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42-157 (9) BP-2024-1 121 57 WOODLAND DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 42-157-001 CITY OF NORTHAMPTON Permit: Acc Structure PERSONS CONTRACTING WITH UNREGISTERED CONTRA(`TOILS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2024-1121 PERMISSION IS HEREBY GRANTED TO: Project# POOL HOUSE 2024 Contractor: License: ACCENT BUILDING& Est. Cost: 193334 REMODELING LLC 060967 Const.Class: Exp.Date:09/27/2024 Use Group: Owner: D IGNERI APRIL M&JEFFREY Lot Size (sq.ft.) Zoning: WSP Applicant: ACCENT BUILDING& REMODELING LLC Applicant Address Eh= Insurance: 81 LAUREL HILL RD 4136260930 ACWC485643 WESTHAMPTON, MA 01027 ISSUED ON: 09/03/2024 TO PERFORM THE FOLLOWING WORK: BUILD 28X20 POOL HOUSE 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 I rams: Gas: Fire Department Driveway Final: Fireplace/ChinuiQ,: Rough: Oil: Insulation: Smoke: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fees Paid: $280.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner �- � / CIV&D Official Receipt for Recording in: nonwealth of Massachuse is ________ . . AUG 3 ding Regulations and S . dam Li 2tia 7F0' ITY Hampshire County Registry of Deeds ; State Building Code, 7:0 C r M ICI tarA 201 60 Railroad Ave. N.?T nu»r), U'E 'To Construct, Repair, Renova - : r:, # 1'gp�c, ised ar 2011 Northampton, Massachusetts 01060 it Two-Family Dwelling a4 0 7ot',0 S Issued To: is Section For Official Use Only TIMOTHY SKROCKI u/ Date Applied: Recording Fees Signature Date x * TION 1:SITE INFORMATION Document Recording Description Number Book/Page Amount 1.2 Assessors Map& Parcel Numbers * * 6/4f,G•4-- DECIS 00012777 15213 312 $105.00 Map Number Parcel Number SKROCKI $105.00 1.4 Property Dimensions: Collected Amounts '-* * Lot Area(sq ft) Frontage(ft) Payment Type Amount * * Side Yards Rear Yard Check 1050 $105.00 Required Provided Required Provided $105.00 ? 37/L.-0200'(- ? .6'o' t Flood Zone Information: 1.8 Sewage Disposal System: Total Received : $105.00 Outside Flood Zone? Less Total Recordings: $105.00 Check ifyes❑ Municipal ❑ On site disposal system le Change Due $.00 )N 2: PROPERTY OWNERSHIP' F `vrLnUl-l (I 0 I 0 G2, Thank You City,State,ZIP _ , MARY OLBERDING - Register of Deeds yo1-,255,. 05S .1 C-t :1345e c.\,,‘oucvA_, By: Shari M Telephone Email Address ION OF PROPOSED WORK2(check all that apply) Receipt# Date Tire ,� 0430763 08/20/2024 01:15p Owner-Occupied 0 Repairs(s) ❑ Alteration(s) 0 Addition 0 Demolition 0 I Accessory Bldg.0 Number of Units Other ❑ Specify: r ckr A Brief Description Proposed Work2: bu, /d Pod //DU.1G. L')tad win Q. I a '><d- oc•t_ A �` eTTocIc.( Pats- 16.T4n4.o,-- a� Claus'r comet. . cm (wale!' wart, wolf hove ce #000 �' Sr,J�t.-- T A To ( ,7, Cc,T/L. S act i ► 1, b L E.A. Gv,fl / T• bL 1J1k llaMMM at c 4J.> ?e 4JA7J. .�ec� tj.;f/ i A c' -c. kiT k a 4' a ti . 4 roavl • e�— ,� "SECTIO4 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ /7242 9 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $h1c4.2 f 4' 0 Standard City/Town Application Fee 0 Total Project Cost'(Item 6)x multiplier x 3. Plumbing $/,146-(/ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire Suppression) $ Total All Fees: ilD o Check No.10 6 Check Amount: )- Cash Amount: 6.Total Project Cost: $if.? 3)y 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor/ a License(CSL) C S_GG G S, 7 o MA 7/a�y 7)/ 4 Q I' License Number Expiration Date Name of CSI, older List CSL Type(sec below) cf-1 LAttpd 1-1.`1 1 itii. No.and Street/ Type Description t L r07�/ 4�b/ Mfr. R of i7 ç Unrestricted(Buildings up to 35,000 Cu. ft.) /N`�/ Restricted 1&2 Family Dwelling City/Town,St e,ZIP M Masonry RC Roofing Covering AKt T. r1�� a etara WS Window and Siding / ,/c4 SF Solid Fuel Burning Appliances (� //3 G. -09 h) A/tr. I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement/ Contractor(HIC) l j-)L't,, /a1d /�f. 0 /tcrk,r Qt'/4�P j 4 Ail ,' L'C. I IIC Registrationgi Number Expiration B/ vWD}2ate? I Company Nam or C gistran me or) LivA44 1 e-0 at'ct4tAAsilytCor,..co ..rnr No.and Street Email address !vein., ,Tu.t MA. &Da" 90' 24.0930 City/Town,'State,LIP 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 Iss of the building permit. Signed Affidavit Attached? Yes V' No .❑ 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 Arai Drib P"�eho'C!, `t to act y behalf,in all matters relative to work authorized by this buil mg permit application Y. �� rt tp‘I SICyI1 Print Owner's Name(Electic 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 contain in 1 i ap.lication is true and accurate to the best of my knowledge and understanding. ae. ii,(1,23 „90,2Y P T OWner's or Ayzfie,ei. Agent's Name(Electr is 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.gov/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 s 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" CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD t 1 5H0Wer fuses ( TOO -?0 i SI E YARD C200 SID YARD -WI o FRONT SETBACK /5 ar FRONTAGE City of Northampton o` , rj•.. -"' N Massachusetts '',� * . G r �v._ DEPARTMENT OF BUILDING INSPECTIONS 3 212 Main Street • Municipal Building 1, }M- Northampton, MA 01060 44!-,,, 0`1` 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: �G I/ �� C� —��y w�',1e Tv�, �. fro �.. it I • V The debris will be transported by: Name of Hauler: /-ccti-7 94114 01-44 LLe / Signature of Applicant: Date: zl( -. The Commonwealth of Massachusetts = Department of Industrial Accidents _.�; 1 Congress Street,Suite 100 `• ,a►el_ Boston, MA 02114-2017 `-"rzt. y WWK.mass.gov/dia %%takers' Compensation Insurance.Affidavit:BuilderslContraetorJEkctricians/Plumbers. to LW FILED V%I IA I HE I'ERMI7TINC ALTIIORITi'. .Innlicant Information ,{ n j Please Print Leeibls Name(:Lousiness Organization lndiv iduai): ;,tr1 I }1 ' 'P Q Ell()i t-1 1 f'ii /(f Address: S) 1/UA V'el - {-Ol.\I 6 C itv!State/Zip: VVQq` U iA P1 I 01014 Phone#: -4{'I3— 102(O- (1 (-) r %re%uu an employer°('heck the appropriate bps: hype ofC project(required): l.� m a a employ with ___,employees(full and'er part•tiinei.' 7. a'1`iess construction 20 I am a auk proprietor or partnership and have nu employees working for me in II. O Remodeling any capaetty.[Nu workers'comp.enwurarux required.[ 9. a Demolition 30 i ant a homeowner doing all work myself.[No workers'comp.insurance requited.)' 4.0 1 am a homeowner and w ill be hiring ixnuni,1ors to conduct all work on my property. I will 10 O Building addition homeowner eraun that all contractors either have workers'compensation insurancx or an sole 11.a Electrical repairs or addition. proprietors with no employees. 12.0 Plumbing repairs or additions 'c.r3 I am a general contractor and I base hind the sub-contractors listed on the anaetted sheet. 130 Roof repairs These sub-contractors have employees and tease winters'comp.insurance. '0 We are a corporation and its officers hay a exercised then right of exemption per Pail c- 14.0 Other 152.§114 t.and we have no anplo,ves.[No workers'comp.insurance required.] 'Any applicani that checks box al mint also fill out the section below showing their workers'cumpcnaation policy informatiun- t Homeowner who submit this affidavit indicating they are doing all work and then hire outside cuntracturs must submit a new affidavit indicating such. 1C'untracton that cheek this box must attached an additional sheet show ini;the name of the sub-contractors and state whether or not those entities have rmplutir., If the sub-cuntractc.r.l,.r.,employees.they must pity.id,1E1,17 .wutkrr. whip.poor.. nuaih.r I um on employer that is pro►iding workers'compensation insurance for my employees. Below is the policy and job site inftrmutiwn. ' Insurance Company Name: L Policy#or Self-ins.Lie.#: 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 MGL c. 152. ;25A is a criminal violation punishable by a line up to S 1.500.00 and or one-year imprisonment.as well as cavil penalties in the form of a STOP WORK ORDER and a tine 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 and r t ' s and penalties of perjury that the information provided above Is true and correct. SILnature: ��QQ�� 1):a, S/ `c /Of 1'luinc ::: 40- /72 �O 5) Official use only. Do not write in this urea.to he completed by city or town official City or Town: Permit,License# Issuing Authority(circle one): ' I. Board of Health 2.Building Department 3.City Jost n('krk 4. Electrical Inspector 5. Plumbing Inspector G.Other (iintact Person:_ Phone#: i ,N 1 I 1 I I I I I 11111 III III OH V 0 2024 0 121// Bk: 1 o'213Pg: 312 Page: 1 of 2 Recoided: 08/20/2024 01:15 PM Planning & Sustainability • City of Northampton planning I resiliency I conservation I place-making I sustainable transportation I zoning I GIS I historic I CB architecture I agriculture and food (413)587-1266•northamptonma.gov/plan Planning Board Decision:Approved with Conditions Applicant: Owner if Different Than Applicant: Timothy Skrocki Jeffrey Igneri 81 Laurel Hill Road 57 Woodland Drive Westhampton,MA 01027 Florence, MA 01062 413-626-0930 ext.00000 401-255-3055 accent.building@comcast.net aprilduso@yahoo.com Site Address: Site Assessor Map ID(s):42-157-001 57 WOODLAND DR Book/Page Number: 12614/324 NORTHAMPTON, MA 01062 Zoning District:WSP-18 Additional Location(s): Permit Type(s): Site Plan Approval- Intermediate Project Description: The project consists of 640 square foot pool house that will contain bathing and kitchen facilities,thus it qualifies as a detached second living unit.The structure will be to the side/rear of the lot. Planning Board Decision Details: Date Submitted: May 30,2024 Hearing Date:July 25,2024 Extension Date: Hearing Closed Date:July 25,2024 Decision Date:July 25,2024 Filed with Clerk Date:July 29,2024 Appeal Deadline Date:August 19,2024 An appeal of this decision by the Zoning Board may be made by any person within 20 days after the date of the filing of this decision with the City Clerk,as shown,Appeals by any aggrieved party must be pursuant to MGL Chapter 40A, Section 17 as amended and may be made to the Hampshire Superior Court with a certified copy of the appeal sent to the City Clerk of the City of Northampton. Planning Board Members Vote George Kohout Favor Melissa Fowler Favor Janna White Favor Richard Baker Favor Stacey Dakai Favor Planning Board Findings Upon review of the application,the Board determined that the standards in Site Plan Review 350-11.6 had been met. Specifically A.The requested use protects adjoining premises against seriously detrimental uses. If applicable,this shall include provision for surface water drainage,sound and sight buffers and preservation of views, light,and air; The 640 square foot structure to the rear and the side of the site is accessory to the principal single family home;and B.The requested use will not alter vehicular and pedestrian movement within the site and on adjacent streets,cycle tracks and bike paths. The structure is accessed from the existing driveway.The Board waived the traffic mitigation, based on the fact that this pool house is not a separate residence and the size would have qualified for an exemption previously as a detached dwelling unit. Access by nonmotorized means for this residence is typical of single/two family dwellings C.The site will function harmoniously in relation to other structures and open spaces to the natural landscape,existing buildings and other community assets in the area as it relates to landscaping,drainage,sight lines,building orientation, massing,egress,and setbacks. D.The requested use will not overload,and will mitigate adverse impacts on,the City's resources, including the effect on the City's water supply and distribution system, sanitary and storm sewage collection and treatment systems,fire protection,streets and schools. E.The requested use meets any special regulations set forth in this chapter,which includes 6.11 for second units F.Compliance with the following technical performance standards: (1)Curb cuts onto streets shall be minimized.The existing driveway will be used. (2)Pedestrian,bicycle and vehicular traffic movement on site is separated,to the extent consistent with single and two family use. I,Carolyn Misch,certify that this is a true and accurate decision of the Planning Board. Abutters and Parties in Interest are mailed notification of this decision. Clevc,64,1 L) ..\14,44a, eive Planning Board Conditions Any air space HVAC systems must be all electric. --� JUL 2 9 2024 City Clerk's Office Northampton, MA 01080 City Hall•210 Main Street,Second Floor•Northampton,MA 01060•NorthamptonMA.gov/plan August 20, 2024 I, Pamela L. Powers, City Clerk of the City of Northampton, hereby certify that the above Decision of the Northampton Planning Board was filed in the Office of the City Clerk on July 29, 2024 that twenty days have elapsed since such filing and that no appeal has been filed in this matter. ?��� Attest: 'SiC!%✓� titt r, At rtai: OM. HAMPSHIRE REGISTER City Clerk, City of Northampton MARY OLBERDING City of Northampton Massachusetts �?S7 Cs, # G ( � DEPARTMNT OF BUILDING INSPECTIONS `• 212 Main Street • Municipal Building J`. Cam ` ..c'' Northampton, MA 01060 ' ' 3-' HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT 151 I t') (insert full legal name), born _ (insert month, day,year),hereby depose and state trie following: 1. I 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. I am not engaged in, and the project or work for which I am seeking the aforementioned lwmeowners'exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 1I0.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. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualifij 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 activihij 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 acknoz -age that 1 am required to and will act as the supervisor for said project or work./ Signed un' e pain an . es of perjury on this (0 day of! " ► 'ty , 20'1 1 (S !, ACCENT BUILDING 8e REMODELING, LLC. 81 Laurel Hill Road * Westhampton,MA 01027 * 413.626.0930 CONTRACT The following estimate is for a pool house located 57 Woodland Drive in Florence, MA and pricing on entire project is based on the prints provided with a couple changes to the prints that the gym area is not being included, however the closet and half bathroom area will be included. Pool house size has enlarged to 28'x20'. It was originally 24'x14'. Closet and bathroom area will stay the same, 12'x8'. The foundation will be poured concrete with appropriate footings 48" below frost line. A 4" concrete pad will be poured on the inside with wire mesh to help keep slab from cracking (this can still occur). Concrete form will be either a broom or smooth finish. If a stamped look is desired to match pool concrete, this can be done but at an additional cost. Area between pool house and existing concrete pool pad is not included. This will be determined during job. Pool house will be framed according to prints provided, with the additional larger build (28'x20'). Concrete company will also pour a slab on the back side of bathroom for an outdoor shower that will be approximately 4'x4'. Interior walls will have sheetrock, taped three (3) Coates and sanded, ready for painting. Cathedral ceiling in main pool house area will have 51/2" bead board tongue and groove wood installed and painted. A 30 year architectural shingle will be installed with ice and water protection up the first 6'from the eaves and 4' in both valleys. 8"drip edge will be installed on all roof edges. Continuous ridge vent will be installed where needed. Vinyl windows and a full length door will be provided by Pella. Full length door will be approximately 20' wide and 82"tall. This door will open all the way to one side, leaving an opening of approximately 14.5'. All interior trim around windows and doors will be 1x4 flat stock with 1x6 flat stock for baseboard. Two (2) interior doors will be installed. All interior trim and doors will be painted EXCAVATION: Due to the placement of this project and distance across the yard we cannot be held responsible for any damage to the yard or driveway. The excavator will, however, provide ground mats to help protect the yard from driveway to pool house area as best as possible. He will dig hole for footings and foundation, provide clean backfill inside and outside of the foundation. He will also dig a trench from pool house to main house by main electrical meter that will have plumbing lines, sever lines and electrical. He will also dig a separate trench from propane tank to pool house. After job is completed, excavator will repair grass area that has been disturbed with new loam and reseeded. Any lawn sprinklers and moving and reinstalling pool fence will need to be done by others and is not included in this estimate. ELECTRICAL: Wire New Pool House to Include: 100A Load Center fed from house 2 conduits laid in trench (trench by others) (1) 1.25"for power and (1) 1"for Internet Wiring for Range, Fridge and Kitchen counter circuits Run pipe to Island for power Run 2 circuits to Gym outlets Provide and install 14 4"wafer lights Light location in closet and (2) Pendant light location over Island (fixtures by others) Wire bath with Exhaust Fan/Light and Vanity light location (fixture by others) Wire for exterior light locations by ea. door(fixtures by others) Wire (3) spotlight locations (lights by others) in rear and sides of building Provide for and wire in (2)exterior GFCI protected receptacles with WP Covers PLUMBING: 1 Gerber comfort height toilet, Delta 3538 SS lay faucet, De4lta Pull down spray kitchen faucet (no sinks), 5-gallon electric water heater, Liberty sewage pump system, sewer and water connections to house. Plumber will install propane to stove and stub it outside of pool house. Propane company will be responsible for running propane line from tank to pool house and making the connection. Plumber will also run hot and cold-water line to outside shower. No drain will be installed,water will just run off concrete slab and onto ground. GUTTERS: Gutter and downspouts will be installed based on print and gutter company specs. INSULATION: All exterior walls and cathedral ceiling will be insulated according to specs on print. PAINT: All drywall will be primed one (1) coat and painted two (2) coats of finish paint this will be the same for all interior trim and doors. SIDING: Vinyl siding and soffits will be instailed according to print. Job site will be cleaned and left safe daily. Removal of all job-related trash is included and will be taken to Valley Recycling. Permit fee to the City of Northampton will be an additional charge. Total Job Cost: $194,334.00 Payment Schedule: $100,000 once permit is pulled and to start project $ 75,000 once drywall is installed Balance plus any extras (permit fee, etc) upon job completion April 24, 2024 Tim rocki or, Ac t Building & Remodeling, LLC Date: S 144 y T eri April geri ssachuse— Commonwealth °ational L censure ®� Division of Occup Board of Building Re Tations and Standards rvisor Conte ion F CS-060967 Y i spires:0912712024 TIMOTHY F g(ROCKI ,� 81 LAUREL MiLN 01027. WESTHAMPI`Y J 1b,Yb[ 1 n 1. e. 1. -c nnnosionc :,/.. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs& Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individ TYPE:LLC expiration date. If found return to: only before the Registration Office of Consumer Affairs and Business Regulation --- Exni_�rati24 1000 Washington Street -Suite 710 117441 10/26/2024 ACCENT BUILDING&REMODELING LLC Boston, MA 02118 TIMOTHY F.SKROCKI 81 LAUREL HILL RD. WESTHAMPTON.MA 01027 '.,-,--, r / ./( Undersecretary Not valid( without signature A Worker's Compensation and Employer's Liability Policy //Berkshire Hathaway NorGUARD Insurance Company - A Stock Co. tNZ/ y Policy Number ACWC485643 idtGi Insurance Renewal of NEW 4`I1 ARD Companies NCCI No. [25844] Policy Information Page [1]Named Insured and Mailing Address Agency Accent Building and Remodeling LLC AXIA INSURANCE SERVICES 81 Laurel Hill Rd 84 Myron Street Westhampton, MA 01027 West Springfield, MA 01089 Agency Code: MAAXIA10 Federal Employer's ID XX-XXX6261 Insured is Limited Liability Co. (LLC) [2] Policy Period From December 1, 2023 to December 1, 2024, 12:01 AM, standard time at the insured's mailing address. [3] Coverage - --- - --- --- _--- -- z_ A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $500,000 Bodily Injury by Disease - each employee $500,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium - - - ---- -- - -- — -- — --- - The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) ITotal Estimated Policy Premium $ 2,305 Total Surcharges/Assessments $ $92.00 Total Estimated Cost $ $2,397.00 INTERNAL USE M2 Page - 1 - Information Page MGA :ACWC485643 WC 000001A Date : 11/16/2023 MANOTE Issuing Office: P.O. Box AH, 39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guard.com ------Nni ACCEBUI-01 CPOROWSKI ACORif, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `--'�- 8/30/2024 -- - - - - -_ 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 NaTACT — AXiA Insurance Services PHONE FAX 84 Myron Street iArc,No.Ext):(413)788-9000 (A/C,No):(413)886-0190 Suite A .inf axiagroup.net West Springfield,MA 01089 INSURER(S)AFFORDING COVERAGE NAIC p INSURER A:MSA Main Street America Assurance Company 29939 INSURED INSURER a:Guard Insurance 42390 , Accent Building& Remodeling LLC INSURERC: _ -- 81 Laurel Hill Road INSURERD: Westhampton,MA 01027 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POUCY EXP LIMITS LTR INSD WVD (MMIDD/YYYY) (MMIDD/YYYYI A X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE 1 CLAIMS-MADE X OCCUR MPT2437C 9/10/2023 9/10/2024 PPREMLGSEEs EaEoncurenea1 $ 500,000 - MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY XJ P r X LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER EPLI $ 10,000 A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 _ (pa accident)- ANY AUTO M 1 P8116 D 9/10/2023 9/10/2024 BODILY INJURY(Per person) $— OWNED SCHEDULED ' AUTOSRE ONLY X AUTOS Ep BODILYBO INJURYp (Per accident) $ 1 X_ AUTOS ONLY X AUTOS ONLY I (Pere c dent)AMAGE $ $ L__ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE-_ $ EXCESS LIAB CLAIMS-MADE AGGREGATE 1 DED RETENTION$ $ B WORKERS COMPENSATION 0T X I PER TH- AND EMPLOYERS'LIABILITY STATUTE YIN ANY PROPRIETORJPARTNER,EXECUTIVE ACWC485643 1211/2023 12'1/2024 E.L.EACH ACCIDENT _$ 500,000 �FFICER�MEMBEREXCLUDED? NIA lindatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below ' E.L.DISEASE-POLICY LIMIT $ A Installation/Builder MPT2437C 9/10/2023 9/10/2024 Limt 100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Northampton THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Northampton Building Department AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD