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38B-069 239 SOUTH ST BP-2019-1047 GIS#: COMMONWEALTH OF MASSACHUSETTS Map,Block:38B-069 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Pennit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2019-1047 Proiect# JS-2019-001708 Est.Cost: $11100.00 Fee $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group RCI ROOFING 774334 Lot Size(sq a.): 10410.84 Owner: DUPREY NICHOLAS D&BETTY L Zoning: URB(100)/ AmUcant: RCI ROOFING AT. 239 SOUTH ST Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:3/25/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF 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: O'd•. 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 3/2520190:00:00 540.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner .. ___— "_'—' '���araiy4ddA uae•oml� f - City of Northampton ShpWradp P�'YmYtt Bullding Department r�rb(liuu4A,luewey Renmli, 212 Meln Street sewaTA§aq'a e'A�eltelalµl,Ia _ Room 100 ve'a+e7/w,rem;Aumtt®511uy Northampton, MA 01060 TWa 5a1s,ol;SArwoGwnal Rk_a!,ua. phone 413.587.1240 Fax 413-887-1272 fptkiliir'ISRA 1T APPLICATION TO CONSTRUCT, A ER, !-Rpqq' EM0 Whi A ONE OR TWO FAMILY DWELLING '.F.CTION 1 SITU, INFORMATION=� 60a— tL?- 16c(7 MAN- rams Aacdl_I�s,,^ '�QT� 1f I:rg,ectlpn Cob:e ¢oin�F/he"teo6Glae c�39 WVn1 S} ' Map:,,,_ Lal:_,_ . urt2.___Unil DFPT OF aUII t)16:f,I"J"SPFOTIONa Nor 1Ip(A NOPTHnUr`=on, lease Ove;nley'DY'ssefoh__, IFI# at Olstnlep' OR Disklict— ECTION 2 -PROPERTY OWNERiS'HIPIAUTHORIZED'.AGENT 7,�_Owne,Lof ae p�orNi , NI<hnl.c- L ()y�P[L �11 fM { m �F f.Ci�irnmT am,e (0"1) f��1�I--�,,�_�,-JyI�� Current Mellln9/ttldleea Telephone yt �J2.Z �n1 (2 a-utharized Agent: YJi—�12�-�_� I arra(Pring �/ � Gurren�l�M�allln\g Addreae, �ry�1 g'BUIB TelephonB Gc110�E�Jv1ATED.C,O� tUCTION tem Estimated Cost(Dollars)to be Official Use only completed by permlt applicant U nlding �p p Pur (a)Sulking ro(LFee _ �leclricalI�Prr�r ru {e) Estlmatsd Total Cost of Construnll©It from.fe) r Numbing - 'eullding Permit Fee nnechanical(HVAC) rl� Fire Protection lotalCheck Nurriber_ �TJ` -_ Thla Secllon For'OffIclal Lee Only_ ©ate' sidtling Permit Numb ; — Issuedl__.==— _ >ignalure; V Bulltling C'ommArsloPerllnspeclor otBulldings. _�___ Oslo _ __ �_oTION a ©es@riaPTLON aF RRraPosRD woR�to�k an aeelreabl� dew House 1 ❑ ❑ 0 Doors Windows Alleratloo(s) 0 Roofing [�] Or Doors O AccessoryBldg. El Demolition Demolition ❑ New Signs (01 DDaku I❑ Skiing (OI Other C)l I-Gnef Descl'ipllon of Proposed mvork. SSuo LAncLlPr`� Aueralbu of exlsling bedroom--Yes —No Adding new bedroomYes No Ausched Narragve Renovating unfinished basement_—Yes __No Plans Attached Roll Sheet _ Sa. If New lloUB_9210f>I!; dILN14V1T 4A eX�':slGim4+hL>»ma4ha-:Fimrmplets+.. rll_[QrlO, wim:a Use of building One Fnmlly__ Two Family Other__—_ b. Number of rooms in each family unit'. Number of Balhroorne___„_ Is(here e garage attached?-- I Proposed Square footage of new-construction. Dlmenalon=.i e. Number of stories? iI Method of healing? Fireplaces or Woodsloves_ Number of each g. Energy Conservation Compliance. Masscheek Energy Compllanee form attached? Type of construction__— Is construction within 100 it of wetlands?_Yes __No, Is construction within 100 yr. floodplain _—Yes _No I Depth of basemen)or cellar floor below finished grade Will building conform to the Building and Zoning regulallons? Yes No SeplicTank-__ City Sewer Private well_ City water Supply S€.CTION 78 -OWNER AUTHORIZATION •TO BE GOMPI,ETED'WHEN OWNERS AGENT OR CONTACTOR APPLIES'FOR BLI ILDINO PBRMIT _ as Ownelof the subiecl t he+ebrle9 �Qcs .0 Ty re s authorizei IvOCIR o act on behalf,In all matters relilve to work authorized by this building permit aR llmallon. 41<_— r)3 - ao-A- IC1 _ Signetore of Owner Dale 1.1-1=0.+- - -!•Il lly �sy /llh� % 6 fy(TPn-j- _, as OwnerlAulhorize` Agent hereby declare that the statements and Information on a foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ' ;�- ----- - - ar;nl varve Dale ( Snare lgluofOwnerlAq.1 __ -- TION a CON87RUCTICN SERV10Es' ase: Cos uo' ��gp1lP£CY131 Not Applicable ❑ ICcenso�gtlet ---UlAO�� ���I`y�0 �� _LL ideensa Num er ; ess� Expiration Date loi aaroie Telephone . 9(aeeey�tome am gent Cl4nhnaw06nt - _ Not Applicable 0 ❑uadn e Registration Number Expiration Dole TelephomoLgL aL2i2ll r,; ION 10 VORKERS' COMRENSATIQN INSURANCE AFFIOAVIT(M•G,Lo 162, 11250(61) ,rxers Compensation Insurance affidavit must be completed and submitted with thla application, Failure to provide this aflldavh will result e dpnal of hle uance he it •led Affidavit Atla9cf l hed Yts .... Qi/ Perm No.. ❑ 1. I o IF�O�wle�J emau rNJ The current exemptlon for"homeowners"was extended to Inolude Dw�.er-occupled Dwellings c 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 heownel nets as supp�lsaClgR780, Sixth Edttlon Section 108351 D ILRtoolof omeownan,;Pere on is) who own a dental of land cr which he/she resides or Intends to reside,on which there Is, or is Intended to be, sunset two famlly dwelling,aRaohed or detached structures accessory to suoN use and/or farm souctu[cs tk tsetsen who t n t acts m e than mel oma lu a shallaotbe con Idersd a ho neo vner. Such "homeowner"shall sdbmlt to the Buliding Offioial,on a form acceptable to the Building Offlolal tit he shsshall le r sonsjb el for asuch xyorh n dorm d under the bulldinit neem L As acting Construetlon St- e or your presence on the Joh site-will be required f ram time to time, during and upon completion cf the work forwhtoh this permits issued, Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 159 )Liability of Employers to Employees for Injuries not resulting In Death)of the Massachusetts General Laws Annotated, you maybe h le for portents) you hire tc perform work for you under this permit. The underslgned"homeowner" certifies and assumes rtepouslblllty for compliance with the Stela Building Code,City of Novthemptou Ordinances,State and Local Zoning Laws and State eCMassaehulleds Consist Laws Annotated. Homeowner Signature_ ( A- W �tAIY ____ 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: -a39 a,4 Sf "9aJilo The debris will be transported by: _6-krAfiQclivr -Q/0R6_e:q The debris will be received by: WeVerrl ReeycI1� %rd MS�eY "5&itlz Building permit number: Name of Permit Applicant I�G� � o� N�f Date Signature of Permit Applicant \ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114.2017 www.mass.gov/dia W-Workers' Compensation Insurance Affidavit: Builders/Contractors/Elect iciandiclumbers. TO BE PILED WITH THE PERMITTING AUTHORITY, Applicant Information // q Please Print Lee(bly Narne(Business/OrganizatioNindividual)I RGI Address: (a .Lint; & City/State/Zip: u#7dm. 7'in /l4/1 0/073 Phone 4: (�7/3) .5.3_'7 - x/'775 Are you"employer?Check the appropriate box: Typo of proj eel(required): LD emaemployerwith r,�0 emplayew(fulland/orpar4lima)." 7. ❑New construction 2 l am a sole proprietor or partnership and have no employees working for mein 8. Remodeling any capacity.(No workers'comp,insurance required.] g.❑ myself. 1 I am a homeowner doing all work [No wasere'vemp.insurance required I r Demolition 4.�1 em a homeowner and will be h firing contractors to conduct all waken my property. ]will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole II.Q Electrical repairs or additions proprietors with no employees. 12. Plumbing repays or additions 5. I am e general contractor and I have hired the have worntrW co pin on the attached sheet. 13.Q'Roof repairs These subcontrectors have employee and have workers'comp.insurance.) 6. We are a corporation and its officers have exercisedtheir right ofexemption par MGL c. 14.E)Other 152,81(4),and we have no employees.[No workers'compinsurance remened l 'Any applicant that checks box hl mux also 611 out the section below showing their workers'compensatian policy information. I Homeowners who submit this affidavit indicating they are doing all work end than hire outside ca osevars must submit anew affidavit Indicating such. tContracmre that check this box must attached an additional sheet showing the name of the sub conlmcton and state whether or not those entities hevc employees. If the leb-contraelors 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 the policy andjob site information. Insurance Company Name. 4l-m /77111 1aYI$¢/e17LeC.J. _ Policy#or Self-ins.Lic.#: VVJP, -/OC-ibe2Z 117 -aD/8FF Expiration Date, /0 -,5-- 19 Job Site Address: a_�01 Cil) r S+roe+ City/State/Zip: t 1,,�u bluff Attach a copy of the workers' compensation policy declaration page(showing the policy number anexpiration(late). 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. ggnn I do hereby cert(fy under t pin shies of perjury that the Information provided above is true and correct. Sia Ire "' Date 03-aU-14 Phone* _(q/3) 5�Z'7 — Z/275— E S Offfdal use only. Do rot write in his area, to be completed by city or town official. City ar Town: Permit/License# Issuing Authority(circle ane): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6, Other Contact Person: Phone#; RCI-Iio�ofm�gtimate Southampton,Ma.01073 7/15/2019 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location NICKY D'S 239 South St. 164 Northampton Street Northampton, MA Easthampton, MA 01027 — - - Terms Rep Chris Description Total Remove existing roofs. 11,100.00 Fumish&install 1/2"plywood over existing decking. Furnish&install aluminum drip edge,pipe flashings,chimney flashings(if needed)and step flashings. Fumish&install CertainTeed Winterguard ice&water barrier along eaves and valleys. Fumish and install synthetic underlayment. Fumish and install Lifetime CertainTeed Landmark Series shingle. Fumish and install CertainTeed approved ridge vent. All exterior roofing related debris to be removed by R.C.I.Roofing. All work will be performed according to manufacturers'specifications. Lifetime CertainTeed material warranty included. All related permits will be obtained by R.C.I. Roofing. Total $n,loo.00 TERMS OF PAYMENT 5%Deposit 1 Customer Sign ore: Balance upon completion Registration# 126235 Date: Construction License 4 074334 Insured by Barras&Fickert Ins. Shingle C Sel n (413)527-2700 SCAT q ZCJJy.-0SO(i�9 ,•' � / ' Of' MEof IMPROVEMENT EMAfft TCONTR CONTRACTOR HOMEIh1PTYPEMENTrship CTOR TYPE:Partnership 120 05105M2020 RCI ROOFING MARK T.DEU5L�t� I• R,. °i Commonwealth of Massachusella BLINE ST \�F ,(* E� R y � I D(vt Bion P ro(dsx ion'-tied nsure SOUTHAMPTON,MA C102fl' Board of eUlldining Rep8uldtlons and ala hdartls Undersecretary con augpltiklSltrvisof ____..�.. ..—.�... __.. . CS•074334 r AOSI0312 i 020 Y i� 48 Ires: Registration valid for individual usa*my a before the expiration date. If found return to: MARK THOMAS DEMI r` Office of Consumer Affairs and Business Regulation Bg BRIGGS STI� 1000Washington Streel•Su71e 710 EASTHAMPTON Boston,MA 02� d a� rU"2tA �. ah • . Commissioner V"'r`� ,J'�'1 Not vaild without signature -• GQMMONWE 'LTH!QF MAS "SP: }'{kfSE Tff HOME IM7 V N 1 ONTOTOR ,GIR<i 0 kG 7t,P SHEER E�.."N riV..t. 99C1 I ' WbRY'FoR,S '.. e J� >1 t k•F� FQL'uONGWYCENB'@ BOtr1'L� eyf>'1�?,Q]M1h )81073 �'A R UN� ` ,TED T De LISLE E Reg o-adon p- 1 ff ea E p&nov r� 0 RIOGs S HIC0624741 i(ol �S 1l '11/30/2019 EAST ',� ASM SIGNEC -'malt vw 1 •x % - w 4a'bE128.'/.?..028s T 486408 � rS uts+AAAlti 1i• OMMONWEPyL HMOF M .,S_�,'A "HUSgi!'f tmT`S ! td4aa.1 sw e g SHE ' Q� tit 7L bRKz Cad f-r ISSUES' �RQGIO�SYJC`j,(g+�a'`�S�- "�fAl� .. CA 3 k�yyr MAR�1C1'IDEAiS4�. ,aF .. • � � I RpORIN,O•u P .. -EAShNIP'�,O,N .N`3r . .• 2"60 °'"0 910 912 019 g� 5422361 � ACC>R fie CERTIFICATE OF LIABILITY INSURANCE D"relMnwdm'rl 03119/19 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. IS SUBROGATION IS WAIVED,subject to the Mems,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 endorsemengs). PRODUC VANE: Michael R.Sanas Bars S Fickert PLANE . 413-627-2700 AIC xe: 413-527-0849 Insurance Agency IYIE89; mbabanasinsurance.cOrn 63 Main Street Easthampton,MA 01027 INSUR SIAFFORDING COVEMOE "IC, INSUREFIA: Admiral Insurance Co. 24866 INSURED INSURERS: Safety Insurance Co. 39464 RCI Floating,LLP INSUMRc: Admiral Insurance Co. 24858 6 Lim Street INSURER D: Southampton,MA 01073 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS ISTO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FORTHE POLICY PERIOD INDICATED. NOTWRHSTANDINGANY 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 BYTHE POLICIES DESCRIBED HEREIN IS SUBJECTTOALLTHE TERMS, EXCLUSIONSAND CONDmONSOF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INNER LTR WPE OF INSURANCE POIJGYMIMBER CMD NMm LIMITS x 0OMMERCIALOENEMLU,SBILITY EgCH OCCURRENCE S 1,000,000 CIAIMSWADE OOCCUR PREMI ES Ee 3 60,000 MEDEXP $ %ODD A X CA000020063-05 03104119 03/04/20 PERSONAL.ADVINAIRY 3 1,000,000 GEN-LAGGREMTE LMnAPPLIES PER GENEMLAGGREGATE 3 2,000,000 POLIOY❑X jEOT D LCC PRODUCTS.COMPIOPAGG S 2,000,030 OTHEq: S AUTOMOBILE LABILITY S 1,000,000 gHTAUTO BODILY INJURY IPerpxam) S CHED OMEOULEOB 0930119 BODILY INJURY(Pptn) f AUTOSONLY xAOSX 6207761 x AUTOSHIRED x AUTOS ONLY FK 3 f UMBRELLA WB pCCUTy EACH OCCURRENCE f 5,000,000 C E.CESSUAe C WM DE X GX000000385-03 03/04/19 03104120 AGGREGATE s 5,000,000 oE0 X REIFNTION$ 10,000 s WORKERS COMPENSATION TRH ANDEMPIAYERYUABIUTY TANTE E ANY PROPRIETORFTIV AIMERADECUEY❑ NIA E EACH ACCIDENT 3 OFFICERNSMSER EXCLUOEDi IM-60MMNN) E.1-DISEASE-EA EMPLO)EFF S IdemtE lets DEBNIPTION OF OPERATIONS W— E DISEASE�POIICY LIMIT i DESGRIPTN OF OPERATIONS I LOCATIONS I VEHICLES ACORD 101,Addleaml Raft Sc ,.Mee W&e W9 MMpCe w"Indl ROOFING CONTRACTOR. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE C®PY AACCRORDANCP �ITHTHE EWOLTION DATE LIICYPROVISIONS. OF,NOTICE WILL BE DELIVERED IN 15 ACORD CORPORATION. All rights reserved. ACORD 25(2D16103) The ACORD name and logo are registered marks of ACORD A CERTIFICATE OF LIABILITY INSURANCE DA E' 91201" ' 0311912019 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 INSURFR(S), AUTHORRED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: N the certificate holder is an ADDMONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WANED,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 If..of such endoreamenl s. IH1oWCM CON Michael Bares BANAS&FICKERT INSURANCE AGENCY PHONE . 413 521-27DD PAc w EI e aGrlwnnce.wm Da a: 63 MAIN ST wsusmf APRINDI.C.Fures xAlce EASTHAMPTON MA 01027 IRaueEn A: AIM MUTUAL INS CO 337M Ixaueso Pausil RCI ROOFING LLP MURERL: IxauR o: 6 LINE STREET INSUR E: SOUTHAMPTON MA 01073 1 1....P COVERAGES CERTIFICATE NUMBER: 379588 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 PERTAIR 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. Ix , TYPEOFPPIMxCE PoLICrxuxeeR eP r cr U— COMMERCW.OMERAL.lI EACH OCCURRENCE f LWM6MNE oLLUR f MED EYP f NIA PERsaxu anpvlxNnY 5 GENLAOOREGNTEUMITAPNESPER'. GENERPL APGItEWTE 5 POLILY�JELT �LOL FRCOUC3-COBPIOPAGO i OrvEfl: AInOMOBILEWBIUfY C.MNNEUsIN.UEINr1 i$ A4Y NR0 BODILY INJURY(Per Wrion) S ALLO'MIEDSCHEDULED NIA ODDILY INJURY(Per a TNM) f AUTQS AOS NOµO ED PROP N GE f HIREOSLTOS A,,, P i um.MLUMB LOGIA FALX OCCURRMLE 5 mu.LMa LWMSMAOE NIA AGGREGATE 3 DED I I RETENTIONS a wDRRMacOMFEN3ATION X I PATUTEER ANOMPLOYMC.APNYYON A OFFIµcewMEu mFXAmRE ECUrIVE N,A Nu xM VWC1006022647201M 10105/2018 10/0SI2019 EL EACH ACCIDENTf 1,000,000 IManGalpyln XNl ELM.EASE-EAIUPL.Es IUUU 000 Ilya EerNE.Wx OESLnIPTICN OF CPERTTN)NSbelbx EL.OISE43E.POLICY LIME $ 1,000.000 WA WouklmOxormansEnon lanafts will paidt MasshP-Aeel Employees aymaWo Endonevnent e,C200 Woms for benefits employees wW be paid lD Masfachuachu employees only.Pureuanl h Fsldonemo a em to 03 O6 B, le of Massachusetts.Is given t0 pay claims for bane0i3 ro employeeB h slates oNE than Messechusetls M the insured hires,or has hired those employees outside of Massachusetts. This Dar65mte Of Insurance shoves the policy in force an Me data Shat this CaNOcate was,Issued(unless Ne Expiration date on Ne above policy precedes Ne Issue date of this certificate of Insurance). The arms of this coverage Can be monitored dally by accessing the Proof of Coverage-Coverage Vellication Search tool at www.mass.gowlwdAvo*em- mpensalbMnvesbgatmse. CERTIFICATE HOLDER CANCELLATION SHOULD My OF WE ADORE DESCRIBED POLICIES BE CANCELLED BEFORE THE F3PYUTIpJ DATE THEREOF, NOTICE WILL BE DELIVERED IN Reference Copy copy ACCORDANCE WRHTHE POLICY PROVISIONS. Reference Copy "WDR=DREPR NWAT 9 Reference Copy Daniel M.0 ,CPCU,Vim President-Residual Markin-WCRIBMA ®1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD