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20-009 (3) 486 SYLVESTER RD BP-2019-0790 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:20-009 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: KITCHEN RENO BUILDING PERMIT Permit# BP-2019-0790 Project# JS-2019-001313 Est. Cost: $21000.00 Fee: $137.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: WYNTER HOWLAND 109919 Lot Size(sq.ft.): 114562.80 Owner: AARON AMY J&PATRICIA JENKINS zoning: Applicant. WYNTER HOWLAND AT: 486 SYLVESTER RD Applicant Address: Phone: Insurance: 45 PLEASANT ST (413) 522-1012 WC SOUTHAMPTONMA01073 ISSUED ON:1/11/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.REMODEL KITCHEN -ADD DOUBLE CASEMENT WINDOW SLIGHTLY BIGGER THEN PREVIOUS 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 1/11/20190:00:00 $137.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-0790 APPLICANT/CONTACT PERSON WYNTER HOWLAND ADDRESS/PHONE 45 PLEASANT ST SOUTHAMPTON (413)522-1012 PROPERTY LOCATION 486 SYLVESTER RD MAP 20 PARCEL 009 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATIO CHECKLIST ENCLO 7 D REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: REMODEL KITCHEN-A D DOUBLFVCASEMENT WINDOW SLIGHTLY BIGGER THEN PREVIOUS New Construction Non Structural interior renovations Addition to Existing- Accessory Structure Building Plans Included: Owner/Statement or License 109919 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: 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 Demolition Delay - //-,-�/ 7 /-//- Signa of Buil mg Official 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. City of Nort am on Building De artr lent 212 Main Stre t JAN 1 0 2019 Room 00 Northampton, MA �uii_�irc INSPFCTI phone 413-587-1240 Fax 4t9-AAV- MA 01 oh APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION t »S INFORMATION 1.1 Property Address: orf 486 Sylvester Rd. 77,77, 777 `, Ellam 4eedr , . ;�ESI SECTION; !! EE#t"Y OYIIIT- ERSHIFlAII'THORIZEV AGENT 2.1 Owner of Record: Amy Aaron 486 Sylvester Rd. Name(Print) Current Mailing Address: 413-586-7765 Telephone Signature 2.2 Authd4zed Aaent: Shelby Howland 45 Pleasant St.Southampton MA,01073 Name(Print) Current Mailing Address: hJLJ y � �� N." .m , Signature Telephone SEG'I`II r'F'i'tHIlIATED CSTiUCTION CCITS' Item Estimated Cost(Dollars)to be completed by permit applicant 1. Building (a)8uitding per it fee_.. 2. Electrical 2500 (b)Estimated Total Cwt of Construction . 3. Plumbing 500 8uttdlrtg PNBrtnitfte 4. Mechanical(HVAC) =.,. 5. Fire Protection 6. Total=(1 +2+3+4+5) v7li& Check Number This Section Fcr'Official Use Ott Budding Permit Nu�ab late Issued: ftnature f — _ 8u�ctingmrr� lrferft► pectt�r of Buildings - Villagecarpentryma @ Gmail.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) all 40''D k6 y New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑✓ Roofing El Doors 0 1 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [0] Other[0] Brief Description of Proposed remodel kitchen with new cabinets and a new double casment window slightly bigger then pervious Work: Alteration of existing bedroo Yes_t"-7 No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll (She a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply ,SEGTION°7s'='OWh1AR AUTi4OR�A 'II 1 1'Q! C(1nrm' ' Wf~11 141 OWNERS POWAt'�R 4014D1A1G PEMIT as Owner of the subject property hereby authorize to act on my be n all matters relat_ a to work authorized by this building permit plication. 2<J i Signature of Ow er Date Shelby Howland 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. Shelby Howland Print Name Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder Wynter Howland cs-109919 License Number 45 Pleasant St. Southampton MA, 01073 04/03/2020 Address Expiration Date UA/V 413-022-1012 Signature VTelephone Not Applicable ❑ Village Carpentry and Landscaping 191955 Company Name Registration Number 45 Pleasant St.Southampton MA,01073 5/27/2020 Address Expiration Date Telephone413-824-0204 51~C 1 OAS'CCOPENSATION INSURANCE AFFIDAVIT{I► G L.x,,152, x5 sj} 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....... ® No...... ❑ City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: Remodel Est. Cost:21,000 Address of Work: 488 Sylvester Rd.Florence Date of Permit Application: 1/3/2019 I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): _Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: "41411J I hereby apply for a building permit as the agent of the owner: 1/3/2019 Shelby Howland 191955 Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts 4 DEPAR241ENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 S Massachusetts Residential Building Code Section 110.R5.1.2 Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. Such homeowner shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building Northampton, MA 01060 Debris 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. The debris from construction work being performed at: 486 Sylvester Rd. (Please print house number and street name) Is to be disposed of at: Valley Recycling (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 kv www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly Name (Business/Organization/Individual):Village Carpentry and Landscaping Address:45 Pleasant St. City/State/Zip:Southampton MA 01073 Phone#:413-824-0204 Are you an employer?Check the appropriate box: Type of project(required): 1.[j]I am a employer with 8 employees(full and/or part-time).* 7. []New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. aRemodeling any capacity.[No workers'comp.insurance required.) 9. Demolition 3711 am a homeowner doing all work myself.[No workers'comp.insurance required.]? 10 Building addition 4.n I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I.E]Electrical repairs or additions proprietors with no employees. 12.[:]Plumbing repairs or additions 5.[]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.r-1Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.n We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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 thepolicy and job site information. Insurance Company Name:LIBERTY MUTUAL FIRE INS CO Policy#or Self-ins.Lic.#:WC231 S613874018 Expiration Date:09/06/2019 Job Site Address:486 Sylvester Rd. City/State/Zip:Florence MA, 01062 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pa.%s and penalties of perjury that the information provided above is true and correct. Si ature: _&L/ iDate: -:� 1 � Phone#:414-824-0204 Official use only. D 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#: Amo 01//0 /CERTIFICATE OF LIABILITY INSURANCE DATE 02/22019019 Y) 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(les)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 John Taylor,CIC NAME: Blackmer Insurance Agency Inc PHCNnEo EtI. (413)625-6527 ac No): (413)625-8210 1147 Mohawk Trail E-MAIL john@blackmers.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC N Shelburne MA 01370 INSURERA: Main Street America Assurance 29939 INSURED INSURER B SHELBY HOWLAND INSURER C, DBA VILLAGE CARPENTRY AND LANDSCAPING INSURER D: 45 PLEASANT ST INSURER E: SOUTHAMPTON MA 01073-9493 INSURER 1: COVERAGES CERTIFICATE NUMBER: GL 2018-19 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AUDL SUEIR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDIYYYY MM/DD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR PREMISES Ea occurrence $ 500,000 MED EXP(Any one person) $ 10,000 A MPT7291V 02/08/2018 02/08/2019 PERSONAL BADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY [:]JEtT ❑LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE— AUTOS AUTOS ONLY AUTOS ONLY Per accident J —_ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ T_ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Operations usual to a carpentry contractor. RE:Kitchen Remodel CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Amy Aaron ACCORDANCE WITH THE POLICY PROVISIONS. 486 Sylvester Rd AUTHORIZED REPRESENTATIVE Florence MA 01062 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD ADATE(MWDD/YYYY) COKU® CERTIFICATE OF LIABILITY INSURANCE 01/02/2019 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(les)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). PRODUCER COAMP CT Betsy Whole -Osell BLACKMER INSURANCE AGENCY INC PHONE EK0- (413)625-6527 FArAXC No: aDDRESS: betsy@blackmers.com 1147 MOHAWK TRAIL INSURERS AFFORDING COVERAGE NAIC# SHELBURNE MA 01370 INSURER A: LIBERTY MUTUAL FIRE INS CO 23035 INSURED INSURER B: SHELBY A HOWLAND INSURERC: DBA VILLAGE CARPENTRY AND LANDSCAPING INSURER D: 45 PLEASANT STREET INSURER E SOUTHAMPTON MA 01073 INSURER F COVERAGES CERTIFICATE NUMBER: 352361 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM/DD/YYY MMIDD/YPOLICY EFF YYP LTR LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE FIOCCUR DAMAGE T RENT D PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ JECT POLICY❑PRO F—]LOC PRODUCTS-COMP/OP AGG $ OTHER: I $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident L BODILY INJURY(Per person) $ SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS PeraccidentAB OCCUR EACH OCCURRENCE $ HCLAIMS-MADE N/A AGGREGATE $ ETENTION$ $ WORKERS COMPENSATION XSPERTATUTE EORH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? WA WA WA WC231S613874018 09/06/2018 09/06/2019 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A - 7 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space 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.gov/lwd/Workers-compensation/investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Amy Aaron ACCORDANCE WITH THE POLICY PROVISIONS. 486 Sylvester Rd AUTHORIZED REPRESENTATIVE Florence MA 01062Residual Market—WCRIBMA Daniel M.Cr y,CPCU,Vice President— ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD i `` urimvrt sc 12'-11 7/8" I{Q(JYZ I soumengm3 4'-8' 1'9' 2' 2'-3" 2'-3" 2'-0" '-3" ;tomer 1'-3" 2'-6' rmation N �i M ZD N ,j N N � r O O O M U to in in �PP� )- 11-►q December 3, 2018 January 3, 2019 1