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31D-151 (13) 7 OLD SOUTH ST-APT 5 BP-2017-0616 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:31D- 151 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:Bath reno BUILDING PERMIT Permit# BP-2017-0616 Project# JS-2017-000919 Est.Cost: $5000.00 Fee:$100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: P&B NEW ENGLAND SERVICES LLC 109528 Lot Size(sq.ft.): 10890.00 Owner: HAMPSHIRE PROPERTY MANAGEMENT Zoning:C13(100)/ Applicant: P&B NEW ENGLAND SERVICES LLC AT: 7 OLD SOUTH ST -APT 5 Applicant Address: Phone: Insurance: 47 COATES RD (413) 650-6010 WC L EYD E N MA 01301 ISSUED ON:11/2/2016 0:00:00 TO PERFORM THE FOLLOWING WORILDEMO CEILING REPLACE SHOWER, VANITY/MOVE ELECTRICAL CONDUIT 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: Housea Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: OI: 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 11/2/2016 0:00:00 $100.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0616 APPLICANT/CONTACT PERSON P&B NEW ENGLAND SERVICES LLC ADDRESS/PHONE 47 COATES RD LEYDEN (413)650-6010 PROPERTY LOCATION 7 OLD SOUTH ST-APT 5 MAP 31D PARCEL 151 001 ZONE CB(I00)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid ( j 6U Building Permit Filled out l Fee Paid Typeof Construction: DEMO CEILING REPLACE SHOWER,VANITY/MOVE ELECTRICAL CONDUIT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 109528 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: dd./Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management I- hatDela r amre of I uil ""-g a"ficial Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. —1 Versionl.7 Con-micraal Building Permit May 15,2000 Department use only 1 City of Northampton Status of Permit by I Building Department Curb Cut/Driveway Permit - =� 212 Mein Street Sewer/Septic Availability W L _ _ Room 100 ater/Well Availability - "' s N rthampton, MA 01060 Two Sets of Structural Plans - pJ5one 413-587-1240 Fax 413-587-1272 Plot/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 This section to be completed by office 1.1 Property Address 7 Old so LA.„ st r« apt- 0 M6 Map Lot Unit `•)0005Ar+P itn ) Ha. Zone Overlay District - - -- - — -- -- Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ,3"'‘.0 )pG Pa G$(a L&(1 a m ol06I Name(Print) Current Mailing Address: I L113 45% G6)0 Signature Telephone 2.2 Authprt2aAAgent. ,. PoBo (08(0_, Nor-thcimptm. mg- Nola Name(Print) Current ding Address 10:13 (aSD-Q201.0 Signature le . A S Si . / i'/ Telephone SECTIr-N 3- TIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building tki)0 U 0 (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing V 7 i 0V11 Building Permit Fee 4. Mechanical(HVAC) �Ov-- /4 6 5-Fire Protection gi/ 6. Total=(1 +2+3+4+ 5) MUD13 Check Number //� 4NNThis Section For Official Use Only Building Permit Number Date Issued Signature'. Building Commissioner/Inspector of Buildings Date • Vet Non! Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations 0 Existing Wall Signs 0 Demolition 0 Repairs 0 Additions ❑ Accessory Building 10 Exterior Alteration ❑ Existing Ground Sign D New Signs D Roofing Change of Use❑ Other 0 Brief Description Enter a brief description � �[ here. UN/f/�� / Of Proposed Work: no CG``MS �RCc S4'4� 7 urn" mo V E Q�b,/ condo SECTION 5-USE GROUP AND CONSTRUCTION TYPE TTT USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 IDA-3 ❑ 1A ❑ A-4 0 A-5 0 1B ❑ B Business 0 2A 0 E Educational ❑ 2B ❑ F Factory 0 F-1 ❑ F-2 ❑ 20 ❑ H High Hazard 0 3A ❑ I Institutional ❑ I-1 ❑ 1-2 0 1-3 ❑ 3B 0 M Mercantile ❑ 4 _❑ R Residential 0 R-1 0 R-2 0 R-3 0 5A ❑ S Storage ❑ S-1 ❑ S-2 0 5B ❑ U Utility ❑ Specify M Mixed Use ❑ Specify S Special Use ❑ Specify _.. _. _. .... COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: . _.... - Proposed Use Group: Existing Hazard Index 780 CMR 34) Proposed Hazard Index 790 CMR 34): _.. SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1s _. ..._ .. _.. 2nd .. _... 3m 3re Total Area(sf) Total Proposed New Construction(sf) Total Height(ft) - Total Height ft 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 systems Versionl 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 Name(Registrant)'. Registration Number Address _.. Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsib l ty Address Registration Number Signature Telephone Exp raton 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 pY R UE ' EP(rLAV? Sep) I(,E5 LL Not Applicable Company Name Responsible In Char e of Construction `17 Co aces /.� s (zovpev,r14 ' I Addr ..�-- (713)77z-9101' Signature Telephone Version1.7 Commercial Budding 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 Fror.t Side L: R L R. Rear _ ..__. Budding Height Bldg. Square Footage Open Space Footage _.. . % ._._.._ .. (Lot area minus bldg&paved --- parking) #of Parking Spaces (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW ® YES Q IF YES: enter Book Page and/or Document B. Does the site contain a brook, body of water or wetlands? NO CK DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO Q IF YES, describe size, type and Location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0 IF YES, describe size, type and location E. MII 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 Q NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Version l.7 Commercial Building Permit May 15, 2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes O No O SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ,as Owner of the subject property hereby authorize . _ . to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of owner ^ ,�,�.L ' `Q 1 �r�J��p //�/���./ /1Q� Date I,i `�J r1r\ y.., \- 1/�.�I 4??F-•-"� er„ ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are truesnd accurate,to the best of my knowledge and belief. Signed under the pains and penalti- .f perjury. '� • tpt t SPD O _ )Qk]r[t�0_1�Y1xt 4 Lr ]� Pri tName Si.•. . ati.wner/Agent C Date CTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: p Not Applicable 0 Name of License Holder 56'r�% F.-._. CS'l0/3zifi. License Number Conies " COnD !c ype ( 014, 013°1 Mc- 105959 Addres Expiration Date YD72 9/0f 0-7/66/ tog —ccL Signature Telephone o7/ietlFC' 'zoi^ - ( SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152,§25C(6)) / I'` Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes g) No 0 The Commonwealth of_Massachusetts _ Department of Industrial Accidents I;fit - Office of Investigations rir i _• 600 Washington Street Boston,MA 02111 www.nzass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): TlSn N`) 6M3) se )flCEs UL Address: I) 63+I Qogil z )E-S3, 4nat) p City/State/Zip: D iia) Phone#: 3 771-y'id 1 Are you an employer?Check tie appropriate box: Type of project(required) I.[�I am a employer with 3 4. ❑ I am a general contactor and I employees (full and/or part-time).* have hired the sub-contactors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. X Remodeling ship and have no employees Those sub-contractors have S. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp.insunnce.t required.] 5. 5 We are a corporation and its ]o, Electical repairs or additions 3.❑ I am a homeoumer doing all work officers have exercised their 11.X Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.5 Roof epahs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' li.❑ Other comp.insurance required.] *Any applicant that checks box.1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tConvactors that check this box must attached an additional sheet showing the nam 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. Iain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. TS- 1411g I>7 ERS r Insurance Company Name: T Yoe1J � / n1",WL Policy#or Self-ins.Lic. #. 'S(Douai' fN Expiration Date: 6 y'v L011 • • Job Site Address: 7 aEP SOz Sk+ak- City/State/Zip: '.Jpi'{itrn'of kV. ONO 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 font of a STOP WORK ORDER and a fine o: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. Ido hereby certify d' pains and penalties of perjury that the information provided above is true and correct. Signature' - ,�'- Date: " Z4 10 Phone#: 11VI3) PL-R/61 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): I.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: IOM Sootk /004174areen [14-. 0IOG0 The debris will be transported by: Pr'd A.J. 6. 31-70 ILES (-LG. The debris will be received by: V pLLE r L yr 11 Building permit number: V Name of Permit Applicant S4,t, r Pi tt.et /1/6 /US/u E 4 LA-U P Sc701 KU tic. Date Signature of Permit Applicant P&B New England Services LLC. 47 Coates Road Leyden. MA. 01301 - (413)772-9109 servingnewengland@gmail.com October 25, 2016 I request that you grant a modification to waive the requirement for control construction for the ceiling and bathroom update project at 7 Old South Street Apt. #5 in Northampton because the work is of a minor nature,will not affect health, accessibility, life, and fire safety, or structural requirements and is impractical in that the cost of control construction is considerable when compared to the cost of the proposed work.Thank you for your consideration. "Mass Amendments, sections 107.1 allows for an exclusion from control construction for this project" Respec , Shane Parker P&B New England Services LLC. 47 Coates Road Leyden, MA.01301 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(WaVIDNY'Y) L./ 10/26/2016 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: H the certificate holder is an ADDITIONAL INSURED,the policypes)must be endorsed. N SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may requite an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER XRMHEtCT Kathy Pols sant Blackmer Insurance Agency Inc PHONE (413)625-6527 FAX .013)625-5210 1147 Mohawk Trail ADDRESS:kathyQblackmers.com INSURER'S)AFFORDING COVERAGE NMC; Shelburne MA 01370 INSURER AGM Insurance Company 14788 INSURED INSURER B: _ P 6 B New England Services LLC INSURER C; INSURER D: 41 Coates Rd INSURER E: i Leyden MA 01301 INSURERF; COVERAGES CERTIFICATE NUMBEROL only 2016 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 SHOVM MAY HAVE BEEN REDUCED BY PAID CLAIMS. L TR TYPE OF INSURANCE IVOR ADOL�/Vap POLICY NUMBER ISDN n le Y LIMITS $ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 A CLAMS-MADE X OCCUR 1 PREMISES(Ey� oel S 500,000 MPE;W;V t/1/2016 j 1/14/2017 AED EXP(Any one person) S 10,000 o PERSONAL&PDV INJURY S 1,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 'POLICY JELOC PRODUCTS-COMP/OP AUG_ S 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO BODILY INJURY Per penal)ALL OKNED SCHEDULED 1 BODILY INJURY( mm $Plen0 S L AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per S _ S • UMBRELLA UAB _ OCCUR F H OCCURRENCE S ..EXCESS UAB CWMSIMDEj AGGREGATE S I DED RETENTION$ S • WORKERS COMPENSATION PER OTH AND EMPLOYERS'UAINLITI Y/N STATUTE ER ANY PROFRIETORIPARTNERiIXECUTIVE EL.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? N/A mNIdmay M Nm EL.DISEASE-EA EMPLOYEE S H yes describe der DESCRIPTION o RIPTION OF OPERATIONS below EL.DRFARF-POLICY LIMIT S 1 DESCRIPTOR OF OPERARONS/LOCATIONS/VEHICLES(ACORD 101.Additional Remarks Schedule.may be Mlecb d N more epxw M required) Operations usual to a residential carpentry contractor. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POIJCIES BE CANCELLED BEFORE City of Northampton, Building Inspector THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 212 Main St. Room 100 ACCORDANCE WITH THE POLICY PROVISIONS. Northampton, MA 01060 AUTHORIZED REPRESENTAT W E K Puissant, CISR/BLAB gartAJI A - iri-ada"`e--- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INSO25/,memi a '4 CERTIFICATE OF LIABILITY INSURANCE DATE T MIWO I"WE 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 POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: It the certificate holder is an ADDITIONAL INSURED,the pollcy0es)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). PRIX wow: Kathy Poissant BLACKMER INSURANCE AGENCY INC PHONE 413 625-6527 PAZ X. : ADDRESS: kathy©biadaners.com 1147 MOHAWK TRAIL INSURER(S)APFOLJDWGCOVERAOE NAJCP SHELBURNE MA 01370 MSYRER A: HARTFORD UNDERWRITERS INS CO 30104 INSURED INWRERB: P& B NEW ENGLAND SERVICES LLC INSURER C: INSURER 0: 47 COATES RD INamw E: I LEYDEN MA 01301 • INSURERF: COVERAGES CERTIFICATE NUMBER: 97261 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 WTH RESPECT TO VWHICH 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.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. OSA: ADOLiWWI POLICY EFF POLICY EXP LTRI TYPE OF INSURANCE yl,wvo POLICY NUMBER (MMNDYYYVI MNDDMYYY1 UMITS IICOMMERCIAL GENERAL LABILITY EACH OCCURRENCE $ ',CLAIMS-MADE OCCUR PNAAGES(aE occurrence) ITh PREMISESAMAGRENTSD el $ i MED ESP(Any one Poem) $ NIAI I PERSONAL 8.ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: 'GENERAL AGGREGATE $ POLICY JECTT LOC PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE TIM? $ I (Ea accident, ANY AUTO I BODILY INJURY(Per Parson) I$ AUTOS E° ---1 SCHEDULED N/A BODILY INJURY(Per amlern) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Pr acdetl $ UMBREUAUAS _ OCCUR : EACH OCCURRENCE $ EXCESS WB I i CLAISMADE N/A AGGREGATE $ OW RETENTION$ $ WORKERS COMPENSAOg1PER 0TH MIDEMPLOYERS'UAduY/X TY 1 X STATUTE ER ANYPROPRIETORMARTNEWE%ECU➢YE A OFFICEREMBER EXCLUDED, WA WA WA 6S60UB9F43408616 01/142016'01 /14/2017 eL.EACH ACCOENT $ 100,000 AI lemmMo,y In NH/ E.L.DISEASE-EA EMPLOYEE $ 100,000 F DEesS RPTION Wv POLICY LIMIT $ 500,000 ydesTION OF OPERATIONSbelow 1 E.LDISEASE- I N/A I I , DESCRIPTOR OF OPERATIONS/LOCATIONS/PORGIES DWORD 101,Amlecul Ramada snows may be mashed It more mew is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govrtwd/workers-compensabonnnvestigationst CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. City of Northampton Building Inspector 212 Main Street Room 100 AUTHORIZED REPRESENTATIVE Northampton MA 01060 Daniel M`Craey,CPCU,Moe President-Residual Market-WCRIBMA ®198&2014 ACORD CORPORATION. All rights reserved. ACORD 25(201401) The ACORD name and logo are registered marks of ACORD