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03-011 (6) 4a LINDSEED RD BP-2020-0892 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:03 -011 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categ ry:demolition BUILDING PERMIT Permit# BP-2020-0892 Project# JS-2020-001520 Est.Cost: $12000.00 Fee: $150.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SCOTT RUMPLIK 102465 Lot Size(sg.ft.): 136037.88 Owner: LAPIENSKI IRREVOCABLE TRUST Zoning: RR(100)/WSP(100)/ Applicant: SCOTT RUMPLIK AT. 4a LINDSEED RD Applicant Address: Phone: Insurance: 125 MOUNTAIN RD (413) 566-2250 WC HAMPDENMA01036 ISSUED ON:2/5/2020 0:00:00 TO PERFORM THE FOLLOWING WORK:demo and remove 2 mobile homes 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: 074" AM FeeType: Date Paid: Amount: Building 2/5/2020 0:00:00 $150.00 . 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner 4a LINDSEED RD BP-2020-0892 GIs#: COMMONWEALTH OF MASSACHUSETTS MV.Block:03-Oil CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:demolition BUILDING PERMIT Permit# BP-2020-0892 Project# JS-2020-001520 Est.Cost: $12000.00 Fee: $150.00 PERMISSION IS HEREB Y GRANTED TO: Const.Class: Contractor: License: Use Group: SCOTT RUMPLIK 102465 Lot Size(sa. ft.): 136037.88 Owner., LAPIENSKI IRREVOCABLE TRUST Zoning_RR(100)/WSP(IOO) Applicant. SCOTT RUMPLIK AT. 4a LINDSEED RD Applicant Address: Phone: Insurance: 125 MOUNTAIN RD (413) 566-2250 WC HAMPDENMA01036 ISSUED ON.21512020 0:00.00 TO PERFORM THE FOLLOWING WORK.-demo and remove 2 mobile homes 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: FeeTvpe: Date Paid: Amount: Building 2/5/20200:00:00 $150.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton's FF _ ut?9f Permit. <•- Building Departme tB Curb C UDriv `way Permit I 212 Main Stre6t ,r \ S �(? ewe/Septi Availability v Room 100 0'`��� Wat r/INeI Availability Northampton, MA 010 �'�oN�n�sp Tw Sets f Structural Plans phone 413-587-1240 Fax 413-587-1 q o� o t/Sit Plans her pecify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map `�q CtNSce (�1 est l �Fld Lot /� Unit Zone Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT i 2.1 Owner of Record: LaP�cA15 k! 1 r t�forC S OfJso, C {t,,, 6(Od'72-1 Name(Print) Current Mai ing Address: 1Atir* ZN51/QA1411 G0 - -74$- S 7 3`7 Telephon Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: 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 (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee Oo 4. Mechanical (HVAC) V's, /�jv, 5. Fire Protection 6. Total=0 +2+ 3+4+ 5) 12 : Check Number (�9 This Section For Official Use Only Building Permit Number: t�j�` �� — ` �— Date Issued: Signature: Building Commissioner/Inspector of Buildings Date G 7 Duff f f6 @ g A4.,t IV 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 in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW YES 0 IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 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 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES i NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 0 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 0 Accessory Bldg. ❑ Demolition New Signs [❑] Decks [Q Siding (0] Other[❑] Brief Description of Proposed Work: �t,vio a,,d l�eMOUL vl Mo�r(e !fu"+S Alteration of existing bedroom Yes No Adding new bedroom Yes No 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 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, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, 5C,if D r �pl �' ��uu^�� {` �S �ry zc 5 as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. SCoff 9v411ptlk PrintN I, 0 S-rgnatbre of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: I^ Not cApplicable 'r❑ Name of License Holder I C C Y t UyN��l�a n L J 10 3 l 5' License Number 0 q - I (", a e).)-4 Addr s Expiration Date ign ture Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Addr s Expiration Date Telephone .14 3 /rbc" }56 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....... 1XINo...... ❑ - City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building wpb 4 Northampton, 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("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 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: bey-,o �), Adk 1p 4yK5 Est. Cost: Address of Work: (�-i/lag"oJ Date of Permit Application: ' ��`�.0 a O 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: 2-g- poaa sca f f f�UIIA41'k 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 Massachusetts DEPARTMENT OF BUILDING INSPECTIONS ' 212 Main Street • Municipal Building 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 s Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building 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 at: HALiv,- )-r-r-d (Please print house number and street name) Is to be disposed of at: G,J e S k r''., /7c cYU (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: f3 S �uMA5-kr_S f Gt.v Ad 0)()3C- (Company 103G (Company Name and Address) .--)A D F�* Signat re 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. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass gov/dia NVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual):n6nrouwJ 13rt^A-r rS 5eryize5 Address: 1((o Nl o v v J,.✓ /ted' G l d 3 G City/State/Zip: MA D►on Phone#: L113 5-U. Are you an employer?Check the appropriate box: Type of project(required): I I am a employer with `. employees(full and/or part-time).* 7. ❑New construction 2.rl I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ®Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.[]1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ p Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 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 andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 1.l•✓seed 9J City/State/Zig: 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 certify under the painsand penalties of perjury that the information provided above is true and correct. Si nature: lk Date: Lt-,?c as Phone#: y 1446 A 7k 5-0 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#: + Jonathan Fla <fla northam tonma. ov> R� 99 1 99@ P 9 ....... Fwd: Removal of Service Completed (3359162) linseed 1 message Kate Rumplik <krumplik76@gmail.com> Wed, Feb 5, 2020 at 10:03 AM To:jflagg@northamptonma.gov Sent from my Phone Begin forwarded message: From: minguanti@cox.net Date: January 29, 2020 at 12:52:20 PM EST To: "Kate Rumplik (via Google Docs)" <krumplik76@gmail.com> Subject: FW: Removal of Service Completed (3359162) Hi Scott and Kate. Below please find the confirmation email I received from Eversource validating that homes. I hope this is sufficient for the permit purposes. Thank you, Mary Mary Inguanti 76 Gray road South Windsor, CT 06074 860-798-5737 -----Original Message----- From: WMASSNewService@eversource.com <WMASSNewService@eversource.com> Sent:Wednesday, December 11, 2019 10:30 PM To: MINGUANTI@COX.NET Subject: Removal of Service Completed (3359162) From: New Service Clearing Desk WMECO/NUS@NU Date: 11-DEC-19 To: INGUANTI,MARY Subject: Removal of Service Completed (3359162) Dear Customer, Your WMECO Demolition/Construction Service Removal Request: 3359162 for Job Location:4A LINSEED HILL RD, HATFIELD, MA has been completed. Service Removal Date: 11-DEC-19 This letter is to confirm the removal of the existing Western Massachusetts Electric(WMECO)service and meter(s)at the above address for the purpose of demolition/construction of the building. GBS Ground Breakers Services 116 Mountain Road — Hampden, MA 01036 Phone: (413) 566 — 2250 January 29, 2020 Mary Inguanti 76 Gray Rd South Windsor, CT 06074 (860) 798 - 5737 minguanti@cox.net 4k RE: Demo of Two mobile homes at-7.Linseed Rd, West Hatfield/Northampton • Obtain two demolition permits @ $75/each • Demolish mobile homes and additions • Take debris to a licensed Recycling Facility • Homeowner is responsible for all utility company sign-offs Total: $ 12,150.00 Thank you, Scott Rumplik NJ QO ro v-e �v,i✓l� M 9 �/ �n�Gu14n� I LAPIENSKI IRREVOCABLE TRUST 1464 1 76 GRAY RD I SOUTH WINDSOR,CT 06074 aDa51-nien2ii J 3 zzi iDateCHECK A�IA08 i Pay to the QQ i Order of f 1�( IA- ( � S�A y Dollars �. PleopbbUnded Bank Ff vaory,f) iZ64 1-1 �i �lliNP 1 1: 22LL72186i: 6500245547Ila L 4 6� f Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 192772 GROUND BREAKERS SERVICES INC Expiration: 08/09/2020 116 MOUNTAIN ROAD HAMPDEN,MA 01036 Update Address and Return Card. SCA 1 ti 20M-05!17 rT"W...rrn�nuvcr�/� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 192772 08/09/2020 1000 Washington Street-Suite 710 GROUND BREAKERS SERVICES INC Boston,MA 02118 SCOTT RUMPLIK �� 4 116 MOUNTAIN ROAD Not valid without signature HAMPDEN,MA 01036 Undersecretary Common 71ealth of Massachusetts Division of PReeulations Licensute and Standards Board of Building g so' EjrPires 0911612020 CS-102465 - i RUMPL SCOTT D IK M 125 OUNTAPt, 036 HAM ,0 MA Commissioner DATE(MM/DD/YYYY) ACORN►® CERTIFICATE OF LIABILITY INSURANCE 02/05/2020 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: Pamela Bodenstab-Krynicki P L KRYNICKI INSURANCE AGENCY ac°NN Ext: (413)543-9119 AI No: ADDRESS: krynicki.insurance@verizon.net 459 MAIN ST INSURER(S)AFFORDING COVERAGE NAIL aY INDIAN ORCHARD MA 01151 INSURERA: AMERICAN ZURICH INSURANCE COMPANY 40142 INSURED INSURER B GROUND BREAKERS SERVICES INC INSURER C: DBA GBS INSURER D: 116 MOUNTAIN ROAD INSURER E: _ HAMPDEN MA 01036 INSURER F: COVERAGES CERTIFICATE NUMBER: 502103 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MO DDY EFF POLICY EXP MM/DD/YYYY LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F-1OCCUR PREM T1. ES Ea occu Once $ MED EXP(Any one person) $. NIA PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY F1 JECTPRO ❑LOC PRODUCTS-COMP/OP AGG $ PRO- OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTYDAMAGE $ HIRED AUTOS AUTOS - Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION x AND EMPLOYERS'LIABILITY X STATUTE EERH Y 1 N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? NIA NIA N/A 6ZZUB0542N31319 05/26/2019 05/26/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 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 the 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/. CERTIFICATE HOLDER CANCELLATION 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 AUTHORED REPRESENTATIVE NORTHAMPTON MA 01060 Daniel M.Crowley,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