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HomeMy WebLinkAbout0017 CROCKER STREET I C o 4' 1. , `S+' a r I . r . F ,. ,, .. q , i _ J w q h'_ f .,'.,. 1. , .. 1 f t r ,. e ...r-.. ,:. *i- t' .. .' , .. ,_ 1, .r.:.: ., ..' :'F L t Y is C ...':gin. �. - - ..t x S "fit.,Xde .. , ,s'. .�� '. .t .� .�»..., ,. ..... .. e a 4.. ,..v. .� i t .. .... :�.,. 4 i. y,. �,... n a y ,i-... ..,. _ x. ..�s-. ,,..., t. . ,... _.. rep ;;, $ ._. i T A. ,,.,.„ , .,... . a. . lie,. '-�{ f ..... ,... ..} �,, ..... -:,, ,....._ .. r _ r ......., r .. ,_ .}. ...� ...s ,: , .. .�' ..._.,..,. .,.:.,. ... , _ .� 4 ...e. .. _ .. ,�.., r 3 .r. '.. z.. .., } :,e.. ....� .... t -4.,....,.,1 x <. x n.. .,. x , ,. ._r. .:,_,..,, :. ., r. ..fir t �. !- .,,i n i.. .. v �.. v . ':v -., ♦.. .. 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F... _. _ . , -..'. ... .. ,.. t ..... ,. .. .. ...' ..r, - "t� ,. v.: -, .. ..,..2 z s. ...._... .r r, 7 ..., ...5. . ...t ........_ :.: .,..: .. 1 ..... '� `r ., . .. v... .x.,.... ..,s :',... ., , , .. t .:....t _. ,� .. t , ,,. a .,zsr,. ,. .._:. f ,.4,' , ,,:- .,v .. ,. is i. .�. ,, ..., ... t ak y., t -y ✓, ti .y,..., n ! k P '') F ti Y & Y i s4 _ .. _—_ _ __ Town of Barnstable Building �Post�This Card S�oThat rt�is'VisiblepFrom the,.Street�A roued�Plans Must Iie;Retamed on Job and-"this Card�Must be�Ke t �` . .z b" PostedUntilFinalflnspeet�on Has Been Made y � , rya+° Where a Cert�ficate:of Occu ane 'is Re u�redsuch Buildm shall Nof be';Oecu ieduntiFinal.lns ection'hasbbeen made : Permit, Permit No. B-18-1530 Applicant Name: SWEET,ANDREW Approvals Date Issued: ,05 17 2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 11/17/2018 Foundation: Location: 17 CROCKER STREET,CENTERVILLE Map/Lot 210 148 Zoning District: RC Sheathing: Owner on Record: CURRAN, MARGARET DContraetor Narne ERICSSON TORRES Framing: 1 x Address: 17 CROCKER STREET Contractor LicenseCSSL 100546 2 CENTERVILLE, MA 02632 r Est `Pro ect Cost: $5,475.00. J 0 Chimney: Description: REPLACE 7 WINDOWS.29 UVALUE Permit Fee: $35.00 Insulation: Project Review Req: f Fie Paiidd $35.00 _ Date 5/17/2018 Final: gym, Plumbing/Gas F Rough Plumbing: � � _. . Building Official ` _ Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorizeMy%this permit is commenced within six months after ssuance. Rough Gas:_ All work authorized by this permit shall conform to the approved application and the?approved construction documents,for which this permit has been granted. All construction,alterations and changes of use of any building and structures shalllbe in compliance with the local zonuig�by laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access streetorroad and shall be maintained open four publ�inspet on for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures bythe Buildmgand FireOffcials are provideii on-this permit. Service: Minimum of Five Call Inspections Required for All Construction Work w Rough: 1.Foundation or Footing » J, _ 2.Sheathing Inspection Fina l: 3.All Fireplaces must be inspected t h hr level a the throatbefore firest flue lining is installed Pg 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT � 1 Town of Barnstable` *Permit# 3 a 'L Expires 6months from issae date Regulato' SuNiCes Fee S 9� 0 MAMp,0$ Richard V.Scali,,Interim Director y Building.Div OR Tom Perry,CBO,Building Commissioner m `►3 200 Main Street,Hyannis,MA 02601 - www.town.bamstable.ma.us t4AY 15 ?69 Office: 508-862-4038 Fax: MR90-6230 EXPRESS PERAuT APPLICATION - RESIDEN � � i V N�S A E J Not Valid without Red X-Press Imprint Map/parcel Number Z 1 d �1 _ Property`Address 1 -7 er'DC 571 (Residential Value of Work$ 5#7 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address fAora, crs ret� C cc,r-r'a A Contractor's Name-r ,F 6T W'SS a yl b it e_S Telephone Number 401-WY`.63$f Home Improvement Contractor License#(if applicable) 1 7"52-� Email: a 5cpeO??S-m Q oa r z y,Yi Construction Supervisor's License#(if applicable) 0 00 ( Norkman's Compensation insurance 66 �\ Check one: ❑ I atit a sole proprietor ❑ I am the Homeowner I have Worker's/Compensation Insurance Insurance Company Name 1 iTT 1�11/�L 11 P/d AJ &r-.,,, f A/ Workman's Comp.Policy# X U) qS s Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U Value_ . 1_ (maximum 335)if of windows #of doors: -- - ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire.Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: ope wner must sign Property Owner Letter of Permission. o Ay the Home Improvement Contractors License&Construction Supervisors License is A_ . SIGNATURE: QAWPFILESTORMSIbuilding p fo �EXPRESS.d c _ Revised 061313 s Home Depot Contractor License Numbers: ` MA: 107774, 112785 Salesperson Name and Registration Number: Janice Campbell : R-1-073-13-00016 Home Improvement Agreement 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. Customer Information: Peggy CURRAN New England South 1-5VPWQFX First Name Last Name Branch Name Lead# 17 crocker st Centerville MA 02632 Customer Address city State Zip (917) 971-4187 7F Home Phone# Work Phone# Cell Phone# pkd1140@aol.com Customer E-mail 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 Shrewsbury MA 01545 Address City State Zip or Email customercancellationnortheast@homedepot.com 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 PROFESSIONAL, 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 CONTRACTOR 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 RIGHT TO CANCEL. Acknowledged by: 04/20/2018 X OT:�� Customer's signature Date I 1 Z D . . ,Y).. - n. ' s�$ - 4 k . ` '� r . »�TH MAR v T S �g 27le Caarmameafth qfMamOkwar 600 Wash l�{i ou&FED Bas&n,MA 02111 • kPttJt'iLi11ffS��V�� _ WOrIM& CM3�ensa ffm Imurnwe Affidavit eIS/Quitr=fursM ers ' . Amfficant Iuft31-rmf6n Please P>E1ut Y -Name r I L'SS�n /orre S ti Addr e= tom_O 5-7.3 Are yDu au employer?Aped€the apprapriate bares Type of project{regaired}= L❑ I am a employes Vffi 4 ❑I am a general canfractar and l Ian(fa]1 a for paw Time * lmge Itized tfie sus contFacEtrss.- ❑New cans iraccMn 2.V I am a sole propdetar orpartner- fisted on the attsthed sheet 7- ❑R— &Hug ° and have no ees se sub-conacors has*e ffiP� The b tt S_ ❑Demolition, vfodiag for me iris capacity employ andbave Wo&Me q- El Stsilcimg addition S=COrap.S�SS1MUCe: Camp_klsn anc l _j 5.F We are a coxpomfiaa and its l°L❑Ekdrical repairs or a,d s 3.❑ I am.a homeowner doing an work of6ce[s trove Wised tl ir. 1L0 Mm3biagrepairs or a am , Mysia€[No F_ tight of emmV6aa per MM �El Roofmmrance rec�ed j i c.1 2,§I{4},artdive have sxo repairs employees.[No vodoess= 13.0-0ther comp_imo aum ] •AapaPg6CMtdarchadsb=inimsszalsofiIIa�fire oabdaar�a gleae ��p aapo5cginfo�aaa nraea�imsalmidrisaf&daeu`imt 8nepaxedamgeggand&>�hrrnaatsidecrai�cma�stsuhz�tanemaffid tWig.sadL fCat& nrsfb2trIIPrttheboot=MStWtarlmdanadAff;rM sheet shosTMgthenameafthe �styetiLe&cgarnotthnseemit�sl�e easp3ayees.7f$se hzce—gay-%&epmustgmyi&&W=dEmV ;.gahU mmsi!r Farr[araeriigRr9urtisprauidirrgt[�urkers'caugrerlsattottipesziraacavrempfule BeIo[visTl[Rguf[eyaradjoy site Frl�gf7fl�TDIl.' � - It�ce�mpaapi�Ea •PORCY 44 or t 21P4_�1 ' SfBLia�Da� . Job Mte Addres-s: CifglState Tor Adach a copy of the worltere campensa&n.policy deChratian page(showing the policy mmober and expiration date). Faiute tQ Sew caverage as requirednuder Section 25A o€MGL c_M can lead to tfie imposition of criminal penalties of a fine up to$UQQ_OG arWor one-yearimpifionmenk as well as d-vil penalties s[the farm of a STOP WORK ORDERand a ffne , of up tea�S M a dog ab�#fie vifllat m He advised that a copy a£ffiis shatemen maybe fAru►arded to the Office of Investigatiom oft he DIAr.for hisarm=cavetae,verfficaficm- I do ker$by cfffift tinder dig pains tarries t f gef,jury ffatif[a irzfarwa&uprm &d abma is true and correct Phone iF D�962-69yri O RTriai uw a* Do not wrRe in fkb xrar to be cmnpfeted by ciip rsrtP[PH offl-d2l City or Tana: PerndtUcemse f 'Wring Autherhy(drde one): L Board of$ealth r.BuMiNng Deparfinmt 3.#.ity1Pown CClexk 4 Electrical h=pcctuc �.ghnuldng Insl[ettor 6.OSier" , - C'onbKt Person Memo: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Boston,AL4 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'blv Name (Business/OrganmtioniTndividual): — Address: Citv'StateiZip: ,5*X r WSJ M o/SY.r- Phone##: 7 VY— ;2 75' - 0? Are you an employer'Check the 4propriate box: Type of project(required): i.�latn a empiover with I am a general contractor and I 1.• I am a employer with_� . �— 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling These sub-contractors have g• ,1—''Demolition ship and have no employees I v Fvorkina for me in anv capacity. employees and have workers' BiLilding addition: (vo workers' comp.insurance comp.insurance.= 5. Q We are a corporation and its 10.7 Electrical repairs or additions required-] officers have exercised their j 11.Q Plumbing repairs or addition ;.Q I am a homeowner doing all wort: myself. Tlo workers' comp. right of exemption per;VIGL 12.Q Roof repass insurance required.]t c. 152,§1(4),and we have no empioveeg. [-No workers' j 11 'Other comp. insurance required-] I , •.ter.}•apoiicant than checks box 0!must also fill out the section below showing their workers'compe cation policy info ation. Homeowners who submit this affidavit indicating they are doing a0 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-contacwrs and state whether or not those entities have ..mpioyees. a 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 sire infurmatwn. 1.� a f �, /J - r hisurance Company dame: I-/Z>' l V 2 oitli�/ t/N/ot✓ /�`�' �it/S . �a _ Polio #or Self-ins.Lic.#: 1 j ! o Expiration Date: 3 Job Site Address: 17 City/Statei P6��111P 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 u:)to$1,500.00 and/or on -ye imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day agjisl� a lator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DLk - cc coverage verification. I do hereby certify un a ti at the information provided above is to and correct Date: 8' jfr/ Si att;re: Phone?: — Official use only. Do not write in this area,to be completed by city or town offidaL City or Town: Permit'L,icense 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#: l: f f / � P ) elf/� t''l'f�.. �t�r f�C,. 9�[/ r,� (�`4 l.'l'uj�C"r -e--i -._ Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Supplement Card HOME DEPOT USA INC Registration: 112785 9 2455 PACES FERRY RD C-11 HSC Expiration: 04/22/201 ATLANTA,GA 30339 Update Address and return card. Mark reason for change. ❑ Address ❑ Renewa! ❑Employment ❑ Lost Card _- .— Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:SUDDlement Card before the expiration date. If found return to: Registration Expiration , Office of Consumer Affairs and Business Regulation 112785 04i22/2019 10 Park Plaza-Suite 5170 40ME DEPOT USA INC Boston,MA 02116 ANDREW SWEET `� C 2455 PACES FERRY RD C-11 HSC �� U ATLANTA,GA 30339 t Undersecretary d IhOu signature AC R O CERTIFICATE OF LIABILITY INSURANCE D021220018DmYY1 llt. � 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 tieu of such endorsement(s). CONTACT PRODUCER NAME MARSH USA,INC. PHONE FAX TWO ALLIANCE CENTER ArC No 3560 LENOX ROAD.SUITE 2400 E-MAIL ADDRESS: ATLANTA,GA 30326 INSURERS AFFORDING COVERAGE NAIC 0 CN101642069-HaneD-GAW-18-19 INSURER A:Old RepLbic Insurance Co 24147 INSURED THE HOME DEPOT,INC. INSURER B:New Ha hire Ins Co 23841 HOME DEPOT U.S.A.,INC. INSURER C:HomeRisk CaDWe Insurance Company 2455 PACES FERRY ROAD INSURER D: BUILDING C-20 ATLANTA.GA 30339 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: ATL-004353439-16 REVISION NUMBER: 3 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 REOUIREMENT,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 ADD SUB POLICY EFF POLICY EAP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMID MMID A X• COMMERCIAL GENERAL LIABILITY MWZY312717 0310112018 03/01/2019 EACH OCCURRENCE S 9•000•000 CLAIMS-MADE a OCCUR PREMISES Ea occurrence" S DAMAGE TO RENTED 1.LUDE D LIMITS OF POLICY XS r � MED EXP(Any one person) ;S EXCLUDED OF SIR:SIM PER OCC EGENERAL SONAL 8 ADV INJURY S 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: AGGREGATE S 9•DOG.000 X POLICY PRO- LOC DUCTS-COMPIOP AGG S 9,OOC,ODG JECT 5 OTHER: A AUTOMOBILE UABIUTY MWTB312718 03I012018 L 2019 Ea accident)identSINGLE LIMIT S 1.000,000 X ANY AUTO 80DILY INJURY(Per person) S —d OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) S AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED NON-OWNED I S AUTOS ONLY AUTOS ONLY Per accident S UMBRELLA A LIAB OCCUR EACH OCCURRENCE S EXCESS L1AB CLAIMS-MADE AGGREGATE s S DED RETENTION 5 _ B WORKERS COMPENSATION WC014122577(AK,NH,NJ,VT) 03I012018 031012019 X STA PE TUTE ER AND EMPLOYERS'LABILITY WC W4122578(WI) 03/012018 03/012019 5,000,000 YIN N E.L.EACH ACCIDENT S B ANYPROPMEfORIPARTNERIEXECLITNE IN N 1 A ( ) OFFICERIMEMBEREXCLUDED? 5.000.0� (Mandatory in NH) EL.DISEASE-EA EMPLOYE S 0 yes,describe under Continued on Additional Page E.L.DISEASE-POLICY LIMIT S 5,000.000 DESCRIPTION OF OPERATIONS below C Excess Auto 297-1-10011-00.2018 031012018 031012019 Linut. 4•�•� DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 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 Mukherjee ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are rogistered marks of ACORD AGENCY CUSTOMER 1D: CN 101642069 LOC#: Atlanta '4�Ro® ADDITIONAL REMARKS SCHEDULE Page 2 Of 3 AGENCY MARSH USA.INC. NAMED INSUREDTHE HOME.DEPOT,INC. POLICY NUMBER HOME DEPOT U.S.A.,INC. 2455 PACES FERRY ROAD BUILDING C20 CARRIER ATLANTA,GA 30339 NAIC CODE .EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation Continued: Carrier:Indemnity Insurance Company of North America Policy Number.WLR C64783191(AL,AR,FL,ID,IA,KS,KY,i.A,MS.MO.NE,NM,ND,OK,SC,SD,TN,WV,WY) Effective Date:03/01/2018 Expiration Date:03ID112019 IEL).Llmit:S1,000,000 Carrier New Hampshire Insurance Company Policy Number.WC 014122576(DC.DE,HI,IN,MD,MN.MT;NY,RI) Effective Date:03/0112018 Expiration Dale 03(0112019 (EL)Limit:S1,000,000 Carrier:ACE American Insurance Company Policy Number.WCU C64783221 PSI)(AZ,CA,IL.NC,OR,VA,WA) Effective Dale:03ID112018 Expiration Dale:0310112019 (EL)Limit:S1,000,00D SIR:S1,000,000 SIR for the states of AZ,CA,IL,NC,OR,VA,WA Carrier:National Union Fire Insurance Company Policy Number XWC 4595580(OSI)(CO.CT,GA;ME,M1,NV,OH,PA;UT) Effective Date:0310112018 Expiration Date:03101/2019 (EL)Limit:$1,000,000 S1,0D0,000 SIR for the stales of CO,MENV,MI,OH.PA,UT S750,000 SIR for the slate of GA S350,000 SIR for the state of CT Cartier:National Union Fire Insurance Company Policy Number.XWC 4595581.(OSI)'(MA) Effective Date:03101@018 A Expiration Date::03101/2019 (EL)Limit:$1,000,000 SIR:S500,000 TX Employers XS Indemniy. Carriedlinios Union Insurance Company Policy Number.TNS C4916693A(TX) Effective Date:=112018 Expiration Date::0310112019 (EL)Lint:S1110D0,000 SIR:S1.00D,000 A ACORD 101.(2008/01) ©2008.ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD