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42-085 (4) 165 GLENDALE RD BP-2021-1013 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:42-085 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ACCESSORY BUILDING BUILDING PERMIT Permit# BP-2021-1013 Protect# JS-2021-001728 Est.Cost: $75000.00 Fee:$192.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: NORMAN YOUNG 025262 Lot Size(sq. ft.): 41774.04 Owner: BOWLER MAURELN Zoning: Applicant: NORMAN YOUNG AT: 165 GLENDALE RD Applicant Address: Phone: Insurance: 75 SOUTH MILL RIVER RD (413) 665-4265 WC SOUTH DEERFIELDMA01373-9733 ISSUED ON:3/18/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:NEW ACCESSORY BUILDING 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 U ON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. • r • )2 )foiy Certificate of Occupancy signatur;: FeeType: Date Paid: Amount: Building 3/18/2021 0:00:00 $192.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner -OK File#BP-2021-1013 APPLICANT/CONTACT PERSON NORMAN YOUNG ADDRESS/PHONE 75 SOUTH MILL RIVER RD SOUTH DEERFIELD (413)665-4265 PROPERTY LOCATION 165 GLENDALE RD MAP 42 PARCEL 085 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: NEW ACCESSORY BUILDING C\1\ New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 025262 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: XApproved 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 f 3/g Si ature of Building Official Date r 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. __..__-- OLL€ti� PL1j, i z m r. The Commonwealth of Massachusetts FOR y S Board of Building Regulations and Standards MUNICIPALITY �° :_,, Massachusetts State Building Code,780 CMRUSE sz C; Building Permit Application To Construct,Repair,Renovate Or Demolish aRevised Mar 2011 n �-► One- or Two Family Dwelling rt'-I n This Section For Official Use Only Z �tiiiT ing Permit Number: ,Pi.?/'/Q1 3 Date Applied: f 1 , 5)1 • 0 %' i ►• 3 /(i' Building Official(Print Name) I Signature 1 Da SECTION 1:SITE INFORMATION 1.2 Assessors Map&Parcel Numbers G�e.Ntscit CWA—O$S--oo1 I.1 a Is this an accepted street?yes X no Map Number Parcel Number ..=D 1.3 Zoning Information: 1.4 Pro erg imensions: d 4Zoning District Proposed Use of rea(sq ft) Frontage(ft 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required ),." tProvided ( Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Public _Private❑ Check if yes❑ Municipal 0 On site disposal system tit SECTION 2: PROPERTY OWNERSHIP' �// Q fkatRiee , �Z/� • 0/0 6 a..e(Print) City,State,ZIP ( 6S 6/educQ, 124 /-tj'/3-�o6S�7vaaa rl�pwrs w.8rWkrt by ea ii im L.• �wt No.and Street CRI )3•S3 .,3(1) Telephone Email Address G • w S -. . . .. �ly) Cot� New Construction% Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.jif. Number of Units Other Ii16 ❑xSpecify: m _ 1 f't,// cl'ovuc i Y a,`iisv l' Our- � fl • oA 4' she • t .&live(' eenAgo..e A ), '6"-"•/ �.ot$ z61-1 i.. Estimated Costs: Item Official Use Only (Labor and Materials) moo 1.Building $ aS'b00 1. Building Permit Fee: $1/a,Indicate how fee is determined: 2.Electrical $ / t Standard City/Town Application Fee Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: / . 5.Mechanical (Fire $ Suppression) Total All Fees: fit,Check No. 4Check Amount: /q,ash Amount: 6011111111.1011.11Mir -.1. s>Ooo• ❑Paid in Full 0 Outstanding Balance Due: .f t5 , .20 1' - -rf '�' perm tii, f i /verivo r / Cm y 4i6 a611 f6 f -r --._ city of Northampton o0" rr ?'� Massachusetts „Ss , f i i r, DEPARTMENT OF BUILDING INSPECTIONS ` 212 Main Street • Municipal Building v� ,.9 � s�. Northampton, MA 01060 s _- '.% PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW 1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES, FENCES, GROUND MOUNTED SOLAR, ETC. • I. Building Permit Application signed by legal owner and filled out by owner or authorized-agent. '2. bne set of plans and specifications of proposed work. (Digital and hard copy) 3. Site plan with location of proposed structure(s)and set backs. 4. Construction Debris Affidavit filled out and signed by applicant. 5.Worker's Compensation Insurance Affidavit filled out and signed by applicant. 6. Con.tFactors must supply a copy of CS License, HIC Registration and proof of Liability Insurance. 7. Energy Conservation Compliance Certificate (new/replacement windows). 8. Home Owner'q License Exemption Form filled out and signed by Homeowner(if applicable). ,� 9. Note any Conservation and/or special permit requirements (if applicable). - ' • 40: thiveway`Pern` (if applicable), 11. Proof of Water and Sewer entry fees paid (if applicable). 12. Trench Permit -public land by DPW/private land by Building Dept. Stretch Energy Code -all new construction will require a HERS Rater Affidavit to be submitted with permit pplicttion before issuance of perk it."-' .. . SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) W.40:2-.. -- /k/6)/cF/Yht4A/ �,�, License Number Name of CSL Holder / / � l List CSL Type(see below) l No.and Street Type Description � Gs ,�}'� G�( \�j Unrestricted(Buildings up to 35,000 cu.ft.) � y 8, Restricted 1&2 Family Dwelling City/Town,State, M Masonry RC Roofing Covering WS Window and Siding -4/2X ilfO3i)'j £ SF Solid Fuel Burning Appliances L/%3 64' 1-1,,,,e.er tA-goa_ j I Insulation Telephone E ail address D Demolition 5.2 Registered Home Improvement Contractor(HIC) AZIEM.AA) cf j,tG HIC Registration Number Ex uation Date HIC Company Name or HIC egistrant Name _cr2(4774- /IL RI, R5z) /114 Cl9-yv'th i -10 No.and Street Email address , Cnr! tN e-e-R /e/Gtl 4414 /1 lP6oS Z � LET/0'1 City/Town,State,ZIP �/ p f 3 Telephone SECTION 6: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 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILAING PERMIT I,as Owner of the subject property,hereby authorize /,'e ein 0[>/Li 6 to act on my behalf,in all matters relative to work authorized by this buildin rmit application. • /--/ 0.DR-1 Print Owner's Name(Electronic Signature) ���?�lt ��0�� Date 011,111111P AtITITOMIRD AERAIrrDPCLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. ZOnstrevier Agetes Name fineetreate Signature) Ors NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass_gov;oca Information on the Construction.-Supervisor License can be found at www.mass.nov/dps 2. When substantial work is planned. provide the information`below: Total floor area(sq.ft.) 940 1 (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms • Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" R CITY OF NORTHAMPTON MAP: LOT: O�a LOT S1ZE:_j. S SEP 7-' REAR LOT DIMENSION . hF.ARI'ARD _ / SIDE WARD ` Ss,C SIDE 1'•11+D/LI ( 07-73 Ia5 • • / 0 ° FRONT LIBACK .'p FRONTAGE IT6 _ KDICATE LOCATJON AND DI ME NS!ONS OF II OLE E GARAGE.ADDITIONS OR ACCESSORY BUILDING. IIE SURE TO INCLUDE FRONTAGE AND LOT SIZE(SQUARE FEET OR ACRIZSI :i - • I I. s j 1 1772-'16- AI ; I wt r ,L t — vim- �1 — • , # i . Ohm Ca v u — - - 77 rwaS _ _ _ zip & . I \f, 1 1 �'�Cam b°' ` - 4tpl ‘Nc-k- 0— ' ' . , viA . --- - , ., -p ,e k 3o,,ie,<-5 h 36(0446.1r.„(_ shay o�"� d\ ; MItiaJ 3 Q�p-i- . ir ---,Jet:,te et",117c — +++...iii I I i I . 1- fil`" if° (4)(_2_1 __C- ' k\,\ \ ..>2.4 t1Ql�- PO4 A I I s ,. •- / I I .g..kii; 640,,Itan eg:iiiitai , ,- --- C I 041v I a gP• a °15- la b,,ti7 • . s - zov-1--- rot-04.) A,;•47,i-illP -- > //J/i /// / /.,` ////// i / //1/, / /-, r 4 / /k ////,////i/ k.2 'A, J////7 i h/�T/7 23 L 14 M N• fl, l 6'EO.E6:4-- B!/czA7LA ET.94 N3.-4 to '% - O7- O c 14.) --i- t-, a a o i.,e •1.9• ,. . i Iv c— al, 3 0 kij A .Q3 ►v- � /Ct,/i9 R 0 .90 1.e4L E. . 17 ' tt.Z o, 8,�st t V Q GEO. dge B tic AvAP —3 v ''1 .e-T elx Q r ,4 AL \ O ET fr . t4t % ft, 1 a f o t rk 3 00 % h 1 O 0 4. 0 8 1).P 'a0 • ,.P 16 --.5 a ° - 07 • — os-,E GL ENO AL E C/FY coo.e. ,pD A.O x •6G87: 9d Y: 38,79.o y' -PV N o 9s /qW1 I/V1 /Y0.4T-iVi9"17 T 0, /mil 9,S.S- o H LM R Y. 0 t BEL D/'G//✓G TD m '4E"O•iPGE' EPI/CZAL.q ET"AIL 4) �°1sT6Rc9 en avaty .�; /9G/ -' S'C AP.Z E- ," s C Q • "u S u_ i• OAi#/.S EA/G/NE'E.e'//1/G C O.d "VO.P 7W047 rJ#2 T'O/ • h The Commonwealth of Massachusetts } j. /. Department of Industrial Accidents 1 Congress Street,Suite 100 ; ' Boston,MA 02114-2017 � www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeeibIv Name(Business/Organization/IndividuaI): cl/�, n,) G 'or/ q d7cylt/S7-/r«t-'r'j6/.1 Address: `So`�711 fn,// 1f� / City/State/Zip: ' Phone#: /1/`j 6 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. 3 New construction 2.1=1 I am a sole proprietor or partnership and have no employees working for me in g. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 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.❑Plumbing repairs or additions s.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13•0 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,§I(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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: /)// "j�� L -/�� (� Policy#or Self-ins.Lic.#: /kr, 6/06, t i(pg A Expiration Date: - /6o/ / Job Site Address: /(OS 6/6-'/1/. 4e-C-. `/ ✓ ' City/State/Zip: y'VQ) orip 7.79Al 0/C 6:2-) 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 certify under the pains ay dpenalties of perjury that the information provided above is true and correct: / AL_ Phamatt . I -- 4 3- - S1a-2-• Official use only. Do not write in this area,ttk¢e compllttcd by city'or town 6ffcciuL . a , 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#: �.�k�t ,l;,� The City of Northampton �� Building Department rp, � � y212 Main Street ii;pa,.•. ,,ate �""rEDN"`'�. Northampton. Massachusetts 01060 Phone (413) 587-1240 Fax (413) 587-1272 IT (FOR ALL DEMOLITION AND RENOVAT ION PROJECTS) - i In accordance with the provisions of MGL c40, s54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, s150A. The debris will be disposed of in: UiCL-5lk.. `QV 1 C.CQ. Location of Facility S P el In F1 The debris will be transported by: Name of Hauler VV CtcJe 1717e- i cic, k," - 711/14(414A--___8-Signature of Applicant: MG�(� Date: '—`5"-'v2- City of Northampton ► Y iaK�N"�rr� 5(.1 SI Massachusetts �fSR�~�i m *.� j` ' r Ak DEPARTMENT OF BUILDING INSPECTIONS P 212 Main Street 4, Municipal Building �vj• `‘-' Northampton, MA 01060 s %yY�;j1�OC 4401 UWAI4 4'EXEMPTION MOBILITY ilEEDAVIT • Ih _ _ (insert full legal name), born _ (insert month, day,year),hereby depose and state the following: 1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a parcel of land to which I hold legal title. 2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners' exemption, does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3. 3. I qualinj under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2: Person(s) who owns 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 home owner. 4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work on my parcel, I am not engaged in construction supervision in connection with any project or work involving construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any provision of the Massachusetts State Building Code. 5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work. 1114 Signed under the pains and penalties of perjury on this l� day of vo 20.2f 4..(1/174416./(---- (Si ature) • t r ) •4.. f • K' . • • 4 .. 1111W. .• • • a'• • Cornnionweaan oi Division of Professional Licensure Board of Building Regulations and Standards CS-025252 akpires:05123/2-022 NORMAN E YOUNG 75 S MILL Ri110-k ku S DEERFIELD-SA 01373 • • Commissioner, ert ACc CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/11/2021 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: Elizabeth Downie ENCHARTER INSURANCE LLC IN No. (413)549-4971 FAX (A/C, E-MAIL ADDRESS: edownle@encharter.COm 25 UNIVERSITY DRIVE INSURER(S)AFFORDING COVERAGE NAIC# AMHERST MA 01002 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: NORMAN E YOUNG & MAXINE YOUNG INSURER C: NORMAN E YOUNG CONSTRUCTION INSURER D: 75 SOUTH MILL RIVER ROAD INSURER E: SOUTH DEERFIELD MA 01373 INSURER F: COVERAGES CERTIFICATE NUMBER: 631130 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. NOTVNTHSTANDING 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 EFF POLICY EXP W LIMITS LTRINSD VD POLICY NUMBER (MM!DD/YYYY) (MM/DD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Es occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE ER YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? NIA NIA N/A AWC40070266692020A 07/06/2020 07/06/2021 (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 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.govAwd/workers-compensation/investigations/. No partners have elected coverage. Continuation of above Named Insured:NORMAN E YOUNG AND MAXINE YOUNG 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. 210 Main Street AUTHORIZED REPRESENTATIVE Northampton MA 01060 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD VORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY NFORMATION PAGE &.I.M. Mutual Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-097C (800) 876-2765 NCCI NO 26158 ,OLICY NO. AWC-400-7026669-2020A1 PRIOR NO. I AWC-400-7026669-2019A! ITEM 1. The Insured: Norman E Young& Maxine Young DBA: Norman E Young Construction Mailing address: 75 South Mill River Road FEIN:**-***3983 South Deerfield, MA 01373 Legal Entity Type: Partnership/LLP Other workplaces not shown above: See Location the policy period is from 07/06/2020 to 07/06/2021 12:01 a.m. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limn 3odily Injury by Disease $ 100,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audi' Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 000368068 INTER SEE CLASS CODE SCHEDULE Minimum Premium $500 Total Estimated Annual Premium $500 GOV GOV Deposit Premium $506 STATE CLASS MA 5645 State Assessments/Surcharges $161.00x3.5100% $6 This policy, including all endorsements, is hereby countersigned by 06/18/2020 Authorized Signature Date Service Office: Encharter Insurance LLC 54 Third Avenue 25 University Drive Burlington MA 01803 Amherst. MA 01002 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission: Office of Consumer Affairs and Business Regulation 1000 Washinaton Street - Suite 717 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual Registration: 191278 NORMAN E YOUNG D/B/A NORMAN E YOUNG CONSTRUCTION Expiration: 04/04/2022 75 SOUTH MILL RIVER RD SOUTH DEERFIELD,MA 01373 Update Address and Return Card. SCA 1 0 20M-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 191278 04/04/2022 1000 Washington Street -Suite 710 NORMAN E YOUNG Boston,MA 02118 D/B/A NORMAN E YOUNG CONSTRUCTION NORMAN YOUNG n 75 SOUTH MILL RIVER RD ( j04 SOUTH DEERFIELD,MA 01373 Undersecretary Not valid without signat