12C-092 (8) 7 MARY JANE LN BP-2017-1156
GIS#: _ COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C-092 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: FIRE RESTORATION BUILDING PERMIT
Permit# BP-2017-1156
Project# JS-2017-001945
Est. Cost: $81500.00
Fee: $489.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: KYLE SAVAGE 100069
Lot Size(sq. ft.): 10018.80 Owner: LEAF BRIAN 1&GWENDOLYN L
zoning: RIO00)/URA000)/wSP(77)/ Applicant: KYLE SAVAGE
AT: 7 MARY JANE LN
Applicant Address: Phone: Insurance:
62 MOUNTAINVIEW DR (413) 687-9751 WC
BELCHERTOW NMA01007 ISSUED ON:4/14/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:GUT SINGLE LEVEL HOUSE TO STUDS,
ENCAPSULATE & REPLACE TO MATCH EXISTING FINISHES
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: O1: 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 $489.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
i. ---- ---- - City of Northampton
I Building Department
I 212 Main Street
LA 13 LUII I Room 100
Nj 13 58h -1240, MA 010603
°Ep r '�;�p 5f o�r�esA' 13 587-1240 Fax 413-587-1272
r.,i m cyr..,^�c,o
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION Y
1.1 Property Address , ' ;Thle spctianRodblkt tt
a¢ , .Ib*itly 0 ,
1 lkftg � " AUC LANE NY i4 L° � kS.
Ji
NlG1`iE•iHl*ri£rcTS.t tV./{ +r", I' - - -'7:',S '
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
KpctAM uEAr -1 MAv.4 (AtU Lau,
Name(Print) Current Mailin Address'
1!u{ 32,0 2, 7_
Telephone I
Signature frenal l- steac-tho41m(Atl,corn
2.2 Authorized Anent: 1
_��It,r\t' j31/Mo�, . tet t✓�aon}rnln thew i>0_, Q2�Cbeitaih,(.1Lj' j}
Name( rnt)-1, c....) Current Mailing Address:
Signature5. cC.) Telephone —
SECTION 3-ESTIMATE('CONSTRUCTION COSTS
Rem Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
I. Building —10 00(3 (a)Building Permit Fee
I
2. Electrical 1/5-'0 6 (h)Estimated Total Cost ConstructionMfrof
from(6)
3. PlumbingBuildingPermit Fee
,L ` y$
trj 0� 7l
4. Mechanical(HVAC)
5. Fire Protection I/I�4 0 - � n
6. Total=(1 +2+3+4+5) $ /3I t CC) 0 Check Number ,�/L' /!y
This Section For Official Use Only
I
Building Permit Number. ste
: ssued: . {/ /
Signature: > ! -tg _ / 7 --
Budding Commissionerenspectorof Buildings ' Date
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Clue To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled io by
Building Department
Lot Size 1 7 —��
Frontage I-- • i
Setbacks Front I [—I L.._
Side Lr I R: L:I-1 R:I I I
Rear 11
Building Height 1
Bldg.Square Footage 1-1 /o --'] I 1
Open Space Footage °o _
(Lot area minus Lida&paved I J � 1 l )
parking)
#of Parking Spaces I r-1
Fill: — — — (
(volume&Location) ,_ I
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ODONT KNOWI I. YES Q
IF YES, date issued: ,_._7
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW g YES O
IF YES: enter Book — Pagel 1 and/or Document#1
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q , Date Issued:
C. Do any signs exist on the property? YES O NO tcli
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO ,(Qf
IF YES, describe size, type and location:
E. WII the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over I acre? YES 0 N
IF YES,then a Northampton Storm Water Management ermit from the DPW is required.
•
f
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable]
New House n Addition ❑ Replacement Windows Alteration(s) 14 Roofing 0
Or Doors 0
Accessory Bldg. ❑ Demolition 11/ New Signs [0] Decks [q Siding [D] Other[DI
Brief Description of Proposed
Work: (DVC Strrje level hOUt. +0 N.IiCkS I rnClCITSXAOCk and reploc . to r eAtch
^^'' extS4-)Y-5 otS1.aS-
Alteration of existing bedroom Yes No Adding new bedroom Yes K No
Attached Narrative Renovating unfinished basement Yes 0( No
Plans Attached Roll -Sheet
r; .. . . ....... .. . . .......1isi tl 'E yin t s.
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: i 6rNumberof Bathrooms 1- i/7.--
C. Is there a garage attached? LIC-3
d. Proposed Square footage of new construction. 3AYYI€L Dimensions Sift re-,E
e. Number of stories? I._'
f. Method of heating? 6A4 IZDA-Y'._X-) Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction ..5-5
i. Is construction within 100 ft.of wetlands? Yes V No. Is construction within 100 yr. floodplain Yes \/No
j. Depth of basement or cellar floor below finished grade -t/- (0-1 ETT'
k. Will building conform to the Building and Zoning regulations? V Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE.COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, R2l R K) 1 't Pte , as Owner of the subject
property q
hereby authorize t4yiE )PrVA(oL-
to act on my behalf, in all matters rdlative to work authorized by this building permit application.
Signature of Owner 3
Date 1,3
I, 04‘ilc}. SA VACO , as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
t21E SAVALflL
Print Nanle J 47///3//
, 1
9 42/Agent /l i3I�1
Signature of n Date -
SECTION -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0 ('�
Name of License Holder: ;}j t Q. AVACo 4 1. jOn COI
License Number
teL Mounkxu'Vttu dii 8-dditarkown IAA 0106-7 /zo ( i'1
Address Expiration Date
• 4t1s (Al s'
Signal."'"Sgnat"'" �.. j "attentions
Y}3AVA ,E`1\3 ecyno,tl,Paovv\
Not Applicable 0
(,osS CS4Wehm+t\ t i q 303
Company Name Registration Number
IZ c,lcNuxr2sa NAL/4 ( S- M (‘A.R 41S--
_Telephonene_„
SECTION 18-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.0 L c.:152,§25q6})
Workers Compensation Insurance affi evil must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the bui ing permit.
Signed Affidavit Attached Yes....... No 0
c, kc o
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 7$0, Sixth Edition Section I083.5.1.
Definition of Homeowner:Person(s)who own 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 homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible For all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,duringand upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
r
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: 1 Mg211"SgNO-
The debris will be transported by: PIssoc.telt o 1 LOMA, (�iceC- CC S
The debris will be received by: TtzpwSc.' Fli(ilLltAA
Building permit number:
Name of Permit Applicant �. CD355 CcinsArcoCTAa'''l
c,l ' �3 I11 n
Date Sig ure of Perm pplicant
The Commonwealth of Massachusetts
_,_— Department of Industrial Accidents
'ukpayra gt TOffice of Investigations
_:al=
t, -o 1 Congress Street,Suite 100
•�_�=44 Boston,MA 02114-2017
MP-. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): . GCS'S Cc nsI t1.V CD
Address: It (a14 N v0.0t5V 021\)
City/State/Zip: Oecsit%15,Lp M -11
A 010%c Phone #: c3 t.12 Cu Cart
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
9 ❑ Building addition
[No workers' comp. insurance comp.insurance.:
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself.[No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box kl must also fill out the section below showing their workers'compensation policy information
I Homeowners who submitthis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tcontactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. lithe sub-contractors 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 and job site
information. q �
Insurance Company Name: T2N�w+Lv�S
Policy#or Self-ins.Lic.#: EA A Expiration Date:
Job Site Address: 1 INA PH IAl.* (A 1--)4 City/State/Zip: k cvral2 AMPt6Ti
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby e ify u •er the •ains and penalties of perjury that the information provided above is true and correct
,
t
Si. ature: L_ _��_ ^t p� Date: e' a
/
Phone#: "11� UZ1d (go-21
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that`every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomrance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE
Revised 7-2013 Fax# 617-727-7749
www.mass.gov/dia
City of Northampton
�t r ro.
Massachusetts " L {�.
( otai
DEPARTMENT DP BUILDING INSPECTIONS Si�� e,
212 Hain Street . Municipal Building spy`,, ca
Northampton, EM 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
f ut. 0 t :.r...EMPT b2- • KN IQEDQ u. NT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends 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."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footings (before backfiilk sonotube holes(before pour).a rough building insp on.
/before work is concealed). insulation inspection /if reauired)and a final building inspection
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing& gas)the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
09/13/2017 04:04PM 8552786332 R JASAK PC INS PAGE 02/02
s►c o® CERTIFICATE OF LIABILITY INSURANCE DATEthlM1ODT
IN.....--"' 04/1312017
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: H 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 endorsemeet(s).
PaeoucER ,G AC Regina Jasak
REGINA JASAK INDEPENDENT INSURANCE INCENIC
orEed (855)834-9607 T�+I «i
naNsEss, reginalAregn*Sekcorn—
PO BOX 543 a18UREN1Sf AFFORDING COVERAGE NAIC4 _
LUDLOW MA 01056 INSURERA t TRAVELERS INDEMNITY CO OF AMERICA 25686
INstxtio hxsuRma. — --. .
GOSS JARROD DBA GOSS CONSTRUCTIONIxeVRERC
tNSURER V,
12 GLENNWOD DR INSURER E
WESTFIELD MA 01085 a+suRER F: •
COVERAGES CERTIFICATE NUMBER: 143759 REVISION NUMBER:
THIS IS TO CERTIFY THAT Tl'+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 SEEN REDUCED BY PAID CLAIMS.
IMSA. TPE°FINSIIPWM AUUL PMICYEXP
, a� pOLKYXVNeER tAWDO Yrr. MVOPTYYY LIMITS
- COMMERCIALGEtERAL Wreathe I EACH OCCIKMENGI S
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AUTOMOBILE LIABILITY 1 . MBMEDSINGL' it S
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AUL OWNED SCHEDULED N/A .ODD INJURYIP oU 6
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A s e D' �NO4 NIA i WA 6HUPIH68099116 09/1612016 09/16/2017 --
IWeeny InNH) Eh-DISEASE•EA EMPLOYEE 5 100,000
Uwe c
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oe EscHETION OF satoe 'EL.DISEASE-EogunING $ 500 ON
N/A
DESCRIPTION Of OPERATIONS I LOCATIONS I VEHICLES WORD 101,additional Remarks Schacht ,may be attached N mum spare is requited)
Workers'Compensation benefits will be paid to M6ssachusetls employees only.Pursuant to Endorsemenl WO 200306 B,no euthorizat'on Is giver)to pay claims or benefits to
employees in states other than Massachusetts B the insured hires,or has hired those eapinyees outside el Massachusetts.
This GeriiInate of Insurance shows the policy to/Owe on the date that this certl}icatewas owed(unless the a pi¢Gondate on the above policy precedes the Issue date 0f this
cerbkaIe of issuart^e1_ The status of this coveragecan be monitored daily by accessing the Amor or Coverage-Caveeay Verification Search lad at
ermemass govAwe;workers-cempensationrmveM19Btunst.
Sale proprietor has not elecled coverage.
CERTIFICATE HOLDER CANCELLATION
steam)ANY OF THE ABOVE DESCREIED POLICIES BECANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
TOWN OF NORTHAM PT N ACCORDANCEWITNTHE POLICY PROVISIONS.
210 MAIN ST AUTHORIZED REPRESENTATIVE
Th. Q L,e(,-
NORTHAMPTON MA 01060 Dames M.Crxoy,CPCU,Vice President—Residual Market–WORIBMA
I
01088-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
09/13/2017 04: 04PM 8552786332 R JASAK IND INS PAGE 01/02
Aconct CERTIFICATE OF LIABILITY INSURANCE DATE YTI
04ro)1DIWW
T. -
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 A
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 policypes)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).
PRODUCERChristina Wieeler
P11Regina-lank Independenl Insurance Inc sic es E.4' (413)315-5775 IFa,Rol. (855)278-6332
en
P 0 Box 543 ADDRESS.
PGURERIS)AFFORDING COVERAGE aAFC
Ludlow MA 01056 INSURER A: Concord Group-CL
INSURED INSURER e: Concord Group-CL
Jarrod Con DBA Goss Construction INSURER C
12 Glenwood Dr IS/SLIDER D.
INSURERS
Westfield MA 01085 INSURER F.
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS I5 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTNETHSTANDING 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 POLICIEOSIX.�LsIUMITS SHOWN MAT HAVE BEEN REDUCED BY PAID CLAIMS.
ernttsaunas, pony Exp
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POLICY NURSER OAMODNYYY1 IMNAMYYTYYI LIMITS
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2000000
COMMERCIAL GENERALITIDD
(Ea occurrence) 100000
AM .AD nOCCUR
MED EXP(AnMYna Texa) 5000
❑ 3/16/2017 31161201B PERSONAL SAW INJURY 2000000
❑
GENERAL GGREGATE 1000000
GENT AGGREGATE OMIT ROUTES PER PRODUCTS.cOMRaPAGG 2000000
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DESCRIPTION Of OPERATORSILOCATIONSI VEHICLES(Arch ACORD IDI,Additional Remarks Schedule,11 mon apace is required/
CARPENTRY
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
NORTHAMTON BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
NORTHAMPTON,MA AlmwRZED REPRESENTATIVE
CHRISTINA WHEELER
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