338 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-S%JBR - - - - -- 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 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A MPP3465C 06/05/2023 06/05/2024 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER- GENERAL AGGREGATE $ 2,000,000 PO- POLICY JE° ' LOC PRODUCTS-COMP/OPAGG $ 2,000,000 Individual Risk Mod Prem $ OTHER: _ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED - S• CHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY _� AUTOS HIRED N• ON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB ^- CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ 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 apace Is required) Proof of Coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Springfield ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Columbus Ave AUTHORIZED REPRESENTATIVE Springfield MA 01119 t (l8.7hxrY'ld ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD