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25C-111 (4) 46 GRANT AVE BP-2019-0686 GIs#: COMMONWEALTH OF MASSACHUSETTS M ck:25C- 111 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Penmit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateuory:ROOF BUILDING PERMIT Permit# BP-2019-0686 Project# JS-2019-001118 Est.Cost: $1800.00 Egg, 540.00 PBRMISSIONIS HEREBY GR,4NT.ED TO. Const.Q§s; Contractor., License: Use Groum: RCI ROOFING 774334 JLot Size(sgft,): 7579.44 Owner: Lydia Rackenberiz zoning:URB(99)/ AWLiggant: RQI!3QOFINQ AT. 46 GRANT AVE Applicant Address: hone: Insurance: 6 LINE ST (413) X27-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:12/10IX18 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF - FRONT PORCH ROOF ONLY POST THIS CARD SO ITIS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Finals Final: Final: Rough Frame: Gas: Fire RQnartment Fireplace/Chimney: Rough: il• Insulation: Final: Smok . Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupangy si na re: FeeType: Date Paid: Amount: Building 12/10/2018 0:00:00 $40.00 212 Main Street,Phone(413)587.1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner �'Ioo P�(Pvrck) ...... Citof North y ._ 4 Y ampton ,t ,'icu >orflt,, , ..,.,,,. .. �Miding Department 212 <(3i;`rbt(�uitYro ' �:. •, :nEv;�:v����;R��®:n�,t'EF� �..,,___�___—_ Main Street ;::vi:jfci` vatl;auil;I;ty,'_ _ Room 100 ` Northampton, MA 01060 T.':t:.a?6;e:tsb::l'S:4:r;wrghw,nal Ia;�: phone 413••587-12.40 Fax 413-587.1272 APPLICATION TO CONSTRUCT, A ER,RTE , R EMUMH A ONE OR TWO FAMILY DWELLING :s.PCTION 1 --8-ITC, INFO:RMA•.TI:O:N:_._ ,.1 Property Addrelss; r If r':I,I s;eeal.utl t'o b;e c:o:m:pa'e;te!d'Ib:y a.tflce �_ L,o,t>, Unit y� DEPT.OP BUILDING IECTIONSN�` p 1� NORTHAMPTON60 _ Q;y,e:nlay D'i'stnl'c:t__, .__ _, !E�Im S.t•,Dla.tr�hot;__._ �„�„ C;B�D:Is.t'tfct'„^,-,_�____._. :r.CT10N 2 •PROPERTY OWN:F.R-�HIP7AUTH'0'.R1ZED'.A(IEN7 >_1_Owner of Record; d�Q ckeh b�rq _ raiz Sf Ale Mlq elo&c). same (Prim) Current Mailing Address: 21f LL Telephone ianature ,,2 Au-thorized eir t, •:arne (Print) ."y � Current Mailing Address: iynalure Telephone j CTIOA 3 : EEM•ATE:D :O.NS:TFIU,C.T.CO:N G:O.$T:S• Estimated Cost (Dollars)to be -�^ .Uf:fPcial-Use...Onty ___ - com leled by permit applicant, I BUilding _ (•a':)Bwll.dln.g:P.rlrmbt:Poe Electrical f ^' (.—M iRsthMad:Total Cos.l of i Plumbing _ _ ?:Bulldln:g Pe:ernLt:Fee /ij� i (oechsnical(HVAC) sire Protection Total 0 + 2 + 3 + 4 + 6) Igen, 0h:e6k N'urribeer —,--- - - T::h►.a 8'e.e.tlon For'Affl:cd;a'i:tJse 3ullding Permit Number:__ D.a:te BUINIng C'MMl:islomer/INPec(or:01-Rulldings: Date: �I S.EC.T:fON 6;D_„FS.CR�If�'•�f0,j� OF,P",R.IJ.P�O��D"W:ORK(ch•�•:k:aal annl.hnahla•:): New blouse [] Addition [] Replacement Windows Aite.ratlon(s) Roofing�� r� Or Doors ❑ i Accessory Bldg. Demolition u New Signs (CD) Decka ([:� Siding (ED) Other(0) Brief Description of Proposed --- Alteration of existing bedroom .-Yes No Adding new bedroom Yes _ No Attached Narrative Renovating unfinished basomerit Yes No Plans Attached Roll Sheet —" `— s a.. ff;N.e, h ous a:; ' .:cat. �r�ttJ��aas;,o';tA�'t t n., � ," .•' i i,. :i, I .._..�`�::�_.�- ...�: •ti'' X•�stil'i, g,=fro'r!�s;Rtlrii �G:�:rrtt�•;1'e�i��<;ti �,:• or`I,o,.•.�1. a. Use of building ;One Family._ Two Family Other b. Number of rooms in each family unit: Number of Balhroornq—­ Is [here a garage attached? _ Ici. Proposed Square footage of new•constructton, Dimensloml e. Number of stories? I. 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 r_No. Is construction within 100 yr, floodplain _Yes No I. Depth of basement or collar floor below finished grade R. Will building conform to the Building and Zoning regulations? Yes No , I. Septic Tank__r, City Sewer Private well City water Supply SECTION 7.a •.O.WNF.R AU>1%H:ORIZ-f*.7aON.•T0:I :B.C.QMPhir.CEp ''.W..H'eN OWNERS AGFN>T.U.R<•C.Q!N'rlkA.CTO.R.APPI,I!*$ FO:R t3.lJllkfJ:I.N4 PE"F2`MIT Y _ as Owner of the subjecl i properly y -r hereby authorize •_ �y ( CIfZ. r �� , _I. t Imo(` jto act on my behalf, in all matters relative to work authorized by this buliding permit aRtiilc tion, Signature of Owner ® Dateown J= ' (� ���„ ��IN1(9Yl l Pr� n(1ent _ __ _, as Owner/Authorized Agent hereby declare;that tho statements and information owhe foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains-and-penalties of perjury, Print Name ,•sC��y'�� Signature of v �. / Dale ��� -�"---- ----------- "TION 8 License Nurr�ber Expiration Date Ll 1111 5 isluie Telephone Not Applicable 0 A Li Registration Number Tolephone CT\ON 1G`WOR>�E:Ra'-COKARE.N8�\�|� � �N |08U��N�2 Pfi���|? (M�G.L. u. 1'02/ � ` . ,rkers Compensation Insurance affidavit must be completed and submitted with lhl(i application, Failure to provide this affidavit will result iie denial of the issuance of the building permit, ?hucurrent exemption fb,"homeuv/num"was extended toInclude (2 families m)(| to allow such homeowner to unQaQo an individual for hire who duoo not po:,,oaoox license, . ?jIlLperyLsov, Cl�lka8-O-, Sixth Edition j)eriLiLt[Li of HomeowneK� 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 ntruotures accessory to such use and/or farm structures.A=on-who P.Onstructs more than one home In a two-XpaLnorl.od shR11 got be considei-ed. a lipmemyner, Such "homeowner"shall stibmit to the Building Official,on a form acooptable to the Building Official, that he sli_e shAll Le As acting Construction SitnerYlsor your presence on the job site will be rquired fi-om 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 Gmp|oymm for Injuries not resulting In Death) utthe Massachusetts General Laws Annutu\ad, fo'yum»»(s) you hire tuperform work for you under this permit, The undersigned ''h8mVOYvAe[" certifies and assumes responsibility for uo8Api|unua with the State Building CoJv, City of NorthxmptooOrd\nxnmm` Qtx1w and Local Zoning Laws and State ofk4ouuuuhuooMu 8onu,8| Laws Annotated, �omao�ov,&bOuotm'a_ ____ The Commonwealth of Massachusetts Department oflndustrialAccidents -- I Congress Street, Suite 100 Boston, MA 02114-2017 ' www.mass.gov/dia W'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeeiblY Narne (Business/Orgarsization/Individual): R, ., /Ppp•,0/hq _ ,L..L•0 Address: City/State/Zip: , u#99, bh /1/4 010)73 Phone #: a/3) 55�'7 - x/'775 Are you an employer?Check the appropriate box; Type of project(required); 1.Q lam a employer with c;�-U employees(full and/or part-time).' 7, ❑New construction 2.Q 1 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.(No workers'comp.insurance required.] 3.0 1 am a homeowner doing all work myself.[No workers'comp,insurance required.]t 1 F-1 Demolition 10 ❑Building addition 4.Q l am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 1, Electrical repairs or additions proprietors with no employees. 12,[]Plumbing repairs or additions 5.7 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13, 'Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.Q We are a corporation and its officers have exercised their right of exemption per MGL C. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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: A, L,f�')•./�'l/ flCGrc/ f'►Su�'Qdi�� CJ- __ Policy#or Self-ins.Lic, #: Gt1UJ& /Q/7-&Q,V_,Zkc1'7 4/7A- Expiration Date: /0 Job Site Address: #6 S7f City/State/Zip; 17A 0/060 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 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification, 1 do hereby certify under th ains d penalties of perjury that the information provided above is true and correct. , C Signature "' Date: /,2- -2, -/,P/ _ Phone# Official use only. Do not write in this area, to be completed by city or town official. 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#: 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; The debris will be transported by; �✓f'�_ . .. dlc/ih a,nd _.e_ The debris will be received by; 1rd1'7S-4PY/-'a- Building permit number; Name of Permit Applicant Date j - ,3 Signature of Permit Applicant RC-1. Roofing Date 6 Line St. Estimate Southampton,Ma. 01073 11/26/2018 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location Lydia Rackenberg 46 Grant Ave. Northampton, MA 01060 Terms Rep Estimate valid for 30 days Chris Description Total Remove existing roofs. 1,800.00 Furnish&install aluminum drip edge,pipe flashings,chimney flashings(if needed)and step flashings. Furnish&install CertainTeed Winterguard ice&water barrier, 6 feet along eaves. Furnish and install synthetic underlayment over existing deck. Furnish and install Lifetime CertainTeed Landmark Series shingle. Furnish and install CertainTeed approved ridge vent. ' All exterior roofing related debris to be removed by R.C.I.Roofing. All work will be performed according to manufacturers'specifications. Lifetime CertainTeed material warranty included. All related permits will be obtained by R.C.I.Roofing. Add$2.50 per sq. ft. for wood decking replacement if needed. Estimate is for front porch roof, only. WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $1,800.00 TERMS OF PAYMENT 5%Deposit Customer Signature: Balance upon completion Registration# 126235 Date: Construction License#074334 Insured by Banas&Fickert Ins. 7 (413)527-2700 Shingle Color Selection: SCA 1 20M-0-05/17 ��✓✓ CJ1te�pant�7toottue¢ttft oeC�/�/�aatac�iueeltd Office of Consumer Affair &Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE,Partners hio ReaistratJpti Expiration 126235 l 05/05/2020 RCI ROOFING ( P',: t1 Commonwealth of Massachus ! ett Division of Professional Licensure MARKT.DEL 6 LINE ST . ;, . /� Board of Building Regulations and Standards SOUTHAMPTON,MA'�Q103 Undersecretary Ccns�ry. 4it l�tvP5 rvisor f CS•074334 f;Xplres; 05/03/2020 Registration valid for Individual use onlyctix•1/ before the expiration data. If found return to: MARK THOM 4S D.ELii. Office of Consumer Affairs and Business Regulation 69 BRIGGS STI ; 1000 Washington Street_Suite 710 EASTHAMPTO Boston,MA 02118 1� Commissioner • , Not valid without signature LIZ we I <'S 0.0MMON:6EALTH-OF MAS:�A HUSETTS; e e . HOME IMP�OVFj NT,CONTRACTOR "' B:QgRC7 O:P R�`TOI1v� ,i LP SHEET NI>=fi;AL WC3RKFR:S _�/ G f IN ST`r ISSUES THE.FO.LLOVII)NG LfCENS`E ' SOirTTAM�TQ > }01073 ':'` N(ASY ER U:IJ:RE,SZ'RICrl ED it T;DELISLE `z E'RIGGS.,S.T Re istration'#; l ffectiVC Expiration EASTHAIIJip�ON,`MA .Q1;0, 7;a..' HIC.0624741 �r ur �$ �� " 11/30/2019 2. 1..7.38: �W --- SIGNED - 466498 .. ...................... .:_.:E'.;;- >•...:"."`2i , ir ; . OMMONINA'LTHOF,M`AACH.tSET'fS>:<, :f1 . Q g SHEAT MT.; L` 0:f2K�R$ ISSUES THS FOLLOWIN i«lC1=NS`E 4fa' Y BUSINESS„ MA1K 1%D:ELIS 4 ° f < OI RO'AFING EI.P 26— I` 1 4T<.)(1, 6 LdN��S`f Sfr�' � .; EASWAMP ;gN ................' , . , "60 :,€€'"> 0 910 912 0 1'9 34'2236:;:..: .. .. - ... n nri>..-., ...n I1.tl%Y.r'..:H'f+'1.4rYW.•`.i..k�`.•.1;tryli,jtl�l�4�e1...i}'A .i— ' ' i ` nOct, 4. 2018 4: 39PM No. 3123 P. 1 CERTIFICATE OF LI�BILITY INSURANCE DATE(MMIOOhTYY) ACORD �/ I 10/04118 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 ORALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTEA CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PACOUCER,AND THE CERTIFICATE HOLDER) IMPORTANT. If the certifleate holder is an ADDITI NAI.INSURED,thl policy(ies)must have ADDITIONAL INURED provisions or be endorsed. If SUBROGATION IS-WAIVED,Subject to the terms and conditions of To policy,certa)n 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 NAME; Michael R.Barras Banas&Fickert PHCNt 0 Exr: 413-527-2700 F No; 413-527.0849 Insurance Agency P-MAILADDRESS; mb�banasinsuranoe.com 63 Main Street Easthampton,MA 01027 INSURER(N AFFORDING COVERAGE NAICµ INSURERA: Admiral Insurance Co. 24856 INSURED INSURER B: Safety Insurance CO. 39454 RCI Roofing,LLP INsuRSRC; Admiral Insurance Co. 24856 6 Line Street INSURER D: Southampton,MA 01073 wsuReR Ia INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVq BEEN ISSUED TO THE INSUREO NAMED ABOVE FOR THE POLICY PERI00 INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION 0 ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCR18E0 HEREIN IS SUBJECT TO AL1,THti TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR TYPE OP INSURANCE IVSD WVD POLICY NUMBER MMjpD 1 M1CY DD P LIMIT$ X COMMERCIALGENERALUABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE �OCCUR PREMISES Es oceurrenca $ 50,000 MEO EXP(Any oneperson) S 10,000 A X CA000020963.04 03/04/18 03/04/19 PERSONAL&AOV INJURY S 1,000,000 GEN'LAGGREGATELIMIT APPLIESPER; GENERALAGOREGATE S 2,000,000 POLICY X PR 7 LOC PRODUCTS-COMP/OP AGO s 2,000,000 OTHER: I I IS AUTOMOBILE LIABILITY Ee BINEDtl SINGLE LIMIT $ 1,000,000 ANYAUTO BODILY INJURY(Per person) s B OWNED r7 SCHEDULED X 6207761 09/30/18 09/30!19 BODILY INJURY(Por acddent) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PRO ERT AMA $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA UAB H OCCUR EACH OCCURRENCE $ 5,000,000 C EXCESS LIAO CLAIMS-MADE X GXO00000385.02 03/04/18 03/04/19 AGGREGATE $ 5,000,000 OFD I x I RETENTIONS 10,000 $ WORKERS COMPENSATION P$ETAT iJ QE AND EMPLOYERS LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE 77 N 1A E.L.EACHACCIDENT S OFFICERIMEMBER EXCLUDE07 (Mandatory in NH) E.L.DISEASE-PA EMPLOYEE s I Ins,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT I S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks S hedule,may be attached If more space Is required) ROOFING CONTRACTOR. The General Liability policy includes an Additional Insured endorseme t that provides Additional Insured status to the certificate holder,only when there is a written contract that requires Such status,and only with regard to work performed on behal of the named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICI_WILL BE DELIVERED IN -*...Reference Copy"" ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REP 5 IVE 15 AC D CORPORATION. All rights resorved. ACORD 25(2016/03) The ACORD name and loco are reoistered marks of ACORD Oct, 4. 2018 4: 39PM No, 3123 P, 2 " ' ® �►CORQ CERTIFICATE OF LI BILITY INSURANCE D-.119(MM/DD/YYYV) 1 10/04/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 0�1LY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AME D, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(5), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDEf�. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,"policy(ies) must be endorsed. If SUBROGATION 15 WAIVED,subject to the terms and conditions of the policy,certain policies may requiro an endorsement A statement on this certificate does not Confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER GON AGT NAME: Michael Series SANAS& FICKERT INSURANCE AGENCY PHONE (413)527-2700 Ac No: mD ADDRL banasinsuranca.com • ADDRESS: Q 63 MAIN 5T INSURERS AFFORDING COVERAGE NAIC Ir EASTHAMPTON MA 01427 INSURERAI AIM MUTUAL INS CO . 33756 INSURED INSURER 0: RCI ROOFING LLP INSVRERC I INSURER D 6 LINE STREET INSURER E: SOUTHAMPTON MA 01073 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 322172 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 CONDITI N OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFC RDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY H VE BEEN REDUCED BY PAID CLAIMS, t1L u POLIC EFF POLICY LTR INR TYPE OF INSURANCE POLICY NVMBER MM M/DD LIMITS COMMERCIALGEN6RAL 1.IA51LrrY EACH OCCURRENCE S CLAIMS-MADE F7OCCUR PR MI5 $Me"Joyanaal S MED EXP(AnY one person) S NIA PERSONAL&ADV INJURY S GEN'L AGGREGATE RLIMITAPPLIESP`LIES PER: GENERAL AGGREGATE $ POLICY a PeiU LOC PRODUCTS•COMPIOP AGG S OTHER:' S AUTOMOBILE LIABILITY COMBINED SINGLE IMI S Ea acald nt ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS NIA BODILY INJURY(Per socilent) S AUTOS NON*OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS P r c Iden 5 UMBRELLA UAB OCCUR EACH OCCURRENCE 5 9XCEs3 LIAe CLAIMS-MADE N/A AGGREGATE $ DED I I Re•rENTION 1 1 1 S WORKERS COMPENSATION XIMTUTe ERH AND EMPLOYERS'LIABILITY nNYPROPRIEYOR/PARTNER/EXECVTIVE YIN N E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBERBXCLUOED9 N/A NIA N/A VWC10060226472018A 10/05/2018 10/05/2019 (Manila"In NHI E,L.DI$tASE-EA EMPLOYEES 1,000,000 ir 0 ee, IN'T a under E.L.DISEASE.POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACOR0101,Additional Remarks Srf edule,may be attached If more specs Is requiro") Workers'Compensation benefits will be paid to Massachusetts employees o ly.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the In ured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this ce ificeta was issued(unless the expiration date on the above policy precedes the issue date of this canifcate of Insurance). The status of this Coverage can be monitored daily by accessing the Proof of Coverage•Coverage Verification Search tool at www.mass,gov/Iwd/workers-compensationlnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY Or THE ABOVE DESCRIBED POLICIES BE CANCELLED aEFORE THE EXPIRATION DAYE THEREOF, NDTICE WILL BE DELIVERED IN Proof of Coverage ACCORDANCE WITH THE POLICY PROVISIONS. 00000 AUTHORIZED REPRESENTATIVE l' 00000 MA 00000 Daniel M.Crab+ y,CPCU,Vice President—Residual Market.-WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD