HomeMy WebLinkAboutMiscellaneous - 70 RALEIGH TAVERN LANE 11/18/2015 i
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PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CEITIULIFICATE
COMPLIANCE
As of: 11/18/15
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
On-Site Complete Repair of an
By: John Shaw
At:
70 Ral,eiuh Tavern Lane
Map 107A Lot 107
North ndover, MA 01845
III WWWII
The Issuance of this(certifi ate shall not be construed as a guarantee that the system.will function satisfactorily.
l n ,
Michele Grant
Public Health Agent
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978,688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
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PUBLIC HEALTH DEPARTMENT
Community Development Division
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System(*4f constructed;( )repaired;
By:---J(m I o� ILL
(Print Name)
Located at: ':20 6 1,6
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
1
;,—-I ; and last revised on ,with a design flow of
'MV gallons per day. The materials used were in conformance with those specified on the
approved plan;the system was installed in accordance with the provisions of 310.CN4R 15.000,Title 5 and local
regulations,and the final grading agrees substantially with the approved plan.All work is accurately represented on
the As-built which has been submitted to the Board of Health.
Bottom of Bed Inspection Date:
Engineer Representat ve(Signature)
And—Print Name
Final Construction Inspection Dater
Engineer Representative( ignature)
;,?
And—Print Name
Si nature Date:
Installer: ( g )
And—Print Name
__
Engineer: ° (Signature) Date: 11 ' A`
And—Print Name
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.6 .9540 Fox 978.688.8476 Web http://www,townofnorthandover.com
TOVM of North Andover — Septip�Sstem a AS-BUILT CHECKLIST
,77,1) All changes to the design plan have been reflected and noted on the as-built plan
2) As built plan has a suitable scale; (I inch= 40 feet or fewer for plot plans)
3) Assessor's Map and Lot Number
Street Address,
4) ---�tLLot Lines and Location of Dwellings served by the system
5) Locations,Elevations and Dimensions of As-built system components,including reserve (if applicable)
6) Ties to all tank openings,d-box,and leach area from dwelling or Permanent Structure
7) Setback distances are shown on the as-built plan from system components to:
dim Subsurface,interceptor&foundation drains
Catch basins
Property lines
Dwellings or other structures
I Private water supply or irrigation wells
I'll
:]�-71,Watercourses or wetlands
8) Locations of Wells,Drains,Wetland Resource Areas within 150 feet of system
9) Location of water,gas,electric lines,cable,control panel (if applicable)
10) Location of Structures within 6 inches of Finished Grade
11) toriginal Stamp &Signature
12) cation and holder of any easements which could impact the system
13) 1 upervious Areas;Driveways,etc
14) /North Arrow
15) Y Location &Elevation of Benchmark used
16) I–STATEMENT ON PLAN (NA 5.3)
a, "I certify the locations, elevations, ties, cover material;exposed component covers etc.,
shown on thisqs-builtsubstalitiql]Ydgree with the approved plan andhave determined that the
break out elevations,Yapplicable,have been inct
Signature of Designer Date
b. "If a STUCTURAL WALL IS PRESEAT( 4. a Letter or statement on the qszb1IJIt indicating
with the intended design and j
the wall- was fl a a
s or was not,constructed in accordance w
manufacturer's specifications.
Signature of Designer Date
Revised 3/17/15
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Map-Block-Lot
107.A0107
Commonwealth of Massachusetts --------------- j
• ,� 1 . I
�f Permit No
BOARD OF HEALTH BHP-2015-0298
North Andover FEE $250.00
----
P.i. _ — —
F.I` ----- `� IT
DISpoSALWORKS Permission is hereby granted 30l???_T•
-------------------------------------
------ - -
Disposal System.an Individual osay .P -------- -- ---
to(Construct) _
LANE __ -"----
July
at No 70 RALEIGH TAVERN _____
--- - 15 029 Dated 0�° ---------
lication for Disp
osal Works Construction Permit No. B�"2 i
as shown on the app -
-------------
BOARD OF HEALTH
Issued On:Jul-08-201
-------------
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Application for Septic Disposal
'�� ���� TODAY'S
Construction Permit ~.�
- TOWN ���
NORTH ANDOVER, MA 01845 $12&6d-Component
Important: Application is hereby made for a permit to:
When filling E] Construct o new on-site sewage disposal system*
forms unthe
computer,use Repair or replace on existing on-site sewage disposal eyotem°
only the tab key
mmov°yvur [] Repair or replace an existing system component—What?
oumu, do not
use the return A. Facility Information
key. �
VQ Address or Lot#
City/Town
*TYPE OF SEPTIC :
> F� rvmp uu Gravity(choose one)
°°1Y pump system, attach copy of electrical permit to application"*
> E] Conventional System (pipe and stone system)
> N Infiltrator or Biodiff user(Gravel-Less) (Attach a copy of your certification to install this type ofayatemj
> Pressure Distribution G.A.8.(No D'Bnx)
> L] Pressure Dosed<D-Bon Present)S.A.S.
);� [] Does the system require an effluent filter? Tem Nn_____
If yes, does plan specify make and model offilter? YES=(no further info. needed)
M/0=(installer must specify brand mf filter before QNCissuance)
Mia t is the Make? Wha t is die Model?
/
2' Owner Information \
Name
Address(if different rom ab6ve)
City/Town State Zip Code
Email address Telephone Number
3. Installer Information
Name Name of Company
Address
City/Town State Zip Code
WTelephone Number(Ceff Phone#if possible please)
.. Desianer Information
Name Name mCompany '
Address
City/Town State Zip Code
Telephone Number(Best#mReach)
Application for Disposal System Construction Permit-Page 1 of 2
Application for Septic Disposal System TODAY'S DATE
Construction Permit — TOWN OF
$250.00—Full Repair
NORTH ANDOVER, MA 01845 $125.00-Component
PAGE 2 OF 2
A. Facility Information continued....
s. Type of Building: Residential Dwelling or❑Cornmercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover. I understand that until a final Certificate of Compliance has been issued by
this Board of Health, the installed system is not approved.
Name Date
�ica ion Appro (Board of Health Representative)
Name Date
Application Disapproved for the following reasons:
For Office Use Only:
L Fee Attached? yes No
2. Project Manager Obligation Form Attached? yes V/ No
3. Pump System?ystem? If so,Attach comp of Electrical Permit Yes No
Applican t-received copy of
"Electrical Inspection Notes for Septic Systems" Yes No
Handout?
4. Revicivedapprovallette-r, all paperwork received? Yes_��/ No
Missing:
5. Foundation As-Built?(new construction only): Yes No
(Same scale as approved plan)
G. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
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SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
2 1e
(G�cdsasa a se ptic systcn,) For plans by
" 0 !�
/ -
(Engineer)
Relative to the application of ✓
(Installer's name) And dated
rlg�rtt cafe
Dated L
(I oday's date) With revisions dated
(Last revised clatter)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans ip•tor to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
2. As the installer,I must call for any and all inspections. If homeowner,contractor,project manager,or any
other person not associated with my company schedules an inspection and the system is not ready,then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection,without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or
my company.
a. Bottom of Bed—Generally, this is the first(1'� inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK(or e-mail to: heal.thde Dt cz>t(>wriofi-iortlxandovei°.com) from the engineer must
be submitted to the Board of Health,after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system,all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade—Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other that simple excavatioir)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover, significant fines to all persons involved are also possible.
5. As the installer,I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board of Health staff or consultant.
d. Installation of tank, D-Box, pipes, stone, vent,pump chamber, retaining wall and other
components.
6. As the installer,I understand that I am solely responsible for the installation of the system as per the
approved plans No instructions by the homeowner,general contractor,or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: ("Today's Date)
1 �
( ani —Print) (Name— .igneC)
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TOWN OF NORTH ANDOVER Permit Number j
NORTH ANDOVER,MASSACHUSETTS 01845
ttaRrH Date Issued
A t o-r1-Dade
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Jackie's Law — Permit Ap ication
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant Z I,, Phone Cell 9 g �g
Street Address A �.3 /-/6/-v /�"
Cityrrown MA ZIP
o / '3
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA I ZIP
Name of Owner(s)of Property &J Phone Cell
Street Address -7c) 1(o le/y/
City/Town MA ZIP
Other Contact Permit Fee Received No Yes
Description,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to
be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed.
yQ 1451
Insurance Certificate##:
Name and Contact Information of Insurer:
Policy Expiration Date:
Dig Safe
Name of Competent Person/�as defined rj 52,0'CMR 7,02):
Ga A✓
Massachusetts Hoisting License# Al C
License Grade: A 4 Exr)*ration Date:
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE
AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE
WORK WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE, TO
WORK PROPOSED,INCLUDING OSHA REGULATIONS,G.L. c, 82A,520 CMR 7.00 et seq.,AND ANY
APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT
AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL
COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW,
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND
THE EXCAVATOR TO UNDERTAICE SUCH WORD ON THE PROPERTY OF THE OWNER, AND
ALSO,FOR THE DURATION OF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY
THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK
FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND
REGULATIONS GOVERING SUCH WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY
TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY
THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED
THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE
LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE
THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC
WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH
INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY
THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY
TO DEFEND,INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS
AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES
RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY
PERSON OR PROPERTY DURING THE WORK_CONDUCTED UNDER THIS PERMIT.
APPLICANT SIGNATURE
DATE
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
21Page
P�RLtiIIT,�P�'•.-R(3:�E_8-.�':� .= ,: _ = .� - -
'€'Eltl�!t�"L'INC� -
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CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND 520 CMR 7.00 et seq.
(as amended)
By signing the application,the applicant understands and agrees to comply with the following:
i.
No trench may.be excavated unless the requirements of sections 40 through 40D of chapter 82,and any
accompanying regulations,have been met and this permit is invalid unless and until said requirements
have been complied with by the excavator applying for the permit including,but not limited to,the
establishment of a valid excavation number with the underground plant damage prevention system as
said system is defined in section 76D of chapter 164(DIG SAFE);
Trenches may pose a significant health and safety hazard. Pursuant to Section 1 of Chapter 82 of the
General Laws,an excavator shall not leave any open trench unattended without first making every
reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said
open trench unattended. Excavators should consult regulations promulgated by the Department of
Public Safety in order to familiarize themselves with the recognized safety hazards associated with
excavations and open trenches and the procedures required or recommended by said department in
order to make every reasonable effort to eliminate said safety hazards which may include covering,
barricading or otherwise protecting open trenches from accidental entry.
iii,
Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety
standards promulgated by the Occupational Safety and Health Administration on excavations:29 CFR
1926.650 et.seq.,entitled Subpart P"Excavations".
iv.
Excavators engaging in any trenching operation who utilize hoisting or other mechanical equipment
subject to chapter 146 shall only employ individuals licensed to operate said equipment by the
Department of Public Safety pursuant to said chapter and this permit must be presented to said licensed
operator before any excavation is commenced;
V.
By applying for,accepting and signing this permit,the applicant hereby attests to the following:(1)that
they have read and understands the regulations promulgated by the Department of Public Safety with
regard to construction related excavations and trench safety; (2)that he has read and understands the
federal safety standards promulgated by the Occupational Safety and Health Administration on
excavations:29 CMR 1926.650 et.seq.,entitled Subpart P"Excavations"as well as any other
excavation requirements established by this municipality;and(3)that he is aware of and has,with
regard to the proposed trench excavation on private property or proposed excavation of a city or town
public way that forms the basis of the permit application,complied with the requirements of sections 40-
40D of chapter 82A.
vi.
This permit shall be posted in plain view on the site of the trench.
For additional information please visit the Department of Public Safety's website at www.mass.aov/dps
__ __..w._.._.--._._.,._._......,_,..__........_-.. .... _._ .___--.__--_ _-----....------- ------- — ----------
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Summary of Excavation and Trench Safety,Regulation(520 CMR 14.00 et sea.)
This summary was prepared by the Massachusetts Department of Public Safety pursuant to G.L.c.82A and does not
include all requirements of the 520 CMR 14.00. To view the full regulation and G.L.c.82A,go to www/mass.gov/dps 1
Pursuant to M.G.L. c. 82, § 1, the Department of Public Safety,jointly with the Division of Occupational Safety,
drafted regulations relative to trench safety. The regulation is codified in section 14.00 of title 520 of the Code of
Massachusetts Regulations. The regulation requires all excavators to obtain a permit prior to the excavation of a
trench made for a construction-related purpose on public or private land or rights-of-way, All municipalities must
establish a local permitting authority for the purpose of issuing permits for trenches within their municipality.
Trenches on land owned or controlled by a public(state)agency requires a permit to be issued by that public agency
unless otherwise designated.
In addition to the permitting requirements mandated by statute, the trench safety regulations require that all
excavators,whether public or private,take specific precautions to protect the general public and prevent unauthorized
access to unattended trenches. Accordingly,unattended trenches must be covered,barricaded or backfilled. Covers
must be road plates at least 3/a"thick or equivalent;barricades must be fences at least b'high with no openings greater
than 4" between vertical supports; backfilling must be sufficient to eliminate the trench. Alternatively, excavators
may choose to attend trenches at all times,for instance by hiring a police detail,security guard or other attendant who
will be present during times when the trench will be unattended by the excavator.
The regulations further provide that local permitting authorities,the Department of Public Safety,or the Division of
Occupational Safety may order an immediate shutdown of a trench in the event of a death or serious injury;the failure
to obtain a permit; or the failure to implement or effectively use adequate protections for the general public. The
trench shall remain shutdown until re-inspected and authorized to re-open provided, however,the excavators shall
have the right to appeal an immediate shutdown. Permitting authorities are further authorized to suspend or revoke a
permit following a hearing. Excavators may also be subject to administrative fines issued by the Department of
Public Safety for identified violations.
Summary of 1926 CFR Subpart P-OSHA Excavation Standard
This is a worker protection standard,and is designed to protect employees who are working inside a trench. This
summary was prepared by the Massachusetts Division of Occupational Safety and not OSHA for informational
purposes only and does not constitute an official interpretation by OSHA of their regulations,and may not include all
aspects of the standard.
For further information or a full copy of the standard go to www.osha.gov.
Trench Definition per the OSHA standard:
• An excavation made below the surface of the ground,narrow in relation to its length.
• In general,the depth is greater than the width,but the width of the trench is not greater than fifteen
feet.
® Protective Systems to prevent soil wall collapse are always required in trenches deeper than 5',and are also
required in trenches less than 5'deep when the competent person determines that a hazard exists. Protection
options include;
o Shoring. Shoring must be used in accordance with the OSHA Excavation standard appendices,the
equipment manufacturer's tabulated data,or designed by a registered professional engineer.
o Shielding(Trench Boxes). Trench boxes must be used in accordance with the equipment
manufacturer's tabulated data,or a registered professional engineer.,
o Sloping or Benching. In Type C soils(what is most typically encountered)the excavation must
extend horizontally 1 '/z feet for every foot of trench depth on both sides, 1 foot for Type B soils,
and%foot for Type A soils.
o A registered professional engineer must design protective systems for all excavations greater than
20'in depth,
continued
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• Ladders must be used in trenches deeper than 4'.
o Ladders must be inside the trench with workers at all times,and located within 25'of unobstructed f
lateral travel for every worker in the trench.
o Ladders must extend 3'above the top of the trench so workers can safely get onto and off of the
ladder.
• Inspections of every trench worksite are required:
o Prior to the start of each shift,and again when there is a change in conditions such as a rainstorm.
o Inspections must be conducted by the competent person(see below).
• Competent Person(s)is:
• Capable(i.e.,trained and knowledgeable)in identifying existing and predictable hazards in the
trench,and other working conditions which may pose a hazard to workers,and
• Authorized by management to take necessary corrective action to eliminate the hazards. Employees
must be removed from hazardous areas until the hazard has been corrected.
• Underground Utilities must be:
• Identified prior to opening the excavation(e.g.,contact Dig Safe).
• Located by safe and acceptable means while excavating.
• Protected,supported,or removed once exposed.
• Spoils must be kept back a minimum of 2'from the edge of the trench.
• Surface Encumbrances creating a hazard must be removed or supported to safeguard employees. Keep
heavy equipment and heavy material as far back from the edge of the trench as possible.
• Stability of Adjacent Structures:
• Where the stability of adjacent structures is endangered by creation of the trench,they must be
underpinned,braced,or otherwise supported.
• Sidewalks,pavements,etc.shall not be undermined unless a support system or other method of
protection is provided.
• Protection from water accumulation hazards:
• It is not allowable for employees to work in trenches with accumulated water. If water control such
as pumping is used to prevent water accumulation,this must be monitored by the competent person.
• If the trench interrupts natural drainage of surface water,ditches,dikes or other means must be used
to prevent this water from entering the excavation.
« Additional Requirements:
• For mobile equipment operated near the edge of the trench,a warning system such as barricades or
stop logs must be used.
• Employees are not permitted to work underneath loads. Operators may not remain in vehicles
being loaded unless vehicles are equipped with adequate protection as per 1926.601(b)(6).
• Employees must wear high-visibility clothing in traffic work zones.
• Air monitoring must be conducted in trenches deeper than 4'if the potential for a hazardous
atmosphere exists. If a hazardous atmosphere is found to exist(e.g.,Oz<19.5%or>23.5%,20%
LEL,specific chemical hazard),adequate protections shall be taken such as ventilation of the space.
• Walkways are required where employees must cross over the trench. Walkways with guardrails
must be provided for crossing over trenches>6'deep.
• Employees must be protected from loose rock or soil through protections such as scaling or
protective barricades.
5 Page
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circle Insurance Fax;918-X11-488 Jul Z01� 09 �8ai� Pa011031E{MM/DDYYYY)
CERTIFICATE LIABILITY ITY` INSURANCE
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THIS-CERTIFICATE= IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO (RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERTIFICATE DOES NOT AFFIIRMATIVElY 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 ADL)ITIONAL INSURED, the poliey(iee) must be endorsed, If SUBROGATION 15 WAIVED, Subject to
the terms and conditions of the policy,certain policies may require an endorsemrint. A statement on this certificate does not Confer rights to the
certifilcate holder in lieu of such DndorseMent(s).
PRODUCER CONTACT
NAME: _
CizclO Business Ins. Aquy, Inc PHONE -� FAUX
247 Newbury Street a NG,F3lQ} (Afti No 1
dnae66;
Danvers, MA 01923 INSURERS)AFPQRDING COVERAGH NAlc A
,iNsuRcRA,'Xravelers Insurance 2567,4
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INSURED INSUREt`i; �._��-.�--,._ —
Wildwood Exoavation Inc, INSURER rT
233 HQ1t Road IN URER p
Andover, 1A 01810 INSURER Et: -- -
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: '
THIS IS TO CERTIFY THAI'THE POLICIES OF INSURANCE LISTED BELOW HAVE BEFN ISSUED Yt7 THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT QR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTINCATE MAY BE ISSUED OR MAY Pl!�RTAIN,THE INSURANCE AFFOR05D 13Y THE POLICIES DESCRIBED HEREIN IS SUQJCCT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN R50LICFD BY PAID CLAIMS,
INI.N _-._,_.__.., ADDL5UBR..._...--.--...__..,. Pt�'LTCY
LTR TYPE OP INSURANCE WV POLICY NUMBER M1+,GlDAIYYYY MMIDDIYYYY LIMITS
A GENERALUABILITY Y' 6802174)3508 5/21/�S� 5/21/16 EACHOCOURRENCE I,OOt7,OOQ
COMMERCIAL OGNEMLUABILITY r DANAGE'I'O RENTED
�� $ 300.000
CLAIMS-MADE L X OCCUR 1 MLD EXP(AnyTrr3 I?ersd5) 3 � Jr:�0Q
PERSONAL&ADVINJURY S 1,_Q 9_0 �QQ
CENERALAGCREGA''E S 2,000 000
\,d,,EN'LAOGREGAT_ELIMITAPPUE$PER PRODUCTS-COMPIOP AGO
}{ POLICY PRO; LOC S
A. AUTOMOBILELtAEIUTY �* rrA�175�32� 6/23/19 6/23/1G `Eos�oldeD)INGL
ANYAUTO BODILY INJURY(Per pareon) $ 250 QQQ
AUTOS
ALLOWW;D SCHEDULFI)
$ DOD)LY INJURY Tor acciduni) ) 5500x000
NON-OWNED PR.. .. DAMAGE
HIREbAUros _AUTOS {Poraoci hi) 100 000
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UMBRELLA LIAO OCCUR EACH OCCURRENCE A
EXCESSLIAB CL_AIMS•MAOE A0GREGATE `G
DRQ RETENTIONS p
A WORKERS COMPENSATION .$$ � 6/7/1$ Ci/7/16 W1i STATU- OTII-
AND EMPLOYERS'LIABILITY Y J W I:O]iY_LIMI,T,S TI-1-
ANY PROPRIGTORIPAI�'tNER1EXECUTNG E.L.EACII ACCjQENI' 1dd,X00
Orr=-RIMEMBER EXCLUDED? �I NIA S --
(Mamatory in NH) Ems_ pi$E6se-m EMP Lay EC s 100,000
11p 1worlbeunder -
DES'RIPTIONOFOFERATIONShnlnw GI_.DISF.ASE-POLICY LIMIT F 500,000
DL•SCRIP'IYON OF OPERATIONS l LOCATIONS 1 VEHICLES (Attach A00RD 147,Ad!lllfddal Rormrks Seltodule,lrxoea space Is Ta 0 red)
CERTIFICATE HOLDER CAN.CE',LATION
SHOUG)ANY 4F THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EiIPIRATION DATE THEREOF, N4TIQE WILL BE DELIVERED IN
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