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22B-037 (3) 1 24 CORTICELLI ST BP-2020-0261 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:22B-037 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation JBUILDING PERMIT Permit# BP-2020-0261 j Project# JS-2020-0004471 Est.Cost: $10500.00 Fee: $71.50 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MATTHEW BEAUDRY 108605 Lot Size(sq.ft.): 12893.76 Owner: WERLE GRETCHEN&FELIX HARVEY Zoning: URB(96)/WP(93)/SI(4)// Applicant: MATTHEW BEAUDRY AT: 24 CORTICELLI ST Applicant Address: I Phone: j Insurance: 117 FERRY ST 1 (413) 320-1348 WC EASTAMPTONMA01 0 27 ISSUED ON:8/30/2019 0:00:00 TO PERFORM THE FOLLOWING WORK:BATH REMODEL, EXPAND MASTER CLOSET, NEW TUB, NEW VANITY i I 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: I Gas: Fire DOpartment Fireplace/Chimney: Rough: Oil: Insiulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY-OF ITS RULES AND REGULATIONS. I 1 Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 8/30/2019 0:00:00 $71.50 J 212 Main Street, Phone(413)587-1240,Fax:(413)587j1272 Louis Hasbrouck—Building Commissioner File#BP-2020-0261 APPLICANT/CONTACT PERSON MATTHEW BEAUDRY ADDRESS/PHONE 117 FERRY ST EASTAMPTON (413)320-1348 PROPERTY LOCATION 24 CORTICELLI ST MAP 22B PARCEL 037 001 ZONE URB(96)/WP(93)/SI(4)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tyneof Construction:_BATH REMODEL,EXPAND MASTER CLOSET,NEW TUB,NEW VANITY New Construction Non Structural interior renovations Addition to Existing; Accessory Structure Building Plans Included: Owner/Statement or License 1.08605 3 sets of Plans/Plot Plan L THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Elml Street Commission Permit DPW Storm Water Management Demolition Delay 0 Sig re of Building Official Date j Note: Issuance of a Zoning pe Imit 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. t]epartrtient use Only City of No ha tus" f Permit Building D part ent uib C tlDriveway Permit 212 Mai St et A�� 9 ewer eptieAvailability a Roo 10 2019 Ater ell Availability Northampto , M 0 wo-S is of Struaturel"Plans hone 413-587-12 Fa 12QPEC-no al [Otte a Plans ° p A PTON,MA 01060 e'r pecify~ APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1'=SITE INFORMATION 1.1 Property Address: JThivsection to be-completed by office Map=Ca � Lot v ° Unit Zone Overlay District i. Elm:'St.District CB District SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED"AGENT 2.1 Owner of Record: -e ' a,� �� C ►c���� s F1vre��,�4 l��o� Name(Print) Current Wiling Address: Signature Telephone 2.2 Authorized A ent: I 1 r Name(Print) Current Mailing Address: �T W/3 yx Signature Telephone SECTION 3-ESTIMATED-CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only . completed by permit applicant 1. Building (a):Building Permit.Fee 2. Electrical / �I ,) (b) Estimated Total Cost of v (� Construction from (6); 3. Plumbing1 %1 �U` I Building Permit Fee = V6u , 4. Mechanical(HVAC) 5. Fire Protection - 6. Total=0 +2+3+4+5) Check'Number _. This:Section For�Official Use Oni Building Permit Number: Date " Issued: Signature. .::.' :, �.-- .^7A'� Building Commissioner/lnspector.of`$uildings Date cb @ ghvd. C') EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER <R:CONTRACTOR) i Section 4. ZONING All Information Must-l3e'Completed:Permit Can BelDenied Due To Incomplete Information Existing ,Proposed 's 'Required by Zoning • a t `: Ci3 .This column to be filled in by i Building Department Lot Size 5 Ell Frontage ' Setbacks Front Side L:= R:= L:= R:= Rear Building Height Bldg:Square Footage % Open Space Footage % (Lot area minus bldg&paved azkin #of Parking Spaces Fill: volume&Location) A. Has a Special Permit/Variance/Finding pver been issued for/on the site? NO 0 DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Re&tryRe ' of Deeds? NO 0 DONT KNOW YES IF YES: enter Book Page and/or Document# � B. Does the site contain a brook,'body of water or wetlands? NO 0/1"DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES . NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading,ex vation, or filling)over 1 acre or is it part 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. a SECTION5-DESCRIPTION OF PROP OSED WORKfcheck'alE applicable)' 11 5 New House ❑ Addition ❑ Replacement Windows Alteration(s'I) Roofing Or Doors go Accessory Bldg. ❑ Demolition New Signs [0] Decks [Q Siding[0] Other[C]] Brief Description of Proposed Work: � ���f1Q Surnn��d GIT�'Irwln Kmothl i C- Q ftAl- cioc'k -TwVi �U�, Iwo) Vu►1�y� ahs f�Ur I 1 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating-unfinished basement Yes No Plans Attached'Roll -Sheet sa.lNew houseFanc�..osadciiti©nr#o ezlsting h'aius��l�Y�camp�Cete the fol�o""v`rrrnd: 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 Com plian ce form attached? h. Type of construction J 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 x SECTION 7a,-OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, F as Owner of the subject property hereby authorize r7 g Ill to act on my beh If, in all matters relative to work authorized by this building permit application. S ZI Z-21 Signature of f6wriel VDate. I, a/1 r as Owner/Authorized Agent hereby declare that the statelents and information on the foregoing application are true a 'd accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name 71-41?hSignature of Owner/Agent D e SECTION 6:-,CONSTRUCTION SERVICES 8.1 Licensed Construction'Supervisor: Not Applicable r 0 Name of License Holder: i vj 1 03-1(90 License Number F2 _ 5 �- Address Expiration Date V/3- DO-j3 Signature T hone 9 "Rep�stered,Home"tri�pravement`Contratt or �,. . Not Applicable ❑ Company Name ''FF Registration Number V� 1/1-3/-10 Address Expiration D to Tele phone SECTION 1U=°WORKERS'COMPENSATIONINSURANCEAFFIDAVIT`(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...... ❑ City of Northampton Massachusetts w'E� ,�s F DEPARTMENT OF BUILDING INSPECTIONS , x' 212 Main Street • Municipal Building 3b Northampton, MA 01060 r 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("HIC"). 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 adjacentto 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 l Type of Work: Y`�C.1Ml���� ( �if111 Est. Costal �6 0 er(�/ Address of Work: y C6 9F /Vd4 iMAY\. /V A 0j()(01 ' I Date of Permit Application: 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: rt3: Date Owner Name and Signature I City of Northampton Massachusetts s DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 rev.> iJ 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. i City of Northampton �„• � I 915 S'r� � * Massachusetts Q' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ■Municipal Building n ' Northampton, MA 01060 Sbjy Yl 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 1111, S 150A. The debris from construction,work being performed at: (Please print house number and street name) Is to be disposed of at: SAI Pecq I (Please rint nar4e an• location of facility) I , Or will be disposed of in a dumpster onsite rented or leased from: I I J (Company Name and Address) ! . I Signature of Permit Applicant or Op. 6r'Date I' 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. I . i I i ! I ' � I II Az The Commonwealth of Massachusetts r Department of Industrial Accidents a I Congress Street,Suite 100 Boston,MA 02114-2017 'r www mass.gov/dia l�M 5�9y Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): (� Address: City/State/Zip: II MA Q OV) Phone#: y 1 '32,0 — 13�D Are you an employer?Check the appropriate box: Type of project(required): 141 am a employer with I employees(full and/or part-time).* '7. []New construction 2. I am a sole proprietor or partnership and have no employees workin for me in p p p pg g. RemOdelirig any capacity.[No workers'comp.insurance required.] 3.D I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 2ZDemolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.ELElectrical repairs or additions proprietors with no employees. 12. 'Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.QRoof 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. $Contractors 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 isproviding workers'compensation insurance for any employees. Below is thepolicy and job site information. Insurance Company Name: rr l /�fr'y��!�' r U Policy#or Self-ins.Lic.#: lD S 1p C)U�S�3 ODD)' Expiration Date: J bo Job Site Address: I W -al/ Lf-do(AM/A. /� City/State/Zip: Attach a copy of the workers' compensation policy declaratio 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 certify under the perins.andpenalties of perjury that the information provided above is true and correct Signature: Date: a, Phone M `1/3' 2-0— 13 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#: i n 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 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 maybe provided to the applicant as proof that a valid affidavit is on file forTuture 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 iburn leaves etc.)said person is NOT required to complete this affidavit. I i 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-MASS i E Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia DATE(MM/DD/YYYY) ACORO® CERTIFICATE OF LIABILITY INSURANCE 1 1 08/29/2019 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 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 CONTACT NAME: Barb Van MOUrik FINCK&PERRAS INSURANCE AGENCY INC PAHOICNo Ext: (413)527-3000 ac No: E-MAIL ADDRESS: bvanmourik@finckandperras.com 6 CAMPUS LANE INSURER(S)AFFORDING COVERAGE NAIC# EASTHAMPTON MA 01027 INSURER A: HARTFORD UNDERWRITERS INS CO 30104 INSURED I INSURER B: BEAUDRY MATTHEW INSURERC: DBA BEAUDRY HOME IMPROVEMENT INSURERD: 117 FERRY STREET INSURER E: EASTHAMPTON MA 01027 INSURER F: COVERAGES CERTIFICATE NUMBER: 442926 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 OTHERDOCUMENT 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP I LIMITS LTR D VV1/D POLICY NUMBER MM/DDIYYYY MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DA E TO REN CLAIMS-MADE 1-1 OCCUR i PREM SES(Ea occurDrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ i EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER ANYPROPRIETOR/PARTNER/FXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? NIA N/A N/A 6S60UB2E86300019 05/04/2019 05/04/2020 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if th!e insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www,mass.gov/lwd/workers-compensation/investigations/. I Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF„ NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main Street AUTHORIZED REPRESENTATIVE LtJ . Northampton MA 01060 Daniel M.40y,ey,CPCU,Vice President—Residual Market—WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I CERTIFICATE OF LIABILITY INSURANCE DATE(MM/°D/YYYY) ACORO® ' 08/29/2019 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(les)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 CONTACT Elizabeth Carballo,CISR NAME: Finck&Perras Insurance Agency Inc. a/c°N o Ell): (413)527-5520 A N,): (413)527-5970 6 Campus Lane E-MAIL bcarballo@finckandperras.com ADDRESS: INSURERS)AFFORDING COVERAGE NAIC# Easthampton MA 01027 INSURER A: Safety Insurance 39454 INSURED I INSURER B: I l Matthew Beaudry INSURER C: Beaudry Home Improvement INSURER D 117 Ferry Street INSURER E: II Easthampton MA 01027 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1982704416 f 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. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DDIYYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 UAMM CLAIMS-MADE OCCUR PRESES(3E TOE.occu RENTEante) $ 100,000 MED EXP(Any one person) $ 10,000 A BMA0021095 01/14/2019 01/14/2020 PERSONAL BADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ I OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE s EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Proof of coverage I I i CERTIFICATE HOLDER I CANCELLATION SHOULD ANY OF THE ABOVE,DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEEOF,NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main Stree AUTHORIZED REPRESENTATIVE ""f� Northampton MA 01060 �7�rG(L� "l zG�O @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD I