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HomeMy WebLinkAbout0157 SIXTH AVENUE (HYANNIS) i i Application number....l ..l` 4.... .............................. Date Issued.....,�.'Zy.�.1.`! . ® ..................................... BAAxxsraetis Nnss. � g9. 201� Building Inspectors Initials...... 'OrF1639. A1� OCT 2 3 .... �N 0� B'AnSTABL Map/Parcel.._.....Z-`...5�.......U.7.�.............. ...... T01� � TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDINGIWINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY MORMATION Address of Project: I S 7 (,Ak NUMBER STREET VILLAGE Owner's Name: ;�roc< fro ,n Phone Number Email Address: cc$4 CbM Cell Phone Number Project cost$ I -�cj — Check one Residential ✓ Commercial O 7'V NiLL`W S A Jl H®1`LJl/tATIO As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: See ,A ad,,-Q Date: TYPE OF WORK ED ' ing ED Windows (no header change)#' 0 Insulation/Weatherization !='J Doors (no header inspector's reviewchange)# I Commercial Doors require an ire q P Roof(not applying more than 1 layer of shingles) Construction Debris will be going to w as-4 �, = e �,�7`'_G Jam,m b..��. M✓j CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# 11 Z 7 - (attach co PY) Construction Supervisor's License# ___ _ _ (attach copy) Email of Contractor 5wee� S e m4 l' • Phone number -,�ro /- 71V- 6 3' 9 ALL PROPERTIES THAT HAVE STRUCTURE OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY l5/IV A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORICAPPROVAL BEFORE A PERMIT CAN BE ISSUE®. APPLICATION NUMBER *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one:this event is a:for profit non-profit event Check one: Food served Yes No r Flame Spread Sheet of each tent must be attached.Provide a site plan with the location(s) of each tent If food is being sewed at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES " Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOM EONINER'S LICENSE EXERTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CIR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date All permit applicatio are subject to a building official's approval prior to issuance. Home Improvement Agreement: Pagel Home Depot License#'s - For the most current listing www:Homedepot.cbm/LicenseNumbers MA: 107774, 112785 - `t ' n 4_ Janice Campbell Salesperson Name: u, Registration No. (i -applicable): Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/ or service the equipment listed below at'the price, terms and conditions as outlined on this form. Brown Bruce �. New England South 1-M11Q3AC Customer Last Name Customer First Name. Store #/ Branch ame Customer Lead P # 157 6th Avenue W Hyannisport _ . West Hyannisport IMA 02672 Customer Address City State Zip (505) 469-2482 `° johnsonbrown@comcast.net Home Phone# Work Phone# Cell"Phone# 4 Customer Email Address NOTICE OF RIGHT TO CANCEL: •YOU'MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: = 908 Boston Turnpike Unit 1 •f;:- Shrewsbury IMA 1 101545 , Address • City State Zip Or Email: customercancellationnortheast@homedepot.com Service Provider Email Address BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE' ' ' SUPPLEMENT PROVIDES A'DIFFERENT CANCELLATION PERIOD. THE STATE SUPPLEMENT - CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.' YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE-FOR PICKUP BY HOME DEPOT OR SERVICE PROVIDER; AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED, TO YOU. OR YOU MAY CONTACT HOME.DEPOT FOR INSTRUCTIONS'REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE HOME DEPOT GIVE YOU A NOTICE EXPLAINING.YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICE OF YOUR RIG ANCE Acknowledged by: r 08/05/2019 Customer's Signature t Date Y Contract Price and Payment Schedule : Payment of the Contract Price`is=dueupon signing unless a different payment schedule is required by law, specified below or in a payment addendum. Contract Price: . "$ 3139.00 .- ' ` Includes all applicable taxes. Excludesfinance charges.* Sales'Tak* n$ 0.00 (If applicable) . ~ `Maximum depositONLY applicablein MD, MA, ME(33%), NJ, In7l(99%p) De P25.0 , ` 784. 5% De Remaining Balance $ 2354.25 , 4 The Home Depot 2455 Paces Ferry Roid,.N.W.Bldg.B-3,Atlanta;Georgia 30339-Customer Care: 1-800466-3337 460 HDE Customer Agreement(24 Jul.1 S) v 0.1.7 s' Home Improvement Agreement: Page2 Finance Charges: *Any interest payments or other finance charges will be determined by Customer's separate cardholder or loan agreement, to which The Home Depot is NOT a party, and will be in addition to Customer's payment under this Agreement. Customer is subject to the terms and conditions of the cardholder or loan agreement, as applicable. No funds should be made payable to.Service Provider;.however, Service Provider may collect Customer's payment(s) made payable to The Home Depot. Insurance proceeds will will not be used to pay some or all of the total-amount of sale. Description of Work to be Performed: . Installation of lEntry Doors A more detailed description of the work to be performed is included in the section entitled Scope o Work which appears on page F7 of this Agreement. Anticipated Delivery Date/Installation Schedule Approximate Start Date: 09/30/2019 Approximate Finish Date: 10/28/2019 All dates are approximate and subject to change based on unforeseen events including inclement weather, permitting delays, and delays in confirming insurance coverage of Your claim for any repair, if. applicable. Electronic Records Authorization: You are entitled to a paper copy of this Agreement if you choose. If you consent to an e-mailed copy, your consent applies to this Agreement and all subsequent documents and written communications related to this agreement. By contacting your Service Provider,,you may update your email address, withdraw your consent, or obtain a paper copy of the Agreement or related documents at no charge. By providing your consent and verifying your email address above, you confirm that you have access to a computer that can receive and open emails and PDF documents. By it' ing this paragraph, I consent to receive only electronic records related to this transaction. Initial Acceptance and Authorization: By signing below, you authorize Home Depot to (a) arrange for Service Provider to perform Installation and/or (b) order and arrange for the delivery of special order merchandise, including special order merchandise that may be.-custom made, as specified in this Agreement. Do not sign if blank or incomplete. (Service Provider's/permitting information may need to be provided to You later.) By signing, you acknowledge that you have read, understand, and accept this Agreement in its entirety, including the General Terms and Conditions and State Supplement, if any. You further acknowledge receiving a " complete copy o Agreement. Keep it to protect your legal rights. X 08/05/2,OF197 IThe Home Depot Cus o ' na re Date Service Provider Name X R 08/05/2019 s 908 Boston Turnpike Unit 1 Go-Signer (if plicable) Date Service Provider Address X 08/05/2019 Shrewsbury MA 01545 Signature o INmber . me a of Date City State Zip R-1-073-13-00016 Servi ovi P ne ,. Service Provider License Number The Home Depot-2455 Paces Ferry Road,N.W.Bldg.B-3,Atlanta,Georgia 30339-Customer Care:1-800-466-3337 460 HDE Customer Agreement(24 Jul.18) .' - - v 0.1.7 i P F fth Of maSSdCt3USetCS = DWlsion of Professional Lkens une. SOalrd of Hisidn �® 9• .£UeltfQrtS artd-Stant#ards :Ca1s €� 4€ taagmsr - 7(3f��713012020 Tp - #s FALL ST MMEHM Mai 12671 Cc}€t' Missione3 r - �' Office of Con sWnerAffairs,&9usiness Regulation r i Y HOME iMPROVEMEf+1T t:0N7RACFOR Registration valid Cot individual t e ontg TYPE f'arh►eashiD before'fhe exprration d"ate If found reQim'to;` Y Reaistrdlion E�ctiirafian t fice.of Consumer Affa's`s and Business Ft yt han 132349' 0 111 012 021 low Washington Street=Suite 711l- �= JOSEPH;C DUARTE Soston,MA 0211ti ' _ # t . b6k J tx J RE MODELlNb m JOSEPH C, DUA I I= 15 FALL$T of vand,without signature WAREtii4M MA}'62571 Undersecretary: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 1 Congress Street, Suite 100 Boston,MA 02114-2017 wivw.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: Ci /State/Zi : 02,67 Phone#: 77 - 76 6 ' aka Are you an employer?Check the appropriate box: . I am a general contractor and I Type of project(required): I.El atn 4 g a employer with . 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.;K1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. []Building addition [No workers' comp.insurance comp.insurance. required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing'all work officers have exercised their ,1 LM Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12Q Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 1.3Q Other 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. *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 providing workers'compensation insurance for my employees.Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: 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 hereby ce uncle the pain�nd penalties of perjury that the information provided above is true and correct. S Datg: Phnne#• " 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#: T Tire Commonwealth of Massachuse#s Department of IndustrialAccidents 1 Congress Street,Suite 100 -,.Boston,MA 02114-201 7 Tw6rkarv wwwmass.gov/dia Compensation Insurance Affidavit:Benders/Coatmetors/EleeiriciauMtombem TO BE FILED WITS THE PERMITTING AUTSORM, AR13heantinformation Please Print Lesilsly Name(Business/Otganizatbn/ladividtmi). ,W n{+-t er• Address: C1 �Sl'C'1.'le�Zi , ty A• S lot//' l`1 Or S4 5" Phone#: 7 7 L -) 5^ 2. 1 5 S" Are yon.an employer?Check the appropriate bon Type of project(required): 1Q r am a empioyerwith, ,uployccs(fw and/or part time).t ` ' , 7. []New conshuctioa. 2.[]l am a sole proprietororpartataship and have no employees corking foam=is 8. ❑Remodeling any capacity[No workers'comp.insurance requuc,J 9. El DemOlitlon 301 am ahom�wn�doiogall wasIcmyset£{Nowodmars camp msumncercquired j r 10❑Building addition •!.❑ram a homcuwnerandwM tc huiogsronhaatars to conduct an workonmy property.Iwill ensure that all contractors either hareworkere compensation insmanoe or are solo 11.❑Electrical repairs or additions pr'oprietorswith no employees s. Iama y 19❑Flutnbingrepairs or additions general oonhactor and Ihave hired the sub•conhaetors listed oathe attached sheet 13.❑Roof repairs These sub-co�actons have c*oyees and have workers'comp insurance; 1"" 6 We era a os and its offitxus bave exorcised their - 14. ✓[�Ot1lel P�lorfr ❑ �p�ti rightof exemption parMGL o �L lA§i(4),and we have no employees.[No wadmrs'comp insurance required.] *Any spolismutthat aheolts box#1 must also M out the section balow showing their workers'compensation policy information. t How,cowaars who sabmirtUS affidw*indicating they we doing of i work and then hire outmde ecouacrors mast=bmit a naw affidavit indioatasg such. �Cont actors that eheckl9s box must attached an additional sheet showing the name of the sub-contractors and stM whothor or aotihose entities have employees. If the sub-contractors bave employees,they must provide their wodwe comp.policy mrmber. I am an employer that is providing ivorkers'compensation insrerance for my employees. Below it dwpolicy and job site InsnranceCompanyName N enGt�� (Anion _ �r. J Policy of Self-ins,Lic. : it Z;*:5 (05 5 '1 7 Expiration D e: Job Site City/Sware5p: W. Lai i--s/2o--to N� Attaeh a copy of the workers'eompensation:policy declaration page(showing the policy number and eapira�tl0n'.ate)., Failure to secure coverage a§r " ed under MGL.c.152,•§25A is a criminal violation punishable by a fine up to$1,500.00 . . and/or mt:•year imprist nm as ell'as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator,fty. finis statement may bc.forwarded to the Office of Investigations of the DIAfor in'MMMct>coverage verificati on I do hereby cer*un an enaltires o information provided above is lire and Correct , Simatttre 2- /9 ar Ofidal rise only. Do not write in this area,to be completed by dV or tmvn off ciai . City or Town: $ Perniibucense# BiWng Authorht (circle one): L Board of Health 2.BuRdin;Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector ' 6.Other .. Contact Person: ' Phone#: , f /- xe Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Horne ImprovemeaLContractor Registration - -- - --_---- _- Type: Supplement Card HOME DEPOT USA INC _ Registration: 112785 P O BOX 105451 - _ Expiration: 04/22/2021 ATTN: LICENSE MGMT TEAM ATLANTA,GA 30348 -- Update Address and Return Card. SCA 1 C+ 20M-05i17 Office of Consumer Affairs$Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE;gDlement Card before the expiration date. If found return to: Reaistrat9on Expiration Office of Consumer Affairs and Business Regulation 04/22/2021 1000 Washington Street -Su 10 HOME DEPOT[� Boston,MA 02118 ANDREW SW EEF 2455 PACES FERRY-I�C41 HSC ATLANTA,GA 30339 Undersecretary NWAIIIt ut sl nature OA'E(MMIDOIY'/'!YI CERTIFICATE OF LIABILITY INSURANCE )2106;201'3 THIS CERTIFICATE IS ISSUED AS A ,IAATTER 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 CONTACT NAME: MARSH USA,INC. PHONE FAX PNO.ALLIANCE CENTER c,o Exit, AIC No: 3560 LENOX ROAD,:SUITE 2400 =,+MAIL A T LANTA,GA 30326 doDREss: _— INSURER(S)AFFORDING COVERAGE NAIC..4 CN101642069-HomeD-GAW-19-20 _ INSURER A:Old Republic Insurance Co 24147 INSURED INSURER e:New Hampshire Ins Co 23841 THE HOME DEPOT,INC. HOME DEPOT U.S.A.,INC. INSURER c:HomeRisk Ca live Insurance Company 2455 PACES FERRY ROAD INSURER D: :BUILDING C-20 ArLANTA.GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: AFL-004353439-28 REVISION NUMBER: 21 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 'BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOPNITH STAND ING 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. IN SR 'AODLsUBR; POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY'NUMBER i MMIDDIYYYY MMIDDIYYYY ' LIMITS A € X :COMMERCIAL GENERAL LIABILITY 'MWZY 314574 - 03/0112019 :03/01/2022 EACH OCCURRENCE I i 1.000,000 DAMAGE CLAIMS-MADE %OCCUR PREMISESaEccurrencel ` i 1.NTED 000.000 X SIR:S1,0%000 VIED 2xP{Any one person) S EXCUJDED PERSONAL 3.ADV INJURY i 1,000,000 GEN•LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE i 1;300,000 %< POLICY jE� J LJC PRODUCTS-COMPIOP AGG ; i 1,000,100 OTHER: .A AUTOMOBILE LIABILITY MWTB314573 :0310112019 10310112022 ''OMBINEDiINGLELIMIT i 1!300.000 _ accitlentl X :ANY.AUTO BODILY INJURY(Par Person) i OWNED SCHEDULED i SELF INSURED AUTO RHY OMG BODILY INJURY(Per accident) i .AUTOS ONL! AUTOS HIRED �VON-OWNED PROPERTY DAMAGE i .AUTOS ONLY AUTOS ONLY ! Per accident ii UMBRELLA LIAR OCCUR i EACH OCCURRENCE i EXCESS LIAR CLAIMS-MADE' !.AGGREGATE S DED I RETENTION i 8 WORKERS COMPENSATION "NC 012717099(AK NH.NJ.W1T) I 1 03101i2020 X ;TERTUTF �RH 8 AND EMPLOYERS'LIABILITY Y/N WC 0 12717 100(WI) 03I01/2019 03I01/2020 5.000,000 'ANYPROPRIETOR/PARTNER/EXECUTIVE E.L,cACH ACCIDENT b 'OFFICERIMEMBEREXCLUDED? N :;NIA , (Mandatory in NH) E.L.DISEASE-EA EMPLOYEEI 3 5.000000 If yes,describe under Continued on Additional P3ge E.L.DISEASE-POLICY LIMIT S 5,000,000 DESCRIPTION OF OPERATIONS below C I Excess Auto 297110011002019 03/0112019 03/01/2020 Limit: 4,000.000 A Excess General Liability iMWZX 314580 0310112019 03I0112022 Limit: 3.000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ICI EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukheriee _1tiLauatrs �� ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: C1\110 1042069 A�D` ADDITIONAL REMARKS SCHEDULE Page 2 of 3_ 'AGENCY NAMED INSURED ,MARSH-jSA.INC. rHE HOME DEPOT,INC. HOME CEPOT U.&A..INC. POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C-20 ---- --- _.---. ArLANTA.GA 30339 CARRIER NAIC CODE EFFECTIVE DA TE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Cartificate of Liability Insurance 'Narkers Compensation Continued: Carrier:Indemnity Insurance Company of North.America Policy Number:'NLR C65890549 rAL..ARFL,ID.IA.KS.KY.LA.HS.,NO.NE,VM,ND.OK,3C.SD.rN;NV.'NY) Effective Date:03101019 Expiration Date:03/0112020 (EL)Limit:35,000,000 Carder:New Hampshire Insurance Company Policy Number:'NC 012717098 (OC.DE.HI.IN.MD.MN.MT.NY,RI) Effective Date:03101r2019 Expiration Dale:0310112020 (EL)Limit:35.000,000 Carries.ACE American Insurance Company Policy Number NCU C55890586(QSI) (AL CA.IL VC.OR.`IA.'NA) Effective Date:-13101/201 9 Expiration Date:03101/2020 (EL)Gmd:34.000,000 SIR:31.000.000 SIR for the states of AZ,(,A,IL,NC.0R,VA.'NA Gamer:National Union=ire Insurance Company Policy.Number:XWC 5565596(QSI)(CO,CT.GA,ME,:MIAV.OH.PA.UT) Effective Dale:03101r2019 Expiration Date:03101/2020 (EL)Limit:34,000,000 31.000,000 SIR ror the;tales of CO.ME.NV.MI.OH,P.A.UT $750.000 SIR for the slate of GA 3350.000 SIR:`or:he dale of CT Carder:National Union Fire Insurance Company Policy Number:XWC 5565597(QSI)(MA) Effective Dale:03101/2019 Expiration Date:03/0112020 (EU Limit:0,500.000 SIR:3500.000 rX Employers XS Indemnity: Carderlllinios Union Insurance Company Policy Number TNS C65221019 jX) Effective Date:03101r2019 Expiration Date:113/01/2020 (EL)Limit:310,000,000 SIR:31.000.000 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD