23D-186 (7) 31 WINSLOW AVE BP-2008-0208
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D- 186 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0208
Project# JS-2008-000326
Est. Cost: $8500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KENNETH LYNDS 013668
Lot Size(sq. ft.): 161 17.20 Owner: ROSE-LANGSTON JASON A&
Zoning: URB Applicant: KENNETH LYNDS
AT: 31 WINSLOW AVE
Applicant Address: Phone: Insurance:
P 0 BOX 448 (413) 584-9282 WC
LEEDSMA01053 ISSUED ON:9/4/2007 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE 8 X 10 W/8 X 18 FRONT DECK
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: r( /j.-°7
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: OK o9/V4//07 Lai/Li
THIS PERMIT MAY BE REVOKED BY THE C '''Y OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULA ONS.
Certificate of Occupancy- si nature:
FeeType: Date Paid: Amount:
Building 9/4/2007 0:00:00 $50.003531
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2008-0208
APPLICANT/CONTACT PERSON KENNETH LYNDS
ADDRESS/PHONE P 0 BOX 448 LEEDS (413)584-9282
PROPERTY LOCATION 31 WINSLOW AVE
MAP 23D PARCEL 186 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ` / #3-7,
Fee Paid
Typeof Construction: REPLACE 8 X 10 W/8 X 18 FRONT DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 013668
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 Elm Street Commi ion
Signature of Building Official Date
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.
\-\
Department use only
Pity of Northampton Status of Permit:
B ilding Department Curb Cut/Driveway Permit
2G01 --212 Main Street Sewer/Septic Availability
AEG 2 9Room 100 Water/Well Availability
hlortharrR�pton, MA 01060 Two Sets of Structural Plans
hone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
p`` Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This section to be completed by office
1.1 Property Address:
3' t.)''^S/ L) S li'J4't Map_ Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: / )
(,ron 4- 4 6&e6.4 104 L - L,Brlq.lta K.ilorJ Ji rcid—
Na .nt) Current ailing Address: "
to V
Telephone
ture <l/3 30 3 - 9$ 7o
2.2 Authorized Agent: 1 f
f eA y1 L'1t `t)• �J ,".�,
C -z- 9 Cs.) P v. g oX �L CG4J/ PJ. O'Q 5+J
Name(P'nt) Current Mailing Address:
a re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building is =- (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) 47S Oo i Check Number 3c31
—
This Section For Official Use Only
Date
Building Permit Number: — Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
on/TJ
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
rs° ,- Zee' tlA
Lot Size
Frontage
Setbacks Front FX t-$ri�+/ 2,1" 2,0
� �I .
Side I�l RJR L: R: IS—
Rear
ZIP 2,0
Building Height
Bldg.Square Footage
Open Space Footage
(Lot arca 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 DONT KNOW V YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO IV DONT KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are re any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House 0 Addition 0 Replacement Windows Alteration(s) 0 Roofing 0
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ J Decks K Siding[ ] Other[ ]
Work:Br Descri tion of Proposed n / q,�j?f Fx : �;M, +� - t / ,/ --
1�rrwJ•t- key
�► a !`, �J /� � c�(.l� �o
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓ No
Attached Narrative Renpvating 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. Mascheck 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, J,aS s►.- .- 41,......... 'od.- - 4,....5 Jtel` ,as Owner of the subject
property
hereby authorize Ke..14.m.- "- ' 1ti CA •d ' 7 g GJ
to a nnbehalf, in all • .tters relative to work aufiorized bythis buildingpermit application.
y —_ 1_41\_ — — (5" °1
nature of Owner Date
I �✓'A K W• h 1 t4.CJ 0' 2 - C • ,as Gwwrar/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 nder the pain and penalties of perjury.
vl,w� k 4ywdw ( 4 • of-z ,� c-.,�
Print a e
S' ure of Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Suupervisorj:1 �// !I' Not Applicable ❑ 3 /
Name of License Holder: /( eK�-+'/"► v" `� _ CS v lj `d'
p ` l License Number
/i G.t vdi 10 a g G t,e--d.I DES) _ 7- 2 y• Zoo
Addres / / Expiration Date
lure Telephone
9.Registered H e Improvement Contractor: Not Applicable ❑
ew,L I). Ly� CA ) • 2 9L.\ / 3 " 77
ompan/yy Name /� ',L. Registration Number
I l /`L1 e.9'a,k !C. 04.•� 4 2 4�41 �'�`J' 6/Dr-3 -/y. 2 oo j _—
Addre ,/ ��/ Expiration Date
J / - Telephone Yl1 17 V P 82
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 t— _
Signed Affidavit Attached Yes No 0 M. , IA-- r K. iJe v A {*.p,A 2/4 .�s p,Q� a cewn-
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 1083.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
.
•
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" •� DEPARTMENT Or nuiwrNc INSPECTIOF.S • —,
-
212 Main Street - Municipal 13ntldinp
Northampton, Mass 01060 - 1/'
WW'O21C1:2It'S CONITENSATION GYSURANCE AFPTDAV1T
(110
I, ____ al-_ bJ- LY_Id- CO*_0?• Z i C-) --- __.
(liccuscripermittcc)
s'ntb 2 principal Olace orbusioessJresidencc at.
7/ I'&J44.61,./LXII 1-.1.4.-44 ASP.w of0.t,7 (phone 4//.') Y - aV.-P2?2--
(str�.tJci ty/statcJZi p)
do hereby certify. under the paints and penalties of perjury. h.I
( ) I am an employer providing the following worker's coinncns noe cover2ge for my •
.
etuployccs working on tin job.
!Je✓k- G 4•-•-•• ate- ,46.• ;It e . G/ ,93/49 v4 Log e`
(lns saoc Coocxv) (Policy Nu_cr) (✓.-oirZtior. Date)
O. I am a sole proprietor general contracts : homeowner (cr•ce one) and hive hired
the contactors listed below v • ve the following worker's com0ensznon pchcmes:
�i nt-, ' ?�'uink: (ADirasoa Date)
(Name o;Co......aor) (lnstranr„ Corn�aa)rl ciic, -')
(Name of Contractor) -- (Insuranc: ComoaawPo!icy NWDccr) (Ex-Dir.-loon Date)
•
(Name of Coanaeto,) (Lasuranee Compaoy1Pot;cy Naar bcr) (Espu cioo Date)
(Naive of Contractor) (Iasuran ComcaayIPoticy Numb`() (E.\pi shoo Date)
(.aft i::oc.I,_,cc:it oc,=..ry to mete infct-m oo pert,uniog to.L cora- or)) .
•
( ) I am a sole propnecor and have no one worlang for me
( ) I am a home owner performing all the work myself.
NOTE:ples:bt ew-are tr,..'.i`.!c b<xroo..vcrt..bo employ pc-cont tow :nr-.,..'+ c^-..-_--.:ciao c rc?cu•Sonic on.d••<1L•_1 of
not aoc t '- - .t in..'yeh the bomoowocr(maid=or o-tb-c err. o..,rppertroc"tb.=cn r_-c oLY C->-_lly wo t d:mil to be
ctztploycn..o'er-the'.txi;r r— m r.-zt; Act(GLI 12.o m a
1(S))-npplir-,rioo try.boco° c fer_liter!or;unlit rc:-y c.i-'ooc tbC -
Icgal rtx2u or ea eraloy.r under du,Wor4d.Cooapow..rioa Ac_
I uodc t..nd ttva c Dopy of tbi.mrcm m coy M fo(- .to L.4 to tbo Dop.nm of of lneiorrid Arod^K'!Ofroo of lr So bbc Lb'
novenae vvttctioo wu:1 th1 Liltzc to ccciu<tovcro c under zoctioo 25A of MOL 152 c.,n lad to the vrcwirioo of corm.-';pco-'
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rOcc,is irg of a(roc of up to S 1 .500.00.ndfor mopriaccrw.cut of up to ooc yto end civil peat io in tt>c roan of•Stop Wort Order.rd•
tiro of 5100.00 a cty c Eain i me
1 / For dcp.nm=--'-u•c�ypermit Ntunt —// i,- f a Mzp::__ Lot 1*644/1)(1,4
rc of Liam cc/Pcrrruticc Dote
I NUIt
THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT
TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED.
BUILDING LOCATION ACCURACY IS NOT GUARANTEED
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Board of Building Regulations and Standards
t Construction Supervisor License
'� License: CS 13668
Birthdate: 7/24/1951
Expiration: 7/24/2009 Tr# 17264
Restriction: 00
KENNETH W LYNDS
71 RESERVOIR RD
LEEDS,MA 01053 Commissioner
•
?T�,, am ma.oeu vald rya, ft'ac uic%ucaeQ6
board of Building;Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
6
Registration: 136677
Expiration:p 8/14/2008
Type: Individual
KENNETH WILLIAM LYNDS
KENNETH LYNDS
71 RESERVOIR RD.
LEEDS, MA 01053 Deputy Administrator
1 413 527 5970 P.01�01 _
RUG-29-2007 12:20 _ F I NCK & PERRAS INS , DATE{MMIOWYWY}
, - -—�—M %..14rr' I trtfk.H 1 t, i,at LIABILITY INSURANCE Oa/29/2007
PRODUCER (413)527-5520 FAX (413)527-5970 TTHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Finck & Perras Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
6 Campus Lane HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW.
Easthampton, MA 01027
INSURERS AFFORDING COVERAGE NAIC#
NsuRED Kennet W. Lyn s A A-2-Z Bu ers INSURER A: Commerce Insurance Company 34754
71 Reservoir Road INSURERS;
Leeds, MA 01053 INSURERC:
INSURER D:
INSURER E;
COVERAGES ��
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDIN
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,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ _
ILy
$R Aram R revs OF INSURANCE I, ucY EFFECTIVE PQLICY EXPIRATION
DATA NUMBER DA (�fDDNY) DATE LIMIT$ �—
GENERAL LABILITY YW9364 12/10/2006 12/10/2007 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ __50 000
�--p s MI A(F_s n_frerwm) ,j CLAIMS MADE I ,� I OCCUR MED EX?(A ny one Persgn) $ 5 a 000
A ��--� PERRQNAL&ADv INJURY S 1,000,WO
L.-- GENERAL AGGREGATE $ �t 2.000,00C
GENI.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000
7 F'OLICY� eT (i LOC
AUTOMOBILE LIABILITY
ANYAl170 COMBINED SINGI,.ELIhfR $
(Ea accident)
ALL OWNED AUTOS
_ BODILY INJURY $
SCHEDULED AUTOS (PP,'per')
HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
i
GARAGE LABILITY AUTO ONLY.EA ACCIDENT $
ANY AUTO OTHER TtiAN EA ACC S
AUTO ONLY; AGO S
EXCESSIUMBRELLA LIABILITY —, —^ EACH OCCURRENCE S
OCCUR El CLAIMS MADE AGGREGATE $ —i
$
I L_ DEDUCTIBLE r $
RETENTION $ $
WORKERS COMPENSATION AND 1 T4 Y i IIMrr O v-
EMPLOYERS'LIABILITY
EL EACH ACCIDENT $
ANY PROPRIETORIPARTNERAEXECUTiVE
OFFICERIMEMBER EXCLUDED? EL DISEASE.EA EMPLOYEE S
If Yea,describe under --
SPECIAL PROVISIONS Wow EL,DISEASE-POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT A SPECIAL PROVISIONS —� � �
----
,IERTIFICATE HOLDER CANCELLATION ,
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
City of Northampton 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Attn: Building Inspector BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
Main Street OF ND UPON THE INSURER,ITS ENTS OR REPRESENTATIVES,
Northampton, MA 01060 Au A E
CORD 28(2001/08) FAX: (413)587-1272 3ACORD CORPORATION 1988
TOTAL_ P.01
__�._T-,,AUG. 24. 2007 6 32PhASSOCIATED INSURANCE r t� N . 6 -P. 1/1
( O 703
'3'7'::,'"fit a w'r" 1 1 fkl' � L it t tit y:tll i � •(t� �(� ; ISSUE DATE 0$/29/2007
,t„,d, • Y+' u, , l sat .t,l11:t,I.
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
Finck&Perras Insurance CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE
Agency Inc DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW-
63 Main Street
Florence.MA 01062 COMPANIES AFFORDING COVERAGE
WSURED
Kenneth W Lynda
dba A-2-Z Builders COMPANY A A.I.M.Mutual Insurance Co
P O Box 448 LETTER
Leafs,MA 01053
'trot A;T j' ,' tl I R t f#ti • tiF1.17 r 17r ili
. 1 �� fl' '.e. #M
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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 HAVEBEEN REDUCED BY PAID CLAIMS
co TYPE OF INSURANCE roL1cyNUMBRI[ POLICY EFFECTIVE PQLICV E%PIAATIQN (AMITE
era DATQpmWnorrn DATB(F04IDLYYY)
GENERALtIARIUTY GENIRALAGGRBGATB I
PRODUCTS-COMP/OPAGO. % —_
n COMMERCIAL GONIIJ AM UARIILfTY
PERSONAL a AOv.lO1URY
r1 CLAIMS MAOBfl OCCUR
EACH OCCURRENCE
OWNER'S A CONTRACTOA'S TROT. FIRS DAMAGE(AAyme tiro) $
j . MED,EXPENSE(Atgw,cp.$0.9 $
AUTOMO\ILE UAInL1TY COUmWgD SINGLE
LIMIT I
ANY AUTO BODILY DOWRY
�..ALL ONNBD AUTOS (Per palm)
SCHEDULE+)ALROS
=HIR D AWES DODH,Y RUUILY
NDN.OWIIED AUrOR (P¢aCciJW)
GARAGE LIABILITY
PRaP11xIY DAMAGE
EXCESS LIARuirV TACM Ot;CURRIWCE I
UMRRDL LA FOAM AGGREGATE /
1 OTHER THAN UMFRILLA FORM �' rN } >• �,g� t ;F )i{1"`li`Y�I;elf�}iI'E e,`:%Z,i•d{"6:"Atx•j
WORKERS COMPENSATION AND STATUTORY LIMITS OTHER
RMPLOYERB LIABILITY X
THE PROP B WS/ EL EACH ACCIDENT x 100,000
A PARNF SkEXECUTIvt
OPPICCLERS pRE 6004867012006 12/12/2006 12/12/2007 EL DISEASE-POLICY LIMIT s 500,000
IrrrCL ®EXCL EL DISEASE-EACH $ IOO,000
P�MPLOYEE
COMMENTS/DESCRIPTION OP OPERATIONS OR LOCATIONS:
KENNETH W MINDS IS NOT COVERED BY THE WORKERS'COMPENSATION POLICY.
• ,,,RrW•..,+ni t t `5� } R 1�F�1;,;}'�I T �M 1 ( (11rF+3 F ti!,��w r t• �t t ir{ r :tAycM��7El ",tr+1 k:r :' '�'-.J �,y�� "�'; i. ;r"' �''�•� ri
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.HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE T11E EXPIRATION DATE
C!C7l OF NORTNAMF!ON EREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAILILWRIITEN NOTICE TO THE CERTIFICATE
HOLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION
AT TN:BUILDING INSPECTOR OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
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NORTHAMPTON,MA 01060 AUTHORIZED REPRESENTATIVE