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24C-147 (2)
I ARLINGTON PL BP-2020-1306 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24C- 147 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category: KITCHEN RENO BUILDING PERMIT Permit# BP-2020-1306 Proiect# JS-2020-002190 Est.Cost: $43000.00 Fee: $279.50 PERMISSION IS HEREBY GRANTED TO.- Const. O.Const.Class: Contractor: License: Use Group: THOMAS DADMUN 107919 Lot Size(sa.ft.): 10672.20 Owner: FLYNN RICHARD A& MARY G Zoning: URB(100)/ Applicant: THOMAS DADMUN AT. 1 ARLINGTON PL Applicant Address: Phone: Insurance: 60 SCHOOL ST 1 (413)387-7381 HATFIELDMA01038 ISSUED ON:6/30/2020 0.00:00 TO PERFORM THE FOLLOWING WORK:KITCHEN RENO POST THIS CARD SO IT ISVISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Servicq: 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: FeeTyne: Date Paid: Amount: Building 6/30/2020 0:00:00 $279.50 �12 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner ass ��► t i Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability : 1 ! Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans ; phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify N l94zi1 N TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office i A41 ?L/C Map oLot 7 Unit F-T*A-VA to ti 1k 0(.D(00 Zone_ Overlay District Elm St. District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature V 0iJ l 2.2 Authorized Agent: Name(Pi t)( Current Mailing Address: 413- 73M Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building Z . (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing C �� Building Permit Fee / 5'0 4. Mechanical (HVAC) ` 5. Fire Protection LIU 6. Total = 1 +2+3 +4+5 u- ( ) b Check Number Q /� 7 /,T,his Section For Official Use Only Building Permit Number:e> r �17Z0K Date Issued: Signature: Building`Commissioner/Inspector of Buildings Date �D (�\L Gl l lJ 11 Ci Ltri PA @ 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 15TH' Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[O] Other[a Brief Description of Proposed `- Work: [6 t( pp�. tp krkoutL ll?LW�1�� (4F�IL wlopo") r• FIACI MMW1' Alteration of existing bedroom Yes_?_� No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement YesC�No Plans Attached Roll -Sheet 6a. If New house and or addition to existinq 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. 1. 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 1, 1 1 (�b ��l&2 1-) , as Owner of the subject property II-� hereby authorize T�6,AA-6 WOkA,,,J to act on my behalf, in all matters relative to work authorized by this building permit application. R' I� �J o�_ g , 2-02, Signatu e of Owner Date 1, T144kAA-, Kj-o 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. T40 VA 9A-D KvIJ Print Name Signature of Owner/Agent Date SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ p (� Name of License Holder. t 1 j�642 mA, 1/�MLd V�?— License Number Addres1�0� Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ (jq �6) Company Name Registration Number -M-i- -tUCAL�,t (ANOP, uu: b1),11� Address C . Expiration Date (aO SLt,4-,�DL Sri kNt Ll , M A bj0h Telephone 40 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....... No...... ❑ City of Northampton i Massachusetts w zjL DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 010601'"' jy�a'C 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: k`c oz--J 4woaa Est.Cost: `E 7�,i noO � Address of Work: RIVE N O(L%,IhAQ t-0, O At 0(0�O Date of Permit Application: v 01- 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: ��Lg 14, - 4m k�, Dk'2KVJ 179 &)- Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS ; 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: 1 hz�4 0 i-tvii k�� (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) llw� �j.(�4-6L� ( 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. The Commonwealth of Massachusetts Department of Industrial Accidents s 1 Congress Street,Suite 100 a 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 ;�...,,.V�`` �, II � Please Print Leuihk Name (Business/Organization/Ind�vidual): 1v t, (/T1WaP h�wti Address: (00 z. St. City/State/Zip: l -WUP, MA bLo-bn Phone#: +3'3�?"�3�� Are you an employer?Check the appropriate box: Type of project(required): l.[:]I am 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. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.F1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E] Building addition 4.[:]1 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 I I.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 1I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof 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. :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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 4 0 b M>� Z Zo Expiration Date: Job Site Address: l Aaw(� PL City/State/Zip: NOJTJ prtq q, �ar IANIO 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 certif under the pains ( d p nalties of perjury that the information provided above is true and correct Signature: n�N�i. � U tri Date: Phone#• `� �b " I b b 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#: NOTICE H NOTICE TO a TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA02111 (617) 727-4900 — www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 4614 BUFFALO, NY 14240-4614 ADDRESS OF INSURANCE COMPANY (7PJUB-4N82783-2-20) 02-26-20 TO 02-26-21 POLICY NUMBER EFFECTIVE DATES KING & CUSHMAN INC P 0 BOX 447 176 KING ST NORTHAMPTON MA 01060 NAME OF INSURANCE AGENT ADDRESS PHONE # 0 TUCKER GROUP LLC, THE DBA 60 SCHOOL ST 0 DADMUN DESIGN AND CONSTRUCTION HATFIELD MA 01038 EMPLOYER ADDRESS N EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS =595 W20PIGIS TO BE POSTED BY EMPLOYER Commonwealth of Massachusetts Division of professional Licensure Board of Building Regulations and Standards Constro&i6rl`SUpervisor CS-107919 ��ires:0912V2021 THOMAS DADMUN y 60 SCHOOL ST HATFIELD MA 01038 " Commissioner P�71-w ola6wad� Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Horne Improvement Contractor Registration Type: LLC Registration: 179682 THE TUCKER GROUP LLC. M Expiration: 08;27;2020 60 SCHOOL ST HATFIELD,MA 01038 �M rs �y sa Update Address and Return Card. SCA t tS 20M05J17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. if found return to: 81 ration Ex iration Office of Consumer Affairs and Business Regulation 173682 0$;27,12020 1000 Washington Street-Suite 710 THE TUCKER GROUP LLC. Boston,MA 02118 r ---- ,J' THO}v1AS DADMUN60 SCHOOL SCHOOL ST HATFIELD,MA 01038 Undersecretary Not valid without signature DADMUN Design + Construction Project Address: SubContractor List 1 Arlington Place 29-Jun-20 Northampton, MA 01060 Subcontractor: Has Employees: Yes No SMG Plumbing and Heating X James Elkins Electrician X Northern Granite X Rightway Drywall X Executive Painting X Cortina Tile X CORTTIL-01 LJUKIC ,4coR�' CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/ `--�� 03/06122020020 Y) 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 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 NAMEACT Mary Henderson People's United Insurance Agency,Inc. PHONE FAX One Monarch Place,10th Fir (ac,No,Ext):(413)735-6545 835 (A/C,No):(844)645-1330 Springfield,MA 01144 E•DRIE ,Mary.Henderson peoples.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Merchants Mutual Insurance Co 23329 INSURED INSURER 8: Cortina Tile of West Springfield INSURER C: 1645 Riverdale Street INSURER D West Springfield,MA 01089 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. INSR TYPE OF INSURANCE AN D SSD WVp POLICY NUMBER POLICY EFF POLICY EXPLTR loplyyyyl LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1'000'000 CLAIMS-MADE 7 OCCUR BOP1071849 03/30/2020 03/30/2021 DAMAGE TO RENTED 500,000 PREMISES Ea occurrence $ MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1'000'000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY[::]JEa F]LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COM.d n SINGLE LIMIT $ ANY AUTO BODILY INJURY Per personL $ OWNED SCHEDULED HAU TOSONLY AUUTOpSyyN BODILY INJURY Per accident $ AUTOS ONLY AUTOS ONLY PPeOr a Z AMAGE $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1'000'000 EXCESS LIAR CLAIMS-MADE CUP9146566 03/30/2020 03/30/2021 AGGREGATE $ 1'000'000 DED I X I RETENTION$ 10,000 $ A WORKERS COMPENSATION X PER LITE I OTH- ER AND EMPLOYERS'LIABILITY STAT ER CA1033448 03/30/2020 03/30/2021 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If es,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached K more space is required) Proof of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DADMUN Design+Construction THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Tom Dadmun 60 School Street Hatfield,MA 01038 AUTHORIZED REPRESENTATIVE X &'a ZGre&d 76"�e r*wef, 7w, ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A��® F777E'MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 2,12/2020 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 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 UUNIAGI NAME: Andrea Hill, The Jarrett Agency PHONE 8607454222 g y A/C,No,Ext); (A/C,No): L_MAIL 657 Enfield Street ADDRESS: andreah@koveragegroup.atm INSURER(S)AFFORDING COVERAGE NAIC# Enfield CT 06082 INSURER A: UTICA FIRST INS CO 15326 INSURED INSURER B: Executive Painting&Wall Covering LLC INSURER C 10 SOUTH RD INSURER D INSURER E: ENFIELD CT 06082 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. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMD/YYYY) (MMIDD/YYYY) LIMITS /D X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 41 OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A ART5139982-00 02/13/2020 02/13/2021 PERSONAL a ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 XPOLICYEl PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: ITenants Liability $ 50,000 AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ 1 $ WORKERS COMPENSATION PER UIH_ AND EMPLOYERS'LIABILITY Y/N STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ FFICER/MEMBER EXCLUDED? N I A Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ f yes,describe under ESCRIPTION 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) Holder as noted is additional insured with written agreement not to exceed the limits,[emu or conditions or any policy noted herein. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Dadmun Design&Construction ACCORDANCE WITH THE POLICY PROVISIONS. 60 School Strcct AUTHORIZED REPRESENTATIVE Hatfield MA 01038 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/04/2020 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 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 CONTACT Lynn Bar NAME: y Barry Goss&McLain Insurance Agency A'CNo Ext): (413)534-7355 n//c,No): (413)536-9286 1767 Northampton Street E-MAIL ADDRESS: INSURERS)AFFORDING COVERAGE NAIC q Holyoke MA 01041-1128 INSURERA: National Grange Mutual 29939 INSURED INSURER B: Workers Compensation Insurance 0050 Prestige Granite Inc,DBA:Northern Granite LLC INSURER C: 380 Union Street INSURER 0: INSURER E: West Springfield MA 01089 INSURER F COVERAGES CERTIFICATE NUMBER: CL205406002 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 POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MMIDD/YYYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �/ �E 500,000 CLAIMS-MADE X OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ 10,000 A MP15382Z 04/01/2020 04/01/2021 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY 0 PRO LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) $ 1,000,000 A OWNED IX SCHEDULED MIT2939W 04/01/2020 04/01/2021 BODILYINJURY(Peraccident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY AUTOS ONLY Per accident Underinsured motorist $ UMBRELLA LB "'�"" WE`l""""' 1,000,000 X OCCUR EACH OCCURRENCE $ A EXCESSLIIAB HCLAIMS-MADE CUT2939W 04/01/2020 04/01/2021 AGGREGATE $ X DED RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITYvIN STATUTE ER B ANYPROPRIR/PARTNER/EXECUTIVE __1 N/A AWC-400-7033443-2019 10/26/2019 10/26/2020 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBMBER EXCLUDED? 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) granite installation. Officer of Corp.,Slava Katko,is excluded from workers comp coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Thomas Dadmun ACCORDANCE WITH THE POLICY PROVISIONS. 60 School Street AUTHORIZED REPRESENTATIVE Hatfield MA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DATE(MM/DD/YYYY) ,� r�r.►J CERTIFICATE OF LIABILITY INSURANCE 02/11/20 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 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 CONIACI NAME: Karina Linares Dale A Frank Insurance Agency,Inc. ../CONN Ell: 413-665-8324 FAX No): 413-665-1280 PO Box 455 E-MAIL Sunderland,MA 01375 ADDRESS: info@DaleFranklnsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: RPS-Northfield Insurance INSURED INSURER B: Progressive Rlghtway Drywall Inc. INSURER C Brian Johnson INSURER D 206 Coles Meadow Road Northampton,MA 01060-1111 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. INSR RULIL SUHK POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY MMIDDIYYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO REN I E:n— CLAIMS-MADE FIOCCUR PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 A WS411028 01/20/20 01/20/21 PERSONAL B ADV INJURY S 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 "'CT E' LOC PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY� OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ 250,000 B OWNED SCHEDULED 02849700-4 01/26/20 01/26/21 BODILY INJURY(Per accident) $ 500,000 AUTOS ONLY AUTOS $ 100'000 HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION 5 $ WORKERS COMPENSATION SER__ __ EMPLOYERS'LIABILITY Y/N STATUTE I JER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes describe under 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) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN DADMUN Design+Construction ACCORDANCE WITH THE POLICY PROVISIONS. Tom Dadmun 60 School St AUTHORIZED REPRESENTATIVE Hatfield,ma 01038 Karina Linares ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD