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29-089 (11) 22 BRIERWOOD DR BP-2020-0442 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-089 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-2020-0442 Project# JS-2020-000756 Est.Cost: $11200.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sg. ft.): 16291.44 Owner: KOSTEK EUGENE R& zoninp,: Applicant. SEXTON ROOFING CO AT: 22 BRIERWOOD DR Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 WC HOLYOKEMA01041 ISSUED ON.-101912019 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: 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 10/9/2019 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner 1 1/r Department use only City of NOrtha C E-1V V E tuso Permit: Building Depart aP rb Cut/Driveway Permit t, 212 Mam Str t Sower/Septic Availability Room 00 CT - 7 2019 W ter/Well Availability Northampton, MA 10 0 T Set§of Structural Plans NSR phone 413-587-1240 Fax 13-587-1272 Site Plans DFPT OF EUILDIN IN-PFC P&r Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION (sp 1.1 Property Address: This section to be completed by office Map Lot 0 Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Qwner of Record: ) P44L a Print) Current Mailing Ad ress: / 5 �- l9Sy («< LLA Telephone Signature 2.2 Authorized Agent: Al 1�lo Name(PAnt)' Current Mailing Address: 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) j �O 5. Fire Protection 6. Total =0 +2+ 3+4+5) 2 > - Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: UU Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) ., � �� Son � ,: . . . „` _ ,. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors ED Accessory Bldg ❑ Demolition ❑ New Signs [O] Decks Siding[p] Other[Co Brief Description of Proposed Work: �P.//j�%li� ✓fid �G �19�_L' ���r✓t ..� Xe /`"'. Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or 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 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, (, C Pv1k G as Owner of the subject property hereby authorize to act on�my behalf, in all matte sr/ellatiivve to work authorized by this building ptapp]7'lation. Signature of Owner Da� I, 2'VJL' �e'� ►� ✓t"I �� �� ( .� � as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the sand yenalties of perjury. Print Name Signature of Owner/Agent Date , �t Tom., �, -.v, ,r _ r•,. ... ._ ,..,*.•...... ��... _ ..J... _.._.,r',.! + na -091 MW i x ok .. ry ,is ilit S ' _- , t .r. '•tt ,1' c4-� ._,. }e'3e; J_...,6 L•+�`�' ... ';c „..', '� ,.�+> � �,�.! rr!.'•.�6 �. e..i`x \ ..;t•q; p3^d!' .r.. ,,'�"e.^„}y.7, 'i , , z `,.+ ~ � °7•i:t:tr: ,.Y I `r }a .•,C 7�•? 1 ani`".,.d. ' �ro�7iaR�f. 6� ..r..s.... ,... -...e. ...... . ... ,.,y, ,•.w•+s• ..w..a.,:...«,....,..w.-.+......+i..M:u.•.,_....+r......tirrWw+:m se...�w...�arw..r..:y,� •Ywj Tx Sy! y . _... ... .+Ijn`{.a..y., r .7�"-ry '4 _- , t ...•.µ� �,,.y.,q_.y .... y.�. ...,. .....+-�... Y .•'•M' .•,�w.w{r \ t y '1'K r1 rx ♦. . \�,� .. 1^ .. {` ro._ t. rJy, I / 4 � - J{, .. ... ...«... • +•-r+4^�'" -.«.-1.t.'..::'...1.._.'.Ga1:..:Jr"C:Y!:...'.a• .. ^t:3"r "atRl^.t.;-i'i:10\<:.T_._... .. _,.... `{ � 1�.....�$s a�\�e�. y,"' �.: ;�,:ai;l'z:�i��i"ii ;� � ��W W�3.`.E`•,! �+,.t'�. ..�''` �' e�""""} G� f4.t r_ttii �? tR say.,, .., ....,� t'1r'�ti+•G�+�'ti: '�i��.Lym a3+tid•!,. �-���,tit' `}tt ro9�F': t� +"��IIZ} 2'R7L�e3' •: 4_'�,4arIroV9; •1 S I`�- +j• 'f `fro ` SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: ( a� �, �,G (/ q�/(r d- / Licen a Number c �x 3 'l IMA— Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Companv Name Registration Number �L) . a L, 3 S -7 )' J C/— Z" Address Expiration Date Telephoned SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... 0,-'— No...... ❑ City of Northampton Massachusetts �_� ;4 DEPARTMENT OF BUILDING INSPECTIONS , e 212 Main Street •Municipal Building Northampton, MA 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: ") '2 C� I I : � ­_ � (, -( I)"t (Please print house number and street name) Is to be disposed of at: 4 (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name 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. � :�� ...jit+i. ..KOt'.t1.�' .! ... ��• ail::} w ..'eGlia '�.l+:a,<'` o7r� .b��.1i! -_D` �.' L{',E:g�tt��i ..i ... , . .r." , •:4^t :. .t .t 'i�3�„3.6 � .., qi.+ •`.C. � nw:.� k. a ,�� ��` ,��. ��.."fit. .�. a� t 4.: '�.�.+. •4• !.,�`4i . '.,'U,{1'k'�.� ... t w'. t � 1 _ • �, s 'r �i. j.:;i ;. a'?t:�a ,R,'w!a �{'��` ' -,;sem`* ,T33 ��.»;. �:t:?C,1 y;.ii'�:' 'I J4 •'.i., ,va1^lt�'7 6�la.'S �,,. " °=' . . ..�;:y��ri,.,. .. <'`?�#!1 a':x•;f �t;�?fr'£�: � '+��i,i '�.'+':.��, ..i'.� . �1�R� o E , . � x����t: ^ tl.: . .;,� ! +�� .'x�`.rt �: •!Sti't yM ;10. .r:..yt ''%:.' ,�,.�'�C#��::'.�ii•! t+s!'';J ., %; , =1 x,-si:.� f��;~:. ;F Jy,':'� •''�;t'?S`.:R .. . re'+�ea+� �,•,.- �.•rro•:�xa .w{��' uq)�� +:p�rt� t§}�� ,�.�t r�� � �.,,d�r ,�., . 4 R"'b�y M 8y ? +�t,.P �.'tP y '� .S .• 'La �M ,.� a1 <x•.- �M'�w�'! �Y:,.. s .e� ��,:�' ! ,:,i`r ��"!0!F � �"S1�i` x:.:12': .�i a$'...iP_. a� �+•"� • ..t ;,�" ,j�#';�®'r•1!:ti�..(.:to 7 '*� ka {(�+- City of Northampton Massachusetts DEPS OF BUILDING IffSPECTZONS y IR 212 Main Street • Municipal Building 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 ars 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 he registered Type of Work: Est. Cost: Address of Work: Date of Permit Application: I hereby certify that: Registration is not required for the following reason(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 I42A.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: Datd Contractor Na e 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 ` ..- ....:sw...,.-..,...,...yx. .c ►.w..•..n;-.., ,.y,.... .._.-.,.�,w .,..,.v.o-c,...,r.....,....,.w�».w+.». .�...i.r.........,. - _, ww....:..ti,..;rur.,_.'dwA►A.rjii,.�•....,... .-.,. - .... .. �4..w+ - ..ar.r.�+i}�•�.s aw-..�.�w....ep.,r.»+wi1.b•r..•,..:.3w... >.�.._... .....wwr- +}.••.,.„�,.,w,,.... ..�.,. a r3 iT;ia `-Z?"t'' ; &II ayT°,T''>df bs !stf.:' ,. k t;t'i�'',lT'i`.'"T��. r.-�_,�.,�� ?3• :�C.}1+�.•,'�',.`nl%a z� '': `li�:t,f::�st•'.T;�'ir�.�''»?.t,��f'.1r'r3f}i �e d•�'-%'.+�it.;9� ��'T' Ak.�� i t r i ! '1 ?2 IR r X �;<'y x p`.• Y g. y '.t:@'} ;s :y'4{ >,.2: .1.<� .1 ., ��-tl. cLi 1,.Ci.. •'t.x.:x .'dZ ;K,€`.,�.��r�. �.�;s,'.f3 ��. t yr t Y7 ..f q'� r �' .,+t'a j�liy�►' l�fY A,41.f>1i .e�,�.,i�,, � S}.' c S a'.[�' r'fJX '? ..�!#'flc+f i' .. it t ;d?»':.;'�{;?1tf T,Y} �2t�s a.i:i :n a•.+f rq 4,i�Et�f��.�:£'.1�i � �>1�'f°:*�4�i <.t�*( t+�`�.:, .+`d'!i>?.z.`f 6.j+tftT:"+F'�,�:T_�:�.�;le LOT i.91 'J;.#;, t+'Ji,1, •s?cY�js;r is - <f:2� r,{ i;' i.:, } _ a IE A1. ��. "k�` r •..� ;,, qtr '• .`r.t,.>?Y'!tx�',a ^.t.;Z.•. S•.!!{�1 !Z1�;L`� +.x1}.1.{5.,.�.�}.. . . Too-.y '.:�.;.el'-.'y:,,y_?`�:.l: A"i;- i'iSw ia. •a.�;�. ^.i, _ � ; l .. jk'•°[ a4"a^tif :.:!`.�?1�•�.�lY�"..lri4+` :..4,t1d1»1,..�' 1 ;,tt�^�t?'jq...axCY;':�'{.be3.`.1x+ '.�3sic.+•�Xi:..�h�t..Y:x`:'"wi .^a3�RCrter' '=�tk. `'s�'r3Ui�s _ �,- ��_ t�,.i» �e�G.s ? h� ,.l�rY;bs ?•?;tom �!'•:.' - ,•lf:�i5'.,:r4s.�tf #{t�i��t�'•`'�. .h.0? -tl4i•+` �l zJ�::� .':M,�tc.J� ''ad S':�'k' ^(f" kf'.+�.s_..'#%�, f9 ? .4^ ..,flf� _yN.?tr`#rµ,,,;,: 'dG"? �.lr{;.:,. {y.e .''tf.• �rL,'.. 7i.� .. ^",xf }3i7:.dx` . i.'. '#...ti,:.�?. . t - ..`. :. , '�.�� ��i,.,.d'.3•.) •t.��,�}-1?':tJ'=?'����ifP�'S'1 S a;�: ., \,Y. ',t T.t ��{jt `!'st4 f, t!'' t.. 'SI+ ?-.' :1:. .`+ ... - e�t�.; CS#t ISM 1. Vropoml SEXTON ROOFING AND SIDING INC. (413) 534-1234 P.O. Box 6327 FAX (413) 539-9906 Holyoke, MA 01041 sextonroofing@hotmail.com MA HIC#118239 lfk CT HIC#0605383www.sextonroofing.com Since 198_5 SUBMITTED TO .{7 'Q PHONE " p" -�" DATE e.ei _TREET — �.--_ L r�y� JOB NAME CITY STATE zIPCODE f E' :::::: JOB LOCATION Proposal to furnish and install the following EMAIL J Re-Roof J Tear-Off ain House S•Garage x--51 e Complete Roof Preparation dome exterior to be protected by tarps X Shrubs,landscaping,trees to be protected Entire existing roofing material to be removed to existing decking,Including flashing,etc. i e to be cleaned everyday with roll magnet debris removed at project completion -.t° Deteriorated existing decking replaced at$ 7 d- per sheet _J In all new decking/type: >� Whit Brown metal drip edge installed at eaves and rakes IP-,F8J F-5 .J Rake Edge w flashing will be installed where necessary(see Special Requirements) 1Install new pipe boot flashing ,A"Suearn Exhaust Vent �Reflash chimney with new lead IL t ./,,4a! We shall acquire all appropriate permits etc.for all roofing work Com ete Roofing System Leak Barrier installed at all eaves to protect from ice dams(and meet codes in the north) _j 3' S6'-_" �Leak Barrier installed at valleys,around penetrations and chimneys to protect critical areas d'--Install Roof Deck Underlayment on remainder of roof with Synthetic Felt Shin les t GAF -i CertainTeed� Tamko / J 30 year "J 50 year �etime Color �7 Install Attic ventilation system d Cap over Ridge Vent -1 Roof Louvers Warranty Options 8 We guaranteed our workmanship for 15 full years CO}l se hereb rnish materia labor- plete in accordance with the above ecificalons,for the sum of: U� ,L�. u r1 dollars $ (/ PAYMENT TO BE MADE AS FOLLOWS - �" All Material is guaranteed to be as specified, All work to be completed in a workmanlike manner accordingtostandardpractices.Anyalterationordeviationfromabovespecificationsinvolvingextracosts Authorized will be without notice,and will become an extra charge over and above the estimate. Signature Not responsible for water damage or damage to the house during stripping of roof during construction- Owner to pay responsible legal fees for non-Payment and applicable interest of 1112o.per month. Note:This proposal may be Withdrawn by us if not accepted within &UPtall[r of flropo5al-The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the Signature — work as specified.Payment will be made as outlined above. Date 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. 17 Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston. Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Regis' I orx 11823.9 F-0ROORNG 4u SIDiNG tNC ��on_ �1�M1 F-0-BOX 6327 HOLYOKF-MA 01041 21pd2teAddress=d Retum C-d- EtTERE'I T J SEXTON SR HOME I&OROVLML-W CON'TRACT'OR PO BOX 6327 EVER=J SEXTON SR HOLYOKE,ATA 01041 102 Pate St ( HOLYOXF,MA o1Q4o-2411 SEXrON ROOFING St SIDING CO LIC_1 REG 1�'O. EGTiVI= EJCPiRES TIIC.0645383 /Oi/2028 Zt/30/20t9 SIGNED commonwealth of Massachusetts �— Division of Professional Licensure J Board of Building Regulations and Standards ConstructioPS44Visor Specialty CSSL-099689 4pires: 10105/2021 s EVERETT J SEXTON PO BOX 6327' - HOLYOKE MA;01041 IL Commissioner �— The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information _ Please Print Legibly Name(Business/Organization/Individual):Sexton Roofing & Sidi ng Inc Address:P.O. Box 6327 City/State/Zip:Holyoke, Ma. 01041 Phone4:413-534-1234 Are you an employer?Check the Appropriate box: Type of project(required): 1. L: I am an employer with__ _ __ 4.A I am a general contractor and 1 6. 1 New construction employees(full and/or part time).* have hired the sub-contractors 7_1 ! Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8.[ Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.>_ 9.[ Building addition required] 5. We are a corporation and its 10.I_;Electrical repairs or additions 3. i I am a homeowner doing all work officers have exercised their 11.I Plumbing repairs or additions myself [No workers'comp. right of exemption perm MGL insurance required]t c_ 152,§ 1(4),and we have no 12.X Roof repairs employees.[no workers' 13. 1-Other comp.insurance required.] - - – – —-- *Any applicant that check,box#1 must also fill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ±Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employ nes,the}_must provide their workers_ om -policv number. I am an employer that is providing workers'compensation insurance for my emplt lvees.Below is the policy and job site information. Travelers Property Casualty Company of America Insurance Company Name: Policy#or Self-ins.Lie.# UB-0G078982-19 Expiration Date:06/04/2020 Job 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 Section 25a of MGL 152 can lead to the imposition of criminal penalties of 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 $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do l:erbycertify t der the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Print Naive: "" r e' z- �V e:�''E:T ,.� �'''. �1�1-� Phone#: �}l 3 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 Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other i Contact person: Phone#• ,ti,,.. .. -.- ...�.�.R _»„ �- ... -. _. ..� y... •.-k wr.•...AJ.S,y.,,...d..- .war...... ,fir., f6coAll L`rx t , -t °; M, •. N �'�'� f���t F�. •`s� \�. Y ✓,ii?QS<�y 2xr 1'1':• :4.T+, Fs�'l�� �` 4ki i .it'. t ,a �:. ��'t':'�'4l;9't4R,�.+�'!S'T31�';>"j'Y t:t.r#li�`s�•''k�« +t +' Q >f'� r3� �. i,' s �,1,j �+ �C• � r r a s,r f ,r., -.✓ r {S'� '.t ,. T' 'h �•' ;.}.�f -�y; >f. . �l�,tt,`1 ,V , }-1 �*�' "3.'�, rl`+.,J,,,,"`��' °:F)d�, ,t_r i �:'1F•. .:fir A ,-'�,;(�r t �(.. ir. r d •�✓�y /r��+'.p. 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J '. ..A_',y`.,�_.. .,:.. •, .._ .. -,_ :..u.... „y, .,. «.. ,..... _-.,. • • ► ass�Uc�i¢s� �c�'t�'•v __.. -. _.. ... _ �� .:n.r �;;.:�ts 4� �,�,i�t+ ' + aay�� pp tt 'v 'ker Iry �•� �.. � �tr�Q'4'M Zy'p1.3"t.''.. t�,a�'y1 ,- :;..-::. - ... ,��,� ti!;td.:4�it1}'�r"'A� Y,�'�1`�I a��"i�'�'a�.itl:r<.iy�.`4•I-.. , CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 06/10/2019 TULS.GERTIFICATE 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 and endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: ORMSBY INS AGCY PHONE FAX PO BOX 718 (A/C,No,Ext)- (A/C,No): E-MAIL WFST SPRINGFIELD,MA 010% ADDRESS: 286TY INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVELERS PROPERTY CASUALT-Y COMPANY OF AMERICA SEXTON ROOFING&SIDING INC INSURER B: INSURER C: PO BOX 6327 NStMER D- HOLYOKE,14(A 01041 INSURER E: INSURER F_- COVERAGES COVERAGES CERTIFICATE NUMBER: 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. WSR kDDBRPOLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MWDD1YYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY =ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY AMAGE TO RENTED s CLAIMS MADE F__1 OCCUR. REMISES(Ea occurrence) ED EXP(Any one person) : ERSONAL&ADV INJURY = GEN'L AGGREGATE LIMIT APPLIES PER ENERALAGGREGATE i POLICY PROJECT LOG RODUCTS-COMP/OP AGG 4 AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULE AUTOS Per pew) _ HIRED AUTOS BODILY INJURY s Per accident) NON-OWNED AUTOS ROPERTY DAMAGE § Per accident) UMBRELLA LIAB 8 OCCUR EACH OCCURRENCE ;§ EXCESS LIAB CLAIMS-MADE AGGREGATE is DEDUCTIBLE is RETENTION $ : A WORKER'S COMPENSATION ANDWC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB 0G078982-19 06/04/2019 06/042020 X LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE NIA E_L EACH ACCIDENT $ 1,000,000 01 i-ICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 U yes,describe under DESCRIPTION OF OPERATIONS belowE.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATK)NSNEHICLES/RESTRICTIONS/SPECIAL ITEMS TTUS REPLACES ANY PRIOR CERTIFICATE 1SSITED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. TBE INSUREDS MA WORKERS COMPIENSATION POLICY AND ITS LIMITED OTHER STATES ENDORSEMENT ALITHORE CES THE PAYMENT OF BENEFITS FOR CLAIMS MADE BY THE INSUREDS MA EMPLOYES IN STATES OTHER THAN MA NO AUTHORIZATION IS GIVEN TO PAY C[AIMS FOR BENEFIT'S IN STATES OTHER THAN MA IF THE INSURED HIRES,OR HAS HIRED EMPLOYEES OUTSIDE OF MA. TWIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS- AUTHORIZED REPRESENT E AOORD 26(201G" The ACORD now and logo are registered marks of ACORD 198&2010 ACORD CORPORATION. All rights reserved. The Common wealth of.4 vsach usetts Department of IndustrialAccidents idents (w I ('on,-,ress Street,Suite 100 Boston. 31.4 02114-2017 wwx:nrass,,oiVJia "orkers'Compensation Insurance-kffidavit:Cenral Ek slnesses. Applicant Information i0 BE F1LED"IT[I I I I E PLRNIITTINC AI'THORITI'. Ytease Yrint Le rt�h Business/Organization Name:MNP CONSTRUCTION INC Address:45 EXCAHNGE ST Cih-lState/Zip:MILFORD, MA. 01757 phone�_508-498-8870 Are you an employer'Check the appropriate box (required)LID Business Type - — —- - I am a employer with 5 !_employees(full and � � 5• ❑Retail or part-time).* ! 3.❑ I am a sole proprietor or ( 6• ❑Restaurant Bar Eating Establishment ` Partnership and have no i ;. Office an&or Sales{incl.real estate.auto.etc,) f employees working for me in am capacity. ' f No workers'comp.insurance required] 8. Non-profit ;.❑ We are a corporation and its officers have exercised � t). [] Entertainment their right of exemption per c. 152,$1(•t),and we have no emplovees.[No workers'comp.insurance required)• 10.❑Manufacturing 4.❑ We are a non-profit organization,stat3ed civ volunteers, I I.Q Health Care with no employees.Mo workers"comp.insurance req.) 12.0 Other CONTRACTOR '.•1m applicant that checks box a I mu%t also till out the ick tion trlovv shave Ing thea ucrrkrrs'camperesahpt policy mt'orrnatttxt ��—�- `•If the carporate officers have e\empted themxh es.but the exi oc own has ether r%twk ers,o peers'com org:unzatron should check lso.�1 peon potrcq is requved acrd such an am an employer that is proriding workers'compensation itrsrrranc•eJor mr employees. BelnK,is the poliq•infetrntatiott. Insurance Company 'game:HARTFORD UNDERWRITERS INS CO TRAVELERS-Rtv1D Insurer's Address:P O BOX 5600 City:State:Zip: HARTFORD,CT.06102 Policy;;or Self-ins.I.ic.4 1K709706 _ 11/16/2019 --_ Attach a copy otthe workers'Compensation _-_.___ Expiration Date: Ixnsation polio'declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and:orOne-year imprisonment,as well as civil penalties in the form Of STOP N1'ORk ORDER and a fine of up to$250.00 a da} against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herefit•cerci u et ftties of peilmiy that the information provided abare i.ti true>and rnrrec•t. Signature: Phone#:978-403-5942 — - Offit•ial use only. Do not write in this area,to be completed by city'cry toK n official. C�itv or"Town: PermitlLicense ------ lssuin�Authority (circle one): I. Board of Health 2. Buildin^Department 3.Citv,Town Clerk 3.Licensing Board 5.Selectmen's t)ffice 6.Other Contact Person: Phone g: AcoRD� CERTIFICATE OF LIABILITY TY INSURANCE 17!05/10/2019 TE(MMMoryyyY) THIS CERTIFICATE IS ISSUED A5 A MATT CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY(AMENDON , AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTEONTRAOR CT BEEN mV SUING NSUR>=R(S)AUTHORRAGE AFFORDED BY THE ISED 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)_ PRODUcr ONE FAMILY INSURANCE AGENCY LLCCONTA� An� O acNE (978)4035952 — — —— — -- +�Az E4Aa1L ------ -- 1 Main St Suite 15 xansr s_- 0128(�yahoo.com --- unenburg .._. iNSUREfttS7AFFORD1NG COVERAGE + — --- -- MA 01452 INSURED --- - -- i+su�R!!yHARTFO_RD UNDERWRITERS INS Ca 3p10q '— MNP CONSTRUCTION INC 'N-S"-9 - 1 ►NsuREa c• - —- 45 EXCHANGE ST APT 3E a+SURm MILFORD INSURER E: — COVERAGES MA 01757 THISCERTIFICATE NUMBER_ 401083 INDICATED. IS TO CERTIFY THAT THE POLICIES OF INSURANCE L REVISION NUMSM- INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TER.b1 ORDCpNDIpN OF ANY ISSUED TO THE INSURED NAAfEp CERTIFICATE h1AY 8c ISSUED OP,MAY PERTAIN. THE INSURANCE AFFORDED gY �FOR THE POLICY PERIOD CONTRACT OR OTHER DOCUMENT 1fYlT}I RESPECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOk1T!A`AY HAVE THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 8m; — --— BEEN REDUCED BY PAID CLAIMS. LTR. TYPE OF 1NSURANcE ;ADOL�SUB - iRI -�POCOMMERCIAL GENERAL LIAbILITY POLICY NUMBER p--I+--- __ Lawn �. CLA1L•5-6fADc CCC'�lP. + I t + I EACH OCCURR>a2 S DAfdA L i — _ FREkl[L-S[it rF�mxr ee S G'EN'LAGGREGI TEU6IrA i �PLI PER ' I 1 PERSONAL&ADV 4V,IURr Is {y + Y ECT LOC j �E_M�RAL—AGGREGATE i's -- . 1 1 PRODUC'S-COMp/op Af,G 15 LAUrOMDBR'e LIABnjTY `- ' 1 S — CO.ABLYEO 5 I ANY OWNED � � � mGLE L1MrT if ALL OWn'ED SCMEDU'� S i AUTOS � J AUTOS l 1 N/A BODILY INJURY Weer Peraonj T S -- . + I HIRED AUTOS AUTOS NEO ' I BOOEY MAJR' ---- OSAUTOS ! I f L-PRCFr S I fiact'den:.1DAMAGE I S .. l IRMBL��iR-E UAB t , ! ' -- - --� OCCUR { I �S + i �j/AiCH OcDED TENTION 5 i AGATF - I S AND FOYERS LIA311TTY �' is A.ti'Y?R YIN', !N' v A !�FiCcFJy1EAlBEREX�CL pE �� N/A I NJ WA' i �,^L'STATUTE I I ER 3 !t�nd�tn.y to NH) —�� 1 6S60U81K70970618 Ill/16f2018111/16/2019#-=-!�ACCIDENT �S 1.000.000 --- N Yes,describe unser i I DESCRIPTION OF OPERATIONS be9w ! { I— OISFJLSE-EA EblplOye S 1,000,000 I 1 I 1 !EL DISEASE. I i POLICY uwr I S 1.000,000 i NIA } t I DESCRIPTION OF OPERATIONSILOCATIONSl VEHICLES WMassachusetts employees e ORD'70m,Additional Remarks Slfedute, I I ' Workers Compensation. benefits vrilt be paid to Massacto Chad if mom spa"xi.rgaifod) claims for benefits to employees in states other than ac p Pees only_Pursuant to Endorsement WC 20 03 06 B,no authorization is given:o pay Massachusetts if the insured tures,or has tared those employees outside Of Massachusetts. Thiscertificate of insurance shows the policy in force on the date that this cer'iftate was issued(unless the expiration date on the above ti issue date of this certificate of insurance). The status Of this coverage can be monitored daily by accessing the Proof of Covera Search tool at www•mass,gov/Wd/workers-c pOi�Y precedes t.e �TlPensatlonfirlvesbgationsl- 9e-Coverage Verification CERTIFICATE BOLDER Ii CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE SEXTON ROOFING & SIDING INC THE RDANCEXPIRAWITH DATE THEREOF, NOTICE WILL BE DELIVERED IN 102 PINE ST ACCORDANCE WIT}(THE ppLICY PROVISIONS. AUTHORRED REPREsicJhTATI VE HOLYOKE ,,r lv?A 01040 �` �}}�� Daniel M.Cr4l CPCU Vice President-Residual+lAarket-WCRIBt.IA ACORD 25(2014101) ©1988-2014 ACORD CORPORATION. All rights reserved. ' The ACORD name and logo are registered marks of ACORD