17A-049 (3) 152 BRIDGE RD SP-2019.1261
GIs* COMMONWEALTH OF MASSACHUSETTS
Map:8lock: 17A-049 CITY OF NORTHAMPTON
Lot:.,.001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLcc.1144/2�A)
Catceorv. REPLACEMENT WINDOWS/DOORS BUILDING PERMIT
Emit 0 BP-2019-1261
Proicct k 4S-2019-002039
Est so t $20000 o0
Fey:$40.00 PERMISSION IS HEREBY GRANTED TO:
const,,ciaes: Contractor: License:
UU rouo: JOSEPH KENNEDY 055440
Lot Sin(sg.ft.): 11107.80 Owner: Michelle Boule"
Zoning•,RI(100)NRAaQU Apaikant. JOSEPH KENNEDY
AT: 1152 BRIDGE RD
ADnlfcantAddress: Phone: Insurance:
38 HARKNESS AVE (413) 525-1735 0 Workers
Corripensation
EAST LONGMEADOWMA01028 ISSUED ON.5/2112019 0:00:00
TO PERFORM THE FOLLOWING WORK.•INSTALL 20 REPLACEMENT WINDOWS AND 2
EXTERIOR DOORS
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: Hnu604 Foundation:
Driveway Flnall
Final: Final:
Rough Frame:
Gas: Fire enertmynt FireplaWChimnay:
Rough: .49i Insulation:
Final; singh£i Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate ofOccuoancv Signature:
FeeTlogs Date Paid: Atty,lso ntr
Building 5/21/2019 0:00:00 540.00
212 Main Street,Phone(413)5874240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of N I pton taws Permit:
,> Building Spa mrafltY urb I/Ddveway Permit
212 M in St eel 8 20)9 ewer split Availability
Roo 10 star ell Availability
Northam t n, S of Structural Plans
P ,itnwr,itiavFcri
phone413-587-12 " mP7oc� PloUsl Piens
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 PropertcAddreas.
' Sit Tf l a§P -�-a Map 1714 14 Lot 1I Unit
Zone Overlay District
r Y�" Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Derriere Record:
Name nt) Current Mailing flodesss:^�
Telephone yr 0 /
Sig a a
2.2 Aat rued ent:
Tits v �Pc� �811� �tcrs Ave
No a(Print) Current Mailing Address:
6a7-
Si atum Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Ilam Estimated Cost(Dollars)to be Official Use Only
completed bermitapplicant
1. Building /r G G-0 (a)Building Permit Fee
2. Electrical ) O 0 (b)Estimated Total Cost of
S Construction from 6
3. Plumbing OI't Building Permit Fee 1 '�f
4. Mechanical(HVAC)
5. Fire Protection 0
6, Total=(1 +2+3+4+5) Check Number
This Section For Official Use Onl
Date
Building Permit Number: Issued:
Signature: 5-7-1- 20tq
Building Commissionerllnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Most Be Completed.Permit Can Be Dented Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: LR:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage as
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NODON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO ,t�p
IF YES, describe size, type and location: v
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E, Will the construction activity disturb(Gearing,gradin excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? VES O NO�
IF YES,then a Northampton Storm Water Management Peonit from the DPW is required.
SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacernual dows Alterations) Roofing Q
Or Dooro �S
Accessory Bldg. ❑ Demolition ❑ New Signs (01 Decks [0 Siding[D] Other[M
Brief D . d
tipQn of Pro os
Work: p `Qr-C p D Wlv,10wS "p, kwc- T4wtuDet. .\LtiS II a[toovS
Alteration of existing bedroom_Yes ?L No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes _X—No
Plans Attached Roll -Sheet
62.If New house and or addition to existing housina. 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?
I. Method of heating? Fireplaces or Woodstows 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 ofbasement or cellar door 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
C C � as Owner of the subject
property j
4hereb thorize ll �t�
a II m rs mla i to work authorized by thi uilding permit application.
of Owner --- ^^\\
Date
U(^�V ,as Owner/Authorized
Agent hereby declare that a statements and informatio on the to application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Pdnt Na e
Signalu Of .r/g.1 Date
SECTION S-CONSTRUCTION SERVICES
81 Licensed Construction SSmervinn, 1I,, JIB/^ 1. Not Applicable
Noma of License Holds
License
: S(D 1p - �L V��'P��/ OS��C(Q
License Number
3�1 �cwe 4 � o 7 — a ) - ao
A dress "un-tion Date
t � 6a - -7
Si nature Telephone
9.Re isteretl Im rovement Cot .(car. Not Applicable ❑
C aNLs Cots �..�C °0L� 1 -7 10(81
Com Mame ° I 1 ReCgistratio(ny Number
7
> Q I`�T^A-/I tl <c � �` 4� �C,,, fM�doW �f Ow ] '-L - Cl_ Q��
Ad�/d�esS (j�\�,Ir ,. Expiration Date
h��A(n Q� 1C)� '7 ( aeiLoO,CO�kTelephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,-§25C(6((
Wodcars Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this af0davit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
Massachusetts �s fr'rc
\\ DR BNT OF BUILDING
212Win th • Municipal Building
North, ton,
Om
lai 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 few 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 preexisting owner-occupied building containing
at least one but not more than four dwelling units....or to structures which am adjacent to such residence or building"be
done by registered contractors.
Nate:If the homeowner has contracted with art corporation or LLC,that entity must be registered.
TypeofWork: W -c1S — A6 Uf< Est.Cost l '/ coo
l
Address of Work:
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 RESPONSIBMITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I herfby apply forla buiId pemut a the ag n[of the owner.
'[yap
C. �vz( 0c)(A 1 -7 19 god
Date Contractor Name 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
D212 NaN S OF BUILDING INSPECTIONS
212 Nein St[eet • Muniri010 Building j, A
NortAamp[on, NA 01060 rby6 .yll
Massachusetts Residential Building Code
Section 110.R5.1.2
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.
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 person(s)
for hire to do such work,then such homeowner shall 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 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.
City of Northampton
� ••"t Massachusetts tide
%a
DEP
OF BUILDING INST NS
212Nin Street leunicipal Buildng i
F Cm
J
tlocthaNptov, IG 01060
Debris 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 defned by MGL c 111, S 150A.
The debris from construction work being performed at:
Sa T rridpQ 4
(Please print house number and street name)
Is to be disposed of at:
—�Pp '-)Uc ( l�vulPS l O�� A-P
(Please print name and loc tion of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Nx� 5- 7— / 9
Sig ure o Permit AP icant or O er 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 of7ndustrial Accidents
a I Congress Street,Suite 100
Boston,MA 01114-2 01 7
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Buaineas/orgaaioatiuwlndmiduap: C_
Address: -?(? gof�1 <r k'_'-,Pry
City/State/Zip: I)A ca, C) k 15 Phonek `i c;-
Type
Type of project(required):
LFlame employer with emdoycesdulland/orperfamet* 7, E]New construction
2ama"re preparation or peMcromp and have no employees working for no in g. (�iCemodeling
any capacity.[No crashers'comp,mmere cc metrical]
3 11 as a homeowner dlwork re elf(No workers'cerionesconcre rational ' 9. Demolition
4.R I am a homeownerand will se hiring contractors to conduct all wmk m my property_ i will 10❑Building addition
ensure that au contacwre eithm have workers cnmpenaation insurance or are aide I I.E]Electoral repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
s 1 am a general contractor and I have hired the sub-mnvaclom listed on the stacsed sheer 13.FROof repaiTg
These mb-mnt actors have employees and have workers'comp.imurav
6We ere a wryammnend its oMe—have exercised their right of exemption per MGL w 14.00Ihe2
152,§114),and we have no employees.[No workers'comp.in--required]
•Any applicant that checks box#1 must also fill oat the suction below showing their workers'compensation policy informafion.
t
Homeowners who aubmlt this affidavit indicating they are doing all work and then have outside ammonium mast submit a new andsvit indicating such.
;Contractors that check this sax must mu ched an additional sheet showing the name of the sub-contractors and Stam whether or not those entities have
employees. If the sub-contractors law,employees,they must provide their women comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information. I/ I
Insurance Company Name: k p'Lq (rU P h"C'P
Policy#or Self-ins.Lic.#: W C Expiration Date:
Job Site Address: City/Smte/Zip:
(d
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 time 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.
I do hereby�T11r/ttifry uundeerlith a pains,y�ry/�pena_l_a\eess a,[Q r uryury that the information provided above"isstrue an�dicarred.
Simulate: tw./ " • 1 .Ff 1 / Date �'� / — M
Phone# lel U1j - �d
Official use only. Do not write in this area,to be completed by city or town o ieiat
City or Town: Permit/Licensc#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CityrFewn Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant in 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
ofthe foregoing engaged in ajoint enterprise,and including the legal represcatobves 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 aparownts and who resides therein,or the occupant of the
dwelling house of another who employs persons ro 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)stales"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 authoriryP
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(w)and phone number(s)along with their cenificate(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. Iran LLC or LLP docs have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation cf insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be resumed to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accideata. 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 pennit/license number which will be used as a reference number. In addition,an applicant
that most subndt 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
lawn)."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. Anew affidavit must be filled out each
year.When a home owner or citizen is obtaining a license or permit not related in any business or commercial venture
(i.e.a dog license or permit to been 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, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Commonwealth of Massachusetts.
Division of Professional Licensure
Board of Building Regulations and Standards
Constr40dI`6d topervisor
CB-055440 EA
ires: 07122/2020
16 FOREST BI'
OX 1366
BO DSVILLE
BONWVILLE MA' x009
/4 yrs rlo,N
Commissioner C't
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02106
Home improvement Contractor Registration
Type: Corporation
CHARISTA CONSTRUCTION SERVICES,INC. Reglshafion: 051
982 PD SOX]061 38 HARKNESS AVE F-2PIraGort 05{093;2,2
020
E LONGMEADOW,MA 01028
Update Address and Return Oard.
ori eo Cans meiAtta/rs`b�6usn�s ReRula'nbn
HOME IMRROVEMEW=@ RACTOR Registration valid for i,Miriduaf use only
TYPE:Corooranon before the expnatmn date. 0 found return to:
Re¢islydtlan E 'rado�e Office nt CcnsVmee AffairsmW Business Regulation
171982 05/05/N20 One Ashburton Race-SuRe 1301
GHARISTA CONSTRUCTION SERVICES.ING Bosto,MA 02108
JOSEPH KENNEDY �-
?0 BOX 706f 3E HARKNESS AVE -- -
5. LONGMEADOW.MA 01028 Untlersecrep✓y Ot VaA I ut signature
aco oR a CERTIFICATE OF LIABILITY INSURANCE
SWIA2018
THIS CERTIFICATE IS ISSUED ASA 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 ceHBica[e holder is an ADDITIONAL INSURED,the PONCY(IBal must M1ave ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the team and conditions of the policy,certain Policies may require an endorsement A statement on
this coni icala does not confer rights to the certificate holder in lieu of such endoraemengs).
PRODUCER NME: r ManOn LEnte6
Berkshire Insurance Group,Inc. PHONE (11319351200 FAN Nc- (p13)567 5300
138 Longmeadow Slnw4ca: mlemeOIgDeMunirelnsurancegmup.com
INEUREmS1AFPORDING CO VE. NAlntl
LDngmeadOw MA 01106 INEURERA_ Sia(InsumnodCompany 18023
INSURED INSURER O'.
Chersta Const-action Sennces,Inc INSURERC:
38 Harkness Avenue " URER o
INSURER E:
East Longmeadow MA 01028 NuumaRE:
COVERAGES CERTIFICATE NUMBER: CL18628UI12 REVISION NUMBER:
THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTNATHSTANOING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO MICH 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.
ILrR TYPEOFINSURANCE MUCYNUMWR MVUomYyF aN.XxV xP LIMITS
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CERTIFICATE HLDER CANCEL TION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Chansla COOStNttlUn S ,,ods,Inc. ACCORDANCE WITH THE POLICY PROVISIONS.
AUn10RVED REPRESENTATVE ll��
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks&ACORD
row Rhe CERTIFICATE OF LIABILITY INSURANCE oA"
09M22019
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,MEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREgS),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT. H the certlBeate hats.,is an ADDITIONAL INSURED,Uro policy(les)must lava ADDITIONAL INSURED prevbiomor M andamo.
It SUBROGATION IS WANED,subject to Me ferwas and condbom of Me policy,certain policies may require an andono men- A menern ton
thin cerlMnM does not confer dghte to the,oartl li aN holder in MIND of each aMomermrrthi .
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Chadsta CommSerMxs MWWC:
38 HaTMess Avemle MSIWapp:
Ne1HBR e:
East Lan9mead. MA 01025 Wp '.
COVERAGES CENTIFICATENUMBER: M Cer W(2019) REVISION NUMBER:
THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE USWO BELOW RAVE BEEN ISSI.EDTO THE INSURED NA II DABOVE FOR THE POLICY PERIOD
INDICATED. NOTWTHSTANNNGANYREOUIRE ,,TERMORCONDRIONOFAWCOWf TOROTHERDOCUMEMWTHRESPECTTOWHICHTHIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TOAI.LTHE TERNS,
FXCLUSIMSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPEOFMSURANCE N1KYN111$1 lypta
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A -281002309 04101M I9 011012020 PERBMAL-A wuey { 1000,000
GFNLKa{'AEWIE IJNrt4PPtiES PEp. GENERALMCtaita TE f 2,000,000
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