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23B-046 (282) BP-2022-0544 30 LOCUST ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23B-046-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-0544 PERMISSIONIS HEREBY GRANTED TO: Project# Contractor: License: Est. Cost: FLORENCE ROOFING 071 107 Const.Class: Exp. Date:04/24/2023 Use Group: Owner: COOLEY DICKINSON HOSPITAL INC Lot Size (sq.ft.) Zoning: M/WP Applicant: FLORENCE ROOFING Applicant Address Phone: Insurance: 405 RYAN RD WC2-3 l S-374455-041 FLORENCE, MA 01062 ISSUED ON:05/18/2022 TO PERFORM THE FOLLOWING WORK: ROOFING REPAIRS 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: ' 2 Fees Paid: $133.00 212 Main Street,Phone(413) 587-1240,Fax:(413)-'87-1272 Office of the Building Commissioner f t g, MAY 18 Thti Commonwealth of Massachusetts , 2022 / Office of Public Safety and Inspections Massachusetts State Building Code(780 CMR) NOOTHA k ,•�-'1 : Pe t Ap lication for any Building other than a One-or Two-Family Dwelling ain, Ns �` •`M 10iC7'ON (This Section For Official Use Only) Building Permit Number: Fate Applied: Building Official: SECTION 1:LOCATION 30 Locust St Northampton,MA. 01060 Cool y Dickinson Hospital No.and Street City/To n Zip Code Name of Building(if applicable) Assessors Map# Block#and/or o # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building 0 Repair 0 Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify:Roofing Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No El Is an Independent Structural Engineering Peer Review required? Yes 0 No ❑ Brief Description of Proposed Work: See attached proposalCrAt SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 1-2❑ 1-3 0 I-4 0 M: Mercantile 0 R: Residential R-ID R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 0 IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV CI VA CI VB 0 SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 0 Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify: permit fs enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATIO Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/T. n State Zip to apply for and act on the property owner's behalf,in all matters relative to work authoriz:• by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out A.pendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction i ontrol then check here❑. Otherwise provide construction control forms(see section 107 in the code as required. 10.1 Registered Professional Responsible for Construction Control(the professional coord' .ting document submittals) Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor C. Philip Andrikidis/ d/b/a Florence Roofing Company Name C. Philip Andrikidis CS-071107 U Name of Person Responsible for Construction License No. and Typ•if Applicable 405 Ryan Rd. Florence MA 01062 Street Address City/Town State Zip 413 262.8007 413.585=9171 florenceroofing • gmail.com Telephone No. (business) Telephone No.(cell) e mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.e.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial •ccidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial o the issuance of the building permit. Is a signed Affidavit submitted with this application? Y•s I No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMI FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(f om Item 6)=$ 1.Building $ Building Permit Fee=Total' . i.. a =• Cost x (Insert here 2.Electrical $ appropriate 4 cipal factor)— 3.Plumbing $ 1' 4.Mechanical (HVAC) $ Note:Minimum c tact municipality) 5.Mechanical (Other) $ Enclose check payable 6.Total Cost $19,000.00 (contact municipality)and wrl e check number here A/(0 SECTION 13:SIGNATURE OF BUILDING PERMIT APP I CANT By entering my name below,I hereby attest under the pains and penalties of perjury that a of the information contained in this application is true and accurate to the best of m knowledge and understanding. C. Philip Andrikidis j Sole Proprietor 41 a 262-8007 5/16/22 Please print and sign name Title Telephone No. Date 405 Ryan Rd. Florence MA 01062 florenceroofing@gmail.com Street Address City/Town State Zip Email Address 1' a Municipal Inspector to fill out this section upon application approval: & t ,a I ► •- 5 Na e FLORENCE-OOFINWMA.COM C.PHILIP ANDRIKIDIS dOga 405 RYAN ROAD, FLORENCE, MA 01062 INSURED BY KING z CUSHMAN 413-584-5610 HIC #150673 CSL#171107 • MS #11282 413 262-8007 April 13,2022 Proposal for: Cooley Dickinson Hospital Job Location:30 Locust St. Description: - Areas to receive new roofing marked out in red on attached roof plan. 1,400 sq.ft.+/- - Remove stone ballast from roof. 1,400 sq.ft.+/- - Remove entire EPDM roof system down to concrete deck. :00 sq.ft.+/- - Remove EPDM membrane leaving existing insulation on p•rtion of roof with metal deck. 600 sq.ft.+/- - Fully adhere(2)layers of 2.6"Polyiso insulation to portio of roof with concrete deck using adhesive foam to achieve an insulation value of R-3 1 per building code 800 sq.ft.+/- - Fully adhere.060 Versico VersiWeld TPO to portion of ro•f with concrete deck. 800 sq. +/-Color:Gray - Mechanically attach(1)layer of 2.6"Polyiso over existing •olyiso to portion of roof with metal deck to achieve an insulation value of R-30 per build ng code.600 sq.ft.+/- - Mechanically attach Versico VersiWeld.060 TPO using ' r inoBond induction weld system to portion of roof with metal deck 600 sq.ft.+/-Co •r:Gray - Install(2)Retrofit drains to existing drain pans and sump i sulation. - Install pressure treated 4x4 wood blocking under RTU. - All TPO related flashings and terminations installed per m. ufacturers specifications. - Area cleaned and all roof related debris removed to landfill or proper recycling facility by Florence Roofing. - Versico NDL 20 Year Total System Warranty - All permits to be applied for by Florence Roofing. - All material furnished and installed by Florence Roofing. • City of Northampton Massachusetts SAS.. .,c .. r. DEPARTMENT OF BUILDING INSPECTIONS as a 212 Main Street • Municipal Buildingwisr;o �6S Northampton, MA 01060 44,'• % CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of :uilding Permit Number is that all debris resulting from this ork shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111 , S 150A. The debris will be disposed of in: Location of Facility: Valley Recycling The debris will be transported by: Name of Hauler: Florence Roofing Signature of Applicant: Date: 5/16/22 The Commonwealth of Massachusetts' la-=- = t Department of Industrial Accidents 1.' = 7�'__ I Congress Street,Suite 100 -` Boston,MA 02114-20I7 ti J,ti'�,`ti www mass.gav/dim 11 ut kers'Compensation Insurance Affidavit:BuilderstCmatractontUectricianstPluinbers. TO HE FILED WITH THE PERMITIINGAUTHHORITY. Applicant Information Please Print Leeibly Name(Ilusinesrvorganizabon/individual): C. Philip Andrikidis/ d/b/a Florence Roofing Address: 405 Ryan Rd. City/State/Zip: Florence, MA. 01062 — Phone#: 413-262-8007 Art yaw aft ttrwrbyrr?Cheek tdse appropriate boa: Type of project(required): I.r I am a employer with 5 employees(full arikor pan-tint:).' 2. D New construction 20 I am a role pn/pricint or partnership and have no empkayaxa working for coat in g. Remodeling any capacity.[No worker c' onap_iasurancr aspired" 0 30 I am a homw urnet doing all work myself[No workers'.cone ar nrsancr requitaal]' 4. ®Demoliticxt 4r1 lam a homeowner and will be biting un t nxtora to couh�t all work on my prapwny_ I will I 0 Building addition matt that all contractors either have workers'compensation insurance or are auk 1 LO Electrical repairs or additions proprirtors with Do employees. 12.0 Plumbing repairs or additions 30 lam a general contractor and 1 have hired the sub-contractors hated on the attached slat. 13.0 Ilwse sub-cvntnt.-tara hoar ornployces and have workers'crimp.nt�urau:e• ppRoofingrepairs er 6.0 We are a crxpo ration and Mt affirms have exercised then ion right of exempt per 1w C e_ 14.L LiQ RoofI n g 132,*1(4).and we hart no empkujoes.[No winker;comp_insurance requi sl j *Any applicant Ihta dandtabat ttI onto aim fill old the imam below showing thcar workers earmenution •+: idtmaaims. t klrraeowms MID aldtatmt this affidavit indicating they are doing all woail and then hoe mai&omnactors rase armor*a mew abider.it indicating vask :Contractors that deck Wit boa mint attached in additional show showing the name attic sir cnomcrinrs and trite*hedge or not tow a tidies have amplelres. Nebo 9abeaabitiatt hart emeyors,they mnd peovide their workers'wrap.pub y mnttbct. I am ant employer that is p ev>ta,:worken'comp rssatioa irtsrrwrce for my employees. Below 1s the policy and job site ihttfformatioatr Insur 's=Ctmnprany Name: Liberty Mutual Fire Insurance Company _ Policy#or Self-ins.Lic.#: WC2-315-374455-052 Expiration Date: 1/25/23 Job Site Address: 30 Locust St. City/s t&zip: Northampton, MA. 01062 Attach a copy of the workers'compensation policy declaration page(showing the cy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation unishable by a fine up to$1.500.00 atxil or one-year imprisonment,as well as civil penalties in the form of a STOP WORK RDER 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 In 'gations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information prov ed above is true and correct. Signature: Date: 5/16/22 Phone#: 413-262-8007 , t I Official use only. Do not write in this area,to be completed by city or town officiaL ('its•or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.C'ityTTowtn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.(Mier Contact Person: Phone lt: CONSTRUCTION CONTROL WAIVER From: Florence Roofing 405 Ryan Rd. Florence, MA. 01062 To: Jonathan Flagg Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 The Massachusetts Building Code, section 107.1 allows for an exclusion from requirements for construction control in certain situations. In accordance with code section 104.10, I request that you grant a modification to waive the requirement for construction control of the project at 30 Locust St Northampton, MA. 01060 because the work is of a minor nature,will not affect structural elements, health, accessibility, life or fire safety, and will be done in accordance with the prescriptive requirements of the code. Thank you for your consideration. Respectfully, , 13 ��J e/ a, C. Philip Andrikidis Aco CERTIFICATE OF LIABILITY INSURANCE GATE(MMIDDIYYYY) L...-- 05/16r2022 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 Susan Fleury CI CISR CPIA NAME: King&Cushman Inc. PHONE (413)584-5610 FAX (413)584-9322 (-MAIL,Ext). {AfC,No): P.O.Box 447 ADDRESS: sfieury©kingcushman.com 176 King Street INSURERS)AFFORDING COVERAGE NAIC# Northampton MA 01061 INSURERA: Hudson Specialty Ins Co INSURED INSURER B: Safety Insurance Company 39454 C Philip Andrikidis,DBA:Florence Roofing INSURER C: National Union Fire Ins Co 405 Ryan Rd INSURER D: INSURER E: Florence MA 01062 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2251604794 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 ADMSUER POLICY EFF POLICY EXP W LIMITS INSD VO POLICY NUMBER (MMIOO/YYYY) (MM/DDIYYYY) XI COMMERCIAL GENERAL LIABILITY 1,000,000 �/ EACH OCCURRENCE $ RETED CLAIMS-MADE X OCCUR PREMISDAMASEES0(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A HBD100015188 02/13/2022 02/13/2023 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY PRO- 2,000000 JECT LOC PRODUCTS-COMP/OP AGG $ , OTHER: _ $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED 1700898 01/09/2022 01/0$/2023 BODILY INJURY(Per accident) $ AUTOS ONLY X AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) PIP-Basic $ 8,000 5,000,000 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ C EXCESS LIAB CLAIMS-MADE 8E021372491 09/06/2021 09/06/2022 AGGREGATE $ _ DED 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 NM) E.L DISEASE-EA EMPLOYEE $ II yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Location:Cooley Dickinson Hospital,30 Locust St.,Northampton,MA 01060 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE T HEREOF,NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THEI POLICY PROVISIONS. 212 Maiin St I AUTHORIZED REPRESENTATIVE Northampton MA 01060 �� --Lf�..Liej ©198$-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DATE(MWDD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE �.►/ 05/16/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 NAME: Susan Fleury KING & CUSHMAN INC �NN ): (413)584-5610UVC FAX,No): AL DDRESS: sfleury@kingerushman.com P 0 BOX 447 INSURERS)AFFORDING COVERAGE NAIC# NORTHAMPTON MA 01061 INSURER A: LIBERTY MUTUAL FIRE INS CO 23035 INSURED INSURER B: C PHILIP ANDRIKIDIS INSURERC: DBA FLORENCE ROOFING INSURERD: 405 RYAN RD INSURERE: FLORENCE MA 01062 INSURERF: COVERAGES CERTIFICATE NUMBER: 774830 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 SUER POUCY EFF POLICY EXP W MI LIMITS LTR INSD VD POLICY NUMBER (MDD/YYYY) (MMft9DlYYYY1 COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PET LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETORARTNER/EXECUTIVE/P E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A. N/A N/A WC231S374455052 01/25/2022 01/25/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under -DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I 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/Iwd/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 City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main St AUTHORIZED REPRESENTA111(E Northampton MA 01060 Daniel M.Croy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD