29-232 (5) 118 SPRUCE HILL AVE BP-2017-1100
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:eloek:29-232 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 it BP-2017-1100
Project it JS-2017-001875
Est. Cost: S8600.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
use Group: SEXTON ROOFING CO 99689
Lot Sae(sq. ft.): 16030.08 Owner: FISCHER CALEB
zoning: Applicant: SEXTON ROOFING CO
AT: 118 SPRUCE HILL AVE
Applicant Address: Phone: Insurance:
P O BOX 6327 (413) 534-1234 WC
H O LYO KE MA01041 ISSUED ON:4/3/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE & REPLACE EXISTING SHINGLE
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 St Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: OI: 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 4/3/20170:00:00 $40.00
212 Main Street. Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
• fa
Department use only
_ - City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
r 212 Main Street Sewer/Septic Availability
APR _ 3 it, Room 100 Water/Well Availability
, I - - phone , Northampton, MA 01060 Two Sets of Structural Plans
i 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISHtA ONE OR TWO FAMILY DWELLING
V/
SECTION 1 -SITE INFORMATION /7-/I 0v
1.1 Property Address: This section to be completed by office
ocR
S !^
v/ /1// Map Lot Unit
//e 6 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
(4 b'b r, ,,_ Pr //i Ste ace t.47/ ,-be %s*
Na (Print) CurrentMailing Address:
I f 4 ,�e� Telephone
- s� - 36u/
K �q Telephone
Signature
2. thorizetl ent:
1./
LS)
_.1- =___ i� e� 63� � /rolyak �a 6/01/4
Name(Print) Current Mailing Address:
S`3viz3 '.1
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) U
5. Fire Protection O 0 ,® _
Q
6. Total=(1 +2+3+4+5) / 00Check Number �Q Cr(J
This Section For Official Use Only
te
Budding Permit Number: Issu
// / Issued:
Signature: s//'-/ 7-3-/7
c uilding Commissioner/Inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing 2}-
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[CO Other[0]
Brief Description of Proposed �� / p
Work: rL PpryOve 14,-).,,/ /47/! Pt," en, Sdr/..r,4 teCt73C
Alteration of existing bedroom Yes No Adding new bedroom 7 Yes -.----No
Attached Narrative Renovating unfinished basement Yes —No
Plans Attached Roll -Sheet
se. 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 i : I y unit - Number of Bathrooms
c. Is there ag. -ge attached?
d. Proposed Square .•. ..e of new construction. Dimensions
e. Number of stories?
f. Method of heating? S Fireplaces or Woodstoves Number of each
g. Energy Conservation Compli-. Ma .eck Energy Compliance form attached?
h. Type of construction
i. Is constructio : thin 100 ft.of wetlands? Yes No. Is construction wit' - 100 yr. floodplain Yes No
j. Depth of .asement 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, 0,4 /eh f 3CJ7 er ,as Owner of the subject
property 4 ,(J �/' (\�' py
hereby authorize V-P-�( /i/ {� c( t'79 J J)o(j--[of _J--!'I/C
to a on my behalf, in all matters relative to work authorize by this building pe it application.
l i'/RCT' A ?"r"(
Signature of Owner ,,((77 pDate
I,er )L-f0✓ (�e X.7ow V°-e �^i 4 �-t !'Z7 7 7/C ,as Owner/Authorized
Agent hereby declare 444 at 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.
I:6(re I 2<aY4)->'
Print Name .15e,„.... )
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: c��• ,/ Not Applicable 0
Name of License Holder:/ 4 vit Tr C t S File/L1 99‘,/ 9
License Number
"a )66
X .- ‘,1 -7 �c �Yo vI/✓� r�toyi /a g i �
Address j) Expiration Date
Signature Telephone
9. istered Home Imqwovement Co or Not Applicable 0
k -6 /9�Jt ll d irtJt Pey/ // o)3 9
C9npane Namedl.
� /✓ / Registration Number
( `._)— FSK (._ -3 ,s '7 Fin (L/O ti A/fr3 0/0Y/ � s�
Address / Expi lion Date
Telephone 55Y/237(
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 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 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 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: //9 5;?&c c
The debris will be transported by: '.,0/e4 D'afro srt-
The debris will be received by: am f/cer Of vas-4-c_
Building permit number:
Name of Permit Applicant
Date 3/2$1/49 Signature of Permit Applicant
ma/- --
SEXTON ROOFING AND SIDING INC
cows wvennerwlflnacow
PKO : N. Ai MISTER
Sellins the Smrdanl Lair+"
same moat
to P.O.Box 6327
p.413.534.1234 Holyoke, MA 01041
E 413339.9906
MA HIC N 118239
SerglirOdnialMiilaik9M
SUBMTIT®TO Caleb Fischer PHONE 206-356-3041 I DATE 12$16
STREET 1a Spnr MI An IOC TIAIa
CITY.STATVSIP Northampton Ma )OB LOCATION
SEXTON ROOFING HEREBY SOTMftnSPCCAVICATIQN$AND ESTIMATES FOR:
1) Strip and remove existing shingles and dispose of in proper landfill.
2) Inspect roofing deck and replace as needed (5275 per sqR)
3) Install new metal edging to rakes and eaves of roof.(87 . ,,
4) buten Ice and water shield on eaves(6'),around looney,rent stat.skylight.In venom and a
Intersecting roofs.
5) Install 815 synthetic roofing felt on remainder of root
6) Install new flanges over existing vent sada,new bath exhaust damper vents. +grapy e c LAIL -the
7) Install starter shingles on eaves and rales of roof. .G'
nw
8) Rehash diley with new lead t-i
9) Install 11(0 Arddtemnal style roofing shingles as per manufacturers'spedAcatlaot
10)Insall new cap over ridge vent and 1 new monomer.
11)Supply manufaatues lifetime warranty and SRC 25 yr,workmanship warranty.
ALL CONTRACTS INSURED WITH PROPERTY LIABILITY AND WOWOIAIECCOI46ATSDN.
we einem.hereby to furnish material and labor-complete In accordance with the above specifications,for the amount of
Eight Thousand Six Hundred Dollars($8,600.00)Pe ant w be made as foil um in full upon completion
Al MatrIa*Dann b p marc.d m h m getlhd Amon Ano aompletedltndea b• Aatiwl:ad
deMuNleemaout raordlNto n. .'maridard na
tura coonyahmtlonor
only. on iearne o en eel specification,uIcomian rwa dor gerill be maws
0. awnte mse.e.ren wene.®wan earn =Moots
NM goo
beyond we nn ol. ra mviryfor upon dribs, during c or Eekye Note: (1a pmyssW maybe Hthdrawn by ort if npl accepted
neour control. Not rwpoml6k for water Nm*aM apS llek karma within(14)days.
One m ray ref Wmltle lel hem kr mllyrym.ot aM rppaoMe logra0.
beponen of Piqued The above prices,specifications and
conditions are satlsfacwry and are hereby accepted You are Signature
authorized to the work as specified. Payment will be made as
outlined above. Signature
Dare of Acceptance.
kot
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The Commonwealth of Massachusetts
ori- Department of industrial Accidents
t:.=. � --t'9 1 Congress Sheet,Suite 100
a-.;
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organvatiott ndividua0: ECU Rw1Eucst ( on -tic /dN Zan:-
Address: 3(0 Kin Ss burs, sT , 3
City/State/Zip: (u orcasiert Ys'IOv Phone#: 403—600 --1 39
Are you an employer?Check the appropriate box:
Type of project(required):
I.121am a employer with S employees(full and/or part-time) 7. ❑New construction
2.01 am a sole proprietor or partnership and have no employees working for mc in g. ['Remodeling
any capacity.[No workers comp.insurance replied.] s
9. ❑Demolition
3.01 am a homeowner doing all work myself [No workers comp.insurancerequired.]
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 0 Building addition
re that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietorspwith no employees. 12.0 Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. I 3 3voof repairs
These subcontractors have employeesand have workers'comp.i surance. LTZ
6.0We are corporation and its officers have exercised their right of exemption per MGL a l4.QOther
152.§1(4),and we have no employees.[No workers'comp.insurance required.]
`Any applicant that checks box ql must also fill out the section below showing their workers'compensation policy information.
5 Homeowners who submit this affidavit indicating they arc 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 die subcontractors and state whether or not those entities have
employees. if the sub-contractors have employees,they must provide their workers comp.policy number.
I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:j2Avetepp1S 'Z1 f� cm' ut rH to Of- 4 Vela(64
Co
Policy#or Self-ins.Lie.#: rN U g 7 d/7 U ) 9 Li tk 1 C Expiration Date: 0 I )a-i i 1
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$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.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 gins and penalties ofperjury that the information provided above is true and correct.
Signature: !-✓=F / fawDate:
Phone#:
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):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone 4:
ACCORD, CERTIFICATE OF LIABILITY INSURANCE DATE{MINDDNY n
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(tes)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 Leandro Guimaraes
UNIVERSAL INSURANCE AGENCY PRONE EN. 1508)752-99333 FAX
IL
ADDRESS leandro@universalinsagency.com
374 BELMONT ST. INSURER(5)AFFORDING COVERAGE NAlC0
A: _ : _._.
WORCESTER MA 01604 INSURER TRAVELERS INDEMNITY CO OF AMERICA _ 25666
INSURED wsLRERS:
ECU AMERICA CONSTRUCTION INC INSURERC-.
INSURER O'. _ •
36 KINGSBURY STREET 3
INSURER E' •
WORCESTER MA 01610 INSURER F:
COVERAGES CERTIFICATE NUMBER: 100206 REVISION NUMBER:
THIS 15 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.
IPOLJ
Lm INSURANCENWMD OF D. POLICY NUMBER INtVCYEFF.ic EF I-MMIOOeduceYEX?EI UNITS
COMMERCIAL GENERALLJABILITY (EACH OCCURRENCE i S
CGIMSM1MDE OCCUR DAMAGE Tu RENTED - - -
__.. . _. PREMISEB lea aqun¢nceI �,S.
MED EXP(NW one Per5Onl5
N/A " r PERSONAL.ADV INJURY IS
GEN'L AGGREGATE LIMIT APPLIES PER. Ir GENERAL AGGREGATE 5__
POLICY JRO-
ECT LOC PRODUCTS-COMP/OP AGG '.5 _
OTHER 1 I $
AUTOMOBILE UABILRY COMBINEDIBINCIE OMIT IS
ANY AUTO • BODILY INSJRY‘Per person) E.
CANNEDSCHEDULED
ALL
_ AUTOS NA BODILY INJURY Per accident) S
NONOWNED ��'PROPERTY DAMAGE S_ --- - -
HIRED AUTOS , _AUTOS yPereaKKnll
5
UMBRELLALIAB __ OCCUR I EACH OCCURRENCE I $
EXCESS LIAR CLAMS#LADE I I N/A AGGREGATE S
OW RETEN90N4 S
WORKERS COMPENSATION I I XI PERryTE-t 41-1.I
AND EMPLOYERS LIABILITY YIN i - - - --
A OFrCER/RMREMBER EXCLUDED',EcmrvE WA WAI NIA 6HUB7H74194816 110/22/2016110/22/201]rLFwCH ACCIDENT $ 1000.000
(Mandatory In Nm i EL DISEASE-EA EMPLOYEE $ 1,000,000 _
ludesnhe uMer
SLRIPTION OF OPERATIONS below IEC DISEASE.POLICY LIMIT ' $ 1,000,000
' •
N/A ISI
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES IACORD m1,Aentional Renting Schedule,may be aaached It more apace Is meuireel
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B.no authorisation 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 cefilcate 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 cenificale of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.gov/Iwd/workers-compensationfinvestigationsl.
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 80X 6327 AUTNOWED REPRESENTAIVE
HOLYOKE MA 01041 DaNeI M.Crowley,CPCU.Vice President-Residual Market-WCRIBMA
0 1 903-2 014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
•
/..." SEXTO-2 OP ID: ER
ACORn CERTIFICATE OF LIABILITY INSURANCE DATE IMMmDn'YY1'I
�� 07/01/2016
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 EY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSINTUTE 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 endorsementlei.
PRODUCER I NAME°Ci Eric Dembinske
Ormsby insurance Agency,Inc. PNoe� 413E737-0300 `'x 413.'
698 St PO Box [51Ac No.ENTI F .NOT r 37-55617
West Springfield,MA 01090 E-MAIL
Eric Dembinske ADDRESS'
INSUP.ERISI ARKORDING COVERAGE NAICk
INSURER A-Atlantic Casualty Ins.Co.
IND RE° Sexton Roofing&Siding, Inc. s ae:Quincy Mutual Fire Insurance '15067
PO Box 6327
Holyoke, MA 01041 SURER c
LIwsURER 0 I
YINSURER'
1INSURER P, ._ 1
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
'H,5 IS TO CERLIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN issuer)TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED NAl HSTANDINU ANY REQUIREMENT, TERM OR CONDITION Or ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH HIS'
CERTIFICATE IFICA, MAY BE SSUED OR MAY PERTAiR THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT O ALL THE TERMS,
EXCLUSIONS ANS CONDITIONS OA SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
t'ERI min OF INSURANCE AaotnubR DLI Fp ' POUCYe
tl 4J lava Mltrcr HUMBER Fratorrerrn reavorarytat LIMITS
A X ,COMMERCIAL GENERAL Lcrn;UTY I i - EACS OCCURRENCE I s 1,000,0 xl
C_Aly ,awe IX] OCCUR I i01GLO0219990010612512015 06/25/2017 p¢Emrsps r=eocUEeE„ I s 100,000
-1MED e=cant of peaol Is
65,000
I I PERSONAL.5INJURY Is 1,000,0055
'BENI AGISRESAGE LM.T APPLIES PER I GENERAL AGGREGATE 's 2,000,004.
I Po In, .,3o- 1 LOC I PRODUCTS OMP/OP AGG 15 2,000,00i
OTHER
_
' AUTOMOBILE LIABILITY •
rSM6INEC smni.E LIMIT rr $ 1,000,000
B i ' Loy Lyco IAFV205561 05/15/2016 05/1512017.BODILY INJURiPer De 5
—A Tas 1 ADE DA/MED LINO O IDC ' I SROL JJRv . f— 15
X N RE I AUTOS'OS I X 1 ""D I . t euaP e V SAM E 15
'iI
L_ UMaREv_AUAS I` R45LIRI EACH OCCURRENCE I s .^
JSSLtAS 1 it CLAIMS-ANWE1
1 AGGREGATE r 5 ._
DEO. ' i RETENTION S ( j I S ..
!WORKERS COMPENSATION • I E ”" OTH
EMPLOYERS'LAB LTY IN 6AJ IER
PR R OL? _R X.. l' I' N A. I I E ACCIDENT $
IO ✓_ M4 R Ur- '
'IMMICILINEY PE NH. EL.DISEASE EA EMPLOYE
DESCRIPTION OI O _¢4 IJ1c hti0rr TEL DISEASE q.'PJY'_IMT
•
1
AsscswrioN Or OPERATIONS'LOCATIONS/VEHICLES I TARO 101,AcditicsAl R. ss SLIntiula may be zoernec limon space is rowl,ed) .......
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL 8E DELIVERED IN
Everett SextonACCORDANCE WAll THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Eric Dembinske
R1988-2014 ACORO CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
Cite ((r,i,i1/( ililir(/(IA (,/ n%(Li.i((cAuir(Ii
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: Corporation
Registration: 118239
SEXTON ROOFING &Siding Inc Expiration: 02/14/2019
P.O. Box 6327
Holyoke, MA 01041
Update Address and return card. Mark reason for change.
.. .... n ...____ n o...q...., n emn,nyment n Lnetge•a
® Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CSSL-099889
Corstiucr on Super :sor, Spec It; ea -"t
EVERETT
BOX 6321
H
OLVOK MA E MA 01041j
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1^_ej__,^• Expiration:
Commissioner 10/05/2017 ,