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24C-045 (5)
BP-2024-0584 337 ELM ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24C-045-001 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-2024-0584 PERMISSION IS HEREBY GRANTED TO: Project# EXT STAIRS 2024 Contractor: License: Est.Cost: 3500 JAMES WARD 079104 Const.Class: Exp.Date:09/16/2024 ROACH,DANIEL T JR.& ELIZABETH M. Use Group: Owner: TRUSTEES Lot Size(sq.ft.) Zoning: URA Applicant: JAMES WARD Applicant Address Phone: Insurance: 46 JEFFERSON ST (413)297-2263 WESTFIELD, MA 01085 ISSUED ON: 05/14/2024 TO PERFORM THE FOLLOWING WORK: REPLACE EXTERIOR STAIRS 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: 172... Fees Paid: S65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner 1EG :, ` _. MAY — 9 2024 The:Commonwealth of Massachusetts; VI I FOR Board of Building Regulations and Standards MUNICIPALITY Massachusetts State Building Code, 780 CMR USE FNT.00R TlG r I EG0 3 Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: (.€9, 4,?, c 517 Date Applied: ! EUIiJ55 JZ& y zazil Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 37 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: — Outside Flood Zone9 Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: j/ZitAtfiGt gefAe/4 Np i1%f It f4l/ Name(Print) City,State,Z ,37 Z-7m S2d 40 070 e/ZD,G A ,/YIo�v7'�: 0 Can No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Wore: dge, P e'R/04' SiIcz1118 c/ f/Nf thIttre Nb¢ v►`5;4,Lit -t r-iPi 6r -+-7 Al'. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. Building $ 0.0.6 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire Total All Fees: $ va Suppression) Check No Amount: 6.Total Project Cost: $ F o.JO 0 Paid in 11 0 Outstanding Balance Due: enigA.{ /v waiste_ArIn C.pyma,l-C-o)r) City of Northampton ~ • Massachusetts c t".,,c • • DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Qs. Northampton, MA 01060 ,r40 PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS, DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC. 1. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work(Digital and hard copy). 3. Construction Debris Affidavit filled out and signed by applicant. 4. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance. 6. Energy Conservation Compliance Certificate (new /replacement windows). 7. Home owner's License Exemption Form (if applicable). 8. Note any Special Permit requirements (if applicable). 9. Energy Code—all new construction(Gut/Rehab) requires a HERS Rater Affidavit 10. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton. • p k • • SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) T d C5 07 9�r6/aDa License Number Expiration Date Name of CSL Holder List CSL Type(see below) • No.and Street Type Description /jo ( p__sue S �(. () Unrestricted(Buildings up to 35,000 cu.ft.) City/Town,State,ZII' Restricted 1&2 Family Dwelling h' t7 G� M Masonry Y n/16/7 /i✓1P. D / /' U RC Roofing Covering I/ I''G/ WS Window and Siding p, SF Solid Fuel Burning Appliances 1.9 7i2a63 W SeVA/4o GC ��J�j��-.CU>''� I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 5)/k)-N -- HIC Registration NumberExpiration Date HIC Company Name or HIC Registrant Name /? `8a No.and Street / IJ- Email address City/Town,State,ZIP Telephone SECTION 6: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 Issuanc of the building permit. Signed Affidavit Attached? Yes No . 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this buildin ermit application. q7,4r1 h Y AAA 5/9//2 y Pnnt Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true an accurate to the best of my knowledge and understanding. ,.5.153/ Y Pri er's or Authonzed Agent's ame(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms _ Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" r.ir' , ,,\ The Commonwealth of Massachusetts r =' ,` `(I Department of Industrial Accidents �. s v WO HI I-_ 1 Congress Street,Suite 100 �'�i e Boston,MA 02114-2017 www.mass.gov/dia 1%calkers' Compensation Insurance Affidasit:Builders.'ContractorsElectriciansrPlumbers. It)HE FILED 11'ffll THE PERM, M:At iIIORf11. Applicant Information Please Print Letibls Name IBtrsiness`Chganeztttionindividuall: 59 ot s Address: /0 8 g/nylrt/pJ dL /t/° O / :5-C /l.S4rU S f. ) City/State/Zip: 10,gL4/e/d Phone#: z./ 07 _2626 3 Are you an employer?Cheek the appropriate box: Type or project(required): 1.0 II am:r emplwa with _employees(full and Of part-timer• 7. 0 New construction '.1 1 am a sole proprietin or partnership and have nu empluyo:s working fur me in 8. CI Remodeling arty capacity.(Nu workers'comp.insurance aquinn!_] 9. ❑Demolition 30 1 am a homeowner doing all work myself.(No workcza'cun>p_WEAltalICC required.]' 40 I am a homeowner and will b.bums ouch-actors to conduct all work on my propv'ity_ I will 10 0 Building addition noun that all rrmiraetorta either hate workers'ectmpenaaturn insurance or are sole 1 I CI Electrical repairs or additions proprietors with no cmplovo 12.0 Plumbing repairs or additions 5CI I am a general contractor and I love hired the sub-contractors listed on the attached sheet 131E3 Root-repairs These sub-contractors have employees and!sate workers'comp.insurance.: 4 )6.0 We are a corporation and its officers have exercised then nght of exemption per%kil c. 1 ILIJ' ez / lg(S�l�/2 5 151%$1(it_and v.e have no anpluy+yes.(Nu workers'comp.insurance rcyuucd.] 'Any applicant that elto:ka boos oil must also fill Out the section lxrluw show rri�[hear iv+urkers'conspentauun policy mfonnation '1lomeowi rs.who submit this affidavit indicating they are doing all work and then hire outside col'rtraaata'ti rttuai submit a new alfida4 it indicating suck :Contractors that cheek Ibis box must attached ern additional theft showing the name of the sub-clmtr ctrxl and saute whether or nut those en t/L' Icx.; employees. If the sub-contractors have emplo.cet.tick. must provide their workers'ctmrpi policy number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the lwlicy and job site inforntation. insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City./StaterZip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152.§25A is a criminal violation punishable by a fine up to S 1,500.00 and}or one-year imprisonment.as well as cis it penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sism:tture: Date: Phone#: Official use only. Do nut write in this area.to he completed by city or town official City or Town: Pertnit'License# Issuing Autliurii (circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: City of Northampton Massachusetts ; i .:- ` DEPARTMENT OF BUILDING INSPECTIONS y ;j 4' 212 Main Street • Municipal Building J`' ?ate Northampton, MA 01060 C` �,,�00 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work 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: 1//9l4Y kCVC//A5 The debris will be transported by: Name of Hauler: --j• KfLa I1q VU1` Signature of Applicant: i/YT.0 Date: 9 f/v 1� City of Northampton Massachusetts ate" DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building '`. .Cam Northampton, MA 01060 si ^�3 j�„ HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT 1, (insert full legal name), born_(insert month, day, year), hereby depose and state the following: 1. 1 am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. 1 am not engaged in, and the project or work for which I am seeking the aforementioned homeowners' exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns 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 be considered a home owner. 4. 1 do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel,I acknowledge that I am required to and will act as the supervisor for said project or work. Signed under the pains and penalties of perjury on this day of ,20 . (Signature) ?"1/6, -�= \b ,110 A �, � ACORl5 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `�- 05/09/2024 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 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 THIMBLE httpsJ/support.thimble.com/ NAME: Verily Insurance Services,LLC DBA Thimble Insurance Services PHONE FAX 174 West 4th Street,Suite 204 (A/C.No.Extl•E New York,NY 10014 ADDRESS: support@thimble.com https://support.thimble.com/ INSURER(S)AFFORDING COVERAGE NAIC S INSURER A: National Specialty Insurance Company 22608 INSURED INSURER B: Cedar Falls Construction 209 Prospect St,Chicopee,MA,01013 INSURER C: alltlre209©yahoo.com INSURER D: INSURER E: INSURER F: https://www.thimble.com/check-policy-status/ 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-HE 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 SUBR POLICY EFF POLICY EXP LIMITS LTRINSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) X COMMERCIAL GENERAL LIABILITY 05/02/2024 05/02/2025 EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR 12:00 AM 12:00 AM PREMISES(Ea occurrence) $ 100.000 EDT EDT MED EXP(Any one person) $ 5,000 A — N N IBL-F3HGTJXAN PERSONAL&ADVINJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 1,000,000 X POLICY PRO- 1 ^ JECT I LOC PRODUCTS-COMP/OP AGG S 1,000,000 OTHER S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY ` AUTOS ONLY (Per accident) S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION i PER OTH- AND EMPLOYERS'LIABILITY Y!N STATUTE ER ANY PROPRIETOR PARTNER/EXECUTIVE I E.L.EACH ACCIDENT $ OFFICER MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1Jb/Ud1U14 bSiuuw/a EACH CLAIM f _ 100,000 A Cyber Insurance-Claims-Made N N IBL-F3HGTJXAN 12:00 AM EDT 12:00 AM EDT AGGREGATE 3 100,000 DESCRIPTION OF OPERATIONS!LOCATIONS VEHICLES (ACORD 101,Additional Romarks Schedule,may be attached If more space Isrequlrod) WARNING: THE GL POLICY IS NOT A COMPLETION BOND. IT PROVIDES COVERAGE FOR BODILY INJURY, PROPERTY DAMAGE, AND PERSONAL AND ADVERTISING INJURY. IT DOES NOT GUARANTEE THE COMPLETION OF WORK BY A CONTRACTOR. (con't on form Acord 101) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City Of Northampton Ma 212 Main St#100, Northampton, MA 01060 AUTHORIZED REPRESENTATIVE ?1.414) CI1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: allfire209@yahoo.com LOC#: 1 ACOROP ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Verifly Insurance Services, LLC DBA Thimble Insurance Services Cedar Falls Construction 209 Prospect St,Chicopee,MA,01013 POLICY NUMBER allfire209@yahoo.com IBL-F3HGTJXAN CARRIER NAIC CODE National Specialty Insurance Company 22608 EFFECTIVE DATE: 05/02/2024 12:00 AM EDT ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: Acord 25 FORM TITLE: Certificate of Liability Insurance Description of Operations (con't) Episodic Coverage (THSN CG 02 04 02 21) for policy number IBL-F3HGTJXAN until 05/02/2026 12:00 AM EDT ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIyYYY) `.� 05/10/2024 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 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 NAME: STEVEN A FARNSWORTH INS AGENCY IN No. I�ac,No):413-594-1966 202 EXCHANGE ST EMAIL ADDRESS: CHICOPEE, MA 01013 INSURER(S)AFFORDING COVERAGE NAIC B INSURERA:MAIN STREET AMERICA ASSURANCE INSURED INSURER B: JAMES M WARD INSURER C: 10B PUMPKIN LN INSURERD: WESTFIELD, MA 01085 INSURERE: 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 I ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSO WVD POLICY NUMBER (MMIDOiYYYY) (MMIDDIYYYY) LIMITS A COMMERCIAL GENERAL LIABILITY MPU7219M 5/16/2023 5/16/2024 EACH OCCURRENCE $ 1,000,000 DAGE TO CLAIMS-MADE X OCCUR PREMMISES(EaENTED occurence) $ 500,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ —^OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED ^ NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) _ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'UABIUTY YIN STATUTE ER ANY PROPRIETORiPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? n NIA --- -- (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S I` es.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached i1 more space is required) ELIZABETH ROACH, 337 ELM ST., NORTHAMPTON, MA 01060 CERTIFICATE HOLDER CANCELLATION CITY OF NORTHAMPTON MA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 212 MAIN ST ACCORDANCE WITH THE POLICY PROVISIONS. NORTHAMPTON, MA 01060 AUTHORIZED REPRESENTATIVE EMAIL:KCARSON@NORTHAMPTONMA.GOV I I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD