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25C-251 (109)
54 FAIR ST-3 COUNTY FAIR BP-2018-1042 CIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C-251 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: stage BUILDING PERMIT Permit# BP-2018-1042 Prciect# JS-2018-001894 Est.Cosr. $2000.00 Fee:$100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: T JAMES HANABURGH - RONIN PRODUCTIONS_ Lot Siae(so.ft.): Owner: HAMPSHIRE FRANKLIN&HAMPDEN AGRICULTURAL SOCIETY Zoning: SC(100)/URB(1)/ Applicant. T JAMES HANABURGH - RONIN PRODUCTIONS AT. 54 FAIR ST - 3 COUNTY FAIR ApplicantAddress: Phone: Insurance: PO BOX 398 (413) 687-8522 SUNDERLANDMA01375 ISSUED ON.-411712018 0:00:00 TO PERFORM THE FOLLOWING WORK:TEMPORARY STRUCTURE FOR CONCERT 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 4/17/20180:00:00 $100.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2018-1042 APPLICANT/CONTACT PERSON T JAMES HANABURGH-RONIN PRODUCTIONS ADDRESS/PHONE PO BOX 398 SUNDERLAND (413)687-8522 PROPERTY LOCATION 54 BRIDGE ST MAP 25C PARCEL 251 001 ZONE SC(100)/URB(1)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST EN ED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid TypeofConstruction: TEMPORARY STRUCTURE ONCERT !N New Construction Non Structural interior 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: proved_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 Special Permit 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 Delaylae Signature of Building Official 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 of Planning&Development for more information. sr ' Versiont.7 Commercial Building Permit May 15,2000 Department use only City of Northampton Status of Permit Building Department Curb Cut(Dmewivay Permit 212 Main Street Sewer/Septic Alai lebllity Room 100 WatenWell Availability Northampton, MA 01060 Two Bets of structural Platin - phone 413-587-1240 Fax 413-587-1272 PloytlSfte Plans Other Specify APPLICATION TO CONSTRUCT,REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Pro ert Address: .{ This section to be completed by oirce G ae-1-J. I.?tl j r4/IRrS Map eISC- Lot unit (s8 IR`tf Zone Overlay District Elm at District CB District SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Pant) Current Mailing Address. Signature Telephone 2.2 Authorized Acent: T Ili 1, -Fa: x 9�54dii s7.�7- Name(Print) Curze Mallin Address is�b87-9�� Signature Telephone SECTION 3-E46flMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only conceded b1permit a plicant 1. Building qppd b (a) Building Permit Fee 2. Electrical (b)Estimated Total Cast of Construction from fi 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) Q 'l '^c 5. Fire Protection c.l��Q0. 6. Total=(1 +2+3+4+5) Z Check Number �9 This Section For Official Use Only Building Permit Number Date Issued Signature'. Building Commissionedlnspector of Buildings Date Version L7 Comm:rcir I Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS"HAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition Repairs Additions ❑ Accessory Building Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ R000fiingg❑ Chh"angeof Use U❑ Other Brief Description 'Enter a brief desseription here. Z+�K IJ'I oi-, �- U) ;ft ,f�[/ Of Proposed Work: t)velicv jp�a�/'. d,G✓tSL"e G(� SECTION 5•USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ElA-21:1A-3 El 1A ❑ A-0 ❑ A-5 ] 1B ❑ B Business ❑ _ 2A ❑ E Educational ❑ _ 2B ❑ F Factory ❑ F-1 ❑ F-2 I] 2C ❑ H High Hazard ❑ _ 3A ❑ I Institutional ❑ 1-1 ❑ 1-2 I] 1-3 ❑ 3B ElM Mercantile El _ 4 ❑ R Residential ❑ R-1 ❑ R-2 I] R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 I] 58 ❑ U Utility ❑ Specify. M Mixed Use ❑ Specify: S Special Use Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERC./OING RENOVATIONS,ADDITIONS ANWOR CHANGE IN USE Existing Use Group: .. Proposed Use Group: ... Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEN CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(so __. 1a _....... ...._........ 2nd 2�a 3'tl _...... 4 th Total Area(sf) Total Proposed New Construction (st) Total Height(ft) Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site tlisposal system❑ Version1.7 Commercial Building Permit May 15,2000 8. NORTRAMPTON ZONING Existing Proposed Required by Zoning mis column to be filled in by Building Depamnent Lot Size Frontage Setbacks Front Side L R: _.. L: R: Rear Building Height O `D Bldg. Square Footage Open Space Footage (Lot mea minus bldg&.avid vhiv ) #ofParking Spaces Fill: (wlnme&L,cadon) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW 19 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES O IF YES: enter Book Page f�- and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW © YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO O IF YES, describe size, type and location: E Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it pan of a common plan that will disturb over 1 acre? YES © NO IF YES.then a Northampton Storm Water Management Permit from the DPW is required. Version L7 Comm:rciiI Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant). Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): 7—.—Tai mtct�fiur iL /Kunio l�7� o �f Bl �i1�S Q11 lEr �OL Name d—/ Area of Resp sibility 'F- 0 QI Add Regist ton Number Slgnat Telephone Expiration Data Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor � ��.lr^'LS.... '��(.qu• p4t Not Applicable Com any Name �n;n �ib P�oducha.+s _ Responsible In Charge of Construction vei •gyp c '�;99 � Jr�1� ul .�i4 D 4 S7S— Atltlress 4B W Sii Telephone Version1.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes © No Q SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS 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 building permit application. Signature of Owner Date I. 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. Print Name Signature of OwnerlAgent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone SECTION 13-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 affdavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes © No O City of Northampton 12 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: V�R`- S� ©f ^x44 01860 The debris will be transported by: _ /II'V The debris will be received by: N d2 %S Building permit number: _ Name of Permit Applicant �fe lµc{id n5 Date Signature of Permit Applicant n , . 2r Will e'tt""I �0 The Commonwealth of Massachusetts 1 Department of Industrial Accidents I Congress Street, Suite 100 F / Boston, MA 0211 4-2 01 7 www.mass.gov/dia Workers' Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le¢ibly Business/Organization Name: 4�04 -,A Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Business Type(required). 1.❑ 1 am a employer with employees(full and, 5. ❑Retail orparl-time).' 6. ❑RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no T ❑Office and/or Sales(incl real estate,auto,etc.) employees working for me in any capacity. [No workers'comp, insurance required] S. E]Non-profit 3.❑ Weare a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§1(4), and we have 10.❑Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, I L❑Health Care with no employees. [No workers'comp.insurance req.] 12.0 Other 'A,applicant hat checks box#1 must also fill out the section below shawl.,their ,,kso'compensation polity irdb uscurn. `"If the corporate officers have exempted themselves,but the corporation has other employees,a worked compensation policy is re,oned and such an ergamzation should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Inswer's Address: City/State/lip: Policy#or Self-ins.Lie.# Expiration Date: 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 51,500.00 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date' Phone#: Official use only. Do not write in this area, to be completed by city or[awn official, City or Town: PermiULicense# Issuing Authority(circle one): L Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: wurn.m es.gov/die Information and Instructions Massachusetts General Laws chapter 152 requires all empL Ayers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...es cry nerson in the service of another under any contract of hire, express or implied,oral or written" An employer is defined as"an individual,partnership, isso nation,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and inch dim the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,Monti too Or other legal entity,employing employees. However,the owner of a dwelling house having not more than three spar mens and who resides therein,or the occupant of the dwelling house of another who employs persons to do mair anance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not ecause 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 it,construct buildings in the commonwealth for any applicant who has not produced acceptable evidence oLeomptiance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"hleither th a commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public wnrk inti]acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the cur caning authority." Applicants Please fill out the workers' compensation affidavit coriple ely,by checking the boxes that apply to your situation and,if necessary,supply your insurance company's name,addres and phone number along with a certificate 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' compereatio t 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 permit or license is being re rues ad,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 comp mien should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printe2 leg bly. The Department has provided a space at the bottom ofthe affidavit for you to fill out in the event the Offico of nvestigatims has to contact you regarding the applicant. Please be sure to fill in the perenvlioeuse number which wi d be used as a reference number.In addition,an applicant that must submit multiple permit/license applications in and giv:n year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affida vit it tat has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affid:vit is on file for future permits or licenses. A new affidavit most be filled out each year.Where a home owner or c.tizea is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to bum eaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Coninton'vea Ith of Massachusetts Department )f I 3dustrial Accidents - 1 Cong-ess Street Boston. MA 02114-2017 Tel. #617-727-4900 ext 7406 or 1-977-MASSAFE Fax# 617-727-7749 wwcw.miss.gov/dia Foam Rn-0scd 02-23-15 _ The Commonwealth of Massachusetts Department oflndustrialAecidents I Congress Street,Suite 100 Boston,MA 01114-2017 www.mass.gov/tier NA surfaces'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Informationpn 44PleasePrint Legibly Name (B og t di d pTt A, ' ties AIL41 re pa .0 pi'dy6i7' S Address: - 0 3Fy City/State/Zip: Ola phone#: i/13 697-9 Are von an forymer"Check the appropriate box: Type of project(required): I Iama employer with_ employees(fall and-pon-time).' 7. ❑New construction 2.❑lam a sole propriemror partnership and have no employees working forme in $, ❑Remodeling any capacity IN.workers'compinsurer. rcyuued_] 3_❑1 am a he.--,,doing an work myself IN.workers comp_insurance rc,—it]' 9. ❑Demolition 4 F 1 am a homeowner and will be thing wumtrecmrs to condeat all work on my proson, Iwill 10 E]Building addition an re that all contractors tracer have workers compensationiamrance or me sole 11.❑Electrical repairs or additions pmpn'acrs with no employers. 72.❑Plumbing repairs or additions 5 1 alna general contracmrnnd 1 have hard the sub-conoanors lined omens 'aterd sh cheeet in . 11 Roof repair, (T�{It sub-oontr cmrs have employees and M1ave wed:cn comp_ G-❑tl'esearemmortionand its officers have earmicedommught ofexemption per MGL c. l4. [her�d/`Nt� 153,a 1(4),and we have no employee-[No workers'comp_inanrence required] r S�-r tar�u�e 'Airy applicant that clocks box 41 must also fill out the section below showing theh workers'compensationpolicy ficernaram p1mrsia-mout who submit this affidavit indicating they arc doing all work and then hire create emnhsamrs must submit anew affidavit indcating such. lContracmo that check this box muct attached an additional sheet showing the name of sub-contractors and state whether or not those entities have employee_ Ifthe subconpactors have employees,they must provide their wodas'eump_policy numher_ I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance CompanyName: Policy#or Self-ins.Lie,#: IV69OC /1�(SBqQ��k7�3(yQ31n�/'Z- � Expiration Date: �( Q Job Site Address: 5y -1'Asl S'F /UAlVhAa+tO�nn ./n/7 City/StateJZip: O Attach a copy of the workers' eumpensafion polio dada .,tion 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a face of up to$250.00 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 cerrA under the pains an a ties of perjury that the information provided rrova is true and correct '77Sign Date: Phone#' —G-Z. 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): I.Board of Health 2.Building Department 3.Cityrfown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all e.nph yers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every rerson in the service of another under any contract of hire, express or implied,oral or written" An employer is defined as"an individual,partnership,;Lssoiation,corporation or other legal entity,or any two or more of the foregoing engaged in aIcan enterprise,and incl udinf the legal representatives of a deceased employer,or the receiver.,trustee of an indi vi dual,partnership,association or orber legal entity,employing employees. However the owner of a dwelling house having not more than three apart mens and who resides therein,or the occupant of the dwelling house of another who employs persons to do main mance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall iot I 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 ar h construct buildings in the commonwealth for anv applicant who has not produced acceptable evidenet off ompliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)slates"Neithrr th e commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work i mil acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the con ratting 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)ant phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited _lability,Partnerships(LLP)with no employees other than the members or partners,are not required to carry workerscar ipensation insurance. if an LLC or LLP does have employees,a policy is required. Be advised that this affair it may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also br sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the p,xmit or license is being requested,not the Department of Industrial Accidents. Should you have any questions rgart ing the law or if you ate required to obtain a workers' compensation policy,please call the Department at the run be,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 legi bly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of ovestigations has to contact you regarding the applicant. Please be sure to fill in the perm ulicense number whit)wi I be used as e reference number. In addition,an applicant that most submit multiple permit/license applications it any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Addn ss"the applicant should write"all locations in (city or town),"A copy of the affidavit that has been officially start ped or marked by the city or town may be provided to the applicant as proofthat a valid affidavit is on file for for ire 1 ermits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license it permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said per son is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commomvea.th of Massachusetts Department of htdustrial Accidents 1 Congreis Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE Fax q 617-727-7749 Revised 02-23-15 wwW.m:rss.gov/dia 04i17/2018 13:44 4135686708 ROGER BUTLERINS PAGE 01/01 ACORD® DATRIM —mar l CERTIFICATE OF LIABILITY INSURANCE aAmrzate THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVFLY 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 REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If Me earllfleap holder Is an ADDITIONAL INSURED,fie PeROI(I a)must he"ADOITIO NAL INSURED prwielons or t»endorsed. If SUBROGATION IS WAIVED,w4jact to Me femme and condihous of Na Pollq,certain Pa11Che may N,Sl,an andarsdm", A afatemenl on Nle clrtlfMam does not confarr ale to Me DuRUMMe holder In lieu of such andomemongs). PRODUCES Nom,, Mary Beryamlh OISR,OIO Roger Butler ln3Malm FMN. (413)SG2430rI Are a. (413)56"706 5 COMn SI,ee11 P 0 Enx 819 mlxndamin®IgWefinemm WFURE%EI AFPoRpNGCWERAGE ryglC/ Weel6eltl µq Ot086 m3UpER p, ACE OSA INSUNED tteURFa 9: TJN Fs HvnwLIQF INSURES A PO SM 398 NSURER D'. m3URER E SUNL IanG MA 01315 ftL.F: COVERAGES CERTIFICATE NUMBER: CL18a1)01ESS REVISION NUMBER: TMS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TME INSURED NAMED ABOVE FOR T E POLICY PERIOD INDICATED, NOPMTH9 ANDINGANYREQUIREMENT,TERM(IRC MITIONOFAWCONTRACTOROTHERDOCUR1ENTWTIHRESPECTTOWHICHTHIS CERTIFICATE MAY GE ISSVED OR MAY PERTAIN,ME INSURANCE AFFORDED BY ME POLICIES DESCRIDEO HEREIN IS$MELT TO ALLTHE TERMS. EXCLUSIONS AM CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPEDFalcu CE NSD 4WD Pm1LYUoewca DpryyyY VMITa CORMESCIAL SEMRL LIAEILITI EADHOCGUERCNLE b CIAIMC-MADE �CC.a PREMISP C 5 MEEwF ml PER3MNLq ACVIWURY f GEN:AGGREGATE LINn APPUE3 PER: Ge.YERALAGOPE ATE S Ll-.O DL(q "OSMOS-COMPA'AW S OTMER'. AInOMOTLB LWaNffY ANYAUTO SODI61 NJU RY(Per M ml d AOL 09DONLY gCHESILED 5COILYIWIINYIPorxtlCenn i LlEoDLEA HI ONLY TALI vRIP RT } MI "PERIALALIAe GCCUF E4LN IX:[L4RE F 3 lRoD,LMB CLAIM5,,A.1 AOGREIATE I DEO RETENTIOTCA,NS } AAD O NDEREQPRORKEAREIMPF5 W0pT x Ei9TUTE RH- A FOFFE ESAMARTNEP,p%ECUTNE T N RL WHA:CICEAT vR 3 1011,D30 OFFKGRMEMEE1.11LIN, ❑V NrA PER OF 6SwUS-SH0315B-2.1 n911N2D18 N11412019 IML^YticrYINNMI ELOISEASEI EMPLOYEE 1100.000 1p N&AEp Wier CESCRIPTIOX OPERATIDN9 DNOr: EL DISEASE-POLICY LIMIT b 50D000 LE9CFWTQ40F pPERATONE!t➢CATN)W I VEHICLES (ACORa 1m,gCaltlpml Pvmvrin 9vMN10,mvy PvvRFPMa Nme,v vpPPF IF nPM41 CERTIFICATE HOLDER CANIIATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES RE CANCELLED BEFORE THE IDIRSATION SAM THEREOF,NOTICE WILL DE DELIVERED IN City Of NDnhdrlInc, ACCORDANCE WITH TAE POLICY PROVISIONS. 210 Main Sheet iUT,pSRED REFRE9EMATK p NUM1dT01an MA 01060 ®1988.2015 ACCESS CORPORATION. All HIS.reserved. ACORD 25(2016103) The ADDED name and logo ere r"Istarea marks of ACORD