24A-011 (5) :7 1
122 PROSPECT AVE BP-2009-0733
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A-011 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-2009-0733
Project# JS-2009-001092
Est. Cost: $2900.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 142279
Lot Size(sq. ft.): 39596.04 Owner: ALTIMARIE RON
Zoning: URB(100)/ Applicant: PELLA PRODUCTS, INC
AT: 122 PROSPECT AVE
Applicant Address: Phone: Insurance:
240 MOHAWK TRAIL (413) 772-0153 WC
GREENFIELDMA01301 ISSUED ON:3/13/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 3 REPLACEMENT WINDOWS
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:
FeeType: Date Paid: Amount:
Building 3/13/2009 0:00:00 $35.0032701
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability _
Room 100 Water/Well Availability
n
�n� Northampton, MA 01060 Two Sets of Structural Plans
r.'R 1 L
phone 413-587-,�240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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
\"L(L_ cl.,CjS•Riz_c_ac, \.)-,Q._,- Map Lot Unit
Nc::)-c' \CA.rNr- ,p -f-\ `c . )\cy,s."(.) Zone Overlay District
Elm St. District CB District : "�` �.<,
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
� � R��`N\,ac , (:__ \22 f-RcoS-9_ec
Name(Print) Current Mailing Address:(1 ` `
Se_e_ 5 r C� ,ct Telephone "c��� �O��J C, ��51�
Signature
2.2 Authorized Agent:
1�e \\ c ��._ o c�v C \‘n \55 N\a\c Sk . Gc>? \,- R.`L.
Name(Print} Current Marlin Address:
g Mc,� - o 0\'3
-' ►� ( \�> —1T2 b€
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item �:- ..
Estimated Cost(Dollars)to be ;.,;;�,;;-;,;.;;�: Official Use Only
completed by permit applicant
1. Building lA 2—�� o o L�V 0 (a) Building Permit Fee
2. Electrical "� (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
—".4:,;k,4:::E*4i'::'''',I**;':.41,-'
4. Mechanical(HVAC) r t, .,.,. ; 4. 4
5. Fire Protection �•- � 4 �
6. Total =(1 +2+3+4+5) A L- �2 0 O 00 Check Number 32765/
This Section For Official Use Only TTT'''
Building Permit Number: Date
Issued:
`
Signature: Y " ,, 4*.� y`^
a
' \;1 2t fi
zi{4 �44 � 0-el 'BuildingCommissioner/Inspector of Buildin " ✓
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 j 1
Side L: R: L: I R:1
Rear
Building Height
Bldg. Square Footage ( % l
Open Space Footage
(Lot area minus bldg&paved 1
parking)
#of Parking Spaces [ I
Fill: is
(volume&Location)
A. Has a Sp al Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page _._l and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO et DONT KNOW 0 YES 0
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 0 NO ei
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO ef
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,ex ation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
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 n Addition ❑ Replacement dows Alteration(s) n Roofing n
Or Doors
Accessory Bldg. E Demolition ❑ New Signs [❑] Decks [Q Siding[❑] Other[❑]
Brief DesSClption of Proposed
Work: \L-,e_y\Ct,C,..c\c, . \&,u W J ' \A"N.C...(0 A S�,RC�p$Q,'1, 'N D
cia-
Alteration of existing bedroom Yes No Adding new bedroom Yes No�� v \ `�
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
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, \- :D Yr lk\\--)\ac , as Owner of the subject
property
hereby authorize \G R sp V c ,\`r1( ._-
to act on my behalf, in all matters relative to work authorized by this building permit application.
Se-e___CD.‘%\C‘Q--a. C.cyc-.7\-Nca . 2-\-7--- \ c-\
Signature of Owner Date i
)
I, \ Q-\\C C\,,1.) C- l \nC , 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.
Print Name
\____Q:=AN.L.1.....k.i,...4)
Signatu f Owner/Agent Date
td-f ON 8 4t161STRUctibh,suy
8.1 Licensed Construction Supervisor: \ - Not Applicable ❑
Name of License Holder: \✓(i��1�" V.)� \-e-- 0 k'6
License Number
\55 NMcA:\ (-As rc b\-bo \ k
Address UC1U
Expiration Date
(.4 11Z D 15-5
Signature Telephone
e is e- .; ,Oto. an r.o. e; : n - Not Applicable ❑
Company Name Registration Number
v 55 M-C:6 n (ti4 �� e�� MG .6)36\ 03\Z Av-6
Address CQA
r, C� Expiration Date
A:({ Telephone \j ��7 5
SEC ;IoN i0 WORKEl S'COMPENSr4TION II SURANCE AFFibAVfl(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 buildpg permit.
Signed Affidavit Attached Yes La1/ No ❑
Btine gip., toi
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 108.3.5.1.
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
02/25%2609 O9: 36 413774E:348 F'#GE n8,'E=i8
Site Responsibilities and Terms of Sale
Pella Products, Inc_
155 Main St.
Greenfield,MA 01301
(413)772-0153
SITE RESPONSIBLITIES
Customer: Ron AltimarifStacey Novack Date: 2/102009
Order#: �J/ ��C✓Q Signature:
Salesperson: Paul Picard Signature: " � �
1 50%Deposit required at time of order,balance due on the morning of the last day of installation.
2 Payment is to be made to installation team.
3 If customer will not be present at time of install,payment Is to be made prior.
4 Checks returned NSF will be assessed a fee of$50.00 to cover fees incurred by Pella
Failure to pay your final bill will result in finance charges of 1 1/2%per month
(18%Annual)and legal fees associated in the collection of owed monies.
5 Due to inclement weather or site conditions, it may be necessary to postpone and
reschedule the project.
6 We cannot and will not guarantee specific dates or days of the week for installation.
7 Time given to complete a job is an estimate,extension of time Is possible
8 Pella will call with approximate installation dates. These dates will be confirmed prior to install.
9 Unforeseen rot repair can be quoted on site as additional work
10 Substantial completion is achieved when all available products have been installer)and are operational.
Items such as missing or broken parts and service adjustments are covered by warranty and do not affe t
affect the status of a project from being substantially complete,
11 In the event that any products are unable to be installed,the final payment will be recalculated, The cos of
products not installed will be subtracted from the balance due.A subsequent and final payment equal to the
cost of products not installed as scheduled will be due upon final completion.
12 Order Is not binding until approved by Pella Products management
13 Pella will secure all necessary Building Permits
Type of Installation:
New Construction: (tear out installation)
17 Completely remove interior and exterior Trim, completely remove existing window frame,
install new window In rough opening, re-trim both interior and exterbr of window/door.
Pocket install: (sash replacement,existing frame remains)
x Remove interior or exterior stops, install new window in existing wirnNow frame opening,
re-use existing or replace window stops(Interior or exterior)Some glass lose will occur.
Pella Will Owner Will
x Deliver and unload products
x I I Place drop cloths in work areas
x Remove&reinstall interior and exterior trim if applicable
Li Remove&reinstall existing shutters and awnings by contract
x Remove existing product and adjust or modify opening as needed
x [_.i Provide all-equipment necessary to install products
x Cut all wood and other materials outside of home
x Install all products purchased
x I Insulate and caulk around products
x h Remove stickers and perform initial cleaning of all glass surfaces
x Li Demonstrate proper operation of products
Confirm that all products are in working order
x I Remove drop cloths,vacuum and remove all old products from premises
x Finish(paint or stain)product purchased(Factory Finish)
x Cut-back or tie trees,bushes,shrubs from exterior wall
x Arrange to have alarm system disconnected and reconnected
I x Arrange to have any plumbing or electrical repairs or changes by For all service needs,
appropriate licensed contractor please call.
�i FT
(800)957-3552
l l Ix Remove and reinstall existing window treatments,wall hangings and Please make sure you
air conditioning units. mention that Your project
x Remove and reposition furniture in work area was installed by Pella
xE Secure pets in a safe manner and reference your order
• x Remove valuable/breakable items from work area number
{
x Remove snow from area of worksite if necessary
Pella Products, Inc.
155 Main Street
Greenfield, MA 01301
Phone: 413-772-0153
Cell: 413-834-8799
To: Building Inspector
From: David White—Installation Manager
Date: January 19, 2009
SUBJECT: Building Permit Applications & Designees
Pella Products Incorporated is in the business of replacing windows and
doors for our customers. Our process includes providing a building permit
for each and every project.
I am a licensed Construction Supervisor. Building permits will be applied
for using my CSL #091496 and our HIC, # 142279. Please find a copy of
my licenses below.
tlepa rtment 4.r C►nAttr atttx
ItostrictodtAc Qq
#. ttrntri hf'&twliling Reuul,ti�iaa.p*. V•fNn4 irc4i
t Consiruetian Supkrvisor Licefl a bO^ tittotstrkta4
Ltc.nar. CS 9�4 t'G-t :x,root*Mows
ttO!'tictSn: O
MAO C WHITE
le � P.�but»to�a s�c�+ltrl�dfil�liOt el'`fAc
6.CARP 4TER_S7, , piitoatetutoctto State guild*C&
ORANGE.MA 01 • is.t pare RNt reroatioo oft it*Beare
Refer to:Evoraaiws- testratn sM V.A91ass ft1�'S
4 :wwii..Fa.- To. 0448
. •
‘ • . -
•
t /?,e ect/innno./itee.) ItAceroctek:666-. . .. . . - •. -
Board of BUilding Regulations. and Standards •
aE---_,---,74,AL_____------- ; • •• . .. :
•
One Ashburton Place - Room 1301
• . .
Boston, Massachusetts 02108
-5-*N,
Home Improvemetittitractor Registration
Registration: 142279
..ff-..,i--- -_.,.-7-----1---- ------;:=:--fi
7 7 Type: Private Corporation
4 T.,
Expiration: 3/24/20T0 Tr# 263223
xt"- -- '''-''• ------------11-'i-11
. PELLA PRODUCTS, INC. 1 •— 1 .. 1,-i .
-- P,
GARY SHERMAN ...,,
.
i, ........ ,• i-.., .-
7.,...k 1,
155 MAIN STREET , --
GREENFIELD, MA,01301
•
-k
Update Address and return-card.Mark reason for change.
• 0 Address I:]Renewal 0 Employment 0 Lost Card
c.ou CJ 5014-07/07-PC8450 •
• gge eommonweccia,cAll.-aodackecteaa . . - , ' .
Board of Building Regulations and Standsrdz
License or registration valid for individul use only .. ' • ' . .•--if,- - • ••.
rirl'- HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
' •
RegisteinoM 142279 Board of-Building Regulations and Standards- . • • -
- . .
,,,.........-...,.._-.., 263223
Tr# .One Ashburton PlaceRst m 1301 -
. '• • . • -...,_ .../p2_,Ea.litlillW24/2010
. •-I t:3....------'-'a'Sr.::.--.,-. . Boon,Ma.02108 . ' •- - .• . -- • -.1:it:to:077J yp5%te Corporation :
fi V_---- -4.4.&--i.,..j A . . • . . • . • .. .ELLA PRODUCKVIstf.,2:4 ----'7:--4 14) . • - ' • • '5,11Y SHERMAW, --z41D41/i.''e" • '. . • •
5 MAIN STREETc4;-..-"'',.,.. ....,-.% C --2.4,..,0-A...., • . .
' . .
. . .
'''-'?-j:. .•
IEENFIELD,MA 01301 Administrator "Notva1fwithout signature ' . •. . .
,
• .
. •
• •
. •
• .
• .
. -
- ----
•
•
. . • ' •
___. ....
The Commonwealth of Massachusetts
Department of Industrial Accidents
» f Office of Investigations
= 600 Washington Street
"!=, Boston, MA 02111
ti www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): / C 7/.. /,�p/�v &/S , I)e
Address: /S�r A eV/n- 5(1,4e c`�
City/State/Zipre n-ci a /U/f. /J/3l// Phone #: V41- 771- O/�..?
Are you an employer? Check the appropriate box: Type of project(required):
1.[J I am a employer with 7,0 4. ❑ I am a general contractor and I.
employees(full and/or part-time).* have hired the sub contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub contractors have 8. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P h'. 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
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 indicting 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 and job site
information.
/ ��y
Insurance Company Name: �G�N' i tv � n 5 G! r c`�n �1 ce vn� —
Policy#or Self-ins. I ' .#: C .•5 /02 Expiration Date: O I- G/rcva/ ` �
Job Site Address: .301 Sc`I w I'yt if rnir7 Oa City/State/Zip Qu�/�j �C/CEr�iF�d /v7A-f
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).O/.i73
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce u deer the pains and penalties of perjury that the information provided above is true and correct.
Signature: Ql1.tc Qyyi.[1A} Date: DEC G �r 9 2008
Phone#: 1/.5- 770?- .U/ -� X -302 I/
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
.83/02/2009 15:49 4137743872 MASS ONE INS PAGE 13/14
,ACORD,. CERTIFICATE OF LIABILITY INSURANCE 3/2/�09
PROOUCER (413)773-9 913 FAX: (413)7 74-3 8 72 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Agency
Mas80>�e Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
117 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 638
Greenfield MA 01302-0638 INSURERS AFFORDING COVERAGE NAIC#
muses INSURER A;Continental Wa$tern
Pella Products, Inc. INSURERS:
ATTN: John Benjamin INSURER C
155 Main Street INSURERD:
Greenfield MA 01301-3258 INSURERE: ,{
cOY_ERAGES.
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, I
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,
AGGREGA_T_E LIMITS_SHOWN MA`_HA BEEN REDUCED BX PAID CLAIM _
INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR JI'yRRD TYPE OF INSURANCE POLICY NUMBER DATEjMMIDDIYY) DATE fMM/DD/VY1
GENERAL LIABILITY EACH OCCURRENCE, S 1,000,000
•
DAMAOEToRENTED 300,000
X COMMERCIAL GENERAL LIABILITY PREMJ .S tEa occv ncef S
A i CLAIMS MADE X ,OCCUR CPA020370112 1/1/2009 1/1/2010 MED EXP(Aay ono person) $ 15,000
PERSONAL ,ADV INJURY 8 1,000,000
GENkRALAGGRB GATE S 2,000,000
OWL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000
X�I POLICY FEC.T ri LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Eaacddent) s i.000.{J46
A ALL OWNEDAUTOS MAA020470212 1/1/2009 1/1/2010 BODILY INJURY
S
X SCHEDULED AUTOS (Per prAn) '
X HIRED AUTOS BODILY INJURY E
X NON-OWNED AUTOS (Peraceidentl ..I
., ." PROPERTY DAMAGE
(Per acddent) t d,
f'
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
,ANYAUTO OTHER THAN FAA(C $
AUTO ONLY; AGG $
EXCESSIUMERELLA LIABILITY FA{',H URRENCE $
OCCUR CLAIMS MADE AGGREGATE S
f
— DEDUCTIBLE S ,---i.
RETENTON S — TT�f� 7}1•
$ L
A WORKERS COMPENSATION AND X TQRYS TTLIMRS OER
EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE ELL.EACH ACCIDENT $ 500,000
OFFICERIMEMBER EXCLUDED? WCA020470512 1/1/2009 1/1/2010 EL DISEASE-EA EMPLOYEE$ 500,000
If yea,describe Under
SPEC,AL PROVISIO I( ,beIow EL.DISEASE-POLICY LIMIT $ 500,000.
OTHER
_I
DESCRIPTION OF OPERATIONBILOCATIoNSNEHICLESIEXCLUSI ON S ADDED BY ENDDRS EMENTISPECIAL PROVISIONS ,
Operation# usual to the salsa & installation of doors 4 windows.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
Ron Altimari EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
122 Porepect Ave. 1,0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT
Northampton, MA 01060
FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABIUTY OF ANY KIND UPON THE
INSURER,ITS AGENTS OR REPREE!NTATI VES.
AUTHORIZED REPRESENTATIVE
Robin Sargent/RMS
ACORD 25(2001108) V ACORD CORPORATION 1988
INS025(O1OB).OBe NEW I p((2