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B-19-846 - 0017 ARTHUR STREET - Building Permit I k. 4=L 1 .i The Commonwealth of Massachusetts K a a k Board of Building Regulations and Standards GITY OF , Massachusetts State Building Code,780 C�.�, SALEM %J i 5 AUG _'� A ' Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling •1D This Section For Official Use Only , Building Permit Number: Date plied. i Building Official nnt game) 4 Signature= Rafe SECTION :SITE INFORMATION 1.1 P►•operty Address: 1.2 Assessors Map&Parcel Numbers 17 Arthur Street L l a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: I 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❑ On site disposal system ❑ Check if yes❑ SECTION 2 PROPERTY OWNERSHIP' " { 2.1 Owner'of Record: Stacey Blaisdell Salem,MA 01970 Name(Print) City,State,ZIP 17 Arthur Street 617-548-3498 staceyblaisdell@comcast.net No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WOkW(check all that apply) --TV _ New Construction❑ Existing Buildiny< Owner-Occupie Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify: Brief'Description of Proposed Work2:strip rubber roof replace with.060 EPDM Rubber Roofing SECTION 4`ESTIMATED CONSTRUCTION COSTS rfi r 5< Estimated Costs: Item (Labor and Materials . 'Official Use Only 1.Building $5,850.00 1. Building Permit Fee:$ Indicate how fee is determined: $ .❑Standar4 City/Town Application F 2.Electrical ee n ❑Total Project Costa(Item 6)x multiplier -x 3.Plumbing $ 2. Other Fees:$ .: / 4.Mechanical (14VAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No."" Check Amount Cash Amount 6.Total Project Cost: $5,850.00 ❑Paid in Full ❑Outstanding Balance Due: ��� MA I L—kETTb � ,� SECTION 5: CONSTRUCTION%SERVICES'. 5.1 Construction Supervisor License(CSL) 094763 5/14/20 Tom Dobbins License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 23 R V+inter Street, No.and Street Type Description, U Unrestricted )(Buildings u to 35,000 cu.ft.)g Peabody, ,S 0tatee,,ZIP R Restricted 1&2 Family Dwelling City/Town S M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 978-531-8234 office@lengibely.com I Insulation Telephone Email address D Demolition 5.2 R;egistered Home Improvement Contractor(HIC) 100811 6/22120 Len C-Abely Contracting HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 23 R Winter Street office@lengibely.com No.and Street Email address Peabody,MA 01960 978-531-8234 City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION:INSURANCE AFFIDAVIT(M.G.L c.g152 §_MC(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 ..........5/ No...........❑ SECTION,7a:OWNER AUTHORIZATION TORE:COMPLETED,•WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Len Gibely Contracting to act on my behalf,in all matters relative to work authorized by this building permit application. Stacey Blaisdell 8/1/19 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. Tom Dobbins ---)—O N .9 Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. 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 HIC Program can be found at Nvww.mass.Qov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps 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"maybe substituted for"Total Project Cost" r TY OF SALE RUUM.ING AR U6 4,VASRNG7ONS'IRBRT,3 01FIwR TEL 0078)745-9595 1sRVM-RLEYDpJSCX)LL FAX(979)740-9546 �&i OR THaWS S.T13MRRE DIItECroRO"LlMUCAROPER Y/BLI'�D ODAWSSIOMR 0501 In ,accordance with the sixth edition of the State-BuildingCode - and the provisions of MGf c40,554;Building�'erriait Ig . 7gl)C+M SeetiQn 111• zebras, condition that the debris resulting from this work shall be disposed of in a p:openly iic n=es waste deposit facility as defined by MGL c III,5150A. The debris will be transported by; � `� ;name of hauler, The debris will be disposed of in: (name of facility) (address of facility) Signature of applicant --� (today's date) ��" ' Olt OF SALE Mj1V1ASSACHL1SrTr3 . 120WASI[NGTONSMET,3 F.UflR 'a-L.(578)745-9545 R1VMERUYZ)R'SCMLL FAX(97?)740-9846 AUYo x oMAs ST21ERRE � D -,L-TOR OF P LIBLIC PROP"a.RTYAtIdLD IISSdONER COPIS. ructiris SPO In accordance with the sixth edition of the State Building Code,7,80 CMR,Section 11 I1.5 Debris and the Provisions of MGf c40,554;810ding Permit# condition that the debris resultingfrom is issued with th . or�a rhls;work shall be disposed of in a properly lict nses waste deposit facility as defined by iMGL c 111,5150A. - J ,�`a:q The debris will be transPorted by (name of hauler) T e debris will be disposed of in: (name of facility) CC' E ZC. S'� "�6 C (Cl(C 0 {address of facility) Signature of applicant (today's date) �"' .. .. r� �tY: _ t $ x mitt 774, tr'S5'' df1Ft•s xf r y ! t`�f'''��ta y.f:�1 t ttiyN ; � t ? F �1 4 e1 ;. a, .. aPage'No of ' t Arz.; f Pages i,_EN GIBELY CONTRACTING CO ,iN f ' ` _ s "23R Winter t"�Streettn ^' t f 'rr J I �� Fa "`y P��s } PEABODYMAS SAC NUSU18,0196 +' "' s home jTorovement contractors and subcontractors { (978)5311,8234 Fa '(978)531 9$0irtiprovement'contracting unless v ecif IIsexem t:from re rstration b Provlsions of www lengibelycontracting:corr, ' �. y p 9 y ^s; t y C ter 142A1of'the_general=laws, must be registered / // Y ' rth the Commonwealth of Massachusetts Inquiries { Submitted ! / To: Sc ___ about registration and status'should,be made<,to the ° a bliector Home+ImprovementContract Registration; e �-�W2, " y p# ; tr One Ashburton Place Room,1301 Boston`MAc02108 (61:7) 727"8598 jOwnersr who tsecure their town ' con'structiori'relatedTpermits"o'r deal with unregistered t contractorsrwilif M be excludedr:from the•;Guaranty.Fund i �} Provision oGUc:'142A,t. i PHONE a roa 'f DATE f '+REGISTRATION O.% f ; °tlft"e a t t %_:.` t ai I J BNAME/NO'?`" �� ` 7 h {.Y,r „> aJOB LOCATION At±yam t/ W eieby submit gpy�Ihcefions and estimat r work to be performed and materials to be used ,,,_,<{ , ; ,s Ai - �-._..���r�,;.'; ,, S %zc�LiS n�ltL 7 L�5�� P 2./ P y c i � t - *I4£.': .. . # 0/� f Z '_v,r� _�9S dots .Lsrt- ll T Tvs�-a�!l nee w /`•%f 'N� f"._..�.�c� �.s. .1NS7��-!/ �?��Q .��L-i°i?��t� t ; c SL �n��� /1 U'LJ nr.9- S/C - L ti g, t f , 'T t WORKS Dy1.E � �,/ ;, r= Conlracto 'II not be n the.v:�fµrOimaterials before the third day following the signing of this Agreement unless speafied'nerein wnhng. oriFact illl k on or about " `d$tor.Barring delay 4agsed by clrcumstances�beyond,Contractor's control the work'wilP be comp to y '_ te)���TTTkkke, r'-h by acknowledges and agrees that the scheduling dates are approximate:and that suchjdelays that are not avoidable by the doniractor shal e c gt�er.Jj s violations of t- Agreement.,: Hidden rot or conditions not seen at 6me of estimate that are required to be repaired ln older to complete this contract well be completed at$! V f'per man hour(MAN HOUR)' I ' WARRANTY f =I.4b:il "! "i 1 F .i;EI}t •: -s i / `.{ & r f The Contractor warrants that the work furnished hereunder shall be free from defects in material,'and workmansNp for a period of S mg comp s�I ly with , the requirements of this Agreement.In the event defect inworkmanshlp or materials;or damagecaused by,the Contractor,:his.suit ntracto ,employees or agents is discovered within •• one year after completion,of-any job,including clean.up;ihe'Confractor shall;.at his own expense:forthwith'remedy,repair;correct;replace,or,cause to be remedied repaired;or.Feplaced, such damage or such defect in.materials or workmanship!The'foregoing warrannes:shall survivasny inspection performed-in connectioh with the agreed upon,work. °' t -Y• ,k ,a 4 }.e t V $ •r. 1. Yr' d 'lt.t We Propose hereby to furnish material and labor complete in accordance with above specificattons;xfor the sum of ' '1 % $Soh s I'~{ s d011arS`($ Payment to be made as follows: 3 y' ' t " ,�.l. r 2 r ' s "• ..,- - All guarantees:on`a.products from manufacturer.- f r a�, t i - % Clean Job SIte:And Removd.All JobTrash..'q,i* ')upon signing.Contract, ADD PERMIT COST IF NEEDED-WE PULL PERMIT. ,r ($ ).upon completion of nce:.:N greemen, r hom m ovement contracting work shall require a n pay nt(edyan a epos o more than one-third of the total contract " ($ )upon completion of t pie or th otal amo nt fall p its or`payments which the-eonlractor must ! ,?. ' r m -in ante t, or ran /o otherwise obtain delivery of special order shall be made forewith upon r t't f tr L " m t Hats F equtp ant ^..,rs ma t e p; F —%($ rycompletionof'workunderthtsContractf "a 'it_�y `•i,.y,-, y.t *( 4 .` {4 t� F rah •r � �F i 3 r, t::."a �:i : - Note:This proposal maybe withdrawn by us it not accepted within days - ia`.i', - "•.h7 t� 't .Auth r eH Acceptance of Proposal I'have read both sides of thistdocument and Ce t p Ic s,specifications and coriditjons stated:I understand that upon signing;this.proposal becomes a binding contract.':Youare authorized t do:t a rk 'specified. Payment will be made as outlined above. You,the Buyer a cancel.this tran§action at-`any time pr or t iariight of the third`biusiness day after the " e of art a .tlCancellaUon must be done m vyrl Ing y �(� r, t +' N T SI 18'CONTRA`CT IFTHE E ANY;BLANK SPACES Sign-um AM I .Date Sig azure ; - Oate ! e IMPORTANT INFORMATION ON BACK ,_.�•..,� .. . . .tta:F.tMrf.�.u. - �ttr,,r..Yss:.,c y..intc,a;;»:.t.w+s�w x�;qixrk*e;ar:n•, .>bv"=�s tr yw:.a�+�+,c s:a:ri,n x,:�>.c�.irs.,. i-•a.�wvs i a...cni:•t:.tr,s: �...:t,2 : ' i Commonwealth of;4fassachusetts Division of Professional Licensure Board of Building Regulations and Standards CS-094649 Expires:03i08t2020 N_. BRIAN d DOBBINS Commissioner �%/re`�Cavri�rnriurnir/�r�'•^_-•ltn�,;ri(�rt3ell�• Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation, before the expiration date. If found return to: g'aistrmon Expiration Office of Consumer Affairs and:Business Regulation 10081.1.. 06/22/2020 One Ashburton Place-Suite 1301 I EN GIBELY CONTRACTING COMPANY,INC. Boston,MA 02108 BmAN J.DOBBINS - 23R W INTER.STREET PEABODY,MA 01960 Undersecretary Not valid ithout signature I Commonwealth of Massachusetts j Division of Professional Licersure Board of Building Regulations and Standards CS-094763 Expires: 05.11412020 i THOMAS R'DOBBINS I Commissioner i i I r=�/ze`�r��Lxznzrri�etr✓� �1r�uurrr�r«;PII` I Office of Consumer Affairs&.Susiness Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only i'YPE:SuDDiement Card before the expiration date. If found return to:. Registration_ Expiration Office of Consumer Affairs and Business Regulation j t 00811 06/22/2020 One Ashburton Place-Suite 1301 LEN GIBELYCONTRACTiNG COMPANY;INC, Boston,MA 02108 j 23R WINTER STREET PEABODY,MA Q1960 Not valid without signature Undersecretary i The Commonwealth of Massachusetts Department of IndustrialAeeidents a 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lep-ibly Business/Organization Name: LEN GIBELY CONTRACTING Address:23 R WINTER STREET City/State/Zip:PEABODY, MA 01960 Phone#:978-531-8234 Are you an employer?Check the appropriate box: Business Type(required): 1.❑✓ I am a employer with 10 employees(full and/ 5. ❑Retail or part-time).* 6. ❑RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees. [No workers'comp.insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.❑Health Care with no employees. [No workers' comp.insurance req.] 12.0 Other CONRACTING *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:AIM MUTUAL INSURANCE COMPANY Insurer's Address: 17 Arthur Street City/State/Zip: Salem, MA 01970 Policy#or Self-ins.Lic.#VWC10060109792019A Expiration Date:8/3/20 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here¢y certify,under the pains and penalties of perjury that the information provided above is true and correct. Signatur Date: Z c� Phone#:978-531-8234 Official use only. Do not write in this area,to be completed by city or town official, City olr Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia Ac"REO CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDNYYY) 07118/2019 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 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 Marianne Hoysradt CROSS INSURANCE-WAKEFIELD INC PHopIE 781 914-1000 FAX E-MAIL SS: mhoysradt@tgacross.com 401 EDGEWATI_R PLACE STE 220 INSURERS AFFORDING COVERAGE NAIL 8 WAKEFIELD MA 01880 INSURERA AIM MUTUAL INS CO 33758 INSURED INSURER B: LEN GIBELY CONTRACTING COMPANY INC INSURERC: INSURER D: 23 WINTER STREET REAR INSURERE: PEABODY MA 019605941 .INSURER F COVERAGES CERTIFICATE:NUMBER: 426517 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 IhN1Y 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. POLICY EFF- 7PERSONAL R TYPE OF INSURANCE INSO ADDL SU D_ POLICY NUMBER. MVIO UNM-COMMERCULLGENERALLIABILITY EACH OCCURRENCE $D GETOCWMSMADE OCCUR PREMISES Eaa=urmnce $ MED EJ(P(Any one person)NIA BADVINJURY $. GENLAGGREGATEUMIT APPLIES PER GENERAL AGGREGATE $ POLICY I�JECT LOC PRODUCTS-COMPIOPAGG. $ PRO- OTHER: $ . . AVTOMOBILENABI(JTY- COMBINED SINGLE LIMIT $ i - Ea aoZt` .. ANYAUTO BODILYINJURY(Per Person) $ ALL OWNED SCHEDULED - AUTOS AUTOS NIA - BODILY INJURY(Per amident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE .$ - AUTOS Per"accident $ UMBRELLA LIA1 OCCUR .. EACH OCCURRENCE. $ EXCESS LIAB CLAIMS-MADE NIA AGGREGATE $ DED RETENTION$' - $ WORKERS COMPENSATION X,. PER-�.,, ANDEMPL.OYE,RS'UABWTY YIN - OER ANYPROPRIETOR/PARTNEftIEXECUTIVE E.L.EACH.ACCIDENT $ 500,000 A O,,cE.E.HMC=r=. NIA NIA. WA VWC10060109792019A 08/03/2019 08/03/2020 (MandatoryinNH) If yes,desaibe under E.L.DISEASE-EA EMPLOYEE $ 500,000 - - - - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 NIA DESCRIPTION OF OI?ERA nONS I LOCATIONS I VEHICLES-(ACORD 101,Additional Remarks Schedule,.may be aftched if more space is required). " Workers'Compensation benefits will be paid to.Massachusetts employees only.Pursuant to Endorsement WC 20 03A8 B,no,authorization is given to pay claims for benefits to employees instates other than Massachusetts,if the insured hires,or has hired those employees outside of Massachusetts. This Certificate(if insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance)_ The status of this coverage can be;monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govA.wdfworkers-compensationfinvestigationsi. CERTIFICATE:HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED'POLICIES BE CANCELLIF BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE.WrrH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Daniel M.Cro,N�y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ACORi.Y® DATE(MMIDWYrr) CERTIFICATE OF LIABILITY INSURANCE 01/2212019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS INO RIGHTS UPON THE CERTIFICATE HOLDER.-THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THISCERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING.INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: Of the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. " If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this cei tificate does not confer rights to the certificate holder in lieu of such endorsement(S). PRODUCER CONTACT Stephen Gill NAME: Cross Insurance-Wakefield PHONE (781)9t4-1000 Fnx 81)2245777 Ara do Ezt: No 401 Edgewater Place Suite 220 ADORES 6 sgill a@sennottinsuranee.00m INSURER(S)AFFORDING COVERAGE NAICS Wakefield MA 01880 INSURER A: United National Insurance Co. 13064 INSURED INSURER.B: tY Inde Safe �. randy. 33618 Lan Gibely Contracting Co.,Inc. INSURER Cc: 23R Winter Street INSURER D INSURER E�: _.. .. .. . Ppatmdy MA 01960 INSURER F COVERAGES CERTIFICATE NUMBER: 19-20 Master 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 CONTRACTOR 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 LTR T'YPE.OFINSURANCE DISD-WVD POLICYNUMBER LIMITS EACH OCCURRENCE $. X COMMERCIAL GENERAL LIABILITY 1,00p,000 CLAIMS-MADE FX1 OCCUR DAMAGE TO RERTEff- $D,000 PREMISE occurrence .$. MED:EXP(Any one person) $..5,000 A L7221167-A 01/29/2619 01/29/2020 PERSONAL BADVINJURY $ 1,000.000 GEN'L AGGREGATE LIMITAPPLIESPER: GENERAL AGGREGATE. $ 2.000.000. X POLICY JECT -1 LOC PRODUCTS-COMP/OPAGG $ 2,000,000 oTHErz $ ' AUTOMOBILE LIABILITY - -:._. ..COMB NEO SINGLE Limrr $ 1,DOO,OOD Ea.acddent ANY AUTO BODILY INJURY(Per parson) $ B OWNED v SCHEDULED -.6221693 0112012019 01/29/2020 BODILY INJURY acddent $ AUTOS ONLY ^ AUTOS { ) x HIRED - X NON-OWNED PROPERTY DAMAGE $ - - -- AUTOS ONLY AUTOS ONLY Pers. -- , $ UMBREL;IA W16 OCCUR EACH OCCURRENCE :$. EXCESS(JAB CIAIMSfiMDE AGGREGATE $ .. DED RETENTiCN$. $. WORKERS COMPENSATION .. - PER OTH-. AND EMPLOYYRa'LIABILITY YIN STATUTE ER. AN Y EL �CUTTVE N 1 A ERIMEMSEREXCLUDED? Q.. EACH ACCIDENT $ (Mandatory In NH) .EL DISEASE-EA EMPLOYEE $ If yes,destribe under DESCRIPTION OF OPERATIONS below .... ... EL.DISEASE-POLICY UhWT '$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD,101.Additional Remarks Schedule.may be anachod it nwe space is:repuired) . CERTIFICATE(HOLDER CANCELLATION .SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCE1 I BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN. ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR®:REPRESENTATIVE 1P ♦♦ 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered'marks of ACORD ill