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32A-167 (2) V ionl �Commercial Permit May 15,2000 /k\, Department use only ;' �^•n City of No"pn Status of Permit: Building Department Curb Cut/Driveway Permit - o 212 Main Street Sewer/Septic Availability `yro Room 100 Water/Well Availability o9T�G rthampton, MA 01060 Two Sets of Structural Plans �01one 13-587-1240 Fax 413-587-1272 Plot/Site Plans oti A"�cA Other Specify APPLICATIO ,'CS�t91�ISTRUCT, REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING S OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office [f�Ap Map -�>a 4 Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �d ,4- wA D -� Baa r �� �� �-Sf 2z-� x,.tX IVIAVrA,-- Name(Print) Current Mailing Address: Signature 1 t Telephone 2.2 Authorize ent: - 'j k D-6- � � �� Name(Print) Current Mailing Address: c� 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) X I/ 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date P- V— to -7 7 Issued Signature: Building Commissioner/Inspector of Buildings Date Version l.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofingg Change of Use❑ Other ❑ Brief Description Enter a brief description here. u-e— q Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ ❑ A-4 ❑ A-5 ❑ 18 ❑ B Business ❑ 2A ❑ E Educational ❑ 213 I ❑ F Factory ❑ F- ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1-1 1-2 ❑ 1-3 ❑ 313 ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use El Specify: S Special Use ❑ Specify: f COMPLETE THIS SECTION IF EXISTING BUILDING UNDERG NG RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Prop ed Use Group: Existing Hazard Index 780 CMR 34): Propose azard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING FjkOPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) f 1 St , St , 2^d 2 nd _ 3rd 4th Total Area(sf) Total Proposed New Construction(sf) Total Height(ft) Total Height ft 7.Water Supply(M.G.L. c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system[—] Versionl.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes O No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 4 ui e as Owner of the subject property hereby authorize L ' rz� < ` .1 d �,`� �t - -`t Q.,• to act on my behalf, in/all matters relative to work authorized by this building permit application. Signature of Owner Date S� x-}--' 1'e � `r >' J.�Q 1--Z4 -&-A.L 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 d penalties of perjury. Print Name Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:- � _SL � / � U ` � .: �C�.ts V L 6� License Number Address Expiration Date ---s Signature Telephone SECTION 13-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 buft King permit. Signed Affidavit Attached Yes No O City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: 'G-if 114:�/�� ,s j The debris will be transported by: k-k Q�' ( P (",,,) The debris will be received by: Building permit number: Name of Permit Applicant _ ,v oo 6 � ,�l y� . Date Signature of Permit Applicant Version 1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor .�—6f�od (0,01 O (A-17 �—F l�_ Not Applicable ❑ f Company Name: � (i fa- 0 , ate- c � /� ) S9 Responsible In Charge of Construction Address Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved �. parking) #of Parking Spaces Fill: (volume&Location A. Has a Special Permit/Variance/Findin ver been issued for/on the site? NO O DONT KNOW YES O IF YES, date issued: IF YES: Was the permit recor at the Registry of D ds? NO O D T KNOW O O IF YES: enter B Page and/or Document# B. Does the site cont n a brook, body of water or wetlands? NO O �ONT KNOW O YES O IF YES, has permit been or need to be obtained from the Conservation Co�tmission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O IF YES, describe size, type and location: E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. I ( � Proposal SEXTON ROOFING AND SIDING INC www.sextonroofing.com 41 1ro P.O. Box 6327 lomsallllM Holyoke, MA 01041 Settiiw the Standard _r ar lk p. 413.534.1234 f. 413.539.9906 MA HIC # 118239 sextonroofin a),hotmail.com SUBMITTED TO Robert Wade PHONE 218-0944 DATE 4/7/20 STREET 422 North Farms Rd JOB NAME Rental Property CITY STATE ZIP Northampton,Ma. JOB LOCATION 58 Hawley St Notham ton Ma. SEXTON ROOFING HEREBY SUBMITS SPECIFICATIONS AND ESTIMATES FOR: 1) Strip and remove existing shingles and dispose of in proper landfill. 2) Inspect roofing deck and replace as needed(a) $75.00 per sheet. 3) Install new metal edging to rakes and eaves of roof. (8") 4) Install ice and water shield on eaves(61), vent stacks, in valleys, chimney, and at intersecting roofs. 5) Install#15 synthetic roofing felt on remainder of roof. 6) Install new flanges over existing vent stacks. 7) Install starter shingles on eaves and rakes of roof. 8) Install IKO Architectural style roofing shingles as per manufacturers' specifications. 9) Install new counter flashing on chimney. (1) 10)Install new cap over ridge vent. 11) Supply manufactures Lifetime warranty and SRC 5 yr. workmanship warranty. We Prropose hereby to furnish materia/and/aboi com /ete in accordance with the above specn7cations for the amount of Sixteen Thousand FourNandred DOLLA/?D 6 PAYMENTS ro MADE AS FOLOWS. due in full upon completion All Material is guaranteed to be as specified. All work to be completed in a Authorized workmanlike manner according to standard practices. Any alteration or Signature deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.DAMAGES TO BUSHES AND OTHER VEGETATION'MARKS ON HOUSE MAY Note:This proposal may be withdrawn by us if not accepted BE UNAVOIDABLE AND WE ARE HELD HARMLESS. Not responsible for water within(14)days. damage during construction. Owner to pay responsible legal fees for non- payment,and applicable interest. 21ereVtanee of J)ropooal The above prices, specifications and conditions are satisfactory and are hereby accepted. You Signature are authorized to the work as specified. Payment will be made as outlined above. Signature Date of Acceptance. , f'',', at ,�,iY"s'�i��t"�.. .1's'"Y\.'..d;,'`�,..T.A.'�-$.�ial.r r•4tR� .s`3<°��P �i'�:.'!►` . ,"•! ..'>A.Y'•�:'+� ��.'.",�'sG�s4'lfs:3�.�":' ',- - ;�. .:. A 414 +,.�,y� Y. �� ..`a.Ire.�. • i {�p1S Z �A.. r. �.-y_� .'r i•'�.��� ,�`�rt(-,y _ ,Z�q•' r., ..S. ,}.�• :�I�:.t�K t'a '. rl.!Y ... r r F. r '.s+'s s•s.Se".\r l s. ��...:� £� '_i r't` .. -35 41 alp %r " �,,•J3$r c y .. s , '�•tT'�i! _. �F.�;�-'s�.7... �`-w"�� {,� �,�drS'„��'. .s.� ;6.�t7'�ry.Qc.. 4.,&;.� i. . ti, ?t x' Y } it 12: Z r ,�`•7' # v t' < +.': 'te r _ ''' Yv .. AN 5f: t�+',.,,►+�'Pd '`t••-Ai1.. h,:�� *• s << f , Vii':"x 3 1^ :{if4: ,?s-CLti 11', y < v7 .Y h l4fa !'• u;, £ h' 7 i' • �1`I,fa;t ,j�•r - '� 14 IV t Si.�.y'lt3h!'¢� .tt � J � ,r A ...,. - s� l.r�rl .a it-,► ;r+9yy+�'9Yt'.', r .�' __ ....__ r • .� . � + '•�.- "' Pk JAe,. tr .. Y ,ISR tt .1Ns,* ..'Yr . . . ..may: .. .. _ � ,•�,. _ The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,Masi 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name 03usiness/org,izaition/Individ„al):Sexton Roofing & Siding Inc Address:P.O. Box 6327 Cit,/Stat p:Holyoke, Ma_ 01041 Phone#_413-534-'1234 Are you an employer?Check the appropriate box: Type of project(required): 1_ L' I am an employer with 4.;R I am a general contractor and I 6.LJ New construction employees(full and/or part time).* have hired the sub-contractors 7.['Remodeling 2_ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have S.C1 Demolition working for me in any capacity_ employees and have workers' 9.C7 Bmldin-addition [No workers'comp_insurance comp_insurance. required] 5_ We are a corporation and its 10_1'7 Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11_ U 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. ❑Other comp_insurance required.] *Any applicant that checks box--1 must also Fill out the section below showing their workers'compensation policy information. j Homeowners who submit finis atFidavit indicating they are doing all work and then hire outside contractors mast submit a urw affidavit indicating such_ ;Contactors that cbeck this box mast attach an additional sheet showing the name of the subcoutractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that it providing workers'compensation insurance for my employees.Belaw is the policy mrd job site Travelers Property Casualty Company of America Insurance mpmy Name: -- Policy#or Self-ins.Lie.#:UB-00078982-19 E 06/04/2020 Expiration Date: Job Site Address: �i1w 1 "� City/State/Zip: Q 64L t/ L 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 tip-to-$1,500.00 ann/or one year imprisonment as we as cl`vil pens ties 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 ofthe DIA for coverage verification- I do herby certify der the pains and penalties of perjury that the information provided above is true and correct Signature: / Date: Print Name: � '<^�^ices_';. "`�; c_; Phone#: L+ . fir r -- Official use only Do not write in this area to he completed by city or town official City or Town: Permitilicense#: Issuing Authority(circle one): !.Board of Heath 2- Building Department 3_City/Town Clerk 4_Electrical Inspector 5-Plumbing Inspector 6.Other Contact person: Phone#: ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMMD/YYYY) zi TWSXEITIFICATE 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: OLDERIMPORTANT_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 713 (A/C,No,Ext)-- (A/C,No): E-MAIL WESTSPRINGFIELD,MA 01090 ADDRESS: 286TF INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAY=PS PROPERTY CASUALTY CONIPANY OF AMERICA SEXTON ROOFING&SIDING INC INSURER B: INSURER C: INSURER D: PO BOX 6327 INSURER E HOLYOKE,MA 01041 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 POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDrr1ONS OF SUCH POLICIES_LIMNS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. WSR DDL iUBR POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE SR WVD POLICY NUMBER (MMIDDIYYYY) (NMDMYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE i$ COMMERCIAL GENERAL LWBILITY ; DAMAGE TO RENTED CLAIMS MADE OCCUR. ;5 REMISES(Ea occurrence) I ED EXP(Any one person) j$ ERSONAL&ADV INJURY ;$ GEN'LAGGREGATE UMITAPPUES PER: ENERALAGGREGATE I$ POLICY F-1 PROJECT F-1 LOC RODUCTS-COMP/OP AGG j S AUTOMOBILE LIABILITY COMBINED SINGLE i$ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY j$ SCHEDULE AUTOS Per person) f HIRED AUTOS BODILY INJURY 'S Per accident) � NON-OWNED AUTOS PROPERTY DAMAGE ib (Per acddent) f UMBRELLAUAB OCCUR EACH OCCURRENCE iS EXCESS LIAB B CLAIMS-MADE AGGREGATE $ DEDUCTIBLE S RETENTION $ I$ A WORKER'S COMPENSATION AND X I WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-0G078982-19 06/042019 06/042020 LIMITS ANY PROPERITORIPARTNER/EXECUTIVE [T] NIA E_L EACH ACCIDENT j 5 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E_LDISEASE-EAEMPLOYEEi$ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS beias EL DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPEFATIONS/LOCATTONSNEHICLESIRESTRICTIONS!SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS CONIP COVERAGE. THE INSURED-S ALA WORKERS CONIPENSATION POLICY.4,,D ITS LIMITED OTHER STATES ENDORSEMENT AUTHORIZES THE PAYNIENT OF BENEFITS FOR CLAIMS NtADE BY THE INSL='S MA L%PLOYEFS IN STATES OTHER THAN M4 NO AUTHORIZATION IS GIVEN TO PAY C A,IVIS FOR BENEFITS IN STATES OTHER THAN MA IF THE INSURED HIRES,OR HAS ISD EMPLOYEES OUTSIDE OF NI- THIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA- CERTIFICATE ACERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLI BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS_ AUTHORIZED REPRESENT ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION_ All rights reserved. SEXTO-2 OP ID.- ER A� a CERTIFICATE OF LIABILITY INSURANCE DATE(NM1DDDiYYYY) 07/10/2019 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 have ADDITIONAL INSURED provisions or be endorsed_ If SUBROGATION 1S 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 413-737-0300 NAME:A `T Enc Dembinske Ormsby Insurance Agency,Inc. PHONE 413-737-0300 FAX 413-737-0617 698 Westfield St PO Box 718 IAiG No.E>d►_ (Air,Noy: West Springfield,MA 01090 E-+++UL omlSbyI corn — - Eric Dembirtske ADDRESS: —__ _. TNSURE RJ _AFFORDINGCOVERAGE _ NAIC# - -- INSURERA:COIOny Insurance CO. INSURER B Quincy Mutual Fre Insurance 15067 �ttoiiDRoofing&Siding,Inc. PO Box 6327 INSURER C: Holyoke,MA 01041 INSURER D_ - INSURER 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 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- INSR TYPE OF INSURANCE -BR POLICY NUMBER POLICY EV I POLICY E� -- umns A X COMMERCIAL GENERAL LIABILITY 1,000,000 ( � EACH OCCURRENCE $ _ CLAIMS-MAGE [X]OCCUR 101GL002159903 06/2512019;0612012020 PFZEWGEToocagy 100,000 - { MED EXP IAny one person $ 5,000 I 4 _ _ PERSONAL a ADV INJURY g 1,000,000 GEN1-AGGREGATE LIMIT APPLIES PER: i fl GENERAL AGGREGATE a 2,000,000 POLICY C-1 JE� LOG y I PRODUCTS-COMP/0P AG_G S 2,000,000 OTHER: If I s B AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT 1,000,000 I IEa acdderltl E_ ANY AUTO AFV206561 05/15/201910511512020 BODILY INJURY(Per�erson s AUTOS LX A��ULEDEp N..p BODILY INJURY er accidentSX. AUTOS ONLY AUTOS ONLLY I PROPERTY DAMAGE } LPer,acc- __L_...._ ....___ .5_. ' a UMBRELLA UABOCCUR I j EACH OCCURRENCE $ ESIJ EXCESS AB CLAIMS-MADE i ---- AGGREGATE 5 DED ! RETENTION 5 i S WORKERS COMPENSATIONI ' PLR OTH- AND ENPLDYERS'LIABILITY Y/N A ER _- ANY PROPRIETORIPARTNERJE ECUTNE O BE SENT SEPERATELY OFFICER/MEMBER IXCLUDED? N/A EL EACH ACCIDENT i (Mandatary in NH) I EL.DISEASE-FA EMPLOYE S If yes,describe under I - —._...--- DESCRIPTION OF OPERATIONS belrnr i I EL DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER - CANCELLATION NONE-01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Everett Sexton ACCORDANCE WITH THE POUC!PROVISIONS_ AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION- All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth ofMassachusetts �-- Department of Industrial Accidents 1 Congresv Street,Suite 100 Boston,MA 02.114-2017 www.mass.»ov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITT1VG AUTHOR1Tl'. Applicant Information Please Print Legibly Business/Organization Name:MNP CONSTRUCTION INC Address:45 EXCAHNGE ST City/State/Zip:MILFORD, MA. 01757 Phone#:508-498-8870 Are you an employer?Check the appropriate box: Business Type(required): 1.0 1 am a employer with 5 employees(full and` 5. ❑Retail or part-time).* 6. E]RestaurandBarlEatingEstablishment 2.0 1 am a sole proprietor or partnership and have no 7. E]Office ancb'or Sales(incl real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8.. 0 Non-profit :i.0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees. [No workers'comp. insurance required]' ` 4.E] 11.❑Health Care We are a non-profit organization,staffed by volunteers, with no employees.[No workers' comp.insurance req.1 12.[D Other CONTRACTOR *Any applicaw that checks box#1 must also fill out the.section below showing their workers'compensation policy information. ''l f the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box k 1. 1 am an employer that is providing workers'compensation insurance for my employees Below is thepolicy information. Insurance Company Name:HARTFORD UNDERWRITERS INS. CO. TRAVELERS-RMD insurer's Address:P.O. BOX 5600 City/State/Zip: HARTFORD, CT. 06102 Policy;r or Self-i.ns.Lic.41 K769706 19 Expiration Date:1 Ill612Q;kfp 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 c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or ane-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine —nfup_to-S250:00-a-dav-againstthe-violato —Be-advised-that a copy of t isstatement may be forwarded to the Office of Investigations of the DfA for insurance coverage verification. 1 do herehv certi u� p t d 'pities ofperjuiy that the information provided above is true and correct S i anature: !; Date: Phone n:978- 403-5942 Official use only. Do not write in this area,to be completed by city or town official Citv orTown: Permit/License# issuing Authority(circle one): 1.Board of Health 2. Building Department 3.Cit-v/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: ��1vH•,mass.�ov./dia CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DON" THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANDIGHTS UPON THE CERTIFICATE HOLDER.THIS CONFERS NO RHIS 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 d certificate holder in lieu of such endorsement(s)_ does not confer rights to the PRODUCHr CONTACT ONE FAMILY INSURANCE AGENCY LLC PHONE NAMEE— Art Calvlllo LAIC No,ESI; (978)403-5942 --- (AlC, 1 Main St Suite 15 ADDRESS- acalvillO128@yahoo_com LUnenburg _ 1NSUR-,ERIS)AFFORDINGCOVERAGE NAIC# INSURED --- ----------- MA 01462 INSURERA: HARTFORD UNDERWRITERS INS CO 30104 MNP CONSTRUCTION INC 'NSIIRERB= INSURER C: --- 45 EXCHANGE ST APT 3E INS!-_ D: — MILFORD INSURER E: - COVERAGESMA 01757 INSURERF CERTIFICATE NUMBER: 478475 : — — THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDNAMEDREVISION ERTIFICATE MAY BE ISSUED OR MAY PERTAIN, ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM EXCLUSIONS AND CONDITIONS OF SUCH POLICIESS, INSR .LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- --- LTR TYPE OF INSURANCE ADOL!SUS D' POPOLICY EFF _ V'I LICYNUMBER MINlDi POLICY EXP COMMERCIALGENERAL LIABILfry D LIMITS . ( CLAIMS-MADE ❑OCCUR I EACH OCCURRENCE s ! DA MA E TO RENTED PRF7YIISES once S N/A MED EXP(Arty one person) S ---- GENLAGGREGA_TE LIMIT APPLIES PER; ! I PERSONAL&ADV INJURY $ POLICY JJECT 1-1 LOC G�ERALAGGREGATE ; OTHER' ! PRODUCTS_COMP/OPAGG $ AUTOMOBILE LIABILnY ANY AUTO � i acddeDS SINGLE LIMITALL S _.. AUTOS OWNED =ULED I N/A i BODILY INJURY(Per person)) S HIRI:DAUTOS NON-OWNED BODILY INJURY(Per accident) S AUTOS -PRPRO PaD----- AM erac AMAGE $ ._..--__-_ UMBRELLA UAB � S PRPP OCCUR 1O(CE5$LIAR CLAtMS-MADEM/A I EACH OCCURRENCE S DED I RETENTION$ AGGREGATE $ -- WORKERS CONPEALSATION AND EMPLOYERS,LIABILITY I ANYPRv YIN X i PER OTH- OPRIETOR/PARTNER/EECLntVE I , STATUTE ER A OFFICER/MEMBER EXCLUDED? NIA WA I WA I (Mandatory in NH) ! 6S60UBiK70970619 11/16/2019 11/16/2020 E.L.EACH ACCIDENT $ 1,000,000 yes. IPTIOeunder Ddescribe I ! EL DISEASE-EAEMpLO $ 1,000,000 DESCON OF OpERAT70NS below ! i _ j EL DISEASE-POLICY LIMIT S 1,000,000 } 1 N/A —__-- DESCR1Pi1pN 0_F_0__ PERATIONS I LOCATIONS 1 VEHICLES(ACORD 707,Additional Remarks Schedule,may be attached if rnorp Workers'Compensation benefits Will be paid to Massachusetts employees only.Pursuant to Endorsement is 20 03 06 B,no authorizabon 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. Seartool at www-mass.govBwd/worke This certificate of insurance shows the policy in force on the date that certificate was issued(unless the expiration date on the above policy precedes the t this 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 www -compensationCnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELIED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SEXTON ROOFING & SIDING INC ACCORDANCE WITH THE POLICY PROVISIONS. 102 PINE ST AUTHORIZED REPRESENTATNE HOLYOKE MA 01041 Daniel M.Cr04y,CPCU,Vice President–Residual Market–WCRIBMA ACORD 25(2014!01) The ACORD name and logo are registered marks of ACORD O�CORPORATION_ All rights reserved. n DATE(NM1DDNYY`() CERTIFICATE OF LIABILITY INSURANCE 11/27119 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: OLDERIMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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: Art Calvillo One Family Insurance P�HoNEE,d_ 978-403-5942 tX FArC No): 978-403 943 1 Main St Suite 15 E-MAIL a lfami Irtsurance.com Lunenburg,MA 01462 ADDRESS INSURER(S)AFFORDING COVERAGE NAIC It INSURERA: Evanston Insurance Company INSURED INSURER 9: MNP CONSTRUCTION,INC. INSURER C: 45 EXCHANGE ST APT 3E INSURER D MILFORD,MA 01757 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 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 'NSR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER YID MMfD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X OCCUR PREMISES Ea occurrence S 100,000 MED EXP one n S 5,000 A Y Y 3ET9385 11/03/19 11/03/20 PERSONAL BADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑,'a F ]LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER S AUTOMOBILE LIABILITY COMBINED, SINGLE LIMIT $ acciden ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Peramdent) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY (Per acadenl 5 UMBRELLA LIABOCCUR EACH OCCURRENCE S EXCESS LIAR HCLAIMS-MADE AGGREGATE S DED I I RETENTIONS S WORKERS COMPENSATION PER OTH- AND EMS PLOYERLIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE❑ NIA EL EACH ACCIDENT $ OFFICERIL"BER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(ACORD 101,Addi oral Remarks Schedule,maybe attached it more space is required) CERTIFICATE HOMER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN SEXTON ROOFING&SIDING INC ACCORDANCE WITH THE POLICY PROVISIONS. 102 PINE ST P.O.BOX 6327 AUTHORIZED REPRESENTATIVE HOLYOKE,MA 01040 ART CALVILLO ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 01 ;{HnalmerAffaks ll;l �d $tlsiR 021 Is � Sas' ��Suite 77� ��0� ome Imp,0,e"Mt a fl-—R`3X I—J27 FNG SIDING INCRer tyP� CarFor on LiOLYOfCT �SrIA fl1E3 r7 W _ 7-T x:9 02(1 - --- ——tom � .a � pO BOX 6327 A'OME I"nTwje; , c ZONTPAcZ„OR T SE-vTOtV sR 1 '�. S HOL.`d 01040 24u ' EXTOINRpp - Rca�s�on aX,FTlV`'&.S�zNG Co 'RC-0605383 Effective, SIGNED 1.2 1_12011 Expiration - 11/30/2020 Commonwealth of Massachusetts �•_�_ - _ �= Division of Professional Licensure Board of Building Regulations and Standards Construction,S'4�ei-jspr Specialty CSSL-099689 E1/E 4 Exxpires:14DI ZO2 POB XO ER S��(TON 27, HOLYOKE MA,01041 - :y Commissioners