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43-145 (4) BP-2022-0827 151 GREENLEAF DR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 43-145-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-0827 PERMISSION IS HEREBY GRANTED TO: Project# FIRE DEMO Contractor: License: QUALITY CLEANING AND Est. Cost: 25000 RESTORATION CS-060134 Const.Class: Exp.Date: 11/04/2022 Use Group: Owner: LAPLANTE HICKS KATHRYN & DAVID Lot Size (sq.ft.) Zoning: WSP Applicant: QUALITY CLEANING AND RESTORATION Applicant Address Phone: Insurance: 72 MONTAGUE CITY RD (413)774-7737 7PJUB-0G09579 GREENFIELD, MA 01301 ISSUED ON:07/15/2022 TO PERFORM THE FOLLOWING WORK: INTERIOR DEMO DUE TO FIRE 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: ' • • T)spiT Fees Paid: $162.50 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner RE V pvilh The Commonwealth of Massach setts Wt Board of Building Regulations and tan rds 'Ut OR �tTY Massachusetts State Building Code, 780 MIt' 1 2 2022 USE Building Permit Application To Construct,Repair Re Demolish a evis d Mar 2011 o rNAmspe This Section For Official Use Onl nr�D�ON,M4 1 Q Building Permit Number: 6 ?? ' f -7 Date Applied: t � , Building Official(Print Name) Signature 0 Dat SECTION 1:SITE INFORMATION 1.1 Prop�eerty Address: 1.2 Assessors Map&Parcel Numbers 151 Green eaf Drive,Florence 43 145-001 1.1 a 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 ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownerl of Record: David LaPlante&Kathryn Hicks Florence MA Name(Print) City,State,ZIP 151 Greenleaf Drive 413-537-0183 redsox.java@gmail.com 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 0 Demolition 0 Accessory Bldg. 0 Number of Units Other digiSpecify: interior demo Brief Description of Proposed Work2: interior demo of ceilings,walls,wood floors,insulation SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 25,000.00 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All F tl Check NA D 9 Check Amok I__('ash Amount: 6.Total Project Cost: $ 25,000.00 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-060134 11/4/22 Toshi Kashima License Number Expiration Date Name of CSL Holder U List CSL Type(see below) 15 Union Street No.and Street Type Description Greenfield MA 01301 U Unrestricted(Buildings up to 35,000 cu. ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding _ SF Solid Fuel Burning Appliances _ 413-522-1713 kashimabuilders@yahoo.com I Insulation Telephone Email address D Demolition 5.2 RegisterrAHome Improvement Contractor(HIC) l C / 57 iijhi aHIC Registration Number Expiratite HIC Conan ame or HIC Registrant Name No.and Street Email address 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 III No 0 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 Quality Cleaning and Restoration to act on my behalf,in all matters relative to work authorized by this building permit application. See Attached Work Authorization 7/11/22 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 I contained in this application is true and accurate to the best of my knowledge and understanding. -- c ...00 Cr t 1,.. ._>_., Print Owner's or Authorized Agent's Name(Ele onic Signature) 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 o l o 5 . . S/ Massachusetts �?S` pf 1, DEPARTMENT OF BUILDING INSPECTIONS yJ 'y r 4' 212 Main Street • Municipal Building `1CD Northampton, MA 01060 "^-a;:��� 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: Valley Recycling, 234 Easthampton Road, Northampton MA The debris will be transported by: Amherst Trucking Name of Hauler: Signature of Applicant: Date: The Commonwealth ofMasstachusetts p Department of Industrial Accidents „At— Pi 1 Congress Street,Suite 100 74:1- Boston, MA 02114-201 7 www.mass.gov/din 1%au kern'Compensation.Insurance Affidavit BuildersiContr ctors/EIectriciansi Plumbers. 1111 BE FILET)SA'Fill lHE PERMUTING AUTHORITY. Applicant Information Please Print Legible, Named Business tlrg;ant/altotti ladnid(mq: Quality Cleaning and Restoration Address: 72 Montague City Road City(State/Zip: Greenfield MA 01301 phone #: 413-774-7737 .,re 6 uu an i' Check the appropriate boa: Type of project(required): J. i am a employer with 1 g__ c'no.yccs T tine aade'ur part-timer' 7. 0 New construction '.A I am a sok proprietor or pareserabip and have nu cis layers working for me in g, Q Remodeling any capacity.[No workers'tamp.mrsurance required" 9. EiDemolition x.D I am a laima wait doing all work myself.[No workers'cow.insurance required.]' 10 Q Building addition t.❑I am a Itrnseow no and will be hiring contractors to conduit all work on my propnrts. 1 will ensure that all color--actors either hate workers"compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no crnployets. 12.0 Plumbing repairs or additions 30 I am a general contractor and I hmtt.biwd the sub-contractorssub-cuntractors listed ear the atrac-hcwt shed. 13.0 ROOfrt'Itairs 7hcse sub-cvntraewtx have enlpieAteef Mad have w orkers'vamp.IrCHlydne'e'.: 60 We are a corporation and its officer.have exit ised their iglu of exemption per MCBL . 14. Offer 152,11(4).and we have nu employees.[Nu workers'coop.insurance required.] 'Any applicant tint cheeks bus al mini also fill out the section below showing their worker!,'compensation pelkyiminnmina. llomcvwmas who submit this affdrait indicating they a u dowg all work and then hire outside comtrnctrrs mod seirmit a new affidavit iriitatiag such. :Contractors that check this Imo mug attached an additional sheet showing the nameof the%uh-ctieraractuia Ind dais witherer era theme entities has e employees_ It the sub-cuntrackas luxe eartployueih,trey Mat prosaic their workers'atop.pulley nhnnbcr. I am an employer that is providing workers'compensation insur imce for say employees. Below is the policy and job site information. Insurance Company Maine: The Travelers Insurance Company Policy#or Self ins.Lic.#: 7PJUB-0G09579-4-22 Expiration Date: 6/19/23 Job Site Address: 151 Greenleaf Drive cityistate'Zip: Florence MA 01060 Attach a copy of the workers'compensation policy declaration page(shoving the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,(325A is a criminal violation punishable by a tine up to$1,500.00 andrirr one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up 1tio$2.50.00 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 and penalties ofperjuty that the information provided above is true and correct Si nature: Date: Phone#: Official use only_ Do not write in this area,to be completed by city or town official ( its or Torn: Perniiifl icense# Issuing:authority (circle one): I. Board of health 2.Building Department 3.('ity:'Tuan Clerk 4.I kctriral Inspector 5. Plumbing Inspector 6.Oilier ('ontact Person: Phone#: QuALITy 72 Montague City Road Restoration Greenfield, MA 01301 413.774.7737 FIRE WATER STORM Fed Tax ID#45-4127163 Client: Insurance Company: D ✓ `c 1 1-A-P/A,i1-e- ��68z.t ' ,t f-14r- Address: Local Insurance Agency: lsl 6Arc A) ,4-1if City / / Adjuster: State/Zip: Policy No.: Home Phone: Claim No.: 0,3 - —o l `1` c+®- o ^o 16 7 l, l Business Phone: Deductible: Date of Loss: .-- Type of Loss: 7._ o/z z Client Email: // Adjuster Email: f e cl S ox� rt v/? et-At4fi f, Gp„e-1 WORK AUTHORIZATION AND DIRECTION TO PAY I agree to hire Quality Cleaning and Restoration("Quality")for cleaning,restoration and remediation services. I authorize Quality to enter my property and to complete the work as deemed appropriate by Quality. I represent that I am the owner of the house or property which has been damaged. I further represent that the damaged property has appropriate insurance coverage to cover the loss or damage which is the subject of Quality's work. I authorize and instruct my insurance company to pay Quality directly for its work in connection with this loss or damage,or,include Quality as a co-payee on checks for payment. I assign to Quality my right to recover payment under applicable insurance for Quality's work. I authorize Quality to send this contract to the insurance company for Quality to obtain payment directly from the insurer. If the insurance company pays me,despite my authorization and instruction to pay Quality directly,I agree to pay Quality within five(5)business days after receipt of the insurance payment. I authorize Quality to supply information about this loss or claim to the insurer,as well as a report of services provided by Quality. I understand that I am hiring Quality and I am responsible for full payment for Quality's work and services,regardless of insurance. I am responsible for paying any insurance deductible or charges root covered by insurance,or not paid by an insurer for any reason. I understand there is no guarantee that in all circumstances,items, or property can be restored to their condition prior to the loss or damage. Quality will try in its good faith discretion to ensure that its charges for services will be the amount authorized and paid by available insurance,not including any deductible,client-ordered change orders, or unforeseen damage presently hidden. However,Quality does not and cannot promise this. Where insurance is not available, or insufficient,Quality will charge its customary rates,which are available upon request. Late charges of 18%per annum shall be charged on late payment and I shall be obligated to pay Quality's reasonable attorneys fees necessary for collection. I also agree that,in the event Quality is not paid within 301 days of completing its work,at its option, Quality shall have a lien on my property where the work was done. t3 G �ll�fZ' z Owner Date -440 7 / Quality Cleaning&Re toration Date Commonwealth of Massachusetts Division of Professional Licensure ��TTJJ Board of Building Regulations and Standards ConstWiit' ilt{ rvisor CS-060134 ' spires: 11/04/2022 • TOSHI KASHIMA NAt 1. 15 UNION ST' j MI GREENFIELD-MA 0 ti ,T ik.cNN Commissioner t i . bi&1ac, • fib cm.,rnnu,r ilk/.�. /47-)4..N4.4P/4 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE: Individual Registration Expiration 186757 01/09/2023 TOSHI KASHIMA TOSHI KASHIMA 15 UNION STREET ,(«"uQICG./'a,GfriA GREENFIELD,MA 01301 Undersecretary DATE(MM/DD/YYYY) ACORO® CERTIFICATE OF LIABILITY INSURANCE `....� 05/17/2022 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: Michelle Bettencourt A H RIST INSURANCE AGENCY INC PHONE(A/C.No,Ext): (413)863 4373 FAX (A/C,No): ADDRESS: michelle@ahrist.com P O BOX 391 INSURER(S)AFFORDING COVERAGE NAIC# TURNER FALLS MA 01376 INSURER A: LIBERTY MUTUAL FIRE INS CO 23035 INSURED INSURER B TOSHIHARU KASHIMA INSURER C: INSURERD_:_ 15 UNION STREET INSURER E: • GREENFIELD MA 01301 INSURER F: COVERAGES CERTIFICATE NUMBER: 775255 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUE[) 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 Alt THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL{SUBRT POLICY EFF . POLICY EXP I LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Es occurrence.) $ MED EXP(Any one person) $_ N/A • PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO LOC PRODUCTS-COMP/OP AGG $ .—_ JECT ._. _ OTHER: $ _ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) _}I_$__ 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 LIAB CLAIMS-MADE N/A AGGREGATE $ BED RETENTIONS _ $ WORKERS COMPENSATION X ll PER OTH- AND EMPLOYERS'LIABILITY Y/N _1_STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? N/A N/A N/A WC231S376057022 03/23/2022 03/23/2023(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.govilwd/workers-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 Easthampton ACCORDANCE WITH THE POLICY PROVISIONS. 50 Payson Avenue AUTHORIZED REPRESENTATIVE Easthampton MA 01027 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 AR® CERTIFICATE OF LIABILITY INSURANCE DATEIMM/DD""") 5/17/2022 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 TraceyKuklewicz NAME: A.H. Rist Insurance Agency, Inc. PH Ne.Est): (413)863-4373IA/ IAlC Nel: (413)863-9658 159 Avenue A E-MAIL ADDRESS: P.O. Box 391 INSURER(S) AFFORDING COVERAGE NAIC M__ Turners Falls MA 01376 INSURER A:Phoenix Insurance Company _ 25623 INSURED INSURER B: Toshiharu Kashima INSURER C 15 UNION STREET INSURER 0: INSURER E: GREENFIELD MA 01301 INSURER F: COVERAGES CERTIFICATE NUMBER:2021 CERT 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 EXP LIMITS LTRINSR wvn POLICY NUMBER IMM/DDIYYYYI IMM/DD/YYYYI GENERAL LIABILITY EACH OCCURRENCE — $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ 300,000 A CLAIMS-MADE n OCCUR 6807042c348 7/20/2021 7/20/2022. MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000. GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 —1 POLICY n PRD n LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY $ AUTOS AUTOS (Per accident) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ __ EXCESS LIAB CLAIMS-MADE AGGREGATE $ _ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY I WITS FR _ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A • (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES )Attach ACORD 101,Additional Remarks Schedule,if more space is required) Classification: Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Easthampton ACCORDANCE WITH THE POLICY PROVISIONS. 50 Payson Avenue Easthampton, MA 01027 AUTHORIZED REPRESENTATIVE Tracey Kuklewicz/MB ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD