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24A-005 (2) 211 NORTH ELM ST BP-2017-1124 GIs COMMONWEALTH OF MASSACHUSETTS Man:Block:24A-005 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Sidtpg BUILDING PERMIT Permits BP-2017-1124 Project# JS-2017-001910 Est.Cost:$18400.00 Fee:$100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SERGIY SUPRUNCHUK 104327 Lot Size(sq. ft.): 36503.28 Owner: ST MARTIN THOMAS P& ANN M Zoning:ORB(WOE Applicant: SERGIY SUPRUNCHUK AT: 211 NORTH ELM ST Applicant Address: Phone: Insurance: 536 EAST MAIN ST (413) 883-3802 WC CHICOPEEMA01020 ISSUED ON:4/I0120I7 0:00:00 TO PERFORM THE FOLLOWING WORKGREMOVE OLD ALUMINUM SIDING REPLACE WITH NEW VINYL SIDING, 2 NEW ENTRY DOORS 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 4/10/2017 0:00:00 $100.00 212 Main Street.Phone(4131 587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner . / "- “r .{ , es a 'usttln .� --7.-73,-- .x.:- . City of Northampton ' ,,;.,It! IL '' . y, y, N Building Department a. : `rro , � � 14° ' r--,."' / / 212 Main Streets, ci (1, ,� � - r n„ Room 100 °daigir4e I: I °71fJ111111 me -srsw+ +ate x , ,. Northampton, MA 01060 (+ cr I a t .>�. " "+ ",I, Q' phone 413-587-1240 Fax 413-587-1272 ,3.;,`�,, :Lc i� «w j ' 41 ,.11114 \-. -APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION A P- 17 -1/ 2-/ 1.1 property�AJddre�ss/ ! zCT/his section to be completed by office 2 i i IV D/V-"'t F3 )i"', }� t Map a' i1t Lot e o6 Unit Zone1\IJ ` ELleTU . H 4 C / 060 Overlay District Elm St.District - CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 21 Owner of Record: lb 444 fr f tr,'K cl /VR4'-1 211 Al E 1 L.r S'f AM Name(Print) Current Mailing Address: 4/3 923 2 9 72_ Telephone Signature �tr7Gff t 2.2 Authorized A.e : �1 xi/ ,(/�! Name(P y train" Current Mailing Address / 02013 ls_ 913 883 ?g02 Signal •4'/ Telephone SECTION 3 STIMATED CONSTRUCTION COSTS. Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building i( Ig 4100 0d} (a)Building Permit Fee IQ 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection LJ r�� �t 6. Total=(1 +2+ 3+4+5) n,)I ; - r Oe. ) Check Number /wy 1 (1) This Section For Official Use Only Building Permit Number: Date , Issued: !/ �j Signature: � IIIII � L �O -// Building Commissioner/Inspector of Buildings Date Section 4. ZONING AU Information Must Be Completed, Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning TIM column to be filled in by Building Department Lot Size P ___.. . L _._. __.1 L--..-_ _.-_. Front e _ r _ L _ _ Setbacks Pconi L--- 1 i 1 1 1 Side L L. R:I__....._] L R:L. ] I —I Rear 1----1 (....._.1 I -7 Building Height 1 _.1 PH Bldg. Square Footage 1 I—' % -- -- C L Open Space Footage _ _ % _. (Lot area minus bldg&paved L L....-J ___ parking) d of Parking Spaces _.... — i _ ___Di L ..... Fill: _.. ._ I _.._ volume&Lowuon - A. Has aSpeciat Permit/Variance/Finding ever been issued for/on the site? NO N..1 DONT KNOW 0 YES 0 IF YES, date issued: l IF YES: Was the permit recorded at the Registry of Deeds? NO 42 DON'T KNOW 0 YES 0 IF YES: enter Book I l Pagel I and/or Document N B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained © , Date Issued: f. W. C. Do any signs exist on the property? YES 4/ NO ka IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO O IF YES, describe size, type and location: _L E. Will the construction activity disturb(c/l"e'�aring,grading, cavation,or filling)over 1 acre oris it part of a common plan �,..1 that will disturb over 1 acre? YES NO IF YES,then a Northampton Storm Water Management ermit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing D Dr Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [O Siding Other[01 Brief Despyption of Proposegl i ' y Work: r ewDVP a emu“-t-4/w e-,4,4-4 i New of 1/ 5' i r.`-S ] 2 e�-tr y // r Alteration of existing bedroom Yes lC No Adding new bedroom 4 Yes �1�p . U,/ Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll -Sheet / ea, If dew house':anel or addition to existing"houe'inq, complete the:following: a. Use of buildin :One Famil 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 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 I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I _ /1 x Al / % ee / / a '^` , as Owner/Authorized ••- t h-f-b :eclare at the statements . d infor ation on the foregoing application are true :nd accurate, to the best of my knowledge and belie. Signed under the pains and penalties o_perjury. 9)4,/Print Na a AI ,r7 Signator. Age Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor:vior ( ,{/ NototApplicable ❑ Name of License Holder: �+i/ ✓r / C-� r '\ ifS - 1093 ` . -7 er 3 7 ,ter U/ 4- a r� /gl�Lie<<o2bte S S ���o Addr-+ Addie Exprra on Date ,'3 2:3 32C2_ . rte Telephone gmR, /- S' of / 06j/tarot 61.yc PQ (.t.A-ws--e_lt.( e_ ees/1I 9.RI red Home-ImnrovementContractor: ' `' Not Applicable 0 � , ee l�ot� � � r odea /tie /51.1Z i8 Company Namef Registration Number 3 •Fc C &S/2ee (/ � e / oZ/i9// g Address /,®g(/? a0� 2 r� Expiration Date Telephone VS 2 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 ya( No 0 1L -if ome•Owner Exemption The current exemption for"homeavners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780. Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two family dwelling,attached or detached structures accessory to such use and/or fann structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,duringand upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature 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: 21/ ,f/ E /44 57L- The The debris will be transported by: (n, ,/e/Ca 12 Spo S �/ o The debris will be received by: (�% �D/CTCa of IS/ �0E Building permit number: v Name of Permit Applicant [l i /70 ) a / b& C Date Signatur>4Pe mit Applicant The Commonwealth of Massachusetts �— Department of Industrial Accidents a.ve Office of Investigations • _ h�h_- 1 Congress Street, Suite 100 ••teuu71 Boston, MA 02114-2017 am. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Il�� c Name (Business/Organizatiioon//I/n_dividual): n r'f" /af/j CSC /(a�•te / • (� e Address: 3 %S t/c"i e-d06'Tee- �cf City/State/Zip: Vl2f 9 Phone #: Y/3 Srcr3 380--z_ \Arreetyou an employer? Check a appropriate box: Type of project(required): I. I am a employer with 4. ❑ I am a general contractor and I / 6. ❑ New construction employees(full and/or part-time).'' have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp, insurance.t required.] 5. El We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1I.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ❑Roof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.11 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Hom 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'ecompensation insurance for my employees. Below is the policy and job site information. g n/ Q Al /�M Insurance Company Name: r/ / t / I / 14 /� Policy#or Self-ins. Lie. #: NIN p /P L3 00 6 2 S Expiration Date: /Z �//� / N Job Site Address: 2 ii /1^n. >7 City/State/Zip: �TO s r 41 1./1 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expirati/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. a advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance erage verification. I do hereby certi >•t - t nd r•,• + perjury that the information provided above isisttrrue and coryrect. Signature: - ��� Date: 7 �"'�� Phone#: yi3 (36i 3802 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License if 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer" MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Revised 7-2013 Fax#617-727-7749 www.mass.gov/dia City of Northampton /ter 't Massachusetts 4/A ,A w? } Y Yi ( n` DEPARTMENT OF BUILDING INSPECTIONS o & Er 212 Main Street ♦ Municipal Building 5y ° \' x Northampton, MA 010$0 3'y ,R,‘`t INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEilOEMENT The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to act as his/her construction supervisor. The state defines Homeowner" as, ° Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two- year period shall not be considered a home owner." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill) sonotube holes (before pour),_a,.rouah bullding inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the workcan be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location 0ihiAll home improvement contractors and subcontractors engaged in home itpmvemoot ions of utters 42A of exempt from y� .{moi ,rest tion by Ped withs of Chapter 141A of the general laws, AaYsyni-NPm1 rex a aci must be regiabout teed rathe Commonwealth of Mmade to s. Inquiries about Ye Improve and status P be made to the a Director. Home improvement Contract p(617) One ��, ����� Ip ��A-.. Ashburton Place.Room 1301,Boston,MA 02108(617)727-8598 ChicEast Main 01 1 '- a� a r Phones: ,MA 01038 orP :(413)883-3802 - - Fac{j413)1831-4357)3314358 ytru can pay more,but you can't WY l MA Licp154338 Cr LicM0635847 www.AlllanceHomelnc.cam jail S :EMITTED Ta: e�r gg�� Phone: 4g-q14— 2472 Cell: iA . g • 1 . gvytwPU(EV.A ' O)}t,}�.. Email: We a..E submt? ns and estimates tor work to be • -. and materials te..- u. .„ M • aI,..4, - '" Irl ..,... . 4 ^ /, i 0"-0"--e. — 1 e - 3A /h 1...:' . a .0 riff. 31dfi'��i'T/!/, elr7.1=111111bIM'J�. 1�'AlIF l W , SEINIESIONWIIHMINIISINOIlla €� C.'pN111C' � e TOMIIIa�i/'Mea!1XIM M AM Well) MIIIMV Ip G r /' rr.'r r erirrxrieliatir ,, .yMr, s- n�rrn1711ti trs r r ik IDING Type: _ ...c.: W 4"t a0 log: OLP (R'� �737(C'rGri arrapect Wall Sheeting: //]C 'nsulation 0 HomeWrap,.0'Strip . ,Blocks&Dryer Vents Colotr. Sill -p�r-Iuwres�et/Blocks Color: ❑Shutters Calor: .2Gabie Vents(Louverst Color: S'tl./4`81 .,c OR&R Gutters �ew Gutters Calor: ffd ❑Fascia �-Vented: ES 0 NO Type {�r P, 't Color: r UO• Location: .{. ,0,�aArl^u.minum Trim atilance Trim 0 Flat Coll �..r VC Coll 0 G8 „Color: f.CF(1LC'a�> flamers Color LA/NiA.6. . tMumpster Location: [.trl&tati (2.raaaerial Location:,Coa.(7mx/IN/,ye �aste Disposal: JY�.� . NOM SCHEDULE t) (/ nesseM SI.coomple essm dule-ghee folpoeIMd nr scuk wO be Wind to unkra n dmsmnes ;he Os matt&arae: ri 1 f LI PaneatmNxdp vet Wen mlYaM%ma. 47 t IgLplb wed mmaetivwk W be Ymalaf temNe46 [whined wept tae not beeln untO both pros have veNed.fully executed gen DOM e conbary end the three day reamMn period has expired,The Oros MieW vcNw W lee and agree*that the xMlulira Nin re nominate and thatsl4 dehytlrat an not ava&bk by the but not limrtetltawluOm of Got.Mmres N mabnala.avNems,andailarror delays beyond b control,OW raw be wmELnd as uCtienns of iM Ma tent. WARRANTY Atlmn*l,tt Warman:sus smN eMisee&ed by manufacturer.irtoras mathh haws warm"of one Myear from Me dhatkaW'IYon. ,Ulwhm be con In aworbanlaemenrerermrdWOO standard p'wlrn.Any Alteration orNakton from UM above spMMatitw lnwMN extra costs will be waredonlv i onwrlMn orders,andwlll beam i enratarp over,MaWrrcdw ntMao, PAYMENTS We propose hereby to furnish material an. ••r /yyy piste In accordance with Paymets re M mat hfolbwa: ) a Mal(vtynp�rh�y.�.oi: Lw L� ws 1440 peel wpousNnbN ra,m.n: C'4 6175' �i 'eIr=;d ,;;t ^ ip 0 to d dean ,4.Q.. ws 7,- ('t(3 u o dee.nrvam.mm�; IS $460-� ). � ) e. --tr4._aRs 1'pjb/�. ' a 1'w°^ Isemmgncrr: yZ j�( Name of Salesman• Je . tar 4- top W /F84d,da Idead M m*tt3rhtu Mon J / pimMwnrnanderNataMc't Authorized Signature YM metorner MMrrugeratNM ionisers b par nnrw chug et ISA per moth('gnnalperemige meat m9fl en to outstanding net pdwitln 30 d.y Met mmpledrn ofwaa.M pryments received ate30 daysaftef oXiiplation W wort shall be aepMd dM tounp.id WNeeethins and then to oWtlMIN behmas.In the event ofdefauRcutemer herebnoderm nes and yaws to pat InaddiUan M to o ent:Sh 1Mettanal;an zeb'[Mated wed spilectkla YuiWlra remanent MtorMW's fees. Mepurn al Propose l have rad both tides M this dcrment odac 1 the Otis.spaifrnbn and cond QMstated I underuareithn upon tong tab PrrcNebecomes s MMlyd eons YousRaudWhedW Wwas as spedfr•Pf antiWNbe main dn&odabhe.You,the&M1v,may ceramic tiansertnnit aha erne PTGTt midnight of the 3N beth,day after Ma lou N this tranuNonc.nm14tkn tun be bane mwMmg. DO NOTS ON atTHIS ONTRACT IF THERE ARE ANY BLANK SPACES. p_� / t Signu _/ — 4 - Dat,4-3---/7 signatureSi4- to ..Wkn..'M1.�Data' `4 -S - 1 NDTMCE OF CANCELIATION you MAyesseFLTNISTRfHSKnOM WITHOUT MY PEa4n Oft OBOGAnoN,MINIS THREE BUSINESS DAYS FROM THE PROVE PAM.IF YOU CANCEL MIS PROPERTYT!AOEO IfyANY PAYMENTS MADE BY YOUWIDERTHE CONK OR SALE,MOANS NEGOIMM£INSTRUMENT MECUM Y Y04)WILL SE RETURMOWIMP TEN 8U51NESS OATS FCtLOWW RWBPfmTHEcni ER Of YOUR CANCERATION NOME,AND ANYSECURnY WREST MIRING OUTOFTHE TRANSACTON WILLBE CANCELLED.TO CANCEL THE TRANSACTION,MM OR DELVER A SIGNED ANO DATED COPY Of THISGW[ELAIION NOIICE OR ANY OTHER WnrtIDI NOTICE.CO SENO ATELEGRAM TO;AWAKE NOW IMPRCVEMENTAL.334 957 MAW4 ST,=OM,MA Olen , (Dam.NNW and MMaft excluded) I HEREBYCANCELTM3 leAIISACTION ____lBI e5 hamee! 4. 5 V 0/YrI/MOrtal7.CCrag 0 / 4I14 4 'f 1. . r1 Office of Consumer Affairs and Business Regulation 10 Park Plaza•Suite 5170 Boston, Meseitchusetts 02118 Home Improvement Contractor Registration TYPt Corpoiaticn ALLIANCE HOME IMPROVEMENt14t : 02/19/2019 375 Chicopee St _ Chicopee, MA 01013 • Update Adana and return sad. WtrraaM ter Sell.,... Wm o 401.4e11 _... _ ❑Address n Rowan n EmMayatentrthoM.Cerd crit troonmarnerenerd iesestadvaistri .•... O o el cruor Mafia(aeras Rpulse= 4 . HOME IMPROVEMENT CONTRACTOR aappgeason vitiator Individuals vidual aonly TYPE:Car,rakn before as a01kU. a.date. If tows noun tot 005055151 latalian Oatesat Gnus ARetn and Budnaa Re9WaSn .dG ;,li E16 moms 10 Pak Rasa-aunt 5170 Ecsten,MA 0511 � ALLIANCE HOMLEIPRCYEMENT,INC - // aEROKat rstusicnus 411C' '4.----- 375 Chicopee St 642-C41--- i / Chhopas,MA 01013 Underdcrimy MCtNNRt ,age Massachusetts Department of Public Safety V Board of Building Regulations and Standards License:CS104327 1 TUPRIER:M £3SM � OEASTMAIN STREET', h. f1 . ClacOPE5 MA 070�20 �I,/t(Z fin... Expiration: Coinmiaaioner 11122100017 'p ed CERTIFICATE OF LIABILITY INSURANCE DATE a 2/0 `I 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 SY 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: N the certificate holder h an ADDITIONAL INSURED,the policy/lest must have ADDITIONAL INSURED pravlsbm of be endorsed. if SUBROGATION IS WAIVED,subject to the tenor and conditions of the po9Ey,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). FnooucER WTDavfd lorry Neil&Nara Insurance Agency Inc 413-7324137 I 413-]31-&628 882 RNerdale Street aat (AVC.NFL: West Springfield,MA 01089 wnREo: dienelilins.com imunenI$tAFFORPMGCOVEWE NAICF_ INSURER A, State Auto Insurance Companies STA INNS ED Alliance Home Improvement,Inc. Amain A, SAFETY INSURANCE COMPANY 39454 Bergey Suprunchuk INSURER c: Acadia Insurance Company A0235 975 Chicopee Street Chicopee,MA 01013 INSURER o: INSURER•: INSURER F: _....—_.....— COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED aY 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 37144. CMI WFOI YMR OP INSUNINE RONEY NUDIETS A Rj�cow ERoLao.NEA SII OCCUR I PRP/2089283 0311212015 03112/2017 eeppoccu RExc€ 1,000,000 _ ENRAGE TO RENTED 100,000 CLAIMS-MADE I yI PREMISES Pa c oarellpl MEDEXP/Any one p•rwnj 5.000 I PERSONAL ACV INJURY 1.000,000 GENE AGGREGATELIMIT APPLES PER' GENERALAGdREGATE 2.000,000 voucY nm i I Loc PRODUCTS.cot p DD 22,000.000 OTHER 5 B AutomaRAEuaaIu,v 8228463 12/04/2018 12/04/2017 DOMB15:NtINEEFSINGLEUMIT '3 250.000 11. ANY AUTO _1 EMILY INJURY(Per{MINE $ 500.000 I= OWNED l AUTOSSCHEDED aOOILY lMJURV(Per ettiGnll $ 100,000 AUTOSHONLY �E.AUTOS — I AUTO AUTOS NLY — AIRED LY ANON.CWNY 1PRr xM•nll S 3 UYRNlL1ALW _OCCUR I EACXMrURRENCE $ RIMS CIAO CLAIMSxACE AGGREGATE a_ CEO RETENTION 5 S C EMPLOYERS'i,>IN�, (M4ARP90062b 1216512018 ii2Xi5Y201T Tor A �TH' MO 'NE ANY PROPRIETCA/PARTNER2NECUTIvE E.L.EACH ACCIDENT S 100,000 oFFDERAEMBER ENCLUOE01 a NIA �- IM] C •wml. MiderylnNN) I t E.L NRRASE-EA EMPLOYEE s 100,000 D[SMNON OF OPERATIONS Slow EL,DISEASE.POLICY LIMIT $ 504.000 DeRONPMXMo]SMneNa1LOCATIONS Iv[xlCtas IACdIp Tat.YpllkwlpT•N•raM,Y.mattes Mumma rtmn•pteehr•qu1N>t CERTIFICATE HOLDER CANCELLATION Alliance Home Improvement.Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 375 Chicopee Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED M Chicopee,ASA 04013 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT /••.�) K • C198 S ACORD CORPORATION. A ts resented. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD