BP-84598 Permit No. BP-84598 BUILDING PERMIT'
GIS#: 4034.00 Commonwealth of Massachusetts
Map: 0076 TOWN OF DARTMOUTH
Lot: 0024 400 Slocum Road,Dartmouth,MA 02747
Sub-Lot: 0002 Phone:(508)910-1820. • Fax (508)910-1838
Category: WINDOWS
Project# JS-2017-002340 PERMISSION IS HEREBY GRANTED TO:
Est.Cost: $6571.00 Contractor - License: Phone#:
Fee: $75.00 BRIAN D DENNISON CS-095707 (401)228-9800
Const.Class: 11I-173245
Use Group: R3 Engineer. License: Phone it:
Lot Size(sq.ft.) 40097
Zoning: SRB Applicant Phone#:
Aquifer Zone: N/A SOUTHERN NEW ENGLAND WINDOWS LLC (401)228-9800
Flood Zone: ZONE X ANDREW SWEET
New Const.: N/A OWNER: - I
Alt.Const: N/A WILKINSON HERBERTSff&
Date Typed: 04-04-2017 / - 7
L
DATE ISSUED: I
TO PERFORM THE FOLLOWING WORK: j
Install four replacement windows; SAME SIZE, SAME OPENING
Project Location: 2 SHINGLE ISLAND LN
Approved/Issued By:
DAVID BR ETT kCSt Lf ��
AL BUILD GINSPECTOR
All work shall comply with 780 CMR 8'14 Ed.(MGL Chap.143)and any other applicable Mass.Laws or Codes and plans on file.
Schedule appropriate inspections as-required. U completion,final inspection is required.
I hereby certify that the proposed work is a orize 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 tand ther agencies may have reason to STOP WORK if items under their jurisdiction are not met; not
withstanding the issuance of this Building/ .ung rmit. .
Signature of Owner/Agent:
"Persons contracting with unregiste 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
TOWN of DARTMOUTH - BUILDING DEPARTMENT RECEIPT - 8 4 5 9
l PHONE 508.910.1820 FAX 508.910.1838
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Name:, ! // r 3 Yr Property Owner: : ,. Date:
/ 1 f, ' t . / // - j' -
Job Location: 1'1 ,--}7)//j i LC --...S t/2 /i Map: 7 (
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Description General Ledger#'s Ref. # Amount
Building & Building Misc. 01000-44105 7160 I T .r)
Electrical 01000-44106 -. a 1
Plumbing & Gas 01000-44107 ° -/ i
Trench Safety 01000-44129 ; �3�, '
Other Department Revenue 01000-42420 -
)
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By 7 !.----
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
. :,
JIESIDENTIAL ❑ Phased Approval(R106.3.3)
S25AJ0 APPLICATION FEE IS NON RE-FLNI63BLE a NON-TRANSFERABLE
�uiq DATE RECEIVED
fsMs, DARTMOUTH BUILDING DEPARTMENT
°> R�'i 400 Slocum Road
CI Al\ ' Dartmouth, MA 02747
\�° fifi3'ice Phone: 508-910-1820 Fax: 508-910-1838
/Y`
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SECTION FOR OFFICIAL USE ONLY. :, _
RECEIVED BY: BUILDING PERMIT NUMBER
DATE ISSUED:
SIG_NATURE: LSL.,� ldl, ,4 �*'�' DATE: 0"j/% '�/ 2
_________________ap Building Commissioner/Inspector of Buildings
S
Zoning District: A33 Proposed Use: Zone: OAX O B ❑A O V Aquifer Zone: r
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: - DPW
LI Board of ❑Board of 0 Cons. 0 Planning ❑Address ❑Engineering :- 0 Cross
Appeals Health - Commission Card , Connection
0 Fire ❑Gas ❑Electric 0 Other ❑Water Card-' - 0 Sewer Card Chief ' .Cut Off - Cut.Off _ . ..Cut Off Cut Off
DEPARTMENTAL APPROVAL'(S)
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
D.P.W.: Signature: - Date:
Fire Chief: Signature: Date:
Y 2
Other: Signature: Date:
Brief description of work being performed: a)/nr1
-SECTION 1 -SITE INFORMATION ,
1.1 Property Address: 2- .SA,'n,{�/1\/tee,4154 0 L/'l, 1.2 Assessors Map&Lot Number: // �]
Contact Person: Rj,4L 'co'- Map �c Lot � '1 - [/
Phone Number 1O(-Z?�-2�o ((V// I
1.3 Historical District ❑Yes ❑No
1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Year Built
❑ Municipal ❑ Municipal ❑Altering more than 25%per side of building
0 Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission?
0 Yes ❑No Date:
Revised 5/13
. ❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
tRESIDENTIAL
SECTION2,-PROPERTYOWN..ERSHIP/AUTHORIZED AGENT
2.1 Owner Record: Z S4QI re Is4„/ Ln So&
/g7T//aces I dPcbr-/ A/it/ .0,n A/ Av4Moutti, Hy D274,77. 9gef- 9osN
Name(print) Contact Address Phone Number
2.2 Authorized Agent: ( Leo ALA/ai0
jaRlAP bow/sue S1& ULU /W S L.un�v, z' antic Hai-aat-Y86o
Name(print) Contact Address Phone Number
SECTION 3-'CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor/Specialty License: 5(/Ag PIS0,() License Number. 075707
Company Name/Contractor Name: SDAterau k &021- Q/\ whh ,e6
Address:210 , aj,� j tht,e 4 / 721 6a-6( Expiration Date:
Signature: p ` -2Zr Q� 9 t/Si
9 Tole hone: D
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 persons)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 which
there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory 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.
If you are applying under this section sign below:
Signature:
SECTION 4--WORKER;-COMPENSATION INSURANCE AFFIDAVI -01 c 152§25) ,
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure toyrovide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: 3 Yes 0 No
SECTION 5-DESORIPTION OF PROPOSED WORK_(Check all-applicablai
❑ Deck ❑ Pool 0 Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pelletoo Stove
❑ New Construction* 0 Accessory Bldg. 0 Addition 0 Roofing/Siding i3 Replacement uwindow/door
(Energy report required) (Shed/Garage) (Energy report required) No.of windows ( Doors_
❑ DEMOLITION (specify):
Location of debris removal(per MGL C.40 Sec 54): ❑Dumpster on site ❑ Dumpster On Street
Facility Name: 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):
El HVAC(combined unit)-primary fuel,natural gas,propane,electricity,other(specify):
❑Air conditioning-(separate unit)
0 None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
• {-'. - SECTION 6-ESTIMATED CONSTRUCTION'COST_
Item Estimated Cost($)to be completed by permit applicant
1. Building / ‘ j 7/
2.-Electrical
3. Plumbing -
4: Mechanical(HVAC)
5r Total=(1 +2 +3+4) 65 7/ —
SECTION 7A-:OWNER AUTHORIZATION
(to be completed when owner's agent or contractor applies fat building permit) -
(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.
5re 4-TI4cr!iec( c.03-f Mc+
Signature of Owner Date
• SECT;hi 7B=-OWNER/AUTHORIZED AGENT DECLARATION
,as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true d accurate,to the best of my knowledge and belief.
Signed under the pains an e alti of p rjury.
(3 al/7
Signature of Ow d A n Date
SECTION-8-OFFICE/INSPECTOR'S NOTES
Less Application Fee: $25.00 Remaining Balance: $ Y� '
Total Permit Fee:$ /
Other$Amount$
-Gross Area-New Construction total sq.ft.
Gross Area-Alteration to sq.ft.
Permit Issued to: 7,.s.4 ,�P� �/fittt-'D /„..0 /j-76/10 Gr!`S
• SEtfTIONA:KpESCRIPTIO U1 fmoni BEINGPEIfORNIFU ` .. _ . .. • -
/4S/4// (A ) to 4ce v.e/+I 6✓ 'nJar✓S
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'2Dnuui16
Permit No. BP-84598 Project Location: 2SHINGLE ISLAND LN
Commonweaw Massachusetts
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BRIAN I gt: SON ea,,,,-11.;1144,44,,-,:r1;444,ittlic:104:4.1c1.
% 3 'its 07 0228-9800 7 Sr, � I , �r�°?1 .'� „."x +� i�s! �a ;%,�°titrti,E
�o � 45 a9 e .. _ tttne ,iNS' t1,7 unit " GArchitect a�® Phone#: nrg-y'�&w " y� u'` s,': r{ ., ,�� di
ea
�' ..Y4 .-1, d 0 h1 0 I 3_f riApplicant - ' Ph01)one#: I , -r,, ,A +'�`r t s-�
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SOUTHERN ", LAl , . O S U (4ph 228-9800 7" , -= DI pr;
ANDREW SW
xi, ....
OWNER: , ,
OWNER. SON HERBERT III
DATE ISSUED: rJV '
TO P• ERFORM THE FOLLOWING WORKWM
Install four replacement windows; SAME SIZE, SAME OPENING
DATE TIME TYPE OF INSPECTION&REMARKS INITIAL
RenewalA_ Agreement Document and Payment Terms
�/'Vsl�deNen' dba:Renewal By Andersen of Southern New England Pat Tavares and Herbert Wilkinson
4'= ij�_ Legal Name:Southern New England Windows,LLC 2 Shingle Island Ln
,, North Dartmouth,MA 02747
motel --- RI #36079, MA#173245, CT#0634555, Lead Firm #1237
�� H:(508)998-9084
WINDOW nrtxcrmrnT 26 Albion Rd I Lincoln,RI 02865
Phone:866-563-2235 I Fax:401-633-6602 I sales@renewalsne.com N is
.. LJ C:(508)353-8812
cp „�
Customer(s)Name: Pat Tavares and Herbert Wilkinson Contract Date: 02/23/17
Customer(s) Street Address: 2 Shingle Island Ln, North Dartmouth, MA 02747
Primary Telephone Number: (508)998-9084 Secondary Telephone Number: (508)353-8812
Primary Email: pattslp@comcast.net Secondary Email:
Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Southern New England Windows, LLC d/b/a
Renewal By Andersen of Southern New England("Contractor"),in accordance with the terms and conditions described in this Agreement
Document and Payment Terms,Notice of Cancellation, Itemized Order Receipt,Greensky Payment v4.pdf,Terms and Conditions of Sale,
Lead-Safe Form (CT&MA),Sales Cost Savings Program (SCSP),Important Project Information, and any other document attached to
this Agreement Document, the terms of which are all agreed to by the parties and incorporated herein by reference(collectively,this
"Agreement"). Buyer(s) hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement.
Total Job Amount> $6,571 By signing this agreement,you acknowledge that the Balance Due, and the Amount
Financed must be made by personal check,bank check,credit card,or cash.
, Deposi feceiyed: $3,286
Pei..t 2e Due $3,285 Estimated Start: Estimated Completion:
CS. 8- 10 weeks 8- 10 weeks
`cunt Financed: $6,571
Method of Payment: Financing We schedule installations based on the date of the signed contract and secondarily on
the date in which we complete the technical measurements.The installation date that
Notes 1/2 dep 1/2 bal paid by we are providing at this time is only an estimate.We will communicate an official date
Greensky. Taxes paid in and time at a later date. Rain and extreme weather are the most common causes for
North Dartmouth delay.
Buyer(s)agrees and understands that this Agreement constitutes the entire understandings between the parties and that there are no verbal
understanding changing or modifying any of the terms of this Agreement.No alterations to or deviations from this Agreement will be valid
without the signed,written consent of both the Buyer(s) and Contractor.Buyer(s) hereby acknowledges that Buyer(s) I) has read this
Agreement, understands the terms of this Agreement,and has received a completed,signed, and dated copy of this Agreement,including
the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this
Agreement.
NOTICE TO OWNER: Do not sign this contract if blank.You are entitled to a copy of the contract at the time you sign.
YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT
OF 02/28/2017 OR THE THIRD BUSINESS DAY AN I'ER THE DATE OF THIS TRANSACTION,
WHICHEVER DATE IS LATER. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN
EXPLANATION OF THIS RIGHT.
Legal Name:Southern New England Windows,LLC Customer(s)
din:Rene
,al
IVByyAAn cramr
of Southern New England /y�, '/�//
Signature of Sales Person Signature Signature
Eric Tavares Pat Tavares Herbert Wilkinson
Print Name of Sales Person Print Name Print Name
02/23/17 Page 2 / 11
Massachusetts Department of Public Safety
lit Board of Building Regulations and Standards
License: CS-095707
Construction Supervisor
BRIAN D DENNISON AV
7 LAMBS POND CIRCLE 13 � _
CHARLTON MA 01507 -' -
N'l)X CA--:- Expiration:
Commissioner 09/08/2018
arj= Office of Consumer Affairs i d Business Regulation
VS:Ley 10 Park Plaza-Suite 5170
Boston,Massachusetts 02116
Home Improvement Contractor Registration
—_ --- Registration: 173245
'= Type: Supplement Card
SOUTHERN NEW ENGLAND WINDOWS; Expiration' s/19/201s
BRIAN DENNISON
26 ALBION RD - -
LINCOLN, RI 02865
- Update Address and return card Mark reason for Mange.
scut a mnosn 0 Address 0 Renewal ❑Employment I::Lost Card
F _?R of ConsumerAffairs&Business Regulation Registration valid for individual use only before the
CP expiration date.If return to:
14,„
a OMEIMPROVEMENT CONTRACTOR Office ofdate.Consumer Affairs and Business Regulation
J Registration 173245: Type: 10 Park Plaza-State 5170
Expiration: gry 9/2018: Supplement Card Boston.MA 02116
SOUTHERN NEW ENGLAND WINDOWS LLC.
RENEWAL BVANDERSON_
BRL I DENNISON '
26 ALBION RD \.ti-Cf ?v-
LINCOLN.RI 02865 LIEdersccrelam Not valid without signature
The Commonwealth of Massachusetts
1 f- dl Department oflndustrialAccidents
E iq 1 Congress Street,Suite 100
� _ Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH 1t1L PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individua0: Sa,14.Cin r jet -' En5j4n LA)irn d at.'/ ,
Address: cb 4 h,r7t--1 r2Nri •
City/State/Zip: Lino/n ' r 02 4(�Lf Phone#: ('{o)) Z 18 - 9 g DO
Are you an employer?Check the appropriate box: Type of project(required):
1.[Iam a employer with 2-0 . employees(full and/or part-time).* 7. 0 New construction
2.n I am a sole proprietor or partnership and have no employees working for me in . 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.] 9. Demolition
3.01 am a homeowner doing all work myself[No workers'comp.insurance required]t I0 DBuilding addition
4.0 I 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 11.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0Roof repairs
These sub-contractors have employees and have workers'comp.insurance? 14.R6ther a/r it Ct/
bif
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c.152,§1(4),and we have no employees.[No workers'comp.insurance required.] /e /'Aet 2�/ S
*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 contactors 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 pro ng $s ensation insurance for my employees. Below is the policy and job site
information. �.,, /
Insurance Company ame .:avnTner-f74 I •lies Yrr✓n lets• Co
Policy#or Self-ins.Lic.#: bt/G A 3 13 too e I Expiration Date: 7- / /7
Job Site Address: 2._ SGIII) I e Ts4/Ic1 1-0• City/State/Zip: A/ prtre''odt-t tl 4
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 certib under the p, and penalties of perjury that the information provided above is true and correct
iih
Signature: Q Date: ? -
•
Phone#: (L{OI ) L2Y - n1ROO
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#:
.�.skt SOUTNEW-01 CZOLLINGER
'`` ® CERTIFICATE OF LIABILITY INSURANCE. DATE(MMDDYYYT
6129/2016
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 ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDII1ONAL.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
certiflbate holder in lieu of such endorsement(s).
PRODUCER • CONTACT
NAME:
CoBiz Insurance,Inc. 988-08D4
821 17th St (NC,No,Extl:(303)98843446 we,No):(303)
Denver,CO 80202 E-MAILADDREss,CoBizlnsurante@cobizinsurance.com
INSURERIS)AFFORDING COVERAGE 1 NAM 3!
INSURER A:Continental Western Insurance Company i10804
INSURED INSURER B: I
Southern New England Windows LLC INSURER c: I
DIBIA Renewal by Andersen 1
26 Albion Road INSURER D: I
I
Lincoln,RI 02855 INSURER E: I
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. NOTIMTHSTANDING ANY REQUIREMENT. TERM OR CONDMON 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 ISSUBJECTTO ALL THE TERMS,
EXCLUSIONS AND CONDmONs OF SUCH POLICIES_LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE IADOLISUBR 1 POLICY EFF POLICY ESP 1 L
LTR alsoVA/O POLICY NUMBER 1(MMIDDIYYY)1 IIMMIDDIYYYY).
S
A I X i COMMERCIAL GENERAL LIABILITY i 1,000,000
EACH OCCURRENCE S
DAMAGE IOHFAIFD ! 100,000
I I I CLAIMS-MADE I X I OCCUR CPA3136080 i 07101/2016I 07/0V2017 I PREMISES(EaOmOmnm) 1 5
•
! MED IXP(Arty one Person) I S 10,000
II''� • 1 PERSONAL&ADV INJURY j 5 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER I I GENERAL AGGREGATE I S 2,000,000
1 1 PRO- I I I PRODUCTS-COMP/OP AGG •S 2,OD0,000
i POLICY!`_I JECT ;LOG I
a % (EMPLOYEE BENEFI 5 Z,ODQ000
.i I COMBINED SINGLEUMTT I s 1,000,000
!AUTOMOBILE LIABILITY ` (Ea ac identl
A n ANY AUTO CPA3136080 07101/2015 i 07/01/20171 eODILYINJURY(Peovson) IS
1 1 ALL OWNED SCHEDULED ' BODILY INJURY(Per accident)j 5
AUTOS 11 AUTOS NON-O !PROPERTY DAMAGE
I 1 HIRED AUTOS 1 I AUTOS I(PNadept) 5
'
1 1 11 I I I i 15 .
I X UMBRELLAB I X I BUR 1 EACH OCCURRENCE 'S 5,000,000
A IF LII
EXCESS Lwe I !CLAIMS-MADE! CPA3136080 07101/2016 07/01/2017 I AGGREGATE S
I s IA ate
j LIED X I RETENTIONS DI 1 i ggreg 5,000,000
'WORKERS COMPENSATION i ! 1 bTATUTE I I ERµ 1
A IAND EMPLOYERS'LIABILITY YIN
ANYPROPRIETOR/ARTNERADCECUTIVE I WCA31360BI 071011201E10710112017 EL EACH ACOmENT Is 1,000,000
OFFICER/MEMBER EXCLUDED? 1 I NIA, ,fv `a� i I EL DISEASE-EA EMPLOY- S 1,000,000
Mandatory decry In NH) -,1 I I I 1,000,000
II tySs,deernbe mFer EL DISEASE-POLICY LIMIT 5
.OESCRIRTION OF OPERATIONS belay l
4 l.
1 I I 1 I
DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(ACORD 101,AdE:Iona)Rarterla schedule,may be stacked R more space Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE IHGKEOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOR®REPRESENTATIVE
T
._ .. - - CD196E-2014 ACORD CORPORATION. All rights reserved.
•
ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD
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