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�QEIVED �l��is,�vll� R � Department use only Ci of Northamptona of Permit: NG INSPECOONS ED lding Departmenturb Cut/Driveway Permit " 01050 12 Main Streetewer/Septic Availability Room 100WaterNVell Availability Northampton, MA 01060wo Sets of Structural Plans phone 413-587-1240 Fax 413-587-12721IOUSite Plans ther Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH ONE OR TWO FAMILY DWELLING SECTION I -SITE INFORMATION P-1 y— ✓`D z 1.1 Property Address: This section to be completed by office Map Lot 9 Unit 67 Winterberry lane, Northampton Zone Overlay District Elm St.District 116 District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Edith Mehici 7 Renaissance sq,5th floor, White Plains,NY 10601 Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Atldress'. Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bpermit applicant 1. Building 10000 (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) 10,000.00 Check Number /07 This Section For Oficial Use Only Date Building Permit Number: Issued'. Signature: Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled Ia by Building Department Lot Site Frontage Setbacks Front Side It R: L: R: Rear Building Height Bldg.Square Footage Open Space Footage hAt area m1nuf bldg&reveal arlm l #of ParkingS aces Fill: (volnmu&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW a 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 Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O 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 O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterationls) ❑ Roofing 0✓ Or Doors [l Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[0] Other CJ] Brief Description of Pmposed new mof Work: Alteration of existing bedroom_Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes _No Plans Attached Roll -Sheet ea. If New house and or addition to existing housing- complete the following'. a. Use of building Onel'ani Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? of Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction Is construction within 100 ftof wetlands? Yes _No. Is construction within 100 yr. floodplain_Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? 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 l^J//{j / /e/) Gl as Owner of the subject property // hereby authorize �"f/r• hf�C� to act on my behalf,In all matters relative to work authorized by this building permit application. Signature of Owner /p Dale I, ,(C 4 4 foe ,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 u the pains and penalties of perjury. �r✓i Pr✓ce Print NZ/4 T // Signature of OwnerlAgent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Erich Price License Number 76 North Hillside rd, South Deerfield, MA 01373 cs-097602 Atltlress Expiration Date 5/30/19 Signature Telephone 413-824-9684 9 Reu'stered Home Improvement Contractor: Not Applicable ❑ by 4 /0"1 a/ Company Name Registration Number 76 d/ Hi//Sl14 a✓ Atltlress Expiration Date - 10eer" /71ty" 0/37 3 Telephone �/3'-6i 4/19/19 SECTION 10-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 issuance of the buildin permit. Signed Affidavit Attached Yes..... No...... ❑ City of Northampton Massachusetts c�e DEPARTMENT OF BUILDING INSPECTIONS V1S ' 212 se in Street • Municipal Building S aortheertov, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("H IC"). M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than(our dwelling units...or to structures which are adjacent to such residence or building'be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC that entity must he registered Type of Work: /ri,16iEst.Cost:_�G Address of Work: Date of Permit Application: A/^(3 I hereby certify that: Registration is not required for the following reason(sh Work excluded by law(explain): Jab under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied Other(specifyh OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT. SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature _ City of Northampton s . Q, Massachusetts I DEPARTMENT OF BUILDING INSPECTIONS 212 Mein Street eH xcipal S-1ding , Northampton, a 01060 ✓W ppP° Debris 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. The debris from construction work being performed at: b / Wo'x tir berri �,y (Please print house number d street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented cr leased from: 14ML,1- ga- '2�' WM ///N /nre (Company Name and Add L/' (LD Signature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. City of Northampton Massachusetts 65 ��CC i DEPARTMENT OF BUILDING INSPECTIONS 212 Main Streat • Municipal Building Q Northampton, M 01060 Massachusetts Residential Building Code Section I10.R5.L2 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. Section I I O.R5.13.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a persons) for hire to do such work,then such homeowner shall act as supervisor. 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, during and 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 Commonwealth of Massachusetts -n,-_ Department of Industrial Accidents I Congress Street, Suite loo Boylan, AIA 02114-2077 �...`g taww.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TORE PILED WI TB THE PERMITTING Al OJORI I'1'. Applicant Information Please Print Le ibly Business/Organization Name:Erich Price Construction Address:76 North Hillside rd City/State/Zip:South Deerfield, MA 01373 Phone#:413-824-9684 Are you an employer,"Check the appropriate box: Business Type(required): ^� LE) 1 am a employer with 3 employees(full and/ 5. ❑Retail or pari-time).• 6. ❑Restauranb Bar/Eating Establishment 2.❑ firm a sale proprietor or partnership and have no 7. ❑Office ari Sales(incl.real equ ,auto,dc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. ❑Non-profit 3.0 We are a corporation and its officers have exercised 9. ❑ Emoilainment their right of exemption per c. 152,§I(4),and we have 10.0 Manufacturing no employees. [No workers'camp,insurance requirad]a 4.L] We are a non-profit organization,staffed by volunteers, 11.❑Health Care with no employees.(No workers'comp.insurance pool 12.0 Other 'Am appGuavt gut ohcds box#1 must nim III out the 1111.11 below showing tM1en uvrkers'¢nmpcnsa[ion policy information. "'lithe copwmte()Meer,leve exonpwd themselves,bug the coq binan hes vocreutp.,,,,1 workers'wmpe¢satiln(wllcy is rcgliaa end such an orynrdretinn.a}utd tltck box al. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Narne: Insurer's Addre s: City/State/Zip: Policy k or Selfins. Lic.# Expiration Date:_ Attach a copyofthe workers'compensation policy declaration page(showing the poiley 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 fine up to 51,500,00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy ar his statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerd y urcder the p ' s andpenalties of perjury that the information provided abrrve is true and correct. S�nature: jar Dat . zf_'J.�l f`tY_ Phone g413-824-9684 Of ficial only. Do not write in this area,to be completed by city or town official. n: Permit/License h hority(circle one): Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmmn's Office son: Phone k: a.v,e. ssglvraia 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 ofthe foregoing engaged in ajoint enterprise,and including the legal representatives ofa deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner ofa dwelling house having not more than three apartments and who resides therein,or the occupant ofthe dwelling house ofanother 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 performance of public work until acceptable evidence of-compliance with the insurance requirements ofthis 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 your insurance company's name,address and phone number along with a certificate ofinsurance. 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. Ifan 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 ifyou 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 ofthe 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 permiHlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proofthat 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. q 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia Form Rt,ard 022315 -- -, ACORN® CERTIFICATE OF LIABILITY INSURANCE DA 04111116 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND ORA LTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE 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 NAME. Jordan Bryant Gilmore B Farrell Insurance Ag raX PHac ONE NO E.I. 913-772-0251 be No: 413472-2338 PO Bo.950 ADDRESS: jbryant@gilmoreandfarrell.com 525 Bernardston Road Greenfield,MA 01302 INSURERIs)AFFORDING COVERAGE NAlca INSURER AAtlantic Casualty Insurance COmpa Try INSURED INSURER B'. Erich D Price IrvsuREBE 76 No Hillside Rd INSURER D' So Deerfield,MA 01373 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 MAYBE 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. IN R P I EFi POLICY E%P VMI]$ LTR TYPE OF INSURANCE ASD ME POLICY NUMBER MMIDDIYYYY MMIDDRYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 CLAIMS-MAGE ❑ ODOUR PREMISES Ea amttenee 5 100,000 MEDE%P IAn one person) 5,000 A M261000547 02123118 02123119 PERSONALS Acv INJURY S 000000 GEN'L AGGREGATE LIMIT APPLIES PER CENERAL AGGREGATE 2,000,000 FPOLICY❑JECOT FLOC PRODUCTS-COIAPIOPAGG £ 2,000,000 OTHER AUTOMOBILE LIABILITY EO MBLI HUED SINGIE"LIMIT 5 ANYAVTO BODILY INJURY(Pe,Pvsor) $ OWNED $CH"0ED BODILY INJURY(Per CGIden) $ AUTOS ONLY AUTOS HIRED RON-OWNED PROPERTY DAMAGE $ AOTOs oNlr AUTOS ONLY Per acbbeol 8 UMBRELLA LIAR ODOUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS MADE AGGREGATE $ LEO I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER OANY FFICERIAE MBPRE%Co L%ECUTIVE❑ NIA EL EACH ACCIDENT 3 (Man Earory In NH) E L DISEASE-EA EMPLOYEE $ If ye,.describe under DESCRIPTION OF OPERATIONS below EL DISEASEPOLICYLIMIT 8 DE5CRIP1ION DF OPERATIONS I LOCATIONS[VEHICLES (ACORD 101,AdtliBonal Remads Schedule,may be aXached 1f man apace is mquired) CERTIFICATE HOLDER CANCELLATION SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Northampton Northampton Building Dept 212 Main St#100 AUTHORIZED DEERESE E Northampton,MA 01060 11 ©1988 015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AC O® CERTIFICATE OF LIABILITY INSURANCE °°'°'"MI°°I"'""' 1 04/11/2018 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 pdilicy(ital 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 andomemenl(s). PRODUCER NCAMEpCT Tinothy Farrell GILMORE AND FARRELL INSURANCE AGENCY INC Ihuu"s°x.,_(413)7733686 Usi ra l MAIL Aopxess, iferrell@glmoreandfarrell_com _ 525 BERNARDSTON RD INEURERtSI AFFORDING COVERAGE NAICN GREENFIELD MA 01301 IINURERA: ATLANTIC CHARTER INS CO 44326 INSURED. _—. - - pal_B' ERICH PRICE INEUREND INsuRERD: 76 NORTH HILLSIDE DRIVE INSURER E: SOUTH DEERFIELD MA 01373 INSURER F: COVERAGES CERTIFICATE NUMBER: 256518 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. MTSnR' TYPE OF NEURANCE ADDL Will POLICY NUMBER °IICYEFF POLICYE%P ' LIMITe 11,5I00/YYYY MMIDNYYYY COMMERCIAL GENERAL LlpeltlTY EACH OCCURRENCE DAMAGE TO5 CVAMS-MADE E (OCCUR EM3ESE MED E.Pj_v—m person)- s NIA PERSUCTIacv lwuar s GEN LAGGREGATE LINIi APP ES PER'. GENERAL AGGREGATE 5 OLO ' PRO PRODUCTS LOC PRODUCT$-COMPrOPFGG 5 OTHER AUTOMOBILELIABILITY COMBINED SINGLE LIMIT S HEX_A..-" ANY AUTO BODILY INJURY Perporno) 5 ALL OWNED SCHE RILED ( NIA BOOL INJURY(Per PrOwnp s AUTOS AllT05 NOSUPPER PROPERTY DAMAGE E Amos — _AOTOS e_ n L _.. ° _. s UMBRELLA UAB OCCUR EACH OCCURRENCE Is Excess Lwe _AGGR - CLAIM6MADD ', NSA AGGREGATE i5 DEB RNS S WO0.NERa COMPE NUNAMON SATON x/� IF STATUTE OERH _ ANYPROPRIETORIPARTNERE%ECUTI VE YIN EL EACHh^.CIOENL 5 100,000 A OFFIDEwMFMeeasxauoEov F.it] xrA Nu WCV01360301 032912018 03(29(2019',EL DISEASE EA EMPLmEEs 100,000 PaSy.oN(n NX) Finds, J -- a1/ Ee DESCRIPTION OF OPERATIONS ears, I EL DISEASEPOLICYLIMIT 5 500.000 NIA DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES Rome 101 AEEILIonal RPmaha Senors. ney e, Ua[neE N mare pam le nqulnat WorkersCompensation Benefits XIII be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization Is given to pay claims for Estates to employees In states other than Massachusetts if the insured hires.Or has hired Nose employees outside of Massachusetts. This cenificate of Insurance shows the policy In force on the data that this certxicate was Issued(unless the expiration date on the above policy precedes the Issue date of this cenifiney 011nsurance) The status of this Coverage can Be monitored daily by accessing the Proof Of Coverage-Coverage Verification Search tool at me.WvtllwdMorkerscommnsatioNinvestigationS Sole proprietor has not elected Coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Northampton Building Dept ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main Of#100 AumoRusOREPRESENTATrvE l: Northamon MA 01060 Daniel'M.Crmvley,CiPCtl,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD