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23A-250 191 NONOTUCK ST BP-2019-0033 GIS#: COMMONWEALTH OF MASSACHUSETTS MW-.Block:23A-250 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeorv-REPLACEMENT DOOR BUILDING PERMIT Permit# BP-2019-0033 Project# JS-2019-000045 Est.Cost: $18210.00 Fee: $118.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group JAILYN GONZALEZ 97254 Lot Size(sa ft.): 11891.88 Owner. COSTELLO ALISON Zonine: URB(100)/ Applicant: JAILYN GONZALEZ AT. 191 NONOTUCK ST Applicant Address: Phone: Insurance: 44 BEEBE RD (413) 455-9944 n WC MONSONMA01057 ISSUED ON.-719/2018 0:00.00 TO PERFORM THE FOLLOWING WORK:REPLACE FRONT DOORS, PAINT OUTSIDE & INSIDE TRIM 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 7/9/2018 0:00:00 $118.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2019-0033 APPLICANT/CONTACT PERSON JAILYN GONZALEZ ADDRESS/PHONE 44 BEEBE RD MONSON (413)455-9944 0 PROPERTY LOCATION 191 NONOTUCK ST MAP 23A PARCEL 250 001 ZONE URB(100) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid TvveofConstruction: REPLACE FRONT DOORS,PAFRTClUTSIDE&INSIDE TRIM New Construction Non Structural interior renovations Addition to Existine A cessory Structure Buildine Plans Included' Owner/Statement or License 97254 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF {1KMATION PRESENTED: _Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project. Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance- Received&Recorded at Registry of Deeds Proof Enclosed _Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Weil Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay lenaffire of Building OffiP Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. 7JU�L7 vu2 2018 DEPT OF BUILDING I NSPECTI Department use only City Of orthaDIWAMPION,MA 01060 P., of pauni Building Department Curb CutlDrlvewzy,Permit L 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availabiliry Northampton, MA 01060 Two Sets of Structural Plans ��•.� phone 413-587-1240 Fax 413-587-1272 Plot/Ske 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 Map A Lot 2-50 Unit Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 On.,of Record: _ _:1iIIk. Name P' t� Cunent Mailing Address. Telephone Signature 2.2 Authorized Agent: Namte nt) ` Current Met,Addre,v, � � dfzl tilf'i Sig Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only - completed by permitapplicant 1. Building 1 .- (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 4 5. Fire Protection 4 6. Total=(1 +2+3+q+5) S, ,'i Ill C Check Number This Section For Official Use Only Date Building Permit Number: Issued Signatu Building Comm er1Inspemr of Buildings Data Section 4. ZONING Alt Information burst Be Completed.Permit Can Be Denied one To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Depamusb t Lot Size - Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage Open Space Footage (L,t area minus bldg&raved arkin #of Parking Spaces Fill: volume&location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O 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 O , Date Issued: C. Do any signs exist on the property? YES O 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 disturo(clearing,grading,excavation,or filling)over t aae or is it part of a common plan that will disturb over 1 acre? VES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alto tion(s) ❑ Roofing EJ0r Doors Accessory Bldg. ❑ DempliUon ❑ New Signs [0] Decks [0 Siding[0] Other 10] Brief Description of Proposed Workar,. I Alteration of existing bedroom_Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet fia.If New house and or addition to existing housing, complete the following: a. Use of building:One Family Two Family Other If. 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 Woo istoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction 1. Is construction within 100 R.of we0ands? Yes No. Is construction within 100 yr. floodplain_Yes No j. Depth of basement or cellar floor below finished grade k Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank_ CityServer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, I��I r."'N as Owner of the subject property hereby authonze �. '(dw, ';� �: to act on m��ehalf,in all alters relative to ork authorized by this building permit applicabun C66�! -1 'b``S Signature of O er Date I, , ' l.' '-`� `�� as Owner/Authorized Aggent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge andhelief. Signed under the pains and penalties of perjury. re of er(Agent Data SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not App lica ble ❑ Name of License Holder ,I �`:•�,� r !=i�'� � 1��.=t�� License Number ,),-� , Y;_l, o-. ..1 'I�u ��Cl` I•I �i I ��'> , �� ') IJv )_'. ss Expiration Date 9ign5t Telephone 9.Registered Home Improvement Contractor, Not Applicable ❑ ,.r- h ,tl'_ , iu , a Y lite .IW6) Company Name Registration Number Address Expiration Date . .r:M� 'l�•C•. Telephone 'tl SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT)ill C.152, 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...... ❑ City of Northampton Massachusetts M1is srBQr pEPaRTNENT OF BUILDING INSPECTIONS �i1oq�l� 312 Win Scree[ • Mwicipal Building C� \," aozfdemp[on, IU 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction,alteration, renovation,repair, modernization,conversion, improvement,removal, denwlition, or construction of an addition to any pre-existing owner-occupied building Containing at least one but not mors than four dwelling units....orto structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered TypeofWork: YQoId_� ce &J/. P00t Est.Cost Address of Work: IY/ ,(.rI n,ly-A d . Flyren" , Mb J Date of Permit Application: UIN 5 D1-7 1 hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): Job under S 1,000.00 _Owner obtaining own permit(explain): _Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: 7 .5,o1 JCPt It.✓ 6.C),2Gi e-2 \ ) SCI.-- 15holz Date Com for Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton .rff Massachusetts OWAR�212 Mains OF BUILDING al Building n 212 Main Street • NuNA 01l BOilaing \. No¢tanmpCon' IA 01060 Massachusetts Residential Building Code Section I IO.R5.1.2 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. Section I IO.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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. City of Northampton ' rr Massachusetts D212 Heins OF BUILDING INS Building NS 212 Hain Street •Nuri 01 euilding NorNamptan, IA 01060 Debris 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. The debris from construction work being performed at: (Please print house number and street name) Is to be disposed of at: Oesk S�rrr,til,e�d\rnnc -A-1 a �ol95aw Ave U -s&rj ' r"l9 (Please prim i Le and location of facility) Or will be disposed of in a dumpsler onsite rented or leased from: (Company Name and Address) ignatu f Permit"Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gouldia IV\Iarkero'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant l f tiPlease Print Legibly Name(BromecslorganinatisomIndividual): ,�u' i�, 11 A V' ;' `. 10 AI rig Address: 'I-lkl �,er .s.1 City/State/Zip: 1v10-,xl ., T` i'. CIG' ; Phone#: I> Are you an employer?Check the appropriate bon Type of project(required): I:®Iamaemplcymwith----Lemployeso(full and/or part-time) 7. ❑New construction 2.❑lam.,mc pmpfinmmpmnership and have no employees working for me in g. ❑Remodeling any capacity.[No workers wmpinserence ma,mocdd .❑l am a homeowner thin nweekm If No wolwrs'mm 'ed]' 9. El Demolition 3 ga myself I p.imuance mu�lr 4,11 Tama homeownerand will he hiring contremom to conduct all work on my Xopeny. lwm 10❑Building addition nese Thin all chnlracars either have wnrkm eompensaliormccmermare axle 11.❑Electrical repairs or additions pmpneton with no employees. 12.E]Plumbing repairs or additions 5,M 1 am a a..]comeacmr and 1 have hired the sab-chntaclors listed on the nmched.wel. 13 QRoof repaus Twae sunt-contmcmrs Mve employes and have wohers camp.in 6.❑We are a wrynmbon and is officers have excuiscl then right of oxcmpdov per MGLc 14.©O[he[ I \i ` 152,§I(4),and we have no employees.Mo wulara wmp.issu anw required] 'Any tradition mat checks tax 91 most also fill out the section below showing their workers wmpwsatam policy inf.-60.. I Homeowners who submit this affidavit indicting they are doing all want and then hire huaide comermors must subndl a new allow,hldiumm,such, tC.nbacmrs mat check this box must mostrd as additional sheet show,.,me name of the sub-contractors and sate whether or not those slides have employees Ifthe sot-contactors have employees,they must pmvidc Meir wohersnmR policy tiomM. I man employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: s 'S. 1� Policy got Self-ins LIc #. �c \ - Expiration Date: V F l C ]ob Site Address: i'l City/State/Zip: ��;,< +i''i (afi:C Attach a copy of the workers'compensation polity declaration page(showing the policy number and expiration date). Failure to secure coverage as required"der 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. / her certify under mepaim andpenaldes ofperjuty that the informadonprovided above is true and correct Sdo l �' 114 i li; i Dale' Plany,g. _'t,11'_ "�t• 4 Olimial use only. Do not wile in this area,to be completed by city or town oJTciaf 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as".-every person in the service of another under any contract ofhire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee ofar individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,contraction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)stales"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authon ty." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-counactor(s)name(s),addrexacs)and phone numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. Ban LLC or LLP does have employees,a policy is required. Be advised that this affidavit may he submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also he sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permiUlicense number which will be used as a reference number. In addition,an applicant that must submit multiple pernit/licemse applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit ism file for future permits or licenses. A new affidavit most be filled out each year. Where a home owner or citizen is obtaining a license or permit net related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia ® Commonwealth of 'Jassachusetts Orvison of Pro]essional L¢e nsure Board of Building Regulations and Standards CS-097254 Expires. 04/292020 JAILYN GONZALEZ 44 BEEBE RD MONSON MA 010557 CI`Q- �7 Commissioner Once of ConsumerAt6irs&Bm]eeu Regelafion License or registration valid for individual use only i NOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: x Registration: 151692 Type: Office of Consumer Affairs and Business Regulation Expiration: 8/21/2018 DBA 10 Park Plaaa-Suit.5170 Bond.,MA 02116 JR CONSTRUCTION COMPANY JAILYN ROSARIO 44 BEEBE RD MONSON,MA01057 Undersecretary Not valid without signature ACORH CERTIFICATE OF LIABILITY INSURANCE ;AW2018 ' III I 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:M the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. N SUBROGATION IS WAIVED,sublect 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 Ileo of such endorsement(s). PRODUCER 01016-001 bp1RpXEm RG Neylon Insurance Agency,Inc. WC Ila asa: (413)467-9133 fes,«>; (413)467-9808 PO Box 1210aas Granby,MA 01093 - - - ------ - NSURERE)AEF _pIBS COVIMGE - SAID, INSURER A. Atlantic Charter Insumnce Company VDAC. 44326 INSURED INSURER B: Jalyn Gomalez JR Conebuctbn INSURER L: 44 Beebe Read INSURER D: Monson,MA 01057 - - IMRSURE - COVERAGES CERTIFICATE NUMBER: REWSION 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 MAV 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 p�CLAIMS. p IN TYPE OFINSUMNLE will - - POQCYNUMBEN ).(1e40pIYYTYI LIMITS -GENERAL LUSHLY' _B . - Cq.T1ERCIPL GFNEP4 HPRllIiY PPD EM SESIEi MVOxM E CUUMSNADE IX'AUR MED EXP IAM ore renes) E - PERSONAL A ADV INEURY -6 -....__ - GENERPI AOGREGaTE E GENT AGGREWTF ILITLpIMIT APPLIES PEO. PRODUCTS-COMP,OP AGO 'E -. PULLY uE6 LW AUTOWBILE LIABILITY CONFINED SINGI£LIMIT f A.0soo ANY ALTO WEILYI NNRY(Pa lemn) f ALLOWLT.NED SCHEDAUTV,ULED WpILYIWUflYIPw.lPROPERLY 'f LINE.AUTOS Al. IIP&YMWNAMAGE f UMBIIELLA LIAB 1 OCLUP 'I EACH OCLURRENCE b EXCESS LIAR HCl E.ADEI AGGREGATE E DED REItNT.f Wi S WHR99M x TOMF�G Tn1�r51 ICU A ANYPPOPRIETORPPRTN IECURN YYN «I" WCvOIlSI 3 Bn201T 8112018 I EACH ACCI.ENT f 1Do,Bg0.00 alessessnMENABNEJ)11 EMCLU POIICY Covenage State:MA E.L DISEASE EA EwLOYEE f 100,000.00 II ryryyy�� 9��y9 EL.DIS EASE POLICY LIMIT E 5DO000.00 O�XIPTICNOE.V.PEMTIONS Mow The Workers cmnpenaatlon policy does not provide coverage for Jailyn R GonzMez _. _. _. oESLmPMM as oPEPAno16 i LOLaTM11lS i vEXCLF31AnsY,ACtliD ire.AbtllbN IbnsFA YJe4ub.x mort yNa Is rtyuxe4) CERTIFICATE HOLDER CANCELLATION A50n COSINIO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 191 NOnOtYek SiraBt BEFORE THE EXPIRATION DATE THEREOF THE ISSUING COMPANY Florence,Ma 01062 WALL ENDEAVOR TO MAIL NOTICE WALL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AVnpNEED REPRERFMATVE � �S AC"Ra CERTIFICATE OF LIABILITY INSURANCE ° TE1MMDn YYY, 0]1022016 `' 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 ODES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:M the earNllcate holder is an ADDITIONAL INSURED,the policy(ies)..at m endorsed. H SUBROGATION IS WANED, RUID. t to the terms and condltlons of the policy,certain policies may raqulre an endorsement. A statement on this Certificate does not confer dght5 to the certificate holder In IIeD of such endorsement(s). PRODUCER 01016-001 UPI" RG Neylon Insurance Agency.Inc. _E[6:..(<13)46T-9133 (QA.xe.: (413146]-9806 PO Boz 1220 $; Granby,MA 01033 -- - - - - NSUREFRON h,CharterI MMINGC4VERAGE x326 INSURER A: A11arNc Charter Insurance Compam/ VDAC 44326 INSURED INSURER a: JS I,Gonzabz - JR COmructlan INSURER c: 44 BBBEB Road INSURER D: Monson,MA 01057 INSURER E: COVERAGES CERTIFICATE NUMBER: TENSION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE PONOIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, rySEXCLUSIONS AND CONDITIONS OF SUCH POLICIES SSgLLIIMITS SHOWN MAY HAVE BEEN REDUCEDp � yB�Y PAID pCII-AIIMM ES' ILTR. _ INBR WVD' (NWDOA'YYYL IMYDD%rTLLI. LIMTS TYPM E OF SURINLE POLICY HUMBER GENERAL LIA&4RY EACH OCCURRENCE S CWMERCIALGENERPILA°IUTY PRNEM SE$(6EOSUEn¢M¢) E IC..MAN E - OCCUR MEDEXPIAmora PPK^) f. . PERSGL4 AADV IWURY S GENERAL AGGREGATE E GEN'L AGGREGATE LIMIT APPUIC5PEP: PRODUCTS-COMPiOPAGG E POLICY PRO, LW 3VTOWJBILE LIA&Iltt COMBINED SINGLE LIMIT -E (CX.Q ANYAUTO EOUILYIWURY(Pw,) E AALLOWNED $dEW1E0 BODILYIWURY(Pxx�M) E HIRED AUTOS 'M1 ALS NOED PROPERTY DAMAGE -E Gros e xoxmS E UURELLAOABOLWfl EACN OCCURRENCE E COUNSELLLB CLAIMS MADE AGGREGATE $ LED TCBI E E YSPd' Sgt lAl'3!4 x_'''Ydf�+`UEPFs. OV A q�yppOpp�FTpryppqTNEryEI{ECUTNEYIN A WCV011g1664 611201E WIM019 E.L.EACH ACCIDENT E -HEDD0D-00 OEFICERRAEMBEP E%CLUOEDP Y 'i"I IMEnMory In NXl ' Policy CoverageELOISFASE-EAEMPLOYEE E ,e0,000A0 Slate:MA ELmsFASE-Poucv unn a 5e0,0a0.00 .worlass c mperRATIGnB Dow. Thg workers compensation policy dcea not provide wvemge for Jallyn R Gonzalez DEBCWPn3n ox of CPEMna16r LOCON5 lVEHICLES( AnMI ACOR01D1,AWVMp P Nx Saasoa,Nmare a is rtqulrcLl CERTIFICATE HOLDER CANCELLATION Alison C°StellO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 191 NOnotuck Street BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY Florence,MA 01062 WILL ENDEAVOR TO MAIL NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATVE /, �L