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24D-092 (13) BP-2023-0759 84 NORTH ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24D-092-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2023-0759 PERMISSION IS HEREBY GRANTED TO: Project# RENO 2023 Contractor: License: Est. Cost: 49000 D A SULLIVAN & SONS INC 053667 Const.Class: Exp.Date: 11/19/2023 Use Group: Owner: INC SULLIVAN D A&SONS Lot Size (sq.ft.) Zoning: URC Applicant: D A SULLIVAN & SONS INC Applicant Address Phone: Insurance: 82 NORTH ST (413)575-6035 MCC200000932022 NORTHAMPTON, MA 01060 ISSUED ON: 06/13/2023 TO PERFORM THE FOLLOWING WORK: ADD EXCERCISE AND BATHROOM, ADD ELEVATED DECK AT REAR OF BUILDING 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: (i).\'94 Fees Paid: $343.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner z_OK File #BP-2023-0759 APPLICANT/CONTACT PERSON:D A SULLIVAN & SONS INC 82 NORTH ST NORTHAMPTON, MA 01060(413)575-6035 PROPERTY LOCATION 84 NORTH ST MAP:LOT 24D-092-001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Building Permit Filled out Fee Paid $343.00 Type of Construction: ADD EXCERCISE AND BATHROOM, ADD ELEVATED DECK AT REAR OF BUILDING New Construction Non Structural Renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans/Plot Plan Driveway Grade% THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: X Approved Additional permits required(see below) M V g'2t S is K — 014 PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Specia Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Varia ce* Received&Recorded at Registry of Deeds Proof Enclose. Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water P.tability Board of Health Permit from Conservation Commission Permit fro CB Architecture Committee Permit from Elm Street Commission Permit DP Storm Water Management Demolition Delay p 003 Sign ture of Building Official I ate Note:Issuance of a Zoning permit does not relieve a applicant's burden t comply with all zoning requirements and obtain all required permits from Board of Health,Co .ervation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standar•s of MGL 40A.Contact Office of Planning&Development for more information. ECEI VED JUN 9 2023The Commonwealth of Massachusetts I _ Office of Public Safety and Inspections ,U,LDin, r Massachusetts State Building Code(780 CMR) n�� A'``?oti,,,,4'nti 4 Pe it Application for any Building other than a One-or Two-Family Dwelling _- (This Section For Official Use Only) Building Permit Number: ,q�- 7 ' Date Applied: Biul ilding Official: SECTION 1:LOCATION 1 o'L* NOWT* sl I'Ofl tY% NI MO 010()0 No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used I If New Construction check here 0 or check all that apply in the two rows below Existing Building kr Repair 0 Alteration I, Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: / Are building plans and/or construction documents being supplied as part of this permit application? Yes to No ❑ Is an Independent Structural nginee r' P e X5y,it iod? — Yes ❑ No di Bri sipt flialEor//bV/V l / 11,04f)ta• CW'TI(Zt 017O&) 3 3 it a 2/ aelf/r4 P OF/3aLp ivt— SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Total Area(sq.ft.)and Total Height(ft) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub ❑ A-3 0 A-4 0 A-5 0 B: Business E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2 0 I-3 0 I-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 0 IB ❑ IIA ❑ IIB 0 IIIA ❑ IIIB ❑ IV VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supp . Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal: A trench will not be Licensed Di si r allSi e❑ Public Check if outside Flood Zone Indicate municipal 1rW F Private 0 or indentify Zone: or on site system❑ required 0 or trench ox specify, permit is enclosed 0 f i JYLld Railroad right-of-way( Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable Nr Is Structure within airport arSach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: City of Northampton Massachusetts 4,?7 gk DEPARTMENT OF BUILDING INSPECTIONS F 212 Main Street • Municipal Building • Northampton, MA 01060 PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR COMMERCIAL & MULTI-FAMILY NEW CONSTRUCTION/ADDITIONS/ALTERATIONS 1. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work (Digital & Hard copy). 3. Site Plan with location of proposed structure(s) and setbacks. 4. Construction Debris Affidavit filled out and signed by applicant. 5. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 6. Contractors must supply a copy of CSL and proof of Liability Insurance. 7. Energy Conservation Compliance Certificate (if applicable). 8. Note any Conservation and/or Special Permit requirements (if applicable). 9. Driveway Permit (if applicable). 10. Proof of Water and Sewer entry fees paid (if applicable). 11.Trench Permit (if applicable). 12. Initial Construction Control Documents filled out and signed by the Registered Design Professional in responsible charge. 13. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner bln u.L))//l/l ?s,i1S i,/C 82-64 i4/zTy s1 MATMrraW wok Name(Print) No.and Street Citywn Zip Property Owner Contact Information: b 4s tI LL)✓4ii CDM 14104 L M r/ / P/lES 4/? Sal D3/D P3-Ian- 57.17- Mg121<c -/ Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑. Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor 6/1Su l l t t/�}tyl ' SD>yt /JiC. Company Name t"fi iZ < S1/11 /1/4 Cs• 0g3 LL7 Name of Person Responsible for Construction License No. and Type if Applicable 82. 64 t Aii7' S1 yoFniestPT ?? M4 6/06b Street Address City/Town State Zip 4i3-5 o3/0 1/. - 127 pa Ts14#2 < �1� lilt tv' Gn1�( Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVJ1'(M.G.L c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the ivance of the building permit. Is a signed Affidavit submitted with this application? Yes No ❑ SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor 'q d00 00 and Materials) Total Construction Cost(from Item 6)=$ !� 1.Building $ 2J 0 00,C 4`1 2 Building Permit Fee=Total Construction Cos x_2(Insert here 2.Electrical $ J 000,00 appropriate municipal factor)_ r $ 1 ©0 3.Plumbing $ 0Oa PO 4.Mechanical (HVAC) $ Enclose check payable to t 0 00 C(,i Note:Minimum fee=$ (contact municipality) l5.Mechanical (Other) fP $ 0O( vG� CIO 0`//DO'IN�h,/Plba/ ,,,,""�q 6.Total Cost $ ! 000-A) (contact municipality)and write check number here a4097 SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Please print and sign name Title Telephone No. Date Street Address City/Town State Zip Email Address Municipal Inspector to fill out this section upon application approval: Name Da CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE City of Northampton Massachusetts tiw�S c'f` r. ISM DEPARTMENT OF BUILDING INSPECTIONS Z ' 212 Main Street • Municipal BuildingC� Northampton, MA 01060 �'� �4 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, 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, S 150A. The debris will be disposed of in: Location of Facility: Vfi. LE')/ Ric Gicilue The debris will be transported by: suil ( vIco) Name of Hauler: Signature of Applicant: Date: 6-9-23 The Cinnntun lctealth of;%lassachusetts 1` , i�!I Department of Industrial Accidents ;:�►= = / Congress Street,Suite 100 _I i=_ Boston, M 102114-2017 wive rurss..gov/dia )3 mikers'Compensation Insurance ARdav it:Builders/ContractorsfEleetrieians''Plumbers. 'It)BE FILED 1W'1'1'H'711F:PERNIIITING AI:l IIURITI'. Applicant Information Please Print I.eeibly Name INusinrsseOrganization'1ndi ,dualY___ Address: City/State/Zip:_ Phone #: Are yowl as ernnplotee!(lied.the appropriate bus: Type of project(required): 1.0 t am a cnnnploya with ennphryues I(u1l and or part-inset• 7. Q Ncys construction '_!_!1 am a side proprietor or pwttnenhip and hake no employees worl.ing tot nee in 8. 0 Remodeling any capacity.[No worker;vamp.insurance rcyuirkxd.] 9. 0 Demolition am a larnnmwnet doing all wink myself.INti wuckars'comp.uauanuax required.]' 4.01 am a IWnnr.YlNN act and skill be hiring contractors to eonduei all work on any property. I will 10 Q Building addition ensue that all contra:ton either have winter;compensation insurance or air sole 1 1 a Electrical repairs or additions prirpnelvn with no employees. 12.0 Plumbing repairs or additions 30l am a general contractor and 1 hake hind the sub.cvntracton lured un the attached sheet. 13.1=1Rcwfreptairs These sub.cuuteactors hake ernploy'ecs and hake'Aurken'ciaup.insurance.: 6.D W.an:a corporation and its officers hake exercised their right of exemption per MU c. 14. Other 152.§1141.and wee hake no innpluyces.[No wvrkcn'creep.insurance required.] 'Any applicant that chocks hot#1 must also fill out the section below showing their workers'compensation policy information. liumww errs wbu subunit this affidavit indicating they are doing all work and then hire outside evrntraciuia must submit a ricks affidavit indnalirng such. 1C ontractors that check this hot must attarlrvd an additional shod dunking tie name of the sub-cu ntracturs and state whether or not those amities hake employ-ees If the sub-contractors hake mi rloyees.they must provide their workers'corm.policy nnunber. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: lob Site Address: City/State/Tap: 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage;verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sitnaturc: I)artr. Phone Official use only. Do not write in rlri.$ureic, in 1w completed hi c•irl•or town official ('its or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.(-if,riesn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: The Commonwealth of Massachusetts Department of Industrial Accidents J Office of Investigations '' Lafayette City Center 2Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): D.A. Sullivan & Sons Address:82-84 North St. City/State/Zip: Northampton MA 01060 Phone #:413-575-6035 Are you an employer? Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 20 4. ❑� I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction listed on the attached sheet. 7. ❑■ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. [' Demolition workingfor me in anycapacity. employees and have workers' p 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑■ 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 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *My 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 contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether 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: Selective Ins Co of America Policy#or Self-ins. Lic. #: MCC20020000932022A Expiration Date: 07/01/2023 Job Site Address: 82-84 North 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 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 perjwy that the information provided above is true and correct. John J. FlemingDigitally signed by John J.Fleming Signature: Date:2023.04.27 10:23.11-04'00' Date: 6-9-2023 Phone#: 413-575-6035 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 11:1Board of Health 211 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5.alumbing Inspector 6.0Other Contact Person: Phone#: 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, oral 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 a joint enterprise, and including the legal representatives 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 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 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)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 sub-contractor(s) name(s), address(es)and phone number(s) along with their certificate(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. If an 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 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 permit/license 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) and under"Job Site Address"the applicant should write "all locations in (city or town)." 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. A new affidavit must 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111-1750 Tel. (617) 727-4900 or 1-877-MASSAFE Revised 7-2019 Fax (617) 727-7749 www.mass.gov/dia ACG 0 8/05/05 CERTIFICATE OF LIABILITY INSURANCE DATE //2022 ( 022 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: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,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 CONTACT Barbara Grynkiewicz NAME: Webber&Grinnell PHONE (413)586-0111 FAX (413)586-6481 M 8 North KingStreet WC.No.E nl (NC,No]: ADDRESS: bgrynkiewicz@webberandgnnnell.com INSURER(S)AFFORDING COVERAGE NAIC 0 Northampton MA 01060 INSURER A: Selective Ins Co of America 12572 INSURED INSURER B: Selective Ins Co of S Carolina 19259 D.A.Sullivan&Sons,Inc. INSURER C: MA Employers/A.I.M. 12886 Attn: Mark Sullivan INSURER D: Darwin Select Ins.Co./BRECK 82-84 North Street INSURER E: Northampton MA 01060-3255 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 7/1/23 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. INSR ADDL SUER - ' POLJCY EFF ' POLICY EXP LTR TYPE OF INSURANCE INSD WVO POLICY NUMBER (MM/DD/YYYY(I(MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE ICJ-RENTED 500,000 PREMISES(Ea°cc lomel $ MED EXP(Any one person) $ 15,000 A S2444741 07/01/2022 07/01/2023 PERSONAL 6ADVINJURY $ 1,900,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY X JECOT ri LOC PRODUCTS-COMP/OPAGG $ 3,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED v SCHEDULED A9108782 07/01/2022 07/01/2023 BODILY INJURY(Per accident) $ AUTOS ONLY /� AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY X AUTOS ONLY (Per accident) Underinsured motorist BI $ 250,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 A EXCESS LIAB CLAIMS-MADE S2444741 07/01202 07/01/2023 AGGREGATE $ 10,000,000 DED XI RETENTION$ 0 S WORKERS COMPENSATION PERI OTH- AND EMPLOYERS'LIABILITY X STATUTE I ER YIN 1,000,000 C ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A MCC20020000932022A 07/01/2022 07/01/2023 E.L.EACH ACCIDENT $ OFF ICER/MEM BER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1'000'000 If yes,describe under 1000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ , Limit $5,000,000 Pro(essonal Liability D 03043363 07/01/2022 07/01/2023 Deductible $10,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Evidence of Insurance Coverage ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE cV,-' ©1988-2015 ACORD CORPORATION. All rights reserved. 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