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22D-061 (2) 47 FLORENCE RD BP-2020-0563 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:22D-061 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-2020-0563 Project# JS-2020-000971 Est.Cost: $7300.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO. Const.Class: Contractor: License: Use Group: RCI ROOFING 074334 Lot Size(sq. ft.): 15942.96 Owner: MOCHAK SARAH Zoning: URA(100)/WSP(100)/ Applicant. RCI ROOFING AT. 47 FLORENCE RD Applicant Address: Phone: Insurance: 6 LINE ST (413)527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:11/4/2019 0:00:00 TOPERFORMTHEFOLLOWING WORK:STRIP & SHINGLE ROOF NOT INCLUDING BACK SIDE OF CHIMNEY 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 Si#;nature: FeeType: Date Paid: Amount: Building 11/4/2019 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner c Department use only City of Nort mp n 3 W tat s of P rmit: Building Dep rtm t QCT Curb ut/D veway Permit A 212 Main S reet epti Availability _ Room 10FBV,Losc' 1� Availability �^- Northampton, M 01M 01 Two Sets of Structural Plans_ phone 413-587-1240 Fa 1272 Plot/Site Plans --- - — Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 6P' aw — '5C/ 3 1.1 Property Address: This section to be completed by office 1..17 F lorence. EdMap_�_L Lot n6o i Unit F IOreric,Q, Mq Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: So-ro-ll mo&o-k H j F lore-r)(-e- KJ F1o',PA( lM d O IUteg Name(Print) Current Mailing A dress• _�j3� a o- r 7,3 R &-p d 4+a C hA Telephone Signature 2.2 Authorized Agent: ffirA c (o LI n tz S+ . Srw+hrwop16n ► 16 01093 Name(Print) 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 Pe;mit Fee 4. Mechanical(HVAC) �� 5. Fire Protection 6. Total=(1 +2+ 3+4+ 5) 00 1 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date S-H)orneson @ r6 roo-it',-)2 ..corn EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) + J 1 1 1 :ri: ... ..1�%,f � 4j ....a�SU�' ( yr'�a =�!4'�_ �i,�..• ... ={e t.....i_.. �_._ .�R'".� .....�, � _-.` .�_ _-r. ...i • .. �� , ,"'r-.. � 1.'fllf rJf�;(;a wry✓�`• _ . •.� _ - �_...��.» .. SECTION 5-DESCRIPTION OF PROPOSED WORK(check allapplicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks (M Siding [O] Other[E3] Brief Description of Proposed 1 I I Work: See Q,t a Ghed 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 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, Sa f-cal 1 t ocaL as Owner of the subject property hereby authorize A(dII-') to act on my behalf, in all matters relative to wo authorized by this building permit application. See (Lilac{Zod ►d Signature of Owner Date I, Ma rK tDJis12 — aS t�-0-�DrfZPd lg2tT as Owner/Authorized Agent hereby declare that the statements and information on the foe oing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name '/ '�! Ib 3oJd01°1 Signature of Owner/Agent Date � -� S'�"� iif ri, i r iii�: ..1. ;..1;' r'� w`�-c.:'� ..ry,......., j .i.. ter' � 4Ti�..�i<•'� ! Y- ... ....,. ... _ _......�.. .__ ,.. ......-. ... -. R .. � h. .. - .. � � � i' � f` r ,r .A•...�,..-r., .. � _ r - ..� - _ SECTION 8-CONSTRUCTION SERVICES 7 8.1 Licensed Construction Supervisor: Not Applicable ❑^► Name of License Holder: /!to L i., (d i�le- C S - r/ y IS q License Number rl E ccOIGa 05 - 03- ao a Address Expiration Date 13) Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Iii C Z 1�cel-na LLP _ /L (to i L3,5 Company Name Registration Number LI n e 3+ _ ,tea nrn�2}�n �'Yl C�10`13 _ pS - 05.- a U a U Address f Expiration Date Telephone 413-Sa7-`/?l5 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....... Id No...... ❑ RC.1. RDate 6 Line St. Estimate Southampton, Ma. 01073 10/21/2019 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location Sarah Mochak' 47 Florence Road Florence, MA 01062 Terms Rep Estimate valid for 30 days Angel Description Total Remove existing shingle roofs(not including back side of garage). 7,300.00 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. Furnish 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 related 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 $7,300.00 TERMS OF PAYMENT 5%Deposit Customer Signature- Balance upon completion Registration# 126235 Date: G Construction License#074334 Insured by Banas&Fickert Ins. Shingle Color Selection: (413)527-2700 ��LV�` City of Northampton Massachusetts + DEPARTMENT OF BUILDING INSPECTIONS 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 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. Type of Work: �j Dofi n q Est. Cost: Address of Work: 1-0 F l L YP_Yl u- KO F,Iow t I 0 Date of Permit Application 30 of mq 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 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: 10/3c) o Ig 6 .C . I. &w4r)a L LP co/35 Date -, Contractor Name U 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 I DEPARTMENT OF BUILDING INSPECTIONS xJ a 212 Main Street •Municipal Building p V.", w 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: 4q F1b(P.i1LQ " . FlUatice- (Please print house number and street name) Is to be disposed of at: Wts+prn Ae c wd i'na �Ccn.s-�P Far; lid (Please prin ame a d location of facility) Or will be disposed of in a dumpster onsite rented or leased from: )Si� Qulinu - �occrJrr►� (Company Na6he 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. 7:11.!lj� \ The Commonwealth of Massachusetts Department of Industrial Accidents d I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electt•icians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): (' R(Yrh" nq LL P Address: Ll n P 3+62P+ City/State/Zip: 1)3 Phone#: Ja - 05 Are you an employer?Check the appropriate box: Type of project(required): 1.Edi am a employer with. 15 employees(full and/or part-time).* 7. ❑New construction 2.7 1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp,insurance required.] 9. El Demolition 3.71 am a homeowner doing all work myself.[No workers'comp,insurance required.)t 10E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12,❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. ilkoof repairs These sub-contractors have employees and have workers'comp.insurance.[ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors 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: T M ffir ual - S U r2n L Policy#or Self-ins.Lic.#: V W C n G(n t)_a a Lo V 7,.J 612 A Expiration Date: /0- 0 5- Q U ,?0_ Job Site Address: y9 Fiofsu ( Aad City/State/Zip:. F10(eriCe MA 810(0-1 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 paints d penalties of perjury that the information provided above is true and correct. Signature: / Date: l a 30 a G 1 Cl _. Phone# ( y(I) 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#: 2 _ '. ,�.' . .... ._._ , ._ � _ . ._.__.,i. _ . ,i'r•�i.,. .� _... �.4��1 �:r: I .1e � �� - � ,. � t .1..41. , _, l .. ., :. y., � ' i � ._ .. .......1 ...... .. .. ... � , I �a - 'i-. �} � a_r•�c ...t .1. 4 4" •=r.k. G 1.. .�.;...s .�; , .... .. j. .. ... .. .. ......._....... _.. ' ..........r._.. .. -........ .. _.. 1 — f � 1 ..._.....__.. � � 4'J J-•�::3.. � �.�'(i�!1 lid'.`�� ('.' ��J�1: � .... ... '. ._.... j 1 -T.. "Y r. IRryI�I�•,�r4;-c•- +�./.��r"�.•� .. _ r�1 r- _ ._.. .. — __ �'. .. .. J, '� � .. _. . . _ .._ ... . . .. _. ..... .... .. � . .. . ... ® DATE(MM/DD/YYYY) ACC)R o CERTIFICATE OF LIABILITY INSURANCE 10/07/2019 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(les) 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 CO' IT NA10 Michael Banas BANAS & FICKERT INSURANCE AGENCY PHONEExtIl 413 527-2700 FAA/C No: EMAIL ADDRESS: mb@banasinsurance.com 63 MAIN ST INSURERS AFFORDING COVERAGE NAIC p EASTHAMPTON MA 01027 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B: RCI ROOFING LLP INSURERC: INSURER D: 6 LINE STREET INSURER E: SOUTHAMPTON MA 01073 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 457722 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. INSR TYPE OF INSURANCE A DL UBR POLICY EFF POLICY EXP LTR POLICY NUMBER 1 D IDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTE17- CLAIMS-MADE FlOCCUR PREMISES Ee occurrence $ MED EXP(Any oneperson) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ a eccldent ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NPROPERTY DAMAGE $ AUTOS ED Per accident) HIRED AUTOS AUTOS UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DEC) I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STRTUTE R Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICERIMEMBEREXCLUDED? N/A NIA N/A VWC10060226472019A 10/05/2019 10/05/2020 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only,Pursuant to Endorsement WC 20 03 06 B,no authorization 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 certificate of insurance shows the policy in force on the date that this certificate was Issued(unless the expiration date on the above policy precedes the issue date of this certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Sample ACCORDANCE WITH THE POLICY PROVISIONS. Sample AUTHORIZED REPRESENTATIVE Sample MA 01073 Daniel Danniel M.Crq�ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD A.pCERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYW) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDERO9 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. IMPORTAN : If the certificate holder Is 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 NAME; Michael R.Banas Banas&Fickert PHONE 413-527-2700 Insurance Agency A1C No: 413-527-0849 63 Main Street ADDRESS: mb@banasinsuranco.com Easthampton,MA 01027 INSURERS AFFORDING COVERAGE NAIC q INSURED INSURER A; Admiral Insurance Co. 24856 INSURER B: Safety Insurance Co. 39454 RCI a Streetofing,LLP INSURER c: Admiral Insurance Co. 24856 6 Line Street Southampton,MA 01073 INSURER D: INSURER E INSURER F; 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. TOLED TYPE OF INSURANCE POLICY NUMBER --illi YYYY MM1DD ERCIAL GENERAL LIABILITY LIMITS EACH OCCURRENCE $ 1,000,000 LAIMS-MADE X OCCUR PREMISES Ea occurrence $ 50,000 MED EXP An one arson $ 5,000 X CA000020963-05 03/04/19 03/04/20 PERSONAL&ADV INJURY $ 1,000,000 REGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 Y�JECOT LOC R: PRODUCTS-COMP/OP AGO $ 2,000,000 ILE LIABILITY $ UTO EaaacccidenntB D SNGL T $ 1,000,000 D SCHEDULED BODILY INJURY(Per person) $ ONLY x AUTOS X 6207761 09/30/19 09/30/20 BODILY INJURY(Per accident) $ x NON-ONMED ONLY AUTOS ONLY Per accident $ UMBRELLA LIAR $ OCCUR C EXCESS LIAR CLAIMS-MADE X GX000000385-03 EACH OCCURRENCE $ 5,000,000 03/04/19 03/04/20 AGGREGATE $ 5,000,000 DED x RETENTION$ 10,000 WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT (Mandatory In NH) $ If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) ROOFING CONTRACTOR, 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 REP S IVE ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AC D CORPORATION. All rights reserved. SCA 1 0 20MM.0051177 // 014 111011,wza 6000C�/G�(�/�/JC14JfLC�CIIJP.�4• Office of Consumer Affair &Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE•I,Partnershlo . :.�•.,.� Exolratlon 126 . ' 05/05/2020 C C!r13� RCI ROOFING,l. F?•c;-!Rlli`,'.`;:: ') MARKT.DELISL \ Commonwealth of Massachusell3 11, ;•`•,•/ P 6 LINE ST �t, ` ` C�� / Division of Professional Licensure SOUTHAMPTON,MAS` '1Qr1Ci � Board of Building Reuladons and Slandards Undersecretary Cons�rt�,Ct'1dr�I�tlrvlsor --- CS•074334 I l if I . 4Plres; 05/0312c Registration valid for Individual use only , 'before the expiration date, If found return to; � MARK THOMAS D.E ` j,l% ' ,�• � %� ''':�� Office of Consumer Affairs and Business Regulation 68 BRIGGS ST'�j EEIf '+,�I � l • ` ?a 1000 Washington Street•Suite 710 Boston,MA 02118EASTHAMPTON; A. � r,•'�, >>S "+ %k,�t'; _ Commissioner C o4 Not valid without slgnature NfiNEAC'i'M .O, ;i F:. , HOME RJgV1F IMP N��j�+) ONTRACTOR e a Of_i S'HEET:y'M : SOLrJ,�:' i� Z?I, 01073TEID AX Reglsha1 , . Expiration .n' •::: G$:.,$: a=. > HIC.0624741' 11/30/2019 EAS'TH�ti.M h":aN., MA a �1• 0 AS I(3NED '�; jQ. �- ut .` _...._�,._....._.�____._. ,_..,..._.. t,,�� ��' $ 1.327 "�+1°� ,z,.•;:��;«� '0$/2812020 664 �__ n6�1' ".u•i�� ` x,.14 of i�n,(iY:�'i i,"Ili��";`•1'•'� '':.f`i1' � 'Mv�il+•P7��� , COMMONWEALTH OF MASSACHUSE X,Vr ` SHEET ME7'A;L WORKERS ISSUES THE FOLLOWINGTLICENSE MARK T DELISLE . �: #2CI ROOFING LLA ��v t zw 6 LINE$rI�EEfi ' z EA$THAMPTON,MA 01073 '� i% / •<"s��� ,its ,�; "':.;.. 601e: 09/0912821 714002'