HomeMy WebLinkAboutBld-20-02736 Y O' Office Use Only
1� Permit#
Q; 2
Amount 80
MA-T f� LSL� A
Pemuit expires 180 days from '.
B '\ 0 7 36 issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department ; +
1146 Route 28
South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 5d/I 5"6 fl e r c v e y Dr
ASSESSOR'S INFORMATION: _
Map: Parcel:
rrlo cA04
OWNER: / e K S-`{91S(o Hera)ry[7i• 5% q 78 '3b -62GR
NAME Vex PRESENT ADDIRESS TEL # Email Address:
CONTRACTOR:W nfet,,/k/vr(I a� �oslan LLB c24Cwndtingt a iSA i.la hu ,1 1 i C7 8 I) 4132—'i8O Sr
NAME MAILING ADDRESS Ole°I TEL. Email Addre
sidential Commercial Est.Cost of Construction S 2-1 l 3 7(o —
Home Improvement Contractor Liu# 02S Construction Supervisor Lic.# 072-772.
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: 4 scocia4 eoq An Flay e_r S Worker's Comp.Policy# A) -L-Sho 5-0 1_1?6061--
2011 Os
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares 7 Replacement windows:# 2- I Replacement doors: #
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like
*The debris will be disposed of at: hVc-th 1 L.zia3edei+Ei17 — lt/t7bveci PL1 A
Location of Facility
I declare under penalties of perjury the s,, ' • ed are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for denial or rev.,l :o „:.: ::•••••• :. M.G.L.Ch.268,Section I.
Applicant's Signature: Or� //1/ \ Date: //— 6
Owners Signature(or a ent) Date:
Approved By: Date: /7--7`/
lltrildirrreffigaI esi�
Zoning District
Historical District Yes No Flood Plain Zone: Yes No
Water Resource Protection District Within 100 ft.of Wetlands:
Yes No Yes No
r •WindowWorld.of.Boston MA.HID
Qfllces.ilk Showrooms :...--1 (I 1
•
•
'' U 154 OrreiAktgg Pads U 2 gi.o.p4k Brreol 4 ido0.Boston li(np f to': 18BOg5,, r
F -Woburn;Mn cleat ban O23se !sh ewiliy,•MA.QI its`Psdoral lu A �,, -
(701) .4005 (70I) 6281 f509)eg5 9676 .999a;432 J
YY''���??���--'' -•wwtHW1ntlowWoitaolBastan.carim
Cuiltftno{:_ O(4Q Ci:tYi "a sM • PfiorioOil
Install dfosk: 'y• a iyA Y Phone(c} der-�?,:a- 2
cny:•' ou'�tt . L� stal,:au+zy►.OWW �}Y'. ooktiie 4.c, co.r
WINDOW WOuu.LO;` . GLASS OPTIONS.
1od0 Serig7SingIo¢iuf9 AliWehl •$243 . .41 Sotariorro Elie•Dui Pane 'St2e 2..7o
' 20OpSarleMOH.Ail.Ward 529% .
4000 Serial Dti* .42095)90, • Tdple Patre 4259__r•__ .
606D Bodes OH AIFYVeld OmWINDOW OPTIONS
7 2Uta Slider $429 • :
_3 Lila Older t04.11.44:7.u r Ses9 —' brans •e:NtartBtilY+q• !. g g I►lCLUGEG
. irkiwe'/ROAL.160 :00' lif.•• —f/28erooes Syd1u4QYQ.
_P+ctureEFla{gdtlle•I8413a�t1) 5539 —Poet0lnsulerlanOn•Jerribsand/Mad':-SITI CtUGH).
_._+4wntn9 • 5359 � s SOenplh:Cileltts•;(4000(8000)° '315lrIC U Ed.
___.Cesenienl Pfus:S09:(OH s,Osi RBI $379 ._._Double Locks t>•2 } $aICIUDED
_a Lila Caaemant :tom _,_Full Somme ;$25 -
3 tile idesp Mani•tre at:ter-.1.. As fq.14% - ,,_.Foldht@I.Rt10a:(Contourred!Flal: `3651T,-
,_BasementHopper ,. $469 _Pmuloolkls 376
BayWinirow soirg:tdaunii.0Sfr#ea►$2rl59 •SIm letrid.O1 lded•,'•; 182 .
Bow Window-Soffit Maunt i Ws'so l82999�_. - �
pasden.Window._ .S2179 Tertgrared tit sal• BSO•1T60) $76 _
Bayi8ow,/Aprdan'4Ye*Rs.(+109UI)elm_ •4hs(tiiii lia.or - Sty
�Balae!ALndnd sae :Pee$1nhgN�F, ma 5$
htood0 1 la '�NNx+0P7160A0oey),3I00 •—OOet»t Sacad'Ft9oto. ''�3S
10410.04DaikOPl4. 4't fox.Wgod- PAE.tli7DBUIL'1'�HOME&f Efl!01(A_
.MYHOMEWASBUILTINYFIEYEAR ' initta
•
NA1epUl ttt
6tn.nr�:rie t 8mnzel !•'rorra)slatt_. I+cEI t aNsous
. •'S oiler*Wr rkw 'slily o+a+Om ExxiMior •. num Ciadaee tr el
.-:s1!g�hr tMktdow S� �! �
-I lioitldred$90 B ntaolh.s90. s PP . ' �'_0
1 / :Faaht9 : bye V
Arrwp. Dattwdq< likrltt•B Clad - SYO,_T_,_...
NONCUOt0M000115 .1 dd4Li61MO Siop5: SBO_a 'O:
meiPtiIriaPadaOoor:sgnra., 5r12l9 - • • -Int�atnleiio(cssing ;erartsAt-$95: •
• 1ilAotuniiPOP°glow eh. • Repair- I,.itmb or replace sir nosing•*97e; ..
Add(dbaitP6w(or0HtamRoaa9ParxDew.Um FullS66;396(S4e)replacement •s175
_yam"PM. yi PA.-opor Si.:01 $1.90e _•inavrete iNstgirtt
_ >4tlagwt+b'OooreM x(ps_ .
•
•
__Lrie4lit-11dA,'9ldin so:agoi g1749 —MuU W'FoHm Afii i dart 6t3D'
` y 0
00
_trtlr(trCn`fientolr l ':ry40,
rtokuo*Pit a 3og MaW Window)emoval
_gddrk Pub Dcc, 'S2r0 _Nsw-Gonstrucllon Vklyl`Removal- St 75_�
.Wetitgiaiii-• s. 4399 _New.0194t,E,lt.,pdirc'F'tt: '$t-$0 •
�Cterior0 arbola 5599 r_noolinrB¢y'HBowWindorrs ;.t�gp0. •
`lldaror-; ,2i'•Me. ,.S279 •_RemoalofEXI}6ng-BeylBgvt- $250 ..
t 3, _•saWBoin onireretbi% XL Reuo:Fit 456..
1 -.B6N S 00CIetl(rpl}.. sass thew •Stdlnp VlneNot Match) •
S: .
ROUNDUP FORIiiiNOOw W010.0..oARiS.:,-,
Customer'deofnesextwior wlaA undersfand3.P9!nling and/o'r ihpafr,mei bo to liked InItlpl; ,.
•C'iitaloliler-dedln9RIdODon A Lt.- .:wlndpwsldootti;lnllaf 4 tl-
mielilYErCfusloirtltlil ttaUMl h1b. . ws- tpi :Sperm•Hrrral,Spe?r" :6u0,gilrm0Glfser
•.•.4Mint iklitiidNrdlOre eAreddiebeH r6rr tigait'dldiMperatfl, itektideadoie skfiraPPormillirilkeexeteEteiiRWaf.
NO• EDEMA WORK.IF.NOT tN ylrgrttNol -Cus tdmeragtaes.to`itie terms of pa yawn-ata<.�i�elrlowei
f,it �V Al. Efivaiaerg I-Melenale $ •V •_'�.R"
Site Setup PflrRW DispoaR Oedeery Peas8. c: 'II-
ep 74�
p ~� ,_j/�/ ..
.CtMQiif e ot 3st.s -7-i
Plot¢iit$ledReyML!1gs4G $
g•j.70 DP _ , - . .. -firmoetire�yokulWatlor•t!it:� .
-
NA6dxrr: rr lw4Moudtxortoa -4 tekto tr4Z a d secauyama2!res--1WL .
sasaea row olthe oolgtA 1I31C6tOremm a 7asra;utrrel or 1LJ
pNrra+ltplgxaaba'. Meeriaiaol dgyswaRmsutaon<dttproleusri4waaeeanycdadrt ao°t "` '
apaGel4imeaird el..,,, 1041 41Wireme` adaorb:Mpn F.Mtxme tfasyarl PMIP.Irpeatred aralyy arr iGoabk otoitio aOsrM81' 4*i_otsvititl:9 iMar
t uk DEW DMw eidAD a a$ • Ao4'ree•Pptt d�Doete./dAirille Mired-1617)e73-07e9 .
�Neeewidiu16 Ida le o e w000daesdnod"inoiarsleI*atinRumreSL
WYrdesrwatdofMstaniNirperigeeMOeeter147Aaleteo Wrsii>et 1 4r.itde 0cosl,ueorr ... #aMa'W+wurltdbad:ot.
9a9atWp�daolEedarmMilWali ( ylifilkYkkdl. it.0WftpftesaoWtw tiv.440to 1(+Aaa .•--i 4fs 4190da
BxkirPeAt6i11 til a11Abj�eN101441dleal+didkit4ldrR ttittrlert ii 10140. 11000OR/04.
r.#drr!aNfethewiiddailrpeu;ladtfilet otoop ir:#,ea dte)rW�wlevi8mism teadwaaor:
Ye eft biyer Olt Wool at any limo lnlori.•mfdd Io(Met dbutleem ditattu Dur date tldskyiudlon.:
11011$Ceaull!1(Dhow,l•baid-wr powttalhdgo titer He: al*ttlktv14Elbad!meneetldays
•TNIEraAC1HaTotto DLgwoT-PDA
ThdtI�V,e 00le!Mltdttittla padte�eithrrol &tlid�. BoairrttPewerko.Inc•ie ice4utlaat4 tla:womtr.rre.
414'fry I'"', rt T _ Q •��,
8rr wawa.oanar.fyax,iw�.u..nrol.d(:we.i� ara.,..!..r.*ywli'irYe: -
:arn.comi wr+0e avr ' `-ilkcop.tiro. ,*Gbpr: :twri...-;i�•;.ar•_
le filiziotti Window World of Boston MA HiC Registration
:umber
Offices&Showrooms Number:
it....\.1 0 10A Cummings Park CI 295 Old Oak Street
Woburn,MA 01801 Pembroke,MA 02359 166025
Federal ID#
clit,r,h4
..
(781)932-4805 (781) 826-6281
.. ' • r VitM
www.WiniiowWoridofBoston.com
Customer: CT�-c °/ (i i i! ,KW oK Phone(h) 82-4898432
Install Address;. 'f ''tL 8/-3c3-i:
cf Y s� /ZItRCatiy //may S-�iI7l�P"aJ��/h ,,e, Phone(w) 7
Bill Address: 1 Peelt'e/i/CA $7 ',' !. phOist2Z40 : , v/ E-mail ooicAe /i e` iila;I,coK
VINYL SIDING PURCHASE ORDER
AREAS TO.B IDED PRODUCT CO•L¢F( . •
Front n;vcy Siding y&r�'•t 0ICkI
WW 2000 pr 4006-EP
Lei�� YAP/4000 Ww 6000 Outside Comers l.��f fj�'e d�//G.
Back Efi Other STD' ❑ INSULATED
Right�� PROFILE INSULATION
Other
,di4.tSLQ.. Y// ,. la3/8" ❑ FULLBACK
&fir QNL y Clapboard U or Dutchlap❑ HOUSE WRAP Yes IaNO❑
SOFFIT, FASCIA, FRIEZE BOARD&GUTTERS 'TuckFascia
AREAS TO BE'CQVERED - Under Gutter
Front Left Back Right . Other *Color* 0 Yes O No
Sofit&Faclas , t/' iir
i -A -- -.I.. sown Spouts.
Frieze Board 1 En /,,� r� ,,,,, rf 7 BK 0'c,Y
Soft Only �� go _
Fascia Only wit _ umD yes D No
1 Cover Frieze Board w :G8 Aluminum Coil LI or Vert.Soffit l W/70 *Q0j,O11*
2 New Gutters and Down Spouts to be in lied..in existing Locations,.unless noted otherwise.below. id T
Remove Existing.SIding Yes°Agrafy No CI If yes Vinyl/Wood❑ Aluminum❑
Only Where.new siding is to be installed.Win w.World will NOT remove•asbestos material.
If rotted wood is dlacovered AFTER r`ernocing the existing siding, Customer to Indicate
there.will be an additional chargé of$4.50 per.Sq.Ft. acce•tance b initlalin•
CUSTOM WRAP WITH GS ALUMINUM REMOVE & REINSTALL
#of Fra QV *COLOR" Q . •
Window 7r �* �e Storm Vvitttrow • Bur tar -
Garge/Patio;Doors Storm Doors s fng
Double Garage DOor Awnings-U•" +In pertain markets,Burglar Bars
Build Out Frame Awnin t s-.Over 8' can be removed,but not reinstalled.
FUR OVER MASONRY PORCH CEILING, BEAMS& POST NEW ACCESSORIES
Front - Beaded Soft ColorR E VE
eft F.AI
Universal Location Re *COLOR*
B;. 1.1 Y/N OLOR*
Porch Beam -
Right Poroli Posts ' SHUTTERS
#OF PAIRS *COR*
SPECIALTY WRAP • 'Y/NI *COLOR*COLOR* L(J
Louvered �lZp�as D
Raised Panel 51.-ur
ROTTED WOOD To be replaced'in the following locations:
SP CIAL.0 CONSIDERATIONS,: II/i'iI f�G e'd -iv air eir?D-r .
IL 0 .. .,a S fzE- ). ...el' �3 i �3 ,. • .. ' s ;
Pi . - ,1 - N e- •%- k A c . ,, z 1.,..,i . .r e ..D *b•- 4.4 •7 ' 'uer
Customer -grees to the terms of payment as follows:
SidiniDroi LoPAtion:j,/n� t•¢ u f/ Total Project Cost S. /6/ i. —
t 1/3 initial Payment. s 3 r.�,b
Dumpster Lic atibn: f/ y74-.:, -gs- 1/3 Progress Payment, $. 3 6
�Q� Balance Paid to Installer upon Completion .$
e 9 le ` Amount Finan ed $ l :S
Whtdow world of eostal antklpates.starrng this wor1c n /0 /y and Minas-newsman completed iit3" days:Security Intelsat!Yes No
N deposithquired'ata oot.6uslatofUr SHALLNOTexcted33iR9Gotthetalucoil�et wtheadoalcoslofanymale ore Of;specidarderorcusta Ida tatme,v i
must be oiderod leadvancbbef the Mon is tieuktdassuro that Meet lyald proceed onsebedWl No ford pays eid*Alm demanded until ua ienbactis c�pletad tO the s fadbn on at perils.
Al hotheupprovermalcoarociers pad SubcbnhraCttassShid bereualaed and Ihatany squires about acontract orsubcaniectdr relating to it repisbaatlon should be dlrorded to:Office el Coneumoi Hairs
and Minot Reyulellekten Park Plafa,Sib 6170 Boston,IAA 02116.Phone:(617)973•8700
Ha*AMU bOn prier to Ike sitar*at ttle'eoakael antkaasotllial a tke owner of a topy of sack contract
Marlow World of pio net Napier i42A of the law regiVed el ler acid oWasn al caotbuc0ac•ahted ponds.Window Wald at Boston shall del4 deemed respomide
fot delays BROW eiafc decal*oltliis.e�tteemeal cadser by 1 i• peril �n0pq• es,aulliornlicror roils. p(�
N hikePOl1CHASEERI�S)ablettioMnawecanskaatbsen bill p�rrde for thewark ecceibedunderflik:a wmedordellsgil uareglateredcoelrailmejkeePURCHASER(-ahetebyadvised
Ibatin Me event el a dbpete,pdgealeoland mowed,the PIMCHASER(S)utli not la Wiled to moire a claim of collection from the aranly fled hits 142A,LILL
/L.c. G/ll&'44 (ii.0 99 y-7/23 • d2;;//
9• er.Do of sign ii there are any Wank spa
p t eitiNL--- `Jfl/2--/ /
es flap:Do no sl n if there era any blank spaces. Da Owner Do not sign if there are any blank spades Date
Stdiing.05-1 a White Copy.-Original Yellow Copy-He Pink Copy-Customer
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
CS-072772 Expires: 04/07/2020
JEFF C STEELE '
24 SHERWOOD AVE
DANVERS MA 01923
Commissioner CIL
^/fN l:Nl.N•/K/,P![/lf'(! f!(N.:Ctf/IIIJPIf:
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:LLC
Registration E9Rielti9E1
168025 04/11I2020
WINDOW WORLD OF BOSTON,LLC.
JEFF C.STEELE 64-Cl -^
15A CUMMINGS PARK
WOBURN,MA 01801 undersecretary
=�"_ 1,,'i e Co innio nyealth of ills aic i wsen'.
Department of Industrial<Acc/dents
_ -1 1 Congress Street, Suite 100
x,, www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED R'i'I'H 1'HIt PERMITTING AUTHORITY.
Applicant Information � Please Print Legibly
Name(Business/Organization/Individual):/-lj7 js 4,i �JP/mlf'4� 4/1l'. . gf4 t,/ii a4w r✓dra o fZD i 11
Address: 15 A Ct)m r rA in)S err K
City/State/Zip: Inlohv/'n PIA D / 'o j Phone#: 7'1 - ,i ; Z--/1 p 5
Are yo an employer?Check the appropriate box: Type of project(required):
I. I am a employer with 4N 0 employees(full and/or part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity.[No workers'comp.insurance required.]
3.0I am a homeowner doing all work myself[No workers'comp.insurance required.]t
9. ❑Demolition
10 Q Building addition
3.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole MO Electrical repairs or additions
proprietors with no employees.
12.0Plumbing 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.« 1.3. repairs
14. Other S'Ai/1 i_wr 4)
o.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 5
152,§1(4),and we have no employees.[No workers'comp.insurance required.] ree(e2 ce"1-4 l't f5
*Any applicant that checks box 41 must also 511 out the section below showing their workers'compensation policy information.
1.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: A Ssjc; a.l e d E,"eL ye't- 5 _
Policy#or Self-ins.Lic.#: WC.c -5 DO- co/3(,o c1- 2 o/91{ Expiration Date: L/— S- 20
Job Site Address: 54 d S 6, Merc,tnt Dr. City/State/Zip: S VAre-toa/l 11tf4
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 'olator.A co, o this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verific on.
I do hereby certi und� he pa' a ', ,ienalties of perjury that the information provided above is true and correct.
Signature: / i 1 'MP
Date: H-6 — /
Phone#: - e \ iir 8'- hi 3 9 S
Official use' . I , 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#:
AccDATE(MM/DO/YYYY)RD CERTIFICATE OF LIABILITY INSURANCE 03/26/19
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 ACT amy roberts
M.P.Roberts Insurance Agency Inc. PHONE.Extl: 978483.8073 FAX No): 978-683-147
1060 Osgood Street tie,.
North Andover,MA 01845 ADDRESS: amyimprobertsinsurance.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A: WESTERN WORLD INS COMPANY
INSURED INSURER B: MERCHANTS INS COMPANY
L&P BOSTON OPERATING,INC INSURER C: ASSOCIATED EMPLOYERS
DBA WINDOW WORLD OF BOSTON INSURER 0: '
15A CUMMINGS PARK
WOBURN,MA 01801 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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.
IRSR TYPE OP INSURANCE -At7D1_aurm' POUCY EFF POLICY EXP
LTR
INSD WVD POUCY NUMBER (MMIDDIYYYY) (MMIDDIYYYYt LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO D
CLAIMS-MADE I"J OCCUR PREMISES(Ea occurrence) $ 100,000
MED EXP(Any one person) $ 5,000
A NPP8525379 04/05/19 04/05/20 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000
X POLICY n JEcaT n LOC _ PRODUCTS-CCMPIOP AGO $ 1,000 O00
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE OMIT $ 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
B — AUTOS OMMEOONLY UTOS A
X SCHEDULED MCAI002569 04/05/19 04/05/20 BODILY INJURY(Per accident) $
X HIRED X NON-0WNED PROPERTY DAMAGE $
AUTOS ONLY _ AUTOS ONLY (Per accident)
. $
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000
EXCESS LAB CLAIMS-MADE AN065362 04/05/19 04/05/20 AGGREGATE $ 1,000,000
DED RETENTION$ $
WORKERS COMPENSATION
AND EMPLOYERS'LABILITY X STATUTE ER
ANY PRO
C OFFICER/MEM�MBEREXC UDED?ECUTIVEYn N IA WCC-500-5018609-2019A 04/05/19 04/05/20 E.L EACH ACCIDENT $ 1,000,000
(Mandatory In NH) E.L DISEASE-EA EMPLOYEE $ 1,000,000
If yes,desaibe under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Ix 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 ACCORDANCE WITH THE POUCY PROVISIONS.
AUTHORIZED REP *TATIVE
I Ar. 10—.� ,.1�►v�nr�0#42-
®1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD