31A-047 (6) 249 CRESCENT ST BP-2017-0991
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A -047 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-2017-0991
Project# JS-2017-001708
Est.Cost: $3600.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: SEXTON ROOFING CO 99689
Lot Size(sq. ft.): 6969.60 Owner: WAKIN ELEANOR
Zoning: URB(100)/ Applicant: SEXTON ROOFING CO
AT: 249 CRESCENT ST
Applicant Address: Phone: Insurance:
P O BOX 6327 (413) 534-1234 WC
HOLYOKEMA01041 ISSUED ON:3/3/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE AND REPLACE SHINGLE GARAGE
ROOF/COAT BACK ROOF
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 3/3'2017 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
2_1%A • Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 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 AP- /'7 - q j
1.1 Property Address: This section to be completed by office
Map Lot Unit
Zre5Ce 5i
Zone _ Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
_AT/ 4ticre it. 4ICrAt ) 0,2Y9 t(r- cce _ i 5f4/6 %�� uatM
Name(Pont) Q
dd
4 / / I Current M ng ress:n
6. 4 zc i/4 i�l Telephone ]/
Signature
2.2 frodhorized Agent: �` pp J (pJ / ��q
h'-4�N 2tlDirt di -e sc/ to JLLc fc - J(\X L 3 a 7 2-l731y0l4 � 4-
Name(Print) Curt nt Mailing Address:
ao4 -c) vS"
Signature Telephone
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) g, (, C . - Check Number h/Qa5-
This Section For Official Use Only
Date
Building Permit Number:
Signature: -77
Building Commissioner/Inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Rooting Er
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs 117] Decks ID Siding(0] Other[DJ
Brief Description of Proposed, D o
Work: x19,7 e 4Hdko/geo ch •-17/r 9R'/9�/eccF/Cor'
2oOf_
Alteration of existing bedroom Yes 4"......"—No Adding new bedroom Yes "Thio
Attached Narrative Renovating unfinished basement Yes s----No
Plans Attached Roll -Sheet
ea.If New house and or addition to existing housina. 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 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 confomt 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, A L44/1 N.x/t K/ AJ ,as Owner of the subject
property (��(
hereby authorize .3-e V-10� ]j?cc'(in et
to act on my behalf, in all matters relative to work authorized by this building permit fa plicati
��- (/'cul 4 d4c4,6--/ '� d s/7
Signature of Owner -n' /./ DateDa
I, E ,� TGA �}� /v`t� �COG�vpt tt- d J' iii-(� �L as Owner/Authorized
Agent hereby—declare that a statements and information on the fotegoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains . d penalties of perjury.
�! f ) /a
Print Name
iH - f "7
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: (� Not/ J(Ap�plilic/able 12/
Name of License Holder: ✓ 11c % % 3-z k -I ct,' '-/- if c7
License Number
R -'- L�C'y ( ) -7 I-Iz^ IV° b., (>L4:4 u[ cti// /h - S -i7
Address Expiration Date
010V'J C/ 7 3
Signature Telephone
9.RR(�e``r� e
oistered Home Improv/ment Contra(cttor:p /- Not App- LI
Coanv Name T Registration Number
Address z Expiration Date
4, 1yo �q U i 0,4 t Telephone 5/Y' /7 V
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 buildin emit.
Signed Affidavit Attached Yes @" No ❑
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 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 Stale 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 150k
Address of the work: _2 y 9 Cr e 5 c e T S
The debris will be transported by: Com/44 'i2' Sps d t
The debris will be received by: L2onp/e it Pt ,pc
Building permit number:-
Name of Permit Applicant St v -wR6rf t ' -i c, -15
7
Date Signature of Permit Applicant
ropofiat
SEXTON ROOFING AND SIDING INC.
•
(413) 534-1234 . P.O. Box 6327
FAX (413) 539-9906 �LYt�tar; Holyoke, MA 01041
sextonroofing@hotmail.com
SINS
CT HIC #0605383
MA HIC#118239 www.sextonroofing.com
Since 1985 O
SUBMITTED TO /�p�e ex ��,g.ri✓ PHONE .2.2/— y9/ � DATE.2/S/c.1
STREETel.yq C gescew^- Sr JOS NAME
CITY
SZIPCOLIE TATE °L /hp. m • JOB LOCATION
Proposal to furnish and Install the following EMAIL
3 Re-Roof 12K
meTear-Off ❑ Main House 3 Garage ❑ Shed
Complete Root Preparation
normexterior to be protected by tarps and plywood ^O4 T 3A-cK Luzatz
la'Shrubs, landscaping,trees to be protectedc`f
• -Entire existing roofing material to be removed to existing decking, Including flashing,etc. G{.eOO .e
iySite to be cleaned everyday with roll magnet debris removed at project completion
QV-Deteriorated existing decking replaced at$2.50 per sq.tt
❑ Install all new decking/type: i
uggipprown metal drip edge installed at eaves and rakes F-8 ❑ F-5 LI Rake Edge
n few flashing will be installed where necessary(see Special Requirements)
❑ Install new pipe boot flashing ❑ Bathroom Exhaust Vent
❑ Reflash chimney with new lead
ie shall acquire all appropriate permits etc.for all roofing work
Complete Roofing System
ifeak Barrier installed at all eaves to protect from ice dams(and meet codes in the north) ❑ 3' l
❑ Leak Barrier installed at valleys,around penetrations and chimneys to protect critical areas
St-Install Roof Deck Underlayment on remainder of root 0 #15 Felt C3"tiSynthetic Felt
Shingles
vIKO ❑ GAF ❑ CertainTeed 0 Tamko / ❑ 30 year 0(10 year ❑ Lifetime Color (e%AeC'u-L�C:Y
le-Install Attic ventilation system la -.Cap over Ridge Vent ❑ Rdoi Louvers
Warranty Options _
i3ar /04,„.14We guaranteed our workmanship for 25 full years CD ento f�,,-, /04,„.14 / S , 2a t 7
e Vrapose hereby to furnish material and labor-complete in accordance with thea ve specifications,for the sum of:
/%eetc -7-4ec1.9n.n dollars($ c )o — ).
PAYMENT TORE MADE AS FOLLOWS / .v✓.
Ar
All Material is guaranteed to be as specified. Al work to be completed in a workmanlhe manner Authorized
according to standard practices. My alteration or deviation from above specifications involving -
extra costs will be swanned only Won wntlen orders,and coir become an extra charge over and Signature
above the esomateuiagreements contingentuponndkes.aaidmds ordelayabeyond our Central. Note:This proposal maybe M/
Not responsible for water damage during construction.Owner b pay responside legal fees kr Withdrawn by us g not accepte0 within /�" days.
non paNrwnt and aWlMade interest M Wes car month.
��SR,ptsnrt M firopoSai-The above prices,specifications and conditions r _I�1 `S ,4 - '•/
are satistactory and are hereby accepted.You are authorized to do the SgnaWre — i
work as specified.Payment will be made as outlined above. �_
``nate of Acceptance Signature
ATTENTION HOMEOWNERS:Please cover all personal belongings in the attic,garage or storage areas due to the possibility of roofing debris or dust
coming in through the cracks of the wood. Sexton Roofing and Siding will not be responsible for debris or dust in the attic or storage areas.
Me Coramonweaith of Massachvsets
Depaanneni of Indust x iAcadnts
rP ars nsr" OTCe of BVBSLga1 niS
c r Cac.rgress SP b 1965
3o ca kil 02 31 4-2 01 7
y ..www mew .FG a/_±a
`.4c ic..ersrCorppens anion Tpnseirance;4=;idavit: Bt1•ders&CoI!Ltracorsl lecrci--nz,'Psii hers
tlic.ant Taforrnaio= .__. Please Print'Legib1_y
N- n a te.annessior ea_.retiodln -darty Sexton Roofing, & Siding Inc .,
_c.dLSS P .O . Box 6327
Ci*p/StensiZi_' Holyoke , MA 01041 Phone#. 413-534-1234- ,6
Lot you employer? Ch c`stlat hpprognate AmT-p. O_ c _,1 ee}.
I.El. in Tic- ah '. ; jr Emelt] rmat II ''. I
s,o- es ill analk Watt-' p) 'I
Leah S Yuer chW cans. I I 5. L,jNew cons^ rood 1
2 n 1 ._ a ole__op error or parser. listednrhe z7n r d sheet III 7. 7Ae o ems,'
Tack sun coni s ate ' 0 rl s t
shg .mc lav=no e ntm ees h 11 o L. D n
1 wohumg ek me ie s-4ana ty - n sore s art i ao krs' I 1'ss
1 � a _ I1 3 1 -]1 b weeds_ i .
Belo:worker? pomp insurance oma oorr1 se o
qu..a j S. We axe a comordion cad is III s C 1—�$lecncal ,pus ami-13s
II 3. T }7_ homeowner aping 51 wok ts. cers hap es ecis dt_ir I I 11 In pay-posspgrergirs pr rialtos 11
v.. s-r Qin oSkers' mm :€h ofer a1tonta1i&I III .� rj
p L o ern..
Nrs:rxce raqu$ae1,] t c.1 2 ees [1 d we he ,e Pc 'Ti _ i
+rp�oyees. f,ac W ni er d) I 1 OPner _
u _;»s ar ce e I
=Any aprbcratiat 6ec6 baxkl must aus1311 octa:sectimbelow showmgtheir worker cocs:nsata_pohcy ix£uaaaha
t Honeowocs Tito stator.,eidaat;achatt tram oks;atw,a±adtheo Ilan otdec tntmr mastrinm, n ZZfriRaucng tic-.
-:ontao ontha ae*ais box must rtaaa.d an adtiacmal she<!ahowtgihc ns e efffie rid.connt-tm me MR b.er or LOS-6=eo=es hr,e
e roioyees. 2tie sir-cantxceo<s hays employees;ibcy muenprmac their woStrt comp_noisy mmbcr.
I rn rt eatpioytr cut isyrovidnp'workers'coveteauraton mscmmejor my eirnicy us 3 eine is J _pnflg sa oh ark
Insurance Co_nany 1tl'rtne
Policy#or Skinns.hoc.#-- ragorDa"-e. f //
Io`Sao..g de-toe 2 Y f Cif s c •.c'1 3 1 ofty,s,atemp f kc1141,1ca / ai4
hath a copy tf MA1vockers' co.'agensrbon golieT dent-peon page (slowing tae hthey nre-her noes rtsatan date)_
2elueto save tutorage as tegthnd,mae-Secia>2A oiedOL z 152 caziead o ';ie=tacit c, vd-alp .. __a
.Me hys tos1:=00 ".00 &moi onee-ye;_. amptisoinstrc, as well as c_v:1 pmMaca mle to=..a STD w O tk_0_i'C ar re hne
of p io.l"i50.OD oc.,mends the violator. 3a adrst4 thaaaaoo -su streteranatercass bt ti-a -d _win^O C_=`,
svestigat was offfrt 1.1 for n r o coveragt ve 5cahon
--
7 da hcroby ct,egy xrdr h- •:0,,e Ad penaidce ofpegini, inert the in]ornicart±p-crden Moos is nue mod.co-g
Siena,are ea: Date a/0k�, 2
Phoce#: 4135341234 -
Official nee only Do not write in this can;to be compteasi by Pty, or town endo! -__,
.I Cu(y or io,wn'. _ Permit/License #
Issuing An`onty(Prole one). _
1 Board oiEeahtli 2.Tild'ngLeparl:eent 3. Ctty/Town Clerk 4.F1ec'sica Inspector o Pl maktk Inspector
Other
0
ntactpe:son. Phan=r:
-• The Commonwealth ofMassacleusetts
17Department of Industrial Accidents
" i 1 Congress Street,Suite 100
Boston,MA 02114-2017
< www.neass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organiratio&Individualg ECU FIWIEC#cA & arwc54ia4) swc—
Address: 3co Kln Ss bury sr , 3
City/State/Zip: (tiprcysiert m A Phone#: .-PO —(C)O '�139�
Are-you an employer?Check the appropriate box: Type of project(required):
Dal I lam a employer with employees(full and(or part-time).* 7. 9 New construction
2.9 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
arty eapacay.[No workerscom*insurance required.] s
3.01 am a homeowner doin ll workm if No workers'co surane d 9. ❑DemOlitlmn
ga yse [ top.in arngn,e ]'
an am a homeowner and will be hinng contractors to conduct all work on my property_ I will "lD❑ Building addition
ensure that all contractors either have workers compensation insurance or are sole I1.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5 I am a general contractor and I have hired the sub-contractors listed on to attached sheet.
These sub-contractors have employees and have workers insurance.'comp.i suncI 3.0Roof repairs
16.0 We are a corporation and its officers have exercised their richt of exemption per MGL C. Q.❑Oth¢r
152,§I(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box el must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
?Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and nate 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.
Insurance Company Name:III?/QV•t/Qpp(S to Cin% Di Ty C V 0,1- 4 i.En.f eA
Policy#or Self-ins.Lic.#: b N U p 7 ill 1-41q O k I Expiration Date: I O J (J,a., 11
lob Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to-secure coverage as required-under MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00
and/or one-year imprisonment,as wen as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 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,oains and penalties of peppily that the information provided above is true and correct.
Signature: } /, �v�= Date:
Phone#:
Official use only. Do not write in this area,to be completed by thy 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#:
ACoaoa CERTIFICATE OF LIABILITY INSURANCE DATE
(MWDDm )
11/03/2016
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 NAME Leandro Guimaraes
UNE:
UNIVERSAL INSURANCE AGENCY .np.ENo (509)752-99333 li IN%FAA Not:EMAIL
.
AD sS: leandro universalinsagenry com
374 BELMONT ST. INSURERMAFFGRDING COVERAGE RAID IS
- .-_
WORCESTER MA 01604 INSURER A: TRAVELERS INDEMNITY OF AMERICA 25666
INSURED __..
INSVRER B: __ _ •
ECU AMERICA CONSTRUCTION INC - _
JxSVRERt:
INSURER 0!
.a.. -_..... .
36 KINGSBURY STREET 3 INSURER El •
WORCESTER MA 01610 INSURER F:
COVERAGES CERTIFICATE NUMBER: 100206 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 REOUIREMENT,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 St PAID CLAIMS.
INSRY EXP
1BTYPE OF INSURANCE IINSp':5MVO- POLICY NUMBER I IMMIO IYVYY)11MWOY EFF CDIVYWI UNITS
COMMERCIAL GENERAL LIABILITY HCH OCCURRENCE 'S
DAMA(a21U ENTEO
._ CLAIMS-MADE OCCUR : _PREMISE51Ea-opyl_ren 1 j5
HIED EXPIMv onepmmnl S _
i N/A i PERSONAL&ADV INJURY s
DENY AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE 'Is
POLICY c
PRO
l'CT •__ LOC PRODUCTS{OMPIOP AGO 15
OTHER. j : 5
AUTOMOBILE UABILITY COMBINED SINGLE LIMIT y
(Ea awUenU
ANY AUTO BODILY INJURY(Per person) ',S
— ALL OWNED SCHEDULED •_S
AUTOS _-...AUTOS N/A ,BODILY INJURY(Per sco ani)
NON-OWNED PROPERTY DAMAGE
5
MIRED AUTOSAUTOS Ver&Went)•
5
UMBRELLA LIAR _OCCUR EACH OCCURRENCE __ I S
EXCESS LIAR _ - CLkIMSiMOE N/A AGGREGATE
DEO RETENTIONS 5
WORKERS COMPENSATION x PEATUTE 1 /ETH
AND EMPLOYERS LIABILITYI - -
Y OPRETORPARTNERIEXECUTIVE Ylx EL EACH ACCIDENT 5 1.000,000
A OFFCERrMEMBEREXCLUDED+ WA WA I WA 6HUB1H74194816 10/22/2016110/22/2017
(Mandatory in NH) Et DISEASE•EA EMPLOYEE 5 1,000,000
II yes.describe under
DtSCscriRIP➢ON OF OPERATIONS Below EL DISEASE•POLICY LIMIT S 1,000,000
NIA SII ,
•
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORN 101, setts al employees
only. ,mey be t to EnIf dorsement
apace Is rtyulm0l
Workers Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no authorization isgiven 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.masagovgwcirworkers-compensation/investigationst
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
SEXTON ROOFING INC ACCORDANCE WITH THE POLICY PROVISIONS.
102 PINE ST PO BOX 6327 AUTNONZED REPRESENTATIVE
HOLYOKE MA 01041 Daniel M.Crowley,CPCU,Vice President-Residual Market-WCRIBMA
019B8-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
/ +9 SEXTO-2 OP ID: ER
toccata' CERTIFICATE OF LIABILITY INSURANCE oaTEIMMmD
I...----- 0710112016
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 EY 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 policylies) 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
i certificate holder in lieu of such endorsement(s).
RtI<xwCER CONTACT Eric Dembinski
Ormsby Insurance Agency,Inc. ` none PATE
698 Westfield St PO Box 78 INC No Ent (ASC.(AIC.Nnr 413 737-0647
West Springfield,MA 01090 E,MA'L
Eric Dembinske ADDRESS
INSVRERRI AFFORDING COVERAGE NAIL i
FINSEIRER A.AtlanticCasualty
C25IIdlIns,Co.
waif= Sexton
e on Roofing&Siding,ine, riSURER B.:Quincy Mutual Fire insurance (55057
Box 6327
Holyoke, MA 01041 INSURER C'INSURERC.
INSURER
.'INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
IINDICATED. NS"HVIT4STANDINC'i ANY REQUIREMENT,TERM OR CONDITION OP ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
-- MAY 3E ISSUED OR MAY PERT.IIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SLIEJECT TO ALL THE TERMS,
EXC:U �AE
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Everett Sexton ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
Eric Dembinske
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