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35-285 (13) 28 SYLVAN LN BP-2020-0934 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:35 -285 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categoa: ROOF BUILDING PERMIT Permit# BP-2020-0934 Proiect# JS-2020-001587 Est.Cost: $14900.00 Fee: $80.00 PERMISSION IS HEREBY GRANTED TO.- Const. O.Const.Class: Contractor: License: Use Group: STURDY HOME IMPROVEMENT 093603 Lot Size(sq. ft.): 33279.84 Owner., LEVAY BRADLEY zoning: Applicant. STURDY HOME IMPROVEMENT AT. 28 SYLVAN LN Applicant Address: Phone: Insurance: 459 MAIN ST STE 13 (413) 543-5906 WC INDIAN ORCHARDMA01151 ISSUED ON:2/19/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-NEW ROOF AND REPLACE SKYLIGHTS 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 2/19/2020 0:00:00 $80.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner �z 0-0t 4,9.1 r----__._ Department use only i City of Northampton/ Statin of Permit: (ice Building Departmentf FEB 1 Curb C t/Drivway Permit 212 Main Street - Sewer/ epticj'Availability i�V R t Room 100 WaterANell/availability Alm P6 F Northampton, MA 01 b oFFun Two�ets of Structural Plans �t Fpo, In phone 413-587-1240 Fax 413=5$ � n.r�iAp PTbt/ te PI ns APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: � .--... O h r�k_ Map �� Lot � —Unit I U MA' Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 'P_rCicj �-�_ /Cwt a LA I Vho Lha f Name(Print) Current Mailinb Address: L l 3� 3 ao- 33a� Telephone Signature 2.2 Authorized Agent: S Aky-tn,�� Name(Print) Current Mailing Address: �CI1 a�g�3�a gyp' zJ 13� ignature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building t �l (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of �}— Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2 +3+4 + 5) Check Number /fin rq This Section For Official Use Only Building Permit Number: O l A(7 — t �_ Dated: Signature: ti oao Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[0] Brief Description of Proposed a, — Work5+vi exi��(Z�Pr-S a-,kVrbS. f lace Wr�Lt 2'I S'6 �P.,-�tu eP ahG!'iZ/ -eP tacc O) Skyh Alteration of existing bedroom Yes_LZ No Adding new bedroom Yes l/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, 3 as Owner of the subject property 1 1'. hereby authorize C +,Ly-6 to ar on my behalf, in all matters relative to work authorized by this building permit application. a- Signature of Owner Date 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 pains and penalties of perjury. � ui��k 0,� Print Name re of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: rC Not Applicable ❑ Name of License Holder: ��Lti(/1(% D(u \2 J 0_/l c-�b u License Number LK-9 VRIk 6 11 Ifl-) 12-1 Address Expiration Date ature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ c...�-(,(►-6k�d H6 m&&ice` _ Company Name Registration Number tisc( IC,W allo- 0, 04 CAI 1 CP 12-S 1:)-o z� Address Expiration Date Telephone Ll 3 5�-13-514 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 buildingpermit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton Massachusetts wt :3 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: Est. Cost: C,6 0•W Address of Work: 0�, �u V( ,v La I\,e Date of Permit Application: ��p 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: �- ( Date Contractor Nanle 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 "t Massachusetts ��?S' 'k_ t DEPARTMENT OF BUILDING INSPECTIONS 1 212 Main Street •Municipal Building yJ6 :Ca 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: a� W I V(/V� (Please print ho se number and street name) Is to be disposed of at: 144 (Please print name and to tion of facili y) Or will be disposed of in a dumpster onsite rented or leased from: r—, A4 VV4 , iA"'L V'-+ ((.`ompany Name and Addr s) AA, Signature of Permit Applican wner 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. HOMG IMPROVE- MGNT "No Substitute for Quality" 459 Main Street Indian Orchard, MA 01151 (413) 543-5906 (508)-797-6600 OWNER PERMIT AUTHORIZATION Name : Address: City/State/Zip tio-4I4,-rko^ Mf' �GV CA-i (owner), of the property located at: authorize Sturdy Home Improvement, Inc. to act as my agent for the construction project taking place at the above address. I also authorize Sturdy Home Improvement, Inc. to obtain a building permit for this project. I understand and accept responsibility to comply with all regulations and required inspections. �( - o 2 u S' n re o Own Date Signature of Owner Date 459 Main Street Toll Free (377)378-8739 Indian Orchard, MA 01151 Worcester (508)797-6600 E-mail: HR@SturdyHome.com Springfield (413) 543-5906 S www.SturdyHome.com New Haven (203) 848-2118 Fax (413) 543-3200 HOME IMPROVEMENT, INC. MA REG. #151711 CT REG. #601525 WINDOWS • SIDING • ROOFING • ADDITIONS Name (� Home Phone Business Phone B f G% v' Address0 / Cell P one Other J ��,,, /3- 3 a 0 333 Town/City 1Represenntative Date MA .iL �,Sv�GG, a/tt doZD I/we the owner(s)of the pre ises described hereinafter, referred to as Owner, offer to contract with Sturdy Home Improvement, Inc. hereinafter referred to as Contractor, to furnish, deliver and arrange for installation of all materials to improve the premises as described below. Yes o ROOFING SCOPE OF WORK: ❑ 1. Contractor to obtain required building permit (see attached permit authorization form) 11 2 3_ Family home. ❑ 2. Provide certificate of insurance for workers compensation, general liability. (see attached certificates). ❑ 3. Provide job site dumpster, set on planks, to remove job related debris only. Please Note: dumpster for contractor's use only. (see dumpster clause). 9 ❑ 4. Prior to stripping roof, tarp sides of house beneath work area,from roof edge to bottom of wall. (see additional protection clause on back). ❑A ❑ 5. Keep job site in a clean and orderly manner. Rake work areas at end of job. Use magnetic sweep to pick up nails. ❑ 6. Provide OSHA approved staging to safely perform work. ❑ 7. Work consecutive days excluding inclement weather. (rain, snow, high winds, high heat,thunder showers, etc). ❑ 8. Staff project withualified mechanics experienced in residential asphalt roofing. a� ❑ ❑ 9. Strip existing 1��' 2 3_ layers of asphalt roofing (see roof plan, page 2). Number of squares A. one layer cedar removal. Number of squares B. one layer slate removal. Number of squares ❑ 10. Inspect roof deck prior to re-roofing. Renail loose boards: A. Replace rotted or cracked boards at$ — per linear foot. B. Install new plywood at$ 7S,*" per sheet. C. Number of sheets of plywood included into this estimate: Quantity_ (see unit cost above for additional sheets). ❑ 11. Furnish and install shingles. Color [� 1.2'Furnish and install 8"aluminum drip edge around roof perimeter.White Mill Brown ❑ 13. Install cedar drip edge at eaves under aluminum drip ecce. Linear ft L'J ❑14. Furnish and install ice/water shield at eaves 3' ,/6' other. Three feet in valleys and around all roof penetrations. 15. Furnish and install underlayment to entire roof. Roofer select Diamond Deck ,/ 2wr YlcMnc� ❑ ❑ 16. Furnish and install starter course shingles, eaves& rake. ❑ 17. Furnish and install hip and ridge. ❑18. Furnish and install new neoprene roof boots at soil pipes up to 4" in diameter. Quantity Size (boots at electrical mast to be reused). ❑ d 9. Reuse stove pipe flashing kits. L� ❑20. Reuse existing step flashing at roof/wall intersections. ❑ fZ1. Furnish and install new aluminum copper step flashing at roof/wall intersections. Linear feet . If siding work is needed, a cost assessment will be made at that time. 11 V❑2 . Reuse existing wall flashing at roof/wall intersection. 2 Furnish and install new aluminum wall flashing at roof/wall intersections. Linear feet . If siding work is needed, a cost ❑ � assessment will be made at that time. . Furnish and install new aluminum copper step flashing at base of chimney under existing lead counter flashing. 111 2 . Replace chimney lead counter flashing. 1 flue 2 flues 3 flues other ❑ f266. Install new roof hood to vent bathroom(s)with insulated flexible tube. Remove roof deck to gain access into attic. Color: black Jonly. ❑ 1�?S. Gutter Helmets to be removed and reinstalled by others. ❑ Remove and dispose of gutters attached with spike and ferrule. ❑ . Remove and reinstall existing gutters strapped to roof. Install straps der shingle over shingles ❑ [3 Remove and reinstall existing gutters with hidden hangers. Line eet ❑ 31. Reuse skylight flashing kits Replace skylight flashing kits Quantity I (Velux models, stock only). ❑ j 3 emove and dispose of the following:Antenna Snow/Ice Wires Snow Guards/Ice belts Solar panels ❑ emove Satellite Dish up to 24'in diameter. Alignment and installation by others. F-1PageTwo= ROOF PLAN. ❑ Page Three =VENTILATION. LJ/r36' 36. Page Four=VENTILATION PLAN. Addendum (A) =OTHER WORK. ❑ 38. Addendum (B) = LOW SLOPE ROOFING. ❑399 . Acceptance Page Initials Initials Initials Addendum (A) OTHER WORK I �G��d4S � S}�.r lL1lC`�✓'lnn�G �CG��Y�crr/C t.✓r/�'` �.7airlt�v Initials Initials Initials STURDY HOME IMPROVEMENT, INC. ACCEPTANCE PAGE MA REG. #151711 CT REG. #0601525 ANY WORK NOT STATED ON PREVIOUS PAGES IS EXCLUDED The following schedule will be adhered to unless circumstances beyond the contractor's control arise: Work scheduled to begin the week of03_/ 17 /26 _, Expected completion date;Q__/,ag_/A_Weather permitting. The cash price for labor and material as described above is: 1st payment 2nd payment 3rd payment 4th payment Contract Total (upon signing) Sia,14 O AMS� Roof $ Ventilation $ Other work $ Roofing total $ $ Ola $ bop $ /� 900 Siding $ $ A Z? $ $ $ Windows $ $ $ $ $ Special orders $ $ $ $ $ Other $ $ $ $ $ Totals $ $ $ $ $ i'erms: _Cash Finance Credit Card: Exp. date____ / ____ Code_ 'ayment schedule: 4ny balance not paid in full within thirty days, will be charged 1.8%interest per month. I order to meet the completion schedule, the following materiaUequipment must be SPECIAL ORDERED before the contracted work begins. 'Law requires that any deposit or down-payment required by the contractor before work begins,may not exceed the greater of(a.)one-third of the 'otal contract price or(b.)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the ;ompletion schedule) $ to be paid for $ to be paid for >ny additional work orders are to be paid for once accepted and approved by purchaser. /erbal understandings and agreements with representatives shall not be binding. All understandings and agreements must be set forth in writing in this :ontract. Additional provisions are stated on reverse side and are part of this contract. In witness whereof Purchaser(s)has/have hereunto signed their names his day of ALL.wr... 20 .21 and acknowledge receipt of a true copy of this contract. JNLESS OTHERWISE SPECIFIED, IT IS UI DERSTOOD THAT THE OWNER IS READY FOR THE WORK TO BEGIN. THE PURCHASE PRICE QUOTED \BOVE WILL BE HONORED ONLY UNTIL (Date). lou the Purchaser(s)may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See notice of cancella- ion form for an explanation of this right. Signature affixed below also acts as receipt that Purchaser(s) received separate cancellation forms. -he following is a requirement by Massachusetts General Law,Home Improvement Contractor Law MGL c 142A: 'The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract, the contractor nay submit such dispute to a private arbitration service which has been approved by the office of Consumer Affairs and Business Regulation and the consumer ;hall be required to submit to such arbitration as provided in MGL c 142A. iepresentative: Owner: Owner: JOTICE.The signatures of the parties above apply only to the agreement of the parties to alternate disput resolution initiated by the contractor. The owner nay initiate alternative dispute resolution even where this section is not signed separately by the parties" Do not sign this contract if there are any blan aces 'ubmitted Accepted y: by: (t iluza Representative urchaser bat accepted Accepted .y:_ by: Representative Purchaser Date A Conanonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructs°dr{I§upervisor CS-093603 E)yires;08/07/2021 DAVID DIAZ I 270 TREMONT ST SPRINGFIELD MA 0110 . Commissioner [/ 4� .&wwwnww� office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, M�g.sachusetts 02110 Home Improve mAt'G60tractor Registration Type: Supplement Card Registration: 151711 STURDY HOME IMPROVEMENT, INC Expiration: 06/25/2020 459 MAIN STREET INDIAN ORCHARD,MA 01151 t Update Address and Return Card. I 20M-W117 Qe%Mmronurear i o� uuFiiaelld Office of consumerAffairs&Business Regulation Registration valid for individual use only HOME IMPROVEMENT CONTRACTOR g TYPE 1 element Card before the expiration date. If found return to: Registraae Expiration Office of Consumer Affairs and Business Regulation al Expiration 1000 Washington Street-Suite 710 a == Boston,MA 02118 STURDY H04-1INIP6I'EME0T,INC )AVID DIAZ � �?—� -59 MAIN STREET : N t valid withAt Signature NDIAN ORCHARD,MA 01151 Undersecretary DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 8/7/2019 THIS CERTIFECATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPOM THE CERTIFICATE HOLDER.THIS CERTIFIATEBELOW•THISDCERT FIOES C ATEF OFINSURANCEDOESVELY OR ANOTLY AMEND, EXTEND OR ALTER THE CONST CONSTITUTE A CONTRACT BETWEEN COVERAGE SSUING NSURER(S),TPOLICIES 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). CONTACT PRODUCER NAME: Ma Beth Russell The Dowd Agencies,LLC PHONE 413 538-7444 FAc No).413-536-6020 14 Bobala Road EMAIL Holyoke MA 01040 PRODUCER info dowd.com cu o STURHOM-OZ INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURER A:James River Insurance Com an Sturdy Home Improvement,Inc. INSURERS: 459 Main Street STE 13 Indian Orchard MA 01151 INSURER.: INSURER D INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:1693186448 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. ILTR ADDL SUBR POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MMIDDNYYY A GENERAL LIABILITY 00084917-0 811/2019 8812020 EACH OCCURRENCE $1000000 DAMAMU X COMMERCIAL GENERAL LIABILITY PREMISES Ea occE IV 111=114 Iurrence $100,000 CLAIMS-MADE a OCCUR. MED EXP(Any oneperson) $6,000 PERSONAL&ADV INJURY $1000000 GENERAL AGGREGATE $2000,000 PRODUCTS-COMP/OP AGG $2,000,000 GENL AGGREGATE LIMIT APPLIES PER: POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ (Peraccident) HIRED AUTOS $ NON-OWNEDAUTOS $ UMBRELLA IIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ $ DEDUCTIBLE RETENTION $ WC STATU- OTH- WORKERS COMPENSATION ER AND EMPLOYERS'LIABILITYE.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUIIVE" MIA A OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ (Mandatory in NH) If yes,describe under EL.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below -7- -r DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED EXPIRATIONBEFORE THE W ACCCORDANCE WITHTHE POLICY THEREOF PROVISIONS. NOTICE WILL BE DELIVERED A THORIZED REPRESENTATNE �a ©1988-2009 ACORD CORPORATION. All rights reser✓ed. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD 7 p DATE(MMIDDIYYYY) A�o CERTIFICATE OF LIABILITY INSURANCE 07/22/2019 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(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). IOIT PRODUCER NAMEACT Mary Russell THE DOWD AGENCIES LLC a D"u . (413)437-1050 a/c No: AooREss: mrussell@dowd.com 14 Bobala Road INSURERS AFFORDING COVERAGE NAIC# HOLYOKE MA 01041 INSURERA: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: STURDY HOME IMPROVEMENT INC INSURERC: INSURER D: 459 MAIN STREET STE 13 INSURERE: INDIAN ORCHARD MA 01151 INSURER F: COVERAGES CERTIFICATE NUMBER: 427803 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 ADDLSUBR POLICY NUMBER MM/DDIMYY MMLICY EFF IIDDf(YYY EXP LIMITS LTR IN D WVD COMMERCIALGENERALLIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE F-1 OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY1:1 PRO ❑ LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: AUTOMOBILE LIABILITY COMBINED LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ �/ _ $ WORKERS COMPENSATION X STATUTE �RH AND EMPLOYERS'LIABILITY Y 1 N ANYPROPRIETOR/PARTNER/EXECUTIVE E.LEACH ACCIDENT $ 1,000,000 A OFFICER/M EMBER EXCLUDED, NIA NIA NIA 6HUB51336850519 07/21/2019 07/21/2020 E.L.DISEASE-EA EMPLOYEEI$ 1,000,000 (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.LDISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if 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.govllwd/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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Daniel M.Cr ey,CPCU,Vice President—Residual Market—WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'blv NaMe(Busuiess/Organization/Individual): 4ttvdve- Address: LAS �� k-3 City/State/Zip n �z i„ t`' �iT/1�� a�f� Phone#:_ Are you an employer?Check the appropriate box: Type of project(required): ttk Lm a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. [J Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.®I am a homeowner doing all work myself.[No workeis'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. Roof r airs These sub-contractors have employees and have workers'comp.insurance.t 6.[J We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other a 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 hue outside contractors must submit a new affidavit indicating such. $Contractors 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. lam an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. ---��- /��,� , Insurance Company Name: � � �" 1�/�emn 1� � a/�rAat , Policy#or Self-ins.Lic.# t9 Expiration Date: 714! 20 /A—AtJob Site Address: SLII✓u h L'a AV— City/State/Zip: I )64ta� PIA— Attach tach 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 One 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 One 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 pains and penalties of perjury that the information provided above is trite and correct Sipnature. - - aEi Date - Phone#: N I-�-;) Stns-mm, 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#: