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24C-153 (3) 51 ARLINGTON ST BP-2021-0871 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24C- 153 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2021-0871 Project# JS-2021-001483 Est. Cost: $22500.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STEPHEN CAMP 082531 Lot Size(sq. ft.): 10018.80 ' Owner: MACH CLAIRE F&ELIZABETH MACH Zoning: URB(100)/ Applicant: STEPHEN CAMP AT: 51 ARLINGTON ST Applicant Address: Phone: Insurance: 46 EAST ST (413) 527-7124 O WC EASTHAMPTONMA01027 ISSUED ON:2/3/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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. I I , o Q� Certificate of Occupancy Signature: , ' V • . d� 1 • I FeeType: Date Paid: Amount: Building 2/3/2021 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner RECEIVED I I I i F E B - 3 2021 The Commonwealth of Massachusetts FOR , ,. t _/ oar4i of Building Regulations and Standards MUNICIPALITY assichusetts State Building Code, 780 CMR ;.`V OF FUILDING INSPECTIONS I USE NORTHAINIAdittA Pei Mit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Pe it ber:: ,P' �9)1 r a 71 Date A 'ed: ACuie.�r I�oSs Z 3 ZOZI Buil ing Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers c,fr_ 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? — Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: j M-4- + l far d G yLtaCi/ 44v fc p1. 111L 62 c' Name(Print) City, State,ZIP 57 /1 r 41 y-,,,i/ S fve.e. - Z; 7- `//1/ - _____ No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work': ././e-pti /ecz iG 57i-v) ' Z.-x #5, %oaO l am' e- v ,f /of'/4/l /- e,,,f f i.'`, Li,' e. 5z- lC e 4 S'6..t ci f ✓€,-- e, 4/17 a i.e } - t 7 T, - I/ .0-44,,iic i,:,% 5-4 r.,f(,.// pz vow Dn. p1', p- it.kS (gall,- 4vil ro u-v®� SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ ilqi , Check No.7&( Check Amount: , Cash Amount: 6.Total Project Cost: $ L 2-I 6� © ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) j 3// //�23 — 2/ h) 69-Olf License Number /Expiration Date Name of CSL Holder JJ List CSL Type(see below) y( 4St S e No.and Street Type Description C, T _ -( �h P4� Dl(2 ? �� Unrestricted(Buildings up to 35,000 cu.ft.) State,ZIP R Restricted 1&2 Family Dwelling City/Town, M Masonry RC Roofing Covering WS Window and Siding �y SF Solid Fuel Burning Appliances 1 z?- 7/2� � /I/j r/ ��� /,yJ, p n� I Insulation Telephone / Email address D Demolition 5.2 Registered Home s`Improvement Contractor(HIC) _ 5 iLt / ( �''� � J/ " � " HIC Registration Expiration Number Date HIC Company Name or HIC Registr ame 6' f4S-' S'�z� (AMg1 -t-Y6 f� X1/.1. -� No.andStreppr Email address �- z v°� lest.() 0/002 2?- 7/ City/Town, State,ZIP 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 ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S 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. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION 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. .5-441i4/t)Print Owner's or AuQh' ) ize Agent's Name(E ctronic Signa Date 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.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (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" City of Northampton .•" Massachusetts �� G` DEPARTMENT OF BUILDING INSPECTIONS ti ` 212 Main Street • Municipal Building vs ca' Northampton, MA 01060 '811y 3f'D�^J CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, 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, S 150A. The debris will be disposed of in: Location of Facility: 00-1, g yd /1/r�rt-r i 14-d Srt ,y -ext*/ The debris will be transported by: Name of Hauler: - //4/14; /11 /7 %1F �/� ��✓ Signature of Applicant: Date: / 2 li. ._\ The Common wealtth of Massachusetts it kDepartment of Industrial Accidents ►'- � 1 Congress Street,Suite 100 Boston.MA 02114-2017 t wwatmass.govidia ]1,ulcers'('wupresation Insurance Affidavit:Builders/Contractors/EIrctrieiansiPlutnhers. ID BE f n_1.1)%%I I Il I11E PERMITTING IM; I I HORl rl. 111plicant Iitdorntatiota Please Print I_t-r ihh Name(tit,,tnc:s:tlt ttizatiron l,tdtviduall: Skev✓ 64-4 Address: 2-(6 5-1- 5-t - CityIStateiZip:C/1-34 1e x,f pit.- 01 d Z 7 Phone#: �/5 f 2 ?— ? 12y %re.,on au cmpkner!Cheek the appropriate has:: T,pc of project(requiredl: I tawlacuepltnc�with emploteesifulltuldurpan-Dine►' 7. EJ New .fun 2 I ant a mite prtrpriems or partnership and hate no cuipkrlc1's wofLing for nu:in 8_ Remodeling any capacity_Poi woasis'comp.insurance required.] 30 I out a h onrtrwtrr doing all wort myself:I No molars'corm_nawrancc unquircd_]" 9. 0 Demolition le Q Building addition 40 I aui a ltnnwtintreer and will he hiring xvwtracttus to conduct all.a la on un property. I of ill ullnurc that all rtntractors c-ithcr Irate makers'ctingreatvtuan insurance or me sole 11.0 Electrical rCpdir5 or additions papttctotx with no ciuploycc3.. 12.0 Plumbing repairs or additions 5C3 I am a gnrial contracwr mind I hate hired the sub-ctmtrad on listed on tlu:attached it ccy_ 13 Roof repairs Limn. :sub-contraciun hale employees and hate wart,.% lour.insurance. ', 14.0tr 60 Mrc are a cuupui titm and its offerers hat c criticised dick right ut.cxrnrptiut per MCit.c. 152,11114l.and we hate no ennrlti ass.(No Porters'comp.insult mace reyuuctl.l *Any applicant that dralLs box gI must also fall out ter-.section below shorting their Dodo:is'cuatpeaxation policy itfunmliuu_ t lioereu encrs w her submit this atfnhatit indicating they arc doing all eta+rk and then hie outside contraekas Dora submit a west atfidat it Indic-Aim such. :Ctutracturs that check this bens must attached an additional sheet shooing the mart,of ten snt.-cuttractrxs and state ohs-their o not those cuttitics Intc employees. It the sub-ctxtraxiors lots anplo ccs.tlr-y nano monde their swirlier;n*up_policy atrnlrer. I Gill all employer that is providing, worltert'compensation insurance for aty employees. Below is the polio anti jut,site illAWIll a/afltt. lnsuratne Company Nate ,QGG /9/1-+-w r.414,✓ L$ C i' _ Policy#or Self--in .Lic.#: 6 - 22 — 37,eg0`Z 72- bepiration Date: 9 /— 2- Job Site Address: 57 ,4 v 1 i•, '�vi,/ �`� City �Zp:AD/ / / _ O/04 Attach a espy of the workers'eom1eensation policy declaratimr page(shsvrieg the panty number�tios dale). Failure to secure coverage as required under MGL c. 152.§25A is a criminal violation pumshabk by a line up to$1.500.I11 andior one-year iniprisunun:nt.as well as civil penalties in the form of a STOP WORK ORDER and a tine of up t©S250.00 a day against the violator.A copy of this statement say be forwarded to the Office of Investigations of the DIA for insurance coteralc verification. I do hereby err*,under a pains and petraltie of perjury that,rho:information provided above rs true and correct Signature: C Date: Z�l Z/ C - Phone». l 3 .S 2- 7- 7/2_1/ Official use only' Do not write in this area,to be completed by cite•or lawn official ('its or'foam: Permit/license icense t Issuing Aaths ity(circk one): I.Board of Health 2.Building Deliarlineitt 3.('its?7`vetn Clerk 4.Electrical Inspii tur 5. Plumbing Inspector 6.Other _ _____ Contact Person: Phone#: Stephen Camp Construction 46 East St. Easthampton, Ma 01027 (413)527-7124 Submitted To : Betty & Claire Mach Phone- 584-7319 237-4191 Address : 51 Arlington Street Date— 1-20-2021 Northampton, Ma 01060 We hereby submit this estimate for—Roof Work And General Repairs To start we will strip all the roofing down to the boards/plywood. (Any rotten boards will be removed and replaced as needed.) We will install all new drip edge, pipe flashings and step flashings needed. The chimney and skylights will be flashed with flashings needed. There will be ice and water shield installed on the whole roof. The shingles will be Architectural style color is customers choice. There will be ridge vent on all peaks. The low slope roofs will be stripped and new plywood will be installed. • I will install new drip edge and cut in new flashings at the stucco walls. I will install low slope rolled roofing as required. Any rotten trim boards will be removed and replaced. ((70/0, Trash removal and building permit is included in my price. Materials and labor= $ 22,500.00 Contractor Supervisors License number 082531 Home Improvement contractor Registration number 135204 I propose to supply materials and labor-in accordance with above specifications. This proposal may be withdrawn By us if not accepted within 30 days Authorized Signature Acceptance of proposal Signature ,( t , ,)i1/9 c / ...r•*nn,i owmpo,///i(/n//,,;n(./n.•r/L; Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: Individual Commonwealth of Massachusetts Registration Expiration1 20 - Division of Professional Licensure 135204 03/12/2022 STEPHEN CAMP Board of Building Regulations and Standards D/B/A CAMPS CONSTRUCTION Construction• lervisor CS-082531 Expires: 11/23/2021 STEPHEN P.CAMP �J STEPHEN P CAMP 46 EAST ST. leion,.al4 ra,!/&.4" EASTHAMPTON,MA 01027 46 EAST STREET Undersecretary EASTHAMPTON MA 01027 , /I Commissioner -c.•��^ "'''1"--" t TJ DATE(MMIDDIYYYY) ACC�RIL CERTIFICATE OF LIABILITY INSURANCE 01/29/2021 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 I CONTACT NAME: Diane LaFleche THE DOWD AGENCIES LLC PHONE, ). (413)538-7444 FAX (A/C, ADDRESS: dlafleche@dowd.com 14 Bobala Road INSURER(S)AFFORDING COVERAGE NAICA HOLYOKE MA 01041 _INSURERA: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: CAMP STEPHEN P INSURER C: DBA CAMPS CONSTRUCTION INSURER D: 46 EAST STREET INSURER E: EASTHAMPTON MA 01027 INSURER F: COVERAGES CERTIFICATE NUMBER: 617850 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 EFF POLICY EXPMIDDI LIMITS LTR INSD WVD POLICY NUMBER (MMIDDIYYYY) (MYYYY? COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ GE TO CLAIMS-MADE OCCUR PREMISES(EaENTED occurrence) $ MED EXP(Any one person) S N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY J JE Q LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OT STATUTE AND EMPLOYERS'LIABILITY A OFFICER/MEMBEREXCLUDED? EL EACH ACCIDENT $ 500,000 ECUTIVE N/A N/A N/A 6S62UB5B90972020 04/04/2020 04/04/2021 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I 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/Iwd/woricers-compensation/investigations/. Sole proprietor has not elected coverage. 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 AUTHORIZED REPRESENTATIVE )"Northampton MA 01060 Daniel M.Crow• y, 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 DATE(MM/DD/YYYY) ACORN CERTIFICATE OF LIABILITY INSURANCE 01/29/2021 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 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 Barbara Van Mourik NAME: Finck&Perras Insurance Agency Inc. PHONE H r o.Ext): (413)527-5520 FAX No): (413)527-5970 6 Campus Lane E-MAIL bvanmourik@finckandperras.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Easthampton MA 01027 INSURER A: Main Street America Assr Co 29939 INSURED INSURER B: Camp's Construction INSURER C: Stephen P Camp INSURER D: 46 East Street INSURER E: Easthampton MA 01027-1240 INSURER F COVERAGES CERTIFICATE NUMBER: CL2051904881 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000 DAMAGE TO RENTED 500,000 CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A MPS90683 06/01/2020 06/01/2021 PERSONAL&ADVINJURY $ 500,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 X POLICY PRO JECT LOC PRODUCTS-COMP/OPAGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 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 $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION 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 $ If yes,describe under 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) RE: 51 Arlington Street,Northampton,MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Stephen P Camp ACCORDANCE WITH THE POLICY PROVISIONS. 46 East Street AUTHORIZED REPRESENTATIVE Easthampton MA 01027 '"al#1. ..., ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD