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23B-059 123 SOUTH MAIN ST BP-2019-0717 GIS#: COMMONWEALTH OF MASSACHUSETTS a : lock:23B-059 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-2019-0717 Project# JS-2019-001171 Est.Cost: $4764.00 F e: 4 9.00 PERMISSION IS HEREBY GRANTED TO: Cost. ss: Contractor. License: Use Groun: M L INSTALLERS NY INC 095605 Lot Size(sq.ft.): 7492.32 Own r- Mr2ER EVELYN&KEVIN GUTTING zoniLig:UU(100)/ Applicant: M L INSTALLERS NY INC AT. 123 SOUTH MAIN ST Applicant Address: Phone: Insurance: 36 AMES ST (508) 580-0127 WC BROCKTONMA02301 ISSUED ON:12/14/2018 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,Dgeartmfid 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: FeeTyue: Date Paid: Amount: Building 12/14/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Dec 12 18 11:17a p,1 Department use only ! - City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/SepticAvailability i .� Room 100 Water]Welt Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 x o s Ptam ecify APPLICATION TO CONSTRUCT,ALTER,REP R, RENOVATE OR DEMOLI H A E OR TWO FAMILY DWELLING E SECTION 1 -S[TE INFORMATION 6.,0- A •7/J 1.1 property Address: secti n to be completed by office DEPT.OF PUILDING INSPFCTIONS r. NORTHA N.MA 01060 Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Reccord:-fpm' ` ^� J. pI S MaN-n Name(Prim) Current Mailing Addre k V.)? � Itk"7 Telephone Signature 2.2 Authorized Agent: Name(Print] current Mailing Address:— '��ii�kl— /-? - -561?!?- Si natureVz Telephone SECTION 4=ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only co leted by permit applicant 1. Building r7 L/ z (a)Building Permit Fee 2. Electrical f / ✓ (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection z 6. Total =(1 +2+3+4+5) � / J Check Number This Section For Official Use Only Building Permit Number Date Issued. 1 Signature: 12-1q-16 Building Commissionerlinspector or Buildings Date rn 1'�ns�a tl�2.rs ny ►y5•@ �rna tl�co„� EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER _ V E D 7DEC 1 3 ?018 DEPT OF BUILDING INSPECTIONS NORTHAMPTON.MA 01060 Dec 12 18 11:17a p.2 Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information E-Xisting Proposed Regiil red by Zcning his col in»n to be filled in b_1- 13uilding Department LASize Frontage Setbacks Frnnt Side L: R L. R Rear Building Hei,ght 131dg. Square Footage c Open Space Footage (Lot Inca minus bld_a&paled Parking) #nr Parking Spaces - Fill: (volume&Location) -._. _...... A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO a DONT KNOW YES a ._..... .. ........... ......... IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW Q YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO a DONT KNOW jl'c�D) YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained a Obtained 0 , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YE` a NO Lpl IF YES, describe size, type and location: E. INTI the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan thatvvill disturb over 1 acre? YEF 0 NO q. lF YES,then a Northampton Storm Water Management Permit from the DPW is required_ Dec 12 18 11:18a p.3 SECTION 5-DESCRIPTION OF PROPOSED WORK(checkall applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Im Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs C]] Decks © Siding p] Other[E3] Brief Desc do of Pro�;ose Work: +/�i �' lit" Rng Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement 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. N umber 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 stones? f. Method of heating? Fireplaces or'Woodstoves Number of each g. Energy Conservation Compliance. fulasscheck 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 Wow 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 79-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ke V I r, '01'" as Owner of the subject property hereby authonze to act on my behalf, in all matters relative to work authorized by this building permit applicabcn. Signature of Owner Date as Owner/Authorized 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 pains and penalties of perjury. �i L/ zeHi Pf me Signatu er ent Date Dec 12 18 11:18a p'4 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction�-S�up/e�rvvi)sor: �j Not Applicable � ❑ - Name of License Holder: .J L�1\I �,�A L s f , 6S - ybl` y S(ki 0-5 License Number l eri''1vim' f0)7 0,2 3 6 L/ �o20-� U. Address Expiration Date at ufe Telephone S.Registered Home Im rovement Contractor: Not Applicable ❑ Com an Na a Registration Number 0311b/,;Z,0ao Address d Expiration Date Yr7ZrAff-(/431) q 5 C,q ("7) Telephone J✓ S U-U1 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes.......- Nc...... ❑ Dec 12 18 11:18a p.5 City of Northampton r - Massachusetts it DEPARTMENT OF BI➢ILAZNG INSPECTIONS ?s 212 Main Street • Municipal Building Northampton, MA 02060 r1 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 improticmcnis 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 addificn 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:If the homeowner has contracted with a corporation or LLC,that entity must be registered. u Type of Work: �'7 1 Y fk,) Est.Cost: Address of Work: r J3 `JHa1 Date of Permit Application: s J �C N i7 L _T O I hereby certify that, Registration is not required for the following rcason(s): _Work excluded by law(explain): —Job tinder S 000.00 Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CON-TRACTS WITH UNREGIS'T'ERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME INIPROVEMENT 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: Date Contractor Namc HIC Registration No. OR: Notwithstanding the above notice_1 hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature Dec 12 18 11:18a p.6 _ City of Northampton Massachusetts DkWARTMENT OF BUILDING INSPECTIONS % h +�.. 212 Main Street •Municipal Bul]_dinq \. ._ Northampton, WL 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permif 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: (Please print house number and street name) Is to be disposed of at: CQA N' 0* 3,4Zc1eXYL7,61 (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or[eased from: IV�l ,1 rlr (Company Name and Address) .2 521�. ig,at re f-Peknit Applicant or 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. Dec 12 18 11:18a p.7 The Commonwealth of Massachusetts = Departnteitt of Industrial Accideirts I Coitgi•ess Street,Suite 100 Boston,JYIA 02114-2017 www.mass.gov/dia W(krkers'Compensation Insurance Affidavit:Builders/CentractorstElectricians!Plumbers. TO BE FiLED WITH THE PERMITTING A[ITHORrrY. Applicantinforramion Please Print Legibly f1171e(Busuiess,'Or¢ani�atiorJLidividuall: �L ��tj_�"Q����(' �� Tye[, Address' 3{o -_ S-� City/State/zip:16 —k olni ti\X 03 3ZG 1 Phone#: Are you an emplaver?Cheek the appropriate box: Type of project(required): 1.[Z 1 am a employer with__�employecs(full and/or part-time).* 7. ❑New construction 2,❑lain a sale proprietor arpartnership and have no emplcyeesworktng forme is $. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.D 1 am a homeowner doing all work myself.[No workers comp-insurance required.]` 10E]Building addition a.❑1 am a homeowner and will be hiring contractors to conduct all work on my prapeny. 1 will ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions proprietors with no employees. 12.a Plumbing repairs or additions 5.M 1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.E]Roof re{ - s These sub-contractors have employees and have workers'cotvp.imumnce.• F-,{ J b.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Lel Odter�-�r 152,51(4),and we have no employees,[No workers'comp.insurance required.] *Any appiicanl that checksbox#1 must also fill out the section below showing their workers'compensation policy information. }Homeowners who submit this artidzwit 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-wntractars and state whether or not those entities have employees. If the sub-contractors have employees,t'ney must provide their workers'comp,policy number, i am an employer that is providing lvor•kers'compensation insurance for my entplt vees. Below is the policy aril job site infor'rrla do ii. Insurance Company Name: l�C t✓ �Yfr— I coon =�S: Co . Policy#or Self-ins.Lic.#: G E> o�U " a E IQ`j 5�J "a l g Expiration Date: Job Site Addres5:- o?,�7 j I-Idi)2 5t�et7- Ci:y/StatelZip: 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 andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u d/r ure: thep r am enalties of perjury that the inforutation provided above is true and evrrec•t �7 SignatDate. ZV Lt?llen 4,1.L ,Z O Phone#: Official use only. Do not write in this area,to be coarpleted by city or toren official. Citv or Town_ PeraddLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Dec 12 18 11;19a P.8 ommonwc-alth at Massachusetts Division of Pratesmonal Licensure Bt mrd apt Rtjildinq Rryt mations and Standards 06/1412020 t oi I WAS HBUR N"AVENUE., KINGSTON MA 02364 ayy S gssjoner - ;, : �,/%�Z�r:irinr �•r�•,n�ii r`^li».;n�l>rr// Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Suoplement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 178125 03/18/2020 One Ashburton Place-Suite 1301 IL INSTALLERS NY INC. Boston,MA 02108 ]N WALSH � 3AMES STREET Not valid without signature ROCKTON,MA 02301 Undersecretary g Dec 12 18 11:19a p.9 DATE(MMIDDrfM) AC")?" CERTIFICATE 4F LIABILITY INSURANCE 111 12104/2018 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(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 endorsement(s). PRODUCER CONTACT NAME Nicole Lee J&B INSURANCE AGENCY INC DBA ROCCO ROSE INSURANCE AGENCY PHONE . {508 SS4 7100 No): E-MAIL ADDRE S: Nicole roccorose.com 360 Oak Street INSUREI AFFORDING COVERAGE NA1C 0 BROCKTON MA 02301 INSURER A; ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B ML INSTALLERS NY INC INSURERC; INSURER D: 36 AMES STINSURER E- BROCKTON MA 0230'1 INSURERF: COVERAGES CERTIFICATE NUMBER: 344254 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 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 DF SUCH POLICIES.Llyd1TS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1NSRxp LTR TYPE OF INSURANCE 1WRn SUBR POLICY NUMBER MM/DD1YYYY POLICY EFF MWDb/YYry LIMITS LTR. COMMERCIAL GENERAL LIABILITY FACHOCCURRENCE $ GE CLAIMS-MADE 7 OCCUR PREMISE COSS Ea occurtence� S MED EXP(Am/one person) $ NIA PERSONAL&AOV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: ! GENERAL AGGREGATE $ POLICY❑IRI- F7 LOC PRODUCTS-CCMPIOP AGG S JI OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ea actidenl ANY ALTO BCD[LY INJURY(Per person) $ ALL OWNED SCHEOULED NIA BODILY INJURY(Per accident) S AUTOS ALTOS NON-OWNED I PROPERTY DAMAGE $ HIREDAUTOS AUTOS (Par scddeIntl $ ] UMBRELLA LIAR OCCUR EACH OCCURRENCE "6 EXCESS LIAB CLAIMS-MADE NIA AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION ANDEM PLOVERS'LIABILITY X STATUTE ERH ANYPROPRIETOR,PARTNERIEXECUTIVE Y f N E.L EACH ACCIC"ENT S 1,000,000 A OFFICERIMEMBER EXCLUDED? N1A NIA NIA 6S62LIBI K21581 t 18 03125/2018 03125(2019 fMandatOrylnNHl !E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE•POLICY LIMIT S 1,000,000 NA DESCRIPTION OF OPERATIONS ILOCATIONS I VEHICLES IACORD 101,Additional Remarks schedule,may be attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts it the insured hires,or has hired those employees outside of Massachusetts. This Certificate of insurance shows the policy in force on the date that this Certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at vm%v,mass.govAwdlworkers-compensalionfinvestigationsl. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Northampton ACCOROANCE WITH THE POLICY PROVISIONS. 212 Main St AUTHORIZEDREPRESENTATiVE t Northampton MA 01060 Daniel M.Cr�y,CPCU,Vice President—Residual Market—WCRIBMA 0 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD Dec 12 18 11:20a p.10 A�CORl71® CERTIFICATE OF LIABILITY INSURANCE P AT1JMWD16 I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED 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 have ADDITIONAL INSURED provisions or 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 endorsement(s). PRODUCER WN IAL;I NAME: J and B Insurance Agency Inc AicN o Kt : 508-584-7100 WC.Nol: 508-580-4924 d/bla Rocco Rose Insurance a VAI.L 360 Oak Street : email;mlinsta[lersny1459@gmail.com Brockton,MA 02301 INSURER{SIAFFORDINO COVERAGE NAIC p INSURERA: Endurance Insurance INSURED INSURER B: United Specially Insurance Company ML Installers NY Inc. INSURER C: 36 Ames St INSURER D Brockton,MA 02301 INSURER E; INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTOALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. !NSR POL LTR TYPE OF INSURANCE INSD 1'yVD POLICY NUMBER MM DGK1 OL yIrYYY MM DD.'YWY LIMITS X COMMERCIAL GENERAL LIABILITY EACF OCCURRENCE $ 1,000,000 CLAIMS-MADE � OCCUR PREM! ES Ea occurrence $ 100,000 MED EXP(Any one persori $ 5,000 A CBC20001096602 02108118 02/08119 PERSONAL&ACVINJURY s 1,000,000 GEN'LAGGREGATE LIMITAPP'_IESPER: GENERALAGGREGATE $ 2,000,000 POLICY X PRO. JECT LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANYAUTO BODILY INJURY(Per person) S 041NED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-DINNED PROPERTY DAMAGE $ AUTOS ONLY AUTOEON_Y Peraccidentl v $ UM13RELLALIAS X OCCUR EACH OCCURRENCE $ 11000,000 B X EXCESS LIAB CLAIMS•MADE USA4226710 08108/18 08108119 AGGREGATE $ 1,000,000 DEC) RETENTION$ $ WORKERS COMPENSATION I FIE UT ORH AND EMPLOYERS'LIABILITY V r N ANY PROPRIETOWPARTNER!EXECUTIVE❑ NIA A ELEACHACCIDENT $ OFFICERIMEMBER EXCLUDED? 414andatay In NH) E.L.DISEASE-EAEMPLOYEE $ If yea describe under DESCRIPTION OF OPERATIONS belo,v E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES (ACORD 1D1,Additional Romarks Schetlule,may Da aoactrvd if more apaoa Ia..q.rired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS, 212 Main St Northampton,MA 01060 AUTHORIZED-REprtesEN lt4 a4. ,*- , ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016103) The ACORD name and logo are registered marks ofACORD Dec 12 18 11:21 a p.11 The Commonwealth ofAlassachusetts Department of Indu.vtrial Accidents o I Congress Street,Suite 100 Boston,.SIA 021I4-2017 www.rnass.gov/dia \Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED VATH THE PERNUTTING AUTHORITY. ! ,( Applicant Information Please Print Legibly 1\aMC(Business/Organization/Individual): ML '` Address: City/StaielZip:'SttCL�On1 NJNA 0a30 I Phone#: SOS Arc you an ernployer?Check the appropriate box: Type of project(required): 1,Z 1 am a employer wilh___emplayces(full and/or part-time)," 7. L]New construction 2,❑1 am a sole proprietor or partnership and have no employees working for me in S. E]Remodeling any capacity.rNo workers'comp.insurance required.] 9. El Demolition 3-O 1 am a homeowner doing all work myself.Ilio workers'comp.insurance required.]' 10 E]Building addition 4❑I am a homeowner and will he hiring contractors to conduct all work on my property. Ii-,ill ensure that all contactors ether have workers'compensation insurance or arc sole 1 LQ Electrical repairs or additions proprietors with no emaloyccs. 12,❑Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-conlractors 1 isted on the attached sheet. 13.❑hoof relpi These sub•conlructots have employees and havc workers'comp.insurance.- 14,(Other Tk�J 6.❑We are a corporation and its officers have exercised their right of exGnption per MGL c. y� 152,i 1(4),and wehave no employees.[No-,corkers'camp,insurance requircc.l 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I flomoowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contraams and state whether or not tlrose entities have employees. If the sub-contractors havc employees,they muss provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my enlployecs. Below is the policy andjob site information. Insurance Company Name: Ace 1{ O-Y\ e0 . p Policy#or Self-ins.Lie.#:�U_ .a F 101 S 3 'a —�� Expiration Date: Job Site Address: City/State!Zip: 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify rudr the p Vap enalties of perjury that the information provided above is true and correct. Si nature: Date: Phone#: O a' 0 t Official use only. Do not write in this area,to be completed by city or to►vfl official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2,Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: