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31A-285 (3)
3 JAMES AVE BP-2017-0349 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:3I A-285 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ROOF BUILDING PERMIT Permit# BP-2017-0349 Project# JS-2017-000575 Est. Cost:$8000.90 Fee:$40,00 PERMISSION IS HEREBY GRANTED TO: const.Class: Contractor: License: Use Group: THOMAS DADMUN 107919 Lot Size(sed ft.): 8929.80 Owner: HICKS KATUERINE Zoning:URB{IOON Applicant THOMAS DADMUN AT: 3 JAMES AVE Applicant Address: Phone: Insurance: 60 SCHOOL `+s T (413) 387-7381 HATFIELDMA01038 ISSUED ON.:911412016 0:00:00 TO PERFORM THE FOLLOWING WORK RE-ROOF HOUSE 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 ft Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: 01: 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 9/14/2016 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use al* CityildinofNorthamptStatus of Pen* Bug Departmenton Cum CWDdveway.Aarrng FQ _ 212 Main Street Sevier/Septic Avatiability 'I Room 100 WaterrWenAvailabiwty --1 .-- Northampton, MA 01060 Two sets of Stapcturat Plans +...._ - phone 4-1 -587-1240 Fax 413-587-1272 Rot/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 3 t6 A" Map _ Lot_ Unit hllKxtivMproP 1 VIA 0060 Zone overlay District Elm 3t District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ILA I4aE (- _ )M CIEWILisri Sr, , NoRh f - 3 . Name(Pr1nQ Current thug le e s. /`[b7 ('IQ±/lL(L4"FX 4 /1423 .._.._ Telephone Signature 1 l — 2.2 Authorized Agent: / •wlw p r ‘11.) (PS SCVjvot- Sr, -AllIlt•D MA ow38 Name(Print •a~ (T v' Current Ma➢13 -bh 7. 12 O Signature It 'F TelePhonee / J , SECTION 3-ESTIMATED CONSTRUCTION COSTS item Estimated Cost(Dollars)to be Official Use Only _completed by permit applicant __ 1 Building (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) Check Number of�)/ �/ g This Section For Official Use Only Date Building Permit Number: Issued: Signature: , ____ Building Comrmssionerflnspector of Buildings Date Section 4. ZONING MI Information Must Be Completed,Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This ceiomn to be filed in by Building Department Lot Size Frontage Setbacks Front Side, L: - R: L: R: Rear Building Height Bldg. Square Footage - o Open Space Footage (Lot area minus bide&paved arki t#of Parking Spaces Fill: tvelume&Lueationl A. Has a Special Permit/Variance/Finding ever been issued far/on the site? NO 0 DONT KNOW O YES O IF YES,date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW O YES 0 IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO O IF YES, describe size, type and Location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O ✓ NO t p IF YES,then a Northampton Storm Water Management Permit from the DPW is required_ SECTION 5-DESCRIPTION OF PROPOSED WORK tcheck all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) J Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [q Siding[D] Other[O] Brief Description of Proposed p� p Work: 1—�- ecitita 40.0°aC Alteration of existing bedroom Yes )0 No Adding new bedroom Yes )n No Attached Narrative Renovating unfinished basement Yes p No Plans Attached Roil -Sheet Ba.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 Woodsloves _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 ]. Depth or 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.- I, -ATMA SC. 6\L{$ _,as Owner of the subfect property 'L �) hereby authorize 1 y� Art 'I" •� to act on my behalf,in all matters relative to work authorized by this building permit pplication. Signature of Owner 'l Date .11.11111111.111.111.1111111111.1 I. 4a'al�'1, " OA"OkWtJ -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. 114wq6 OAVIArro p Print Name l0 1to Signature of Owner/Agent Date SECTION 8 i CONSTRUCTION SERVICES 8.1 Licensed Construction Supervise(: �} Not Applicable ❑ Name of Uceose Folder: wafts 4ftAUt3 CS - le'?ai� License Number (aa 5r(d pt Sr, HNwtrf.w, VNA o(ob& 1/2412011 Address ' Expiration Date t( nn 4W-157-473bt Signature Telephone S.Recistered Home Improvement Contractor Not Applicable ❑ i-s 1vuk cntooe LI-6 lint.3_ Company Name Registration Number tit SC t,(2,l (2<3,Ib Address Expiration Date 401f.A,0 NIA• Deo 30 Telephone 4(3 -357 "738 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. Signed Affidavit Attached Yes No 0 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 and on which hershe 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 stmctures.A person who constructs more than one home in a two-veer 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 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: J ,:i3/4-0.0,25 AVE The debris will be transported by: /LTFALPM JL ( ty614 4 The debris will be received by: Building permit number: Name of Permit Applicant IN'ti)ht y3 9f7)46-0 FapiSriciltnoa 2400 /v.•r � . Date Signature of Permit Applicant lip Massachusetts-Department of Public Safety Board of Building Regulations and Standards (-fln truction Supcn nor License: CS-107919 THOMAS DAIMON 60 SCHOOL STREET'fil f HMMeld MA 010 j j..f„—,...690. " Expiration Commissioner 0924/7017 cclt-e cztro/m/ntartwea/a o/ iaoicac�?eeoe 1 Office of Consumer Affairs and siness Regulation 'e' 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 1733882 4 Type: LLC , _ .. Expiration: 828/2016 Tr* 419291 THE TUCKER GROUP LLC. THOMAS DADMUN 60 SCHOOL ST HATFIELD, MA 01038 Update Address and return card.Mark reason for change. AddressRenewal Employment I Lost Card _,a c, 23Mos,n �• __ %/r Y....N.............///,/' fl Regulation . License or registration valid for individual use only Office of Consumer Amin A I{ooe�Regala ,. HOME IMPROVEMENT CONTRACTOR before the Consumer date. If found returnssRegulation .l - ibgNtnBon:' iT41h82 type: Office of Consumer Affairs and Business Regulation ' Expiration: `812&X18 LW 10 Park Piaxa-Suite 5170 Boston,MA 02116 THE TUCKER GROUP LLC. THOMAS DADMUN 60 SCHOOL ST HATFIELD.MA 01038 Undenantsry Not valid without signature A�Et CERTIFICATE OF LIABILITY INSURANCE DALE 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 INSURERCS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pnlicy(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). PRDSUCER COirrASAM, Susan Fleury, CIC, CISH Ring S CUBhovan Inc. ANN 1413)584-5610 FAX Nei:(413)sea-e322 P.O. Box 447 nooniss:SFleury@KingCushman.mom 176 Ring Street INSURE/SS)AFFORDING COVERAGE NAICM Northampton ML 01061 INsuRERA Main Street America Assurance Co. 29939 iNSUPEP INSS INSURER ON DADMDESIGN S CONSTRUCTION INSURER c: 60 SCHOOL ST INSURER o: INSURER E: HATFIELD MA 01038-9747 W9URER P: ... _. COVERAGES CERTIFICATE NUMBER:CI.161501268 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, ISM I _ sle ' OR POESY EEE EOM,EW I {.TR. TYRE or issuance INSO MC POIJOY NIAIMER iSVALSOCNYT1,31ASEEDOEMII LILTS X COMMERCIAL GENERAL UABWtt EACH OCCURRENCE 1,000,000 A ��CWMSduDE X OCCUR SAMMTO' 500,000 PREMISES(E-wn rcal rre 1RT4694Q .11/13/201511/13/2016 MED EXP(MY OSS p[nacl 10,000 _ PERSONAL d ACV INJURY 1,000,000 OGEHLAGOAEGATE Ma APPLIES PER. GENERAL AGGREGATE 2,000,000 FOXY JECT IIOC PRODUCTS.COMPIOPAGG 2,000,000 OTHER SWINE Rezven, AUTOMOBILE LIABILITY (OMB^IN�j IINCSYL LIMIT ANY AUTO I BODILY INJURY(Pel person) I ALL WAVED -SCHEDULED AUTOS AUTOS BODILYwJi9tY(Fm av±de.9} HIRED AUTOS '-OPERTY DAMAGE J AUTOS Per accident UMBRELLA UAO _ OCCUR EACH OCCURRENCE S EWE"LISS GUESS-MADE I AGGREGATE -- S DEC SENSOR S S WORKERS COMPENSATION 1ER OTH- ANBEMPLOYERS'LLABIUM' V/N _. 9WTUTE ER ... ANY PRWRIErOR/PARTNERIEXECUNVE E.L EACH ACCIDENT S OFFICER/NEWER EXCLUDED, Li Ni I A IMmpsmy In NH) E.L.DISEASE-EA EMPLOYEE S Ilyas @xtiM uttk: DESCRJT1044 Of OPERATIONS Mmv EL CSSEASE-POI.CY LIMB £ , I ESSCMPTION OP OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AgORbnal ReiYb eceaule,may be aaathal Smart space is remirms CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Sample THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POI S: AUTNORREO REPRESEMTATVE . ,ltd A If 01))4/ ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS02412m4m1 The Commonwealth of Massachusetts c� Department of Industrial Accidents P—'.T-' - Office of Investigations astatel - I Congress Street, Suite 100 Boston,MA 02114-2017 'Nos," www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly fi Name(Business/Organization/Individual): itiAVAVO btkte,3 iLaJSCYCA.ittroJ Address: �'� NIL Sr.. City/State/Zip: iintiA4 A 0 03$ Phone 0: 4115'3bl-75S Are you an employer? Check the appropriate box: Type of project (required): I.❑ I am a employer with 4. I am a general contractor and I employees (fill and/or part-time)v have hired the sub-contractors 6Li New construction 2.❑ I am a sok proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurances required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12 tZ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] "Any applicant that checks box#1 must also fill nut the section below showing their workers'compensation policy information. "Homeowners who submit this affidavit indicating they are doing ail work and then hire outside contractors must submit a new affidavit indicating such. H::ontractorsthat check this box must attached an additional sheet showing the name of the sub-contractors and stata whether or no 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. Insurance Company Name: Policy#or Self-ins. Lie.24: Expiration Date: Job Site Address: 3 ciA AVE City/State/Zip: NqO(L11'1'Fio'tPtu9) 0(oGo Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 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 S 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 cert f under the pai and penalties of perjury that the information provided above is true and correct. )40,4„.„.. Signature: Date: q (al22c(_ Phone#: 4 lb 'M51 .1'551 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone Ii: /"1 DURABRO-01 SKOVACS A`RI7 CERTIFICATE OF LIABILITY INSURANCE D" 9161/20162016"" ' 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 (COFAME:NTACT McClure Insurance Inc. "vxDaE ,VAX 183 Van Deena Ave. . 413)Z81-S7tt ;uc,son{4t 3)731-8548 A West Springfield,MA 01089 A+DRESS: INSURE-R(5j AFFORDING COVERAGE NAICP INSURER A:Endurance American Specialty,„ INSURED - _ INSURERS: Dubay Brothers _INSURER C: 35 Edendale Street INSURER O: _ Springfield,MA 01104 INSURER E: _ INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES Ui INSURANCE, LISTED BELOW HAVE SEEN ISSUED CTHEOTHER D NAMED WITH POLICY WHICPERIOD INDIS TATCA. IDNOTWITHSTANDING ANY PERTAIN,REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTPLIIEOR DESCRIBED DOHEMEN I RESPECTWSUBT TOL TE MS, LUSIOCERTIFICATES MAY BE ITIONS OR MAYCPERTAIN, THE INSURANCE AFFORDEDAVBY THE POLICIES D LAIMIBf:O HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED RY PAID CLAIMS EXP INSR. .s F 41:-I vMjDDN EfFY.. Poucf RAP Lffi' ttPfiOFIN6URPNCE , , ,AM POLICY NUMBER MM1aINYYYYj iMW00n'TYY1 LIMITS A X +COMMERCIAL GENERAL LABILITY I i EACH OCCURR£N E IY 1.DDD.DD9 CtAIMSMAOE X OCCUR CBC20001$85400 I0712212016 07(2212017'..PREMISES( ,gym) 5 100,00F I W..� MED EXP(Any ...person, $ 5,001 PERSONAL a ADV INJURY $ 1,000,000 .OEN'L AGGREGATE LIMIT APPLIES PER: ;GENERALAGGREGATE ,s 2.000,0GL r.1X(POLICY _ _.__ �...... POLICYI bac LOC PRODUCTS-cormroP ACG s 2,000,001 O'NEfl "'OWNED SINGLE LIMIT AUTOMOBILE LIABILITY I (Fe accident) $ I ANY AUTO 'SCIOILYINJUR (Pee parson) I$ ALL OWNED —'. SCHEDULED OIIDILY INJURY Balm, $ RUtlTO}'3MEO EATYDRNADC I. HIRED AUTOS ATOS j {PM ka 1 $ UMBRELLA LIA8 OCCUR EACH OCCURRENCE !.$ EXCESS UAB ■ CLAIMS•MADE AGGREGATE i$ — lin DED RETENTION5 '3 ,WORMERS COMPENSATION 'PER I...•TOTH' AND EMPLOYERS LIABILITY Y/N.. f : ISTATIE ;ER ANY PROPRETORPARTNEREXECJTIVE EA_EACH ACCIDENT I$ OF MER/MEMBER EXCLUDED? 'NIA -- '-- (Mandatory InNH) E L.DISEASE•EA EMPLOYE $ IIIII ( yes.pescipa under "— DESCRIPTION OP OPERATIONS Below I EL.DISEASE POLICY LIMIT $ 1. .. � DESCRIPTOR OF O46MYI W S/LOCATIONS VEHICLES(ACORD 1%.AtlgUnnll Remarks Schedule.may be attached I/more space Is required/ _CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Katherine Hicks THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN K JamesAve ACCORDANCE WITH THE POLICY PROVISIONS. Northampton,MA 01060 AUTHORIZED,UTr�$ � REPRESENTATIVE�$a�N Ia A$'4CIW layy ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2044101) The ACORD name and logo are registered marks of ACORD '�R® CERTIFICATE OF LIABILITY INSURANCE DATE TAo1e 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 pollcy(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 Suzette Kovacs MCCLURE INSURANCE AGENCY INC. Pt1pNwAX ,rc (413)]81-8]11 l iAnc No): A-M IILAS'm wL zehB�mU'Ur2ins.COm PO.BOX 339 INSURER(SIAPPORDNG COVERAGE HNC if WEST SPRINGFIELD MA 01090 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED f INSURERS: DUBAY BROTHERS ROOFING INC INSURERC: INSURER 0: 35 EDENDALE ST INSURER E: SPRINGFIELD MA 01104 INSURER F: COVERAGES CERTIFICATE NUMBER: 53529 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. NCTWTHSTANDING 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 POUGIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED SY PAID CLAIMS. INSR LTR TYPE Of INSURANCE AOOL wueeR WOONY SIMMONW LIMITS 6JED POLICY NUMBER IPOUCYEW1 ISOUCYE P COMMERCIAL GENERAL UA&uTY EALHOLLOI EN1LD E S UAMI CLAIMS-MADE !OCCUR PREMISES Iffy Jn nre) S MED EXP(thy one person) .1,f WA PERSONAL B ADV INJURY 1 6 GENL AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 1 POLICY I I'M' I LOC PRODUCTS-COMP/OP AUG I S I OTHER 16 AUTOMOBILE LABILITYCOM9INEOSINGLE LIMIT 's :Es a4149nO —l'. ANY AUTO I i BODILY INJURY(Per WNW!) tI 1 ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) S 11 AUTOS „.,AUTOS iNON OKNEO PROPERTY DAMAGE S HIREDAVTOS _1 AUTOS (Per accident) I UMRRELLAUAB I OCCUR EACH OCCURRENCE S - I EXCESS LIAR I CWMSAMDE N/A AGGREGATE E DED I RETENTON5 �/ S WORKERS COMPENSATION XSTAET I MISUSE I KH - AND EMPLOYERS'LIASILlry AA O WICERAXEM EH EXCLUDED?EBLT VE MAI WA NMA 6S62UB9F44274416 01/22/2016 01/221201➢ EL EACH ACCIDENT E 100000 (Mandatory In NH) E.L.DISEASE.EA EMPLOYEE S 100,000 DESCRIPTION OF OPERATIONS below EL DISEASE.POLICY LIMIT S 600000 N/A I DESCRIPTION Of OPERATIONS/Lnefits NSI VEHICLES o Mass WI,Aetl n I Remarb Sened,JP,may Sent to Edd MOM spit.N required/ Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 0613.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 expiraton 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.govtlwdiworkers.compensationnnvestigationsl CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Katherine Hicks ACCORDANCE WITH THE POLICY PROVISIONS. 3 James Ave AUTHOR2E0 REPRESENTATNE Northampton MA 01060 `Daniel anW M.Cm y,CPCU,Vice Presitlent-Residual Market-WCRIBMA ©1988-2014 ACORD CORPORATION, All rights reserved. ACORD 25(2014(01) The ACORD name and logo are registered marks of ACORD