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13-014 (6) 11 LAUREL LN BP-2021-0077 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 13 -014 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:windows replaced BUILDING P E RM I T Permit# BP-2021-0077 Proiect# JS-2021-000120 Est.Cost:$14400.00 Fee: $97.50 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: STURDY HOME IMPROVEMENT 093603 Lot Size(sg. ft.): 19602.00 Owner: LAMOTHE PHILIP Zoning. Applicant: STURDY HOME IMPROVEMENT AT: 11 LAUREL LN Applicant Address: Phone: Insurance: 459 MAIN ST STE 13 (413) 543-5906 WC INDIAN ORCHARDMA01151 ISSUED ON:7/21/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 17 REPLACEMENT WINDOWS AND 1 DOOR POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 7/21/2020 0:00:00 $97.50 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Status of Permit: Building Department Curti Cut/Driveway Permit f 212 Main Street Sewer/Septic Availability !� Room 100 Water/Well Availability '- Northampton, MA 01060 Two Sets of Structural Plans o one 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify w O 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 Lct r) c Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Thi 11�1P �Li Ntc�1'l��t I L ,✓ La,vt �/ti-� /A Name(Print) Current Mailing Address: ( "'113) RL Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: r Signature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building I Lf, qn . on (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee /+ 4. Mechanical (HVAC) 5. Fire Protection 6 6. Total= 0 + 2 +3 +4+5) �� Check Number This Section For Official Use Only Date Building Permit Number: �" ��' . � / Issued: Signature: -7- 21-Z40 ZQ Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 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/Finding /ever been issued for/on the site? NO © DON'T KNOW y YES IF YES, date issued: Ill��7 IF YES: Was the permit recorded at the Registry Deeds? NO O DON'T KNOW YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 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 (D,,,-' IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, excav i n, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 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 ❑ Replacemen W' dows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[p] Other[O] Brief D cription of Propc&Qd - Work:'Ktnb Ute} A213 426 VLf�� 1}k&)-- :kOLA� W^y�h 1 y 1714*3 Ca�gCvoee' Alteration of existing bedroom Yes No Adding new bedroom Yes Not/`' Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT kI, L 1 I op as Owner of the subject property hereby authorize � �'�` `—� '�1 L. to act on my behalf, in all matters relative fb work authorized by this building ermit application. Signature of Owner Date I, V�`1 � N = as Owner/Authorized Agent hereby declare that the statements and information on 1he foregoing application are true and accurate,to the best of my knowledge and belief. ned under the pains a penalties of perjury. ig ature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor li Not Applicable ❑ Name of License Holder: -O V ck tel/{�Z e J — d`r i 3l Y o 3 License Nu r 4SS r t V, Ste- S� 3 �,G . V4 Cr, Ad j Expiration Date Signature %plhbae 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name M�l Registration Number Address r r Expirati n bate Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavit must b completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the b (ding it. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton i Massachusetts !<< DEPARTMENT OF BUILDING INSPECTIONS Z 212 Main Street • Municipal Building Northampton, MA 01060 fs •»� O 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: I h-UXAA, S Est. Cost: Address of Work: 1 V51V oo Date of Permit Application: 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: rz�L- �kA_ 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 ;w Northampton, MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: (Please print house number and street name) Is to be disposed of at: LAS4 WAxJ l�-AJSL�vv (Please print name and location of f cility) Or will be disposed of in a dumpster onsite rented or leased from: tEA�'u\/U)C , (Company Name and Address) Si ature of Permit Applicant or Own ate 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. • 4b`J IYlaltt JUeel Toll Free (877)378-8739Springfield,MA 01151 9�9%�o Mv k A 0 r Worcester (548' 797-6600 E-mail:HR®SturdyHome.com Springfield (413)"543-5906STURDY www.SturdyHome.com New Haven (203)848-2118 Fax (413)543-3200 WINDOWS SIDING '• ROOFING • ADDITIONS MA REG.#151711 CT REG.#0601525 f 1 r,` ► Home Phone Business Phone Name Address Cell Phone Other 1 1 (.. AA&i LldwG Tow City Representative Date 14W 114< (' &";W 11we the owner(s)of the premises described hereinafter, referred to as Owner,offer to contract with Sturdy Home Improvent, Inc.hereinafter referred to as Contractor,to furnish,deliver and arrange for installation of all materials to improve the premises as described below. Yes No WINDOW SCOPE OF WORK: Z ❑ 1. Contractor to obtain required building permit(see attached permit authorization form) 1�2 3 Family home. Uj� ❑ 2. Provide certificate of insurance for workers compensation,general liability. (see attached certificates). Ld ❑ 3. Keep job site in a clean and orderly manner in a broom swept condition. ( ❑ 4. Provide job site dumpster,set on planks,to remove job related debris only. Please Nate:dumpster for contractor's use only. (see dumpster clause). ❑ 5. Homeowner to remove all personal contents away from all windows as needed in order to install windows. If additional labor is needed at the time in order to remove personal items,a cost assessment will be made at that time. &r ❑ 6. Provide manufacturers warranty on all windows. UK ❑ 7. Remove and dispose f (quantity)windows, L;Fr ❑ 8. Remove and disp of 1? (quantity)storms. 5r ❑ 9. Remove and reinstal stops. please note: if stops need to be replaced,an additional cost assessment will be made at that time. �❑ 10.Remove and reinstall trim. Please note:if trim needs to be replaced,an additional cost assessment will be made at that time. Please note. The normal process of removing stops and trim on o!d windows will disturb paint/statns/wood on windows. Sturdy Home Improvement, Inc. will-not be held liable for any palnt/stain/wood surrounding the opening of any windows. LJ U1111. Remove weights in pockets and dispose. [A' ❑12. Insulate vZeWhttaw&s with fiberglass insulation. �SG� • ❑13, Provide all silicone'sealant. ❑14. install aluminum wraps around windows. Quantity l Color [•]' 1015. install new V-6 replacement windows. Quantity y" Manufacturer Z5b Stw tModei CLt ❑ WrT6.Install new construction windows. Quantity 40� Manufacturer Model ❑ ir17. Install bay/bow windows,Vinyl______ a_Wood­_____, 2_ Quantity, D Manufacturer Model Other IJ 18. Install new glazing on each window:Low-E O Low-E with argon other ❑ e19. Install grids in each window: 5/8" © Colonial style­___0 other O GBG 0 Interior Grids, SDL h Brasstone Brushed Nickel Top Sash 0 Bottom Sash-----4—> - i ❑20. install new hardware on window. Color f� `� t� aluminum � fiber lass !r' ❑21. Provide screens with windows:half screens /J ��full screens g !�IJ22. Owner agrees to meet the installer during the hours of 7 AM to 4 PM for final measurements. All final measurements will be made by the Installer. Failure to meet with installer will delay the Installation of windows. [(�3. Addendum(A)=OTHER WORK. j fvCL (J1 e�, d��-torn. 8 Sri�s S'To,c». 'ptwo..– wtl k ❑ ❑24:Acceptance Page ❑ ❑25. Work not included: i. Final cleaning of windows 2.Any rotted wood(other: tnitinIn Initials initials TURDY HOME IMPROVEMENT, INC. ACCEPTANCE PAGE MA REG.#151711 CT REG.#0601525 NY WORK NOT STATED ON PREVIOUS PAGES IS EXCLUDED ie following schedule will be adhered to unless circumstances beyond the contractor's control arise: 'ork scheduled to begin the week of-____/- —J_—_.•Expected completion date____/_!_Weather permitting. ie cash price for labor and material as described above Is: '1st payment 2nd payment 3rd payment 4th payment Contract Total (u on signing) W, /; plAAky Roof $ i► 'DelIU-i-t , "'�'`p �WI G of-CTo4' Ventilation Other work $ 4U., TIlSet�uk_Aj AMI 't Roofing total $ $ $ $ $ Siding $ $ $ $ $ Windows $ V3,(.00 $ $_ $ $ Special orders $_ $ $ $ $ Other Tobit-, $ gCk�, $ p$ $ $� 17 Totals $ i g goo $ ,,�\c( � 5700,Loo $ 5 bo. " $ 15 00. :rms: _Cash Finance �\ Credit Card:#_ _ _ _ - _ _ _ - — - _ _ — Exp.date----/ Code iyment schedule: / ,y balance not paid In full within thirty days,will be charged 1.8%Interest per month. order to meet the completion schedule,the following material/equipment must be SPECiAL ORDEREfJ before the contracted work begins. awrequires that any deposit or down-payment required by the contractor before work begins,may not exceed the greater of(a_)one.•thlyd of the fat contract price or(b)the actual cost of any special equipment or custom made material which must he special ordered In advance to meet the unpleflon schedule) $_f- to be paid for ,$ to be paid fory iy additional work orders are to he paid for once accepted and approved by purchaser. irbal understandings and agreements with representatives shall not be binding. All understandings and agreements must be set forth In writing in this ntract.•Additional provisions are stated on reverse side and are part of this contract. in witness whereof Purchaser(s)has/have hereunto signed their names s_ ;2+H day of Vim- 20!Ld . and acknowledge receipt of a true copy of this contract. VLESS OTHERWISE SPECIFIED,IT IS UNDERSTOOD THAT THE OWNER IS READY FOR THE WORK TO BEGIN. THE PURCHASE PRICE QUOTED 3OVE WILL BE HONORED ONLY UNTIL (Date). iu the Purchaser(s)may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See notice of pancella- n form for an explanation of this right. Signature affixed below also acts as receipt that Purchaser(s)received separate cancellation forms. is following is a requirement by Massachusetts General Law,Home Improvement Contractor Lacy MCIL c 142A: he contractor and.the homeowner hereby mutually agree in advance that.In the event that the contractor has a dispute concernfng.this contract,the contractor 3y submit such dispute to a private arbitration service which has been approved by the office of ConsumerAlfairs and Business Regulation and the consumer all be required to submit tosuch arbitration as provided in MGL c 142A. ipresentative: V[�f'TK� hfv�-G�jG� Owner: Owner: MCE:The signatures of the parties above apply only to the.agreement of the parties to alternate dispute resolution Initiated by the contractor. The owner iy initiate alternative dispute resolution even where this section is not signed separately by the parties" Do not sign this contract it there are any blanks aces bmitted /) ,4Cl'4, Accepted <G&r(�'LJ by: Representative Purchaser• Date cepted Accepted by: Commonwealth of Massachusetts It®i� Division of Professional Licensure Board of Building Regulations and Standards ConstrM&Or3 Supervisor CS-093603 Expires: 08107/2021 DAVID DIAZ'.• 270 TREMONT ST SPRINGFIELD MA 01104 I I Commissioner ��Pi ���ni��2�/?iCltP�iCiG���i���L21✓�,-�'C1��CGr�-Pi��' Office of Consumer Affairs and Business Regulation: 1000 Washington Street e Suite 710 Boston, Massachusetts 02110 Home Improvement Contractor Registration Type: Supplement Card Registration: 151711 STURDY HOME IMPROVEMENT, INC Expiration: 06/25/2022 459 MAIN STREET INDIAN ORCHARD,MA 01151 Update Address and Return Card. CA 1 0 20M-05/17 � r .P 4/91/Y1,4/1-CC-L'CL�L 4-✓ 'Cl1)QC 1CCJ'P-l�J Office of Consumer Affair's&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 1517f!—:'1. 06/25/2022 1000 Washington Street Suite 710 STURDY HOME IMPROVEMENT,INC Boston,MA 02118 DAVID DIAZ 459 MAIN STREET;;. D;, �� _ �✓ INDIAN ORCHARMA 01151 Undersecretary N®t valid With®uthi nature D�817120 CERTIFICATE OF LIABILITY INSURANCE 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 THHETPOLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Ma Beth Russell The Dowd Agencies,LLC PH c°N o£ :413-538-7444 plc No)(Al4I3-536 6020 14 Bobala Road EMAIL Holyoke MA 01040 ADDREss: info@dowd.com PRODUCER STURHOM-02 CU TO ID# INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:James River Insurance Com an Sturdy Home Improvement, Inc. INSURERS: 459 Main Street S T E 13 Indian Orchard MA 01151 INSURERC: INSURER D. INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1693186448 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iNSR AODL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVD POLICY NUMBERMMIDDIYYYY MMIDDIYYYY A GENERAL LIABILITY 00084917-0 Bf112019 8812020 EACH OCCURRENCE $1,000,000 )C DAMAGE RE D COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $100 000 CLAIMS-MADE [75�]OCCUR, MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $2000000 POLICY PRO - LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULEDAUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION ORWC STIM�US ER AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT $ ANY PROPRIETORIPARTNERIEXECUTIV= OFFICERIMEMBEREXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,descr be under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. A THORIZED REPRESENTATIVE -------------- ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD p DATE(MM/DD/YYYY) AC"R o CERTIFICATE OF LIABILITY INSURANCE 07/22/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT Ma Russell PRODUCER NAME: Mary THE DOWD AGENCIES LLC PHON o Ext: (413)437-1050 FAX No: E-MAIL ADDRESS: mrussell@dowd.com 14 Bobala Road INSURER(S)AFFORDING COVERAGE NAIC# HOLYOKE MA 01041 INSURERA: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: STURDY HOME IMPROVEMENT INC INSURER C; INSURER D: 459 MAIN STREET STE 13 INSURERE: INDIAN ORCHARD MA 01151 INSURER F: COVERAGES CERTIFICATE NUMBER: 427803 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _FTINS TYPE OF AODLSUBR POLICYNUMBER MM/DD1YEYYY MMLDDY EXP LIMITS LTR INSD WVD COMMERCIALGENERAL LIABILITY EACHOCCURRENCE $ DAM TO RENTED CLAIMS-MADE F OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO ❑LOC PRODUCTS-COMP/OPAGG $ JECT $ OTHER: Ea COMBINED ccidetnSINGLE LIMIT $ AUTOMOBILE LIABILITY BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE NON-OWNED Per accident $ HIRED AUTOS AUTOS $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION /� STATUTE EERH AND EMPLOYERS'LIABILITY Y 1 N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED7 NIA NIA NIA 6HUB5B36850519 07/21/2019 07/21/2020 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If as,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization Is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Daniel M.Crcyey,CPCU,Vice President—Residual Market—WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents a 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ,, ++ Please Print Legibly Name(Business/Organization/Individual): =�1?trn1V me_n�-:17rtL Address: i4S9 UCA I"S4,cy e + S-�d l City/State/Zip• i ti ©i- r Phone#: (Ll I�9 S4 3^ S9 d Are you an employer?Check the appropriate box: Type of project(required): 1.�am a employer with _employees(full and/or part-time).* 7. E]New construction 2.FJ 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.FJ I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ttOf 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.eher ) 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. - Insurance Company Name: �►�G V S S Policy#or Self-ins.Lic.#: (P tt(Ab5133(og 7o Slq Expiration Date: '21 -2 b Z O Job Site Address: tj C C U,{ f, L C/1.01� City/State/Zip: J 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 v 'fication. I do he ebyrdify under the pains andpenal res of perjury that the information provided abov is true and correct Si allb Date: ' Phone#: 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#: