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17D-037 29 SUMNER AVE BP-2018-1105 GIs#: COMMONWEALTH OF MASSACHUSETTS MaoRlock: 17D-037 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-2018-1105 Proiect# JS-2018-001992 Est. Cost:$8200.00 Fee: $40.00 PERMISSIONIS HEREBY GRANTED TO: Const Class Contractor: License: Use Gro= RCI ROOFING 74334 Lot Size(sp ft)7 4486.68 Owner: LANE JONATHAN&KIRSTEN KOWALSKI-LANE Zoning, URB(100)/ Applicant. RCI ROOFING AT: 29 SUMNER AVE Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:4127/2018 0:00.00 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 4/27/2018 0:00:00 $40.00 212 Main Street,Phone(413)5874240,Fag:(413)587-1272 Louis Hasbrouck—Building Commissioner '2c'o '= 'ItY of Northampton `ixtuuc, etr-5fW Ei Ilding Department u®way.RanfnlT_ t� %16 2 Main Street s§xuoa2s`�,p p s;ualta 1l11y.�.�.-�- Room 100 ANredNrNdmil Ayre Pa&II(lbL,,- y:� r"Northampton, MA01060 Taaa sots-t'a S&rwiw't��R§alis .— +, pOffe 413.687.1240 Fax 413-687.1272 IPQ,6Nfplams I . PP ANON TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMMC)[...18H A ONE OR TWO FAMILY DWELLING nTIONr. RUINFORMATIOM' — - bis,4'+r9actNh to lyo compiafed y.eGWL+a v o ,e�tycgtl d,i sE . q S'i,C1YY1PY fiUG'- ' tetafp -- O ta4_ - _Wilt Y.�nt'LYICA. 1Y7A Emma.___„_.___oaam�,v'Elm at,at.Dlk}fil'tiA �__...__...�.., an DlgtGlo't'_,. IlON 2 .prfopERTY-OWNER:;btIP'dA WTHORIZEDAfEENT ..cvr� at,8ecarg- /, tf,int) Ourrent Vi3711N]A6ciress: . dZ � Telsphaaa trr NsI11,1J.dVeSS; CU ee(n/l(M'ldllUt;\9 Addles/&� r CTI,TN 3 ESTIM'.'TED CUmLti TIC,11�00$T:S _ Eallmaied Cost (Dollars) bt�h _ �U4lfaia1 k1sa0niy cs,1Matedp"petmll appllceRnrmil Fee d Total Cost of .10h (ramrrTltFeeL-10.UD (HVAC) �P'oiedion2+ 8 +46) . : P Th(a Seatidn For Offid I �Da19 Irlin9 Perrifl 6rnidina Dom i;adperiinepeplooei.E,uiidinga �.. Date CTION ErDESfl(YdP TIOH aF PatDPOS ED 1^ ORFYI h Ck -II rz 11 b9B). 1 Idsw douse [] Add tion [] Replacement Windows Alteratlon(s) Roofing�� Or Doors ❑ �_-- 2ccossory Bldg. ❑ Demolition ❑ New 9lgns f❑I Deakn ([] siding (D:31 Other M) enef Description of Proposed :\derallon of ezlsling bedroom^_Yes, No Adding new bedroom____Yes _ No '0'ohed Nauadvo Renovating unfinished basemen _ Yes —No Plans Auached Rall -Sheaf — sa.-1f New housj- d ol,ad d,PAlorn Lo ett rstYna hr�ws4n.a^:campPeB� �LOdlowl Use of building ', One Fnni Two Family Other___--, b. Number of rooms In each family uniC Number of Balhrooma _ s'here a garage attached? cl Proposed Square footage of new Construction, Dlmenaiona_ e. Number of stories? f Melhod of healing? --__ Fireplaces or Woodsloves_ Number of each o Energy Consorvallon Compliance, Massoheck Energy Compliance form allached?—� - Type Of Wne'rucdOn Is conswcdon withln 100 fl. of wetlands?_ Yes __ No. Is construction within 100 yr. floodpla'n__Yes_No Depth of basement of cellar floor below finished grade wir!building conform to the BoAding and Zoning regulations? ,Yea—__._No Sampo Tank__— City Sewer— Private well_ City water Supply - SECTION 7a -CWNER AUTHORIZATION -TO-BEOOMP4BTE0WHEN CWNERS AGENT OR,CONTRACTOR APPLIES FOR,BUILDING PERMIT TQlni'k0_ _ as Owner of the subject properly 7—, _ ` I m (� _'—'_ herebyau'hor69 (yjClk fL-t-_ �t �. IIPYN'I(1(` mad on my behell, !n all matters releflve to work aalhorized by This building permit aR�1l-Tette -� l _.-- -- 'I SiDnemre of Owner Date y'r�nv12P,Cj—Cp(1 cn _, as OwnedAmhorized neem hereby di That the statements and Informallon on e foregoing applloallon ere true and accurate, to the best of my knowledge and bear Signed under the pains and penalties of perjury, ",ii forma mss{ 9gnalma of OwnerlAgunl Dale - — I0N8 CONSTRUCTION SERVICES --- r,ce rsed Co st uel o �SupENI yg� Nol Appllll/o�abl{s� �O Lloense Number Expiration Dale ,�i,� ..�'—z___"� �y I'�) 'i ail • �I`1'1 5 __ ,.e,. e Telephone fslerec!;lyorre npWOtd t Cro_�k p�d, 66r,I _ - No(Applicable ❑ a -Y Ua,me Registration Number - T— Expiration Date rvess j�I�LYJ7f;Ly�rnL�Clrl-r-s.i� �������� ielephone�yf�,:iL�� T ON '0 WORKERS' OOMPENSATION INSURANCE AFFIDAVIT (M'.C.L, c, 162, ars Componsauon Insurance affidavitmust be Completed and submitted with Ihla application, Failure to provide this allldavll wild result ental of the issuance of the buliding permll. Affidavit Allaehed Yea, No.,,,,, ❑ I3locmlexl]RxuiklgYz'.o, The ourrent exemption for"homeowners"was extended to Include Ownergeenpled Dwelllnes of one(1) or Iwo(2)families and to allow such homeowner to engage an Individual for hire who does not poasess e license, provtded thbt the o mer IS ps s ujpoylsm_'CIyLR 80 51xth Edltlon Seetta r 108 3 51 l eLrLItton Person (s) who own a parcel of land on which he/she resides ov intends to reside,on which there ls, or is Intended in be, a one of two family dwelling,attached or detached nuuotures aocessoiy to such use and/or farm slruotnres, Creon who pOn9tYLLets more than oue home hr ah goglotl sh LI not be considered aJmoue ynen Such "homeowner"shell submit to the Building Official,on a form acceptable to the Building Official thit he/she shall be Igspoys�Le for II did Wpr1<❑ C r eU and th bulidln p eft, Ae acting ConstructLon Slilaeryisto your presence on the job site will be required flour time to time, during and upon completion ofthe work for which this permit Is Issued, Al eo be advised that with reference to Chapter I SO(Womais' Compensation) Ind Chapter 153 (LI ability of Employeram F,mployees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be Ilnble for person(s) you hire to perform work for you under this permit. The rmdeisigned "homeowner"certifies and assumes responsibllfty for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massaohuuens General Laws Annolaled. HomamvuerSiguattu'e_ 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: -� 9 Tzo"6zr, :AL'sL A/cl-ence />iA_ The debris will be transported by 30 NVAM The debris will be received by: 0'0 �vp��s� E 1 Building permit number. _ Name of Permit Appjcant �<)u �j 1 C LL-P Date Signature of Permit Applicant The Commonwealth of Massachusetts UE Department of Industrial Accidents �a -- 1 Congress Street,Suite 100 Boston, MA 02114-2017 -x, www.mass.gov/dia \Porkers' Compensation Insurance Affidavit: Builders/Conh'actms/Eleetriclans/Plumbers. TO BE RILED WITH THE PERMITTING AUTHORITY. Asun icant Information /� //�� Ple 'P' t L 'bl Nalne (Business/OrgenizatioNIndividual): I� C. 1 R/lOnn� z z Address: Llne City/State/Zip: 'Souflmd 67`SSn 04 0/093 Phone 4: (7/3) 527 - Al'775- Areyou anemployer?Check the appropriate box: Type of project(required): L[rpj tem eemployer wlh old emplolees(toll end/ar pan-tlme)• 7. ❑New construction 2 am sale proprietororpanncer And havencemployees working forme in $, ❑Remodeling anycapacity-[Noworkers compinsurArco read ired_I J.❑l am a homeawnerdeinglel work myself lNoworkeas'ampinsurance required]t 9. ❑Demolition 4.❑l am a homeowner and will be hiringacirmeters to conduct all work on 10 E] Building addition my ensure that all oontranorsuther havewerkers'compensation insurance or are sole ll.[] Electrical repairs or flddilions proprietors with he employees. 12,❑Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub contractors fisted on the attached sheet. 13.[2-Roof repairs Threw sub-contractors have employees and have workers'comp.insurance t 6.71We ere a wrporation cod its officers have exercised hairier of exemption per MOL c. 14,❑Other and we haveno employees.[No workers'asap.insurance reovired.j 'Any applicant that checks box 91 must else fill out the section below showing their workers'compensation policy informatio,. rHom who submit this affidavit indicating they are doingall work and then hire outsidecontractors must submit a newa[fidavitmdicatingnah_ tCoulocar eethat check this box must attached an additional sheet showing the name of the,cleca nt,avers and state whether or not those entities have employees. If the enbachm,aters have employees,they must provide their workers'comp.polloy number. I not an employer that is providing workers'compensation Insurance formy employees, Below is the pollcy andjob site information. Insurance Company Name: �. l -m /1'lttfZ[!l $G(Yrti9P'e Cil _ Policy H or Self-ins. Lic, B /� /p (a O92 : a/[ — Q- 41tac/7 a O/74 Expiration Date', /O S Job Site Address', -2 17 ano/ f-h'Z C'dy/State/Zip:�/OYO u '4/h7q Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date), Failure to secure coverage as required under MGL c, 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/er 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 Cay against the violator A copy of this statement may be forwal'ded to the Office of Investigations of the DIA for Insurance Coverage verification. 1 rho hereby certify and th aims a elpenalties ofperjury that the information provided above is true and correct. Sienattlrm -"'"`�� Phori (693 ) 3027 -77S Official use only. Do not write in this ares, to be completed by city or town official City on Town: Permit/License N Issuing Authority(circle one): 1. Board of Health 2, Building Department 3.City/Town Clerk 4, Electrical Inspector S. Plumbing Inspector 6, Other Contact Peisenl Phone tic RC.I. Roofing 6 Line St. Estimate Date Southampton,Ma. 01073 11/302017 Phmi(413)527-4775 Fux(4 13)527-8469 Name/Address Job Location John Lane 29 Sumner Ave. Florence, MA 01062 Terms Rep Estimate valid for 30 days Chris Description Total Remove existing roofs. 8,200.00 Finnish & install aluminum drip edge, pipe Flashings, chimney flashings(if needed)and step Flashings. Furnish &install CertainTeed Winterguard ice&water barrier, 6 feet along eaves and 3 feet in valleys. Furnish and install synthetic underlayment over existing deck. Furnish and install Lifetime CertainTeed Landmark Series shingle. Furnish and install CertainTeed approved ridge vent. All exterior roofing related debris to be removed by R.C.I. Roofing. All work will be performed according to manufacturers'specifications. Lifetime CertainTeed material warranty included. All related permits will be obtained by R.C.I. Roofing. Add$2.50 per sq. ft. for wood decking replacement if needed, A sly. and D�/�/I (�2 °r y�c C*' c . - Cu'- 4 A"5 ,? WE LOOK FORWARD TO DOING BUSINESS WITH YOU. To I $8,200.00 TERMS OF PAYMENT 5%Deposit Customer Signatu Balance upon completion Registration# 126235 Dare' �N Construction License#074334 0 InsuredBanos&Fickert Ins. Shingle Color Selection: (4 13)5277- Shi 2700 g Massachusetts Oepadment of Public Safety — 20mosni t 1 Board of Building Regulations and Standards P� License, CS-074334 n r r uaalt/r,o O/�t e /rr�aC2. �.^U- h za, OlFec fCo ime, Affnlrs&IInslncss Reg intlou Co nsh ucllon Supe) rlxrr to HOME IMPROVEMENT CONTRACTOR �I 126935 Type: MARK TDELISLE tjr,�*�'�, r'k" B 69 BRIGGS STREET a d RO 9tfAIOn - L Exphatlon 6,1612098 pamners Np EAST HAMPTON MA 01,Q21r`- F C I. ROOFING MARK DELISLE - 6 LINE ST Z`; `—' Expiration'. nnIssioner 0610312018 SOUTHAMPTON, MA 01093 Und....< etmMIXy �N�4tag0 �I` �I tW� lam' '1 o�p��lffl,.�/ S�;f5, ; L,Ip P s t X8(7 © i HOME IMPRpVHMEN'A,gqONTRACTOR �" R CI ROOPINt,LLP t ywr bH6E dt PIAFL sEWq �01073 ywE EolELow�N:� vi Elvis G7LINETO � r.. TOI N,iv(At S, Iat }� 'A '11A9fE(q WyyI�&8.1.tt CTEO , j SOUTHAMP �i ss b git'Y", tfq' 6'F1ISLE t o, LIG.I REG NO EFFECTIVE EXPIRES i ! 59 aitlaa A $ HIG0624741 �12/Ol/2017 - 11/30/2018 r dtK N�lrr � qj i'DMRf0N rrulh�lfn 01027 17)9 � I �: � a CO MONtWEOALTH: ,H NI�'SSAr-uWl1ST S .r,"'id a o f ® g ap1 " SHB F' iWORKftR,5 e IssuEs rW� FotLowlNotit,�c.�us<E rt BUSINESS ?�r� $'- af3 I RbCRINO LLP 38LIM,ft87RfAcfiF` a l t 'M re�9t H'J EASISFr1AMP7DN M4 S�1� i y �, „ a. BDA z r t d910919019 � OA223pe E.E tl $� Aur. 4., 2016 10'.500 No, 2462 P, 1/I ac 20 0® CERTIFICATE OF LIABILITY INSURANCE °A77" ° ' `--�' 04I04I18 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NOR IGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT A FFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INS URER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the cert111catehOol lsan ADDITIONAL INSURED,the pollcy(ies) must have ADDITIONAL INSURED provisions Orbeendorsed. If SUBROGATION IS WAIVED,subject to the fermi and conditions of the policy,certain policies may require an endorsement, A statement on this certificate tices not confer rights t0 the certificate holder In lieu of such eneomament(5), PROe'JOER rvgme: Micha47el R,Sanas Bangs B Fickert "a"c°u , 413-$ 2700 we ua: 413-527-0649 Insu,OmcSAgency NAMY5: mb@banaSIDEuMnte.COm 63 Main Street Easthampton,MA 01027 W9URERIS AfiOR01NGCOVEMGE NAICR INSURERA: Admiral Insurance Co. 24856 LVSUReU INSURER B: Safety Insurance Co. 39454 RCI Roofing,LLP INSURER C: Admiral Insurance Co. 24856 6 Line Street INSURER o: Southampton,MA 01073 INSURER 9, INSURERF', COVERAGES CERTIFICATE NUMBER: REVISIOUMBER: THIS IS TO CERTIFY THA TTHE POLICIES OF INSURANCE LISTED BELOW HAVE BE EN ISSUED TO THE INSURED NAMED OVEll TME POLICY PERIOD INDICATED, NOTNITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCEAFFORDEO SY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID GIMME. ILTi TfPE OF INSURANCE CULL POLICYNUMRER MIO° EF MM/ODf(Y,Y LIMITS COMMERCIALGENERALUAINLIT( X EPCN OCCURq ENGF E 11000,000 CWMSAMDE OOCCUR P ISE 50,000 PEO Exv An em E 10,000 A X CA000020963-04 03/04716 03/04/19 PER OVAL g AO" INLURY g 1,000,000 CEN'LAGO REGATE LIMIT AP PO ES PER: (HI GREATE 5 2 000,000 POLICY I PRO. ❑ JEST LOG PRODUCTS-comproPAGG a 2,000,000 OTHER. POM RLE UAE1UTY COM IN IN LE LIMITEeBLYINJ I, 1000,000 ANYquro aooav INJURY Rergnon) sBOAfi Im EOHEDuIEOX 8207761 09130/17 09/30118 eocsnNLuar perea5dem s AUTOS ONLY x AUTOS 1 )HIR'_n X NO NO'MJEO PROPERTY gMA4E AUTOS ONLY AUTOS ONLY PBrB ICBM i i UMBRELLA UAB OCCU0. EACH OCCURRENCE E 5,000,000 C (EXCESS Use 01-U. .MADE X GX000000365.02 03/04/18 03/04/19 AGGREWTE g 5,000,0011 OIG I x RETENTIONS 10,DDO ZRNERSCOYION EMPLOYERVUADRS'LIPBILIIY YIN -TAT F ER �ANY WF9,ECIfiIVE❑ NIA EL,EACH ACCIDENT E ueF�aaeNMEMBER EXCLUDED) ry In NH) ET DISEASE,G EMPLOYEE S D rBc,cordo.�mr PA DESCRIPTION OF OPEIONS DseC E.L.DISEASE-POLICY LIMIT S GfSCRIPTION Of OPEPATONs I LOCATONs/VEHICLES IACORO tO1,AdCllla,el Remahz E�ppdVle,mey pe BRecl,ed II mon ppae la rpuireC) ROOFING CONTRACTOR. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN REFERENCE COPY. ACCORDANCE WITH THE POLICY PROVISIONS. AVTHCAREDREF I E -_—'-- 1WRIWISAaORD CORPORATION. All rights reserved, ACORD 26(2016/03) The ACORD name and IogO are registered marks ofACORO act o CERTIFICATE OF LIABILITY INSURANCE (P 1012512017 10125120172017 ' 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 certifcate holder Is an ADDITIONAL INSURED, the pc icy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER 01978-001 ANTACT Branch 1978-1 �qAI�OMogIE� __.___.__ ,_ qy M R Sanas Insurance Agency Inc fCI1o.ELtl'. (113152]-0288 Ilpl` No (913)52]-0099 63 Main Street E.L.A` l Easthampton,MA 01027 --- -- _._1NSPRER(SIAEFQRQINU_4DVEgADE _._ ...MAIC.a. M.Motual Insurance Company _ __�8�Z58 . INSUREDCR RCIROOFING LLP INSURER 0, ,1NSVRERL _ - 6 LIN'e STREET SOVTRAMPTON, WA 01°]3 INSURER i.INSURER E:.. _.. _. . 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 NMICH 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 SHOWitl MAY HAVE BEEN REDUCED BY PAID CLAIMS. �rq�`Iy-V[{ pp ``IIccyy_EEXX _. _. IAEPBILITY NEVRALA ILIAEILnY _ 1 POLIOYNVMBEP IIJM ppi$YVl] IMMIODIYY�f� LIMITS _ . L� �gk � GE LERVAtt DACH MAGET GN Up S I `DAMAGE TO kE EU $ PRCMISCB IFusnceL CLAIMSMADE OCGIIR ! MED C.F M.P.11 S PERSONAL 4 ANY INJURY $ .GENERALAGGREGATE $ GEN L AGUREGATIF LIMIT APPLIES PER -'..PROD Cts COMFOPAW 4 CL CY EGT RO' LOC AUTO MOBILE LI aLlb I.OMOiNED SINflF Lllli $ ..- V AUTO BODL INJURY IFer Pe sd I f IIT.A O SCHEDULED ion Auios e00I JURY1Pro1cJen) $ RCO UTOB NOMOV,AJEO k PgOPFRT OAMAUE Amos IIP c semi $ 4 UMERELLA LIA°' _-� Iocwa IEACH occuaRENCE s EXCESS LAS I CLAIMS MADE 4 AGGREGATE S DEO RETENTION 3 � a arySpd`CrypBCq&S�#pppECpya`gailry4pfp4p x T`3 ET V. OFTW A 9iLRRITnjiZWW1TJBEU+XEGUTVE(YVxI NIA VWC 100-6022647-2017A 1 101512017 101512019 EL FAC'AGETIRRI- s 11000,000.00 N,ndi I i EL OEEARS IEMPLOYEE s _. 1,00$000.00 �d °Secl4-SID Ha ifl-iSPERATO spelaw_ I _ 'E o ASASC POuevLMT a 'Proofof Coverage"OPERATIC NSILOCATIONS/VEHICLES IpMa[O ACO0.E D1 AEtlILlonolgem9Me3ef,etlula llmomvpacola requlm4l "Proof of Coverage" Workers Compensation Coverage Applies to Massachusetts Employees Only No Partner is covered by the workers compensation policy. CERTIFICATE HOLDER CANCELLATION RCI Roofing LLP 6 Line Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Southampton,MA 01073 THE EXPIRATON DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE _ Up 1998.2010 ACORD CORPORATION.All rights reserved. ADDED 25(2010105) The ACORD name and logo are registered marks of ACORD