42-014 (3) 254 WEST FARMS RD BP-2019-0275
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:42-014 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Deck BUILDING PERMIT
Permit# BP-2019-0275
Proiect# JS-2019-000456
Est. Cost: $13492.00
Fee: $87.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ALISHA PHILLIPS 106378
Lot Size(sa. ft.): 19994.04 Owner: HEIHSEL LAURI A&ROSEMARIE J BRODEUR
Zoning: Applicant: ALISHA PHILLIPS
AT. 254 WEST FARMS RD
Applicant Address: Phone: Insurance:
40 PINE VALLEY RD (413) 586-5986 WC
FLORENCEMA01062 ISSUED ON.9/10/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:10X16 DECK
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 9/10/2018 0:00:00 $87.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
— ylbi
File#BP-2019-0275 p
APPLICANT/CONTACT PERSON ALISH- PHILLIPS
ADDRESS/PHONE 40 PINE VALLEY RD FLORENCE (413)5ft•5986 ✓/' u��-w
PROPERTY LOCATION 254 WEST FARR13 RD
MAP 42 PARCEL 014 001 ZONE
THIS SECTION FOR O'F ICiAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T eof Construction: 10X16 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106378
3 sets of Plans/Plot Plan
TH FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN ORMATION PRESENTED:
Approved 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 Delay
C;1/1- / 9
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.
�1611LA&"
Department use only
City of Northampton Status of Permit, t
r y Building Department Curb Cut/Driveway Permit _
212 Main Street Sewer/Septic Availability_ _
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PIOU ite Plans
pecif,
APPLICATION TO CONSTRUCT,ALTER, EPA R, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION SEP - 4 2018
1.1 Property
Address:
This
h s s!e ion to be completedby office
Ms DEPT OF BUILDING INSPECTIONSLot4 - Un
lt
rSN NORTHAMIMMMA 01060
q All 0/1V� Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
I �J /� tiol/ r/
Z.SLi Lied FgiNrs lGyFlo,-(�1L( .
Na Print Current Mailing Address:
-Q I?- "3
_ Telephone
Signature
2.2 Authorized Agent: /
Am (lPrint) Current Mailing Address:
Signature Telephone
SECTION 3-ESTI TED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building I 11.2
Q -5-0 (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) 52 5-0 Check Number Q >5
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
00(um I q&1 �q#1)�OMt elm4, I. GGA
�i
;�
s
iGo — J ;'s
-1 46"A"f/'Clio
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 in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: K:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Sp 'at Permit/Variance/Finding ever been issued for/on the site?
NDON'T KNOW Q YES 0
IF YES, date issued:
IF YES: Wit recorded at the Registry of Deeds?
<NO
rm
DON'T KNOW Q YES 0
IF YES: ener Book Page a /or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradin <vafion,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
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 Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0) Decks Siding[O] Other[0]
Brief Description of Proposed
Work: C)
Alteration of existing bedroom Yes No Adding new bedroom Yes —
No
Attached Narrative Renovating unfinished basement Yeso
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other---
b. Number of rooms in each family unit: Number of Bathrooms___
c. Is there a garage attached?
d. 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
i. Is construction within 100 ft.of 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
{.
I, N /�(�f'H r / 1 C 14 as Owner of the subject
property
ll ll. JI r
hereby authorize
to act my b half, in all matte s r ative t work authorized by t is building permit application.
Si re of Owner Date
1
I, f S / / _� as Owner/Authorized
Agent hereby declare that/he statements and infor ation 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
Sig u Ow r/Agent Date �_
SECTION 8-CONSTRUCTION SERVICES 7
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: It St, A' 1(S ` lQ/v 3 /1
3-
License Number
IN U 1/., lr v t z
Address / Expiration bate
glut Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
�( U V., f�t eer►c t M-4 2 04 2-015--
Address Expir tion D to
G/
Telephone I 1 J? -5�fS G - si 54
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavWi must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil ng permit.
Signed Affidavit Attached Yes....... No...... ❑
i
9/5/2018 IMAG1531.jpg
E
- r
F,
a
c
� 4
, mad ••� z,:� �� #
KA
IRPI
i Y !
i
y „F
£
https:Hniai I.g oog le.con-Vmai I/u/0/M nboxlLXphbRLrg hATJmtWVXhVhLvXnTFwpJGRnWrcpmmbiq?projector=1&n)essag ePartld=0.1 1/2
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS 1' F„
212 Main Street • Municipal Building
a`
Northampton, MA 01060 rs=n ��
3 -
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("H1C").
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 four 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 be registered
Type of Work: tit 1 t A o f Li_ d.c,k Est. Cost: IR 1/521 'ro
Address of Work: Lid _ ivvi/i t
Date of Permit Application: 3r/
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
Job under$1,000.00
Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
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
�r Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building il rt'
� Northampton, MA 01060
Massachusetts Residential Building Code
Section 110.R5.1.2
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 110.R5.1.3.1
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 person(s)
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.
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS a, x
212 Main Street •Municipal Building vti
Northampton, MA 01060
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 a �f/�t:
?-5'q L,/es f F°itm S )L4 1` ltl-pou /' l�
(Please print house number and street name) y
Is to be disposed of at:
U^11o, Z 31 Fg s(4 timAn
lease print me an ocation of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of P =debris
r D e
If, for any reaso disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
Y
The Commonwealth of Massachusetts
Department of Industrial Accidents
0 1 Congress Street,Suite 100
Boston,MA 02114-2017
'4 www mass.gov/dia
NVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information / Please Print Legibly
Name (Business/Organization/Individual): t'(,M
Address: - 0 P"AL 1A r/l 4 l
City/State/Zip: Ryle t t 0106 Phone#: /13 - 51(o - 5-71no
Are you an employer?Check the appropriate box:
Type roject(required):
1m a employer with_employees(full and/or part-time).* 7 New construction
2 u 1 am a sole proprietor or partnership and have no employees working o me in 8. Remodeling
9. ❑Demolition
3.FlI am a homeowner doing all work myself.[No workers'comp.insurance required.]
10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I Hill
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.Ej Plumbing repairs or additions
5.C]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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. If the 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.
Insurance Company Name: L 1,
Policy#or Self-ins.Lic.#: h/C s 33^1S_ II)S71 3— 0/ Expiration Date:I'
Job Site Address: ? S- West /moi.-Mf &Ad City/State/Zip: Ndkr 0/0(e 2
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 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby�under ' es of perjury that the information provided above is true and correct.
Si nature: '/� Date: a U
Phone#• yt3 59 e-4
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 a joint 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 performance 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
t
I
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 a joint 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 i
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 1
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 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 your insurance company's name,address 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'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.
I
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). 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Form Revised 02-23-]5
rN
AC`a'I CERTIFICATE OF LIABILITY INSURANCE DATE(MIWDntYYYY)
azazola
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THtS
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(les)must have ADDITIONAL INSURED provisions or bo endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,cortain 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 FINCK&PERRAS INSURANCE AGENCY INC NAME:
6 CAMPUS LANE PHa;.t _ FAx
EASTHAMPTON,MA 01027 . . :_.._.
E-MAIL
._____ eNSURERL5ZAFFORDiNGCL?1[ERAGE NAIGP
__1111... 1_111.. ......._.._
INSURER A; LN!lnSuranre CaTgL,
INSURED INSURER 0:
AXIOM LANDSCAPE& HOME:IMPROVEMENT LLC
40 PINE VALLEY ROAD INSURER C:
FLORENCE MA 01062 INSURER D; _._._-.__.-
1NSURER F.:
INSURER F;
COVERAGES CERTIFICATE NUMBER:431109878 REVISION NUMBER.-
THIS
UMBER:THIS IS TO L:FRTIFY THAT THE POLICIES Of: INSURANCE LISTED BELLOW HAVE BEEN ISSUED To THF IWWRED NAMED ABOVE FOR THE POLICY PFRIUO
INDICATED, NOTWITHSTANDING ANY F'iEOUIREMENT,TERM OR CONDITION OF AVY CONTRACT OR c1iHL"R DOCUMENT INt-H RESPECT TO WHlcri THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE rAAL:CIF'S DESCRIBED HEREIN 15 SUBJECT TO ALL THf;TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN R>DUCEO DY PAID IGLAIMS.
.............. __.. _... 1 _111_..,
LTR
y ... .........._. ADOL Sub I POLICY EFf POLICY FXP '1111 llMf TB
TYPE OF INSURANCE POLICY NUM6F.'R MVID iY'4YY I ,
COMMERCIAL GENERAL LIABILITY ;tAG:H OCCURRENCE S
IDA0AXGET4YR TTI.`—T
t.,.._.i,....... CL.AIM1.'-VAC ..___�C7['.r.;lft i P';iEidlSsO Ca cccemenrn� 5
MED EXP(An.ra.e c.ersarl S _.
,
I i I PERSONALY,ADY NJURY i S _
._...I _......___�_
-WLAGOkf-.t TE LIMO APPUFS PER CEW-ft4L pC£RLGATE S
C_ T L'LOG I PRC,JUCTS•COMP OP AGC._. 9
OTtI6R:
Aln-OMOBILEUABILITY
COM INCJ S!I%G-C'a IMIT
ANY tai"0 I Pt)L:It.Y Iht.11. Y pat Pewft) S
0i'MED -HE-'JLCG
ALTOS ONLY AUTOS'
4IRE0 NON-OWNED
Autos ONLY :AUTOS ONLY
iIMORP1LAt.fAa 4tCCUF1 EAA(:NO%:[:URNENQ.F; $
EXCESS LIAS CLA:LIS..MAUE 1 Ai'*V'6AIF S
7ED "RETENTION 5 S
A WORKERS COMPENSATION WC5-318-612.5123-01A -4?17}2018 4NT,20'19j''E , TI'I•
AND EMPLOYERS'LIASILITV YIN T STA UTE
ANYPRf R,RIETOR.'PARTNER,'EXECJ'IVE f>I. EA,HACCIDENT 1501100€1_
OFFICFIv1EEMBERE%CLJDED� El NIA _.
(NarAstory 14 NH} 4:.L D..�SkASE.-Eh EMPLG)YEt S
III Yrs.deb,,nbn w'dCt i I i 111 1 D. ._1111.__. 1111..
OESCRIFTIC,k OF OPERATIONS bnlvx 1 E.L DISFASE.-POLICY LI&O' t�iG0C�1{I
1
DESCRIPTION OF OPERATIONS I'LOCATIONS I VEHICLES(ACORD 101,Additional RarnarRs Sc hsd€ft,may be*1440"A mora sµsce is mgaired)
WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA.
This Certificate cancels and supersedes all previously issued certificates,only as they relate to vrCrkers cornpersation coverage.
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
212 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS,
NORTHAMPTON MA 01060
AU THORIJECI REPRESENTATNE
Join 5ma4h -�
1998-2015 ACORD CORPORATION. All rights reserved-
ACORD 26(2018103) Tho ACORD name and logo are registered marks,of ACORD
i
9/5/2018 254 west farms plot plan.jpeg
wps4 FP m
Ott k
i v
v'
hftps://maiI.google.com/mail/ca/?shva=1#inbox/165aa301554992d2?projector=1&messagePartld=0.1 1/2
9/5/2018 254 west farms plot plan.jpeg
https://maiI.google.com/mai I/ca/?shva=1#inbox/165aa301554992d2?projector=l&messagePartld=0.1 2/2