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38B-060
BP-2021-2135 279 SOUTH ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 38B-060-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-2135 PERMISSION IS HEREBY GRANTED TO: Project# ROOF Contractor: License: US METAL ROOFING Est. Cost: 17300 DISTRIBUTORS, INC 115825 Const.Class: Exp.Date: 12/31/2024 Use Group: Owner: BRUNELL SHARI L Lot Size (sq.ft.) Zoning: URB Applicant: US METAL ROOFING DISTRIBUTORS, INC Applicant Address Phone: Insurance: 740 HIGH ST, SUITE 2 4133749470 WC2-3 I S-6 1 6974-0 1 1 HOLYOKE, MA 01040 ISSUED ON:11/03/2021 TO PERFORM THE FOLLOWING WORK: NEW 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. Signature: If CI° Fees Paid: $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner --------.4 Z=11,...,/_..E0 A The Commonwealth of Massach s Nov W Board of Building Regulations and$tanOR Massachusetts State Code;780CIPLTI Y Building f� . F USE Building Permit Application To Construct,Repair!Renov :t 4S#;�1�� Revi d Mar 2011 h'.Ma n,n ol° S One-or Two-Family Dwelling This Section For Official Use Only BuildingPermit Nu er: '�+I 'A6 3 Date Applied: ' C-VIiJ 1 05} //. Z'ZoZ 1 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 r179p c e ,dress:S ( 1.2 Assessors Map&Parcel Numbers ou , 1.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 qw ner of Record: Shan Bru/)e// itIDrftiar 10►-jAfi Name(Print) City,State, a3q sdvjt, 54 y13-531-756e Sh4,zbashetzb. Lom No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2 (check all that apply) New Construction 0 Existing Building 0 Owner-Occupied/A Repairs(s) pe Alteration(s) 0 Addition 0 i Demolition CI Accessory Bldg. 0 Number of Units Other CI'Specify: See cttl1c1 ,orofoca1 Brief Description of Proposed Work': I ', SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1 Building $ 17 O!v 1. Building Permit Fee: $ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: Check No.11 /check Amount:6 I-10 Cash Amount: 6. Total Project Cost: $ ' 7l 300 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS— 115 saa.5 la I3i Re kko-et rt License Number Expiration Date Name of CSL Holder U 01 y q Qa4Ps Rat List CSL Type(see below) No.and Street Type Description A. . SO r j� .7 0 U Unrestricted(Buildings up to 35,000 Cu.ft.) /1'n R Restricted 1&2 Family Dwelling City own,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances LI13-37t 9y7D betykuldra-c1-aSyahoo,cern. I Insulation Telephone Email addr D Demolition 5.2 Registered Home Improvement Contractor(HIC) 3 y-7 y 1 /'$(acaa (Y1e4a l Roo 4 t)M 'an C.- HIC Registration Number Expiration Date HIC Company,1Name or HI Regi ame `t0 �fn 5 StI re '4- e i tt,Q s me lrno4nq,coin No. d Street Email address �J l of Dice MA olOLIO yC337y-94/7D ig City/Tow State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.$ 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 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize O,S i (YI€c a.\ RD o�• t s# -my) to act on my behalf,in all matters relative to work authorized by this building permit alication. Shan; Brunet( id/a8/ao41 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER1 OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. R42.2rA /ayl Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" _ The Commonwealth of Massachusetts "'4�` Department of industrial Accidents 111I � 1 Congress Street,Suite 100 =105Boston,MA 02114-2017 wow mass.gov/dia Is uskers'Compensation Insurance Atfidasit:BuildersiContractonlElectricianslPlumbers. It)1►IK FILED Willi THE PERNITI ING AUTHORITY. Applicant Information h � ( y� Please Print Leeib Name(Business(r antaattem lndn trial): U t 5, 1/'1,e7i.a I (a04 t nl D.31 T r C_ Address: '1 Ito S CityeState/Zip: (130 ice- MA Dl o4v Phone#: 1-113- 37q - 9470 Are you an employe?Cheek rhr appropriate iroy: Type of project(required): I J ,n a employer wait_ cn plcloccs dull and'orpart-until.• 7. Q New construction 201 am a soh pn,prretur or pcotnenhq+and hair no employee!.vtarrl.0 fur nne in S. Q Remodeling any capacity.INu worsts camp.irouranct mooed" 9. ❑Demolition 301 am a hometowner airing all wink myself_[No tudtm'cans.insurance nqurtedd.l loci Building addition 4.0 I am a humaow vier and will be hiring.uiaractors to condud all Nark on my property. I N ill ensure that all camtr:rturs other have*odic&compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no nnpk,yecs. 120 Plumbing repairs or additions 31:11 I ant a general contractor and I huge bind die sty-rontraetors fisted on the attached sheet. 1� Wt repairs These soh-a:arnrractun have cat rloyees and have workers'comp.rtrsuraace_• 14.I:3 other 6.®lice an:a corporation and its otte-en lot act n:ixd their right of exemption per 54( L c. — I5-'_§It 4).and Ne have no employee.,1So ooilen"comp.instranee required I 'An)applicant that chocks box aI must also fill out the welkin brio%Aiming their otakerti aoattpan+oapabiy rifueanalioa. ilmnouwners who minim tim nnlaatrng thi-y an:doing all Mork and then hire outside wasraeratoawn sdnd anewatsdwi iadiratilsseek ;Contractors that check thu h ,.y must attached an aak.tional shed showing the name of the mule-oontractora and dile,tehttheror sot Won amities have enrpdoyees. It the to-ttunraciurs hate employees,they must pru%'de then 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. ((_ 1 _I In surance Company Name: LM.1-e f' r uL' I -`4,,�IS 11CCl.Vl(e _ Policy#or Sell-ins.Lic.#: WC a - 31 -616 q'7 4-D f t Expiration Date' CP/i /at)a ). Job Site Address: a 7 1 Sot,-}-it, S t CitylStatrrZip: LD4tia175D/011/p1 f Attach a copy of the workers compensation policy declaration page(showing the policy number aid expiration date). Failure to secure coverage as required under MGL c. 152,(125A is a criminal violation punishable by a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 certifj•under the pains and penalties of perjury that the information provided above is true and correct Signature: R ( LL __ Date: i o/r) '/;4 Phone#: 13 - 31%4- I ' 110 Official use only. Do not write in this area to be completed by city or town owe ial < its or Town: Permit/License# s Issuing Autborit (circle one): I I.Board of ilealth 2.Building Department 3.('it-.,'Tuwn Clerk 4.Ekctrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: �....„,0 USMETAL-01 LAURA ACORO CERTIFICATE OF LIABILITY INSURANCE DATDIYYYY) �� 7/12/212/2021 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 Laura Misseri NAME: Phillips Insurance Agency,Inc. PHONE FAx 97 Center Street (A/c,No,Ext):(413)594-5984 I(NC,No):(413)592-8499 Chicopee,MA 01013 ADDRESS:(aura@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:State Automobile Mutual Ins Co INSURED INSURER B:State Auto Property Sr Casualty US Metal Roofing Distributors,Inc. INSURER C:Liberty Mutual Fire Ins Co 740 High St. INSURER D: Holyoke,MA 01040 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 ADDL SUBR W POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD VD (MMIDD/YYYY) IMM/DD/YYYYJ A I X 1 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PBP2910662 6/1/2021 6/1/2022 DAMAG TO TE PREMISEE S(FaREN orr�irrencelD $ 600000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 • GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY X 5' 9 l X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO BAP2483772 6/1/2021 6/1/2022 BODILY INJURY(Per person) $ OWNED SCHEDULED _ AUTOS ONLY AUTOS BODILY INJURY(Per accident), $ HIRED ONLY _ NON-OWNEDS ON ( rPROPERTY(DAMAGE $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE PBP2910662 6/1/2021 6/1/2022 AGGREGATE $ 1,000,000 DED X RETENTION$ 0 $ C WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N WC2-31S-616974-011 7/26/2021 6/1/2022 600,000 OFFICER/MEMggOER EXCLUDED ECUTIVE Y N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 600,000 If yes,describe under 600,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Equipment Floater PBP2910662 6/1/2021 6/1/2022 Leased/Rented 60,000 1 f DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Keith Rehbein is excluded/exempt from the Workers Compensation Insurance as an officer of the corporation. Deductible on leased/rented equipment is$1,000 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 ,s7V17`a y w u I ACORD 26(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD U.S. METAL ROOFING DISTRIBUTORS . I N C . 740 High Street•Suite 2•Holyoke,MA 01040 1-800-232-0399.1-413-536-5474•Fax 1-413.533-8166`,� ,,.,,tea www.usmetalrooting.net //J s Zj R ID Si/Are /rr.1i, , (iisj-53/- 756 tin a*wan nod KibitERS z7y south s - �.��. , Ow.STAR Me!MGM* • Nn.// r�pfdn 54ia ze 0 ,Sha z 6,Coin myniows /til. 7 , 51a/7r Sect-lob ay, fQn4 We will furnish and install new Englert Standing Seam mechanically locked system,24 gauge as listed below. Work is guaranteed for /d yao and the manractwer wammrs the sash on the meta for 35 years. Cocoa nj eGiALLLAti Vile SPECIAL INSTRUCTIONS I COMMENTS ROOF: /eQ/-j ea /J A- �n 5a.1 /hC//e01,.S .S177fiRz%Jy ra77p1 SOFFIT: / -- IO a//s sa'/�/.,f ffz-e axic/7 7 /5/•1 .0 t-*ad FASCIA: 'vL _ /j�j y///a=,/1Q/�Qf /� il/ l i SW Pirw000: 125 ;6- 67)X i2 /l..mnV afr_r,r pt2fjrr ranA RIPrREMOVE: Ye S G...-f/ ., J h/nr7,/ kiii/At j 7 c1 /7/7 °leer OTHER. ✓ F.7C/S17 .' q- der,k hoe ill c. HOUSE: ye._c � Ak A../i// AP/ /y /-7 1r,-),� i« 414r/ PORCH: ,r��,Y," r'11'7-1 r 9 -r/ a ✓a r/I�, 7/7/"a fro t ADDITION: —^/,�ri G2l�l..�. / /Mil/ rat..-H /j el,/,77,2rt/ GARAGE. ' !v D a' (p/,s-i-' ,,-, I/LiJe • / GUTTERS: Nfo� /� / `.,'�/' DOWNSPOUTS — N3' /-/7C/ /S S�t4e' --t ti 7G r_ /- ' /etene-1 REPAIR y5 days of i;S p1200 Sti[ . C.L.,Io� MI TA // /� 6P/a/°r�/,�a�r/y /6 Aiezks f<a724 a«eA/n rife of jvrd2.,s AL rr�t�2 - �¢a.r etc7'7 o/7 A/1//7re�tilf? s/.s-4.- Fra-er9- pPor-C wi// /;, ne..ce� 4#- roafi„9. Contractor will begin work on or about (date).Barring delay caused by circumstances (data). work was be completed by '--' beyond Contractor's control,the All roofing panels are custom fabricated on-site with state-of-the-art rollforming equipment. 'As with any roltform steel panels,a certain amount of waviness or ed canning may become evident al certain times of the day when sunlight hits them.This is Standard in the industry and does not affect the inlegny of the metal.This shall not be construed as a product defect and shall not be cause for refection. Contractor does not perform or assume any responsibility lot any painting,staining or wood or wall finishing on interior or exterior. The confronter does further agree with the owner that(a)he will begin work within a reasonable time atter the exeCution thereof,and will prosecute it diligently and with due care,and in a good and wOrkmareike manner:(b)in doing the work,he will comply with all statutes, Ran regulations and ordinances applicable thereto: Contractor to procure all permits required by law.Contractor shall provide public liability Insurances. Owner warrants that he is the owner of the property on which she work is to be performed or that he is otherwise authorized on behalf of the owners to enter into this agreement. We Propose hereby to furnish material and labor -complete in accordance with above specifications for the Sum 01: ' 7Lh P 'u r l /zc 1T7.Sl �/ .efiet— iwitara IS /7_3(XV0 ) Payment to be made as follows: .3o x (51yo--; *.MET LROO,NGOtpe... vino.al rig Cowan: U.S.METAL,ROOFING OISTRIBU1ORS,INC. �... Sinn near �J/� x IS ; _t upon Stan d leO 740 High Street Suite 2,Hotyake,MA Moo i/e) x IS `�,. 2 o I upon 1rz we coneletion. ,o,�n ).rye raa7.0 CT.602546 /D .•.is /93°i drag be made banns),upon compl.wn w�.P urn whist thus contraet NWO agreement agment In.train mMmM m pri WnWrue wont sn. woo..e a ewer same.. .va,,, d so, , Want.d•pam7 of mac awn one-0nra fir iv total Conine peso or Inc total sMpnl of Se xx 9 wpa,ts or prowl.*hell the contatter mint male,er aem a se. er ardor tllorrn. / /.t /J. 11 - %leAr alum dospa.'n e7 ospa.' mi war m esd.o ates and ca rdtch me.it rs t ✓ To ee e.t.a p pW Acceptance of Proposal I have read both sides of this document and accept the paces,specifications and conditions staled. I understand that upon signing,this proposal becomes a binding Contract.You are authorized to do the work as specified.Payment will be made as outlined above. You,the Buyer,may cancel this transaction at any time prior to midnight o file third business day after the date of this transaction.Cancel( on must be done In writing.See accompanying cancellation. O NOT SI r IF THERE ARE ANY BLANK SPACES svLl O t(�T�A.-.IS CO AC+aM/�('�~ ;-/ a taw {/� IMPORTANT INFORMATION ON BACK 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: ail 9 Sov+h S Nor Maim f kel-iin The debris will be transported by: U,S, M eAa ecoctl b s+ =pc. The debris will be received by: Ca.5 eArt W4s4e S j5-}er1S Building permit number: Name of Permit Applicant U,S, I'V2- a ( on nU.sk t,o1,aql?0 \ Date Signature of Permit Applicant �.....„, USMETAL-01 LAURA A�COR� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 7/12/2021 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 Laura Misseri NAME: Phillips Insurance Agency,Inc. PHONE Fax 97 Center Street (A/c,No,Ext):(413)594-5984 (NC,No):(413)592-8499 Chicopee,MA 01013 ADDRtSS:(aura@phillipsinsurance.com INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:State Automobile Mutual Ins Co INSURED INSURER B:State Auto Property&Casualty US Metal Roofing Distributors,Inc. INSURER C:Liberty Mutual Fire Ins Co 740 High St. INSURER D: Holyoke,MA 01040 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMM/DD/YYYY) (MM/DD/YYYY) LIMITS A I X 1 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PBP2910662 6/1/2021 6/1/2022 DAMAGE TO RENTED 500,000 PREMISFS(Fa nr.nirrencel $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 • GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY X PE0 X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident% $ X ANY AUTO BAP2483772 6/1/2021 6/1/2022 BODILY INJURY(Per person) $ — OWNED SCHEDULED _ AUTOS ONLY — AUTOS Ep BODILY INJURY(Per accident)_ $ AUTOS ONLY _ NON-OWNED. ONLY (Per accidentDAMAGE $ $ A 1 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 ' I EXCESS LIAB CLAIMS-MADE PBP2910662 6/1/2021 6/1/2022 AGGREGATE $ 1,000,000 1 DED X RETENTION$ 0 $ C WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N WC2-31S-616974-011 7/26/2021 6/1/2022 600 000 ANY PROPRIETOR/PARTNERJEXECUTIVE +OFFICER/MENDER EXCLUDED? E.L.EACH ACCIDENT S Y N/A (Mandatory inNH) E.L.DISEASE-EA EMPLOYEE $ 600,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 600,000 A Equipment Floater PBP2910662 6/1/2021 6/1/2022 Leased/Rented 60,000 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Keith Rehbein is excluded/exempt from the Workers Compensation Insurance as an officer of the corporation. Deductible on leased/rented equipment is$1,000 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. e AUTHORIZED REPRESENTATIVE l ACORD 25(2016/03) ©1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 6/74/2-?,0/m~die/ Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 134740 U.S.METAL ROOFING DISTRIBUTORS, INC. Expiration: 01/18/2022 740 HIGH ST.SUITE 2 HOLYOKE,MA 01040 Update Address and Return Card. SCA 1 Ca 20M-05/170.�� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 134740 01/18/2022 1000 Washington Street -Suite 710 U.S.METAL ROOFING DISTRIBUTORS,INC. Boston,MA 02118 GARY C.REHBEIN i� 740 HIGH ST.SUITE 2 air r.m G. 'a/Z HOLYOKE,MA 01040 Not valid without signature Undersecretary Commonwealth of Massachusetts fr Division of Professional Licensure - Board of Building Regulations and Standards Construction Supervisor CS-115825 Expires: 12/31/2024 KEITH A REHBEIN 249 BATES RD WINDSOR MA 01270 Commissioner i • ' r 1 •