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HomeMy WebLinkAboutbld-23-003549 01( (IltS ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department 1146 Route 28,South Yarmouth,MA 02664-4492 . 508-398-2231 ext. 1261 Fax 508-398-0836 .._ lE� Massachusetts State Building Code,780 CMR Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: sti)-zs-cocti7 Date Applied: \ 1� - Building Official(Print Name) • gnature Date SECTION 1:SITE INFORMATION 1.1 Property Address: g, 1.2 Assessors Map&Parcel Numbers 141-1 rr-L fcr:S. CI rlizic) , fitor 1.1 a Is this an accepted street?yes no Map Number P3rc.: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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: Outside Flood Zone? — Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2. Owner' 0=.4-tt,/ I o v Record: ci. -)CA,Lq' V Lifer 'rwtA-C- h• t IVIA , � Name(Print) ! City,State,ZIP 1-4C�"zl i r C "Z-R-V 2,2 Cc fratar, ( (a crO. No.and Street Telephone Email Addre SECTION 3:DESCRIPTION OF PROPOSED WQRK2(check all that apply) New Construction 0 Existing Building El Owner-Occupied ❑ I Repairs(s) 0 Alteration(s)„a Addition 0 Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of ProposedWork2:_ v c , SECTION 4:ESTIMATED CONSTRUCTION COSTS. Estimated Costs: Item Official Use Only (Labor and Materials) 1.Building $ (() if LISP 1. Building Permit Fee:$�s'ha1 Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ a 0 Total Project Coal 6)x multiplier x 3.Plumbing $ ;C,Gl(] 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ - Suppression) Total All Fees:$ r Check No. Check Amount: Cash Amount: { 6.Total Project Cost: $ f fj I (1 0 Paid in Full 0 Outstanding Balance Due: .1)1. . . . . -• - . . • •r"- jz-_,-':r1,404140.,filir ( . • r 0'24' t SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) /i /o ^4 1 1 rf <>1 ) License Number Expiration Date Name of CSL Holder i 7/) P �1�� S List CSL Type(see below) L.,• No. d Street ' " t Type _, Description /1� " 3 ( Unrestricted(Buildings up to 35,000 cu.ft.) C " Restricted I&2 Family Dwelling City/Town,State,ZIP lvi Masonry RC Roofing Covering WS Window and Siding (� • � // SF Solid Fuel Burning Appliances ht 2 q {-)L410Oh10 �` �I Insulation Telephone Email addres D Demolition 5.2 Registered Home Improvement Contractor(HIC) l .7 L 2 ,1 L-}- :Ih�.��} ' Lk( �� �' � �<-� S*Ve-&01- HIC Registrationis Number Expiration Date 1EC Cbmp y Ngme or311C Regis ant i�gme No,and Street Email ddress h-4iv, ZJ�--c. a l U 2_�SCj �� c2(0 Lil`(( /Town,State,ZIP Telephone S C? �i(6 b Co vvi SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(IVI.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 APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize_ to act on my behalf,in all matters relative to work authorized by this building permit application. 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 is true and accurate to the best of my knowledge and understanding. Iv /Z % / 7 Print Owner's or Authorized Agent's Nam lectronic Signature Date NOTES: I. 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(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the BIC Program can be found at www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos 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" The Commonwealth of Massachusetts iM= l Department of InclustrialAccidents =7,e1._= 1 Congress Street, Suite 100 %74.111=,= Boston, MA 02114-2017 www.mass.ao v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TILE PERMITTING AUTHORITY. Applicant Information Q Please Print Legibly Name (Business/organization/individual): /5r114�•- lA , L L C ( I 4C f- • Address: 5/ (.� pr PQA-k---- �,1,,;c_ . • City/State/Zip: 1=ON },a` /ek t ; 1)2 3SC Phone #: / Z7 Y12Z Are you an employer?Check the appropriate best — Type of project(required): i.[17,11 I am a employer with,7 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] g• )tentodeling 3.Q I am a homeowner doing all work myself (No workers'comp insurance required.]t 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.[�Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12' Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13•❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per NIGL c. 14.❑Other 152,§I(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. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new anidavit 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:, 4 C 0): Policy 4 or Self-ins.Lic.m: wGC__ ` - CC7.2-1-(?) (p1 70:LA Expiration Date: r / `77 123 Job Site Address: LI4—f 67E37 s'; r4`r'c"IC CC' Attach a copy of the workers' compensation policy declaration page(showing the policy nuip: mber er Li and�� ✓fie). • 0 2� � Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to S1,500.00 date) 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sig 1nature: ' � p �( .4, Date: f 2 ( -7 I Z Phone g: '( e Z.. C--, (.-(/q, Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License r 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#: The Commonwealth of Massachusetts Department of Industrial.Accidents _'r�l�7. 1 Congress Street, Suite 100 -Ct.41:1V Boston,MA 02114-2017 ., www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Q Please Print Legibly Name (Business/Organization/Individual): /fit„4' /4 c L L�_ c , t\, ] _ &, iO Address: + v 1 , `f�c `T� City/State/Zip: fw9je, , / C 235-d Phone#: 1-0 fl Z Are you an employer?Check the appropriate box: - Type of project(required): 1.07j1 am a employer with Z employees(full and/or pan-time).' 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8• temodeling • 3.❑I am a homeowner doing all work myself.(No workers'comp.insurance required.]t 9 ❑Demolition • 4.0 f 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 sol proprietors with no employees. 11.(]Electrical repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 1 ❑Plumbing repairs or additions . These sub-contractors have employees and have workers'comp.insurance.: 13•El Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MI-c. 14.El 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. Jam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Z�<� liJJe 10-1 � w Policy g or Self-ins.Lic.II: �( (`j�t�.� Vim?_7,-2."Z�� Expiration Date: 1 f Zvi I7-3 Job Site Address: t41-1 67_37 Crs5 Ct-`r-rjC- City/State/Zip: 5 v(�/'1 (-�.'0- 0 Z64L 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. Sienature: ,__)(_, A.I.I/L1 p 11 ) Date: 12( "J I Z Z Phone 7- : ( CO 6- — 4—?(L( _I (L(i Official use only. Do not write in this area, to be completed by city or town official City or Town: _Permit/License Ai Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Numbing Inspector - 6.Other Contact Person: Phone#: • • • • •�S� o1''Y11k TOWN OF YARMOUTH �' r. e O BUILDING DEPARTMENT o +/� 1146 Route 28,South Yarmouth,MA 02664 % ,,,,,;3`6(a 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at Y Work Address Is to be disposed of at the following location: r 2� - " '‘r`" Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. 2. 5 Signature of Application Date Permit No. oC - TOWN OF YARMOUTH _21 BUILDING DEPARTMENT �KrTM� s=�-. � 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 F 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 DP CODE The current exemption for `Homeowner' was extended to include owner—occupied dwellings 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 which 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 buildintr pe `t. (Section 110 R5.1.3.1) The undersigned 'homeowner'e sagn.edassumes responsibility for compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned 'homeowner' certifies hat he / she understands the Town of Yarmouth Building Department minimum inspection procedures and equirements and that he / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE APPROVAL OF BUILDING 0 CIAL INSURANCE COVERAGE: \ I have a current liability ins ranee policy or its substantial equivalent, which meets the requirements of MGL Ch.142. Yes 1 .,1\1- If you have checked ves, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Bond O WNER'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:horneownrlicep:emp THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Streit-Suite 710 Bopton;.Massathwsetts 02118 Home ImprovementContractor.Registration ?Type" LLC Registration: 193023 BYLO HOLDINGS LLC Et::: 09/08/2024 D/B/A BAY STATE BATH - a 55 B CORPORATE PARK DRIVE r�� PEMBROKE,MA 02359 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Registration valid for Individual use only before the Office of Consumer Affairs&Business Regulation Re g str ti dn l If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation TYPE_LLC 1000 Washington Street -Suite 710 fig193023OU E/08/2 24on Boston,MA 02118 193023__� _ 09/08/2024 BYLO HOLDINGS LLC..` _ D/B/A BAY STATE BATH - JENNIFER BYLO 1.;t_- ,� / -� 55 B CORPORATE PARK DRIVE i�w..(4./ �l PEMBROKE,MA 02359 Undetsecretery Not slid Without gnature Commonwealth of Massachusetts IPDivision of Occupational Licensure Board of Building R ulations and Standards ConyontC j�isor CS-103995 i ires: 11/12/2023 JENNIFER S$YLO '' 60 HUMPHRELY'S LAN I ig R DUXBURY MICA 02332 ?6i,'-`.L a3a' Commissioner „i+, ! f°.�' �1 • .r -i..-..t. Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/01/2022 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 NAME: Arlene Pucillo Charles River Insurance Brokerage, Inc. PHONE FAX 5 Whittier St. 4th Floor (A/C.No.Ext): (508) 656-1400 (A/C,No): (508) 656-1499 E-MAIL Framingham MA 01701 ADDRESS: apucillo@charlesriverinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Associated Employers Insurance 11104 INSURED INSURER B: Safety Indemnity Insurance Com 33618 Bylo Holdings LLC dba Bay State Luxury and Bath INSURERC: 55 Corporate Dr B INSURER D: Pembroke MA 02359 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:Cert ID 10958 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. INSRL TYPE OF INSURANCE ADDL INSD SWVD POLICY NUMBER YY) POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY)'(MMIDD/YY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO-JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 B ANY AUTO 5922430 10/15/2022 10/15/2023 BODILY INJURY(Perperson) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- A AND EMPLOYERS'LIABILITY YIN WCC50050243192022A 01/29/2022'01/29/2023 X STATUTE ER ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBEREXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 I If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Rhode Island Contractors' Licensing & Registration is listed as Additional Insured with regards to Auto Liability when required by written contract. 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. Rhode Island Contractors' Licensing & Registration 560 Jefferson Blvd, Suite 100 AUTHORIZED REPRESENTATIVE Warwick RI 02886 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Page 1 of 1 "$` • r{ .w✓ . f'n, .may "y�."'�`S��^W. + •� 4 ... as Y 3 .w ` w1 chi rs � it y, . DATE ACORD® CERTIFICATE OF LIABILITY INSURANCE �..� 12ro1/2022 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 House NAME: Selective Insurance Company of America PHONE (877)744-3125 FAX (877)378-3033 (A/C,No,Ext): (A/C,No): P.O.Box 13325 ADDRIESS: clientservicecenter@selectjve.com INSURER(S)AFFORDING COVERAGE NAIC# Richmond VA 23225-0325 INSURER A: Selective Ins Co of Southeast 39926 INSURED INSURER B: BYLO HOLDINGS LLC DBA BAY STATE LUXURY BATH INSURER C: 55 CORPORATE PARK DR STE B INSURER D INSURER E: PEMBROKE MA 02359-1959 INSURER F: COVERAGES CERTIFICATE NUMBER: 2022-2023 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/ID/YYYY POLICY EXP ( ) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �/ DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 15,000 A Y S 2378137 11/30/2022 11/30/2023 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY PRO- 0$ JECT LOC 3,O0 00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS-MADE S 2378137 11/30/2022 11/30/2023 AGGREGATE $ 2,000,000 DED RETENTION WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS beiov: E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RICRLB is included as Additional Insured for General Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN RICRLB ACCORDANCE WITH THE POLICY PROVISIONS. 560 Jefferson Blvd STE 100 AUTHORIZED REPRESENTATIVE Warwick, RI 0288E ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD