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18C-120 (2) 38 FRANCIS ST BP-2020-0186 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C- 120 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window re laced BUILDING PERMIT Permit# BP-2020-0186 Proiect# JS-2020-000311 Est.Cost:$9781.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: WINDOW WORLD/ROBERT E BUSHEY JR 57011 Lot Size(sg.ft.): 7492.32 Owner: LANDSMAN MARCIA B C/O JAVIf R D CAMPOS Zoning: URB(100)/ Applicant: WINDOW WORLD/ROBERT E BUSHEY JR AT: 38 FRANCIS ST Applicant Address: Phone: Insurance: 1029 NORTH RD (413) 485-7335 O WC WESTFIELDMA01085 ISSUED ON:8/13/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 11 REPLACEMENT WINDOWS 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 si(nature: FeeType: Date Paid: Amount: Building 8/13/2019 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner l� (A/00 6V J ( � Department use only City of Northampton thtyfs of P rmit: r Building Department Curb ut/D iveway Permit 212 Main Street AUG Sew r/Sep is Availability Room 100 2 201 I atgr/Wel Availability r ` Northampton, MA 01060 Two of Structural Plans »n phone 413-587-1240 x F 7r=1272 P49V�5ite P ns — 01111 V, tithe ify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: QThis section to be completed by office 3!? f_rG�'o; ' 5 &-h- ` Map 0 Lot_ Unit _ n,Ur *amp�On �AA 01()L,0 Zone Overlay District 1 Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: I n vtrr Dix �-►-a nu 5 1-. no y ,U I yo A 0 ( O Name(Print) I Current Mailing Address: �l?�- Telephone Signature 2.2 Authorized Agent: f�Ciba't , 10'2ci NOV VY) k6 1NC"Oic,,A A MA 0\0165, Name Print) Current Mailing Address: Signature 1� 4-13�- ' `�5 -_13 Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (� 1 (a) Building Permit Fee 2. Electrical t� (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) �D 5. Fire Protection 6. Total = 0 +2 + 3 +4+ 5) Check Number This Section For Official Use Only Building Permit Numb e Date Issued: Signature: 9-12- 20)g Building Commissioner;Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Vyindows Alteration(s) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O) Decks [CJ Siding [0] Other[p] Brief Description of Proposed Work: � l` J Alteration of existing bedroom Yes No Adding new bedroom Yes N Attached Narrative Renovating unfinished basement Yes % No 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 oor below finished grade_ k. Will building confofm 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 l 1� j2 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. c,On,hf(a Signature of Owner Date I, i/t ruS�lf� as Owner/Authorized Agent hereby declare that the statementd 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 Nome J Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:—. License Number G i r� Ln _� lAh�ls r'?� M� t�10 �l C 11 Expiration Date Address �— 4A 3 c�nL�.�v Sign Pre Telephone p 9.Registered Home lmprt vbment Contractor Not Applicable ❑ obat 11015 b 41 Company Name Registration Number IN ind w Wor.1rl Of' Inc, 314 /20 Address yU �! } Expiration Date 01 Iv oftil VIA tkStfi-''� MA 01&5lephone 4I� 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 building permit. Signed Affidavit Attached Yes....... No...... ❑ 11. - Home Owner Exemption 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 780 Sixth Edition Section 108.3.5.1. 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,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 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 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia «porkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name(Business/Organization/Individual):Window World of Western MA Address:1029 North Road City/State/Zip:Westfield, MA 01085 Phone#:413-485-7335 Are you an employer?Check the appropriate box: Type of project(required): I.❑✓ I am a employer with 20 employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. any capacity.[No workers'comp,insurance required.] 9. F1 Remodeling 3.01 am a homeowner doingall work myself t 9. F1 Demolition y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my PPAY•ro I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[:]Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.Q Plumbing repairs or additions These sub-contractors have employees and have workers'comp,insurance.= 13.[:]Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑✓ Other Replacement Window: 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:Liberty Mutual Insurance Policy#or Self-ins.Lic.#:WC2-31 S-377947-020 Expiration Date:05/07/20 Job Site Address: 3L. City/State/Zip:l I KA M n X Q Attach a copy of the workers'compensation policy declaration page(showing the policy number and a piration 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 certify under pains and penalties of perjury that the information provided above is true and correct Si lature. l Date: � l'7 Phone#:413-485-7335 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#: ( Commonwealth of Massachusetts Division of Professional Licensure Board Of Building Regulations and Standards TE OF LIABILITY INSURANCE GP�►it�N6titl11�tip8rviai)f DATE(MM/DD/YYYY) tMATI IN ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. CS-057011 E=xpires: 06/28!2021 VELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ROBERT E BUSHEY.JR ; )T CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED 12 DAIRY LN :ATE HOLDER. SOUTHWICK MA 01077► INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. f " toil conditions of the policy,certain policies may require an endorsement. A statement on Calder in lieu of such endorsement(s). NAME: 413-858-2680 Commissioner �/�� PHONE /u"`^ ` A/C No Ext): A/C No): 413-858-2685 ADDRESS: SCA 1 0 P011101.06117 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: ARBELLA PROTECTION INSURANCE CO. INSURER B: LIBERTY MUTUAL FIRE INSURANCE CO. INSURER C: INSURER D: INSURER E: COVERAGESINSURER F: CERTIFICATE NUMBER: REVISION NUMBER: _7717 HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO '1HE 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. I LTR TYPE OF INSURANCE INSD R POLICY NUMBER POLICY FI_V6UUTFXj- — X COMMERCIAL GENERAL LIABILITY MM/DD/YYW MM/DD/YYYY LIMITS EACHOCCURRENCE $ 1,000,000 CLAIMS-MADE � OCCUR PREMISES Ea occurrence $ 100,000 A MED EXP(Any oneperson) $ 10,000 7520025998 04/09/19 04/09/20 PERSONAL BADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: JECT LOC GENERAL AGGREGATE $ 2,000,000 POLICY❑ PRO- PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO Ea accident $ 1,000,000 A OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY X AUTOS 1020063881 04/09/19 04/09/20 BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ X UMBRELLA LIAB $ X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE 4600055451 04/09/19 04/09/20 AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A Certificate To Follow E.L.EACH ACCIDENT $ (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Of Northampton ACCORDANCE WITH THE POLICY PROVISIONS, 212 Main Street Northampton,Ma.01060 AUTHORIZED REPRESENTATIVE Attention: Building Department, ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AFFIDAVIT In accordance with the provisions of MGL c 40, §54, 1 acknowledge, as a condition of the Building permit, all debris resulting from construction activity governed by this Building Permit shall be disposed of at (NAME OF FACILITY) a properly licensed solid waste facilitya, defined by MGL C 111, §150A. Date Signature of Permit Applicant u PRINT OR TYPE THE FOLLOWING INFORMATION: (NAME OF PERMIT APPL CANT) (TYPE OF M4 TERIAL TO BE DISPOSED OF) (PROPERTY ADDRESS) .y a iY -mnurRr,or - Wt or destroy the Mi Windows And Doors a Ml WindowSAnd doors 650 West Market St tiF'PC 650 West Market St l4r€ -C Mt Gratz PA 17030 Grate,PA f7030 1685 - Esso ficultto SLIDER21VINYL/Grids Rabr � DHNINYL/No Grids sthat can be Nab-6FeniStrahDt '9�;Will ^� Panel18,2:Lite-1:(118',Clear,LQE,Anne Rat1s�00uncil� (1BPan�'Gear,NONE,(Anneafed);Argon 4511Y)X 45 1 2 (1t8-,Clear,NoNE,Anneated);Ar' n 37e�'Lite•2: •e cleaner 112 X 37 m for differnt MEI A_ MEI-A-2MO 3g4-0'll Individualproclucts 216.03403.00co1 and doors lnc lvlduW products may be subject to variation In performance +naY be subject to varietton then using a in errormanee ENERGY PERFORMANCE p down on the ENERGY PERFORMANCE RATINGS U-Factor STINGS (U.S./I-P) SolarHeat Gai U-Factor(U.S./1-P) Solar Neat Gain Coefficientn Coefficient Oe�7 . . 'egenerally 027 026 � OrL 9 Iductcer- A�D►TlONAL.pERFO ovations in Visible Transmittance RMANCE ' ADDITIONAL PERFORMANCE RATINGS Visible Transmittance Air Leakage(U. . SH-P) 0 C Ila. V a72 Air Leakage(U.S,/I-p) _ 0.3 0 3 t,bake < sruracrurerst r4 _Ge��r��srtce.r,ulaIestnatmeserarir,sc a RC Ratings art aarerr:a�crsaset creryrarmerrta�conamprs arra;: wK . - n �:csrNtrec- F�olaNFkCprxeourestoroetermin ma wncturer aepvunt tnatinua raanpa conmrm to epp5amt NERC p aceauros for aeS6rinln nq,mme proeun err"°"Q a n pro�+nsra axs rmrxarrsrs7�rwie i partor C11-rrfRC Rtnnpr ata oeurminea mr s tc.a aet et armro-wnerxu coramana dna a apnctlk proouet sae. manvratturcr atrawrc mramer too c�an'aYCrary pra�u rcr;r, Cd c pr Y=F.tc3de s 1 HFRC apes not taCotnrriana anypreoutt ano Duda not Omer grog of Performance 1:1any PrNuctinfoi.mm n.trry epeLtric use.ConswS wiµ.q�c.ora penormante irdGrmahpr_ S.Use a � manunca,raN frrraima rot Amar pratfuet paRo[manea LnfCrA11L'on. - -I sFillt i i • ' 1 y >v/!Q ,y,` �c�,� ener9YSW.gov/windowa emrgyattu.govtwindows For full infonn�tbn,sea label on product ri(ficado Pli CeK�ied/CeKifiead0 Para intomtacion Com feta,consnitar la elirueta del prorfucro- Far full infomiation,see label on product. 1 11 Para infomiacibn completa.consuhar la t liquete del producro. Perf Grade � LC-PG35- +OP(ASD) -DP(ASD Perf Grade +DP ASD -DP ASD Water 35.30 } Water (ASD) ( ) n Max Test Size 60.13 LC-PG35 35,09 35.09 6.06 40.OoX 72 00 Aaa/2.op i Florida ID 5'43 Max TestSize eport# - STC 1 OITC 20840 _ 72.00 X 60.00 F2o96,01-109-47dm - 29124 atirigs are for individual windows - r stacked units, lease contact our addles re oresentat ve.Pos and Ne Ratings are for individual windows and doors only. For information regarding muffed nd fest size rened to y hr For information regard g r e9 9 STA1 E1300. DV IC) a entati e. g mulled Or stacked units,please contact your sales representative.Pos and Nag DP limited by i dditional informer formation regarding may concealed b 05 Glass AD �mied by e unit test size.Tested to AAMAUDMAICSA 1011l.S.2/A440.05 AAMA label may be installation Inst y giaz ng bead or track filter. For o concealed by glazing bead or track filler. For additional information regarding ructions, rl installation instructions,please visit www.miwd.eom. )6786673 1.1 Please visit yvwev miwd Com. v V 3• 26772468.1.1.1 Printed9:03 M :10:1Printtl on m '3 7f62016 3:69:03 PM a/12l2at6 6:ta:12 qrq Window World Of Western MA 1029 North Road 413-485-7335 westernmass@windowworld.com Javier Campos javiercampos@mac.com Estimate : Partial Bill Address: Install Address: Estimate#E1565125326118 38 Francis St, 38 Francis St, Northampton,MA Northampton,MA Date of Estimate:8/6/2019 101060 01060 Valid Until:9/5/2019 DESCRIPTION • • Mullion Removal 2 60.00 120.00 Basement Hopper 2 375.00 750.00 SolarZone Low-E 11 110.00 1,210.00 Full Exterior Capping 11 110.00 1,210.00 4000-2 Lite Slider 2 549.00 1,098.00 4000 Casement 6 549.00 3,294.00 4000 Series DH 1 389.00 389.00 Permit&Administrative Fee 1 200.00 200.00 Install Interior/Exterior Stops 9 80.00 720.00 Tempered DH Sash($90 with package) 3 180.00 540.00 Setup and landfill disposal fee 1 250.00 250.00 TOTAL AMOUNT $9,781.00 CUSTOMER PAYMENT DETAIL Credit Card Amount $3,000.00 TOTAL PAID $3,000.00 CUSTOMER DUE $6,781.00 *No extra work if not in writing *Customer Comments: *Installer Notes: Design Consultant-Tim Drost HIC:165641 FEID#27-1993659 Customer ID Details Id Type I Driver's license Id#* S24677 Id Issue State* Masd Id Expiration Date 24t6y payments to be insecure.However,where the contractor deems himself to be insecure he may require as a prerequisite to continuing said work that the balance of funds due under the contract,which are in possession of the owner,shall be placed in a joint escrow account requiring the signatures of the home improvement contractor and the owner for withdrawal. Arbitration;Window World of Western Massachusetts and the PURCHASERS)hereby mutually agree in advance that in the event Window World of Western Massachusetts has a dispute concerning the contract,Window World of Western Massachusetts may submit such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration in M.G.L.c 142A. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Customer Signature Sales Rep Signature NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor.The owner may initiate dispute resolution even"where this section is not signed separately by the parties." This Window World®Franchisees independently owned-and operated by Window World of Western Massachusetts, Inc.under license from Window World,Inc. At ORD® CERTIFICATE OF LIABILITY INSURANCE =0'41M0/2/"1 /YYYY) 9 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must 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 UUN[ACT NAME: Forrest Insurance Agency PHONE 413-858-2680 603 North Main St Arc No Ext: A/c No: 413-858-2685 E-MAIL East Longmeadow, MA 01028 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: ARBELLA PROTECTION INSURANCE CO. INSURER B: LIBERTY MUTUAL FIRE INSURANCE CO. WINDOW WORLD OF WESTERN MASSACHUSETTS INC INSURER C 1029 NORTH RD INSURER D WESTFIELD, MA 01085 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. I R LTR TYPE OF INSURANCE INSD WVD POLICY NUMBERMM IC YYVY MM/ DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 19OCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any oneperson) $ 10,000 A 7520025998 04/09/19 04/09/20 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY❑ PRO- ❑ JECT LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO Ea accident $ 1,000,000 BODILY INJURY(Per person) $ A OWNED SCHEDULED AUTOS ONLY 1020063881 04/09/19 04/09/20 BODILY INJURY(Per accident) $ X AUTOS X HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY X AUTOS ONLY Per accident $ X UMBRELLA LIAB X $ OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE 4600055451 04/09/19 04/09/20 AGGREGATE $ DED I I RETENTION$ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ E.L N/A Certificate To Follow .EACH ACCIDENT $ (Mandatory in If yes,describe under E .DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main Street Northampton, Ma. 01060 AUTHORIZED REPRESENTATIVE Attention: Building Department, f' ("( (.0(Q.�,t:rQ ©1988-2015 ACORD CORPORATION. All rights reserved, ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDmYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 5/5/2019 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 INSUREII AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(iesI must have ADDITIOAL INSURED provis Nions or be endorsed. If SUBROGATION IS WAIVED, subject toterms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does I'llnot confer rights to thee certificate holder in lieu of such endorsement(s). PRODUCER FORREST II'llNSURANCE AGENCY 603 NORTH MAIN STREET NAMEA E LONGMEADOW, MA 01028 P. A/C N'No.Ext FAX E-MAIL LC NoJ__ ADDRESS_----------- ---- — -- -- INSURER INSURED SAFFORDING COVERAGE : Libert Mutual Fire Insurance NAIc# INSURERA WINDOW WORLD OF WESTERN MASSACHUROADSETTS INC INSURER B 23035 : -- WESTFIIELDHMA 011085 INSURER C INSURER D: INSURER E: COVERAGES CERTIFICATE NUMBER: 48525637 INSURER F: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD REVISION NUMBER: 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. INSR LTR TYPE OF INSURANCE L COMMERCIAL GENERAL LIABILITY POLICY NUMBER POLICY EFF POLICY EXP MM/DD MM/DDry LIMITS CLAIMS-MADE r_1 OCCUR EACH OCCURRENCE $ A PREMISES Ea occurrence $ MED EXP(Any one person) $ GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY $ POLICY❑PRO JECT LOC GENERAL AGGREGATE $ OTHER: PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY $ANY AUTO Ea .1 EDtSINGLE LIMIT $ OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY AUTOS _ HIRED NON-OWNED BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLA LIAR $ _ OCCUR EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE $ DED RETENTION AGGREGATE $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY 7947-019 WC2-31S-37 $ ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N 5/7/2019 5/7/2020 PER orH- TATUTE ER OFFICER/MEMBEREXCLUDED? N/A I/ S (Mandatory In NH) E.L.EACH ACCIDENT $1000000 Dyes,describe under E.L. DESCEDISEASE-EA EMPLOYEE $ RIPTION OF OPERATIONS below 0900 E.L.DISEASE-POLICY LIMIT $1000000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more apace Is required) 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 workers compensation coverage. CERTIFICATE HOLDER CANCELLATION TOWN OF NORTHAMPTON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 212 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. NORTHAMPTON MA 01060 AUTHORIZED REPRESENTATIVE Jon Smith1988-2015 �~ ACORD 25(2016/03) The ACORD name and logo are registered moa ks of ACORDORD CORPORATION. All rights reserved. 98525637 1 1-377997 1 19-20 WC I n0270258 1 5/5/2019 7;59;95 PM (PDT) I Page 1 of 1 AFFIDAVIT In accordance with the provisions of MGL c 40, §54, 1 acknowledge, as a condition of the Building permit, all debris resulting from construction activity governed by this Building Permit shall be disposed of at (NAME OF FACILITY) a properly licensed solid waste facility as defined by MGL C 111, §150A. Date Signature of Permit Applicant PRINT OR TYPE THE FOLLOWING INFORMATION: (NAME OF PERMIT APPL CANT) (TYPE OF MAERIAL TO BE DISPOSED OF) 01*0 (PROPERTY ADDRESS)