43-042 52 AUTUMN PR BP-2019.1216
GIs s: COMMONWEALTH OF MASSACHUSETTS
MU:Block:43 .042 CITY OF NORTHAMPTON
Lot;-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category ROOF BUILDING PERMIT
Permits BP-2019-1216
Proiects JS-2019-001969
Est.Cost $9000.00
Fe : S4Q.00 PERMISSION M HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group RCI ROOFING_ 074334
Lot Size(sa t): 15246 00 Owner., REARDON ELLEN D&JAN ANNE MARIE REARDON
zQninz A nlp icant.• RCI ROOFING
AT. 52 AUTUMN DR
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:4/3012019 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & 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 Foundation:
Driveway Final;
Final: Final;
Rough Frame:
Gas: , gt Ftrep4ce/Chimney:
Roughs 001 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 Sienstur
Ii eeTyne: Date Paid: Amount:
Building 4/30/10190:00;00 $40.00
212 Main Street,Phone(413)587.1240,Fax:(413)587.1272
Louis Hasbrouck—Building Commissioner
D CLM t-
City of North mpt
Building Dep me t .1 91)
212 Mein St Set
Room 10
Northampton, M 010 T�=NIt��,ln "c
phone 413-587-1240 Fa 41 58W` >-
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address T'h}la section tabe completed by office
5a A0y'Vln 0(kVe MapT? Lot_ OC -;2,
FiOr"Ce' ISA -Zone Overlay District
-Elm St.District _ CB DlstAct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
Owner of Record:
_ E12n VZzo'cdan 5Q AAjn,n pf IFI ictl I-no
Name(Print) Current Melling Address
11 �-1iil �5xm- �tmc
&I, (hl'brhod Telephone
Signature
2.2 Authorized Agent:
4 - i� C2 Rnn�ln� (o L1ne S4 Sal lri�11K1 01073
Name(Print) "-"' -- Cupent Mailingast —J
�413� 5a1 - 4`1'15
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted on, ermit matlicant
1. Building U, p i n o0c) (a)Building Permit Fee
2. Electrical O� (b)Estimated Total Cost of
_ Construction from 6
3. Plumbing Building Permit Fee
4. fAechanlcal(HVAC) 'rz
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number 7
This Section For Official Use Only
Dale
Building Permit Nu r. Issued:
Signature: 14 N-30 ���
Building Commission roinepector of Bulldr gs Date
S+hompson @ rcI roo-kn5 .com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signa [I7) Decks [q Siding[O) Other Im
Brief Description of Proposed III ,, 11
Work'. See Q'Ml C_�Pll
Alteration of existing bedroom_Yes_No Adding new bedroom_Yes No
Attached Narrative Renovating unfinished basement Yes __No
Plans Attached Roll -Sheet
ga. If.N ewm'haS?sftzafidCot=>SdHFYldif[o'?§zi6tinsailiousYn d:icom Dlete?th er-followina:
a. Use of building:One Family Twp 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 stoles?
f, Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance farm attached?
h. Type of construction
I, Is construction within 100 ft. of wetlands?^Yes _No. Is construction within 100 yr. floodplain_Yes_No
I. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes_No.
1. Septic Tank_ City Sewer_ Private well_ City water Supply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIESFORBUILDING PERMIT
I,_ C��tLf\ 1``0 AY IXvn as Owner of the subject
property � l� � �n
hereby authorize ]�T p+lYlY lYlq to act on my behalf,in all 1matters relative to w0 authorized by this building permit application.
sitnatureof Owner Date
I.
In SIC nPICIQ — IIy110�1 al� QCp>Y)-f- as OwnerlAuthorized
Agent hereby declare that the statements and information on the f0 Ding application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
TarK Odic le e'
Print Neme
O`{ -Q9 -19
Signature of OwnerlAgent Data
SECTION.8•CONSTRUCTION SERVICES
8.1 Licensed Construction Suoorvlsor: Not Applicable ❑
No..of License Holder: M(IrKCol,nle CS - O'1 '/3:3q
License Number
5li 6nW, E + o10a 05 - 03- a0a0
Mures Eryiratlon Date
I413) 5a7-4795
Signature Telephone
9 Renlstered Ktime�:�Im/+provement Contra 1=o Not Applicable ❑
Vj C Z I'1W1"I nC ( 1J� _ /a tod35
company Nam— a Registration Number
L + (35 - 05
Address T"� Expiraccn Date
Telephone 413-Ja7-4775
SECTION 18-WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M.O.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.
Signod Affidavit Attached Yes....... No...... ❑
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
wwn'.mass.goP/dla
9Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant I f tl p Please Print Legibly
Name (BusiaonakngennadoMndwidnal): R(',:[ K(lb O6 , LLP
Address: b L mi, Yoe+
CityjState/Zip: A 0109Phone#: b13 `Js, - 75
Are you an employer?Check the appropriate box: Type of project(required):
I.5dl em a cmployer with—15 _emplovece(full and/or pan-time).• 7, ❑New construction
1.❑Iemeaolepmprietm orpMnerahip and have no employees working formein g. ❑ Remodeling
anyovacity.[No wmkce camp, marvice required]
3.Om l sa homeowner doing all work myself.[No workers'comp.inmorearegnirecil t B. []Demolition
,❑1 am a homeowner and will be hiringcontractors to conduct all work on m 10❑Building addition
4
c Y property. 1 will
ensure that all contractors either have workes'wmpenserion insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.C]Plumbing repairs or additions
51 em a eneral contractor and I have hired me sub-conlrcto..listed can me attached sheet.
❑These .b-.nge,t.,a have employees and have workers'comp.insurance., 13.10toof repairs
6.❑We era a corporation end its officers have excaised their right of exemption per MGL c. 14.❑Other
152,§I(4),end we,have no employees.[No worker'comp.insurance required.]
•Ary applicant that checks box 9 must also fill out the section below showing their workers'compensation policy information.
f Homeowners,who moral this affidavit indicating they e,a doing all work and then hire outside contractor must submit a new affidavit indicating such,
iContrsetors that check this box must attached an additional sheet showing me name of the sub-aonbactors and state whether or not hose entities have
employees. If the sub-wmracton have employee,racy must provide Meir workers'comp.policy number.
I an,an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. n
Insurance Company Name:A T m ffirhdllZn.$Iyl'nnt0 U
Policy#or Self4ns.Lic.#: VS/C_f C)C)f n fl d alp. 7d d 1 R A Expiration Date: J0L x 0 19
Job SiveAddress: 5a ALrh mn On vy. City/Slate/Zip: Eli fe(i(QrjY]R O101aa
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 In it penalties of perjury that the information provided above is true and correct.
Sirmatuare
Dateo4 -Q9 -j9
Phone 4: 3� 5x7- V795
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#:
City of Northampton _
Masaachusetta
DEPARTMENT OF BUILDING INSPECTIONS
212 Mein Street a Municipal BuildingZ`
Northampton, MA 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, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Nate:If the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work: A041 na Est. Cost: qtqa,0
AddressofWork: 5a Aki-hnin cl ofIVP Flue u rMA
Date of Permit Application: I'r(Jtl � aq 3M
I hereby certify that:
Registration is not required for the following remon(s):
_Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
_Building not owner-occupied
_Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT. SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
01/ LL' 1 10135
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts
'x
DEPARTMENT or BUILDING INSPECTIONS
212 Main etuat •Municipal Buildingla �/ C
Northampton, MA 01060 �
x.71
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
5a %ut-rimn jor F(� rDnce
(Please print house number and street name)
Is to be disposed of at: —�
U)DS-{'OYn �i Cal ll'linC�ar FAr� �I'ti
(Please prin ame d location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
USA Nnr, lin and Leo<trltn
(Company N e and Address)
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
SCA1 O 2OM-05117
d�oncmmw�ml!/��eaar/veaeld
Ofilae 6 a Tuletlen
HOME
IMPROVEMENT
CONTRACTOR
TYPE:
Penn ershlP
ggg�BZ21' 05105/ 020
1�827$ �� 06106/2020
RCI ROOFING II I
4�3
•r� p°y Commonwealth of Massachuse113
MARK T.DEL //r Division of Professional6 LINE ST Licensors
SOUTHAMPTON,\\M�'Q102, C., Y' Board of Building Re66..ulations and Slaptlards
Undersecretary Cons�lµCtidr�ltNafarvisor
/f.
CS-074334 '+ SgPlres 05/03!2020
Registration valid
at for Indivdate. If found enly
tur
befare fConsumer Aair and
log MARK THOM,4 DEBI �•• J
ORice of Consumerreet- end Business Regulation 63 BRIGGS SL EET I'
Bostn,MAWashington211 Straet•Suite 710 EASTHAMPTO
Boston,MA 02113
Commissioners l,,*4—
Not valid without signature
O M0NWE—MR 0F'Mi
e e e a s l Pi�TTaR sx
HOME IMP V N, ONTRACTOR �s�te: �t
GILPSHEEfTIfylCs�TL W6RK
GLINi3`S•'L'� ISSW6 �+ a
, �1 FOLL01�i7NA SE
. SOTy14$AMPTO4,�*01073 R-UN frTED �p>
1 K T DELISLE
nr .. eao n. 31 dean a ExP„om° ' EAST
1GG SiN
HIC.0624741' (J 11/30/2019 � A07 e
SIGNED
1327
5y0 Obl2B/2020 � ;p
.�iT3 ft 8/ ?7 486498 -
10MM8NWE5:1 HS' 0FM`f'S A ET ARt'
�. a e a • a g a l ,
WORRK % .
ISSUES THE OLUONU, Elf
BUSINESB,
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M�(Y DELIS4 2 '
TROOPING P � rty�'
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80 � i� 08109I2019 � 242238 -
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A` ® CERTIFICATE OF LIABILITY INSURANCE OATEN
03HVDD
THIS CERTIFICATE IS ISSUED ASA 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 INSURERS),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder 13 an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder In lieu of such endorsement(S).
PRODUCER Michael R.Banas
NAME;
Banal IS picked PH NE I 413527.2700 AJc Ne: 413-527-0849
Insurance Agency AoOaEss: mb0Lb.`naslnsurance.com
63 Met.Street
Easthampton,MA 01027 INSURERS AFFORDING COVERAGE RAID
INSURERA: Admiral Insurance Co. 24856
INSURED INSURER B: Safety Insurance CO. 39454
RCI Roofing.LLP INSURER C: Admiral Insurance Co. 24856
6 Line Street INSURER o:
Southampton,MA 01073
INSURER E:
INBURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NA ASDABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDINGAYY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECTTO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT MALL THE TERMS,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR TYPI OF INSUMNC! AIY.QPOLICY NUMBER MM/DDM'YY MM/DDIWYY UNITS
�( COMMERCIgL OENEML WBIUTY EACH OCCURRENCE 5 1,000,0L
ClAIM3M10E O OCCUfl
PREMISES E 50,00
MED EXP E 5,00
A X CA00002096345 03/04/19 03/04/20 PERSONAL S ADV INJURY 15 1,000,00
GE N'LAGGREGATE LIMITAPPLIES PER: OENERPLAGGREGATE 3 2,000,00
POLICY❑X jECaT FLOC PRODUCTS-COMPIOPAGG $ 2,000,00
OTNER. S
AUTOMOBILE LIABILITYE 1,000,00
aiscaR
ANYAUTO BODILY INJURY(Per mmcn) E
BNED OWX SCHEDULED X 6207761 09/30/18 09/30/19 (Par wddmn E
ANED NLY AUTOS BODILY INJURY )
X HIRED X NON-OWNED AUTOS
AUTOS ONLY AUTOS ONLY Pw'.claenl
S
UMBRELLA UAB OCCUR EACH OCCURRENCE E 5,000,oO1
D EXCESS LAB CLAIMS-UADE X GX000000385.03 03/04/19 03/04/20 AGGREGATE 5 5,000,00(
OED I X I RETENTIONS 10,000 s
WORKERS COMPENSATION
AND EMPLOYERS'UABILITY YIN STA ER
ANY PROPRIETORIPARTNERIMCUTNE❑ MIA E.I.EACH ACCIDENT E
OFFICER,IAEMBER EXCLUDED?
(MantltlmYANN) E.L.DISEASE-EA EMPLOYEE E
n y;y e.ealea x
DFS..RIPTION OFwaOPERATIONS.I. ILL DISEASE-POLICY LIMIT 3
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101.Aatl Jamal R.m.M3 Sc;w ula.may be anchad 11 man space I.np1
ROOFING CONTRACTOR.
CERTIFICATE HOLDER CANCELLATION
®® J//s� THOULD E EXPIRATION
THE DATE BOVETHEREOF,
DESCRIBED POLICIES BE CANCELLED BEFORE
C®�� AA„OC RDANPEWIOTHTVEEPOLICYPROVISIONS BE DELIVERED IN
15 ACOFID CORPORATION. All rights reserved.
ACORDl5(2016/O3) The ACORD name and l000 are reDletarad mark.of Arron
AkI o' CERTIFICATE OF LIABILITY INSURANCE 0&19n01)
THIS CERTIFICATE 13 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 polloyfles) must be endorsed. If SUBROGATION IS WAIVED,subla::t to
the term.End..edition.of the policy,certain policies may require an endorsement. A statement on this certlficale does not confer rights to the
certlBcale holder In lieu of such endorsement a.
PRODOCE0. NCAMTN ACT Michael Banos
BANAS& FICKERT INSURANCE AGENCYCall Pnoxe413 527-2700 Fa xa
.Is v. al banasimurence.com
63 MAIN ST INSURER.AFFORDING COVlRAGE NAL.
EASTHAMPTON MA 01027 INSURERA: AIM MUTUAL INS CO 33758
INSURED INSURER a:
RCI ROOFING LLP IxauRER c:
IxaURERG:
6 LINE STREET meuRu e:
SOUTHAMPTON MA 010]3 INSURER F
COVERAGES CERTIFICATE NUMBER: 379588 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.
IXSR TYPEOFINSUMNCE POLICYNUMEEA al LY! MPOLICY. UNITS
COMMERCIAL GENERAL LIABILITY EAOHOCOURRENOE S
CUIMSMADE F7 OCCUR S
MED EXP S
NIA PEASON"ADVINJUAY $
GEN L AGGREGATE LIMITAPPUES PER: GENFJULAGGREGATE S
POLICY❑P.c' LOC PRODUCTS-COMPIOPAOO S
OTXER: S
AUTOMOBILELIHBILIr'! Tw N L S
ANYAUTO BODILY INJURY I mmman) S
M.1i0OWNED p OSVIEO NIA BODBYINIURY(Per soy S
HIREDAUT09 AIOSWNED PROPERLY DPMAOE S
S
UMBRELLAWB OCCUR EACNOCCURRENCE S
EXCESS UPS GIMME-MADE NIA
AGGREGATE a
EO I I RETENTION 3 S
WORKERS COMPENSATION x _ ATUIEO
ANDEMPLOYERS'LWILIry YIN
ANYPROPWETONPARTNERJE%ELUTIVE E.LEACHACGIDENT S 1,D00,000
A CFFICandEAHoryLl Bxj EXCLUDED? x1A NIA NIA VWC100602264]2018A 10/05/2018 10/05/2019 EIDISEASE-
11 m,ohmarm unCer EA EMPLOYEE S 1, ,
DESCRIPTIONO PERAnOm beloP EL DISEASE-POLICY UNIT S 1D6DBOWD000D
NIA
DESCRIPTION OF OPERA➢ONS I LOCATIONS I VEHICLES(ACORD IOL,Adeflamd Barnett SobSW,may buXaehas If mon space IS N,wmdl
WorkersCompensation benefits will be paid to Massachusetts emplayeas only.Pursuant M Endomement WC 20 03 06 B,no authorization is given to pery
claims for benefits to employees in slates other then Massachusetts if the insured hires,or has hired Mose employees outside of Massachusetts.
This Certificate of insurance shows Me policy In farce on the date that INS certificate was Issued(unless the expiration data on the above policy precedes the
issue date of thls entrails of Insurance). The status of MIs coverage can be monitored daily by accessing the Pmof of Coverage-Coverage VerificatlDn
Search tool at www.mass.govAwtllworkers-compensation/Investigations..
CERTIFICATE HOLDER CANCELLATION
Y SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERErr IN
Reference Copy ACCORDANCE WITHTHE POLICY PROVISIONS.
Reference Copy
AVTXOR¢EOgIPAEBEMATV!
Reference Copy CXf
Daniel M.CrgNpay,DPDO.Vice President—Residual Markel—WCRIBhIA
m 1988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
RGI. Roofing
6 Cine SL Estimate Date
Southampton,Ma.01073 q/q/2p1q
Phone(413)5274775
Fax(413)527-8469
Name/Address Job Location
Ellen Reardon
5'L Autumn Drive
Florence, MA 01062
Terms Rep
Chris
Description Total
Remove existing roofs. 9,000.00
Furnish&install aluminum drip edge,pipe flashings,chimney flashings(if needed)and step
flashings.
Furnish&install CertainTeed Winterguard ice&water barrier, 6 feet along eaves and 3 feet in
valleys.
Furnish and install synthetic underlayment over existing deck.
Fur:iish and install Lifetime CertainTeed Landmark Series shingle.
Furnish and install CertainTeed approved ridge vent.
All exterior roofing related debris to be removed by R.C.I.Roofing.
All work will be performed according to manufacturers'specifications.
Lifetime CertainTeed material warranty included.
All::elated permits will be obtained by R.C.I.Roofing.
Add$2.50 per sq.ft.for wood decking replacement if needed.
WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $9,000.00
TERMS OF PAYMENT
5%Deposit Customer Signature:
Balance upon completion
Regis:reticn 4 126235
Construction License q 074334 Drive:
Ec il� O/
Insured 5272700 s&Fickert Ins.
(4 13) Shingle Color Selection: Gr I'I
ctrl e rctL