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17A-228 (6) 105 LAKE ST BP-2018-1032 GIS 4: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-228 CITY OF NORTHAMPTON Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Above ground pool BUILDING PERMIT Permit# BP-2018-1032 Project# JS-2018-001872 Est Cost: $6800.00 Fee: 540.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JELLY BELLY'S POOLS & SPAS, INC 126929 Lot Size(sp. ft.): 18556.56 Owner: BENOIT RICH Zoning: URB(100)/ Applicant: JELLY BELLY'S POOLS & SPAS. INC AT. 105 LAKE ST ApplicantAddress: Phone: Insurance: P O BOX 936 (413) 568-1700 Workers Compensation WESTFIELDMA01086-0936 ISSUED ON:4/12/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 27X52 ROUND ABOVE GROUND POOL 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: 2 FeeTyoe: Date Paid: Amount: Building 4/12/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2018-1032 0 r— APPLICANT/CONTACT PERSON JELLY BELLY'S POOLS&SPAS,INC ADDRESS/PHONE P O BOX 936 WESTFIELD (413)568-1700 Q�� PROPERTY LOCATION 105 LAKE ST MAP 17A PARCEL 228 001 ZONE URBH00)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid lttt Building Permit Filled out �S Fee Paid Tvoeof Construction: INSTALL 27X52 ROUND ABOVE GROUND POOL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included' Owner/Statement or License 126929 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO_KMATION PRESENTED: --Approved 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 Signature of Building Official 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. J r Department use only �'. City of Northa pt n �tus f Permit .' Building Depa me t.Urb.Curt/DnveWay Perms 212 Main Street - "- SevreRSeptic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans l phone 413-587-1240 Fax 413-587-1272 Ploi Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address'. This section to be completed f by oce IVS- 44e Map I Z& Lot IU / Unit �jn�H7PP /r1/- d/nba Zone Overlay District Elm SL District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2. Owner iR ord: S k $ en�i f /�s (<��fP f f Name(Pant) Current Mailing Address: b/2 5-f �j/i /_? f N �� / l A 7 Telephone gnature /�/fJ p.1� / yj7 �/ f 2.2 Authorized f'// r G,S d- f!/T� t0 93b Ifief�IelI to Name(Pant) Current Mailing Address: Y13 Signature Telephone SECTION 3.ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com leted b sm t plicant 1. Building /a�O/Gr eJ (a) Building Permit Fee 2. Electrical 0 /GO (b)Estimated Total Cost of Canstmclion from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) Y� 5. Fire Protection 6. Total=(1 +2+3+4+ 5) O'O/0 // Check Number This Section For Official Use Only Building Permit Number: Date Issued Signature'. Building CommissionertInspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) $eCilOn 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column W be filled in by Building Department Lot Size Frontage Setbacks .raft C0'L JZ aye / / Side L R: L R: S Rear J35 Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved rk n ) d offiarking Spaces Fill: (rolnme&Loaatianl A. Has att`ttSpecial Permit/Variance/Finding ever been issued for/on the site? yy NO T' DON'T KNOW O YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW CI YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW Q YES O IF YES, has a permit been or need to be obta ned from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or addit ons of signs intended for the property? YES O NO t p; IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradinegcavabort or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO lRY�7(1` IF YES,then a Northampton Storm Water rdanageme of Permit from the DPW is required. SECTION S DESCRIPTION OF PROPOSED WORK(check all applicablel New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [C3] Decks [q Siding[o] Other[ O/ Brief Description of Proposed Work1 n( of 110;4 / G p Ol7 / � ) ' lo(In // : J '/ (�/ Alteration of existing bedroom_Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Sa, If New house and or addition to existing housing, complete the following. 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 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 Ip K `Or�r0.`l� `s-�'1�O Nk as Owner of the subject property D eec hereby authorize �Z�/I/ (�f/�4 P"" to act on my behalf, in all matters relative to rk out n d by this building permit application. Signature of Owner Date I, ]w� 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. riot Name ignature of Owner/Agent Date A f SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder'. License Number Address Expiration Date Signature Telephone 9. Reiiistered Home Im ravement Cotractor: Not Applicable C3T(' "eF e �s sods /16 fa 9 Company Name Registration Number Seu> c��I�Lj _ y%,1/,10 Addre/ssIIs'' / �/ .�/ Expiration Date WP l 0,er5 Teeph..rne /(3 JO0 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must be completed and s ibmitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. _ Signed Affidavit Attached Yes....... No...... ❑ City of Northampton �., s. Massachusetts DEP,?UZ NT OF BUILDING INSPECTIONS ; 212 Main Street a Municipal Building S is Northanpton, IA 01060 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. Nate:If the homeowner has contracted with ancorporation or LLC, that entity must be registered. of Work: -raff4C e e- Est. Cost: Address of Work: ms / �� 37' (� Fleye-& rp/ Date of Permit Application: 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 Other(specify): 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: Date ContractotName 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 ` r Massachusetts �3 s FJ ; DEPARTMENT OF BUILDING INSPECTIONS 212 Mai St—t N nicipal Building Nactha ptor.. MA 01060 Sdyq .f j Massachusetts Residential Building Code Section 110.R5.1.2 Homeowner: Person (s) who own a parcel of lar d 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 strictures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a persons) for hire to do such work, then such homeowner ;hall act as supervisor. 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 presmce 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 inj urics not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for persons) you hire to perform work for you under this permit. City of Northampton Massachusetts DEPABTNENT OF BUILDING INSPECTIONS 212 Main Street eMunicipel Building p Northampton, NA 01060 SMy,. Q,Cm Debris Disposal Affidavit In accordance of the provisions of MGL c 40, 554, 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: Norte (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Permit 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. The Commonwealth of Massachusetts Department o f Industrial Accidents I Congress Street,Suite 100 Boston, MA 02 11 4-2 01 7 cow ensass.gowidia Workers'Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information q Please Print Legibly Business/Organization Name: tr Address: JO u/I City/State/Zip: _ Pone 4:�3 / Are you an employer?Check theappppropriate box: Bus' ss Type(required). 1.� I am a employer with employees(full and/ 5. Retail or Part-time). 6. RestaurantBadEating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales Qncl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] S. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per v. 152,$1(4),and we f ave 10.❑Manufacturing no employees. [No workers'comp. insurance requred]" 4.F1We are a non-profit organization,staffed by volunteers l l ❑Health Care with no employees. [No workers' comp.insurance req. 1 12.0 Other "Any applicant Natchecks box pl must also fill out the section below dwava g Mev workers'compensation policy iuronnatien. '9[IM corpomteoErmn have exempted lAeuuelves,bmthceoposcoun has ohucmployces,aworkers compensation policy is required and such an organization should check box#I. I am an employer that is providing workers'compenss/ation insurance far my employees. Below is the policyinformation. Insurance Company Name: Insurer's Address: City/State/Zip: __ __ Policy#or Self-ins.Lie.# 1'I/ ✓I/ l.i � �t�o3 Expiration Date: 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 fine up to$1,500.00 and/or one-year imprisonment,as well as r ivil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised tha a copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance cover e verification. I do hereby certify,under p ns and ofperjury that the information provided above is nue correct Si nature: >' _ Date: Off Phone#: F-t_3 S17 / 71"' Official use only. Do not write in this area,to be completed by city or town official. City or Town: _Permit/License It Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityrf own Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.m ssgovldia 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,and 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 ajoint enterprise,and including the legal representatives of deceased employer, or the receiver or tmstee 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 bean employer." MGL chapter 152,§25Cod 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 your insurance company's name,address and phone number along with a certificate 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. Iran 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 ofthe 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/ieense 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). A copy ofthe 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 most 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.massgov/dia rom,Revised 02-5-15 JELLY BELLY'S POOLS & SPAS 58 SOUTHWICK ROAD PO BOX 936.14131568-1700 • FAX 14131 572.1218 WESTFIELD. MA 01086-0936 www.leuybellygpoo[S.tom �ELIY BEt(Y .Sic �!1<rr e S d'y G 79G b` 80 I�6 II , H 8 � D C v Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration - Registration: 126829 Type: Private Corporation - Expiration: 8/10/2018 Tea 419291 JELLY BELLY'S POOLS & SPAS, INC. GARY SCAVOTTO -` P.O. BOX 936 WESTFIELD, MA 01085 - Update Address and return card.Mark reason for charge, scni a zomosn Address ❑ Renewal L�j Employment ❑ Lost Card �� OMceof Couaumer ARain&Busiaeu Regutadoo License or registration valid for individual use only wl �y HOME IMPROVEMENT CONTRACTOR before the expiration date. If found rNurn to: Registration: 126929 Type: Office of Consumer Affairs and Business Regulation Expiration: 8/10/2018 Private Com.rauon 10 Park Plena•Suite 5170 Boston,MA 02116 JELLY BELLY'S POOLS&SPAS,INC. GARY SCAVOTTO 58 SOUTHWICK RD _ WESTPIELD,MA 01085 Undersecretary Not valid without signature 2 2018-03-30 11.23:40 EDT 14136479930 From: Karen Britt ./1 JELLBEL-01 KAR ORO" CERTIFICATE OF LIABILITY INSURANCE nimi(TR mDmva 031302018 THIS CERTIFICATE 15 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 ISSINNG INSURERISL AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)most have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, Subject to the terms and conditions ofine Policy,cartain policies may require an mudomement. Astt mentor Mia certlficah does not conhr ri hts to Me«rtiawte holder in lieu of such eT Rose s. PRooucER LicenseAT 8062 8JoxTACTgcT Rosemary DiNetele HUB International New England I xe Fqx 96 Shaker Rd PHGAm,x°,ARL AK,N°, East Lonameedow.MA 01028 E�ABPs,ROSemary.diru Ie�huOintemarionatCOm NSI RiSl AFFORDING LDVERAOE NSURERA RegentlnauranceCampanv 24449 INSURED Ixau ae:CommerceinsuranceCompanV 34754 Oeltf Bku,y ibob 6 Spas Inc Nsun., WesCO Insurance Company 25011 PO Box ads IMwRER D Westfield.MA 010864906 1 INSURER E'. INSURER F'. COVERNES 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 IN NCATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR COND71ON 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. IHER TYPEOFMBVMMLE MBA PoLILY NUNBER PoUCTEFF nLICY GP LIMITS A X <wn.DNC'g R"EIALLuBLln I P IEgLrI OCCURRENCE s 1,000,000 :.ULAIIA.A.Ci�X LCCUR CCH2O5358 071OIQO1707101R018�DPVEu sERa ouTwin= s _ -100,000 ' I MED Em An °m vN+°n> s 5.000 PERwNU B ADV INJURY S 1,000,000 GEM,AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE S 2'000'000 X Poucv I_i LGL Ili I PRODDCTG. 2,000,000 MP/GPA S OTHER: E B AVT[MOBLE OABIUT L0 6INED SINGLE LIMIT 10110 000 ANY AUTO BOVGVL ' 12115120171L15120181 SODRVIx.luxv Per rsan s xAUTTW ONLY X Ap'.SNEDUUsDDI I NousY INJURY aaUMl S X MO.ONIY X '�AVT.M9 PPG,Mo,Rj;m DAMAUE E E UMBIELLA LWB OCCVR j IEACx CCCURREN-E__ EXCESS LIgB CLU LISMAOE gGGREGATE 5__-_ OEO IIPSTEUmoNT C NroRRERs cDNPExSATION I X '5EF X ANO FLOLOYERB'LNial - ApNp'INU.II.ANARITERE.EDV➢VE YIN G32BB034 10710112017 a7m11$D1Bj E L EACH ACCIDENT a 1'000'008 IMaAM In NN1 F3RVOEO? '� NI41 EL OIgASE-EA Euxov s ._____1,000.000 n "d°a=Rea°�Ix' 1,000.000 DESCRIPPON OF OP pgilONS ONOY/ E.L.DISEASE POLICY LIMIT E DESCRIPTION OF(°ERATIDxS I LOCATIONS i VENICLESIACMI D IDA.Addir-Al R°maft Schedule,rMy balticMO IT m°n AM"nnRNIANT) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Sarah Benoit THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 105 Lake Street Flonnce,MA 01082 ANNORQED REPRE9ENTATNE ACORD 25 I2016fO3) ®1988-2015 ACCORD CORPORATION. All rights reserved. The ADDING name and logo are registered marks of ACORD