Loading...
35-043 (11) 971 RYAN RD BP-2021-0024 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35-043 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Catego!y: ROOF BUILDING PERMIT Permit# BP-2021-0024 Project# JS-2021-000031 Est.Cost: $8500.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sg.ft.): 19994.04 Owner., COSMIAN DUTCH Zoning,: Applicant. SEXTON ROOFING CO AT. 971 RYAN RD Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 W(' HOLYOKEMA01041 ISSUED ON.71812 02 0 0.00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy SiLnature: FeeType: Date Paid: Amount: Building 7/8/2020 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis.Hasbrouck—Building Commissioner ` t ` Department use only City of North�rrlpt tatus of Permit: Building Dep�rtm nt bCuUDriveway Permit i 212 Main 'Str /Ser/Se icAvailability J Room 10Q r/W IIAvailability Northampton, MA 01 set of Structural Plans phone 413-587-1240 Fax 41 ' i Plans ()In r; other pecify APPLICATION 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 ? � . d f /J Map v� Lot Unit A- Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: 0 ,*YGc-^( a4-�,�i Telepho5e Signature 2. Authorized A ent: Name(Prin Current Mailing Address: s"-3 Y z-,3 y 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 Lo//� 4. Mechanical (HVAC) '�-It1v1 5. Fire Protection 6. Total=(1 +2+3+4+5) 'jj Check Number This Section For Official Use Only �,(� Building Permit Number. :-::]DateIssued: Signature: -7- 8-ZOW Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) �Ehi+R LL( tyw [-a� Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information 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 I Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces i Fill: volume&Location A. Has a Special Permit/Varianc 'nding ever been issued for/on the site? NO O DONT K W YES O IF YES, date issued: IF YES: Was the permit r rded at the egistry of Deeds? NO O NT KNOW YES O IF YES: enter B k Page and/or Document# B. Does the site contain brook, body of water o wetlands? NO O DONT KNOW O YES O IF YES, has a per it been or need to be obtain from the Conservation Commission? Needs to be ob ained 0 Obtained O , Date Issued: C. Do any signs ex�st on the property? YESO NO O r IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs inte ed 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. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) Roofing Or Doors ED Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [O] Other[dj Brief Description o�,Proposed / Work ►^V c l-e- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa If New house and or addition to existing housing complete the followinq 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 new con<grade irFiensions e. Number of stories? f. Method of heating? or Woodstoves Number of each g. Energy Conservation Compliance. k Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of tlannstruction within 100 yr. floodplain Yes No j. Depth of basement or ce r floor belo i k. Will buildingconfo 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 LI ('&S p► t A nJ as Owner of the subject property hereby authorize 473 - (ZC-'CJY l /,Z' to act on my behalf, in all matters relative to work authorized by this building permit application. r /, Signature of Owner L� D to 71, L `L , as Owner/Authorized AgehtFere-by declare that the statements and information on the f6regoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains Wd penalties of perjury. Print Name S ure of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Constructioupervisor. j� Not Applicable ❑ Name of License Holder: L Iroy- JJ l License Number U C� ole 40 lo-s- —z Address Expiration Date Signature Telephone 9.Rodstered Home Improvement Contractor: Not Applicable ❑ ComDanv Name Registration Number , e L -7 /—,X A Address Expi tion Date Q (� 0 t! G � Telephone 5 3 biz 3 L/ 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...... D City of Northampton <<� •' Massachusetts rf DEPAR71AMT OF BUILDING INSPECTIONS \\ 212 Main Street • Municipal Building yJd �D Northampton, MR 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: /ozLw�-- Est. Cost:—Z -0 *Z r Address of Work: / /�� /,✓ Date of Permit Application: ("3 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 herebyap ly for a building permit as the agent of the owner: el 14 Date Contractor NaAe 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 pilyws- 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: (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 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. Proposal SEXTON ROOFING AND SIDING INC www.sexton roofi n g.com 4fivo P.O. Box 6327 Setting the Standard Holyoke, MA 01041 p. 413.534.1234 f. 413.539.9906 MA HIC# 118239 sextonroofing@hotmail.com SUBMITTED TO Dutch Cosmain PHONE 888-6382 DATE 616/20 STREET 971 Ryan Rd ___ JOB NAME CITY,STATE,ZIP Florence,Ma. JOB LOCATION 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 @ $75.00 per sheet. 3) Install new metal edging to rakes and eaves of roof. (8") 4) Install ice and water shield on eaves ( 6'), 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. (Add $300.00 per chimney if needed) 10)Install new cap over ridge vent. 11)Supply manufactures Lifetime warranty and SRC 5 yr. workmanship warranty. i I We Propose hereby to Awrrhrh maty AW and labor-conWhP&in accordance wfth the above iyaNcallonsr for amamow.t o% E/ght Thousand Flw iflwmhrd DOLLAM (S ,SOQ.aO) PAYNENT3 TO BE MADE As FOLOW due In full uparn_ 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 BE UNAVOIDABLE AND WE ARE HELD HARMLESS. Not responsible for water Note: This proposal may be withdrawn by us if not accepted damage during construction. Owner to pay responsible legal fees for non- within (14)days. payment,and applicable interest. Acceptance of Proposal The above prices, Signature specifications and conditions are satisfactory and are Si 9 hereby accepted. You are authorized to the work as specified. Payment will be made as outlined above. Date of Acceptance. Signature The Commonwealth of Massachusetts Department of Industrial Accidents �d Office of Investigations Lafayette City Center / 2 Avenue de Lafayette, Boston,MA 02111-1750 =� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Sexton Roofing & Siding, Inc Address:P.O. Box 6327 City/State/Zip:Holyoke, MA 01041 Phone#:413-534-1234 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.n Roof repairs insurance required.] t c. 152, §1(4),and we have no 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. 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:Travelers Property CAS CO OF AM Policy#or Self-ins. Lic. #:7PJUBOG07898220 Expiration Date:6/4121 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for Jigrance coverage verification. I do hereby certify under t ins and penalties of perjury that the information provided above is true and correct. Sig-nature: Date: Phone#: 413-534-1234 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 1❑Board of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5alumbing Inspector 6.❑Other Contact Person: Phone#: CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDrrrr() 06/09/2020 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(Sb 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 an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemerd(s). PRODUCER CONTACT NAME Kathi Hutchinson ORMSBY INSURANCE AGENCY (AICONN Exti: (413)737-0300 a No)- ADD ,: : khutchinson@ormsbyins.com P O BOX 718 INSU S AFFORDING COVERAGE NAIC# WEST SPRINGFIELD MA 01090 INSURERA: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B: SEXTON ROOFING &SIDING INC INSURER C: INSURER D- PO BOX 6327 INSURER E: HOLYOKE MA 01041 INSURER F: COVERAGES CERTIFICATE NUMBER: 541733 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. INS-11 LTR TYPE OF INSURANCE FNSD WVDSUBRI POLICY NUMBER MMID POLICY EFF MMIDDt ERP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE O Ea R CLAIMS-MADE OCCUR _PREMISESocaarence $ MED-EXP(Any one pennon) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ' GENERALAGGREGATE $ POLICY D PROJECT LOC PRODUCTS-COMPIOPAGG $ OTHER: $ AUTOMOSILELIABILITYCOMB INED SINGLE LIMIT $ Ea acdde ANYAUTO - BODILY INJURY(Per perwn) S ALL OWNED SCHEDULED N/A BODILY INJURY(Per aaiden( $ AUTOS AUTOS ) NON-OWNED PROPERTY DAMAGE HIRED AUTOSAUTOS Per accident) $ S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE NIA AGGREGATE $ DED I RETENTIONS E WORKERS COMPENSATION V PER OT AND EMPLOYERS'LIABILITY YIN /� ANYPROPRIETORfPARTNERIEXECUTIVE EL EACH ACCIDENT S 1,000,000 A OFFICERIMEMBEREXCLUDED? NIA wA 7PJUBOG07898220 06/042020 06/04/2021 (Mandatory in NH) EL DISEASE-EA EMPLOYEd$ 1,000,000 If yes,describe leder DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 107,Additional Remarks Sctwdule,nay 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-compensahonrinvestigations/. 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. _ AUTHORIZIDREPRESENTATIVE Amherst MA 01002 Daniel M.Coy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD AcoR�® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) Illk.� 6/26/2020 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 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 NAME: Ormsby Insurance Agency,Inc. PHONE FAX _. 698 Westfield Street (E MCNNo.Ertl: (413)737-0300 (413)737 0617 ADDRESS: West Springfield,MA 01089 NOUREF AFFORDING COVERAGE Rw aX INSURERA: Colony Insurance Company, 39993 INSURED INSURER B: Sexton Roofing and Siding Inc INSURERC: 102 Pine Street INSURER D: Holyoke,MAO 1040 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. _ - 1 TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LTR D POLICY NUMBER MMID MWM1LIMITS A X COMMERCIAL GENERALLIABIUTY 101PKGO02159905 6/25/2020 6/25/2021 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I OCCUR DAMAGE T RENTED PREMISES Eaoocurrenoa $ 100,E MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY $ 30,000 GEWL AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 N CT LOC -COMPlOP AGG i 2,000,000 POLICY 1:1 JE OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT— (Ea Ea accident ANY AUTO BODILY INJURY(Per person) S ATOSCHEDULED AUUTOSS AUTOS INJURY(Per BODILY $ HIRED AUTOS NON-OWNED 1 PROPERTY DAMAGE $ AUTOS Per ooddertt S UMBRELLA LIAB OCCUR EACH OCCURRENCE i EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION $ WORKERS COMPENSATION PER TOTH- AND EMPLOYERS'LIABILITY YIN ATUTE R ANY PROPRIETOR/PARTNER/EXECUTIVEF—] N/A E.L.EACH ACCIDENT = OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under = DESCRIPTION OF OPERATIONS bekrw E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached d 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD r The Commonweab*of Massachuseits De¢arfnwnt of Ind uM ial Accidents _ ij I Congress Stree4 Suite 100 Roston,M-A 02114-2017 W4lti4.mas&a ov1dLa IK-i..kers Compensation Inmrnnce Affidavit:Builders!Contractor-slf;lectriC=nslPlumbers, TO BE FILED WITH THE PER'*Ifl-MNG ATTMORM'_ Al2yHc.nt information rr se Print i.cZibh'. Name(Business`ortanization.Individual)_ Address: i ; r t^itciState!'�ip_ �'L1,� �I� l Q ! 7-�-7 Phone#: Arc cos are emptoytr?Check the appropriate box: ! Type of project(required): !LJ i am a c"Tlo}% ttiith—----emplo}ec5(full mtdlorpart-tim)-- t ?_ E]New construction , 2.❑Imua;olepmpritmworpartrterstupsnd1cvtnoformeia ; 8 E]Remodeling MY ca -city.[No workers'comp,rnstua=required.] i z 3-F]I am a bonwo mcrdotag all vtiwk mvsdf LNowori ccs' f j 9. ❑Demolition i rxrmp.ttutaztxrrCquozd]' 10 El Building addition 4 E]I am a homcown rand mll be hiring conhactoTr to conduct alt v;er'd en ray property- 1 will ter=that all corm stors either h1v cuvrl Gra'wrepeuzsatioa ir>surarrtc oc are sole 1 ! I I.Q Electrical repairs or additions propriclors with no cmPirnx-cs 32 E]Pltmtbing repairs or additions 5-❑I=a ger aa1 canuactor mrd I have hired the sob-cuni[xtors listed on the nttmnh�d zha 13 Q Roof repairs rncszsul*c�ctrnshnzcmpioyresand have wuias-comp.i xa:r,n=- 60 we area corporation and its officers have aerciscd their u.-la of exemption per NIGL c- ; 14.E]Other M 15.' §I(4),and ue l-ve no employees [No v%vz xrs'comp.insurance requirrd-1 j 'Am'aMticmrt-at chid s box 9I roust also fill out the scctou below slxvvacg their urska6'aumpenszrbun policy mforrr==- t Honreavvtttrs echo submit this affidava mdi=1mgthey are doing all ami:sed Chert him outsi Ic contrao =must Sttbenrt a neve affidavit uLdtattu r such =Cantrxtors that check this box must atmcbcd an additioml she:t shm%,uT the tame of the sub-conaactor =J shite%,bc-i teror not those crhi tie,]rase cngtlo;ccs_ tf the sub-mrrr�^io-.s!mvt mTkKees,they must Favide their warkem'comp.policy number. 1 am rue enWoyer dua is providing worms'cor*,,nrsairon Insurance for my employers. Below is the pobcy and job site irrforrrtol7orL _ Insurance Company'Name. �'4'N''4'N'VA- hr) 1Ct�44Y(J',Ncc S Policy T or Self-ins.Lic_;~: 7r 7U tv Expiration Date: tr! Job Site Address: City/Stafelzip: Attach a copy of the workers'compensation polity declaration page(showing the policy number and expiration date). Failure to secure coverage as required ander MGL c.I57,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-yea imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to V-50.00 a day against the violator_A copy oftlis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verigcatiort_ 1 do hereby certify underthepai s and penalties of perzsry that the Wornzation prosided a&osr is tme and cm7rrt Signature' -/Z,-4, Phone Ojf,rtvd zme only. Do not write in flus arra to be completed by city or town ojjzcizd City or Town_ Permit/License Issuing Authority(circle one): I_Board of Health 2.BuildinglDepsriment 3_City)Town Clerh 4.Electrical Inspector 5.Plumbing Inspector .6.Other Contact Person_ Phone "AOC"R[7® CERTIFICATE OF LIABILITY INSURANCE DATE(17Mr1DDlYYYy) a' THIS CERTIFICATE IS ISSUED AS A MA �:. ITER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE C 11/27I207g CERTIFICATE DOES NOT AFARMATiVEI Y OR NEGATNIIY AMEND, CERTIFICATE HOLDER THIS r BELOW_ THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE B THE COVERAGE AFFORDED BY THE POLICIES f5 REPRESENTATNE OR PRODU ETWEEN THE ISSUING INSURER(S), AUTHORIZED CER,AND THE CERTIFICATE HOLDER rf" HOLDER- IMPORTANT- the certrficabe holder is an ADQIT1ONAl the teras and conditions of _INSURED,the policy(ies)must be endorsed- If SUBROGAN TION IS WAIVED,subject to . the pot; certificate hall--- lieu of such endorsement(S�Gcies may require an endorsement A statement on this certificate does not carrier rights to the PRODUCER ONE FAMILY INSURANCE AGENCY LLC PI) M CalvH►o No (978)403-5942 FAX JAX No- t Main St Suite 15 A acahnllo128@yahoo_com Lunenburg INSU AFFDRffiiG COVERAGE NAIL n INSURED MA 01462 A: HARTFORD UNDERWRITERS INS CO 30104 MNP CONSTRUCTION INC INSURER B: INSURER C 45 EXCHANGE ST APT 3E INSURER D MILFORD INSURER E- COVERAGES MA 01757 INSrrRERF- CERTIFICATE NUMBER- 478475 THIS IS TO CB�TIFY THAT THE POLICIES OF INSURANCE LISTED BEL W HA BSN ISSUED TO THE INSURED NAKED ABOVE THE POLICY PERIOD ON NUMBEjz- INDICATED- NOTWITHSTANDING ANY REQUIREMENT CERTIFICATE MAY BE I.iSUm OR MAY p�fpJN TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VYITII INSPECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, INSR LTR TYPE OFINSURANCE ADD7� POLIC-YNUMBER POLrm-EFF f POUC.YEXP COMMERCIAL GENERAL Lmeri-rY 1 LIMITS � I r'°IA—M DE FIOCCUR EACH OCCURRENCE S I O14MAA 7U RBYTED PRE]b115E5 omarP -S 1 N/A M®EXP(Arty aw pe son) S GEN'LAGGREGATEUMITAPPLIESPER- y PERSONAL&ADV INJURY 5 POUCYPRO- r��1 1 E]JECT ,—1 LOC 1 GENEAALAGCREGATE $ OTHER: ' f PRODUCTS-DpMPIOPAGG S AU7DMOBILE11AgILl7y -----'---- s ANYAUTO i COMBINED SINGLE LWIT ALL 1 $ AUTOS SCHEiDLRID NIA BODILY INJURY Pg�n) S HIRED AUTOSNAllTOS ED !� BOOILYB�LRJRY(Pa-addenl� S — - -- J I PROPERTY DAMgGE— L7MIBFtf11 6 Upg I(( S OCCUR S EXCESS LIAB CLAIM_5-MADE + N/A L EACH OCCURRENCE S DED l RETENTION S S WORXERS COMPENSATBIN — -------- --- AND HIPLOYESS-UABHJr r t S YIN PER A ANYPOFF)CERIMEMBER EXQ CED? NfA NIA WA !ERADcEcurivEI STATUTEER (bm>ia4*yinNH) ❑ 6S60UB11Q0970615 - 11/16/2019+11/1612020 ELEACHACC[r)-- S 1,000,000 It res.desolbe under 3 1 OESCRfPnON OFOPERAE-L DISEASE_FA EMPL TIONS below � S 1,000,000 + ELDISEASE-POucyLIMIT S 1,000,000 i N/A -:DESMVr;bNOF0 - - _.-- PERATW NS/LOCJCTIONS/1tEFflCLJ=S(ACORD 107,AddiSami Ramria 5etredul ' Workers'Compensation benefits Ionil be paid to Massachusetts em a�be auWPgx e Z&req1Emd) claims for benefits to employees in states id to Man Massachusetts Only-Pursuant to Endorsement WC 20 03 06 B,no authorizafron is given to pay assachusetts 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 issue date oat w w_macerMs of irlsurarrce)_ The status of this coverage can be monitored daily by accessing ttte prhoof of Coverve age on date an the Policy Precedes rage Verification e Searrtt tool atwwwsrrass_govltwdAvorkers-compensation nvestiga6ons! CERTIFICATE HOLDER CANCELLATION ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIAADESEXTON ROOFING SIDING INC THE �'p" DATE TT'�OF, NOTICE INACCORDANCE WITH THE POLICY PROVISIONS102 PINE ST UTHORIZEDD REPRESENTATIVE HOLYOI� MA 01041 M-Cro vyCPCU,Vice President—Resid ACORD 25(2014101) ©1988-2014 ACORD CORPORATION- All rights reserved. The ACORD name and logo are reist registered marls of ACORD i {, DATE(HMIDD/YYY'n CERTIFICATE OF LIABILITY INSURANCE 11127119 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 condrSons of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certirficate holder in lieu of such endorsement(s)- PRODUCER CONTACT NAME: Art Cahnllo One Family Insurance PHONE Ea 973-403-5342FAX No 978-403'SS43 1 Main SL Suite 13 E-MAIL Lunenburg,MA 01462 ADDRESS_ art@lfamilyirmurance.com INSURER(S)AFFORDING COVERAGE NAIC 9 INSURERA: Evanston Insurance Company INSURED RISLIRER B MNP CONSTRUCTION,WC. INSURER C- 45 EXCHANGE ST APT 3E MILFORD,MA 01757 INSURER D: INSURER E: ORSURIIR F_ COVERAGES CERTIFICATE NUMBER REVISION NUMBER THIS IS TO CERTIFY THATTHE 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 SUB,IECrTD ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ POLICY EFF POLICY ERP LTR TYPE OF INSURANCE NSD WVD POLICY NIJUSE2 MM wD LIACTS X I COMMERt7AL GENERAL LI UMM EACH OCCURRENCE S 1,000,000 CLAIMS-tJADE �OCCUR PRE�M15 100,000 WD EXP one pw ) 5 5,000 A Y Y 3ETS385 11/03/19 11/03120 PERSONAL dACV MJURY 5 1,000,000 GENLAGGREGATELIMRAPPLIES PER GENERAL AGGREGATE 5 2,000,000 JECT �LOC PRODUCTS-COMFIOPAGG S 2,000,000 POLICY E] PRO-OTHER $ AUTONORM ITARRITY - CAMBSINGLE LPArr $ ANY AUTO BODILY NJURY(Per permn) $ OWNED SCHEDLILED AUTOS ONLY AUTOS BODILY JURY(Prac�nt) S UTOS Q� HIRED NON-OWNED PROPERTY DAMAGE S ALROS ONLY AUTOS ONLY amdentl 5 UMBRELLA LIASOCCUR EACH OCCURRENCE S EXCF3S LIAR HCLAIMS-MADE - AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION AME ER AND EIMPLOYERSLLANLrTY YIN ANY PROPRIETORIPARTN6LE)GH;UT1VE L EACH ACCIDENT 5 OFrICEtA"BER EXCLUDED> ❑ E NIA (Man Litnry in NH) EL DLSEASE-EA EMPLOYEE S (ryes,de�cnbe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LMrr S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORDlt".Addifivaal Rettnri,-cSchchde,mzybea=cbeddmame pa stegemtid) ffi CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCHIF BEFORE THE EXPIRATION DATE THEREOF,NOTICE MLL BE DELIVERED IN SEXTON ROOFING&SIDING INC ACCORDANCE WITH THE POLICY PROWSIONS. 102 PINE ST P.O.BOX 6327 AUTHORIZED REPRESENTATIVE HOLYOKE,MA 01040 ART CALVILLO ©1988-2015 ACORD CORPORATION_ All rights reserved- ACORD eservedACORD 25(2016103) The ACORD name and logo are registered marks of ACORD OM� - Colo lm I 4 emelt-S � � PLO 1OLI'DK>�i+6�1 iE9 _ Expkagum 02n EOATE PO,BO-X6327 vE $L� rp � MII1L�:CONS .• F ERE -7 SE 'OGTpR SIZ YJoLyoTING* CO SIGNED Fnvc: 0/2020 T Commonwealth d,Massachuse - t Division of Profess7onal licensure Board of 11-Trg-g Regulations and St,Adards Constru(:ff --c 'Ft• IIpen sqr Spe , Ity CSSL-099689 =.<.- " E-xpires-10/0512027 EV>=F2E7T J S�OAk__ HOLYOKE mkt 07 'fK041:- :-.= Commissioner /�-{ �