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31A-032 21 FRANKLIN ST BP- 2011 -0716 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 032 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: PLUMBING REPLACEMENT BUILDING PERMIT Permit# BP- 2011 -0716 Project # JS- 2011- 000862 Est. Cost: $47000.00 Fee: $282.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: LOUIS TONELLI 65242 Lot Size(sq. ft.): 37592.28 Owner: SILBERSTEIN HARVEY & JULIE Zoning: URB(100)/ Applicant: LOUIS TONELLI AT: 21 FRANKLIN ST Applicant Address: Phone: Insurance: 35 FLETCHER AVE (413) 323 - 5074 BELCHERTOWNMA01007 ISSUED ON:3/10/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN 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: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 3/10/2011 0:00:00 $282.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2011 -0716 APPLICANT /CONTACT PERSON LOUIS TONELLI ADDRESS /PHONE 35 FLETCHER AVE BELCHERTOWN (413) 323 -5074 PROPERTY LOCATION 21 FRANKLIN ST MAP 31A PARCEL 032 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out / da e?. Fee Paid Typeof Construction: REMODEL KITCHEN New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 65242 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOJYMATION PRESENTED: VApproved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay O 3/ Signature of Building •fficial Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. ����� City of Northampton � " Building Departme � - ° x kt p } y r 212 Main Stree i 9 ail Room 100 ;� orthampton, MA 01060 � a _ - E � 4 3- 587 -1240 Fax 413- 587 -1272 k ' � R' APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAM DW ELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: � J� Map - L, " ot� Unit v ` � � `�k� Zo Overlay District Elrrt St. District CB District: SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: J J Ih e S . 1-€'1\D 17-111-11M21-1 LA'. , �1e. - ctk ;(r , M Ak Name (Print) Mailing Address: sl ` v0(oC7 Telephone Signature 2.2 Autho d Agent: Name (Print) Current Mailing Address: (A * Sign Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item m) to be Official Use Only completed Estiated Cost by permit (Dollars applicant 1. Building k , 1,00 00 (a) Building Permit Fee 2. Electrical / i� . timated �!/l (b) Es Construction Total fro Cost (6) of 3. Plumbing / OD• Buildin Permit Fee ' ( G 4. Mechanical (HVAC) 5. Fire Protection -- O 6. Total = (1 + 2 + 3 + 4 + 5) 6 �,L7(�'�•C7O Check Number /o7�d� p�p� This Section For Official Use Only Date Building Permit Number: Issued: Signature: Build Commissioner/Ins o Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information ' Existing Proposed Required by Zoning This column to be filled in by Building Department ; Al ' Lot Size 1 i i , i Frontage ? _ it `s, Setbacks Front s � b I Side L: .. I R:L- i L:f_...__.___. R:' 1 4 Rear 1 . I I Building Height i j = I 3 Bldg. Square Footage € I I : % r - - - - 1 I I 4 Open Space Footage % (Lot area minus bldg &paved ( -_ 3 parking) 1 _ # of Parking Spaces l 1 * ° Fill: r .,...—_. . , i r ____ _ (volume & Location) II ' i A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW le YES 0 IF YES, date issued:1 IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 9 YES Q IF YES: enter Book 1 Page ? and /or Document # —.- B. Does the site contain a brook, body of water or wetlands? NO irk DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ,Date Issued C. Do any signs exist on the property? YES Q NO *r IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO (r# IF YES, describe size, type and location: 1 E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • . . ■. • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ® Roofing ❑ Or Doors ®. Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [El Siding [0] Other [0] Brief Description of Proposed Work: VA< %-kl7r7V Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes )(, No Plans Attached Roll - Sheet 6 , alfj ` Ori ditif t ©e aiha r s O i. itaw s: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN , OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 'J J I ■ I b -1-e, ►"' , as Owner of the subject property II ,,,, ll f / ,,, l �,,^� hereby authorize 1k k I V —) /�vc , G� �Lt� � e,6`7 to act o behalf, in all matters relative to work authorized by this building permit application. A I, ;(,( S.Otok I Signature 'M ner Date I, k )15 Ti Ut / -K(v= 1 - , 4- 1 - 3 1/1( 1 - t v� «� , as Owner /Authorized Agent hereby declare that the stat ments 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. • ame Signature of Y ner /Agent ` Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: , , Not Applicable ❑ Name of License Holder : /0k) t " \/ / `' " (a'6 a' ✓ License Number ■Ao 000') yj(te \ 1 ( Address Expiration Date (4k 'o) - Telephone #13 ` s "(ste " r °asi >, r �, .� it►t�n . o 1 d ni; ... ; a "7-Q7772122 Not Applicable ❑ Company Name Registration Number 6.6(1..tk G - Ak1 S\1A k t Address Expiration Date - 1U - erzAJI -4 ) 1J�„� Oto 7 Telephone (4 5 — SECTION 10- 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 I'J No...... ❑ '*Ckwiteefttiriptioit The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature The Commonwealth of Massachusetts Department of Industrial Accidents = . -zigi. _ t Office of Investigations • c = l ^ y 600 Washington Street =�= a Boston, MA 02111 � � www.mass gov /dia • -Workers' Compensation Insurance Affidavit Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print Legibly Name ( Business /Organization/lndivichtal): )ly 'o61..set,i,1 /2- L--ii-3 r Val j Address: 5 Ci,�iCU - l� - . .. City /State/Zip: of ,1,4 _, -M .( c0i Phone. #: C4i) - �° 7 - Are you an employer? Check the appropriate box: Type of project (required): / 1.0 I am a employer with 4. 0 I am a general contractor and I 6. 0 New construction employees (full and/or part-time).* have hired the sub- coniiactors 2. I am a sole proprietor or partner- listed on- the'attached sheet 7. ❑ Remodeling ship • have no, employees These sub - contractors have. .8. Demolition working for me in any capacity. empl and have workers' . - • 9 Buil = addition [No workers' comp ins - comp. mcnranze # ...._ _ required.] 5. 0 We are a corporation and its 10 0 Electrical repairs or additions j officers havexercised their 3.0 I am a homeowner doing all work .r 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0. Roof repairs • and we have no c. 152, §1(4), insurance required] f 13.0 Other employees. [No workers' comp. insurance regmred.J 'Any applicant that checks box #1 must also fill out the section below showing their Workers' . compensation policy information. t Homeowners who submit this affida .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-ornot those entities have employees. If the sub - contractors have employees the 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: . Policy # orSelf.ins. Lic. #: Expiration Date: Job Site Address: City/Stafe/Zip: Attach a copy of the workers' compensation policy declaration page•(showing the policy number. and •exxiratton date). .. rinre to- secure coverage - - f .. + Fi ge.as required imd"ci Section 25A'ofNIGI: C. 152 can lead�in fireimposition of 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 a copy of this statement maybe forwarded to the Office of Investisahons of the for'insurance coveraee verification. _ ._ -.:. .;.1 -: -, _ "do her ertif, under the pains penalties ofperjury .that the rnformatconprovuledabov is u e_aad-correet Signature. �_ .. ff Da 1 l Phone 0: (41 V ' ' 4 - - • • • Official use only Do not write in this area, to be completed by city or town offcciaL City or Town: - Permit/License # Issuing Authority (circle one): .'1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: • r :, HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two -year period shall not be considered a home owner." The building department for the City of Northampton wants person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform. work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper P.ermits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to Date Address of work location J4 -62, „ . 4 4 OW _ face o onsumer A airs an.. usiness e u ation 11 z�►_ � g 10 Park Plaza -Suite 5170 � Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 156978 Type: Individual Expiration: 8/21/2011 Tr# 287809 LOUIS TONELLI LOUIS TONELLI - - P.O. BOX 497 BELCHERTOWN, MA 01007 - Update Address and return card. Mark reason for change. Address ❑ Renewal E Employment Lost Card tiPS -cm sa 50M- 04/04- G101216 ��/ �J J717. 6o n monwea4 0 itaaocultaxseac Office of Consumer Affairs & usiness Regulation License or registration valid for individul use only = ; =V _ =1t HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation ( .‘ t _ 1 Registration: 156978 10 Park Plaza -Suite 5170 � Expiration: 8/21/2011 Tr# 287809 Boston, MA 02116 - Type: Individual LOUIS TONELLI LOUIS TONELLI 35 FLETCHER AVE. BELCHERTOWN, MA 01007 Undersecretary Not valid without signature , 1,1 65242 00 LOUIS A TONELLI 35 FLETCHER AVE BELCHERTOWN, MA 01007 8/10/2011 3591 Silberstein Kitchen Confirmation 1 330 3/4 t . CI I10 11 112 213 r PERIMETER CABINETS CHERRY /CARMEL STAIN #6 •9 • 2. 1" SQUARE INSET - -. -. PROVIDENCE DOORS .16 + # 1 4 F LAT & 5 -PC DRAWER FRONTS V -33 KNOBS, V -32 PULLS --13 #8 _ es ANTIQUE BRONZE HINGES .. g .:::::. : # 15 . . 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I;> i::::: i-::::. . v.:: -,.:::: . :.:::: :::.: ::::: ::::: -.. 1 i 4 :::::::':::::::::::::::::::::::::::::::::::::::::::\ } 330 3/4 t i Job Number: 61407 Crown point Cabinetry Designer: Debra Foster Client Name: Harvey & Julie Silberstein PO Box 1560, 462 River Road, Claremont, NH 03743 Date 02/08/11 1 800- 999 -4994 800 -370 -1218 Fax } 2181/2 i' 'I 32 l' 42 'I' 144 1/2 i 32 } 42 9 3b 35 1/2 34 24 'I' 34 1/2 1 40 -1- - , o ' I ! .. - t 1 4- ,) _ __ ___, ______ _________ _ , \ ( . ti _ , 1 _ - ._ ,1 ; .0 _ .... _ _.... ...... # 9 - co _ - - -- _ - - - ---- - _ — - -- ... 1 L ■ o I # 8 # • a CHERRY CARME CABINETS I — N - 1 r V L L •F ;F ! --- I M ( 1 , I , n =�--� 4 4 ' I 1 I . � . #1 #2 #3 #5 #6 1 DOUBLE BASKET TRASH 32 T 42 1 9 344 35 1/2 1 � 8 24 )1' 48 1/4 J 24 7/8 3!4 ■ Job Number: 61407 Crown Point Cabinetry Designer: Debra Foster Job Name: Silberstein Kitchen Confirmation PO Box 1560, 462 River Road, Claremont, NH 03743 Date 02/09/11 2 1 Client Name: Harvey & Julie Silberstein 800- 999 -4994 800 -370 -1218 Fax . . 1701 /� 'I' — 1 / . N. No iN 1 I I 1 CV I ° BASE CABINETS - CHERRY /CARMEL I PULL OUT STORAGE CUTLERY DIVIDER _— f i 1 f q ua - -7. .a r =-_c .tnwa:,,_—.....: a. n: .:.::_ ^�r. :. xr :-':: xa . c�-�! I.-...J ' --I.—i t , ' ' 5 .. __ _ .__.. . .�.�:WI 5 :.... m:- ,.mWK.: r \_. _ _._ —_J Y ....... __- .....__. 111 1 1 I i 1 J L 1£ C � 1 �� 1 -� � - -tea — . I _ :\ i #11 I #12 #13 1 5/16 MAGIC CORNER 3 ROLL OUTS 3 ROLL OUTS 11 48 -25 1/4 - 48 1 48 i 1 989/16 1 2323/16 s Job Number: 61407 Crown point Cabinetry Designer: Debra Foster Job Name: Silberstein Kitchen Confirmation PO Box 1560, 462 River Road, Claremont, NH 03743 Date 02/09111 3 Client Name: Harvey & Julie Silberstein 800- 999 -4994 800- 370 -1218 Fax i BASE CABINETS - MAPLE UNFINISHED 1 851/2 f .1-24 16 N A -4 \ - I I \ �_ �� r' s--s i rz,.: v oi ch M L1I1H1I . \ #15 #14 #16 1 TRAY DIVIDER 1 DOUBLE BASKET TRASH RIGHT IIDE 1 41 1 /2 . 1' 44 f 40 I ■ • 1 851/2 i N i r,. IT" N M N M M Ln V 1 M co I \ #17 #18 #19 ` } 24 1' 581/2 Jr LEFT SIDE Job Number: 61407 Crown Point Cabinetry Designer: Debra Foster I Job Name: Silberstein Kitchen Confirmation PO Box 1560, 462 River Road, Claremont, NH 03743 Date 02/09/11 4. Client Name: Harvey & Julie Silberstein 800- 999 -4994 800- 370 -1218 Fax 03/09/2011 12:47 1 JSTOLAR PAGE 01/01 CERTIFICATE OF LIABILITY INSURANCE DATE IBMDDITYYT) 3/9/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOTS 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. - -, RTANT 1 me C : - holder Is an • .' IONAL IN -' I - D. the poilCy(IES) must be B • orsed. If - 1 : - . . •"` IS W • • , subject to the terms end conditions of the policy, certain policies may i quire an endorsement. A statement on tills certili:ate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER THE J. STOUR INSURANCE AGENCY INC. N0. EM a WC, Nep 2001 CALICOS ROAD / PD SOS 8 ADLMESa, TERSE' RIVNPS, KA 01080 CUSTOMER lO N: INSU@Lii(El AFFORDING COVERAGE NNC • INSURED impost ABCO't'TSaAL'E IRS'ORANC$ COMPAN LO17I13 TOMELLI IIPJ{IRET[ e - TRITON CONSTRUCTION SERVTCBS, i.LC BtBiL11ERC: PO BOx 497 IN6IMERD: WEII=MMW OWL MA 01007 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIC0 na)TCATED, NOTWITHSTANDING ANY REtNRREMENT, TERM OR CONDmON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED DR 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. TYPE OF exexe RCS eisR RNs pommy NUMBER IN1eCUlYYYY) owlet WWI LIMITS Gk71eRAL CP81206644 5/10/20105/10/2011 Ei9H rrerme $1,000,000.00 COMMERCIAL GENERAL LIABILITY PREMEES (Ea eee„ s 100, 000.00 CLAle6.MADE nacaJp two exP(Ant sirrranlon) s 5,000.00 PERSONAL. &AOV�P4JUA s 300,000.00 GENERAL AcaREOATE 32,000,000,00 GEN%Ae.oREGATELINT APPLIES PER: PROVUGre COPP/CPASO $ 000, ADO. GO POLCY El C ri LOC _ $ AUTOMOBILE LIASILrtY COMBINED SINGLE LIMB L (En Accident) ANY AUTO BODILY INJURY (PIE piano) S ALL OWNED AUTOS BODILY INJURY (Per acciannt) S SCHEDULED AUTOS PROPERTYAAMAGE ¢ Hiatt) AUTOS (Per accident) NON-OWNED AUTOS .. 9 9 - UMBRELLA LAAN - OCCUR EACH OCCURRENCE II EXCESS LIAR CLA1MS - MADE AISSREGIATE DEDUCTIBLE RETENTpM S ...... =RICERS corewErtgAlfat MO EMPLOYERS' LIEDILITY Y r R III TORY LIMITS �Ia ANT PROPRIETOPJPARTNERIMcuTIvE a R / A E.L. EACH ACCIDENT $ CFFICERrMEMBEREtCLUDED7 (Mmd16err In PRI EL. DISEASE . EA EMPLOYEE S DESCRIPTION OF OPERATIONS deien E,L. DISEASE - POLICY LIMIT S OESCRIFTIOM OF OPERATIONS I LOCATIONS / VEHICLES (ARIER ACOR0 lar, AEI menet N mmis trasdds. Mime wpm 1. ANIPnw1) CARPENTRY CERTIFICATE HOLDER CANCELLATION NORTBAMATCN BITILDIIe6 DEPARTMENT RE : 21 FRANKLIN STREET SHOULD ANY OF THE ABOVE SESOMBED POLICIES SE CANCELLED BEFORE - ow mottoT10M DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORCANdE wail THE POUCY PROVISIONS. AUTHORIZED IEPAEBENrATE ..., �— N FAS: 413 -S87 -1272 `' ) / -"", / 1 OL ` , i , : :1 I AMR') CORPORATION. AR rights reeervme0. *CORD 25 (2009f09) The ACORD name end logo are registered Marks of ACORD