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HomeMy WebLinkAbout0022 GOLDENROD LANE (2) I ;� I rl � e i o i F wiversal oneTm 'Nww myuniversalop.com phone:1-66&756-4676 UNVIO501 MADE W USA S�iau�c� tp- a-no4�r --�old8y- e ` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application #a u _ &a 17 Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee �S Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation/ Hyannis Vti1 :! Project Street Address o��= d 0 a,-J R- /U —Village Owner //'' A r•e_e-� c�1 I°�'P�✓� Address Telephone=G4(7 9 - [ /.3 A Permit Request U � �� c� Ce, l J i 'c 0 L C 3 2- Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 3 `7 00, OCConstruction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family OZ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No : Fireplaces: Existing New Existing wood/coal stoves❑Yes, ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑.existing ❑'new size_ Attached garage: Elexisting ❑ new size _Shed: ❑ existing ❑ new size _ Other: =' CD Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name l 'lam i Telephone Number �b�;� 7,k9 - b Y 3 G Address 0y Cj License # J A -7 7 �t 'kvti� Home Improvement Contractor# ' ®y 1 Email�/� ��.��y �i �l C-� �� Worker's Compensation# yqt,-") ePdk ) 6 U ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO DATE SIGNATURE . FOR OFFICIAL USE ONLY 1: z APPLICATION # �. DATE ISSUED MAP/ PARCEL NO. V ADDRESS VILLAGE OWNER DATE OF INSPECTION: j FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH G FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT I ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents 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 THE PERMITTING AUTHORITY. Appticant Information Please Print Leeibly Name(Business/Organization/Individual):RetroFit Insulation Address:PO Box 105 City/State/Zip:Seekonk, MA 02771 Phone#:508-989-6436 Are you an employer?Check the appropriate box: Type of project(required): l.�✓ I am a employer with 1 employees(full and/or part-time).` 7. ❑New construction 2.❑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. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.[]l 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.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.❑✓ OtherWeatherization 6.❑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.] '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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:STAR Ins. Co. Policy#or Self-ins.Lic.#:V9WC802160 Expiration Date:8-2-18 Job Site Address:22 Goldenrod Lane City/State/Zip:Centerville, MA 02632 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 and penalties of perjury that the information provided above is true and correct. M Si nature: Date: `y t Phone#:508-989-6436 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#: ok "E ro Town of Barnstable Regulatory Services BAMS TABU, Richard V.Scali,Director MASS. w Building Division. Paul Roma Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office:508-8624038 Fax:508-790-6230 Property Owner Must Complete and Sign This Section I, Maureen Ward as Owner of the subject property hereby authorize Retrofit Insulation to act on my behalf, i in all matters relative to work authorized by this building permit application for: 22 Goldenrod Lane. Centerville, MA 02632 (Address of Job) -- _ CI C 1 G 4 Signature of Own er Date J 's Print Name If.Property owner is applying for permit,pease complete the Homeowners License Exemption Form. i C:1UserstdecolliklAppData\LocatlMicrosoft\windows\lNctCache\ContentOutfooklL7U69LF2\EXPRESS(2).doc Oi%25/l 7 �' Corntnonweaiih ofi Massachusetts DJVISIt n of Professional ticensure Poard of:Eiiiidm :Re aiations;an d Standards' "` Gr�nstructiaj S t'"r SpecWty CSSLLAO' 71: ,�� ��pires t1t310B12U19 JOSEPH J Ri LY. PO.BOX 106 r ` '". SEEKONK MA:O„j39: COMM"issidnQf l✓'w S r. C office of Consumer Affairs and B g Reguldion 10 Park Plaza-Suite 5170 Boston,Mas 02116 Home impro ent. „, RogisWdon Maws RETROFITINSULATION INC. JOSEPH REILLY P.O. HOX 105 .„ SEEKONK. MA 02771 � amwwd 0100*wmi pL*" WA � �►+, or reorwAdm�a ire�rl nra anty o> �rsAm .aa » bdon&# tat COMMAC a , 'ON"od«�r1e+� m 'low > n la prekpkm-ldbe 5"0 bow,MA C1,1C i FALL IWA l � it .r U!!O!l�CJ't�rY 1qOL Yllld A r • v n ` RETRINS-01 DCARVALHO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 07/27/2017 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 License#1780862 CONTA NAME:CT Diane Carvalho HUB International New England PHONE FAX 222 Milliken Boulevard (A/C,No,Ext): (A/C,No): Fall River,MA 02721 Al DRIE s:diane.carvalho@hubinternational.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Selective Insurance Company of South Carolina 19259 INSURED INSURER B:National Liability&Fire Insurance Company 20052 RetroFit Insulation,Inc. INSURER C: PO Box 105 INSURER D: Seekonk,MA 02771 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 BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FX OCCUR S 2187653 08/15/2017 08/15/2018 DAMAGE TO RENTED 100,000 PREM SES Ea occurrence $ MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY CO BIKED SINGLE LIMIT $ 1,000,000 ANY AUTO A 9100182 08/11/2017 08/11/2018 BODILY INJURY Perperson) $ OWNED rx SCHEDULED AUTOOS ONLY AUTOOSWN BODILY INJURY Per accident $ X AUTOS ONLY AUTOS ONLY P�acGdenI DAMAGE $ A X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE S 2187653 08/15/2017 08/15/2018 AGGREGATE $ 1,000,000 DED I I RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE OE YIN 9WC802160 08/02/2017 08/0212018 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ PMandR/MEMBEREXCLUDED? 1,000,000 ory In NH) E.L.DISEASE-EA EMPLOYE $ If es,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE National Grid THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 40 Sylvan Road 02451 AUTHORIZED REPRESENTATIVE /?V ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map PP Parcel ��V J Application # S� Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address Cad t 6 en12�po) L,.iU A b.2C32- � Village Owner V 2 e^) Address Telephone 3 Z P rmit Request��� (A a e- S c;A l A-x x 16 SL Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation a Ebb, .Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: 0 Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ exisfMILdlnewsize ❑ � ® _ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing new size _ Other: EP7-; MAY 2 6 2011 Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ TpW�OFBAPNS�A3L� Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 1-m V /MC ►`J2ul(. Telephone Number (�y � � �y - (� `��to Address �l7 `J O sC 1 o S— License # O a 7 I AL 7'? Home Improvement Contractor# __AO Email i�,r re, !q ct '�n G V n&A nl Worker's Compensation # 6 Y s�a O/ 0 0 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO AMC _#X4,0_f l I A01h,V,�P ry, SIGNATURE o 1 DATE s'I('ct(! ;2 FOR OFFICIAL USE ONLY r: APPLICATION#. DATE ISSUED MAP/PARCEL N0. ADDRESS VILLAGE - OWNER DATE OF INSPECTION: FOUNDATION FRAME ` • P r INSULATION FIREPLACE K n• t' ELECTRICAL: ROUGH FINAL _ PLUMBING: ROUGH FINAL -. r' GAS: ROUGH FINAL FINAL BUILDING e DATE CLOSED OUT 1 • l ASSOCIATION PLAN NO. r Town-of Barnstable o� .L x�nrasT Regulatory Services �M Ltichard'V' Scali,Director 1659 Building Division Tom Perry,BuS dhig Commissioner r 200 Main Street,Hyannis;MA 02601 , www.town.barnstable.ma.us Office: 508-8624038- Fax: 508-790.-6230' 'Property Owner Must Complete and Sign This Section If Using ABuilder, v � as Owner,of.the:subject property hereby,.authorize Retrofit Insulation. to action,n bebalf, is all matters relative to work_authorized by this building permit application for. 22 Goldenrod Lane, Centerville, MA (Address ofjob)- . Tbol`ferices,and.41r=,areAie responsibIty.of lie°applicant.-P 6ls are Rot 16.-be.-f ilkd,or ut l zed before fence is-installed and all final in pections performed and accepted. Sigriar of Owner Signature of Applicant Print Nalnq N •.PrintName Dates Q:FORN1s:0%VNF_"ZW. .JSS1oNPO01S The Commonwealth of Massachusetts Department of lndustrud Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 .- www massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TSE PERMITMIG AiITHORTTY. Applicant Information Please Print Legibly Name(Business/Organizadon/Individual):_ 1Z�}�t� P - ��j-1 8 Address: b- City/State/Zip: S L'�1:1e oiv1� YVV� Phone#: �� f 9 f Are you an a pioyer?Check the appropriate box: vJ.77 Type of project(required): l,�i a�employer with YP P J employees(full and/or part-time).* 7. ❑clew construction ❑I am a sole proprietor or partn=hip and have no employees working for me in S. ❑Remodeling any amity.[No workers'comp.insurance required.] 3. 1 am a homeownu doing all work 9. Demolition ❑ g myself(No workers'comp.insurance required.]t 4. I am a homeowner and will be o 10 Building addition ❑ hiring contractors to conduce all work on ray property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. ❑ S.Q 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 ban workers'comp.insurance,: 13.❑Roof repairs 6.E]We art a corporation and its officers have exercised their right of exemption per MGL c. 1�' er �L✓�,��`• L � 1 ,§1(4),and we bave no employees.[No worl=-camp,msrranoe required] 'Any applicant that checks box 91 must also fill out the=lion below showing thew workers'compensation policy information. t Homeowners who submit this aindavit indicating they are doing all work and then hint outside contractors must submit a new affidavit indicating such Contractors that check this box mast attached an additional sheet showing the name bf the sub-contractors and state whether or not th=s 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: f-pnf(2 Policy/r or Self-ins.Lie. :_ J d t{S�� e� D C-) Expiration Date: Job Site Address: 2 �— �j() 7c��,.�/�-v►� L City/Statemp: (.L vi--/✓i ((e Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration te). 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. 1 do hereby certify under tit p is and penalties of perjury that the information provided above is true and correct Si ature: Date: �l Il Phone : l.f Official use only. Do not w ' in this area,lo be completed by city or town official City or Town: PermitlLicense 9 Issuing Autho " (circle one): 1.Board of Health.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: O£fice of Consumer Affairs and Business Regulation 10 Parr Plaza- Sufte 5170 Boston, Massaeh setts 021-16 Home Improvement 1 Copt for Registration Registration: 160461 • ;i�'�- �._�;__� •,,_�-: Type: Private Corporation ! ���- 5 `="';`• Expiration: 7/2912018 Tr# 289184 RETROFIT INSULATION, INC. w!• JOSEPH REILLY P.O. BOX 105 SEEKONK, MA 02771 Update Address and return card.Mark reason for cliange. $CA 1 0 2OM.os11 0 Address El Renewal Employment Lost Card .. vlce t�c�v�rma,+GcudGG�✓a�c,�vGa4rtac,�uc6a�fd• • Office of ConsumerA,Bairs&Busvaess Regulation License or registration valid for individual use only HOME IMPROYSMENT CONTRACTOR before the expiration date. If found return to: Reglstratlon.s;'js0484 Type: Office of Consumer Affairs and Business Regalation Espirdtign=��/ "`• 18 Private� vate Corporation"' 10 Park Plaza-Suite 5170 39/2fJ f= —.'. Boston,WA,02116 RETROFIT W$ULAY>y.f;11V JOSEPH REILLY 644RODMANST '.••• ` '�„ 'J _�.,e. FALLRNER,MA 02721 Undorsecretary ev2rid ut signature 4 afliPletb9�f, teL�4ic'Safe .'., Massachuselfs :gip • r ' .�93P83®t.l�ldla4�t@9g'�e��iaxb��d'3Pd�3.��a�sa�a�►ds`•�", � taetrrase s. o�� asae��s�lcs6risTy ,License CSSL 90277V joll 1'`u StcclonlYMAJ02y791!;' �'� t,,''' :Y• �iP2191Cez1w r + Ir 17 ' • �r t;�PPPIP11SS1®i1PP. r"^/ •V`�[ +` { 1 AC • RETI2INS-01 RBLAPKI �.� CERTIFICATE OF LIABILITY INSURANCE DATE(MMDDIYYYY) 811112016 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 poffay(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 License 9 5780862 CONTACT HUB.International New England HONE 222 Milliken Boulevard Est:(508)676-1971 a Nei. 508)678.2750 Fall River.MA 02722-9946 EMAIL ADDRESS: INSURFR(S)AFFORDING COVERAGE NAIL iruiiREc INSURER A:Selective Insurance Company of South Carolina 119249 INSURER 8:Star Insurance Company 18023 RetroFit Insulation,Inc. INSURER C: PC'BOX 105. INSURER D: Seekonk,MA 02771 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: T ISSUED TO THE INSURED HIS lS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN NAMED ABOVE FORTHE POLICYPERIOD INDICATED, KOTWITHSTANDING ANY REQUIREmExr, TERM OR CQNDITION OF ANY CONTRACT OR OTHER DOCUvIEZTWiTHRESPECT'TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEI2EINISSUBJECiTOALLTHETERMS, EXCLUSIONS AND COND_1TIONS OF SUC*H POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPEOFINSURANCE 1 0 POLICY NUMBER POLLCYJYEFr PMIuD'Y DCP LIMITS A X. COMMERCIAL GENNERALLw$n!]Y EACH OCCURRENCE s 1,000.000 CUUMS MADE a OCCUR n S21876.53. 08115/2016 081IV2017 PREMISES Ee'oaSFrence S 100,000 MED EXP(Anyone person) S 5,000 PERSONAL&ADV INJURY- S 1,00000 GEN'L,AGGREGATELIMRAPPUES PER: GENERAL AGGREGATE S 2,000,000 POLICYLJ JF� 0l OC OTHER PRODUCTS-CAMP/OP AGG S 2,000,000 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIFAfT g 1,000,000 A (Ea aeddent ANYAUTO 100782DD 08/1112016 08/1112017 BODILY INJURY(Per person) $ ALLOWNm �( SCHEDULED AUTOS AUTOS SODILY INJURY(Per accident) S X HIRED AUTOS X AUTOS PROParacrJdentPERTY DAMAGE . S x (I6zREIJ A LIAR S OCCUR EACH OCCURRENCE S 1,ODQ,ODO A EXCFsstlA9 HCLAIMS-MADE S218T653 08/1512016 08/1512017 AGGREGATE $, DED X RETEMiONS 0 S 1,OOD,Q00 W9RI<FRSCOMPENSATION I PER O.TH AND EMPLOYERS?LVZ'BJTY STAGE � $ APCRo IN ERI ed oER�LUD©EcurNE Y❑ N/a. C0845201 0810212016 0810212017 a_L�,Cr(ACCIOENr s 1.000,000 lfryyyaass,.descr eunder T(ONOFOPEATIONSbelow EJ_DISEASErPOUOYUMrf S 1,000,000025C E.L.DISEASE-EAEMpLO S todo,000 MCRIPnON OF OPERATIONS I LOCATIONS!YENICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE National Grid - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN so Washlogton Street ACCORDANCE WITH THE POLICY PROVISIONS. Westborougd,MA 015,81 AUTHORIZED REPRESENTATIVE ©1988 2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD