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38D-016 8 CHARLES ST BP-2021-0088 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38D-016 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPLACEMENT WINDOWS/DOORS BUILDING PERMIT Permit# BP-2021-0088 ` Project# JS-2021-000137 Est.Cost:$19577.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RENEWAL BY ANDERSEN 090125 Lot Size(sq. ft.): 9496.08 Owner. BELL JULIE A zoning: URB000Applicant. RENEWAL BY ANDERSEN AT. 8 CHARLES ST Applicant Address: Phone: Insurance: 30 FORBES RD (508) 919-0900 W(' NORTHBOROMA01532 ISSUED ON:7/24/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 4 REPLACEMENT WINDOWS AND 1 PATIO DOOR 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: FeeTvpe: Date Paid: Amount: Building 7/24/2020 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR Massachusetts State Building Code,780 CMR MUNICIPALITY USE Building Permit Application To Construct,Repair,Renovate Or Demolish a 'Revised Mar 2011 One-or 7i o-Familp Dwelling This Section For Official Use Only BuildirW Permit Number Date Applied: tul►J >154� 72y2aZo Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 8 Charles St �S o -61-4e— 38D-016-001 1.1 a Is this an accepted street?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.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Public❑ Private E3 . — Check if es❑ Municipal 13Onsite disposal system ❑ SECTION 2. PROPERTY OWNERSWP1 2.1 or Record: 11 ea ptall Northampton, MA 01060 ame(Print) City,State,ZIP 8 Charles St 413.530.2905 jabellcnm@hotmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ TAddition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other A Specify: Brief Description of Proposed work-2- replacement of 4 windows and 1 patio door SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) 1.Building S19,577.00 1. Building Permit Fee:S Indicate how fee is determined: 2.Electrical S ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing S -2. Other Fees: S 4.Mechanical (HVAC) S List S.Mechanical (Fire $ Suppression) Total All Fees:S Check No. Check Amount: Cash Amount 6.Total Project Cost: $19,577.00 ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Jaime Morin CS-090125 10/06/2020 License Number Expiration Date Name of CSL Holder 86 Gardiner St List CSL Type(see below) 1• No.and Street Type Description Lynn MA 01906 U Unrestricted(Buildings up to 35,000 cu.fl. R Restricted-M2 FamilyDwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Sidin SF Solid fuel Burning Appliances 508.351.2277 t Insulation Telephone Email address D Demolition 5.2 Registered Rome Improvement Contractor(HIC) 170$10 12/22/2021 Renewal by Andersen HIC Compan Name or HIC RegistrantName NIC Registration Number Expiration Date 30 Forbes Rd rbabostonpermittingCaD-andersen.com No.and Street Email address Northborough, MA 01532 508.351.2277 Cit /Town,State ZIP Telephone 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..........X No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Jaime Morin to act on my behalf,in all matters relative to work authorized by this building permit application. . Julie Bell 7/17/2020 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application' e and accurate to the best of my knowledge and understanding. Jaime Morin 7/17/2020 Print Owner's or Auth rat's Name(Electronic Signature) Date NOTES: 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 Horne Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at xv%w.mass.ttov/oca Information on the Construction Supervisor License can be found at%+-An;v.mass.ttov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.fL) (including garage,finished basementlattics,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. '?otal Project Square Footage.'maybe substituted for"Total Project Cost" 1 I i CITY OF NORTHAMPTON SETBACK PLAN i MAP:---- _ LOT:_ - LOT SIZE: REAR LOT DIMENSION REAR YARU 51DE YARD__ SIDE YARD— i FRONT:S E,rBACK- d FRONTAGE_,.___,___- I i I The City of Northampton Building Department a. x 212 Main Street Northampton,Massachusetts 01060 Phone(413) 529-1402 Fax (413) 529-1433 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance with the provisions of MGL c40, s54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, $ 150A. The debris will be disposed of in: Location of Facility 4 Techology Dr Westborough MA 01581 --- --- ---- ---- --------- The debris will be transported by: Name of Hauler- Renewal by Andersen _ _ - _ - _ - _ _ _ _ _ Signature of Applicant:__ _ _ --- --_ --_ _ Date:- 7/17/2020 I The Commonwealth ofttilassachusetts Department of In du strial A ceiden ts I Congress Street,Suite 100 Boston,MA 02114-2017 www n:ass.gov/dia M-orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information I Please Print Leeibly , Name(Busin(-ss/Organizadon&dividual): Renewal by Andersen Address: 30 Forbes Rd City/State/Zip:Northborough, MA 01532 Phone#: 508.351.2277 Are you an emplover'.'Check the appropriate box: Type of project(required): I.M l am a employer with 30 employees(full andlor part-time).' 7. New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.(No workers'comp.insurance requited.) IF I am a homeowner doing all work myself.(No workers'comp.insurance requited.)t 9. 'Q Demolition a.❑ willI am a homeowner and wbe hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contactors either bave workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 3.0 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 warkers'comp.insurance.= 6.[3we area corporation and its otlieets have exercised their right of exemption per MGL c. 14.K]Other_ re pla cement 132,§1(4),and we have rm employees.(No workers'comp_ir+�ce required.) `Any applicant that chedo box Nl must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractocs must submit anew 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 infarmatiom Insurance Company Name: Old Republic Insurance Co. Policy#or Self-ins.Lic.#: M WC 3145819 _ Expiration Date,: 10/01/2020 Job site Address: 8 Charles St City/State/Zip: Northampton, MA 01060 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. I do hereby certify and re pa' enalties of perjury that the information provided above is true and correct Signature- Date: 7/17/2020 _ P #: 508.351. Official use only. Do not write bi 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 ' Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building titin b� Northampton, MA 01060 1 HOMEOWNERS'E E%4P77ON ELIGIBILn YAFFIDAVTT I, jinsert fu111ega1 name), born _(insert _ month,day,year),hereby depose and state the hollowing: 1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.85.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for'which I am seeking the aforementioned homeowners', exemption, does not involve the field erection of manufactured,buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition bf"homeowner"as defined at 780 CMR 110.R5.1.2: Persons) who owns 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 home owner. 4.. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, aIteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel,I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of 20_. (Signature) ReneWal Agreement Document and Payment Terms byAn&rsen. dba:Renewal by Andersen of Boston Julie Bell Legal Name:Renewal by Andersen LLC 8 Charles St HIC#170810 Northampton,MA 01060 WINDOW NE LACEMIENT 30 Forbes Road I Northborough,MA 01532 11:4135302905 Phone:508-351-22001 Fax:(508)986-7072 1 rbabostonbooking®andersencorp.com Buyer(s)Name: Julie Bell Contract Date: 07/03/20 Buyer(s)Street Address: 8 Charles St, Northampton, MA 01060 Primary Telephone Number: 4135302905 Secondary Telephone Number: Primary Email: jabelicnm@hotmaii.com Secondary Email: Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Renewal by Andersen LLC d/b/a Renewal by Andersen of Boston("Contractor"),in accordance with the terms and conditions described in this Agreement Document and Payment Terms,any documents listed in the Table of Contents,and any other document attached to thisreement Document,the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. Total Job Amount: $19,577 By signing this Agreement,you acknowledge that the Balance Due,and the Amount Financed must be made by personal check,bank check,credit card,or cash. Deposit Received: $0 Balance Due: $19,577 Estimated Start: Estimated Completion: Amount Financed: $19,577 8-10 weeks 1-2 days Method of Payment: Financing We schedule installations based on the date of the signed contract and secondarily on the date in which we complete the technical measurements.The installation date that we are providing at this time is only an estimate.We will communicate an official date and time at a later date. Rain and extreme weather are the most common causes for delay. Notes: Gs#2735 1/3 start, 1/3 install, 1/3 sub complete Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid without the signed,written consent of both the Buyer(s)and Contractor.Buyer(s)hereby acknowledges that Buyer(s) 1)has read this Agreement,understands the terms of this Agreement,and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement. NOTICE TO BUYER: Do not sign this contract if blank.You are entided to a copy of the contract at the time you sign. YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT OF 07/07/2020 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION, WHICHEVER DATE IS LATER. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Legal Name:Renewal by Andersen LLC dba:RnewaI by Andejwq of Boston Buyer(s) 1�k L�- -) P.-I-� tit- Signature of Sales Person Signature Signature Michael Richardson Julie Bell Print Name of Sales Person Print Name Print Name UPDATED: 07/03/20 Page 2 / 18 Renewal Itemized Order Receipt byAndersen. dba:Renewal by Andersen of Boston Julie Bell Legal Name:Renewal by Andersen LLC 8 Charles St 2HIC#170810 Northampton,MA 01060 WINDOW NE LACENIENT 30 Forbes Road I Northborough,MA 01532 H:4135302905 Phone:508-351-2200 1 Fax:(508)986-7072 1 rbabostonbooking®andersencorp.com • ROOM: 101 sun room Window: Casement, Double, Vented, Base Frame, Exterior White, Interior White, Glass: All Sash: High Performance SmartSun Glass, No Pattern, Hardware: White, Screen: TruScene, Full Screen, Grille Style: No Grille, Misc: Aluminum Wrap, Aluminum wrap of exterior trim. 102 sun room Window: Casement, Double, Vented, Base Frame, Exterior White, Interior White, Glass: All Sash: High Performance SmartSun Glass, No Pattern, Hardware: White, Screen: TruScene, Full Screen, Grille Style: No Grille, Misc: Aluminum Wrap, Aluminum wrap of exterior trim. 103 sun room Window: Casement, Double, Vented, Base Frame, Exterior White, Interior White, Glass: All Sash: High Performance SmartSun Glass, No Pattern, Hardware: White, Screen: TruScene, Full Screen, Grille Style: No Grille, Misc: Aluminum Wrap, Aluminum wrap of exterior trim. 104 sun room Patio Door: Gliding, 200 Series Perma-Shield, 2 Panel, Active I Stationary, Exterior White, Interior White, Glass: All Sash: Tempered High Perf. SmartSun Glass, Hardware: Tribeca®, White, Exterior Keyed Lock, Screen: Gliding, Full Screen, Grille Style: No Grille, Misc: Aluminum Wrap, Aluminum wrap of exterior trim., Lower/Build In Opening, Includes framing, siding, drywall and one coat mud & tape. 105 sun room Window: Casement, Single, Right, Base Frame, Exterior White, Interior White, Glass: All Sash: High Performance SmartSun Glass, No Pattern, Hardware: White, Screen: TruScene, Full Screen, Grille Style: No Grille, Misc: None WINDOWS:4 PATIO DOORS: 1 SPECIALTY:0 MISC:0 TOTAL $19,577 Renewal by Andersen is committed to our customers'safety by 8�A complying with the rules and lead-safe work practices specified by the EPA. UPDATED: 07/03/20 Page 3 / 18 Commonwealth of Massachusetts Construction Supervisor Division of Professional Licensure Unrestricted-Buildings of any use group which contain Board of Building Regulations and Standards less than 36,000 cubic feet(991 cubic meters)of enclosed Gonstrrltctldrt'StlWvisor space. C5-090125 E_rpires: 10/06/2020 i JAIME L MORIN 86 GARDINER STREET LYNN MA 01906 Failure to possess a current edition of the Massachusetts A State Building Code is cause for revocation of this license. �jyk For information about this ficense _ji'-,Prnissioner Call(617)727-3200 or visit www.mass.gov/dpi Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Supplement Card Registration: 170810 RENEWAL BY ANDERSEN LLC f a _ Expiration: 12/22/2021 30 FORBES RD NORTHBOROUGH,MA 01532 Update Address and Retum Card. W,A1 $ 20WVW17 C=Y�e �martuRea�l�o�(`,f� r Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supnlemerit Card before the expiration date. If found return to: Reoiistration g irn ation Office of Consumer Affairs and Business Regulation 170810 12!2212021 1000 Washington Street -Suite 710 RENEWAL BY ANDERSEN LLC Boston,MA 02118 1, 7,1 JAIME MORIN 30 FORBES RD , NORTHBOROUGH,MA 01532 Undersecretary -'f{ Not valid ithout signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Businessftanization/Individual): Renewal by Andersen Address: 30 Forbes Road City/State/Zip: Northborou h MA 01532 Phone #: 5083512277 Are you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with 30 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers'comp. insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.[] Roof repairs insurance required.] 1 c. 152,§1(4),and we have no employees. [No workers 13.© Other replacement 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 eontnwtots must submit a new affidavit indicating such. :Contractors that check this box must attached an additional shed showing the name of the sub-contractors and state whether or not those wtitics have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. m: I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Old Republic Insurance Company Policy#or Self--ins.Lic.#: MWC 31415819 _ Expiration Date: 10/01/220 Job Site Address: 11 Alcott Way City/State/Zip: North Andover, MA 01845 Attack 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 under the pains and penalties of perjury that the information provided above is true and correct i to e• _ Date: 12/23/2019 Phone#,. 508 351 2277 _ Official use only. Do not write in this area,to be completed by city or town ofJrciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: Page 1 of 1 ACOIREF CERTIFICATE OF LIABILITY INSURANCE '09/l /2029"' 1114� 09/18/3019 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: H the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. N SUBROGATION IS WANED,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 Willis Towers Matson Kidwest, Inc. NAME: _`--- --' -- c/o 26 Century Blvd PHONE . 11677-945- -- – FAX Not 1-668.467_2376 EMAIL P.O. Bos 305191 DDRE • Corti ficateserillin.com Nashville, Til 372305191 USA MSU AFFORDING COVERAGE NAIC8 MSURERA: Old Republic insurance Company 24147 INSURED INSURER 0: Renewal by Andersen LLC 30 C Forbes Road INSURER C; Northborough, UL 01532 USA INSURER 0: INBURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:W12663065 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. MBR TYPE OF INSURANCEADDL SUM P N ER POLICY EFF POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE L=j OCCUR eRMISES Es occu S 500,000 A MED EXP(Any one f 10,000 BUSY 314141 19 10/01/2019 10/01/2020-PERSONAL AADV INJURY S 1,000,000 GEWL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE f 4,000,000 X POLICY 171JJEEC 1-1 LOC PRODUCTS-COMP/OP AGG f 41000,000 OTHER: f AUTOMOSILELIABILRY COMBINED SINGLE LIMIT S 51000,000 �(Es poadam) �( ANY AUTO BODILY INJURY(Per person) i A OWNED SCHEDULED HIM 314159 19 10/01/2019 10/01/2020 BODILY INJURY(Peraoddem) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE f AUTOS ONLY AUTOS ONLY Per em f UMBRELLA UAB HOCCUR EACH OCCURRENCE f EMU LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS f WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATU R _.–_--- A. ANYPROPRIETORR'ARTNERIE XECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMSEREXCLUDED7 Q NIA MNC 314150 19 10/01/2019 10/01/2020 (Mandatory M NH) E.L.DISEASE•EA EMPLOYEE $ 11000,000 K yes,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 11000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddWonal Remerbe SdwduN,may be athehed I mon spa"Is"keo CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE j evidence of insurance '"' -"4• bid~ ®1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 01 ID, 16532909 aA=i 1372547 ...� t�,.r•-www... E_' _ ..,M^ ..A t PRODUCT PERFORMANCE Andersen NRC Certified Total Unit Performance «! 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