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HomeMy WebLinkAboutBLD-19-2437 it ONE & TWO FAMILY ONLY-BUILDING PERMIT Town of Yarmouth Building Department o►""r • 1146 Route 28,South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 F *iii Massachusetts State Building Code,780 CMR Building Permit Application To Construct,Repair, Renovate Or Demolish. a One-or Two-Family Dwelling REIVED This Section For Official Use Only Building Permit Number" ►_,�,,-so..♦ .Date Applied: 4 [1j ti LI/ drat, , .� . A!e DING DEPART ENT B" m c, (PriatName) igeSign• .. s-: . SECTION 1:SITE INFORMATION.. • 1.1 Prop"erty Address: 1.2 Assessors Map&Parcel Numbers I I Kelp Ln. Soto h Yarw.otcls Ua,S"' CD 1.1a Is this an accepted street?yes ✓ no Map Number Parcel Number 1.3 Zoning Information: 1.4��ro er Dimensions: R E C t l V E 0 R-a 9/ 4s �et� Zoning District Proposed Use Lot Area(sq ft) Fro.tag. (ft), 1.5 Building Setbacks(ft) rea • Front Yard Side Yards g . 'ta,•GDEPAHTME I Required Provided Required Provided Required er. O•-.e• 1.6 WatererSupply: (M.G.L c.40,454) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 12 Private❑ Zone: _ Outside Flood Zone? Municipal CI / On site disposal system E Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: . — �7 _ ')v ex-- Moe —Aiea/ � d t'o tvrot t. LW a O 2 617?— Name Name(Print) City,State,ZIP /TS 4sIa•ci Sl -7B( 3y ( Voo No.and Street Telephone Email Address ' SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) ' New Construction❑ Existing Building 21 Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Wore:_ tS lklot,� f��ce.. e,7 r SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ t 30 d Building Penult Feel$(, Indicate how fee is determined: $ ❑Standard City/TownAppltcationFee 2.Electrical Cl Total Project Cost'(Item 6)x multiplier. x 3.Plumbing $ 2. Other Fees: $ CJS' 4.Mechanical (HVAC) $ 5.Mechanical (Fire Suppression) $ Total All Fees $ Check No.T_Check Amount: Cash.Amount. �/ 6.Total Project Cost: $ UCJJ 0 Paid in Full . . CI Outstanding Balance Due: ' !" r SECTION 5:.CONSTRUCTION SERVICES 5.1 Construc�. yl tiiion Supervisor License(CSL) CS—09/9// S-/9 a0/y • c-`` 1,"4- me i ( License Number Expiratien Date Name of CSL Holder ^ �+ List CSL Type(see below) u IAS ClArvier 2,1 No.and Street Type . Description n C a. Rik nt ,k . iM A va5310 ® Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted l&2 Family Dwelling City/fown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding � f SF Solid Fuel Burning Appliances S "AGS o9r/// acckt.�i men+c7 Sq @ grin.;/.COM I Insulation Telephone Email address / D Demolition 5.2 " rtRegister(e�d Home Improvement Contractor(HIC) (Sczei 0.'044 .lI(424tog 3 oa/dsia0. at HIC Registration Number Expifation D on Date HIC Company Name or HIC Registrant Name f /9S Cccrr;cr Rd Scettpintenitd 54& qmed,esti) No.and Street Email address &.5l- /79(wou-iii, ma , aas34, Gmaj a1411 City/Town,State,LIP 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 ❑ No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN : OWNER'S AGENT OR CONTRACTOR APPLIESFORBUILDING PERMIT .. I,as Owner of the subject property,hereby authorize cc0 t( {' 1 M e I-1-6' to act on my behalf in all matters relative to work authorized by this building permit application. t er's NameE( le tropic Signature) /6 /iIus 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 s applicatio i true and curate to the best of my knowledge and understanding. /0�j7//8 Print Owner's or Authoriz d Agent'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 Home Improvement Contractor(MC)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 www.mass.gov/oca Information on the Construction Supervisor License can be found at wwtv.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,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. "Total Project Square Footage"may be substituted for"Total Project Cost" t —y— The Commonwealth of Massachusetts — _ � / Department of Industrial Accidents illi_ • 1 Congress Street, Suite 100 sdif_—=11 Boston, MA 02114-2017• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciansfplumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information yy�� {� Please Print Legibly Name (Business/Organization/Individual): /-t, . 2t,` Corporq t;on Address: 1 LIS -i strinc CSk-t2�f-� 1 • City/State/Zip: Sttplx9ht-on IMA. lz3o7a Phone #: (7631 31-1 1 -LJ&b Are you employer?Check the appropriate box: r Type of project(required): I. I am a employer with/. D employees(MI and/or part-time).* 7. O)Few construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp,insurance required.]t S. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.t - 13.0 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. 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. t 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: Peat-ad _Lrad ,r4 ice Co.eO Policy#or Self-ins.Lic.#: 51-130 9S-05 Expiration Date: //_0/c ey Job Site Address: ) j r.1J Ln (1,01--h %rotor,-fh City/State/Zip: P7A Ddletey 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 ce y r th pair�s.pKt pe f perjury that the information provided above is true and correct Signature: C�/('v Date: /0bp(l9 Phone#: 78)-3 41 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#: •YqR TOWN OF YARMOUTH c BUILDING DEPARTMENT „ _ �, 1146 Route 28, Yarmouth, South MA 02664 508-398-2231 ext. 1261. HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: JOB LOCATION: \ \NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" \ NAME HOME PHONE % WORK PHONE PRESENT MAILING ADDRESS \ / CITY OR TOWN\ / STATE ZIP CODE The current exemption for'Homeowner' was extended to include owner—occupied dwellines of one or two units and to allow such homeowners to engage an individual for hire who does not possess a license,provided that such homeowner shall act as supervisor. (State Building Code Section 110 R5.1.3.1) Definition of Homeowner: ' Person(s)who owns a parcel of land on whi he/she resides or intends to reside,on which there is or is intended to be, a one or two family attached or detached structure assessory 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;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. (Section 110 R5.1.3.1) The undersigned 'homeowner' assumes responsibility for compliance with the State Building Code and other applicable codes,by-laws,rules and regulations. \ The undersigned 'homeowner' certifies that he / she understands the Town of Yarmouth Building Department minimum inspection procedures and requirements and khat he / she will comply with said procedures and requirements. \ HOMEOWNER"S SIGNATURE i \APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent,which meets the requirements of MGL Ch.142. Yes No If you have checked y , please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent h:homeownrlicetemp .r°"4, TOWN OF YARMOUTH vg BUILDING DEPARTMENT • - Zy 1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext 1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOLITIONDEBRIS DISPOSAL AFFIDAVIT Pursuant to M.GL Chapter 40,Section 54 and 780 CMR, Chapter 1, Section 1113, • I hereby certify that the debris resulting from the proposed worlddemolition to be conducted at 11 Vele L n Work Address Is to be disposed of at the following location: /A p FoccS;-i2.d Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A.. jlita //13 Signature of Application /D//Date Date Permit No. • 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 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 . 4 f ONE or TWO FAMILY —BUILDING PERMIT APPLICATION REGULATORY APPROVALS NOTICE Address of Proposed Work: I I Kelp L n , c5ou_A-k 7+loi c F, Scope of Proposed Work: K,1chPr Papw,odd aoio repnccw.e44- ',�vo\U:ncj }kende_r- Chnner Date: AY/978 Based on the scope of work described above,the applicant is required to obtain approval sign-offs from the following departments as checked-off below: INITIALS Health Dept.—508-398-2231 ext. 1241 Conservation Comm.-- 508-398-2231 ext 1288 Water Dept.— 99 Buck Island Rd.phone no. 508-771-7921 Old King Hwy.Hist. Comm.—508-398-2231 ext. 1292 Engineering Dept.—508-398-2231 ext. 1250 -Ctsre 'ept.—Kevin HuckMames Armstrong,96 Old Main St SY Note: Please call Fire Department for an appointment. 508-398-2212 Other ti Appropriate plans and/or application shall be provided to each of the departments checked-off above. Each of these regulatory authorities has t}teii own requirements outside the jurisdiction of the Building Department All applicable approvals shall be obtained prior to submitting a building permit appf'cation to the Building Dept. Thpnk you for cooperation. i • 1 Receipt Acknowl dgement: i t/ /0//9 /8 /Applicant's Signature Date • Rev.Dec.2015 • • DOUBLE 2X10 KD HEADER DOUBLE KING STUDS CV iP 1111711 SINGLE JACK STUD ill1 t . 15'-9 1/4" t \ . i OWI'! 07 y t-es;MOU i C KITCHEN WINDOW WALL REVIEWED FOR BUILDING APoD ZONING CODE COI¶PL- Scale: 1/4" = 1-0" ANCE. ERRORS 0R 0t.1u!isAsif:�DO NOT RELIEVE .E LPPLICANT FROM TME FZLrCNSIBILITY OF'AS BUILT COMPLIANCE. DATE:�n7LO/ d * •feeJI •ING OFFICIAL • (11i ER FILE COPY , 11 '. , ?` alPeg�k�z ' t:; X18 ?., f50,� ` e. • • e2e%ntmonwealtA ofQ fla.uackaetti • OtlIce 01 Consumer&Hairs&CusineSS RogIllation ..t HOME IMPROVEMENT CONTRACTOR TYPE:Individual a figgielfatign, gainiti2n 16,9643 -- " 02125/2020 SCOTT PiMENTAL SCOTT PIMENTAL 125 CURFIIER RD. EAST FALMOUTH,MA 02536 Ur.dersecretary ---- ----- , .: ---------------_ 9; Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction'Supervisor CS-091911 Expires: 0510912019 . .. SCOTT G PIMENTAL -, 125 CURRIER HD E FALMOUTH MA 02536 .... .'.•.,.. i ,S•- , ' • • 4.....-- Commissioner Ci • . . . . • 1 F U K I t '1:11:1 MEMBER REPORT PASSED Level,Wall: Header • 2 piece(s)2 x 8 Spruce-Pine-Fir No.1/No.2 Overall Length: 5' Jy mcppge r151q++siR+>f±` 3'.4ns.n—w,pte'^.iyPr[PM,P'M1IIV, 'ra,M". ,.-9- 4s .s.","'""*"71r""11 9" i at A All locations are measured from the outside face of left support(or left cantilever end).All dimensions are horizontal. Design Results+: ,..a:':Actual @Location:.. :Allowed Rewra .. IDF ^Load k combinetbn(Pattern) v-*': _ system:wall Member Reaction(Ibs) 631 @ 0 1913(1.50") Passed(43%) - 1.0 D+0.75 L+0.75 S(All Spans) Member Type;Header Building Use:Resben1al Shear(Ibs) 652 @ 4'3 1/4" 2251 Passed(29%) 1.15 1.0 D+0.75 L+0.75 S(All Spans) - Building Cade:IBC 2015 Moment(Ft-lbs) 942 @ 2'11" 2645 Passed(36%) 1.15 1.0 D+0.75 L+0.75 S(All Spans) Design Methodology:ASD Live Load Deft.(in) 0.019 @ 2'6 1/16" 0.167 Passed(1/999+) — 1.0 D+0.75 L+0.75 S(All Spans) Total Load Deft.(in) 0.032 @ 2'6 1/16" 0.250 Passed(1/999+) -- 1.0 D+0.75 L+0.75 S(All Spans) • Deflection criteria:LL(L/360)and TL(L/240). •Top Edge Bracing(Lu):Top compression edge must be brazed at S'o/c unless detailed otherwise. •Bottom Edge Bracing(Lu):Bottom compression edge must be braced at S o/c unless detailed otherwise. •Applicable calculations are based on NDS. ,t r' „s,!,,. ,;Beadrry Length. .; •:r Loads to SUPPorts(Ibs) -- �;',. Supports ' ToW -: Arallable Required Dead Floor Live snow Total Aaassaiea 1-Trimmer-SPF 1.50" 1.50" 1.50" 335 176 485 996 None 2-Trimmer•SPF 1.50" 1.50" 1.50" 295 144 431 870 None .'Dead r Floor Live Snow° v"t,.i Loads Location(sive) Tributary wGNn (0.90)5 (1.00) (1.15) Cornmenb':. 0-Self Weight(PLF) Oto 5' N/A 5.5 - - 1-Uniform(PSF) 0 to 5' 2'6" 16.2 - 30.0 Roof Load • 2-Point(Ib) 3" N/A 100 80 135 Linked from:Floor; hist,Support 1 3-Point(Ib) 1'T WA 100 80 135 Linked(nom:Floor: Joist,Support 1 4-Point(lb) 2'11" N/A 100 80 135 Linked from:Floor: Joist,Support 1 5•Point(Ib) 9'3' N/A 100 80 135 Linked from:Floor: Joist,Support 1 Weyerhaeuser Notes Weyerhaeuser warrants that the slzlrg of IE products will be In accordance with Weyerhaeuser product design criteria and published design values.Weyerhaeuser expressly disclaims any other wamdnti s related to the software.Use o ethis softwareIs not Intended to circumvent the need for a design professional as determined by the authority having jurisdiction.The designer of record,builder es Gamer Is responsible to assure that this calculation Is compatible with the overall project.Accessories(Rim Board,Blocking Panels and Squash Blocks);re not designed by this software.Products manufactured at Weyerhaeuser facilities are third-party certified m sustainable forestry standards.Weyerhaeuser Engineered Lumber Products have been evuated by ICC-ES under evaluation reports ESR-1153 and ESR-1387 and/or tested In accordance with applicable ASTM standards.For anent code evaluation reports,Weyerhaeuser product literature and Installation dealls refer to www.weyeRueusermrNwaadprodxWdocumerd-0bary. The product application,Input design loads,dimensions and support Information have been provided by ForteWEB Software Operates SUSTAINABLE FORESTRY INITIATNE WeyerhaeuserY • Fortewea Software Operator lob Notes Designed: 10/18/2018 3:17:41 PM UTC David McLean Falmouth Lumber ForteWEB v1.4,Engine:V7.3.0.262, Data:V7.2.0.2 (508)7W-5807 amdtdad.mm File Name:Scott Pimenta) Dana 1 / 1 ® ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE ne� onDl THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS a 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 NAME: Stephen Turner Boston-Alliant Insurance Services, Inc. PHONE FAX 131 Oliverliver Street,4th Floor INC No Fir&617-535-7200 I INC.No:617-535-7205 - Boston MA 02110 ADDRESS' sturner@alliant.com INSURER(S)AFFORDING COVERAGE NAIC N - INSURER A:Executive Risk Indemnity Inc 35181 INSURED AAWLLC-01 INSURERS:Federal Insurance Company 20281 - A.A.VViIsland Corporation INSURER D:Allied World National Assurance Company 10690 145 Island Street Stoughton, MA 02072 INSURER D:Water Quality Insurance INSURER E:Allied World Assurance Company(U.S.)Inc 19489 INSURER F: COVERAGES CERTIFICATE NUMBER:853126310 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 ADOL SUER POLICY EFF POLICY EXP ITR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DDIYYYY) IMM/DDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY 54309528 9)302018 9)302019 EACH OCCURRENCE $1000,000 CLAIMS-MADE A OCCUR DAMAGEO RENTED PREMISES RENTED 5100,000 _ MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY $1,000,000 e „ GEN!AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 52,000,000 POLICY El 28r 0 LOC PRODUCTS•COMP/OP AGO $2,000,000 - OTHER: S B AUTOMOBILE MAGATY 54309527 9/30/2018 9/30/2019 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) — X ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS _ HIRED NON NED PROPERTY DAMAGE $ _ AUTOS ONLY AUTOS ONLY (Per accident) • $ C X UMBRELLA MB X OCCUR 0310-9519 9/30/2018 9/302019 EACH OCCURRENCE _ 520,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE 520,000,000 DED RETENTIONS $ - 8 WORKERS COMPENSATION 64309529 9/302018 9/30/2019 X AND EMPLOYERS'LIABILITY Y/N STATUTE OTH- ER ANYPROPRIETORIPARTNERIEXECUTNE ElNIA E.L.EACH ACCIDENT $1,000,000 OFFICERIMEMBEREXCLUDED7 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 E Contractors Pollution Liability 0310-9515 9/30/2018 9/30/2019 Each Clalm/Aggregete , $5,000,000 D Vessel Pollution Liability 5282099 9/302018 9/30/2019 Each Oct./Aggregate $5,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Evidence of Insurance 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. A.A.Will Corporation 145 Island Street Stoughton,MA 02072 AUTHORIZED REPRESENTATIVE✓ ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD