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39A-033 (4) City of Northampton Map:Lot 39A-033-001 Massachusetts Date issued 10/20/2022 Inspector of Buildings Permit # BP-2022-1335 Permit Fee $220.00 SIGN PERMIT Business Address 115 CONZ ST Applicant Installer ACTION SIGN COMPANY LLC Applicant Installer Address 3276 RIVER RD, RENSSELAER, NY 12144 Work Description REFACING FAIRFIELD INN SIGNS Estimated Cost $13600 Building Department Approval by: Jonathan Flag i1 )2 . 11 . File # BP-2022-1335 z-6k APPLICANT/CONTACT PERSON:ACTION SIGN COMPANY LLC 3276 RIVER RD RENSSELAER, NY 12144(518)479-0506 PROPERTY LOCATION 115 CONZ ST MAP:LOT 39A-033-001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Building Permit Filled out Fee Paid $220.00 Type of Construction: REFACING FAIRFIELD INN SIGNS New Construction ,��V Y� Non Structural Renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: J Approved Additional permits required(sec 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 , e 007)a Sig ture of Building 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 Northampton Massachusetts t "g" � ` n DEPARTMENT OF BUILDING INSPECTIONS y� 212 Main Street • Municipal Building J\ Northampton, MA 01060 7131N4. \\\ Application for a Permit to Place or Maintain a Sign Or r other Advertising Device, or Marquee 6A201 -13 ( pp o tiain typewritten) Number Plan st be filed with the B i in n ect Erection ( ) before a permit will be granted. Alteration ( ) OCT 1 4 2022 Repair ( ) Repainting ( ) Re oval ( ) DEPT.OF BUILDING INSPECTIONS Qp NORTHAMPTON.MA 01060 F PAGE r4LoT. ��� Northampton, Mass. 2 Application for a permit to place or maintain a sign or other advertising device, o marquee BUSINESS NAME -ra-t e--(t. cf P� I v- n 1. Location, Street and No. \ ,'5 a Cu r1 2— S+ 2. Owner's name To-1 t\,- r\��� -� 3. Owner's address a ZD IL-'� &1 ) b r- -mil r1 In() 14 4. Maker's name 5. Maker's address 6. Erector's name .... .L"h.!?(1...nn.�.1�n nn '' 60 - 7. Erector's address 3f-�� '1 tr l am• iterIS J i n 1. a-1 4`+ SIGN KIND OF SIGN (Designate) 1. Sign will be (check one) illuminated Non-illuminated 2. Will sign obstruct a fire escape, window or door? Marquee 3. Lower edge will be ft ins above the public way. Projecting 4. Upper edge will be ft ins above the public way. Roof 5. Height ft ins Width ft ins Temporary 6. Face area sq. ft. Wall 7. Inner edge will be ins from the building or pole. Ground 8. Outer edge will be ins from the building or pole. Other 9. Face of building or pole is ins back from the street line. 10. Sign will project ins beyond the street line. 11. Sign will extend ft • - .bove the building or pole. 12. Of what mate al will sign be const ,cted? Frame Face 13. Estimated c st $ The undersigned ertifies that t - Aove statements are true to the best of his knowledge and belief. (Signature of Owner or Agent) Page 1 of 3 THIS FORM IS PART OF THE SIGN PERMIT APPLICATION File No. ZONING (INFORMATION n/ PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: /-f --h D r\ J i C r Ld Address: 3d1 Le 2;V PinssdLte/ r1 Telephone: 5 I q" 47-1 - o J5 LPL) 2. Owner of Property: `Q_-t 6— YYIa►'1G�9 CfYI Lr)f c/ Address: 3 Lit Fes; (N5 S�"• Telephone: y'i 3• >'7^ a l op 3. Status of Applicant: Owner Contract Purchaser Lessee Other(explain): i Q n j r' .s 4. Job Location: `J Parcel ID: Zoning Map# Parcel# District(s) (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure/Property: 4 ' _i r Ti _1 d .Ln n 6. Description of Proposed Use/Work/ProjectlOccupation: (Use additional sheets if necessary) rt4 n\ 6 16 r\5 7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans 8. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW YES IF YES,date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: Enter: Book Page and/or Document# 9. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES IF YES: Has a permit been,or need to be, obtained from the Conservation Commission? Needs to be obtained Obtained , Date issued 10. Do any signs exist on the property? YES NO IF YES: Describe the size,type and location: Are there any proposed changes to,or additions of,signs intended for the property? YES NO IF YES: Describe the size,type and location: Page 2 of 3 11. ALL INFORMATION MUST BE COMPLETED: PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION. 12. This column to be filled in by the Building Department. Existing Proposed Required by Zoning Lot Size Frontage Front: Setbacks:(for sign)Side: L: R: L: R: Rear: Building Height Facade Square Footage # of Parking Spaces 13. Certification: I hereby certify that the information contained herein is true and accurate o the best of my knowledge. DATE: /L/' ' / APPLICANT'S SIGNATURE LIA-w{^-c r1 l.L J• NOTE: Issuance of a zoning permit does not relieve an applicant 's burden to comply with all zoning Requirements and obtain all required permits from the Board of Health, Conservation Commission, Department of Public Works and other applicable permit granting authorities. FILE# Page 3 of 3 8959 Tyler Bo levord Stratus- Mentor,0 44060 888.5,3.1569 strotusunlimi,ed.com LETTER OF AUTHORIZATION August 4'1', 2022 To Whom It May Concern: This letter is to certify that Stratus /Action Sign Company LLC or agent thereof is authorized to survey,permit and install signage on behalf of Fairfield by Marriott and Tala Manageme t, Inc at the following property address: 115a Conz Street Northampton, MA 01060 1111_ Amp W�o`•. By S►gnat re Tit Date* 4,40, Approved By Printed Name Approved By Contact Information Enclosures:# CC: PROJECT PROPOSAL View in Google Maps Untitled Map Legend • • Aacror Facial Plastic Surgery t Fairfield Inn&Suites by Marriott Springfield NoMamptonrAmherst 0 Feature t f; -_- . _ 0 Feature 2 i - R — 0 Feature 3 -- -r'J-2 - ' - ' .'— 0 Northampton Wastewater Treatment Plant :Y •y(�•. 0 Shell . - +. - 'e ' w,.G . X' o -c 5 '& .' • t • t.. Fd 7 Zr. • - • ♦ 9 i • �, �Y:_�. '^R t.y'. �• .` fit. ' .a •7• i -- r rim -� .' • ' . v'L'9rp l' "�a-, . ,y ., ,f __ < R - ', n �, , �' ''ram a3/1: -6 7S J W tr L :1 Y.• •a • -;-`* V" —-- • a MARRIOTT I FAIRFIELD NORTHAMPTON, MA MARSHA # BDLNH Is this project eligible for the Signage Retrofit program and subsidy? Yes / Unknown Is this project a Marriott managed project? Yes / Unknown Customer Date• Prepared By Note:Cola output may not be eaadwhen hewingaprinting this dranng.Ncolas used are PMS or be doseM CM FAIRFIELD INN-E#388197 06/22/22 Z-RA equivalent If thesecabis are intoned.please amok the correct MS match and a revision to this dra«mgvalbe made. 1 1 ocation• 115A OONZ ST File Name: Eng: Stratus NORTHAMPTON,MA 01060 MARRIOTT/FAIRFIELD INN/2022NW/Fairfield Inn_Northampton — SITE PLAN Fairfield BY MARRIOTT 115A CONZ ST NORTHAMPTON, MA 01060 FXISTING CHANNFI I FTTER-SET EXISTING CHANNEL LETTER SET BEING REPLACED WITH 3 BEING REPLACED WITH NEW REMOTE CHANNEL LETTER SET NEW REMOTE CHANNEL LETTER SET \� -, " «: , J ,� e 1/4 EXISTING MONUMENT CABINET "Ngic \ ", / " ,, ,' w , EXISTING SIGNS: BEING REPLACED WITH -al;., . '\ " NEW MONUMENT CABINET s Ili t \ 12" PORTE COCHERE a... \. �- t A © 30"CHANNEL LETTER SET M « � �` 0 30"CHANNEL LETTER SET 1 ' �'Y�` ,, ,�.\ 11 { 0 4'-0"X 8'-0"+/-MONUMENT CABINET 4j1) . EXISTING PORTE COCHERE LETTERS TO BE �/ \ c, r PROPOSED SIGNS- REMOVED AND NOT REPLACED ` % .:..00 REMOVED AND NOT REPLACED '4,4- ., _ ! i \`'� © 30"STACKED CHANNEL LETTER SET N, v , impa , FF-CL-30-BW .s ra 4 t 0 30"STACKED CHANNEL LETTER SET FF-CL-30-BW ! '0 0 3'-5"X 6'-0"MONUMENT CABINET \*.-4frANA- '`' Customer Late: Prepared By Note:Color mice may not be exact when vdewingorpmtrglhisdraving.Al colors uud are PMSor the dosed CMYK FAIRFIELD INN-E#388197 06/22/22 Z-RA ego-dent If these colors are intonedt please Ronde the coned PMS match and a melon to this drawing cod be made. Stratus stratusunlimited.com Location- 115A CONZ ST File Name' Eng: NORTHAMPTON,MA 01060 MARRIOTT/FAIRFIELD INN/2022NW/Fairfield Inn_Northampton — °sa.5°3.,ses ENTRY ELEVATION ALL DIMENSIONS SHOWN HAVE BEEN ESTIMATED— STANDARD SPECS ARE USED FOR THIS PROPOSAL SURVEY REQUIRED! 0 - r Ni - 1. i . lig ii! N. 1111 t . . * * 4PS AS 111 1°Mratigia, 0011111021akisisa..--- i_ ''''',+......„-.,.. EXISTING PROPOSED 12"+l--"F" Scope of work: 1. Existing Porte cochere letters to be removed and not replace. APPROVAL BOX-PLEASE INITIAL CUSTOMER APPROVAL Customer Data: Prepared By• Note:Cob(output may not be exact wizenviewingapdning this drawing.Pl colors used are PMSa the doseslCMYK FAIRFIELD INN-E#388197 06/22/22 Z-RA e1urvaent If these colors are incorrect please provide the correct PMs match aid a tenon to this drawigwdee made. stratusunrmiteaoom 1 ncatinn• 115A CONZ ST File Name• Eng: Stratus 888+W 6 888.583.1 56 9 NORTHAMPTON,MA 01060 MARRIOTT/FAIRFIELD INN/2022/WV/Fairfield Inn_Northampton — EAST ELEVATION ALL DIMENSIONS SHOWN HAVE BEEN ESTIMATED— STANDARD SPECS ARE USED FOR THIS PROPOSAL SURVEY REQUIRED! © - 28'-0"+/.-- - #: J ! . ?` , • .151.0"+/- '`` '''' — ...,- { ap K..�,� ev MARRIOTT ed �e., 4de Olit jit6fift t74",..•' t r. � � ;... a , ! y#o,'i t , .�y/. ,' F, ., * .i; • car' , * 's. t 4 i 71. . EXISTING 30"+/-- "F" PROPOSED 30" STACKED FF-CL-30-BW Face lit channel letters: 50 Square Feet Blue day/white night Tagline: 12'-8 15116" Black day/white night - • LED illumination 3"deep alum. returns 2'"6 Fa 1 rfi_el 1' 8 1/4" 25" or more: trimcap to be used s""1 "118� Flush mounted 8-3/4°BY M A-R R LOT T Scope of work: 1.58"stroke 8'-11-3/4" 1 1. Remove existing channel letters GRAPHIC DETAIL 2. Patch and paint old mounting and electrical penetrations on wall surface SCALE: 1/4"= 1'-0" 3. Install new channel letters by connecting to existing power at sign location 4. Wall material - Not provided at this time APPROVAL BOX-PLEASE INITIAL CUSTOMER APPROVAL Customer Date. Prenared ll Note:Color output may not be exact when viewing or owing this draMng.Al colors used are PMS or the closest CMYK FAIRFIELD INN-E#388197 06/22/22 Z-RA egurvaent It these colors are incorrect,please prosde the correct Plds match and a revision to this drawxingwl be made. �� us stea oeunl mited.com Location' 115A CONZ ST File Name Eng: "o", ° 858.503.1589 NORTHAMPTON,MA 01060 MARRIOTT/FAIRFIELD INN/2022/ VV/Fairfield Inn_Northampton — NORTH ELEVATION ALL DIMENSIONS SHOWN HAVE BEEN ESTIMATED— STANDARD SPECS ARE USED FOR THIS PROPOSAL SURVEY REQUIRED! 0 50e-011+1- 1 'ill.1 i • ,. , . , . k't ♦ ' t ' '' . !VG"..' dry'--<: • x. it._; ° t�� •. ., _ +fit • k y�"e �. .. • I. r 1 1 a EXISTING 30"+1-- "F" PROPOSED 30" STACKED FF-CL-30-BW Face lit channel letters: 50 Square Feet Blue day/white night Tagline: 1z'-8-15116" Black day/white night •Fair - el LED illumination i F 3" deep alum. returns 2'6 ' 1- -114 3'-11-118" 25" or more: trimcap to be used _____1 Flush mounted 8- 'BY M A R R_IO T T u Scope of work: 8'-11-3/4 1.5/8-stroke 1. Remove existing channel letters GRAPHIC DETAIL 2. Patch and paint old mounting and electrical penetrations on wall surface SCALE: 1/4"-1'-0" 3. Install new channel letters by connecting to existing power at sign location 4. Wall material - Not provided at this time APPROVAL BOX-PLEASE INITIAL CUSTOMER APPROVAL Customer Date. Prepared By Note:Color oulpd may not be sal Wien viewing a printing m5 Gamrg Al colas used are PAC a Me closest CMYK FAIRFIELD INN-E#388197 06/22/22 Z-RA equrrAerk If these colors areincared.please proode the cared NSrnakn and amaanto Ito Cony oil eemade. Stratus ,iratusunlimaed.com 1 ocation: 115A CONZ ST File-Name. Eng: NORTHAMPTON,MA 01060 MARRIOTT/FAIRFIELD INN/2022MN/Fairfield Inn_Northampton — DIF ILLUM. MONOMENT SIGN ALL DIMENSIONS SHOWN HAVE BEEN ESTIMATED— STANDARD SPECS ARE USED FOR THIS PROPOSAL SURVEY REQUIRED! EXISTING SIGN SF: 32 - ,t _,' "I :ati , PROPOSED SIGN SF: 20.5lir.t f r y. `.arr Fairlield ii T - �. .. W _7. -- EXISTING PROPOSED 4'-0"X 8'-0"+/- D/F ILLUM. MONUMENT SIGN 3'-5"X 6'-0" DIF ILLUM. MONUMENT SIGN @ 8'-0"+l- OAH @ 8'-0" OAH 6'-0" 67-1'-6"-16., DIF Ilium. Monument Sign: Alum angle frame cabinet- 18 inch deep 3'-5" Fairfield Aluminum face w/routed copy BY M A R R I OTT Copy backed up w/polycarbonate LED illumination 8'-0" 1T3" Alum. pole cover OAH 4'-4" Scope of work: • 1. Remove existing D/F monument cabinet and pole cover and scrap. GRADE 2. Install new pole cover on existing steel. 5 1'-2'-8" � " 3. Install new D/F monument sign on existing steel. FRONT VIEW SIDE VIEW 4. Connect to existing power. GRAPHIC DETAIL APPROVAL BOX-PLEASE INITIAL SCALE:1/4"=1'-0" CUSTOMER APPROVAL Customer Date Prepared By Note:Color output may not be exact when*mg orpmhg this dra+mg.Al colors used are PMSor the closest MK FAIRFIELD INN-E#388197 06/22/22 Z-RA equivalent Ktliese colors are incarect.please provide the coned PMS match and a revision to this drawing wit be made. stratnsunhimiled.com 1°cation' 115A CONZ ST File Name• Eng: Stratus NORTHAMPTON,MA 01060 MARRIOTT/FAIRFIELD INN/2022NW/Fairfield Inn_Northampton -- eJ 1a9 A CORE, DATE(MM/DD/YYYY) CO CERTIFICATE OF LIABILITY INSURANCE 10/11/2022 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),AUTHQRIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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 Linda Abodeely NAME: Hughes Insurance Agency,Inc. PHONE(A/C,No,Ext): (518)793-3131 FAx (A/C,No (518)793-3121 328 Bay Road E-MAIL Linda@Hughesinsurance.com ADDRESS: PO BOX 4630 INSURER(S)AFFORDING COVERAGE NAIC# Queensbury NY 12804 INSURER A: Selective Ins.Co.of SE 39926 INSURED INSURER B: ACTION SIGN COMPANY LLC INSURER C: 3276 RIVER ROAD INSURER D: INSURER E: RENSSELAER NY 12144-5121 INSURER F COVERAGES CERTIFICATE NUMBER: 22-23 Master 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 ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIM TS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED I 500,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 A S 2126834 07/31/2022 07/31/2023 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3'000'000 POLICY X PRO LOC PRODUCTS-COMP/OP AGG _ $ 3,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED S 2126834 07/31/2022 07/31/2023 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE S 2126834 07/31/2022 07/31/2023 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A 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 $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Subject to all policy terms,limitations and conditions: Certificate Holder is Additional Insured when required by written contract,agreement or permit. 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 Mainb Street AUTHORIZED REPRESENTATIVE ,p. Northampton MA 01060 o ,.,1 ,,rr cscu. I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD STATE OF NEW YORK WORKERS' COMPENSATION BOARD CERTIFICATE OF NYS WORKERS' COMPENSATION INSURANCE COVERAGE la.Legal Name&Address of Insured(Use street address only) lb.Business Telephone Number of Insured Action Sign Company LLC (518)479-0560 3276 River Road Rensselaer,NY 12144 lc.NYS Unemployment Insurance Employer Registration Number of Insured ld.Federal Employer Identification Number of Insured Work Location of Insured(Only required if coverage is specifically or Social Security Number limited to certain locations in New York State, i.e., a Wrap-Up 141818262 Policy) 2.Name and Address of the Entity Requesting Proof of 3a. Name of Insurance Carrier Coverage(Entity Being Listed as the Certificate Holder) Selective Ins.Co.of America 3b.Policy Number of entity listed in box"la" WC 9007707 City of Northampton 212 Mainb Street 3c. Policy effective period Northampton,MA 01060 10/1/2022 to 10/1/2023 3d. The Proprietor,Partners or Executive Officers are included. (Only check box if all partners/officers included) X all excluded or certain partners/officers excluded. This certifies that the insurance carrier indicated above in box "3" insures the business referenced above in box "l a" for workers' compensation under the New York State Workers'Compensation Law.(To use this form,New York(NY)must be listed under Item 3A on the INFORMATION PAGE of the workers'compensation insurance policy). The Insurance Carrier or its licensed agent will send this Certificate of Insurance to the entity listed above as the certificate holder in box"2". The Insurance Carrier will also notes the above certificate holder within 10 days IF a policy is canceled due to nonpayment ofpremiums or within 30 days IF there are reasons other than nonpayment of premiums that cancel the policy or eliminate the insured from the coverage indicated on this Certificate. (These notices may be sent by regular mail.) Otherwise,this Certificate is valid for one year after this form is approved by the insurance carrier or its licensed agent,or until the policy expiration date listed in box"3c",whichever is earlier. Please Note: Upon the cancellation of the workers'compensation policy indicated on this form,if the business continues to be named on a permit,license or contract issued by a certificate holder,the business must provide that certificate holder with a new Certificate of Workers' Compensation Coverage or other authorized proof that the business is complying with the mandatory coverage requirements of the New York State Workers'Compensation Law. Under penalty of perjury,I certify that I am an authorized representative or licensed agent of the insurance carrier referenced above and that the named insured has the coverage as depicted on this form. Approved by: Linda Abodeely (Print name of authorized representative or licensed agent of insurance carrier) Approved by: �. ht-fr +► October 11,2022 (Date) ( ) Title: President Telephone Number of authorized representative or licensed agent of insurance carrier: 518-793-3131 Please Note: Only insurance carriers and their licensed agents are authorized to issue Form C-105.2. Insurance br'kers are NOT authorized to issue it. C-105.2(9-07) www. cb.state.ny.us