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35-258 (10) Client#: 18316 SELWA1 ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE 04/04/2014 ) 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 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 Cynthia'E.Milewski,AAI White-Jubinville Ins.Agency PHONE 413 538-8293 ac,No; 413 538-5970 A/C,No,Ext 39 Lamb Street E-MAIL cind mn.ubinville.com ADDRESS: Y @j P.O. BOX 789 INSURER(S)AFFORDING COVERAGE i NAIC# South Hadley,MA 01075 INSURER A:Western Heritage Ins.Co. INSURED INSURER B:A.I.M.Mutual Insurance Company Wayne J.Selkirk Chimney Cleaning and INSURER C: Selkirks Family — - INSURER D: 272 Newton Street South Hadley,MA 01075-2371 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 CONTRACTOR 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. LTRR TYPE OF INSURANCE NSRL WVD POLICY NUMBER MMNDY EFF MMO/LDICDY EXP LIMITS A GENERAL LIABILITY SCP0972238 1011512013 10115 120141 EACH OCCURRENCE _ $3001000 X COMMERCIAL GENERAL LIABILITY i PREMISES(EaE�urrence) $100,000 CLAIMS-MADE OCCUR MED EXP(Any one person) l s 5 000 PERSONAL&ADV INJURY s300,000 GENERAL AGGREGATE 1s600,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s 600,000 POLICY PE O LOC I is AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident Is ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ! BODILY INJURY(Per accident) S AUTOS AUTOS NON-OWNED 1 PROPERTY DAMAGE HIRED AUTOS AUTOS !(Per accident) j S Is UMBRELLA LIAB OCCUR EACH OCCURRENCE is EXCESS LIAB CLAIMS-MADE AGGREGATE s DED RETENTIONS $ B WORKERS COMPENSATION AND EMPLOYERS'LIABILITY AWC7025214012014 1!24/2014 01124/201 X WCSTATU- ', OTH- IAN Y PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? LNj N/A �(Mandatory in NH) i E.L.DISEASE-EA EMPLOYEE $100,000 yes,describe under ON OF OPERATIONS below ,E.L.DISEASE-POLICY LIMIT 1$500,000 Ti I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,It more space is required) LLC Members are not included for Workers'Compensation coverage These are the limits at policy inception CERTIFICATE HOLDER CANCELLATION Town Of Agawam SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Public Works Municipal Annex ACCORDANCE WITH THE POLICY PROVISIONS. 1000 Suffield Street Agawam,MA 01001 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S16266/M16265 CEM - . ,. i pa-' � � t .''e,� elf>` f'�'�'.` •` ,.. �.��;',�y�� .-� +� .. v, ti • �r ,_ .• �•�.,�►. +sit �� .t'. t+ ' 'y•• y.; t' � City of Northampton 5�5-.r, •fJ� Massachusetts DEPARTMENT OF SDZ.tDZNG ZNSPECTZONS 212 Main street a Municipal Building Sh ^a Northanpton, b% 01060 SINGLE OR TWO FAMILY SOLID FUEL APPLIANCE PERMIT APPLICATION FOR WOOD, COAL, PELLET, CORN, STRAW OR SIMILAR STOVES, OR FIREPLACE INSERTS Permit Fee: $25.00 Check# A(P14 PLEASE TYPE OR PRINT ALL INFORMATION 1 Name of Applicant: c Address: �. SP phone 2. Owner of Propertty::�+ i �; / ` �1 �G c�,t Address: 1 Urf QCk, LQ.I��Telephone: ( ( l 1�o-t J-)'t 3. Status of Applicant:`Owner �Contractor 4. Type or Brand of Stove: Wd A,� 8 11."A _ Inc 'FC'ogt«S-IiZ, � ri A If applicant is not the homeowner: Construction Supervisor's License Number L` J Lam- L/ t lExpiratioDae Z- /k Iq /-! Home Improvement Contractor Registration Number MS D � Expiration Date ,.� All Applicants must complete a Workers Compensation Insurance Affidavit before we can issue a permit 5. Certification:I hereby certify that the information contained herein is true and accurate to the best of my knowledge. DATE: L APPLICANT'S SIGNATURE DATE: HOMEOWNER'S SIGNATURE �Y APPROVED DATE: BUILDING OFFICIAL 91 TURKEY HILL RD BP-2015-0333 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 -258 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: woodstove BUILDING PERMIT Permit# BP-2015-0333 Project# JS-2015-000617 Est.Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WAYNE SELKIRK 99212 Lot Size(sc. It.): 79714.80 Owner: WHITE CHRISTOPHER Zonine: Applicant: WAYNE SELKIRK AT: 91 TURKEY HILL RD Applicant Address: Phone: Insurance: 272 NEWTON ST (413)455-9965 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON.912212014 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL WOODSTOCK SOAPSTONE PROGRESS HYBRID 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: 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 9/22/2014 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner