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35-248 (7) 15 LADYSLIPPER LN BP-2017-0420 GIS#: COMMONWEALTH OF MASSACHUSETTS Mpp:Block:35-248 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category; INSULATION BUILDING PERMIT Permit BP-2017-0420 Project ti JS-2017-000694 Est.Cost:$1874.88 Fee: $65,00 PERMISSION IS HEREBY GRANTED TO: Const Class: Contractor: License: Use Group: JASM ENTERPRISES LLC 108517 Lot size(su.a.): 59677.20 Owner: CHEUNG FLOYD&SHERI zoning._ Applicant: JASM ENTERPRISES LLC AT: 15 LADYSLIPPER LN Applicant Address: Phone: Insurance: P O BOX 1276 (413) 427-5481. WC CHICOPEEMA01201 ISSUED ON:9/28/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:ATTIC OPEN BLOW CELLULOSE 12" OVER 1008 SQ FT 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 ft 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 9/28/20160:00:00 $65.00 212 Main Sheet, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0420 APPLICANT/CONTACT PERSON JASM ENTERPRISES LLC ADDRESS/PHONE P O BOX 1276 CHICOPEE (413)427-5481 PROPERTY LOCATION 15 LADYSLIPPER LN MAP 35 PARCEL 248.001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOS'1 REQUIRED DATE ZONING FORMYILLED OUT 7 Fee Paid Building Permit Filled out Fee Paid Typeof Construction: Al tIC OPEN BLOW t Tina'LO' VER 1008 SQ FT New Constriction Non StrucNral interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 108517 3 sets of Plans/Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION 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 Deo.i' Ale; �2T Signature of:uildi"g i" ial 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 MOL 40A.Contact Office of Planning&Development for more infonnation. . • F c _Department use only ;^° City of Northampton 8taffisofFermit ,r: ,, RC.rr-r\ _ Building Department CBtb cuf/OrivSay,Permit r--A^ uw r —I l 212 Main Street 8e*N/Se dAvallablll i r tY Room 100 Wafer/WeICAVatlsbtlity, s& 2 8 �U t Northampton, MA 01080 Two+Set§ofSiruct rel Plans phon�413-587-1240 Fax 413-587-1272 prbVSite Plans. "" DEPT OrPA+. i sem ;- ,W Other Speciy ' APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: t This section to be completed by office /5 /ay S Jr peer /yy Map Lot Unft 7o rich c e- /n /90/ 0677- Zone Overlay District l' 973 Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: f /" f1/6yC[ t/&nt Some Name(Print) (J Current Mailing Address: //�1 _ A/./..5 vis yv 78 Sae Au /101120._ Grit Telephone Signature irr'intir't f 2.2 Authorized Agent: ((d;,,, Sgan /3racis1 n.J Name(Print) Current Ma hng Address: 4113a250 - 41/714 Signature Telephone SECTIO 3- - -TIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 1' 1 8'7!J $$' (a) Building Permit Fee lid Y. 2. Electrical (b}Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection // ,r 6. Total= (1 +2+3+4+5) Check Number a0 '7 K�-5 _,,, This Section For Official Use Only Building Permit Number Date Issued: Signature: Building Commissioner/Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due Ta Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size i__ _. I I I I Frontage I.. 1 I I _. .I Setbacks Front II _ . Side LI. I R:I L'P IRI Rif—I L _ I i1 Rear I —I F—-I I Building Height t--- — --i I I Bldg. Square Footage - — / -- Open Space Footage % _ _ (Lotarea minus bldg&paved 1--1 I 1 I.. I I- I parking) if of Parking Spaces I 1 1 H_ Fill: _. ..__ (volume&I,oeanon) _I__ _._ A. Has aSp cial Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW O YES O IF YES, dat • sued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O I IF YES: enter Book _._1 Pager and/or Document# I B. Does the site contain a brook, body of water or wetlands? NO4�J. DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: I C. Do any signs exist on the property? YES O 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 �Jy/ IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, gradin ation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION O.DESCRIPTION OF PROPOSED WORK(check all applicable) New House El Addition El Replacement Windows Alteration(s) Roofing i i Or Doors Q Accessory Bldg. n Demolition n New Signs [Cl Decks [q Siding[CO Other isif Brief Description of Proposed -TA Y:.10.17oA Work: fj-rc open 610 let/c, /use, /2 over /005504 Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes No No Plans Attached Roll -Sheet 6a.If New house and or addition to existing housings complete the following: a. Use of building :One Family X 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 wale,Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FORBUILDING PERMIT f(i irk grite— 1, (111 as Owner of the subject property /: - hereby authorize SLG' �-+�S a to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Dale f� _ _/ I, lin (✓ra015-41-J ,as Own r/Authorize Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best owledge and belief. Signed under the pains and penalties of perjury. Se(+. f3re,015ARUJ Print Name „ Z? Sep /tFl Signature of OweAe �. � Date 41110rr SECTION 8-CONSTRUCTION SERVICES 8',1 Licensed Construction Supervisor.- - - /^q _t [femme ._ __.. .. __ Not Applicable. D me of License Holder' i !� S n ((.iCv S hal CS /085 / license Number q(, ConElec. h w { Ale- Snnal�ie (a /2 -/U ' Address d �f0L/ Expiration Date Ii/.3 250 s Y S' ur Telephone t.irn., • li 3asmen itr' r'I ses LSLC ... Le,istere_ ♦.me Im. . > . en Co or Not Applicable C TASm EV/-feet()scs 4Lc /6( 07'1 Company Name Registration Number PO &)X '29 , CArc. in 0/02 , 4/-2/-/8 Address Expiration Dale Telephone L/3 36/16/6 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152,§25C(6)) 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 shy No C] 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of 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 he considered a homeowner. 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,duringand upon completion of the work for which thispermit 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. The undersigned"homeowner^certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature 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: Lariv.571p c r /h The debris will be transported by: USA OL, M 435/2( The debris will be received by: USA a otps{e Building permit number: Name of Permit Applicant Seen BerehlaKi gics,01 2 ak Date Signatu e of Permit Applicant The Commonwealth of Massachusetts me ODepartment of Industrial Accidents Office of hivestigaiions Ilk. 1 Congress Street, Suite 100 Boston, MA 02114-2017 o www.mas . ov/ is s d g Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Huslncss/Organiration/Individual): Address: City/StatetZip: _ Phone #: Are you an employer? Check the appropriate box: Type of project(required). 1.0 I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).' have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet, 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.t required] 5.❑ We are a corporation and its 10.❑ Electrical repairs or additions .3.❑ I am a homeowner doing all work officers have exercised their I L❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12,0 Roof repairs insurance required.] t c.152,§1(4),and we have no employees. [No workers' 13.❑ Other [ comp. insurance required.] *Any applicant that checks box III must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they arc doing all work and then hire omsidc contractors must suhmit a new affidavit indicating such. tContractots that checkthis box must attached an additional sheet showing the name of the sub-contractors and state whether or not(hose entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer flint is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: _. Policy#or Self-ins.Lir,.#: Expiration Date: Job Site Address: City/State/Zip: 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 fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. �.. Signature: _....._....._._ ......Date:, Phone 4: Official use only. Do not write in this area,to he completed by city or town official City or Town: Permit/License it 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#: Alok Permit Authorization f'r RIas.s SaV'e' Form I•44.111•11•10 MOW ovary aWR Site ID: 500050209330 Customer: FLOYD CHUENG I, FLOYD CHUENG ,owner of the property located au IO..ees Name.P'W..) 15 ladysllpper Ln FLORENCE fw.n..nsort Pane) (CRY) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform Insulation and/or weatherization work on my property. Owner's SJgnaure: Date: 7/z 7/4 FOR CLEAResult OFFICE USE ONLY CLEAResuh has assigned the following Mass Save Home Energy Services Participating Contractor to the / above referenced project: ThS11' (n7err tses «C 28 Sepi 2O/4 Participating Contractor Date coma* • SO WMInP.n sort sancta • %Alan*w 01311 • 32:04.074n ❑I - For Mar U..On* Rev. 102015 The Commonwealth of Massachusetts w..=- -isi. Department oflndastrialAccidents tai,tn I Congress Street,Sae 100 _�`'—_ a lloston,MA 02114-2017 www.massgovldia Workers'Compensation Insurance Affidavit yen. TO BE FILED WITH THE PERMITTING AUTHORITY. Anvlieant Information Please Print Legible Name mumesogiganbedon/hdivdua0:JASM Enterprises. LLC. Address: P.O.Box 1276 City/State/Zip: Chicopee, MA 01021 phone g: 413301-8010 An yea aaemployer?l ark the appropriate box: Type of project(required): I.©l me a ampler.with 9 employees(full ander paNkm).• 7. 0 New construction 2❑Ison.sob pgpieter orpermaWp and gave nowpIoysaa waking for mein saw capacity.P40 W aa•comp.insurance requited.) 8. ❑Remodeling 301 mi a homeowner doing all work my.damb. f.(No workers'c . u.am required.]• 9. 0 Demolition Tam ahomeow.asad will be 10❑Building addition a hiring contractors conduct all wort my property. s will ens at all orntraaas Sites have workers'mwpmunnn insurance ware sale I l.0 Electrical repairs or additions prorietae with m<mgmees. 12.❑Plumbing repairs or additions Salam arad mummer and thove hired the sub-contrarian listed an =o theche!sheet. 13.0Roof repairs Those sbmmseas have employer end haw workers'mum.insurance.. inseletien 60 WC ore a mtp..man and is officers have manned line riga demean*per MGL c. 14.0Other 152,PIM.and we hove no employees.[No sambas'romp.immmce aquired.l *any applicant that meat boa tl neat also fill not as,«tion below shmvtg Mair workers`compensation policy information. t Eoaeowma who submit this affidavit Indicating t6ry ore doing all work and then hire outside contactor,mast submit a oew affidavit indicating such. 'Caixw a that check Mie box must attached en additional that showing tie name of the wecmvocmn and nate whether or not those entities haw eaployem. IfWe sbaxm.cton have employees,they®m provide their wanton'comp.policy meta. I am an employer that is providing workers'compensation iota mfee for my employees. Below is the policy and job site imJerwalion. Insurance Company Name: Liberty Mutual Policy#or Self-ins.Lie.e: WC2-31S-372772-015 Expiration Date: IJ — .Z- i i rob Site Address: Cp Attach a copy tithe waworkers'compensationcompensationpolicy declaration page(showingg lyea policy number and expiration date). Failure to secure coverage as required under MGL c.152.§25A is a criminal violation punishable by a fix 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 S25Or0 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 ander the et✓tles of perjury&oohs information provided above is true and cornett. &nature: Date: 5— a— el-oI¢ phew r. 413-301-8010 ODlcfa use only. Dona write in Chit area,to be completed by city or town efeial. City or Town: PermWUceose e Suing Authority(circle one): 1.Board of Health 2.Building Department 1 City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone d: C?c`4e c2o wnry>uoea % ole a.1JacAiaielt Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 166074 Type: LLC Expiration: 421/2018 Trp 419291 JASM ENTERPRISES LLC JEFFEREY BRADSHAW P.O. BOX 1276 CHICOPEE, MA 01201 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card SCA I O 20M.05.111 r; ,,`Flauiurn,unni//ar/r'/wyvr✓rte//. :v, Office of Consumer Affairs&Rosiness Regulation License or registration valid for individul use only ,rHOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: is Registration: 168074 Type: Office of Consumer Affairs and Business Regulation -�It.y Expiration: 4/21/2018 LW 10 Park Plaza-Suite 5170 '°ryes" Boston,MA 02116 JASM ENTERPRISES LW -' JEFFEREY BRADSHAW } / B05NEWBORYST / SPRINGFIELD,MA 01104 Undersecretary N t valid without signature /', JASME•1 OP ID:JT AC ORO CERTIFICATE OF LIABILITY INSURANCE 08,11'"/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: N the certificate holder Is an ADDITIONAL INSURED,the pollcyQes)must be endorsed. If SUBROGATION IS WANED,subject to the tams 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 ACT RAKE Raymond Lukas Chase Clarke Stewart 6 Fontana PNo, FAx 101 State Street,P.O Box 9031 WCBs�1u:413-7884531 sac,Nal:413.214.8180__ Spdngfeld,MA 01102 EA w ss:riukas@m chaseins.co Raymond Lukas INSYREIOS1 AFFORDING COVERAGE I ENCS INSURER A:Northland Insurance Companies INSURED JASM Enterprises LLC tauten a:Liberty Mutual Assig Risk Jeff Bradshaw INSURER C:Arbella Protection 41360 PO Box 1275 -- Chicopee,MA 01021 INSURER 0:Torus Specialty INSURER E: 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 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. PIER TYPE OF INSURANCE AWL SNR Y EFF EXP LTR -.- VIVO W a POLICY NUMBER IDDIYYVY) (MIdYYYY) LINTS A X coreautau.GENERAL LNBERY EACH OCCURRENCE S 1,000,000 CLAMART/ADE X OCCUR X W5281416 100/20/2016106/20/'2017 PRFMMDAMAGE riErI „co $ 100,000 ( 5,000 MED ESP A,yOne Rena) S PERSONAL SADV INJURY S 1,000,000 GENL AGGREGATE UNIT EA APPLIES P : GENERAL AGGREGATE S 2,000,000 POLICY I j TCS: i LOG PRC4s NIS-COMP/OP AGO E 2,000,000 OTHER S AUTOMOBILE MERRY COMBINED SINGLE LIMIT S 1,000,000 Ma enn C ANY AUTO 1020008523 10/05/2015 10/05/2016 BGDILY MIRY(Per parson) $ AALL OWNED X AUTOS SCHEDULED DIMLY INJURY(PH accident) S X HIRED AUTOS X dWN AUTOS PROPERTY acciden(DAMAGE S Me rS X UMBRELLA UM — OCCUR EACH OCCURRENCE S 2,000,000 D X EXCESS UAB CWMSM40E 76851K162ALI 06/20/2016 06/20/2017 AGGREGATE S 2,000,000 OD RETENTIONS S WORKERS COMPENSATOR PER OTA AIM LOVERS'LIABILITYI STATUTE ER B ANY PHOIHEIDPRARRIERA.XECMINE Y/M WC231S372772-016 05/01/2016 05/02/2017 ELF aI ACCIDENT S 1,000,000 O%ERAMEMBER EXCLUDED? n N/A (Y ndatINy In NH/ E.L.DISEASE-EA EMPLOYEE S 1,000,000 DW& ee OF" POLICY LIMIT S 1,000,000 E$CRIPIIgi OF OPERATIONS Wow ELMSE4SE- DESCRIPTOR OF OPERATIONS/LOCATIONS I VEHICLES ACOIO tO1,AddlXonalRUWa WNA/a,may MaN[lM flMOM Waco 4Apuetll Action Inc.and National Grid USA its direct and indirect parents subsidiaries and affiliates are listed as Additional Insured in respect to General Liability Jeffrey Bradshaw Is excluded under the workman comp policy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE NetiOnel Grid THE EXPIRATION O N DATE THEREOF, NOTICE WILL BE DEERED NO Box ACCORDANCE WITH THE POLICY PROVISIONS. Northborough,MA 01532 AUTHORIZED REPRESENTATIVE Raymond Lukas I ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD • Unrestricted - Buildings 14 an use group which . .,• „-�s contain less than ?t ($)tl cubic feet (991m') of ' „•„, °r•„,.. : `* enclosed space CS-108517 ° SEAN BRADSHAW ani 246 CONNECTICUT AVENUE Springfield MA (111W Failure to possess a current edition of the Ma...acIs iwtt1 ...-41-48tr. State Building Code is cause for revocation of the,license. i. _. 12110/2018 For DPS licensing intern+ation visit www.May,(lov/OPS