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BP-80966 Permit No. BP-80966 BUILDING PERMIT GIS#: 4288.00 Commonwealth of Massachusetts Map: 0079 TOWN OF DARTMOUTH. Lot: 0048 400 Slocum Road,Dartmouth,MA 02747 Sub-Lot: 0051 Phone:(504910-1820 • Fax:(508)910-1838 Category: INSULATION Project# JS-2016-002704 PERMISSION IS HEREBY GRANTED TO: Est.Cost: $6924.00 Contractor: - License. Phone#.• Fee: $75.00 ROLAND LANGEVIN_ CS-103861 (508)567-6706 Const.Class: HL=180797 Use Group: R3 Engineer: License: Phone#: Lot Size(sq.ft.) 40000 Zoning: SILB Applicant: Aquifer Zone: ZONE 3 PP Phone#: Flood Zone: ZONE X INSULATE 2 SAVE INC (508)567-6706 New Const.: N/A OWNER: AIt Const: N/ABOTELHO DEBORAH L . ,fif ',./(77/. : -, . Date Typed: 04-11-2016 DATE ISSUED: ' TO PERFORM THE FOLLOWING WORK: Install cellulose insulation to attic and garage along with weatherization Project Location: 35 RUNNING DEER RI) Q e?een' Approved/Issued By: C•a � j '/�DAVID BI E,LOCAL BUILDING INSPECTOR All work shall comply with 780 CMR 8TH 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 authorized 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 understand other agencies may have reason to STOP WORK if items under their jurisdiction are not met; not withstanding the issuance of this Building/Zoning Permit. Signature of Owner/Agent: c — ram; i Le 7 - "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 : - ' TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 0 80966 PHONE: 508.910-1820 FAX: 508-910-1838 t, u Date: j, Name:---1' )s. ,( ( if, ) -n)61 t,-. -----' Property Owner: Date:yt---)0‘, i.2- , --) Job Location: --I 1) 1 ( t I( 1, i t j/.,..0 i (?&L map: P1 1 Lot: (-7„/)-- 5/ IDescription General Ledger#'s Ref. # Amount Building & Building Misc. 01000-44105 itiritil, -- -- ik I -- Electrical 01000-44106 ,f '*" K.-T i.. ,S, ,---' ,,,.. Plumbing & Gas 01000-44107 g...--, r--1. s r m AVO' ';'•-z-- Trench Safety 01000-44129 Other Department Revenue 01000-42420 , 1 .„,...,.‘,4,i White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department ReCeiVeW,/ _ THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS aiza.try Ewrr1.11;FA1'1d11Y 1{'LL 1WB11' 11E-leUN11AULL fdI .ILEA 1`VSt144111:1 : ' "D, TE'RLCB1 %E DARTMOUTH BUILDING DEPARTMENT irOA I 400 Slocum Road =2 = ' :gip �� Dartmouth, MA 02747 -.� �y. • Phone: 508-910-1820 Fax: 508-91'J-1838 • �•-..�� _.. i www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING :;: T EGTI [ fOR Ok RCIAL USA C}1`ti:Y°: RECEIVED Bl' BUkLDING PERNilT NUMBER is ATE fSSUE-D: S[f,N,4TURE DATE:. BuiIdi�g Cammissro erilnspecforof Builsiings Zc�rmg , : -' Pnaposecl Use � done: fE B f7-IV❑V.:- A Zone, Th#E OLL WIN AGENCI S GHOt}LQ 1EtQ1IFI D DP I l(Board sf ❑Board of ❑Corn Lt:Planning ❑Address ❑Engineering. ❑'Cross Appeals 1-teafth olr�mtssiiin Gard ,Connection !Fire ❑Ga ❑Electra b father ❑Wafer Card, ❑9e rer Card Chief : Cut;Off Gut OfF : • Cut OfF •Clit_Off - - _._ _ _ L'.►�PART�1�1`RlL,4;I�FRt�i/A�{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: I‘Jt 1.1 Property Address: 35 R�nm;) Deer J�.eel 1.2 Assessors Map&Lot Number: Contact Person: Dzk cek ? t2I t o Map /1(1 Lot Phone Number: Li 0 -1.13- ?Lt(v 1.3 Historical District 0 Yes 0 No 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Year Built ❑ Municipal 0 Municipal 0 Altering more than 25%per side of building ❑ Private Well 0 On Site Disposal System Has application been submitted to the Historic Commission? 0 Yes 0 No Date: Revised 5/13 ❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT 2.1 Owner Record: 1 r� 6,ba'e-i`t &okikQ 35 h'u>,n;^ (�eu 0- N a/41—wM✓ + 'fo/ - 7Y3- 85(JO Name(print) Contact Addr&ss Phone Number • 2.2 Authorized Agent: 1Ze.i.r �.2,.r',rrh (tD C rsv-c S r?U ft wtt 14174. 5-0,3-seo 7— 6 70(6, Name(print) Contact Address Phone Number SE4T1C1Y „CO STRUGTION SERVICES ;`,. 3.1 Licensed Construction Supervisor/Specialty License: C („ License /� ®Number: (038 ( Company Name/Contractor Name: d��n� La„_r,h CI i ( _ f �1 O 7k(7 Address: L i 0 G,-we__ 7�;,�*' (']ILExpiration Date: Signature: XI. 2-' 1i( -Telephone: 0 s% S ry 7-1,'1 0ip gi 2 V/7 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 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: /7Z : ,ECt t tt T.WQF Ntt 001Vite-NSA'#` rf SVRMV 4Mi►WI`f kt r4 1f52V: 1-_ .g. . r_ 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 _A.MA. $0CTIO1.5 t3ES:0RIP]`0, :00:01St=C WOR t Cf#e6101 60:4.abl }` _.. . _ ❑ Deck 0 Pool ORepairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove ❑ New Construction* 0 Accessory Bldg. 0 Addition 0 Roofing/Siding 0 Replacement window/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): 0 Dumpster on site 0 Dumpster On Street Facility Name: ,A 1( @c{ LI )1A-'- Location: 108'0 A. cam& 0.-( ;(( (�,`rt� MA C 7"LC' *If near 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 ❑Furnace(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 I. rsuuuing t'oq 1 3 , Gi 3 2. Electrical 3. Plumbing 4. Mechanical(HVAC) 5. Total= (1 +2+3+4) Co 3 SE1TI N lA C� iTi'Id1�� f 1 fcr#s ,ra ptetert +tihi� ,owi e s a en tar frac r pp1"f fsti uildirtg p rmit _ _ - (Please Print) I, -rraA jahq-ic , as Owner of the subject property hereby authorize to act on ehalf, in all m ers relative to work authorized by this building permit application. A -i-aclwI cf'/6`/(e mature of Owner Date , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing applon are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. //i it �A/ie Signature of Owner/Authorized gent Date .d Less Application Fee:$25.00 Remaining Balance: $ Total Permit Fee:$ 7 5 Other$Amount$ Gross Area-New Construction total sq.ft. Gross Area-Alteration total sq.ft. Permit Issued to: ,A71L .- �� �L,C�^�� � eA (4jj i ez�L ' N` QP . 'T,s6 v.1_0 ,ce „),Av, Far a f r��2�`i 0, Ac.e —prffput i-i;) .cr� s k%,.a it(Z), (�srrar �c 6 St, 6 6> 'lr Cie%t.�g ""p, ye-4 Xl,"St-c�vc��3) ��Sk-lZ ,nd �,'�z t,✓/� , Ea-0), ;kt- c,.el0i,/tiC (0.) Permit No. BP-80966 Project Location: 35 RUNNING DEER RD Commonwealth Massachusetts UTH = , �, TO �� , �'AR 1 , P 40�1 ari o d.Dart o r A 0 'A% , Ph; IT ' (518)')10 82.0-/ ) 10 g ; g I a , .,..., ..„.„, a N- ,": ,'--.11-- iu ,;,„ G rig. ,it, ,.' :', 'el � .,..„t4. -,,,,,--4, , 1 "„,,ii.e...„.„,....,-r...i:,„„.•,4-,;;41,:zw.',«,...11„..4ro, a g33,v .1,4 44,, ,.ria fi G, = PP O�'COntYael ��� ISe: One#: fl ril ROLANpAEVIN � v d � 861 �� �° C 567-6706 L"t Engineer.t,t �� ' rPhone#: si7'7FR T41, ,: '?-.„ ram.. Applicant: ,- , �. , Phone#: P . INSULATE 2 SC -; .V (508)567-6706 OWNER: 7 w BOTELHO DEBORAH _ DATE ISSUED: caglEcirED TO PERFORM THE FOLLOWINGWORK. kir Install cellulose insulation to attica and garage along �ith weatherization DATE TIME TYPE OF INSPECTION&REMARKS INITIAL •! . .., . 1:01//,/iin0 iii(lie{/4/ Vr/11:;:tdjOr/C414jea; Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 . Home Improvement Contractor Registration • ., Registration: 180747 • Type: Corporation Expiration: 12/29/2010 Tr# 261507 INSULATE 2 SAVE INC.ROLAND LANGEVIN • 410 GROVE ST• FALLRIVER, MA 02720 1 .• Update Address and return card. Mark reason for change. Address Renewal ErnpIoyment Lost Card SCA 1 C: ?OM 05•11 • ......, , v,,,,,, (,/,',4,/—/4,,,,,,,,,/,7,(1/., - Office of/Consurner Affairs&Business Regulation License or registration valid for individul use only 'FI'----:-.-t4. :FIOM E IIVIRROVEMENT CONTRACTOR before the expiration date. If found return to: • Registration: 180747 Type: Office of Consumer Affairs and Business Regulation \Expi ratin; 12/29/2016 Corporation 10 Park Plaza-Suite 5170 -'..x,',,rilL4-7.,.•.':. o • '>,,I--_-„'",,i',"'" -... •\ Boston,MA 02116 INSULATE 2 SAVE ,INCC ROLAND LANGEVIN 410 GROVE ST FALLIRIVER. MA 02720 Undersecretary Not valid without signature ' am Massachusetts Department of Public Safety • V Board,of Building Regulations and Standards • Licen e- CS-103861 -A„4,.. ‘,•,,,-:,' Construe *on Supervisor 4,,,,! ,....,6„, '•,,,,/, I ROLAND LANG VIN • I 56 HIGHCREST R Pe...A. 1 AAAA 0 FALL RIVER MA i L.•••••••••&..A. ,.....• •,....._,—• \ Expiration 1 Cornm r \Isslone \ 08/24/2017 i i • , ()NA. \ER At 'i H-[(ORI A'T U) FOR (`():N -RA(*T()R TO f F(ORM WORK !c t;ftf.ltr..) `need. t('!pr t uk tl t':r .r. :lilt: +l<Stt" 7 c< itltN ti: to 4{; tier of.tile ru st rtt 1tl E't€C1 ti 0-27/7 ttt ttEttct3s,ft hoidcr of MA (-tIntra:tcor reLt iNtratlnn . tisit. cxpiratic)fl date /.tt u:zent N t..rutheri,atti€orn uczrk€c) be pc:€ (In—t eti at the :tho%s c'i 7Lit zcl prtapc r 11r7€ht"in c'rtt drat /cli rarr * i/It-c i),x,rfrc•I,,s-,4sl t e'et cd I will lre,gih'the Itr(•:l Building Offki rl rsl rre 'cr t and prrns•icfc'l Fs�..'l lire, l ltirt ;i with'kelt.rrwt-itc'r urwwhrari:utirrn€letter. t4"P2tr e s;`.,YFi3%Str 141 ::L i) / 3-8416 000 0 0 0 © © © © V © 0 0 0 .===000 O 0 0 0 0 © p p� O O a o r r� r . c r ..S N e N M N M N = M N +,. ;O O en �° a h eny 'Ct �O O Q 'a i co nel ��n , O O.. cz c A �000 o AC j ti .°'+ -,'' o o o o O V ' A o00 0 ��� o `� �' .. ors "?.000 A U - 0 o q V N en > `'d t' 14,icbto: ' ' bAN bb >oNN .� U yL -zR A NN ' O� O N O N as U`a kd N.r M z O a3 T4'•�y0:el 0ti.O cC > 'c� N :„.„-II"'„,:„Cr _- N 000 a� NN . •• M. ler u. 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Job Number:351552 — 250 Griffin Street Work Order Date:7/15/2015 Fall River,MA 02724 Ownership:Owner Phone:508-679-0041 unas Audi=. :Jay . —,des 031 • il ) 0'34 Deborah Rotate NSTAR Electric .-.....i,„:. 1 35 Running Deer Rd Total N Dartmouth Ma 02747 1101- 111S- iiiib . • '7=,,PC'q,,-A 0--7:::: „ ::-.:i;i:1741"ii:::,44.,":;204.1.44,550:A.:' 5164%47-41Vail."- 54ii-4--71:,,E. -:,<C.,,:- '''''- , -,,,t,"„ : ,=, - II-10-20 unrestricted-settled 2240 S3,22,5-60 cellulose %-----,-, ---- --- ,,,,--..,-.------ grcf,s-zmvwevr, ,,..4z,,,---:5- z --A,- -,":-,-.1-.- -----'-----47;;,-.• -- '-- ,-wi,g,,' ,--0,--4.--,_,-,',--,.0,. -rw -.-—9*- -,.,-..v,.,-'..---.9.6,,-, ,,..T...,..&,--------,,,, , -:. -,-- ...-,,,--t. -, •,-r, Xl,PV;,-:v:r:'-;ikt.'4i,;,'k,*:'';' Aeuvent Proper 20 $4.60 $92.00 Roof vent 865(.4 sq ft NFV)small 6 $90.00 s54e.00 Garage ceiling cavity filled with 364 $2.35 $855.40 blown cellulose Clothes dryer vent including $100.00 $300.00 11111111111111 Exhaust Duct „..,,,,„.,„„,,„ ,.,,,,, , • , :.''''t'''''f'''-''''''''''''''''' '''-v';''It:- '-''''''':::t;'-'1•:'14.414''4;42 '''''':''' ''''''''''-'itIrt'''. 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', - -,,,,:,-pi ,, - Domestic water pipe wrap 6 $2.95 $17.70 Duct Insulation R-$ 20 $3.47 $69.40 Date:7/15/2015 Pagel Work Order: Job Number: 351552 l;o uia ,. a psi a r E tt P a. accover interior <00 $520.00 ' f, '; t i b 4-heiivi tat ac cover interior Attic hatch weatherstrip,dam& 2 $67.00 'S134.00 insulate R=code Attic sealing with two-part foam - 6 $84.00 S504.00 Blower door set-up with pre&post 1 $45.00 545.E tests Recessed Light Enclosure 12 S33.00 S396.00 Replace Clothes Dryer Transition 3 S45.00 S135.00 Duct only Total S6894.11 Contractor'Instructions Before Starting the Job: Doming the Job: I.Please notify us 24 hours before starting or scheduling a job. 1.Incorporate lead safe practices as applicable. 2.Obtain required building permit 2.Total for Heath&Safety and Repairs cannot exceed S2500.00. Additional Contractor Instructions: Attic Inspection form attached? Yes N/A Cat e One) Certificate of Insulation posted? Yes No (Circle One) unassigiued hereby certifies that this job was supervised and completed in compliance with all Department of Labor Standards and Lead RRP regulations, Contractor Signature: Bate: RRP License#: Date:7/15/2015 Page 2 • 0, • ' • . , ,•__ .. The Commonwealth of Massachusetts •• Department of Industrial Accidents ilf'',1:',:,7-;s-i,•--V--.1;.-.', I Congress Street, Suite 100 ''''''''.'.._,.:'',J47F7.1-..::-':•C:: Boston, MA 02114-2017 •,.,.. --:::,E, :,••, ,.•, www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. . ! TO BE FILED wrru THE PERMITTING AUTHORITY. Appliefint Information Please Print Legibly • • Name musimiss/or.anizaLiontindividuali:Insulate2Save/ Roland Langevin Address:410 Grove Street C ity/StatelA p:Fall River MA 02720 Phone ti:508-567-6706 _.: Are you an emplqyer?Cheek . the appropriate box: Type of project (required): i, . 1.0 I ant a empl w,yerwith 20Limpioyees ihill and or pa I- 7. 0 Ness construction 2.0 I am a sold proprietor or partnership and have no employees working for me in S. 0 Remodeling i any capaeH [No workers'comp.insurance required.1 9. E: Demolition 3.0 I urn a hon4wner doing all wiork.myself.IN°workers'comp insurance required.] lo 0 Building addition 4.0 I am a hoineiwner and will be hiring contractors-to conduct all work on my property, I will ensure that a'il contractors either hir,e ivorkers'compensation insurance or arc sole 1 1.0 IlAeetrical repairs or additions pri.Trictors,,ilifl no employees. 12.0 Plumbing repairs or additions 5.0 I dm a act,:fili contractor and I have hired the sub-contractor:listed on the attached slicei. I 3.E Rf repairs These sal-cqntractors have emphiyees and have wors'rke comp.insun race., oo i 14.00therinsulat10n 6.0 we arn a corkration and Its officers have exercised their right of exemption per MCil.a. . I 52..;1(4i,aid we have no employees,[No workers'camp insurance required.] Any appilennt that 411ecks box 4! must also fill out the section below showing their lVorkers'compensation policy informa)ion. ' Homeowners whosubmit this affidavit indicating they are doing all work and then hire outside contractors must submit a liov affidavit indicating such.4.:ontractors that chel.ek this box must attached an additional sheet showing the name of the soh-contractors and state as or not those entitie have employees. lithe si.t -contractors have employees,they:mist provide their workers"comp,policy number. • • I am an emplopir that is providin,g workers'compensation insurance for my employees. Below is the policy and job site information. 1117iralice,_;-•7.nptiri'lly.'NT'a—m. eTL rty Mutual Insurance Ai • Policy 4 or seir_ins Lie. 4:kiV-S 56418741 - ' Expiration 12/10/16 Date: I Job Site Addressi 35-, R.-iirm;"-6, a.ter (LI City/StatelZipN, „i),_1f4-,vrd_f_il11A7ti ? Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to securceoverage as required under MG!.c. 152,§25A is a criminal violation punishable by a fine up to$E,500.00 and for one-year ilmprisorunent,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veritluition. • • I do hereby certirr under the pains and nalti s of erjmy that the information provided above is true and correct ___A „•••.,.• ) • Signature: , Date: Phone 4,508-56?-6706 •. 1 . • , Official use Ditty. Do not)vrite in this area,to be_ completed hy city or town official. • City or"Irowni Permit/License# Issuing AuthOrity(circle one): I. Board of'Ilalth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector ft. Other Contact Person; Phone#; •—• • • __ CERTIFICATE OF LIABILITY INSURANCE DATE(MM12//' ACORlJ 15 ® TFS 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 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: Anthony F. Cordeiro Insurance PHONE FAX 171 Pleasant Street (Eiai E"t); (508) 677-0407 (A/c,No): (sos) 677-0409 ADDRESS: hsouza@cordeiroinsurance.com Fall River, MA 02721 INSURER(S)AFFORDING COVERAGE NAIC# _ INSURERA:Liberty Mutual Insurance INSURED INSURER B: Insulate 2 Save, Inc. INSURER C: 410 Grove St. INSURER D:_ • Fall River, MA 02720 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED 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 TI-E 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 SUBR POLICY EFF POUCY EXP LTR TYPE OF INSURANCE INSR WVD POUCY NUMBER (MMIDD/YYYY) (MM/DD/YYYY) LINTS A GENERAL LIABILITY Y Y BKS 56418741 12/10/15 12/10/16 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence) $ 300,000 CLAIMS-MADE rX1 OCCUR MED D(P(Anyone persm) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE L IMI T APPLIES PER PRODUCTS-COMP/OPAGG $ 2000,000 X l POLICY LOC $ A AUTOMOBILE LIABILITY Y Y BAA 56418741 12/10/15 12/10/16 {EOMB�N D�;INGLELIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED (Per AUTOS AUTOS accident)BODILY INJURY $ X NON-OWNED PROPERTY DAMAGE HIRED AUTOS X AUTOS _Ter accident) $ $ A X UMBRELLA LIAR X OCCUR Y Y USO 56418741 12/10/15 2/ 16 EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 10,000 DED RETENTION$ $ A WORKERS COMPENSATION XWS 56418741 12/10/ 5 12/10/16 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N —SORY I IMITS FR ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? ( N/A (Mandatory in NH) �.L.DISEASE-EA EMPLOYEE $ 500,000 Dyyes des ION O O E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Re nu rim Schedule,if more space is requ red) Proof of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Dartmouth ACCORDANCE WITH THE POLICY PROVISIONS. Slocum400 Road � Dartmouth, MA 02747 AUTHORED REPRESENTATIVE GyK I ©1988 2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: