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BP-82804 Permit No. BP-82804 BUILDING PERMIT' GIS#: 3897.00 Commonwealth of Massachusetts Map: 0074 TOWN'OFDARTMOUTH Lot: 0005 400 Slocum.Road,Dartmouth,MA 02747 Sub-Lot: 0002 :Phone:(508)910-1820 • Fax:(508)910-1838 -Category: WINDOWS - Project# JS-2017-000832 PERMISSION IS HEREBY GRANTED TO: Est.Cost: $5000.00 Contractor - ,License. .. Phone#r. Fee: $75.00 BRIAN D DENNISON CS-095707 (401)228-9800 Const.Class: HI-173245 Use Group: R3 Engineer License.• Phrase#:' Lot Size(sq.ft.) 40001 Zoning: SRB Applicant - Phone#: Aquifer Zone: N/A SOUTHERN NEW ENGLAND WINDOWS LLC (401)228-9800 Flood Zone: ZONE X ANDREW SWEET New Coast.: N/A OWNER: Mt Cons[: N/A SILVA JAMES V& Date Typed: 10-06-2016 DATEISSUED: l TO PERFORM THE FOLLOWING WORK: Installation of two replacement windows; SAME SIZE, SAME OPENING Project Lo ation: 41 OLLWOOD DR Approved/Issued By: DA UNETTE,LOC L BUILDING INS ECTOR All work shall comply with 780 CMR 811'Ed.(MGL Chap.143)and any other applicable Mass.Laws or Codes and plans on file. Schedule appropriate inspections as required. Upon completion,final inspection is required. I hereby certify that the proposed work is ut' 'zed by the owner of record and I have been authorized by the owner to make this application as his agent and to receive this permit, I further and' stain. other agencies may have reason to STOP WORK if items under their jurisdiction are not met; not withstanding the issuance of this Building/��nini •ermit. Signature of Owner/Agent: 'rate. ill 1 /„ "Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)" Inspector of Inspector of D.P.W.Inspector Building Inspector Inspector of Gas Fire Department Plumbing Wiring Water Service#: Footings: Underground: Oil: Underground: Service: Foundation: Rough: Smoke: Rough: Rough: Sewer Service#: Rough Frame: Insulation: Final: Final: Final: Cross Connection Final: Final: Board of Health E-911 Additional Comments: Planning Board Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary inspections signed off. Department phone numbers are listed on the white"Required Inspections"document provided with the issuance of the building permit. POST CARD SO IT IS VISIBLE FROM THE STREET \ ` (, C 1 ` ,tip\ TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 82304 PHONE: 508.910.1820 FAX: 508-910-1838 1 Name: , ,,- Date:..d `- I'rdpei(y O uxer: J 1 1'J i ft i s Li �j � Job Location: f A i 1 vi (t s`- Uc (.[-'. - I Map: /}L/ Lot: C—6 — Description /a! o, it. r #'s Ref.# Amount Building & Building Misc. 04%00-44105 i,�i, _ / TA) " ft'Electrical , 1 )113-cal06 Plumbing& Gas 0100%441R7 Trench Safety i ti ri I ` 9 Other Department Revenue 01000-42420 f , a ' , White-Collectoi s Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By, / THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS.; RESIDENTIAL ❑ Phased Approval(R106.3.3) S255.00 APPLICATION FEE IS NON BE-FUNDABLE & NON-TRANSFERABLE DATEREC• EIVED` �° T" DARTMOUTH BUILDING DEPARTMENT ioo-� y7. a__ b;.. 400 Slocum Road r—* Dartmouth, MA 02747 - a� `tom yYi Phone: 508-910-1820 Fax: 508-910-1838 `' www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ���a Ei{l$ a C OPPiC L QSEC3NLY xar S'� c 3'i1i a e3'= -r rr - n =BUILDING PERMIT NUMBER: r rc- -DATE ISSUED 4sfir ! /j '.Z�sx ` . _ " BATE SIGNATURE* - -�,7- Building Commrsswnerlspectoro{Bwldings � "-` S E43 � " pro used Us ,, Zone215 ❑S t A I7 V = AquiferZone ZdntrlgKL7lstrictfi�`�p P , 72.: } 3krF's -i x i c=1 et a "r O t 4 L „- , e''DPW ` 4,001 -6WitsfcEAGEOQIWs [anL'b BE r oT'I� ,`" tt K- .+ - F U En ineenn ti Crross - CI"Edard of -± Board of -p Cons l7 Ptamm�q ❑Ca T 9 9 Connector_ `._3ifpea�s Health :-Commission _ _ _ - O Por - Ll Gas -0 Electric , l7 Other _ ❑WaterCard • D.Sewer Lard - - Chief BtitOff =Cut off ,. - . Cut Off Cut Off DEPARTMENTAL`APPROVAT-(S}'= Board of Health: Signature: Date: — Conservation Commission: Signature: Date: — D.P.W.: Signature: Date: — Fire Chief: Signature: Date: — Other: Signature: Date: — Brief description of work being performed: — - SECTION 12=SLTE'WFORMATION` ,. ,,- - 1.1 Property p rty Address: -f f�/toil6✓ od �c• A ) 1.2 Assessors Map&Lot Number. '� Contact Person: �lR/ �'P/1(-IU/bdt'v Map /y Lot c -! Phone Number: 2.--7_,P Q 0 1.3 Historical District 0 Yes ❑No • Year Built 1.4 Water Supply(MbL c40 s54): 1.5 Sewage Disposal System: ❑ Municipal ❑ Municipal ❑Altering more than 25%per side of building ❑ Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission? ❑Yes 0 No Date: - Revised 5 113 0 CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT RESIDENTIAL SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Record: 4( K/!oi/t✓ood Dr 1ndct ct SsI� N rrAw-1--1 MA (7�7 .6So8?3111—Y 57 Name (print) Contact Address / hone Number J ,��t"j' )� Jj zb 41�a1- /I 4pI) 2.2 Authorized Ale)). �RItW ��,vu�d / " _J" J ,� 1 r� � � �, C� `/l,/�(�(JS (/`tit Address_ K/( 6fv Phone Number Name print) Contact 3.1 Licensed Construction Supervisor/Speciiaalty_Licensea&'l41.) heil)ese/" License Number: o y Company Name/Contractor Name:'0(LT h1H /-`^'y/°_b ' rA)/ S yy, / � Address: ] 4�� lCAr (ijµ ik,t' o 6S /Gn Expiration D e: j\ Telephoneloi- -100 / r le �.. ��., 3.2 Homeowner Exemption-One&Two Family Only Section 110.R5.1.3.1 Exception: FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR.THEIR OWN PROJECT Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section;provides that if a Homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor. For the purposes of this section only,a"Homeowner is defined as follows: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on whi r,h there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or fans structures. A person who constructs mom than one home in a two-year period shall not be considered a Homeowner. - If you are applying under this section sign below: Signature: V _SaM.R. --IWORS(JIVI0140- Tit$Ti i1f211NC4E_AFgI01tYF tttalt to _ _t:elai Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: 0 Yes 0 No SECTION.cs-DESCRIPTION OFF ROPOSE iNORtf;Ichcclt' 1` p}iltcablek - �t � q= ❑ Deck 0 Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove ❑ New Construction* 0 Accessory Bldg. 0 Addition 0 Roofing/Siding L9'Replace ent w k•`,w/door (Energy report required) (Shed/Garage) (Energy report required) No.of wind ws_A Cobrs__ ❑ DEMC2LITION (specify): Location of debris removal(per MGL C.40 Sec 54): 0 Dumpster on site 0 Dumpster On Street Facility Naive:- Location: *If new construction, please complete the following: Single Family: No. of Bedrooms No.of Baths Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1 No of Bedrooms Unit 2 No. of Baths Unit 2 ❑Fumace(hot air)-fuel gas(natural or propane),fuel oil,electricity,other(specify): ❑Boiler(heating)-fuel gas(natural or propane),fuel oil,electricity,other(specify): ❑HVAC(combined unit)-primary fuel,natural gas, propane,electricity,other(specify): ❑Air conditioning-(separate unit) ❑None of the above to be provided 0 Hot Water: Gas - Electric Fuel Oil Other f SECTION-6 Ei ESTIMATED CONSTRUCTION COST Item Estimated Cost($)to be completed by permit applicant 1. Building C000 — 2. Electrical 3. Plumbing 4. Mechanical(HVAC) 5 Total = (1 +2+3+4) 5,noo SECTfPN 74+OWN UTF(ORIZATION- {to'be campleted wt oWnar',agentor co efor apph I bUiIdifld penfirtj ;<< _ I (Please Print) , 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. k See— t- mca4 l n MU - Date Signature of Owner SECTION 7B OWNERIAUTHON7ZED fSGENT DECLARATION.. I, B r via.) LffluN sotto , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains an penalties of perjury. Signature o ner/Auth e Agent Date giKQ } t" w STOfibtFB OFF1OEi1t 1�EGTOlf;SNOTES._. Less Application Fe 25� Remaining Balance: $ _ Total Permit Fee:$ Other$Amount$ ?S Gross Area-New Construction total sq.ft. Gross Area-Alteration to I sq.ft. Permit Issued to: Ailaice# 1. _ , - ,. ,___ C tD T14NS ,ESCI2TPY(D2 llrWSateiltt EQRfilEp, ,, , //lSia // (a) telo/4cerienf w;e1dor.J.S /1(o 5-try c±u(G-( Permit No. BP-82804 Project Location: 4 KNOLLWOOD DR Commonweoassachusetts TO h► 4, 0 UTH y��q > {� � , .40 10 ii Road:� ..b0: ` 41�1 {L k P Ia " IT.t20 '(r 10 fv{ iPvii�� i - -; 1 ,,,,,,,,'4 � ;bs�d � 41 Y7IX3 - 5 g apk yI � y a I " � 'I ?� ' -s : . i s r -4: o 's -a' - fr sibs m ; ,� COntracif/y5'7 '1 a �C.' > One#: [ - Y y Y T 1 -4---, ei - l I a' F ? BRIAN SON t, i>� ' — Agle -I )228-9800 -� r �'� Ni t-45 I Yi�� 3 =a.� �F d J .atix' u [ t 'C F.9 Y 4 P ' ' t - l 9 4 2 T Architect f g p Phone# r Ic ` 5',4` t L r ad itb i� a Applicant s ,a S. f" � _ Phone#: �. t ,,rvi Ii' i.z- SOUTHERN GL O 'S (401) 228-9800 �' 4 ' ; A � esa.,,,tmswrs°A'-��-" OWNER: SILVA JAMES V& DATE ISSUED: TO PERFORM THE FOLLOWING WORK: Installation of two replacement windows; SAME SIZE, SAME OPENING I DATE TIME_ _ TYPEDPLNSPECTION&REMARKS - - INITIAL-_I 10 Park Plaza - Suite5170 1 / Boston, Massachusetts '02116 Horne Improvement Contractor Registration Registration: 173245 Type: Supplement Card Expiration: 909/2013 SOUTHERN NEW ENGLAND WINDOWS LL BRIAN DENNISON 26 ALBION RD L INCOLN, RI 02865 Update Address and return card.Mark reason for change. — Address — Renewal _ Employment = Lost Card Office of Consumer Affairs &Business Regnladan Registration valid for individual use only before the ex7iradoa date. If found return to: -- HOME Itil?RO'1E19ENIT CONTRACTOR Office as Consumer Affairs and Business Regulation Regastratia 1 i?2� f T•p e: 10 Park PLuza-Suite 5170 Expiration 9i19/2013 Supplement Card Boston.MA 02115 SOUTHERN NEW ENGLAND WINDOWS LLC. RENEW AL 3Y.ANDER=01'1 BRIAN DENNISON - 26 ALBION RD w:-- LWCOLN, RI 02365 —I;ndersecretary Not valid without signature ... ^‘?atisai.i.t.i$eatS Department rtment of PUO:IC Safety t 3oar6 of Building Regulations and Standards _ rise: CS-095707 — 91'-1 ne . .. ._ BRIAN D DENNISON 7 LAMBS POND CIRCLE •' CHARLTON MA 01607 nj s.o` sion:er 09108;2018 Renewal Agreement Document and Payment Term Gli?v I 1 t1Cjerseri db+ Rrnewtl Nr,n,lc,,rn ofSnutl,rrn Nrw Fnttlarrd �` 51m and Linda Silt' aP>T'ItV RI t3€079, MA d'17324S,CT 00634555, Lead Firm 01237 n nr r 1temn nr elEllig,.t El ,., tt.tyt, rt aei-11 '*1:1 .,, •.5z, I eftte""' c;nlwtnrit;i Nam, Tim Silva and Linda Silva 09112/16 t:.tnnrrtr'.rto NI tea Atldr>t: 4_Knollwo.od Drive, North Dartmouth, MA 02747 P'rm.,n• G:Ieilhnm 'Celek : (5081989.2268. t_,: rd»ry G_lapsarn: \una+rl (508)3244631 i5nn:lrt I'.n:aii: jvc-1'comcast.net itut I,1 Ir celp n loth .n;d t vr Ili putcitnI tint rmtiut t, dhr. ,4 tRe,.ui Sotleit In Nov i tl •int,d W'ald,n.+ 1 v!lk>', 'Rterie wit] Rr Ai',iuvt9+tit ''a„ lh r t Net4 1 npll n11"4 ertlani it'!, II It E .I d;trt tot Otte teret,.aHit,.t,udl 11 nt dtX llbed In dtil AgteUle:/11 Mt Iner r And 1'urnent IErrl Moire of I incelIttirn, Itrrnrrd t trrl:r Ikrreipt. SNF.GrccnA, Nil Ftprr: 0111it tiS I't ib ari l t nitll wm it Sdki. +dc's I r C'rl:;r.ltli l}(:Sri l e khS,I2 l nn;t:'I S NI Ali. Important l'r ycc; inl tnitarit n 4114.1 am UIIIU 14,w nttn at IJ ed 1a r1111 tgreelltel t,lanici t, tllc let Ilk w1 Ili ati all ,l:iR'd it' ht the ram Il. and tb.0 1 it,nied hcttnl he .retrrcrwc, nl n:I„ this '.NLrtt;It'; r 1 Iil yrr,:j h=writ.-a rcr••II at:n a esr Iiplrri,nr c.rriht,I ahrr :on;racily ha:unnplited II work will r I hi% A=n•e m•m. -I'Irtl; iHI, Seecn;m; 55,000 By-4ij;nnr ; Baart rrnrnt.rnn l;kruw`r; r. Mal 111elII an,.t d>ur. arid :C;11t;Milt t T.L 1'i11.11Lt•t111tirel be l l td h ;kit.,n 11 Jet**.batik dill .t Pali lard, Di Lodi. iw.tit ltc.:ivnh 52,500 ;tal,nlsc lyur; _ 52,500 ;.ninlai,d `i iri; k 'nlnr{I ed taNti'yjt'I nYn: Alit lintel I itnrerd; $5,000 8-10 Weeks 8-10 Weeks NI et d i i €St'lan,i^I: Financing NV- l lul a t:a ll w I e l,a sed , Ili:Jar of d,e ti i,i,c l ,ultr,lct .ail 4 ,.nilauiy nn Nin u. 50'SbdB & 50%, Sal aid thy slate in .hi h etot:I rirre the Irlitnaak , , a sure tntn tc. Il:c in:ial:ati„n dur I hat pp 'At;arc prim ding it hut tiratc it only-In ett rnitc, N$'r tvit) ronlunlnic ttt an Ii Kill ILIII' Dartmouth Taxes paid in N. and lirae at a i.luvr d,k. Ft:nn an I x;rc-I:I xc. - Dartnlouth lily all'^t rlilnt tunlrin n, t.n i,tv Lc riClat'. ;'tralrlcl agrees,ill I Ilnder1,1114h that Illi% ilf4`?.IS4`I5f toi lrirtlrctir 14 eft I i 1,111:10, JIa11nl(\he werll li)4 ilartkliarid 111 1 there al Li 1,9hal I tl1litr t l rill J y,:615410194 or Ittzttiitif ili g atn id li e tl'nins l lien.Ar;I iii tnf: No Ilk`al/ tl,s ti,kirJI:i:n„ai. Ibr;9I lins IF;lmnl ill it Ili l:,t,Inl v.'dorm di. sri�nst , wnnrn r r,,tnr,if limb the Ititerr Ind(•nnrrr'tor. t,r;,.rt I li rs-isr a k1I wtuil:,,: that liayerdl I1 ha, n•;nl rhir Agreement..Inli,rtlunh the, t rm.,,I this 4i,r u in. and hl Nc i #.t nnupl r d i.n eti m l-la.td y01 lilts 7Lr-I-cra. n+Ii1i EIF ISNa atrl ',Itsk Mints.%ni.t anixt1{Hnit, r I- chic-not wrWin d .-r .n,i ! n,it{tram'Irdt,rlllrti lot lit rant ci I Ili,; tr,.I I,:kli lti% \rre.-n,nit. Nit,i( h {r s,)'t1 Nkli: i 5tinit I;II du+ .nn[ryf 1. tt Hank 15111 At r1t411rd no t UIIl,`IIt th!'iuL•1 r:h I .11 the time. fI••I', • YOU,,TILE BUYER, MAY CANCEL,TI1IS ERANSACFION AT ANY TIME NM' LATER TITAN MEDNiC;IIT 01'09/15/2016OR'It IE'1'111RII BUSINESS DAY Ant R"IlilEPATEOrTH1STRANSA(;'I'ION, WFIICIIEVEIt 1)A El', IS LACER,-SET: AT I A(;I1E6 NMICEs()I'CANT;ElA ArION ! (?RlM FOR AN LT,dIFTIANulFIOL1 .41161111 ,1t 441(1111'. Al/ dtp • tt ai "ittl:.a,n, u1 ial.'t It unit 4aa:,irurt. _. .. Sicn:n III1 Nino Giamei, Project Manager Jim Silva Linda Silva u 4,ItN1 of iv' 4 1fill, Nall le- _. _-. .. _.. •t;lit Nano The Commonwealth of Massachusetts iR Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 'n, ww11).iltaSS,toy/dice \• workers-Compensation insurance Affidavit:Builders/Conlractorsisiectrlcians/Plumbers. TO BE FILED WITH THE PER%1ITTING AUTHORITY. Applicant Information Please Print Legibly amei5usiness:Organization'individuap: a0e.Ljhe,rm feu) �4,4k/I\ 0IVinto' / i ` pp Address: Zip 4t io,J -R 4 - a, / t City/State/Zip:Ger i}� i I '7�ohs P_-tene=: 10f- 2.2- Are you an employer?Check the appropriate hex: Type of project(required): 1.Z I am a employer with _2O'tenplovecs(full andiorpart-tune).' 7. ❑New construction 2.0 I am a sole proprietor or pamhcship and have no employees working Tor me in 8. ri Remodeling any capacity.[No workers comp.insurance required.] 9. 0 Demolition 3.0 I ama homeownerdoin_all work myself.[No tvorkvd comp.insurance required.)' 10 ❑Building addition 4.0 i am a l,o:neow.ner and will be l,idne contractors to cendue:all work on my props y. i will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑lama general conCctor and I have hired thesub-cnmmctors listed on thearua;hed sheet 13 ❑Roof repairs These sue-contractors nave employees and have workers comp.. insutanet- 14.[tJ/Other t,,/Ind at.J 6.0 We are a corporation and its officers have exercised their right of exemption per MCI_c. 152. t5), do and we have fin einvees.[No workers'comp_insurance require___ 1 ter lk Cyr,+s" t 1 'Any applicant that checks box-i must also fill out the section ono--sirph`ill?their workers'compensation policy information. 'Homeowners who submit this affidavit indicating they are doing ail work and then hire outside contractors must submit a new affidavit indicating such.. :Contractors that cheek this hos must attached an additional sheet.showing the nave of the sub-conuactors and state whether or not those entities have employees. tithe sub-contractors have employees.they must provide their workers"comp.pokey number. l; 1 and an employer that is providing workers'compensation insurance for)n}'employees. Below is the policy and job sire information. g I �ArrilDeti%r� Ares it QU a, s . en _ Insurance Company Name: 4 ( t Policy'orSelf-ins.Lie_ a, CA /31360 Expiration Date: 7/7/ A7 Job Site Address: Y Ka0//woof bey. City/State?Zip: tV i)ar•'('nld tit it.tA 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250A0 a day against the violator_A copy of this statement may be forwarded to the Office of Investigations of the DLa.for insurance coverage verification. ‘ — I do hereby,cer ' ender the p,-Is and penalties of perjury that the information provided above is true and Date: /ov-o2 2- /SO Phone : 1601' 7iZ9.-- [cT Official use only. Do trot write in this area,to be completed by,city or WIV I official. City or Town: -. PermitLicense n 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: /....1 SOUTNEW-01 CZOLLINGER A�D' CERTIFICATE OF LIABILITY INSURANCE DATE(MM)DM'YYY) 6/29/2016 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 ISSUINGINSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(Ies)must 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: CoBf2 Insurance,Inc.-CO PHONE 821 17th St MC,No,Eat):(303)988-0446 (FAX Ere,No):(303)9884804 Denver,CO 80202 Wass:CoBizInsurance@cobiZinsurance.com INSURERIS)AFFORDING COVERAGE NAIC 0 INSURER A:Continental Western Insurance Company 110804 INSURED INSURER B: Southern New.England Windows LLC INSURER c: DMA Renewal by Andersen 26 Albion Road INSURER D: Lincoln,RI 02865 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 BYPAID CLAIMS. L1RR TYPE OF INSURANCE INSOL WIND POLICY NUMBER HIMIDWY'n'f -IMMIDDIYYYY) UNITS A X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE S 1,000,000 CLAIMS-MADE I X I OCCUR CPA3136080 07/01/2016 07/01/2017 DuAIOE RmNSuErt rXe) S 100,000 MED EXP(Any one person) $ 10,000 IPERSONAL BADV INJURY ;$ 1,000,0004GENLAGGREGATEUMITAPPUESPER: GENERAL AGGREGATE IS I 2,000,000 X POLICY jECaT I LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: I 1 EMPLOYEE BENEFI s 2,000,000 I COMBINED SINGLE UNIT $ 1,000,000 iCPA3136080 ! B WILY INJ) AUTOMOBILE LIABILITY A X ANY AUTO _ !I 07101/2016I 07/01/2017 rODLY__ . (Per person) $_ A OWNED SCHEDULED BODILY INJURY(Per accident) $ � AU_�r_ AUTOS i I NOON-0NMED AOS ! _ I I PROPERTY rnDAMAGE :$ HIRED AUTOS i ;AUTOS X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 0,000,001 — A EXCESS LAS I I CLAIMS-MADE CPA3136080 107/01/2016 07/01/2017 AGGREGATE $ 0I DED X RETENTIONS Aggregate I S 5i000,000 WORKERS COMPENSATION i PER ERH AND EMPLOYERS'LIABILITY A ANY.PROPRIETOR/PARTNER/EXECUTIVE Y)N U/A WCA3136081 � 07/01/2016 07/01/2017 EL EACH ACCIDENT iS 1,000,000 OFFICER/MEMBER EXCLUDED? 1,000,000 (Mandatory In NH) E.L DISEASE-EA EMPLOYER S OESCRI OF OPERATIONS below !E.L DISEASE-POLICY UNIT i$ 1,000,001 f I 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Renato Schedule,may be sdaohod N mace 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORED REPRESENTATIVE c ©19B6-2014 ACORD CORPORATION. All rights reserved. • ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 000 0 0 0 0 0 0 0 U 0 0 0 - 0 000 o 0 . . . e o oo e Q . yt^em VI C w a n e r N. `e e ON 4 O. j N y ti M N .-i h q N o^ 1"�1 COD e o k °2,a u� O N h U 'x t C niTS CO O h � v ti O 0000 oU C- qC m j o m �V000 Foy 0.. �' a v q � mvoiem e. iso ,000 0 0' tiUo ''e. Ts rR kz, R \Ott OC rifle, 'l e O ` J M V}en riii o o o a (w�7 w a f-0 pa pa a 4° vnwm °'a VQg0.0.0. �' m "Co 4 =1 '' h q. R V ti G O ooe ewv to wtgn. ab_o — 0 > o ., o voi„vm � C d `m 0.Vl 0...1 I ro u ,C 4) ° .N.' ny o > > a .� u a W g a V...... ~°. r., a id > > o c� `� y F' co o ea O V 00 of Fo d > _j > 3 O-ei . 0 .� q •� � w �.�NNN C CL X O a 9q " •• el eeee 'd 'd 'O TJ ° 0. 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