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17C-222 (6) City of Northampton Map:Lot 17C-222-001 Massachusetts Date issued 12/09/2022 Inspector of Buildings Permit # BP-2022-1575 Permit Fee $60.00 SIGN PERMIT Business Address 131 MAIN ST Applicant Installer SAXTON SIGN CORP Applicant Installer Address 1320 Route 9, Castleton, NY 12033 Work Descri s tion ILLUMINATED WALL SIGN - FULL CIRCLE BIKE Estimated Cost $3000 Building Department Approval by: Jonathan Flagg Z—OR File #BP-2022-1575 APPLICANT/CONTACT PERSON:SAXTON SIGN CORP 1320 Route 9 Castleton,NY 12033 (518)732-7704(102) • PROPERTY LOCATION 125 MAIN ST MAP:LOT 17C-222-001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Building Permit Filled out Fee Paid $60.00 Type of Construction: ILLUMINATED WALL SIGN -FULL CIRCLE BIKE New Construction 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: )( 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 SpecialPermit 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 a/C /3A Sly.ature of Building Official i 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 cf Planning&Development for more information. City of Northampton Massachusetts ki' _ -.ct G./ ( � DEPARTMENT OF BUILDING INSPECTIONS Si .4 *,Jr It 4 212 Main Street • Municipal Building Sv` YJ Northampton, MA 01060 rs `�o Application for a Permit to Place or Maintain a Sign Or other Advertising Device, or Marquee �� (Application to be filled out In Ink or typewritten) Number .. e?'l J. Plans must be filed with the Building Inspector`—'\ Erection ( ) before a permit will be granted, i -`C j• Alteration ( ) j Repair ( ) �l y Repainting ( ) / Qt. Removal ( ) / FC 2 or_,r ���2 FPAGE PLOT Op l NoF?r AM' In�,�pF rthancipton, Mass. j� 20. a Application for a permit to place or maintain a sign or other advertising device, or marquee BUSINESS NAME ...C:1 11.lar.� c.i ',,....ibiL,... 1\4 1. Location, Street and No. -1. 1 1.),116k. IlAckA A. 2. Owner's name tJ.c.t.Q,, .. r ,.n►1.,�d...Q.0. ...j..1...r�...C,. i , 1 1 3. Owner's address Qa.Q1 1 N.)Q h...l�t-1 n dav6....,el. ......Q.1.a.Lr. ........ 4. Maker's name ..6. . CDC-PI T ' 5. Maker's address ..tJaQ (CT 01 C i...5 l.i+0.?'1....'.4!.Y... ..Ja, . 6. Erector's name ...a t7.C\.. z‘. ....\:!Uf..p 7. Erector's address i ke! 01 C'.c ,Siltian..... j, 1a0w3 SIGN KIND OF SIGN (Designate) 1. Sign will be (check one) illuminated .'.... Non-illuminated 2. Will sign obstruct a firs escape, window or door? .K.).b.. Marquee 3. Lower edge will be .IQ..ftc .' ins above the public way. Projecting 4. Upper edge will be it` ft..$`:..ins above the public way,. i, Roof 5. Height ft ins Width ft ins@ O.)S Sc I',•c Tempora 6. Face area sq. ft. 3 0 Wall 7. Inner edge will be 0 ins from the building or pole. Ground 8. Outer edge will be o ins from the building or pole. Other 9. Face of building or pole is ins back from the street line. 10. Sign will project 0 ins beyond the street line. 11. Sign will extend ..4,2..ft ins above the building or pole. 12. Of what material will sign be constructed? Frame ,A60/1 Face ALA 13. Estimated cost $ 5.1 — The undersigned certifies that the above statements are true to the b akof his ,nowledge and belief. - 41111W (Sig 'ature o'Owne or At ent) Page 1 of 3 THIS FORM IS PART OF THE SIGN PERMIT APPLICATION File No. ZONING IINFORMATION PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: �-Art C 1''&N COrp Address: Oat) VI "t CcQ.S* or, JR_c 3 Telephone: 'SI Y1; �6- � 7c'y-apa (e O 2. Owner of Property: �J{� (?Qg(l'��`v � 0 f L�L . p�a Address:Q Q. OJc PlotPlot-}\ A 015 _ D\a.�7 `O Telephone: 3-(0 F�v0i -( 3. Status of Applicant: Owner Contract Purchaser Lessee _Other(explain): '86)tA i C E�i/c1 I91 c1 n.trr*C4- Q t t` (n1+0.1(-P r, 4. Job Location: 13 I iiA4L I►l pt e A Parcel ID: Zoning Map# ( f G Parcel# a0D D District(s) 00 (TO BE FILLED IN BY THE BUILDING D ARTMENT) 5. Existing Use of Structure/Property: C-o (V\P(Cai a 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary) YVW 1-L, C plo,cL . QI;sit;Q) sib 7. Attached Plans: '! Sketch Plan )e 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? 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: I h ALvp t �� i a L. 10 '" Q-E fri(vl) Are there any proposed changes to, or additions of, signs intended for the property? YES >' NO IF YES: Describe the size, type and location: ALL, (,i'`I 1')& 6 j C-'A C-t7 (o azAyo, l d ak f 1 cA c.ui ufthFaill 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 la 17 60 ja tl7 $v Frontage ' i Front: b Setbacks:(for sign)Side: In L: R: L: R: Rear: NA Building Height I (,' I- I ()ri 'l icy) Façade Square Footage 9Q, (7 9 (6 it # of Parking Spaces I Q 13. Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. DATE: ` Ia 1`9`; APPLICANT'S SIGNATURE 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 PAGE 2 OF 6 13 5.2 5" PRODUCTION WORK ORDER Due Date:_ Leeway No Leeway FULL ( IRCLE--- 20.75" J T BIKE SUOP 20.75" J- 135.25" I SIGN COLORS SW 6463 Black Corten Steel Painted Texture Breaktime Lettering Border DESCRIPTION: QTY (2) 20.75"H Aluminum pan signs with painted SW 6463 Breaktime background and cut black vinyl lettering. 1 .5"W Border to be made out of .080"Thick aluminum and painted to look like a corten steel texture. Removal and Disposal of ALL Existing Awnings, Roof Like Awnings, and Existing Signs, and Installation of all New Signs by Saxton SAXTON CLIENT: JOB LOCATION: DATE: 11/22/22 -'� SIGNCORP 125 Main Street FOLDER: MPIGoodwin Block MEMeEti IP Florence, MA 01062 FILE NAME: 220032-03 New Store Front Signage UNITED STATES 1 -800-942-6366 CUSTOMER APPROVAL DATE "`"COUNCIL REVISION: 518. 732-7704 DRAWN BY: CM :01 fax: 518. 732-7716 THIS ORIGINAL DRAWING AND DESIGN IS THE PROPERTY OF SAXTON SIGN CORPORATION AND MAY NOT BE DUPLICATED OR REPRODUCED IN WHOLE OR IN PART AS A DRAWING saxtonsign.com SALESPERSON: DK BBB. PAGE 1 OF 1 ***WIDTHS ARE A ROUGH ESTIMATE*** 1 171.5" 1 135.25"—I I— 130" UNITED STATES POSTAL SERVI(E125•• 1 ULL (IR(l 215•• FLORENCE VILLAGE li " FLOREN (E, MA. 01062 20.75" BIKE SHOP 2.5" FLOWER & GIFT SHOPPE 2.5" 1 165.5" I I 135.25"---I I 210" I T TAX l4 PAYROLL SERVICES T T FLOREN (E BARBER SHOP 20.75" RI ( K KRISTEK 20.75" PIRA FACTORY 2.5" 146" I— 118" I-- 84" 1 SIGN COLORS Cotten Steel SW 6463 Black Painted Texture Breaktime Lettering Border DESCRIPTION: QTY (9) 20.75"H Aluminum pan signs with painted SW 6463 Breaktime background and cut black vinyl lettering. 1 .5"W Border to be made out of .080"Thick aluminum and painted to look like a torten steel texture. Goose neck lighting to go above signs. at SAXTON CLIENT: JOB LOCATION: DATE: 11/22/22 142141,4 'A SIGNCORP 125 Main Street FOLDER: DrawingslDarren/Goodwin Block --MEM R---E--R- 4V Florence, MA 01062 FILE NAME:: 220032-02 New Store Front Signage 6 ,,,,,,,r,,,. 1 -800-942-6366 CUSTOMER APPROVAL DATE REVISION: 518. 732-7704 THIS ORIGINAL DRAWING AND DESIGN IS THE PROPERTY Pr SAXTON SIGN CORPORATION DRAWN BY: CM 0 fdXS-518. 732-7716 AND rvI Y NOT BE DUPER ATI:0 or PEPRGDLJCCE1 IN JUHOL. ' OP IN PART AS A ORAWIN(:- �6 saxtonsign.com SALESPERSON: DK BBB. December 1,2022 Philip A. Lipman Tigre Opportunity QOB, LLC PO Box 13 North Adams, MA 01247 Dear Northampton Plan Review: This is to certify that Saxton Sign Corporation is my designated agent for the sign permits at: 9 N Maple Street 5 North Maple Street 143 North Main Street • 139 North Main Street 137 North Main Street 123 North Main Street They are authorized to act on my behalf regarding sign permits for these addresses. Thank you. I can be reached at plinaz@gmail.com or 520-609-6093 with any questions. Sincerely, Philip A. Lipman Tigre Opportunity QOB, LLC Managing Member Philip A. Lipman December 1, 2022 Philip A. Lipman Tigre Opportunity QOB, LLC PO Box 13 North Adams, MA 01247 Dear Northampton Plan Review: This is to certify that Saxton Sign Corporation is my designated agent for the sign pert 9 N Maple Street 5 North Maple Street 143 North Main Street 139 North Main Street 137 North Main Street 123 North Main Street They are authorized to act on my behalf regarding sign permits for these addresses. Thank you. I can be reached at plinaz@gmail.com or 520-609-6093 with any questior Sincerely, Philip A. Lipman Tigre Opportunity QOB, LLC Managing Member Philip A. Lipman I r_n .fit.._ "-•l/ I �U i 17C3274111 1fpWi„ MU MS / , r - 17C-215-001 0 147 w LV 17C 221-001 -I 1j tt LJJ 0.201 Ill J ) ff a Q t7c21aoo1 a L 1 MO ix 99 17C-0ZI.M1 z , Li t I 0203 1I1 1TC 213- 00 k ! 1- 1 i:i -..----' -------1------.----_____J —_ _ 7_ ___ 0RMA/NS BEET I TREET _ s w J a -- Q 2 i- 01 { 17Cf27-0 1.1$ N ( I II 23A-068-001 - 0 474 23A-070-0 0123A-069-000 036 1 l p3r d OatHAM.j6,,, 1/25/2022 10:45:08 AM �`=� ) Scale is approximate ..- The information depicted on this map is for planning purposes only. It is not adequate for legal boundary definition,regulatory interpretation,or parcel-level analyses. —NOTE— THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS IOT TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED. BUILDING LOCATION ACCURACY IS NOT GUARANTEED. LOCATION OF FENCES ON OR NEAR BOUNDARY LINES IS NOT VERIFIED BY THIS INSPECTION. CURRENT SNOW COVER NEGATES THE ABILITY TO ASCERTAIN ENCROACHMENTS UNDER SAID SNOW. A 46 t rn 0 Z H- BOOK 4113, PAGE 70 0 6, TRACT 2 REFERENCE I — �A32 t PLAN BK. 203, PG. 113 NOTE:PROPERTY LINES BOOK 4113, PAGE 70 � // TRACT 1 SHOWN ARE APPROXIMATE, A "0 / o FULL FIELD r cn (D w SURVEY IS cri 3 2 EASEMENT TO CITY REQUIRED TO o cD,- 0- OF NORTHAMPTON ACCURATELY N- C.' S SEE: PLAN BK. 110, DETERMINE THEIR ° 125 PAGE 75 LOCATION. # TAril / " S 4 ramp 111'± MAIN STREET (ROUTE 9) TO: CONNECTICUT ATTORNEYS TITLE INSURANCE COMPANY TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING MONUMENTATION ALL VISIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOC TED ON THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LI ES, EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR COMMUNITY #250167 —NOTE— SURVEYOR �. I THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY AND DOES NOT CONSTITUTE A PROPERTY SURVEY 2 P��N OF ,ugssif —MORTGAGE LOAN INSPECTION PLAT— NORTHAMPTON, MASSACHUSETTS RANEDALL PREPARED FOR ° IZER kn TIMOTHY E. SHEA TRUST #35032 SCALE: 1"=50' JANUA Y 28, 2022 (94, Si R .: HAROLD L. EATON AND ASSOCIA ES, INC. REGISTERED PROFESSIONAL LAND URVEYORS 235 RUSSELL STREET — HADLEY — M SSACHUSETTS A o CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/22/2022 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. ORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be ...idorsed. 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: ARTHUR J GALLAGHER RISK MGMNT SVCS INC n/ONNo Ext): 518-869-3535 FAX Nok 30 CENTURY HILL DRIVE SUITE 200 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# LATHAM NY 12110 INSURER A: SELECTIVE INS CO OF AMERICA 12572 INSURED INSURER B: SAXTON CORPORATION, BONI SIGN CORP, INSURER C: 1320 ROUTE 9 INSURER D INSURER E: CASTLETON ON HUDSON NY 12033-9686 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. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) x COMMERCIAL GENERAL LIABILITY X S 2139450 1/1/2022 1/1/2023 EACH OCCURRENCE $ 1,000,000 I DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 15,000 A PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY PECOT- X LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: $ A AUTOMOBILE LIABILITY X S 2139450 1/1/2022 1/1/2023 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS x HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ ONLY X AUTOS ONLY A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 S 2139450 1/1/2022 1/1/2023 EXCESS LIAB CLAIMS-MADE 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 fn 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) This Certificate of Liability Insurance was created by Selective on behalf of the agent. CITY OF NORTHAMPTON is included as additional insured with respect to Automobile, General Liability as required by written contract or agreement. CERTIFICATE HOLDER CANCELLATION CITY OF NORTHAMPTON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 212 MAIN STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. thampton MA 01060 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC#: l 6 ACCORD ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED ARTHUR J GALLAGHER RISK MGMNT SVCS INC SAXTON CORPORATION, BONI SIGN CORP, POLICY NUMBER 1320 ROUTE 9 S 2139450 CARRIER NAIC CODE CASTLETON ON HUDSON NY 12033-9686 SELECTIVE INS CO OF AMERICA 12572 EFFECTIVE DATE: 1/1/2022 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE:CERTIFICATE OF LIABILITY INSURANCE JOB JOB LOCATION ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NYSIF New York State Insurance Fund PO Box 66699,Albany,NY 12206 I nysif.com CERTIFICATE OF WORKERS' COMPENSATION INSURANCE NAAAAA 141670108 • SAXTON CORPORATION OF ALBANY o-91 ; ' a 1320 RTE 9 Q „ CASTLETON NY 12033 SCAN TO VALIDATE AND SUBSCRIBE POLICYHOLDER CERTIFICATE HOLDER SAXTON CORPORATION OF ALBANY CITY OF NORTHAMPTON 1320 RTE 9 212 MAIN STREET CASTLETON NY 12033 NORTHAMPTON MA 01060 POLICY NUMBER CERTIFICATE NUMBER POLICY PERIOD DATE G 813 625-1 526616 11/01/2022 TO 11/01/2023 11/22/2022 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 813 625-1, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY, IF YOU WISH TO RECEIVE NOTIFICATIONS REGARDING SAID POLICY, INCLUDING ANY NOTIFICATION OF CANCELLATIONS, OR TO VALIDATE THIS CERTIFICATE,VISIT OUR WEBSITE AT HTTPS:/NVWW.NYSIF.COM/CERT/CERTVAL.ASP.THE NEW YORK STATE INSURANCE FUND IS NOT LIABLE IN THE EVENT OF FAILURE TO GIVE SUCH NOTIFICATIONS. THE POLICY INCLUDES A WAIVER OF SUBROGATION ENDORSEMENT UNDER WHICH NYSIF AGREES TO WAIVE ITS RIGHT OF SUBROGATION TO BRING AN ACTION AGAINST THE CERTIFICATE HOLDER TO RECOVER AMOUNTS WE PAID IN WORKERS'COMPENSATION AND/OR MEDICAL BENEFITS TO OR ON BEHALF OF AN EMPLOYEE OF OUR INSURED IN THE EVENT THAT, PRIOR TO THE DATE OF THE ACCIDENT, THE CERTIFICATE HOLDER HAS ENTERED INTO A WRITTEN CONTRACT WITH OUR INSURED THAT REQUIRES THAT SUCH RIGHT OF SUBROGATION BE WAIVED. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STAT SUR NCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING VALIDATION NUMBER: 207156002 I I 'JCZ