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31B-310 (15) BP-2024-0339 71 STATE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31B-310-001 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-2024-0339 PERMISSION IS HEREBY GRANTED TO: Project# INSULATION 2024 Contractor: License: Est. Cost: 24160 IMPERIAL WORLDWIDE 077508 Const.Class: Exp.Date: 02/28/2026 Use Group: Owner: MICHAEL'S HOUSE LLC Lot Size (sq.ft.) Zoning: URC Applicant: IMPERIAL WORLDWIDE Applicant Address phone: Insurance: 708 GRAFTON ST (508)791-2200 CS-WC-007368-02 SHREWSBURY, MA 01545 ISSUED ON: 03/27/2024 TO PERFORM THE FOLLOWING WORK: INSULATION IN ATTIC 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: Fees Paid: $169.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner 4,7 1. Oa 6, ` „�- Iql� The Commonwealth of Massac tsetts Office of Public Safety and Inspections. Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or TWO-Family Dwelling 3s (This Section For Official Use Only) Building Permit Number:).4' 33/ Date Applied: Building Official: SECTION 1:LOCATION - hilltiaw,p 0006o /'}7i t PI c C9/S /JCJ 1Si No.and Street City/Town Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA Statete Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building Repair 0 Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 0 Specify: 3 OG'Yl 41 S(,1/ 'tyt Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No 11K- Is an Independent Structural Engineering Peer Review required? Yes 0 No C� Brief Description of Proposed Work: /4?Y 5c--pf L7vi / "-R6 d✓1 iv) it ii le SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34) 0 Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) • Total Area(sq.ft.)and Total Height(ft.) / } SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5❑ B: Business 0 E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 ❑ H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1❑ 1-2 0 I-3 0 I-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA CI IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV 0 VA 0 VB SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 0 Private 0 or indentify Zone: or on site system 0 required 0 or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No❑ Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly space: City of Northampton E‘ Massachusetts ' ' I r c, iu y DEPARTMENT OF BUILDING INSPECTIONS 9‘ ',7 . 212 Main Street • Municipal Building Northampton, MA 01060 `r�N .'�1�C PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR COMMERCIAL & MULTI-FAMILY NEW CONSTRUCTION/ADDITIONS/ALTERATIONS 1. Building Permit Application signed by legal owner and filled out by owner or authorized agent. 2. One set of plans and specifications of proposed work (Digital & Hard copy). 3. Site Plan with location of proposed structure(s) and setbacks. 4. Construction Debris Affidavit filled out and signed by applicant. 5. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 6. Contractors must supply a copy of CSL and proof of Liability Insurance. 7. Energy Conservation Compliance Certificate (if applicable). 8. Note any Conservation and/or Special Permit requirements (if applicable). 9. Driveway Permit (if applicable). 10. Proof of Water and Sewer entry fees paid (if applicable). 11.Trench Permit (if applicable). 12. Initial Construction Control Documents filled out and signed by the Registered Design Professional in responsible charge. 13. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact ormation: 1 ynk 404 erca ilic 3viC _-____- Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here l Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals) #71/ daii4A9s4fiel LL S al--NY - aide) doa 7.0 Tz Name(R`egiistrant) Telephone No. e-mail adsireess Registration Number 7�06 &4+[� '11- S�,r+uxbt.ry n�6� 4 1PO�' Street Address City/Townf State Zip Discipline Expiration Date 10.2 General Contractor Company Name William Gd (5 'a)7 b Name of Person Responsible for Construe on License No. and Type if Applicable g& Po��I 44 7 r2J (?d,07451-, eV) Street Address City/Town State Zip aeL-42). 70-)6 (419 - -- ?aa-a iz1Bydduv-kan t9 ye140 /cd *, Telephone No. (business) Telephone No. (cell) a-m tl address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6) =$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate m , ip. . •r)=$ . 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum '••4 (vtA , tact municipality) 5.Mechanical (Other) $ Enclose check payable • 6.Total Cost $ > L,J(,c7.00 (contact municipality)and write check number here SECTIONl13:SIGNATURE OF BUILDING PERMIT APPLICANT 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 b knowledge and understanding. '4- - 9,46 ehIN)r Please print and si name Title Telephone No. Date W l s i a/- x� elf d'c'c 4 a Y6e) t,_t Street Address City/To�+c°n State Zip Email Address /C1 Municipal Inspector to fill out this section upon application approval: //gi: j 27'ZOZ Name Date ya hco, Cruz A CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE City of Northampton (r- „ej s.: '+r Est,,,' 1�t i. ,it Massachusetts �` M' �DEPARTMENT OF BUILDING INSPECTIONSt 212 MainStreetMuncipalBuilding „J,r g Northampton, MA 01060 �iti Property Address: ' / 4 („ : fir•{-- itiotikia j'? 7 Ma_ (7/0 ha Contractor ------ Name: -�17/.1-' ' G`�►'f/(./A -- Address: -7C7f` - City, State: 4/i1V/LA 1 E L-.- / 1 . Phone: 4// A/a`7 � .3 917)C' Property Owner Name: �,1 ?vl rr d ,i-fizi r Address: -71 7kiii,-- �-�7L City, State: 'Lr/iw+d/i//i /7 / It I, t a1✓1 ! _,{Liu.:) -- (contractor)attest and affirm that the building I intend to insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have provided the property own 'th a copy of this affidavit. Contractor signatur Date go) 0(/ • a Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix islo be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing(include local connections) 9 Gas(Natural,Propane,Medical or other) 10 Surveyed Site Plan(Utilities,Wetland,etc.) 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review(521 CMR) 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information tdeT CUB elM -De> - -Vac. 20 bc,d beelheyaboe.ctwi Name(Registrant) Telephone /No. / e-mail address Registration Number P140-');YlelPi Street Address City TownState Zip Discipline ptrahon Date - - Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date - - Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. V Commonwealth of Massachusetts Division of Occupational Licensure Construction Supervisor Board of Building Regulations and Standards Unrestricted-Buildings of any use group which contain less than Tf 35,000 cubic feet(991 cubic meters}of enclosed space. Con si lrc n�git' t rvisor CS-077508 --• , � .; spires: 02/2812026 WILLIAM H \ EBB 292 PARTRICE HILL RD, ,> CHARLTON MA 01507 ' 4 <-lf.I V 4i,'S tt Fa to possess a current edition of the Massachusetts State '' Building Code is cause for revocation or this ticonse. Contact OPSI: (617) 727-3200 or visit www.mass,govtdpllopsi Commissioner , evvei.,f.z......- THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration ° Type- LLC ti : Registration: 202703 HILL COMPANIES LLC `" ` Expiration: 07/29/2025 708 GRAFTON ST ; SHREWSBURY,MA 01545 b,. 51 Y t # . ..-.., ' 9 ..'.. Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:LLC Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 202703 07/29/2025 Boston,MA 02118 HILL COMPANIES LLC EDWARD HILL 708 GRAFTON ST • SHREWSBURY,MA 01545 Undersecretary Not valid without signature City of Northampton r t`�y Massachusetts '��� ''r,ri P. DEPARTMENT OF BUILDING INSPECTIONS �: - -� R 212 Main Street • Municipal Building �' 0� {� v� Northampton, MA 01060 1 �'11 3`3" rs t. • 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 1S0A. The debris will be di 3 Re° YU '`UIeCt s ct Ut U&' Location 7C' E.,. l`t-,1\ sr-1- C t- tor? `w- ve p tC c,_ > v v., 3 u Y� C. u - If n Cat b1 ?h by: • Name of Hauler: 1 ( ) `D 4 .S - Ste,` • Signature of Applicant: 7 .1 Date: ../>>i The Commonwealth of:11ussachusetts 1' of De rurtnreul olf Industrial.lrcir/c�nts .ii1/4,,,AID. '- ; I J � .4,,L i Congress Street.Suite 1(1(1 . "" 1►-= r� , Boston, M-t t02114-2017. i -h. .t„3t it-wwinass.got/dia 1loikers' Compensation Insurance.lf1idavit: fluildersr('oa1ractorvElectriciaus;Plumber.. 10 HI.t li l t)',1111 1111•.PERMUTING AIr"ifoki 11. Anpticant Information Please Print l.teihh Name(Busincsitit kgmization lndividualt: 744QCrJ`41 1 CIO/1Gfalalµ- .Addre ss: /6 C r4 S C'tty State lip: 3t/l ,:lt,ry A ,/(V w Phone##: j) '7r do .ire van employer'(hock the appiupriatc hot: k Type of project(required): I. aria a empk►ytt aid, !c enrpluy (full and or part-trine).' 7, 0 New construction 20 i am a sole proprietor in diers tip:nnd have rk+employ e aurkutg for nee in It. 0 Remodeling any capacity.(Ni.autkers'comp.inouranee regit:Na.) 30 two a In n:sots c-t dohs;all oink myself.No markers'comp.insurance requited" 9. Ej 1)einolitilnt 10 J Building addition •t.Q 1 am a ilonrhlttna7 and tt ill tR lnrrnei ttnttratitrrs W conduct all work wi tity pin s.-r is I tY ill eitsute that all ctmtiaeturs Colter llat a aor1,ert'compensation insurance or are sole 11.0 l:lee tt leaf repairs or additions proprietors.silhrr+emrlu),ex, 12.0 Pluming repaint or additions Sr:j I am a general.ununetur and I haae hiresd die sub-cuntringurs listed 'n the attached sheet. 13.0Root repairs I hese sub contractans have cnnployecs and has.%ottcers'comp.in..nt:mee. 6.0 We me a LatrporatiUrr and its officers ha►c criert:istti their engirt of exemption per Mitit_e. 14. (c h 1' _„ls_ o -tern► 152.i[1(4).and ise hate lit+employees.[No aurften'comp.nistaanee require i AR )1'• 'An}applicant that check%l.n 1 must also tilt oolitic seetiun Woo shoo icy,then a oilers'compensation policy information. t 1k:tiv.ntsei.Ali o.ubtuit this attidatit tridicatinc they are tkmig all at+rk and then hire outside ctxltraettxa must sul.,nit a nets ati cat it inthtatl ie such. :l'ontrattons that'check this h..v must attalued an additional sheet shoo itas•the name oldie mob ctaltraetcxs and state sihether or not those enllues have ..,,,, t::ipllt.tee+.. It die s l.-e.'I:tr.et.'.s base cur l...ee..that duds$rr.'tIlk then 0.orker.'tac'mp.pv_i..s nlnnher., I ant an employer that is providing winker''compensation insurance far my employees. Below is the policy tint!job site infrrrmniiun.Insurance Company Nane:eialy_ 5�JySe n OKI00al ., _. ._ _--._.._._._____.___. — Policy#'or Self-ins.Lie.#' C_S.:774k — OC)7 4.b " Expiration di/Si:9.� _ p� toot, iratuxt Dale: . Job Site.1ddress: 3 /tld'M'i II _, C'ttyiS1ateizip:/'OV 4a `??q �a.. .1.ttach a copy of the ssorkers'compensation polio} declaration page(shoring the policy number an expiration date). t aaiurc to secure coverage as'conned under Ming t•. 152. 25:1 is a t:ivaunal s it+lataon punishable by a fine up to S 1.50 0.tlf) :hide or s'ne-4 t:at itupristtniucnt.as%s ell as cis it penalties in the tin in of a STOP WORK ORIM R and a fine of up to S250.00 a day against the violator.A copy of this statement ilia} be tiro st ai ded to the Oflfice of investigations of the DIA for insurance coverage verification. /do hereby c•erti - ande'r a pa' .% 'realties perjury that the information provided above is trite and correct. ienctttnc: I 21 - 1):ic ')/• C Phone;:: _Pi -7g( d c)-0/9 Official rise only. Do not write in this urea.to be completed by cite or town official. (*its or limn:_ _ —. __-- PermitiLicense a_—_.______.__________ _ ._ Issuing.Authority (circle one): I. Board of health 2. Building Department 3.(•ity;Tossu(*Jerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other ('intact Person: Phone#• AC RD® CERTIFICATE OF LIABILITY INSURANCE DATE 2/14/2O24rr) 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 Herlihy Insurance Group PHONE Chris Rose FAX _ 51 Pullman Street INCA°,elt):508-756-5159 4(ac,Ho):508-751-5747 Worcester MA 01606 ADDRESS: certificates©herlihygroup.com INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:Selective Insurance INSURED IMPEWOR-01 INSURER B:Clear Spring Property and Casualty Company Hill Companies, LLC dba Imperial Worldwide 708 Grafton Street INSURERC: Shrewsbury MA 01545 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1804545359 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 SUER POLICY EFF POLICY EXPMI LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MDD/YYYY) A X COMMERCIAL GENERAL LIABILITY Y Y S 2512815 2/15/2024 2/15/2025 EACH OCCURRENCE $1,000,000 I DAMAGE TO RENTED 1 CLAIMS-MADE X i' OCCUR PREMISES(Ea occurrence) $500,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X jECOT- X LOC PRODUCTS-COMP/OP AGG $2,000,000 j OTHER: $ A AUTOMOBILE LIABILITY Y Y A 9109223 2/15/2024 2/15/2025 COMBINED SINGLE LIMIT $1,000,000 (Ea acddent) ANY AUTO BODILY INJURY(Per person) $ - OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS xy HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ A X UMBRELLA LIAB X OCCUR Y Y S 2512815 2/15/2024 2/15/2025 EACH OCCURRENCE $3,000,000 - EXCESS LIAB CLAIMS-MADE AGGREGATE $3,000,000 DED X RETENTION$in nnn $ B WORKERS COMPENSATION Y CS-WC-007368-03 2/15/2024 2/15/2025 X PER OTH- . AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNERIEXECUTIVE n E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) I I E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Pollution Liability S 2512815 2/15/2024 i 2/15/2025 Each Inc$300,000 Agg limit-$300,000 A Equipment Coverage S 2512815 2/15/2024 2/15/2025 $100,000 Limit $1,000 Deductible DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Subject to policy terms,forms and conditions.Certificate holder and any person or organization required in a written contract is included as an Additional Insured with respects to the General Liability policy for ongoing operations per form CG8810-04/13 and for completed operations per form CG8583-04/13 when required by a written contract.Coverage is provided on a Primary and Non-contributory basis and a Waiver of Subrogation is afforded on the General Liability policy where required by written contract per form CG8810-04/13.The Automobile Liability provides Additional Insured status and a waiver of subrogation where required by written contract per form CA8828-10/11.A Waiver of Subrogation applies when required by written contract on the Worker's Compensation policy per form WC 000313-4/84. Umbrella policy is follow form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN M2 Holdings LLC ACCORDANCE WITH THE POLICY PROVISIONS. DBA Paradigm Energy Services 2 Richdale Ave AUTHORIZED REPRESENTATIVE Somerville MA 02145 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD