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35-287 (7)
BP12023-0267 29 SYLVAN LN COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 35-287-001 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-2023-0267 PERMISSION IS HEREBY GRANTED TO: Project# KITCHEN RENO 2023 Contractor: License: Est. Cost: 5850 VK DESIGNS INC 117535 Const.Class: Exp.Date: 12/25/2025 Use Group: Owner: MURPHY GREGORY R&EMILY R S NGER Lot Size (sq.ft.) Zoning: WSP Applicant: VK DESIGNS INC Applicant Address Phone: Insurance: 51 Al HOLYOKE ST (413)527-1500 WC231S624125012 EASTHAMPTON, MA 01027 ISSUED ON: 03/07/2023 TO PERFORM THE FOLLOWING WORK: KITCHEN RENO 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 VI4ATION OF ANY OF ITS RULES AND REGULATIONS. Signature: •14 fv • ''/ • � ! I Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner IP ,ems The Commonwealth of Mass hus = Board of Building Regulations d S ..i dare I % Massachusetts State Building de a' I CMR 6�0 ` ,��CII AL rry Y�: Af Building Permit Application To Construct,Repair',Rto r Demolish a R sised Mar 2011 One-or Two-Family Dwelling In c.This Section For Official Use Only q`r„ /0/vp Building Permit Number: ,S Q^3'3""..1-C, 17 Date Applied: )4 ut ` /`055 // ZOZ3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers as Sy 1 v a,n lx� 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❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: etrea M u-(D‘c\ A 1\kocNnamo1-on 1 M A Ole ko J Name(Pit) City, State,ZIP c C1 S' a.A La.AQ ( ' sap.-),581.1- ci�ecio f rnur014@gt l.Conn No.and Street Telephone mail Address SECTION 3:DESCRIPTION/ OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building m Owner-Occupied ClRepairs(s) 0 Alteration(s) H/ Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:KAto\ci:n remoCt1�l Brief Description of Proposed Work': k\{-Chen remfl(LQ,l SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 3 5 Q Q 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 1 5 O 0 ❑ Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 53 50 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire Suppression) $ Total All Fees: $ too.S Check No. f 13 I Check Amount: Cash Amount: 6. Total Project Cost: $ 5 0 5 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 10535 ►ala5lo15 Dorn►n►c J L.C on reel License Number Expiration Date Name of CSL Holder t-re e List CSL Type(see below) 5 i Hoy o t.e c- No.and Street 1 TYpe Description 1 S�In0.1yl n i {{ b 0 L Cx U Unrestricted(Buildings up to 35,000 Cu.ft.) P R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances (44 5%C -LAD 50 V 1L1•tC,k'�4 h S U 43 e,q mai►. co m I Insulation Telephone Email addlQss D Demolition 5.2 Registered Home Improvement Contractor(MC) �o�nnin;c J ©conr\zit aOc�Boa oa (►� 3 HIC Registration Number Expirati Date HIC Company Name or HIC Registrant Name 51 HQ►4C k-e Siek- @ No.and Street Email a ess FVS4kAGUYIpinh, tat otooa1 ('k-13)50 -Rio 6() 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 0 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. ( / ' . /vl,, 1, oa114-laS Print Ownerli Name(Electrdhic 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 co med in this applicati is true and accurate to the best of my knowledge and understanding. o t �.,,.�-L1 oaI aL+ I a3 Print Owner's or Authorized Agent's Name(Electronic 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 halfybaths 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 �?' i�� C ` LL�p DEPARTMENT OF BUILDING INSPECTIONS t `.;calf: 212 Main Street • Municipal Building > k. a Northampton, MA 01060 'rf{`�,"�-•- jW CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, 554, 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: vatle' Q..eCLiknq The debris will be transported by: Name of Hauler: .\)kbe 'OS Inc. . dba \1k\eel K-etcher Signature of Applicant: Date: e- la4-(a3 N N. N. \ \ (-Y1. W i 03 O 1-4 \ e N co Co C ' j .1.,..,0 1 NI_ AI-, ' / PAN-1/4(4X8') c1 V co 401990 o^>j i / ,_, 442530 XlN —6i. B18R — 0 co 02 ,m a.in N = -. N co A N F- 0 \ v— ; N .1. _ co ao -im 0 w \ o1 J co 0 co DB18 :::: W \ a co N /., W1830R W0930-H r0930L co o \ \ \ /.� —I \ \ \ N._./ I "a 68k" 101+" f-18" / 30" / 33" / \ 47 N \ / 68,8' f-18" / / 30" / /9"7/24" / / 149:6" / 901D C2D je T- All dimensions_size designations This is an original design and must Designed: 1/20/2023 J given are subject to verification on not be released or copied unless Printed:3/6/2023 � , job site and adjustment to fit job applicable fee has been paid or job IV I I 0 3c p conditions. 2020 order placed. Greg Murphy Vers 1 I All Drawing#: 1 No Scale. ei D p aSe--- _____IX ) N N \LI, N N i co N N i. t w 0 .1., r —\ Im J 'IN - i A al co Co mew A a J.1-• t 1 1 1 1 / 8 / I N -+ i PAN-1/4(4X8'� ca w C N co/ 401990 0 uu A CO 442530 m Co / 3F�� B18R \ 1 \ I w N N N ib.: N A N o i. - N . �1. 0 0 (NI CO N � n> s -.1 N N ° M CI -,I 0 -I 0o N. "I= X co ' ": �—<' `' r \ v DB18 FFEF3018LM CP o GO Nr N F14AR11AL:l1MC 0 co N N / 2Bs� / / 87" 4 A W1830R W0930-H 0930L °' o `"0 4" 1 444" / 18" / 30" / 33" / NiNN N 1014" / 474" / \I Al2"7/ 564' /-18" / 30" /9"/ 24" / / 1494" / All dimensions size designations This is an original design and must Designed: 1/20/2023 given are subject to verification on not be released or copied unless Printed:3/6/2023 job site and adjustment to fit job A O�O applicable fee has been paid or job conditions. 1 order placed. Greg Murphy Vers 1 All Drawing#: 1 I No Scale. The Commonwealth of Massachusetts PI _=Ai_ Department of Industrial Accidents __'=111'= 1 Congress Street,Suite 100 _..? Boston,MA 02114-2017 www mass.gov/din tit mkt-vs'('compensation Insnrancr:tida'it:Buildrrsi(`ontractoniElectricians Plumbers. 10 Kt. 411 4,1)%5 I III T11E:PERMITTING Al t 11t/111"11. :lpplicatit Inturntat' Please Print Leeibls `/ Name a liusin:-ss{A'gatiuratiunmalts tdual): KC)e'h Ci n S 1 Y\C , ctbCk V oak e•A <t tc h en S Address: 5 t Not 4 o tc e are e-V City/state/Zip: EOkS-k-hampton ,IAA 0t0&1 Phone#: (,4-13) 5t t- 4"6 50 Are yaw an employ,ail('hark Ilk appropriate boa: Type of project(required). I ccirl'iun a rmpiopti with I' awtplu cis hull and ur Nit t-itna l.. 7. 0 New Cunslructio t 20 1 am a sole peoprxtua or point-ram and halm no curio!,.cti VI.erkMr lest inn in 8. Fa/Remodeling an!..apacay..[Nu workers'coanp msurancr munrcd.1 30 I ant a 1n.mtussnel Jong all work mssclf I No wurkor. conic, utturanc reels nred.l` 9. ❑Demolition l0 0 Building addition i.fl 1 am a Iwniconnt and will lit hung exottletsoon to cite/duel all*oak on my prorate,. I well cn.utr that all cr.ntt:rl oft other have wvrken'ctanprtisalion nauiaesx die an sok I I.3 Electrical repair*or additions peegtrneteas seat net.tnplotap. 12.0 Plumbing repairs or additions 30 lam a pitnttal contrackr and I have hued the sab,-eesHnacturs tasted on the attached daces_ Thew soh-contractors hawempltlecs and hate*taker.:stoop.insurance.' 13 Roof repairs b❑We m a corp.aatoon and nts officers bast tarn-iatd tarn nigh(h(of esenana per M(il. c 14.0 Other 132,§1(a).and wt have no employees.(Nu workers'croup insurance requital *Amy applicant chat chocks boa al runt also fill out the section lerktw showing their Illo talc's'compannliaw policy iatormation. t Iiosoowaos who submit in attains;unccatutj they m dating all work and dim him oulsi do contractors rtttatl stdiaiit a new atfidas it unhamitig such tCatteeados that shack this boa must attached an additional sacra slaws rug die nano:of the saib retorts►tans and Mlle winder or not those aMI¢OS Mae asployout. Mho alb.00112e11c1urs hate envie, Ce,,this nn.i pne.thole then workers'may.policy ou dice. lane an employer that is providing worAers'compensation insurance far iwp earlp plebes. Below is the polity and jab site lafatn Mon. Insurance Company Name: L.tbeY M \AUk'V at t►nsuv anti Pokey#or Self-ins.Lic.#: UW C a" 31 S - k,0 aL}'1 a 5- 0 t a. Expiration Date: 0 3 (aLt" ( 6t 3 Job Site Address: aci Nivmy\ Lo ne cityistateizip:Notvn.aicpvt\ mA ototoa Attach a copy of the workers'compensation policy declaration page(showing the policy number and(l piratioa date). Failure to secure coverage as required under M(it. a:. 152.*25A is a criminal violation punishable by a line up to S 1.500.00 and/or one-year imprisonment,as well as cavil penalties in the form of a STOP WORK ORDER and a line of up to 5250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance e sserage verification. jo I do hereby c f t, pains and penalties of perjuty that the information provided above is true and correct_ Signature: Date o a I at-i. I a 3 Phone#: L1.4't3\ mi - 1440 6 d Official use only. Do not write in this area,to he completed by city'or town o//iciui City or Town: Permit/License# Issuing.-tuthorits (circle one): I.Board of llralth 2.Building Department 3.( it' `fossn Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other ("outset I'rrson: Phone#: AC�® DATE(MM/DD/YYYY) `�. CERTIFICATE OF LIABILITY INSURANCE 02/24/2023 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 NAME: Michael Banas BANAS & FICKERT INSURANCE AGENCY (Pvc°No,E ); (413)527-2700 FAX (A/C, EMAIL ADDRESS: so@banasinsurance.com 63 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC C EASTHAMPTON MA 01027 INSURERA: LIBERTY MUTUAL FIRE INS CO 23035 INSURED INSURER B: VK DESIGNS INC INSURERC: INSURER D: 51 HOLYOKE STREET UNIT Al INSURER E: EASTHAMPTON MA 01027 INSURER F COVERAGES CERTIFICATE NUMBER: 865616 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 SUER POLICPOLICY NUMBER (MM/DDY/Y LTR INSD TYPE OF INSURANCE INSO WVD YYY) (MMIDD/YYYY) LIMITS LT COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE 1 $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X PER STATUTE OTH- ER A OFFICER/MEMBER EXC EXCLUDED'?ECUTIVE N/A NIA N/A WC231 S624125012 03/24/2022 03/24/2023 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I 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.govAwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Greg Murphy ACCORDANCE WITH THE POLICY PROVISIONS. 29 Sylvan Lane AUTHORIZED REPRESENTATIVE Northampton MA 01062 Daniel M.Croy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACOR CP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YY Y) 02/24/23 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 NAME; Michael R.Banas NX Banas and Fickert a( c.o En', 413-527-2700 (AA/c,No): 413-527-0849 Insurance Agency E-MAIL 63 Main Street ADDRESS: mb@banasinsurance.com Easthampton,MA 01027 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Union Mutual Fire Insurance Company INSURED INSURER B: VK Designs,Inc. INSURER C: DBA Valley Kitchens INSURER D 51 Holyoke Street Unit Al Easthampton,MA 01027 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ADOLBUBR 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 $ 2,000,000 DAMAGE TO D CLAIMS-MADE X OCCUR PREMISES(EaENTE occu occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 A BOP0195521-02 07/28/22 07/28/23 PERSONAL a ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 POLICY E JEO E LOC PRODUCTS-COMP/OP AGG $ 4,000,000 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 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 (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Bath&Kitchen Furniture Sales,Installation and Remodeling CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Greg Murphy ACCORDANCE WITH THE POLICY PROVISIONS. 29 Sylvan Lane Northampton,MA 01062 AUTHORIZED REP ESI IVE t I t C : •t''115 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD