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31B-006 (8) 49 ROUND HILL RD BP-2017-0368 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block:318-006 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: demolition BUILDING PERMIT Permit# BP-2017-0368 Project# JS-2017-000611 Est. Cost: $110000.00 Fee: $300.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CHARLIE ARMENT TRUCKING INC 017764 Lot Size(sq.II.): 101930.40 Owner: CLARKE SCHOOL FOR THE DEAF ROGERS HALL HUBBARD HALL Zoning: URC(100)/ Applicant: CHARLIE ARMENT TRUCKING INC AT: 49 ROUND HILL RD Applicant Address: Phone: Insurance: 47 WAREHOUSE ST (413)739-8431 Workers Compensation S P RI NG F I E LD MA01118 ISSUED ON:9/19/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:DEMO BUILDING, REMOVE DEBRIS & LEVEL SITE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 9/19/2016 0:00:00 $300.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner INN 1/43`-‘ f1/4% Version).7 Commercial Building Permit May 15, 2000 / �raN) 5 Department use only �V .� •Ity of Northampton Status of Permit: Q` , Building Department Curb Cut/Driveway Permit C41 212 Main Street Sewer/Septic Availability n � ._ Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plat/Site Plans Other Specify APPLICATION TO CONSTRUCT,REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: 7 01 This section to be completed by office `! ( 20.JJ All , Map Lot Unit Zone Overlay District --- - -- - ' Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Mnr fhSnv Name(Print)/o///cgbaYt_ c—eiaf'1E--19 rirtvki, n Current Mailing Address Signature 2 te 71--' Telephone 2.2 Authoriz/� Agent: C. w4ce �treWel T Ir. tl2 k tJl .se 5041 rt Name(Print) Current Mailing Address Y13- 931-th9i fi3-02$161/2.1 Signature / -, � Telephone SECTION 3-ESTIMATED CO TRUCTION COSTS Item Estimated Cast(Dollars)to be Official Use Only completed by permit applicant 1. Building ; (a) Building Permit Fee 2. Electrical - (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4 Mechanical(HVAC) --- --5. Fire Protection _ — ... 6. Total=(1 +2+3 +4+5) -OM 000, r`r Check Number a�/lol/7q )O This Section For Official Use Only Building Permit Number Date /., Issued Signet 9/ /9-/c B r g Comminno�uildings Date Versionl.7 Commercial Building Permit May 15,2000 1 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations 0 Existing Wall Signs Er Demolition❑ Repairs 0 Additions ❑ Accessory Building 0 Exterior Alteration ❑ Existing Ground Sign 0 New Signs 0 Roofing❑ Change of Use❑ Other 0 Brief Description Enter a brief description here. Of Proposed Work: (\� 11-Mn Bait 207125_,,_ C.nlwc.(J 1%5 th...bet,/ s, _.... SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) I CONSTRUCTION TYPE A Assembly ❑ A-1 0 A-2 0 A-3 0 1A J ❑ A-4 0 A-5 0 1B 0 B Business ❑ 2A ❑ E Educational ❑ 2B 0 F Factory ❑ F-1 0 F-2 ❑ 2C 0 H High Hazard 0 3A 0 I Institutional ❑ I-t ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile 0 4 ❑ R Residential ❑ R-1 0 R-2 0 R-3 ❑ 5A 0 S Storage ❑ 5-1 ❑ S-2 ❑ 5B ❑ U Utility 0 Specify: : M Mixed Use ❑ Specify. S Special Use ❑ Specify. COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS ANDIOR CHANGE IN USE Existing Use Group Proposed Use Group Existing Hazard Index 780 CMR 34) _ Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 3rd _. . 37' ..._. ...... . . 4in Total Area (sf) Total Proposed New Construction(sf) Total Height(n) Total Height H 7.Water Supply(M.G.L. c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone.:__..... ... . Outside Flood Zone❑ Municipal ❑ On site disposal system Version).7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L ..' R _. L It Rear Building Height --- Bldg. Square Footage - Open Space Footage Va _ (Lot area minus bldg&paved ' parking) #of Parking Spaces - _I Fill: (volume&Location) _... A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW O YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q YES 0 IF YES: enter Book Page and/or Document ft B. Does the site contain a brook, body of water Cr wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading, excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre, YES 0 NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version)7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES -FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable 0 Name(Registrant): ... . _. .. ...... .. Registration Number Address _ .... _.. Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number it Signature Telephone Expiration Date Name Area of Responsibility... Address .._ Registration Number ....... . Signature Telephone Expiration Date Name _. . _.._ Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor ..._ _... Not Applicable Company Name. _. Responsible In Charge of Construction Address ..._.. Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) f� Independent Structural Engineering Structural Peer Review Required Yes 0 No 0 SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. ,as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work authouzed by this building permit application. Signawro or Owner Date SinISIC- I, .. ... __.... , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name _. .. ... Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction(Supervisor: Not Applicable 0 Name of License Holder encovi.. 03'Cl/)e License Number Address ...... Exaraoo Date VC-02 //2J., Signat • Telephone SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.162,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the dental of the issuance of the building permit. Signed Affidavit Attached Yes 0 No v • The Commonwealth of Massachusetts x - Department of Industrial Accidents x=�l' Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information yy.� Please Print Le2ibly (( �t 1n ( Name (Business/Orga'nizlation/Individual): kJ-tie 64111313jek if Address: V7 t^�6 1c. S t— ,/ City/State/Zip: , di . Phone#: — 1)3 - P)? Are you an employer?Check the appropriate box: Type of project(required): 1.VI am a employer with ))._ 4. ] ram a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have S. �ernolition working for me in any capacity. employees and have workers' 9. I Building addition [No workers' comp.insurance comp. insurance.( required.] 5. n We are a corporation and its 10.E I Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t e. 152, §1(4),and we have no 13.❑ Other employees- [No workers' comp. insurance required.] 'Any applicant that checks box#1 must also 011 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 contactors must submit a new affidavit indicating such. tcontrectors 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:'7Ydm +k„ Policy#or Self-ins. �Lic.#: I(e/Eta WO P23 AM Expiation Date: � / £ 7 Job Site Address: l 1X& �i 1441-0.. City/State/Zip: /1ti ap/aa 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$259.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of e DIA for insurance coverage verification. Ido hereby ce i //'uncle th pains m penalties of pedal),that the information provided above is true and correct. Signature: (� 6..y Date: 9�i5/i Phone#: 713- calYk/I .a Official use only. Da 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#: • City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: 1// an) Arlt Pd. The debris will be transported by: l `C{�;, 4 w���,�, The debris will be received by: ydir_ Building permit number: Name of Permit Applicant ! 4 1 ,t- /yc (;i4„ Date Signature of Permit Applicant Columbia Gas of Massachusetts A NiSource Company 995 Belmont Street Brockton,MA 02301 Date: September 15, 2016 To Whom It May Concern: The address listed below has had the gas service(s) disconnected and is now ready for demolition. ADDRESS : 49 Round Hill Rd TOWN : Northampton STATE : Massachusetts Sincerely, Heather Meunier Integration Center Columbia Gas Of Massachusetts 508 580 0100 Ext 1342 '..... PT HRM',o CITY OF NORTHAMPTON,MASSACHUSETTS i DEPARTMENT OF PUBLIC WORKS �, _ L if 125 LOCUST STREET N: t'^'�" NORTHAMPTON, MA 01060 �'� 413-587-1570 FAX 413-587-1576 Donna Lascaleia Director September 14,2016 Louis Hasbrouck, Building Inspector Municipal Office Annex 212 Main Street Northampton, Ma 01060 Dear Mr. Hasbrouck: The water service at#49 Round Hill Road has been disconnected from the city water supply and the water meter has been removed from the premises as of September 14,2016. Please contact me if you have any questions. Sincerely, Andrew Dunn Superintendent of Water Cc: Donna Lascaleia, Director of Public Works David Veleta, City Engineer 9/16/2016 City of Northampton Mail-FW:EXT II Rogers Hall 49 Round HiII Road a lir;' orthanw ,1ci 1P Louis Hasbrouck<lhasbrouck@northamptonma.gov> :11ton74 FW: EXT 11 Rogers Hall 49 Round Hill Road 1 message Derose, Joanne Y. <Joanne DeRose@nationalgrid.com> Fri, Sep 16, 2016 at 11:09 AM To: Louis Hasbrouck <Ihasbrouck@northamptonma.gov> Hi Louie, The local supervisor has indicated that we did disconnect power to the Rogers Hall building the night of the fire. Please continue to work with Customer Fulfillment to ensure the proper demolition paperwork is submitted to our company for certainty. Regards, Joanne From: Normandin, Peter J. Sent: Friday, September 16, 2016 10:56 AM To: Derose,Joanne Y. Subject: Re: EXT 11 Rogers Hall 49 Round Hill Road Yes we did Primary taps were lifted on the street we could not get to the riser pole that night Sent from my iPhone On Sep 16, 2016, at 10:42 AM, Derose, Joanne Y. <Joanne.DeRose@nationalgrid.com> wrote: Hi Pete, Louie is working with Customer Order Fulfillment to complete the demo request form. In the meantime, can you confirm for me that we disconnected the power to the building when the fire was reported? Thanks, Joanne 1 J/mal.gooijaccm/mail/ca/WMui=28ik=ec5(19x5/e8vicw=pMseerch=inbox8ih=15]338be266868248simI=15/336be26a86824 1/3 W16/2016 City of Northampton Mail-FW:EXT I Rapers Hall 49 Round Hill Road From: Louis Hasbrouck [mailto:lhasbrouck@northamptonma.gov] Sent: Friday, September 16, 2016 10:35 AM To: Derose, Joanne Y. Cc: Meghan Cahill Subject: EXT I I Rogers Hall 49 Round Hill Road Joanne, Rogers Hall, the building at 49 Round Hill Road in Northampton, was destroyed by fire on August 5, 2016. At the request of the Northampton Fire Department, a National Grid line crew disconnected the power to the building the night of the fire. IVe issued an order to demolish the building. The building code requires verification that utilities have been shut off and secured. Can you provide verification that the power to this building has been disconnected so demolition can proceed? Thank you. Louis Hasbrouck Building Commissioner City of Northampton Town of Williamsburg (413) 587-1240 office (413)587-1272 fax This e-mail, and any attachments are strictly confidential and intended for the addressee(s) only. The content may also contain legal, professional or other privileged information. If you are not the intended recipient, please notify the sender immediately and then delete the e-mail and any attachments. You should not disclose, copy or take any action in reliance on this transmission. You may report the matter by contacting us via our UK Contacts Page or our US Contacts Page (accessed by clicking on the appropriate link) Please ensure you have adequate virus protection before you open or detach any documents from this transmission. National Grid plc and its affiliates do not accept any liability for viruses. An e-mail reply to this address may be subject to monitoring for operational reasons or lawful business practices. For the registered information on the UK operating companies within the National Grid group please use the attached link: http://www.nationalgrid.com/corporate/legal/registeredoffices.htm httpsl/mal.gooye.com/mail/caMOPui=28ik=ec5f19a57e8view=p[8search=inbon8ih=157338be26a8E8248sim1=15/338be26386824 2/3 City of Northampton T S20 Massachusetts aiaiF Din Su\ OF BUILDING INSPECTIONS 212 Naim Street a Micipal Building J ,i7212 Northampton, MA 01060 INSPECTOR James Hebert Michael Siddall Historic Round Hill Summit LLC 1776 Main Street Springfield, MA 01103 September 12, 2016 Re: Rogers Hall 49 Round Hill Rd. Dear Mr. Hebert and Mr. Siddall, The survey of Rogers Hall on September 8 2016 concluded that Rogers Hall presents serious risk to public safety and cannot remain in its current state. I have included a copy of that survey. I have received a report from your architect stating that the building cannot be made weather tight and therefore cannot be made structurally stable. I agree with the architect's conclusion. I am ordering that the building be demolished as soon as possible in accordance with my order dated August 24 2016. A copy of that order is also included. You may appeal this order in accordance with M.G.L. 139 section 2. Respectfully Louis Hasbrouck Building Commissioner City of Northampton (413)587-1240 I hasbrouck©northampton ma.goy CC: Northampton Fire Department, Northampton Police Department, Northampton DPW, Mayor of Northampton, Northampton Office of Planning, Crocker Builders City of Northampton Massachusetts -fs�- � I` 4, DEPARTMENT OF BUILDING INSPECTIONS i `'�` - 212 Main Street • Municipal Building n� 'aC Northampton, Q. 01060 .y4��c James Hebert Michael Siddall Historic Round Hill Summit LLC 1776 Main Street Springfield, MA 01103 Re: Rogers Hall, 49 Round Hill Road September 8, 2016 Survey Report concerning the structure at 49 Round Hill Road in Northampton Rogers Hall, 49 Round Hill Road in Northampton suffered significant damage as a result of a fire on August 5, 2016. In accordance with M.G.L 143 section 8, Fire Chief Duane Nichols, City Engineer David Veleta, Andrew Crystal from O'Connell Development Group (acting as a disinterested person) and Building Commissioner Louis Hasbrouck surveyed the building on September 8, 2016. We have determined that structural damage is so extensive that the building presents a serious risk to public safety and cannot remain in its current state. Based on our survey, the board has determined that the building must be made safe or removed. In order to make the building safe, it must be made structurally stable. In order to protect the exterior brick walls and other structural elements, the building must be made weather tight. If the building cannot be made stable and weather tight, it must be demolished. Please provide a plan of action on Monday, September 12, 2016.Work must commence on or before Tuesday, September 13, 2016. You must submit a permit application for any work on the building as soon as possible. Since work must begin by Tuesday, the building department will issue an emergency permit on Monday. Respectfully Louis Hasbrouck David Veleta Building Commissioner City Engineer Andrew Crystal Duane Nichols O'Connell Development Fire Chief CC: Mayor of Northampton, City Solicitor, Office of Planning and Sustainability Clientlk 17303 CHAARI ACORD-. CERTIFICATE OF LIABILITY INSURANCE DATE IMMTDDmYY1 9/19/2016 THIS CERTIFICATE 15 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 ADDI11ONAL INSURED,the policylies)must be endorsed./!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 Kathy T.P.Daley Insurance Agcy,Inc (ACNE --788- - --_- 1381 Westfield St. IAk.No,BRE 413 endale 1 e,co co) 413 739-2645-- ADMDAResS. kathleendaley@tpdaleyinsruance,Com P.O. Box 1150 wsuRERISIAFFORDING COVERAGE NAme West Springfield,MA 01090 INSURER AScottsdale Insurance INSURED INSURER B.Travelers Indemnity Co. • Charlie Arment Trucking,Inc. mouse Safety Insurance Group - 47 Warehouse Street - -- — -- -- Springfield,MA 01118 INSURER INSURERS 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 Vr4ICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS MID CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EFF LIR TYPE OF INSURANCE AWL SUER POLICYPOLICY EXP 1- _-.. INss Wm POLICY NUMBER _. (MMm ) lMMNDY/YYI LIMITS_. _ A GENERAL CAECA' CPS2361299 01131/2016 01/31/20171/v.:, jiiciPPi0P0 - ;100,000 -c=TE e2,000,000 -L- - - -EVE 1,000,000 IE L- X E III - • C AUTOMOBILE LIABILITY 1 COM055055601 01(31201601131/2017 c--- - ;1,000,000 X - X /vet.- X A X UMBRELLA UAE X XLS0098777 01/312016 01/31/20171 - _-_ /5,000,000 EXCESS LIAB [. b 5000000 -__ XirE:viIK::10000 { _ B WORKERS AMENYNj 6HUB4951P33A16 01/311201601/31/2017 X ';,I D EMPLOYERS' m x1,000,000 (Mandatory InILLI) N N A J•.F 1,000,000 DESCRIPTION OF OPERATIONS r LOCATIONS i VEHICLES(Attach A CORD 101 Additional Remarks Srnmwe s more space is resumed) General Certificate CERTIFICATE HOLDER CANCELLATION City of Northampton Building SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EYBIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Dept. ACCORDANCE WITH THE POLICY PROVISIONS. City Hall,210 Main Street Northampton,MA 01060 AUTHORIZED REPRESENTATIVE .0•CaJ/ Q0./L. 19888010 ACORD CORPORATION.All rights reserved. ACORD 812010/05) 1 of 1 The ACORD name and logo are registered marts of ACORD #5132295/M126404 KJD