Loading...
29-126 (5) IO ALAMO CT BP-2018-1021 GIS 9: COMMONWEALTH OF MASSACHUSETTS Map'Block:29- 126 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category:ROOF BUILDING PERMIT Permit# BP-2018-1021 Project# JS-2018-001850 Est.Cost: $19500.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: STURDY HOME IMPROVEMENT 093603 Lot Sm(so. R.): 11325.60 Owner: MORIN CHRISTOPHER S&JOANN W Zoinng;. Applicant: STURDY HOME IMPROVEMENT AP 10 ALAMO CT ApplicantAddress: Phone: Insurance. P 0 BOX 51033 (413) 543-5906 WC INDIAN ORCHARDMA01151 ISSUED ON.•4/11/20180:00:00 TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeTvpe: Date Paid: Amount: Building 4/11/20180:00:00 540.00 212 Main Street,Phone(413)587-1240,Fax_(413)587-1272 Louis Hasbrouck—Building Commissioner I Department use only City of Northampton Status of Pernik ""' 9 P Building Department Curb Cut/Dnvewa nult Y Pe 212 Main Street Sewer/Septic Availabliity Room 100 Water/Well Availability. Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 PloVSite Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A/OONEE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: /� This section to be completed by office / `'7 /1larh to nil a r / Map r. Lot Unit TV/O✓fP7ni � A ��O(P2 Zone Overlay District f- !!77 Elm SL District CB District SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ('h i5kn;�hPr �lovin io A �amp L erg Name(Pont) CNIMail g Te one Signature 2.2 Authorized Agent: 40yyValg4 provemP,r,l `�5�1 h S lyau -S�e 0 Name(Print) � Current Mailing Address: ,rte- ( 913) x4'3- a eeph�— SECTION 3.ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building j(� C 0 GAJ _ (a)Building Permit Fee 2. Electrical "�� (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee J�'. qD 4. Mechanical(HVAC) � 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number f This Section For Official Use Only Building Permit Number: Date Issued: Signatu b Aul Building Co nedlnspector of Buildings Data EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed, Permit Can Be Denied Due To Incomptete Information Existing Proposed Required by Zoning This eulumn to be brief in by Funding Department Lot Size Frontage Setbacks Front Side L R:. . L:'.... R Rear Building Height Bldg. Square Footage Open Space Footage (Loi area mine bldg&paved rkioo nofParking Spaces - — Fill: _. . ("Ions,&i eemlon A. Has a Special Permit/Variance/Finding er been issued for/on the site? NO O DONT KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the R f Deeds? NO O DONT KNOW YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 10 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 (9' 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 G' 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 O NO O IF VES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable! New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing W-� er Doors 11 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[D] Other[O] Bnef D'e�scriptioa of Proposed _ e }C�Ltv�Gl CL/c LIG. Woflit�-r105U1G�`nt.�/tS�tcl111'54,Qct lPtra.�-r S $(1 wtC CPlaca a Wut]e ��. 1. sl.r rtKw t Ice r,.,ld.l— rs �-c,�r,31�� Slri-G "or Alteration of a sling bedroom Yes No Adding new bedroom es No ! lZyp4 . Attached Narrative Renovating unfinished basement Yes SLI o Plans Attached Roll -Sheet Sa.If New house and or addition to existing housing, complete the following: a. Use ofbuilding :One Family Two Family Other b. Number of roams 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 Be. 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. 1. Septic Tank_ City Sewer Privatewell City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Cas 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 a.r., ( I I J Date as OwnerlAuthorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the ains and penalties of perjury. rl� iJ] a2 Print Name gnature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construictiennervisor: Not Applicable El Name of License Holder j Z ' 6 f (/G License Number pira on D e sal , I �s ress a Ex �3qa- ]gnaturs Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Com an N me Registration Number Address ^ ff (� I ,� Expirati ✓o1QN (J✓(y GS�,II W (.)l t S:k Telephon L 3- 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 therm i ld i ng rmit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton Massachusetts DEPARTHENT OF BUILDING INSPECTIONS 214 Main Street • Municipal Building Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation ("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction,alteration,renovation, repair,modernization, conversion, improvement, removal,demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building'be done by registered contractors. Note:Lf the homeowner has contracted with u corporation or LLC,that entity must be registered w Type of Work V_o c7 (� i 'C' e IC�ct'Vr/b.2✓V Est.Cost Address of Work: 10 A i c, lM0 OGI-tCf kA Date of Permit Application: c1I •{ I I O i I hereby certify that: Registration is not required for the following reas'o.(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 build,.g iI as the agent of the owner: UtQ Date' Contractor lame 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 Fj C u ; DEPARTMENT OF BUILDING INSPECTIONS 210 Hain Street a Municipal BuildingLt .CE Northampton, M 01060 e Massachusetts Residential Building Code Section 110.R5.1.2 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 farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Section I IO.R5.13.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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 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. City of Northampton Massachusetts s DM` 12 TWFMain S OF BUILDING INSPECTIONS NS 2� 212 Main Street •Municipal Building0 rCh NorNampton, H6 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: to 4(6 .i"xo onilY � (Please print house number`and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: Uj (Company Name andAdddre Signature of Permit Applicant or 6wner Dater' 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. WORCESTER SPRINGFIELD ITARTFORD 459LV,W STRHBT-P.O.HOX53033-SPRINGFESM,MA 01151 MA.REM 151711 CT.RHG 601525. 877-38TURDY FAX413S43-3200 M rflAznVROMHCotK aWN ER PERMIT AUTHORIZATION Name_ VIRIsFoolle �✓/� Address: P ACRM a CT City/State/Zip: re`tCeA 0106 --7— S tO6 --7—S b Aoy /'10R/a (owner), oftbeproperty located at: /o A"? a G Com- authorize Sturdy Rome, Improvement, Tnc. To act as my agent for the construction project taking place at the above addres8. 1 also, authorize Sturdy Home Tmprovemcnt,Tno to obtain a building permit for this project. I understand and accept responsibility to comply with all regulations and required inspections. Rrgnatare v Date Qo rl 1M ou,r ,3-� -18 Signature of Owner Date Toll Free 877 378-8739 n O Main Street ( ) Indian Orchard,MA 01151 Worcester (508)797-6806 ��� E-mail: HR@SturdyHome.com com Springfield (473)543-5906 www.SturdyHome.com New Haven(203)848-2118 Fax (413)543.3200 WINDOWS • SIDING ROORNG • ADMIONS MA REG. #151711 CT REG.#0801525 Name /' 'RaS ,Y,yl�f Un/ \ - Hone Phone Business Phone f- Address ) _ me) Coma, W Cell Phone Olher Town/City JO Representa've Date Fto Keuwler fyJA ✓b L 3 30 X615 I/we the owner(s)of the premises described hereinafter, referred to as Owner,offer to contract with Sturdy Home Improvement, 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 ROOFING SCOPE OF WORK: &' ❑ 1. Contractor to obtain required building permit(see attached permit authorization form) 1 ✓2 d 3 6 Family home. ❑ 2. Provide certificate of insurance for workers compensation,general liability.(see attached certificates). �Iijl ❑ 3. Provide job site dumpster,set on planks,to remove job related debris only. Please Note:dumpster for contractor's use only. (see dumpster clause). ❑ 4. Prior to stripping roof,tarp sides of house beneath work area,from roof edge to bottom of wall. (see additional protection clause on back). ❑ 5. Keep job site in a clean and ordery manner. Rake work areas at end of job. Use magnetic sweep to pick up nails. I� ❑ 6. Provide OSHA approved staging to safely perform work. Er ❑ 7. Work consecutive days excluding inclement weather. (rain,snow, high winds, high heat,thunder showers,etc). ff- ❑ 8. Staff project withquplified mechanics experienced in residential asphalt roofing. - g ❑ 9. Stdp existing 1_ 2_ 3_layers of asphalt rooting(see roof plan,page 2). Number of squares A.Qone layer cedar removal. Number of squares e5? 5 InZ?AI-, B. t-? ne layer slate removal. Number of squares /O ®' ❑10.Inspect roof deck prior to re-roofing. Ransil loose boards: A. Replace rotted or cracked boards at$ '7.v per linear foot. 91 p B. Install new plywood at$�Xp er sheet. �OYGH�. C. Number of sheets of plywood included into this estimate: Quantity Z (see unit cost above for additional sheets). Ur ❑11. Furnish and install Cer71 t,Te+Q eAll hrxi.('_ shingles. Color Aw* ❑12. Furnish and install 8"aluminum drip edge around roof perimeter.White ® Miller_.Brown ❑ 2513. Install cedar drip edge at eaves under aluminum drip edge,Linear 0 LJ 14. Furnish and install ice/water shield at eaves- e O other. Three feet in valleys and around all roof penetrations. f� ❑15.Furnish and install underlayment to entire roof._Roofer select /r/Di4mee44Beek Y�F fjK❑16.Furnish and install starter course shingles,eaves&rake. @r ❑17.Furnish and install hip and ridge cap. '3 J ❑18. Furnish and install new neoprene roof boots at soil pipes up to 4"in diameter. Quantity--/-Size S-�( (boots at electrical mast to be reused). �❑1s. ��Q�e f`Tae�P1�e ❑ 2'1f0. Reuse existing step flashing at roof/wall intersections. ❑ ff'21. Furnish and install new aluminum © copper step flashing at roof/wall intersections.Linear feet . If siding work is needed,a cost assessment will be made at that time. ❑22. Reuse existing wall flashing at roof/wall intersection. ❑ f$23. Furnish and install new aluminum wall flashing at roof/wall intersections. Linear feet . If siding work is needed,a cost assessment will be made at that time. f� ❑24. Furnish and install new d aluminum aayper step flashing at base of chimney under existing lead counter flashing. f�❑25. Replace chimney lead counter flashing. i flu-e�2 flues ®3 flues�other�. ❑ 0'26.Install_new roof hood to vent bathroom(s)with insulated flexible tube. Remove roof deck to gain access into attic.Color:black only. ❑ e27.Gutter Helmets to be removed and reinstalled by others. ❑ 8118. Remove and dispose of gutters attached with spike and ferrule. ❑ EM. Remove and reinstall existing gutters strapped to roof. Install straps under shingle lover shingles-0 . ❑ ,f-. b Remove and reinstall existing gutters with hidden hangers. Linear feet 0 ❑ LYsI. Reuse skylight flashing kitsi O Replace skylight flashing kits-CD Quantity O (Velux models,stock only). ❑ Or 32. Remove and dispose of the following:Antenna_Snow/Ice Wires_Snow Guards/Ice belts &Solar panels_ ❑ f033. Remove Satellite Dish up to 24'in diameter. Alignment and installation by others. ❑ &'A Page Two=ROOF PLAN. W�❑35. Page Three=VENTILATION. $F}wyL-�V,4yQ- 0' ❑36.Page Four=VENTILATION PLAN. 3� ❑37. Addendum (A)=OTHER WORK. 1'1'1 FIVU SAI4L ❑ 218, Addendum(B)=LOW SLOPE ROOFING. y�, 0�❑39.Acceptance Page initials_ Initials � Initiaell M Addendum (A) OTHER WORK ToSuMU, Aid1'�,j 5 A V, (sive 1, ,eL x S'unl ` Zv,Wc It to I l`l [NiN i-Lex �b6e. Initial IndialsQ�Initials)-0/ 7 L. STURDY HOME IMPROVEMENT, INC. MA REG. #151711 Leoend. CT REG. #0501525 PAGE 4 - VENTILATION PLAN ! 8 = 8x16 T � 6\- 6x16 i— a fo �_ x 16 Soffit Vent Proper Vents � -rr S+F Vented soffit 1 Panel + Alum _ Facia Wrap — � s.o. I ��__ + I��— Ventesoffit ond y Fascia only '- - Gutters RoofHood ❑k _j _ _ Kitchen Hood FRONT OF HOUSE c G F, Close Gable Initials NI MHIII End Vent STURDY HOME IMPROVEMENT, INC. ACCEPTANCE PAGE MA REG. #151711 CT REG. #0601525 ANY WORK NOT STATED ON PREVIOUS PAGES IS EXCLUDED The following schedule will be adhered to unless circumstances beyond the contractor's central arse: Work scheduled to begin the week of /_ /_ _. Expected completion date---- /_ _!_ Weather permitting. The cash price for labor and material as described above is: 1st payment 2nd payment 3rd payment 41h payment Contract Total (u on signing) yK N ce�alcP. p-j-C,� Co»I/j.e�t„1 RoofDdwev-,J ?lykf , C54T Ventilation $ ALE, (ci"I ;APPTI� Other work $ Roofing total $ 1-,6001� $�S�®.a $ '76U0 $ '7oGt9� u' $ IStb.`max Siding $ �' $ $— �' $ $ Windows $ $ $ _ $ $ .� Special orders $ $ 1 $ $ $ Other Sui uo d$ OCI $ $ Totals $ t gloo $ —} $ 5,60, $ 7b60, $ ( . Terms: Cash Finance — GiC ik g42+rn --Credit Card:#_ - _ _ _ - _ _ _ _ Exp.date_ _ / ____Code_ Payment schedule'. Any balance not paid In full within thirty days, will be charged 1.8%Interest per month. In order to meet the completion schedule,the following matedal/equipment must be SPECIAL ORDERED before the contracted work begins. (Law requires that any deposit or dawn-payment required by the contractor before work begins,may not exceed the greater of(a.)ane-third of the total contract price or pi the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule) $ 0to be paid for $ o to be paid for 0 Any additional work orders are to be paid for once accepted and approved by purchaser. Verbal underst endings and agreements with representatives shall not be binding. All understandings and agreements must be set forth in writing in this contract. Additionalp rovidons are stated on reverse side an are part of this contract. In witness whereof Purchasers)has/have hereunto signed their names this j day of MA 4-L IF 20 M and acknowledge receipt of a true copy of this contract. UNLESS OTHERWISE SPECIFIED, IT IS UNDERSTOOD THAT THE OWNER IS READY FOR THE WORK TO BEGIN. THE PURCHASE PRICE QUOTED ABOVE WILL BE HONORED ONLY UNTIL (Date). You the Purchasers)may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See notice of cancella- tion form for an explanation of this right. Signature elfixed below also acts as receipt that Purchaser(s)received separate cancellation forms. The following is a requirement by Massachusetts General Law,Home Improvement Contractor Law MGL c 142A: 'The contractor and the homeowner hereby mutually agree in advance maim the event that the curnmetor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as prroviided_inGL c 142A. Representative: \11D t t �k— Owners y7�^ owns, NOTICE. The signatures of the parties above apply only to the agreement of the parties fo alteMate dispute resolution initiated by the contractor. The owner may Initiate alternative dispute resolution even where this section Is not signed separately by the parties" 1 Dont sign thiscontract if there area /y blank spaces Submitted 1/'y u�i./4c le— Accepted �1 Representative Whitaker Date O Accepted Accepledx by: by:� � lTUir't a Representative urchaser Date 0� �a�� (��fice o onsumer Affairs d Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 151711 Type: Supplement Card STURDY HOME IMPROVEMENT, INC : - Expiration: s/zs/zots DAVID DIAZ — - � 459 MAIN STREET -- INDIAN ORCHARD, MA 01151 Update Address and return card.Mark reason for change. U Address [] Renewal [_] Employment n Los[Card :CAI e 20rl - dWl �dez,aoo�.aerrllX7C/C� �Offec of Consumer Affairs&nosiness Regulation Licensecrregistrationvalid forindividual useonly -SWOMEIMPROVEfyI€NT CONTRACTOR before the expiration date. IIYound return to: Office of Consumer Affairs and Basiness Regulation egieftetsn 151711.. Type: 10Park Plaza-Su@e5170 Expiration; 6126/2018, Supplement Card Boston,MA 02116 STURDY HOME IMPROVEMENT,INC DAVID DIAZ 159 MAIN STREET NDIAN ORCHARD,MA 01151 UnJersecretary Not valid without signatur Commanwealth of Massachusetts Division of Professional Licensure - Board of Building Regulations and Standards Construga6ri'Supervisor - CS-093603 EJtpires:08107/2019 DAVID DIAZ - 270 TREMONT ST SPRINGFIELD MA .011,04 y� Commissioner Nom:Lisa Hibbert Fax:MM3)437-1443 To:4135433200@Sfax.con Fax: (413)543-3200 Page 3 of 3 OSM7201710:28 AM A� CERTIFICATE OF LIABILITY INSURANCE (/7/2(1,7 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(ms) must be endorsed. If SUBROGATION IS WAIVED, subject to the tens and conditions ofthe policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Hou of such endlorsoment(s). PRODUCER NOR- I NAME: Orchard-Dowd Insurance Agency LLC HO x 14 Bobala Road a E.1:913-538-"1444 RLIC No:413-536-6020 Holyoke MA 21040AODRESs: 'bor es@dowd.com cusioMEa lDc STURHOM-UZ NSURERNRAFFORDING COVERAGE NAIL/ INSURED INSURERA.Atlantic casualty Insurance Cod,Cny 42814 Sturdy Home Improvement, Inc. INSUREIRB:Safety Insurance Company 39454 P.O. Box 51033 Indian Orchard MA 01151 INSURER _ INSURERD' _ INSURER E: NSURERF: COVERAGES CERTIFICATE NUMBER:1467993759 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.NOTWITHSTAN DING ANY REQUIREMENT,TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WH ICH 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. her TYPE OF INSURANCE INSR MGM POLICY NUMBER MMIDWYYY MMIDDNYYC1 LIMJTS GENERALVAEILITY PLI5000199-1 9/]/201] 9/1/2018 EACH OCCURRENCE $1,CC 0,UOG SCOMMERCIPL GENERAL LIABILITY PREMIEES Ez oc[u„enca ;5G,00G CLAIMS MADE O OCCUR MEO REPAY,one person) 55,000 PERSONAL b ADD INJURY s1,000,000 OEN33PL AGGREGATE $2,000,000 GEN'LAGGRE i,IMIT APPLIESPER. PRODUCTS-COMP/OPAGA $2,000,000 POLICY PRO LCC 5 G AUTOM(IBILELABILLY 2106453 6/24/2017 6/24/2U1S COMBINEOSINGLE LIMIT 111000,000 ANY (EA1-dall) AUTO ROP'LV:NJURY;Perperson) S ALL OWNED AUTOS BUDDY NJURY Pa aEenl S SCHEDULED OG PROPERTY OAMA6E nPEDAT70S Pe,acdEanl) 5 X NON OWNED AUTOS 5 S UMBRELLA UPS CCCUR EACH OCCURRENCE S E%CESSLIAB CLAIMS-MADE AGGREGATE S DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STAT) OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMIT$ ER ANY RtOPRIETORPARTNEREACCUTIVE❑ NIA EL.EACH ACCIDENT $ OFFICERIMEM BER EXCLUDEFO (Manda\ory In Nm E1.OIGfASEEA EMPLOYEE 4 1y daamEa undo, DE SCRIPTONOFOPERATIouSnalow EL.DISEASE-PoucYUMIT S DESCM?P ON OFOPERATIONSILOCATIONSIWHICLES (Affach AWRD 101,Acculonal RemaMa Schedule,R more apace Is RVINSI) 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. AUTHORITEO REPRESENTATIVE �` � ©1988-2009ACORD CORPORATION. Allrightsrsuaremd. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD �1 CERTIFICATE OF LIABILITY INSURANCE DAM 7124GR/Yl'YYI TW$CERTIFICATE IS ISSUED AS AMATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement On this Certificate does not confer rights to the certificate holder In lieu of such endomement(s). PRODUCER CONTACT NAME: ORCHARD PIS AGCY TRIC PHONE FAX 485 MAIN STREET /VC,No,Exq: IfJC,Na): EMAIL IIVDTAN ORCHARD,MA 01151-1241 ADDRESS: 28YCR INSURER(S)AFFORDING COVERAGE NAIL# INSURED INSURERA: TRAVELERS MDEM ITY COMPANY OF AMERICA STURDY HOME IMPROVEMENT,INC INSURERB: INSURERA INSURER D: PO BOX 51033 INSURER E: INDIAN ORCHARD,MA 01151 INSURER R 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 IHaRATEn NOTWITHSTANDING ANY FROUIREMENT,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 PAIDCLAP S. /NSR ADD SUB POLICYEFFDATE POLICYEXPDATE LTR TYPE OF INSURANCE L R POUDYNUMBER (MMIDDIYYYY) (MMIW\Y ) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE OCCUR. PREMISES De occurrence) MED ESP(Any one III $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑PROJECT❑LOC PRODUCTS-COMPIOPAGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea auiden) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIREDAUTOS BODILY INJURY $ (P—LLNent) NONOWNEDAUTOS PROPERTYDAMAGE $ (Perarcid,nt) UMBRELLA LAB OCCUR EACH OCCURRENCE $ EX_C_ESS_LIAB_ CIAIMSMADE AGGREGATE $ _ . . _ DEDUCTIBLE 1$ RETENTION $ is A WORKER'S COMPENSATION AND X WCSTATUTORY OTHER EMPLOYER'S LIABILITY YIN U 5B36850S1J 17/211209 07/2112018 LIMITS ANY PROPERITOWPARTNERIGECUTIVE O NIA E.LEACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? (MamaMgInNm ELTISEASE-EA EMPLOYEE $ 1,000,000 Ryes RIPTION OFF EL DISEASE-POLICY LIMIT $ 1,000,000 If,c —YR OF OPERATIONS oelow DESCRIPTION OF OPERATIONSILOCAVONSNEHICLESIRESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. 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. AUTHORREO REPRESENT VE '111 ACORD25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ADDED CORPORATION. All rights..,ad. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information '' II Please Print Legibly Name (Business/Orgmization/Individual):S+Ltrdu tiD/Yle ��1'I1'PYL1Vl�YhP �i'tC Address: t-I.SCI Ma i i 5+rt P 4- Sl-e3 ^^ 1 City/State/Zip: (Ain. o4 Phone #: Cy 13� J`�13�SYi0l, Are you an employer?Check the appropriate box: Type of project(required): 1.®.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 g. ❑ Demolition working for me in any capacity. employees and have workers' 9. E] Building addition [No workers' comp. insurance comp.insurance.# required.] S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised thea I L❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E] Roof re irs insurance required.] t c. 152, §l(4),and we have no employees. [No workers' 13.�ther L comp. insurance required.] "Any applicant that checks box#1 most 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. tContmem.that check this box most attached an additional sheet showing the name of the sub-co mactors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Into an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. tet—r'�1Ve ler$ q /�MQYI [U- Insurance Company Name: pI vt!�Q tVllll-�V l'O D� /-F Policy#or Self-ins./tLie. #:--Q B—riB/3� 10 ''Sb5— In Expiration Date: `I 21 I AA nn rr yy11 Job Site Address: IV /4 loyi l.o l �(7wr-4- City/State/Zip ,P✓'Qh CIC �t`-1 Wa �3 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb i under the pains and penalties of perjury that the information provide abo isand correct Signature, Dater Phone# Official use only. Do not write in this area,to he completed by city or town official City or Town: PermitlLicense# 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#: