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24C-065 (2) 82 MASSASOIT ST BP-2017-1358 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24C-065 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2017-1358 Project JS-2017-002256 Est. Cost: $24000.00 Fee: 540.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: VISTA HOME IMPROVEMENT 110285 Lot Size{sq. ft.): 26136.00 Owner: GHAZEY ROBERT G&HOLLY N Zoning: URB(100)/ Applicant: VISTA HOME IMPROVEMENT AT: 82 MASSASOIT ST Applicant Address: Phone: Insurance: 2003 RIVERDALE ST (413) 382-0249 WC WEST SPRINGFIELDMA01089 ISSUED ON:5/24/20170:00:00 TO PERFORM THE FOLLOWING WORK:REMOVE OLD SHINGLES, REPLACE WITH NEW 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 5/24/2017 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Status of Permit: - \1 j Building Department Curb Cut/Driveway Permit nQy �'. i 212 Main Street SewertSeptic Availability ��y�V Room 100 Water/Well Avadabt4ity �\ !e Northampton, MA 01060 Two Sets of Structural Plans phone 413.587-1240 Fax 413-587-1272 Plot/Site Plans .�. : Other Specify • 'PLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE �OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION g 0�1 f 359 This section to be completed by office 1.1 Property Address: `` ,r�,�•,,�'' y ^^�� 11 ,, t1^^,�,,��^+ r-� c�r^� i �1 Map Lot �N /.(_7 Unit (C. G.. M-C\SSO - 3 \ S \ Zone Overlay Districtlst C�� Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2A Owner of Record: Name(Print) CumFiMsq\Add�`g Q)4dQ. / / (STelepne ) �.(! Signature 2.2 Authorized Agent: We,_Ss-Spill sit e,kd 6SelkLThe 7(4)"a trtaLC 5k m.,... . A Name(Print Current Malllm Address: Signature afr -lephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building a 4.4 opo (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee � ///1 //1� 4. Mechanical(HVAC) LzU V3 5. Fire Protection 6.Total a(1 +2+3+4+5) a14 V`-pt��r'���v Check Number ill( fir/ This Section For Official Use Only Date Building Permit Number: Issued: Signator rilllll/' ,r P Z/17 Building Commissioner/Inspector of Buildings Date 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 .o Open Space Footage ro (Lot arca minus bldg&paved parkin¢} q of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O 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 O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © 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 n Addition ❑ Replacement Windows Alteration(s) I Roofing Or Doors ❑ Accessory Bldg. El Demolition ❑" New Signs [O] Decks CI Siding[0] Other[0] spp .Wrk: Vf? \ VPVc c ccce_OVO S., W` \ \ ULO . — 3-e ecY 1.t tf t Alteration of existing bedroom Yes PO No Adding new bedroom Yes C. No Attached Narrative Renovating unfinished basement Yes )O No Plans Attached Roll -Sheet sa. 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR nAPPLIES FOR(� BUILDING PERMIT I, d 'O\ 1 L� -4 " io `�`�` \7 L , as Owner of the subject Probe y hereby authorize V l V 3L \SY y VNl A V\Q] \Dc']yt to act on my behalf, in all matters relative to work authorized b this building permit applicet`on. 11 cee-S Owner e la�\v i Signature of Owner � \�\_}�\ �\ \' -+ (� 7�DDatte� p \ n ,(�cn��p�r��n `� I,- (-At, `-\--)e.\/\\I-Ni�t V 147 \it \Y 11 Y V U( . \ ANDY (z'y lh 1 W.4,-as Owner/Authorized Ag nt her y declare that the statements and information on the foregoing application are tr a and accurate,to the best of my knowledge and�elief. Signe under the pains and penalties s/off perjury. \ Y Print Nam �9�. -- lar))v-1 Signature of Owner/Agent Da SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction�Suuperviisor: 1^f�\ r�_ Nott Applicable 0 QName of License Holder: � - \. y\`f - CS- I 102- g5 License Number IijQ$ S h 2O0� 12i�te�dcux c' , CA boa � aoa o Addres /� 4349i1/1 (efn $�-X -511 /� Expiration ate / Signature Telephon 9.Registered Home Improvement Contractor: Not Applicable 0 //�� ,� A c At \V\ fl(b rernL , & \ l9 7 558' Corhpanv Name Regis ration Number 2 C.)Ci V.:\tex dale S+ h1-ti Gi 102 201G Address Expiration Date t3C O1 & Xpi Telephon (QU$pp -j 19? 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 O the denial of the issuance of the building permit. Signed Affidavit Attached Yes 1p N, No ❑ l 1. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 faun 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, during and upon completion ofthe 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)ofthe 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: B2 I Aay—cLSO14- S4 The debris will be transported by:(I [ P X V SA 9-1A, Vec The debris will be received by: q a_s Building permit number Name of Permit Applicant VcQ4\ DOA\A„., •lakISir !V (t/ Date Signature of Permit Applicant The Commonwealth of Massachusetts —s= Department of Industrial Accidents Office of Investigations _' �= I Congress Street, Suite 100 ' _�_E= Boston, MA 02 114-2 01 7 rvww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ['` Name (Business/Organization/Individual): -, A- '\Q 1 yy\ f _�Q \ ' Address: 20113 A2.i\N ATIO,L Cs+ . �+ City/State/Zip:1NL53\-S. l ,thgy Phone •: [ M -ea ie' Are you an employer? Cheek be appropriate box: Type of project(required): I. Mt a employer with 4. ❑ I am a general contractor and 1 employees (full and/or part-time).* have hired the sub-contractors 6. New❑ construction listed on the attached sheet 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- These sub-contractors have ship and have no employees 8. ❑ 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 10.0 Electrical repairs or additions officers have exercised their I L❑ Plumbing repairs or additions 3.El I am a homeowner doing all work right of exemption per MGLmyself [No workers' comp. 12.0 Roof rep airs insurance required.] ' c. 152, §1(4),and we have no employees. [No workers' 13kather comp. insurance required.] *Any applicant that checks box 41 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. lithe 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 inJornmfion. ���(((��� ��� Insurance Company Name:C1.4-V\/ UA �Q j N (I\9,�� t 2�ft _ '7 Policy#or Self-ins. Lic. #: 'e ` ``y9 Z`�5' `llll1 Expiration DAI: p03\I Z, (,01 Job Site Address: '2 Uss_SSC�0\�- RW City/State/Zip: �U4TkI A Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). G) 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 insurance coverage verification. I do hereby cert' under the pa' nd penalties of perjury that the information provided above is true and correct. Si¢naturr � 'c �� Date: \03\\ Phone#: �Q/V�.b — \�� 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#: - tooting 4ropo5al {EG. No.0621848 REG.No. 162058 Vista L Page No. of Pages HOME IMPROVEMENT it S• ERs r Also from 2003 RIVERDALE STREET 1' }® AwaAAD 2011 Z013 WEST SPRINGFIELD,MA 01089 s"""""""`" Toll Free:1-888-597-2323•Local:413-382-0249 FAX:413-382-0241 BobProposal Submitted To Homeowner Work To Be Performed At Name b &Jbzey Street $a MAssA qi4 str�.�� streeName t _ Gay NO(+h4mp10 1 state MA zip 0I bb0 City _ state__zip Date 5)19 In Telephone Date Telephone Vista Home Improvement agrees to do the following: gtki Acquire all permits for roofingwork ❑ Material Location O Shingle Over Near OX Kl Main House 7 Garage U Shed U Supply Dumpster-Location ❑Inspect Decking for damage ❑Replace Decking 42.7 3_per sheet U Install all New Decking-Type 1 prem sheet Roofing MFG�ft \ Color Style 014(01440(1 White/Brown drip edge XF-0 ❑F5 I-1 Deck Underlayment U X15 Felt U Pro Armor x DeckyyyDefense Weather Lock G Self Sealing Ice on Water Barrier U 3' y 5' U Full >1 FFlash all valleys,penetrations,eaves and chimneys 4'Supply and install pipe boot Clashing Supply and install ridge vent ❑Generic q Ridge Cat U ,_ a Supply and install vent kit U Supply and install soffit vents- oty. 7 R&R Gutters U Total Job clean-up ASupply and install 12 in.lead on chimney WARRANTY 7 Standard G Preferred Protection Platinum Protection Attention Homeowners:Please cover all personal belongings In the sub ,garage,or storage areas due to the possibility of oofing debris or dust coming Hirougm the cracks of the wood.Vista Home Improvement will not be responsible for debris or dust In the areas mentioned.Mao Vista is not responsible for gaps from siding on home and roof line due to multi layer strip.. J Rolled/Rubber Roofing Type Col'o✓. _ Location Older UL l '-- -- - Tra _ . u des ftimlovaI 43f. ' 1/ fah relaf 9rs N' fi5 2nUudeb1 ex-19AsIDVI be 4r &ivewaN daANlsft.th. . *" -lb brlrq Coto( Sawip,cI. Plc—I/Val rnrnnxe on s1_12J )7 0-4 RCI O. All material is guaranteed to be as specified.All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from the above specifications must be made in writing on an Add-on/Modification of Contract form and may become an extra charge over and above the amount stated herein.This agreement is contingent upon delays beyond our control.Owners to carry tire,tornado and other necessaryworkers a insurance.eOur orker re fully covered by Workmen's Compensation Insurance.Homeowner agrees to pay for all work as set forth f the r s ll costs n. att n to below.esureby co[trasur;raS'.Ter ntsropeyhargewin eoalssessei l wmonth al.payments not made within 10 days Of due lisle per the incurred sc We pro a below 0. ereb to furnish ma nal and labor complete In ac roan. air the ab ve a ecifications,for the sum oto Wrw°°r°•i�v roc dusanc� rine and rd 1Pa rPcar . _ _. °L) 1 1 y Said amount shag be paid as follows 1 Ill _.77QS upon S�07n0'� m [owwlefigi. Nola:This proposal may ba withdrawnag xn by us if not within."7n1 S _ gets. YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DAY OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FOR AN EXPLANATION OF THIS RIGHT.(SATURDAY IS A LEGAL BUSINESS DAY IN CONNECTICUT.)THIS SALE IS S r T TO THE PROVISIONS OF THE HOME SOLICITATION SALES ACT AND THE HOME IMPROVEMENT ACT.THIS INSTRUMENT IS Na " • BLE. Signature of Contractor or authorized representative: bio lime)hove reed the brow stateIn. yh leanedlINe)fiau: antihero. to(me/us),and nd then to be satisfactory end hereby acptihero. � �.O,r 5lSignaturem of Xoeowmm(s):k 's�tem-'���Y_ X Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: LLC SAMBRICO LLC Registration. 182058 Expiration: 01/02/2019 2003 Riverdale St West Springfield, MA 01089 Update Address arid return Card. Plait reason for chug*. _ 0 Address 0 Renewal 0 Employment 0 Lost Card Mace of Consumer AttW a Busmen Rn,iaion HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date a fauna a return to: s+9leaafi_n EswoR9b Office of Conwnwr Again and business Regulation 162058 01/022019 10 Park Plus•Suite 5170 Boston,MA 02116 SAMBRICO LLC /° / D/B/A Vista Home Improvement BRIAN RUDD 2003003 Riverdale ' West Springfield,.MA 01089 Undersecretary der ot valid without signature S. STATE OF CONNECTICUT •♦ DEPARTMENT OF CONSUMER PROTECTION ' •'„ / Beit known that � e '> .r SAMBRICO LLC i • y..! • 2003 RIVERDALE ST ; , W SPRINGFIELD, MA 01089-1060 1';-<, i ' is certified by the Department of Consumer Protection as a registered I a HOME IMPROVEMENT CONTRACTOR ' l i' Registration # HIC.0621848 ` „ l , - __._. VISTA HOME IMPROVEMENT Edectivc 12/01/20161I 1 Expiration: 11/30/2017 `"'`tl : ' Altrose mr C♦eeirn ) • eMassachusetts Department f Public Safety 1 Construction Supervisor Board of Building Regulations and Standards RNDiaed to. License-n SupervisoreYS Unrestricted-Su/dings cubicsdenr use Mein) p wlncbContain t Construction la.maned.O9D cubic feet 1891 cubiti ei )Of enwc.a ed-S KEITH W DEVIN 3IMMOUNTNNROLO WEST SUFFELD CT NNy lark._ Expiration: Failure M possess•swam wagon Meta Main/MWY M d„W dM Slate 114101.0 C,W it Cause fa revocation NOS Meese. • DPS Lb,,.ny Infanu,b,visit WNW.MNM.OWIFIS 08/23/2016 2:47PM FAX 4135729191 WILLIAM MIS INSURANCE W0001/0002 CERTIFICATE OF LIABILITY INSURANCE ee"l"secoNYT'1 OB/23/2016 ' THIS CERTIFICATE IS ISSUED AS A MATTER OF REFORMATION ONLY AND COWERS NO RIGHTS UPON THE CERTIFICATE NQLDEK TENS CERTIFICATE MES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A cONTRAGT BETWEEN THE ISSUING INSURER/SI, AUTHORIZED REPRESENTATIVE OR PRIX/UDEN AND TNR CERTIFICATE HOLDER. IMPORTANT: It Me cerifRCe holder 13 en ADDITIONAL iNSURFL, Nle peIRYPeeJ Must be endorsed If SUBROGATION IS WANED, subject to me tette es comae/me cif the poIR:y, certain policies may require en endorsement. A Menem on the Cetfede data not coder rights to Um teNNtete holder is Neu re ewe sSorswwd(x). RRmak'R TRI J MIB WILLIAM J MIS INSURANCE moss Enk (413) 568 - 6111 µc.me(413) 572 - 4191 Eat 156 ELM ST Et fTu- N N£STIIIETD, Eu 01085 IwURFAtSTAMORDSUcoLEVAE HAKE wacaa:NATULAS INS CO al c LIVED -INSURERS: 9AfABATCO LLC DATA .. ._. ...—. resumes: .- ... . ..... VI9RA NOME IMPROVEMENTIMPROVEMENTIMURERD: _ 2003 RIVERDALE STREET ImaRSRe: REBS BPRINGFIEW HA D1089 InsCncct: COVERAGES Jam_ CERTIFICATE NUNBBR: ........ REVISION NUMBER: THIS 1$ TO CERTIFY tint THE POLICIES OF INSURSN'LX OSTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE. FOR INE POLICY PERIOD INDICATED. NOTVATIISTANDMG .WY RCOUIRCM NT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO EUNICH THIS CERt61CATE MAY BE SUED OR MAY PERTAIN. TIE INSURANCE AFAOROEO ST THE POLICIES DESCRFIO HEREIN IS SUBJECT TO AI I. THE TERMS. FsCLOS:NS MV CONDITONS OF SUCH PODGIER.LIMITS SHOWN MAY HAYEDEEN REUUCEDED PAW CLAIMS. Lea Tmeceemn.wa am mR P01331 4UWEn MNSM/Ml %%*At RY) tan CONCEAL LI.mun I PACE OCOUENENCE 11,000,000 A X I DmNaACV1DEmxK m G36792O3 iOB/O1J201606/Ol/20171330'°VI t 1003000 1a,roa«wc I l Dees 1 NED EK wmMeml,w t 5000... . ._ PERSONAL CLOLINNRY A _•.• OENEYYADmdWTE ; 2,900,000 MM.AeWEwTEUenwPw CIM ren: I I FNocn.Eaam1AGO 1 1,0 .�. 00,000 —1 POLICY In�Y Lw 1 i AUTMLOste UYEm IiN NWN[uwI pi 33.33•11 ANY AMC vlNutt roe P'^W $ _ Nrpb W ems t HN1vRUR ¢tl eHAR iV •1•....... _ .••••- HIBLONROS A11108U I� YO. i — I I — IMSRELW AB oc Ug •....... EkeoccuMa10E I EXCESS UAS n Pee uARA -tanGOE 1 1101111111510•11316171011 ...- TNC31AYV. ImN HUH RWLOPORS•ueeWY r TORYUMTS i ER ._�.. ANY pjumelLICIV. ThCIIA'NjarIYL 1 I nI EL FKNACEIPCIR i WKICENMEUSERERYOHM IWneaery In NH) E I DISEASE..EA EIWL0VI E Oid0131104WCOERATE.u9u6, EL GaHSE.N'XICYUME i I 033C9I11104 OF UIFMToeerLOPeRWaIVAwaE9 pump ECgm I01,Md4NNI RNnauuneam,n my space c npxwl CERTIFICATE HOLDER CANCELLATION EAHBRICO LW DEA SHOUIL ANT OF THE ABOVE DESCRIBED POLICIES BE CANCELLED REVOKE VISTA ECHE IDIPROJDICNT THE BNPIfATION ORIS TNEREOFJ NOTICE Via DE DELIVERED IN 20113121VERDALE ROAD ACCORDANCE WITH THE POLICY PROVISIONS NEST SPRINGFIELD HA 01089 AJJ//EE DRmRpaiNE i§ 2010 ACM)CORPORATION. All rights reserved. ACORD 2e(101045} The ACORDname and loBw are registered marks AC0*0 _ 0-4 3/21/2017 7: 12. :03 AM PAGE 2/002 Fax Server r lr str i' CERTIFICATE OF LIABILITY INSURANCE I DATE(MMIDDmYYI DGRTIFIC E IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE OERTIFICATE HOLDERR 1] ^- THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER ANO THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)mist be endorsed, If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement, A statement on this certificate does not confer rights to the certificate holder in Lieu of such endorsement(sl. PRODUCER CONTACT NAME: SOUTH WICK INS AGENCY INC PHONE FAX PO BOX 100 (AC,No,E4): (A/C,NN: EMAIL SOUTHWICK,MA 01077 ADDRESS: 28TKC INSURERS)AfPORDINGCOVERADE NAZCA INSURED INSURER A: TRAVELERS PROPERTY CASLIAI.TY COMPANY OF AMERICA SAMBRICO LLC DBA VISTA HOMEIMPROVEMENT INSURER B: INSURER C: (E 2003 RIVERDALE ST INSURER DI { INSURERS: WEST SPRINGFIELD,MA 010.49 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: No STA SARAN-ANT 4Ne POLG6 OF WSUMNCP DATED NBLOW NAVE BEAN MEMO To THE smOR O KNIFE/move FORTNE EQUATOR/000 INDICATED, HOYwnxsTAKONG NyR[OVIRESEHT,TERM OR CONDnE]M OF ANY CONSMR OP OTHER OOCIMENT WRNRE4ECT TOY MCN Tis CRTMGAl£LUT EEIAVBO OR&myPa:CAN inmemac AFFORDEDSY COatWEEO AMAIN 6 SUBJECT TO MJ.Th IRRE.E<CLVELTNS AM CONOIHama SOCA MLCLan SUGAR MAY ENEMIES REDUCED AY HE PAm MAMAT PKWR NSR ADO SUSroucy Err MATE F ICY EA LAIC LTR Nye OF NMacySURAHCE L R PCY NUMBER (Recover ) IAastri VYI users GENERAL LIABILITY EACH OCCURRENCE 1111— C• OMMIERC WL GENERAL LNHILRY DAMAGE A ICLAIMS MACCC . PREMISESIEaEico pE El neence) .,,.,. MED EXP(Mn)one person) $ PERSONAL B ACV INJURY $ GENL AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S 1-11 P• OLICY PROJECT 0 LOC 7RCOUCTS-COMISCP RG l3 S AUTOMOEaE LIABILITY COMBINED SINGLE $ ANY AUTO LIMB(Ea Amide-) ALL WANED AUTOS BODILY INJURY $ SCHEWLE AUTOS (Per person) H HIRED ALIT CB BOOLY SAM S (Per aameM NON-OWNED AUTOS PROPERTY DAMAGEmom $ Wer emmeRO - U• MBRELLA LAB OCCUR EACH OCCURRENCE $ r EXCESS UAO CLAMS-MACE AGGREGATE $ DEDUCT:MN ~m RETENTIONS S A WORKER'S COMPENSATION AND X IWC 9TMuTaav l ODER EMPLOYER'S LIABILITY Y/N DB-2E072183 03/12/2017 D3/12/2018 I LMrt1 LE N tv FROERircese trERIEXECuTIK NIA E.L EACH ACCIDENT S 100,OJO GCF14ERmENeEfie*CLWEc, FL.DISEASE-EA EMPLOYEE S 100,000 I amcnymlf6 rtym,oeema✓we. EL DISEASE-POLICY L:MIT S 500,WD DESORPTION OF VERANDAS below DESCRIPTION OF OPEPATIONSILOCATIONBNENICLESsRESTRICTONSISPECIAL ITEMS TIM REPLACES ANY PRIOR CERTWICATE ISSUED TO THE CERTIRCATE HOLIER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION TOWN OF WEST SPRINGFIELD MA &MOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Inc EXPIRATION DATE THEREOF,NOTICEWe.L BE DELIVERED -_ 26 CENTRAL ST#4 ' IN ACCORDANCE'MTE THE POLICY PROVISIONS. AUTHORIZED REPRESENTAAVE I WEST SPRINGFIELD,MA 01089 '-kr) Sac- +' 'M"' ACORO 25(2010/057 The ACO RD name and logo are registered marks of ACORD 1988-2010ACORD CORPORATION. All rights reserved.