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36-238 (4) I 1 DIAMOND CT BP-2018-1210 GIs#: COMMONWEALTH OF MASSACHUSETTS Mao:Block:36-238 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category' REPLACEMENT WfNDOWS/DOORS BUILDING PERMIT Permit# BP-2018-1210 Proiect4 JS-2018-002162 Est.Cost: $14000.00 Fee: $40.00 PERMISSIONIS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: STURDY HOME IMPROVEMENT 093603 Lot Size(sp.ft.): 47916.00 Owner: FASZCZA GERALD&KAREN Zonine: Applicant: STURDY HOME IMPROVEMENT AT. 11 DIAMOND CT Applicant Address: Phone: Insurance: 459 MAIN ST STE 13 (413) 543-5906 WC INDIAN ORCHARDMA01151 ISSUED ON.-511712018 0.00:00 TO PERFORM THE FOLLOWING WORK REMOVE AND DISPOSE OF 13 WINDOW AND INSTALL EXTERIOR DOOR 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 Sieneture: FeeType: Date Paid: Amount: Building 5/17/20180:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 0911IOVW'NO1dwtlHlaON /win I BNOU.03dSNl ONICTI1S d01d3O IN Department use only BGVC�IiyQ��Iort amp on StatusofPermlt: ld"I De artm 3nt Curb Cutif0ma ay Permit 212 Main treE t Sewer/Septic Availability, 0 D 00 Water/WalllPvailablliry 1060 Tvro sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Sile Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR[//�DEMOLISH A ONE OR TWO FAMILY DWELLING SECTIONI -SITE INFORMATION r✓�^` q _Ia( D This section to be completed by office 1.1 Property Address: Mapes Lot Unit I1 Jiq u a( �ottir 1 r Zone Overlay District Elm St.Outdo CB Distinct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.11 Owner off Record: (�e✓MCitT, )'0.SZL° z� II �Jl a'K l JUJ`t Name(Print) Current Mailingddress: ®� w l�Ja lad �b4o Telephone Signature 2.2 Authorized Agent: .N;GtI I �AZ — �I-14 Ya4 NryftR4-nA p�.� y 1.l�.I ry SIY�'lfiC�iY 13 �-3- a..1�ntY of Name lPrmi I r Current Mailing Address: <�13� 9k3 5Tid7 . nature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bv Dermit applicant 1. Building o� (a)Building Permit Fee I`1 00 2. Electrical (b)Estimated Total Cost o1 '— Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) O 5. Fire Protection B. Total=It +2+3+4+5) fit OL]. O Check Number This Section For Oficial Use Only Date Building Permit Number: Issued'. Signal mining, inner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning Thie column b be fi11W in by Boildms onennmcm tut Size Frouta e Setbacks Front -- -- -- j Side LR.._ L: _ I RI Rear Building Height - Bldg.Square Footage I' % I Open Space Footage % (Lot arw minus bldg&paved _. rkino) ) of Parking Spaces Fill: .. . _ ..) bmlumc&Location1 A. Has a Special Permit/Variance/Finding ev een issued for/on the site? NO © DON'TKNOW YES IF YES, date issued:) IF YES: Was the permit recorded at theRegis of Deeds? NO 0 DONT KNOW YES O IFYES: enter Book Paged and/or Document#', li B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW YES 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 © NO 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,eon,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES C NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement in ws Alteration(s) 0 Roofing Q 6r Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0] Other[D] Brief 5Jacn+pbon of ProposUed oho �v eS er7Uj}e Et+x.n�v DorLSc�0.pchr� . I�� Work. +O� I433�W &WdK�eTlfli � � kv,Y ( o, "bc-l. Allea (o�of existing bedroom_Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basemen[ Yes No Plans Attached Roll -Sheet 6a.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? It. 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 S ECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OW/N//ERRS AGENT rrOR�/,CONTRACTOR APPLIES FOR BUILDING PERMIT I, C-" e✓Yv�-�l 1 Q•S as Owner of the subject property hereby authorize Iry le to act on my behalf,in alllf,in all m�alive to work authonzed by this building permit application. Signature of O''wl!��ner ' I Dale — I, iu.�2 ` as OwnerlAuthoozed Agent hereby declare at the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Si ned under theymnr s � an d penalties of perjury. \{ Signature of OwnerlAgent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: NotApplicable ❑q Name of License Holder' I �+ (r��. License Number .Z A Expvauon Date �— yo� Signature Te bone 9 Registered Home ImprovementConhactor: Not Applicable ❑ c- 51 11 l Company Nlam1e Registration Number la12drl1 � Address 'I Expratiorl Date Telephcat SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(l 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 Ves........ No...... ❑ City of Northampton I Massachusetts x 8se46NT OF BUILDING INSPECTIONS 212 Ne 213 in street • Municipal Building Nortys TuiOn, NA 010 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 owneroccupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"he done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work: W �)J fit.'S 'R 1 �J 00- Est. Cost: Iul 00 J Addressof Work:_�.�lc/��/Yloyte� Date of Permit Application: 7 I c{ I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): —Job under 57,000.00 _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 building permit as the agent of the owner: WI tI llF S ��c Y��It� t�C ( s1 -)I/ Dale Conlr etor Nanrc 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 -. , 1, Massachusetts F DSPART.HENT OF BUILDING INSPECTIONS 212 Win Street •aunicipal Building vj`. 00'• Northampton, M 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: II :F—)IumoyG( C-� . (Please print house number and street name) Is to be disposed of at: U �&L�LLAjl_ (Please print name an location of facility) Or will be disposed of in a dumpster onsite rented or leased from: ( ompany Name and Ad ress) S' nature of Permit Applicant r Owner Date 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. "No Substitute for Quality" 459 Main Street Indian Orchard, MA 01151 (413) 543.5906 (508)-797-6600 OWNER PERMIT AUTHORIZATION Name : Gne+l _1� FAA5_z.GZ4 Address: II DIAtMD[lb CO✓1er City/State/ZiplotZl lJC /MASS , n/01 I �i .� f%'r�ti,Z.� (owner), of the property located at: authorize Sturdy Home Improvement, Inc.to act as my agent for the construction project taking place at the above address. I also authorize Sturdy Home Improvement, Inc. to obtain a building permit for this project. I understand and accept responsibility to comply with all regulations and required inspections. Slt 1� Signature o Q ner Date 4ig�natwe of er Date 459 Main Street Toll Free (877)378-8739 Springfield, MA 01151 Worcester (508)797.6600 E-mail: HR@SturdyHome.com Springfield (413)6435906 sT� www.SturdyHome.com New Haven (203)848.2118 Y Fax (413) 543-3200 WINDOWS • SIDING • ROOFING • ADDITIONS MA REG. #151711 CT REG.#601525 Noma l4 S 2c.Z0. mHaaphope,, 3 (.,Yo y0 Business Phone GK ,4 q / LL Address CellPhong Other Y IIVYG m TawNCity Representative � Data X78 eWC p VOF+0r J 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 WINDOW SCOPE OF WORK: 21 ❑ 1. Contractor to obtain required building permit(see attached permit authorization form) 1 `�2 b 3__P Family home. ❑ 2. Provide certificate of insurance for workers compensation,general liability. (see attached certificates). 3�❑ 3. Keep job site in a clean and orderly manner in a broom swept condition. ff ❑ 4. Provide job site dumpster,set on planks, to remove lob related debris only. Please Note:dumpster for contractor's use only. (see dumpster clause). W�❑ 5. Homeowner to remove all personal contents away from all windows as needed in order to install windows. If additional labor is needed at the time in order to remove personal items,a cost assessment will be made at that time. Lff' ❑ 6. Provide manufacturers warranty on all windows. O —❑ 7. Remove and dispose of (quantity)windows. ) pn'fz= Ooh ❑ d-8. Remove and dispose of (quantity)storms. ❑ 9. Remove and reinstall stops. Please note:if stops need to be replaced,an additional cost assessment will be made at that time. fJ10.Remove and reinstall trim. Please note: if trim needs to be replaced an additional cost assessment will be made at that time. Please note: The normal process of removing stops and trim on old windows will disturb paint1stainalwood on windows. Sturdy Home Improvement, Inc. will not be held Webb for any paint/staln4voodsurroundng the opening of any windows. ❑ 091. Remove weights in pockets and dispose. Ur ❑12. Insulate vAllighteavities with fiberglass insulation. Car Q 13. Provide all silicone sealant. bg ❑14. Install aluminum wraps around windows. Quantity Color L✓��y f L!r ❑15. Install newer replacement windows. Quantity_Manufacturer 960 SfAit Model E'+'AVtitn STIti. ❑ m16. Install new construction windows. Quantiry-_!L�>_Manufacturer 0 Model-0- 0 odelO❑ i]'T7. Install bay/bow windows.Vinyl 0 Wood d Quantity D Manufacturer- Model Q Other 0 I, s� a— ❑18. Install new glazing on each window: Low-E Low-E with argon CGM+�uMr�ther V•�+�-. �. 9G tyAL) H' ❑19. Install grids in each window:5/8" Colonial style other GBG f Interior Grids 0 SDL Brasstone © Brushed Nickel D Top Sash All, Bottom Sash f I&' ❑20. Install new hardware on window. Cok1r d/LC.KC L-. Ir ❑21. Provide screens with windows: half screens a full screens aluminum a fiberglass ❑22. Owner agrees to meet the installer during the hours of 7 AM to 4 PM for final measurements. All final measurements will be made by the installer. Failure to meet with installer will delay the installation of windows. Lr ❑23. Addendum (A) =OTHER WORK. Lr❑24. Acceptance Page [� O 25. Work not included: 1. Final cleaning of windows 2.Any rotted wood (other: IniialsO Initials Initials_ 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 control arise: Nork scheduled to begin the week oF / J_ _ Expected completion date_____I /---Weather permitting. The cash price for labor and material as described above is: list payment 2nd payment 3rd payment 4th payment Contract Total (upon signing) hyp-rmellt y, 2f / I t CuV4fill Roof $ r$ 11vew.l / (1i3T101LIe. o-r�68 Ventilation $ d. Other work $ — A I�) 1 f.0�VT `tph Roofing total $ $ $ $ $ Siding $ $ J $ — $ $ '— Windows $ Nab0. $ — $ — $--:1— Special :Special orders $ $ $__ $ $ Other $ $ $ l $ $ Totals $ / $ $ $ (sp—a - Funds: _Terms: _Cash _Finance CK # /a 95Y Credit Card:#_ _ _ _ - _ _ _ _ /moi _ _ - _ _ _ Exp.date---- / ____Code_ Payment schedule: iI Any balance not paid in lull within thirty days, will be charged 1.8%interestper month. In order to meet the completion schedule,the following matercl aquipment must be SPECIAL ORDERED before the contracted work begins. (Law requires that any deposit or down-payment required by the contractor before work begins,may not exceed the greater of(a.)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered In advance to meet the completion schedule) $­--09—to be paid for $ d to be paid for r) Any additional work orders are to be paid for once accepted and approved by purchaser. Verbal understandings and agreements with representatives shall not be binding. All understandings and agreements must be set forth in writing in this :ontract. Additional provisions are stated on reverse side and are pad of this contract. In witness whereof Purchasers)haslhave hereunto signed their names [his l I It day of /t A 20 19 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 (Dale). You the Purchasers)may cancel this transaction at any time prior to midnight of the third business day atter the date of this transaction.See notice of cancella- tion form for an explanation of this right. Signature affixed below also acts as receipt that Purchasers)received separate cancellation forms. The fallowing is a requirement by Massachusetts General Law,Home Improvement Contractor Law MGL c 142A: The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor 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 provided in MGL c 142A. Representative: J m" . ' 'r — 4— OwnerIroner. OwnerG NOTICE:The signatures of the parties above apply only to the agreement of the parties t *re�ollfid1 by the contractor The owner may culture alternative dispute resolution even where this section is not signed separately by the partles' 1 1 �'/ADo not sign this contract if there ere any blank spaces Submitted �C, 41 ] l� .4 , Accepted (( �� Representative urchaser DI e Accepted Accepted y� /J, le p.p by, by: LI- Nin Representative - Pur@haser D to Addendum (A) OTHER WORK l3 �e vb�e �vvxj ENy +ca-s'I� n/,,-�-�nnL ��`TtklOb _ W t 'y`4+hfe- X ft ¢low tt, t �Ai.09 . To j2ka R. Flui... 'ins4 . �• [A-_i1c Ow, /�Ia /v,c..L . S�e�a-a�.. t..,��. N�c,L -I-�2�N+ S f i� ewe ,d Door r-ax.{f� ��+ R e 51 s7-4krr l.� G'1� lMroT KWaW Initiele Infiialaf—Initials_ fice o onsumer Affairs d Business Regulation Uq 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 151711 Type: Supplement Card STURDY HOME IMPROVEMENT, INC - Expiration: 612612018 I,r DAVID DIAZ 459 MAIN STREET INDIAN ORCHARD, MA 01151 Update Address and return card.Mark reason for change. ❑ Address E] Renewal ❑ Employment ❑ Last Card CA 1 Co E0M asnl —C�Otfce of Consume�rpAoffairs&Business Regulation vaet(e License or registration valid for individual use only ME IMPROVEMENT CONTRACTOR before the expiration date. Iffcundreturnto: '.y Office of Consumer Affairs and Business Regulation 151711 .. Type: 10 Park Plaza-Suite 5170 O'eghitratiourExpiration. 612612018 . Supplement Card Boston,MA 02116 >TUROY HOME IMPI{(NEhMENT;.I N(; )AVID DIAZ 459 MAIN STREET NDIAN ORCHARD,MA 01151 Undersecretary Not valid without signator ` Consao weaBh of Massachusetts Division of Professlnrlal Licensure Board of Building Regulations and Standards ' ConstralCtMn'$Opervisor - ' CS-093603 I '� Opires:0 010 712 01 9. - DAVIDDIAZ = 270 TREMONT$T _ SPRINGFIELD MA nP�d Commissioner om:Llse HILI Fax:(413)437-0443 To:4135433200(ArcfaCcon F., (413)643-3200 Page 3 of 3 COMMIT 10:28 AM CERTIFICATE OF LIABILITY INSURANCE B�]i2017Y' 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: tithe ceNlficats holder Is an ADDITIONAL INSURED, the p011cy(las) must be endorsed, It SUBROGATION IS WAIVED,subject to the terms and conditions ofthe policy,certain policies may require an endorsement. A statement On this certificate does not confer rights to the certificate holder In lieu Of such endorsement(s). PRODUCER E. Orchard-Dowd Insurance Agency LLC FNM 14 Bobala Road ac NO Ext:913-538-7444 GIC,No,4 -53 6-602 0 Holyoke MA 01040 AoOREso 'bot• es@dowd.com cusTDMER IDI:STURHOM-02 INSURER(s1AFFORDING COVERAGE NAICr INSURED PRIORI Atlantic casualty Insurance Company92814 Sturdy Home Improvement, Inc. msuRERe aa£et Insurance -Com an 39959 P.O. Box 51033 Indian Orchard MA 01151 assuand: INSURERD: INSURERE: INSURER F: COVERAGES CERTIFICATE N U M B ER:146/973759 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 CONTRACTOR OTHER DOCUMENT W ITH 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 SUCA POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSR MV) POLICY NUMBER IMMIDOOdYn (MMIDDI LIMITS A GENERALLNBILITY N105DG0199-1 9/7/2U17 8/7/2D18 EACH OCCURRENCE $1,DUU-UUU S COMMERCIAL GPNERALLIABILITYPREWSESEaacwOeUa 850,In, CIA %OCCUR MED EGP(Any one person) 55,000 PERSONAL 6 ADV INJURY g1,000,000 GENERAL AGGREGATE 52,000,000 GENT AGGREGATE LI MIT APPLIES PER: PRODUCTS-COMPIOP AGG 52,000,000 POLICY P D LOC 5 B AUTOMOBILE LIABILITY 2706453 6/24/2017 6/24/2038 COMBINED SINGLE LIMIT 51So O.oar) ,000,000 ANY AUTO BOOLY WHEY(P.,person) S ALL OWNED AUTOS BODILY INJURY(Pel a11I 9 S S SCHEDULED AUTOS PROPERTY DAMAGE X $ HIREDAUTOS (Px ecdtlenQ 3 NON OWNED AUTOS 8 5 UMBREU_AUAB OCCUR EACH OCCURRENCE $ E%CESSUAB CLAIMSMAOE AGGREGATE $ DEDUCTIBLE $ RETENTION 5 S WORKERS COMPENSATION WC ATLL OTD AND EMPLOYERS'LIABILITY YIN TOP MTS ER PUTT HtOPRIETORNARTNERCSECUTIVE❑ NIA EL.EACH ACCIDENT 5 OFH(Me..�MOEIn MR) MIA EL.DISEASE-FA EMPLOYEE 4 Iy deecnne nndm DEa R;TON OF OPERATIONS MIow EL.DISEASE--IT-LIMIT Is DESCRPMONOFOPEMTIONSILOCATOMIVEHICLE3 (AtNth ACOMIOI,AddllonYRemu sSchetl le,lfmonspacelarequlredl CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DAIS THEREOF,NOTICE WILL BE DELIVERED M ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE )A�qt+�' IS 1988-2008 ACORD CORPORATION. All rig his reserved. ACORD 25(2009/08) The ACORD name and logo are registered marks of ACO RD ® CERTIFICATE OF LIABILITY INSURANCE DATE(UMIDONYYY) TWAARKTIFICATE 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 INSU RER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER.AND THECERTIFICATE NO DER. IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to Ne terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not Confer rights to Um Certificate holder In HBO of such endorsements. PRODUCER CONTACT NAME: ORCHARD INS AGCY INC PHONE FAX 485 MAIN STREET (AIC,No,EM): (AIC,Nal: E-MAIL INDIAN ORCHARD,MA 01151-1241 ADDRESS: 28YCR INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: TRAVELERS MDEA41lYCOMPANY OFAMENCA STURDY HOME IMPROVEMENT,INC INSURERS: INSURERC: INSURERS: PO BOX 51033 INSURER E: INDIAN ORCHARD,MA 01151 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THISIS 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 MY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MY BE ISSUED OR MAY PERTAIN.THEINSUMNCE AFFORDED BY THE POLICIES DESCRIBED HERRN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. HER ADD SUB POUCT EFF PATE POLICY EXP DATE LTR TYPE OFINSURANCE L R PoLICY NUMBER IMSIADYYYYl (MNADMYYYY) UNITS GENERAL LIABILITY iACH OCCURRENCE Is COMMERCIAL GENERAL LIABILITY OF TO RENTED CIAIMSMADE OCCUR. PREMISES(EEDcmnence) $ MED EXP(Any One person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ENERALAGGREGATE $ POLICY [_]PROJECTMLCC RODUCTS-COMPIOPAGG $ AUTOMOBILE LIABILITY COMBINEDSINGLE $ ANY AUTO LIMIT(Ea amldent) ALL OWNED AUTOS BODILY INJU RY $ SCHEOULEAUTOS (Perpemon) HIREDAUTOS BOUILYINJURY $ (Pa NONOWNED AUTOS PROPERTY PROAGE $ (Pereaid.At)itleM) UMBRELIALIABOCCUR EACH OOCU RRENCE $ _ EXCESS LIAR ECLAIWMADE AGGREGATE g DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND HER EMPLOYER'SLIABILITY YIN UB-SB368505-17 07212017 0]2112018 LIMITS ANT PROPERITORRARTNERIEFFCUTIVE N❑ IUA E.L.EACH ACCIDENT $ 1,000,000 OurSMSSMBER ExcwDEOR InNHl EL DISEASE-EA EMPLOYEE $ 1,000,000 FFIC RM RE Ifyea.eescA.adn E1.DISEASE-POLICY UMIT $ 1,00,000 DESCRIPTION OF OPERATIONS l iA W DESCRIPTION OF OPERATONSILOCAMNSNEHICLESIRESTRICTONSISPEGML ITEMS TFUS REPLACES ANY PRIOR CER'IDICATE ISSU®TO THE CERTIFICATE ROWER AFFECTING WORKERS COMP COVERAGE CERTIFICATE HOLDER I CANCELLATION SHOULD ANYOFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORU:ED REPREBENT ACORD25(2010105) The ACORD name and logo are registered marks of ACORD 7808-2010 ACORD CORPORATION. Ali �rights ,reserved. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 IV www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers Applicant Information1 d PPl-e-.ase Print Legibly Name(Business/Organizatioatludividual):Stl I YQ W tl'17 e�i21'PY�f IP ...1-YlG Address: LiSo N111 ih 5jrjeel �nn 13 City/State/Zip: p 14. Phone#: 1 3 Are you an employer?Check the appropriate box: Type of project(required): 1.MJ am a employer with _ 4. ❑ I am a general contractor and I 6. E]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) - required.] 5. ❑ We are a corporation and its 10.❑ Electrical repays or additions 3-DI am a homeowner doing all work officers have exercised their )1.❑Plumbing repairs or additions myself [No workers' comp, right of exemption per MGL -12❑ Roof repairrs � insurance required.]t c. 152, §1(4), and we have noylt9� g employees. [No workers' 13.�Odrer t comp. insurance required.] *Any applicaut that checks box#1 most also fill out the auction below showing their workers'compensation policy information. t pauperism.who submit this affidavit indicating they are doing alt work and then hire outside contractors most submit a new affidavit indicating such. tCurrow tors that check this has must attached an additional sheet showing the cane of the sub-connuctom and state whether or not those entities have employees. If the sub-contractors have employees,they most provide thea workers'camp.policy number. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: IY( r— ye-lecs �VtIA'P Yr1i'll-�vl l'O /-FMQYi (G- Policy#or Self-ins.Lie.#:—at—rirr$3(o`l"5(J5—1�1 Expiration Date: Sob Site Address: J\ O I GImW�A�Ot,vr T City/State/Zip: WC n n(t(O Y 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 hereby certify under thepains and penalfies of perjury that the information provided above is true and correct Sicnamr . Date' Phone#: I6Official use only. Do not write in this area,to be completed by city or town official.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 .Other Contact Person: Phone#: