04-011 (3) 666 KENNEDY RD BP-2019-0744
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block:04 -011 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-2019-0744
Proiect# JS-2019-001227
Est.Cost: $33000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 774334
Lot Size(sq.ft.): 344995.20 Owner: KALINA NORA R&JO ROESSLER
Zoning: RR(100)/WSP(100)/ Applicant. RCI ROOFING
AT. 666 KENNEDY RD
Applicant Address: Phone: Insurance:
6 LINE ST (413)527-4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:12/26/2018 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:
FeeTyne: Date Paid: Amount:
Building 12/26/2018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
.-- ) __- -� t: ...•_,i . ;::: :: �,:��• � ��rfi lt�t`ii"'®�QUI' -
. Cty of Northampton
B illding Department
212 Maln Street ��uv, ffla��hl <�u�tialllt�y, � .�
Dv.% 2018 j ! Room 100 w`• .t��Nv�u�:��6,tfal5:iltty,�
No hampton, MA 01060
13- $7-12.40 Fax 413-587.1272 IPOt31&U rte Phans
TI.ON_
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEM01.18H A ONE OR TWO FAMILY DWELLING
EC110N 1 •:SITV, INFORMA.TI:O:N:
.A Property Address; ', �tl,i;l•:r�s;e�c�tLU'I1•�t�o+b;e c:o:m:pa'e;te`.d'tby a.UfiCee
(O��O Kermg % I;pd Unit
ke& A, Aq e1r6-3 Z•on,e:.,,_____,_ _.Owe:nlwy..'D'I`s:trlo.t._—,
E:I0 S.t,
:,FICTION 2 PROPERTY OWN:ER.�>HIPIAUT.H'(D.R.IZED'.,AG•ENT
):1 Owner of R cors;
a l A-1LUI� t�.hr d o a's fh nin5 3 ..
,:acne(P(ini) Current Mailing Address;
?.2 Authorized Aaent;
game (Prini) �,, Current Mailing Address;
Lj
ignalure Telephone
; CTIOrNLGSNA .E:^ OJC .IO:NC: ,OST
SITT:S• -T^
1e,,, Estimated Cost (Dollars)to be -Uao...Onty
com leted by permit a Iloanl• _—
I Budding pa':)f3ull.din.g:-Rorm11,Fee - -
S3 00o.
ieclrical r
(b):5-stimaUW:Tola'I Cost o.f
C.o:nstr.�i_r•,11an:from -
s—Plumbing _ _ .'Bu'Ilelln.g P-w1rrrl.t:Fee-
t toechanical(HVAC) ko
i Fire Protection
I otall(1 + 2 + '3+ 4 + 5) �3 000 — Ch:eck NUrriby -
-� Thi.;'8:odlon :or`p.ffl:cial;fJse Only
)uiiding Permit Kumbe.r;:.__ Daae
>ignalure. .,..,.t _ _.. �Z' 24-hol
f3ullding.C'omml:isl'o er'll'nspeator.o.f•B.ulldings:
Date:
is.�:C.T:fON 6• DF$.CR�I,�•�f0 IOF PR;rJ.P�O�•�p•Vir:ORK•(cherkll analleabie):
New Mouse ] Addition' ] Replacement Windows Alte.ration(s) ] Roofing ( —�
Or Doors ❑
i Accessory Bldg, [] Demolition ❑ New Signs (C)) pecks► (i❑ Siding (C]) Other(0)
Brief Description of Proposed 1\
Alteration of existing bedroom Yes No Adding new bedroom _ _,Yes ,No
Attached Narrativo Renovating unfinished basomelilYes •_No
Plans Attached Roll • Sheet `" --
sa.. If:M.ewv.:h:o;us,�( ��i.(> r. �i,lGi;o,lS; o'�>XrYsltr`liri'as�,�'o •.l ' < 'i s �.
. '�i ,�` '' �!. ._L 11utsun;a�...�.���t�•le� a�::b�i�;�jl,o,.'.�1'
a. Use of building : One Family Two Family Other
iI b. Number of rooms in each (amlly unit Number of Balhrooms— —
c. Is there a garage altaohed?_
ci. Proposed Square footage of new-construction, Dimenslona
e. Number of stories? _
I, Method of heating?— Fireplaces or Woodstoves Number of each_
g. Energy Conservation Compliance, Masscheck Energy Compliance form attached?
i
i) Type of construction
Is construction within 100 fl. of wetlands? Yes __• No. Is constructlan within 100 yr, floodplain Yes No
I. Depth of basement or collar floor below finished grade
k. will building conform to the Building and Zoning regulations? Yes _ No ,
i. Septic Tank__— City Sewer Private well City water Supply
SECTION 7.a •OWNER AU.-l-.'HOR'.IZAT:lO;N.•T0•;f3:E'.C.QMPL TE:p°'.YVWEfJ
OWNERS AGEN>T,U.Ri E.QN'Pd A.CT:O.R AP.:f?L:IEB.Fa.R,:5.U:LLaI.N.g P�ER"MIT
i� -. _ aL _—, _ as Owner of the subject
property
hereby authorize �2.��C�rz. (4-
io act on my behalf, in all matters relative to work authorized by this building permit aR Icatlon,
Signature of Owner Date
I, —Aa. U�1'. CL 4 lrt•i'1(1Y17 PrJ n ocC n I _ _, as Owner/Authorized
Agent hereby deelaro that tho statements and Informallon onde foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and-penalties of perjury,
Print Name
Af
Signature of OwnedAgont _� Dale - `"-�—
V
tJc.ensed Const ructlongl[peNI
Not Applloable 0
)e of Licens o 0 :_A- eVIQ 7,-I_H ,"� _�
Lloonse Number
L�1�-4A n t"Y'\V1 t tN,el a
ess
Expiration Date
:is all Lill I I
Muie Telephone
k�Lcj L&t 'Alil
Not Applicable 0
Name Registration Number
liess Expiratlor) Date
Tolephone�LYL. rL5
CTION 10.WORi(-E.-R6'-CCIMP.E.-N$.-ATIO-N IN'SUR)MCE AF-FIDA-VIT (WO.L. c, 162, § 260:(0))
,vers Compensation Insurance affidavit must be completed and submitted with thlii application. Failure to provide this a(fidavit will result
i)e.denial of the Issuance of the building permit.
-)ed Affidavit Attached Yos_ Cf No•,,,,, 0
The current exemption for"homeowners"was extended to include Dwellings of one(1) or Iwo(2) families
and to-allow such homeowner to engage an individual for hire who does not poi;sess I license, pvoylded that.Lhiowner acts
as juarylsor. Q AR M, Sixth Edition Sectl6ij 08 3,51
I)eflLi.Lfl�Wi of He eownei;; Pei-son (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,,L.Mon who constructs more than 0116 110MO In All not be considered a lioineownet.
Such"homeowner"shall stibmit to the Building Official,on a form acceptable to the Building Official jjLLthjeshe_shall be
res L)g.nsjb1e for'ailsuch work performedunderthe buildingsemit,
As acting Constructlon Si6erylsor your presence on the job site will be required A-om time to time, during and upon
completion of the work for-which this permit Is Issued,
Also be advised that with reference to Chapter 162 (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 llgjAlt for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
-- I Congress Street, Suite 100
o'
Boston, MA 02114-2017
' www.mass.gov/dia
W'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers,
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): R C. 1 /Qpp•4hq . LLP
Address; ,Ll r7 61 (9./.
City/State/Zip; -1 IVI--1 01V73 Phone #: L//13)
Are you an employer?Check the appropriate box; Type of project(required);
I.0 I am a employer with 112-6) employees(full and/or part-time).* 7. F�New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in $. Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.F-]I am a homeowner doing all work myself.[No workers'comp,insurance required.]t
10 E] Building addition
4.7 1 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 1 1.0 Electrical repairs or additions
proprietors with no employees.
]2.[]Plumbing repairs or additions
5.7 I am a general contractor and i have hired the sub-contractors listed on the attached sheet. 13, 'Roof repairs
These sub-contractors have employees and have workers'comp.insurance.1
6.7 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[]Other
152,§](4),and we have no employees.[No workers'comp.insurance required.]
Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. if the sub-contractors have employees,they must provide their workers'comp,policy number.
I am an employer that is providing workers'compensation insurance for my employees, Below Is the policy and f ob site
information.
Insurance Company Name; �, l.fYI../'{'Ji� r /_�/�Su✓Q�i�� �, __
Policy#or Self-ins.Lic, #; tAi'G(��_//1�'�� 2/o�f'7 -�D/7,�1" Expiration Date; /0 19
Job Site Address; City/State/Zip; 1,.,Zd< rYJfl O/o
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/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00.1
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 under h ains d penalties of perjury that the information provided above is true and correct.
Signature: "'" - Date;
Phone#, L/3 6-2-7 `/7 Zr _
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2, Building Department 3,City/Town Cleric 4, Electrical Inspector 5, Plumbing Inspector•
6, Other
Contact Person: Phone#:
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: Z_ads. `ng aIa�;-3
The debris will be transported by:
The debris will be received by: Lc 46Mrn R2 'udlLll %rai�s��rCC�lcfz�
Building permit number:
Name of Permit Applicant C � P'j LLP
Date -�g-IoP" Signature of Permit Applicant
R.C. 1. Ro ofin
�,,
6 Line Street,Southampton, MA 01073
Phone-413-527-4775 Fax:413-527-8469
November 14,2018
Nora Kalina
666 Kennedy Road
Leeds, MA 01053
Re: Roof Estimate
666 Kennedy Road
Leeds, MA
Dear Nora;
Thank you for the opportunity to provide the following estimate for the above
referenced property. Our scope of'work is outlined below.
Scope of Work
Strip existing roofing layers to wood deck and properly dispose
Furnish & install wood nailers as needed for new insulation height
Furnish & install 1-1/2" polyisocyanurate insulation mechanically attached
Furnish & install .060 EPDM membrane
Furnish &install .060 EPDM wall flashing
Furnish & install roof penetration flashing's
Furnish& install roof drain inserts
Furnish&install .040 AL edge metal
Furnish & install .040 aluminum box gutter at rear using existing downspouts
Furnish membrane manufacturers 20-year material warranty
Price: $33,000.00
CeRTIFICATE OF ZrI-7L/ILr! / INSURA E DATE WM/00trrrr)
1 1010411 S
AS A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLAER. THIS
RMATIVELY OR NEGATIVELY AMP-NO,EXTEND OR ALTER THE.COVERAGE AFFORDED BY THE POLICIES
IF INSURANCE DOES NOT CONSTITUTLA CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
JCER,AND THE CERwicATE moLDERI
holdar is an AOOtYt NA INSURED,th policy(ies)must have ADDITL NAL, N5UR D provisions or endorsed.
subject to the terms and conditions of t to policy,cat In policies may require an endorsement. A statement on
�r rights to the certificate holder in lieu of such endorsement(s).
NAM ; Michael R.Banal
He N x : 413-527.2TOO Ac No: 413.527.0849
AOD E mb@banasinsurance.com
INSURER 5 AFFORDING COVERAGE NAIC A
INSURERA: Admiral Insurance CO. 24856 24856
INSURER B: Safe Insurance Co. 39454
24856
INSURER0; Admiral Insurance Ca,
INSURER D
IA 41073 INSURER E I
INSURER;:: REVISION NUMBER:
CERTIFICATE NUMB
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POLICIES OF INz' TERM OR CONDITION 0 ANY CON
(NG ANY REQUIftEMEN1', NCE AFFORDED 6Y THE
POLICIES DESCR18 CLAIMS,HH RE
EREIN is Su ut tTs
)OR MAY PERTAIN.THE IHSURAP 000,000
LIMITS SHOWN MAY}u,VE BEEN REDUCED BY PAIDaD s
NS OF SUCH POLICIES. MIA00 FacKaccURRENCIE 50,000
Pau Y NUMBEE $ 10,000
NCE 19D `�D pR£ ISE5 Ea o Curr rxn
ME EXP M onus°�- s
I,UABI� S ^1,000,000
;t43!04114 PERsaNnL&ADvtwURv $ 2,000,000
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Notes:
Furnish 20 year manufacturers membrane warranty.
Provide a 5-year RCI Roofing workmanship warranty.
All work completed to manufacturers standard details
RCI Roofing will provide crane as needed
All workers are OSHA 10 certified
U KDEUL L A cj KF-Q�— 1\IQ -P—U CU VZ. TC;te'— A a eA
T-�-A S(7� C-01-oV) T ?
We hope that y select R.C.I. Roofing to do this work for you. To accept this proposal,
please sign and return a copy to us. We will obtain required permits and notify you
when we plan to schedule the work.
Keith Hamel
Estimator Commercial Accounts
Accepted by Date 12113: 1 I
IOct, 4. 2018 4: 39PM No. 3123 P. 1
DATE(M Mf00MYY)
a���® CERTI>*ICATE OF LII BILITY 1NSUTANCE 10104/18
THIS CERTIFICATE IS ISSUED ASA 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 HOLDERI
IMPORTANT. If the certificate holder is an'MRNMAL INSURED,they policy(ies)must have ADDITIONAL INISIJRED provisions or be endorsed.
If SUBROGATION IS-WAIVED,subject to the terms and conditions of t is policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu o such endorsement(s).
PRODUCER NAME: Michael R.Sanas
Banas 8 Fickert PHC N Ex:: 413-527.2700 1A Na: 413-527.0849
Insurance Agency ADDRESS: mb@banaSinsurence.com
63 Main Street
Easthampton,MA 01027 INSURER 5 AFFORDING COVERAGE MAIC 0
IMRERA: Admiral Insurance Co. 24856
INSURED INSURER B: Safety insurance CO. 39454
RCI Roofing,LLP INSURERO; Admiral Insurance Co. 24856
6 Line Street
Southampton,MA 01073 INSURER D:
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAV BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI00
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION 0r ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY OF ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCR18ED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR LTR v TYPE OF INSURANCE INS WVD POLICY NUMBFR MMfDD MM/DD OLICY P LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE a 1,000,000
CLAIMSMADE a OCCUR PREMISES Es occurrence $ 50,000
MEO EXP An one ers0n s 10,000
A X CA00002096,W4 03/04/18 03/04/19 PERSONALSADVIWURV $ 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER. GENERAL-A Ge>REGATE S 2,000,000
POLICY F PEt`,OT LOC PRODUCTS•COMP/OP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea ac identl $ 1,000,000
ANYAUTO BOMLYIWURY(Per panon) g
B AUTOS ONLY X AUTOSULEO X 6207761 09/30/18 09/30/19 BODILY INJURY(Per acddent) $
x HIRED X NON-OWNED P O ERTY AMA 5
AUTOS ONLY AUTOS ONLY Per acclaent
$
UMBRELLA UAB OCCUR EACH OCCURRENCE $ 5,000,000
C EXCESS LIAO CLAIMS-MADE X GX000000385.02 03/04/18 03/04/19 AGGREGATE $ 5,000,000
DEC) x RETENTION$ 10,000 $
WORKERS COMPENSATION PER U ERH.
AND EMPLOYERS LIABILITY Y I N
ANY PROPRIETOR/PARTNER/EXECUTIVE r-7 N/A E.L.EACHACCIDENT $
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE
If s. rib
desce under
DESCRIPTION OF OPERATIONS belew E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Sihe(Jule,may be attached if more space is required)
ROOFING CONTRACTOR.
The General Liability policy includes an Additional Insured endorsemer t that provides
Additional Insured status to the certificate holder,only when there is at Written contract that
requires such status,and only with regard to work performed on behalf of the named insured.
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.
AUTHORIZED REP S IVE
15 ACM)CORPORATION. All rights rosorved.
ACORD 25(2016/03) The ACORD name and loco are reolstered marks of ACORD
ct, 4. 2018 4: 39PM No, 3123 P. 2
ac CERTIFICATE OF LI EILITY INSUF DANCE DATE(MmroDryrrY)
�./ 1010412018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION OLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AME D, EXTEND OR ALTER TH5 COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDEF�.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, e policy(les)must be endorsed. If SUBROGATION 15 WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder In lieu of such endor'ssment(s).
PRODUCER cc AGT
NAME: Michael Banas
BANAS& FICKERT INSURANCE AGENCY PHcNE 413 527-2700 AIC Na:
ADDRESS: mb banasinsurance.com
'
ADDRESS:
63 MAIN 5T INSURERS AFFORDING COVERAGE NAIC N
EASTHAMPTON MA 01027 INSURERA: AIM MUTUAL INS CO 33758
INSURED
INSURPR B
RCI ROOFING LLP INSVRERa I
INSURPR D:
6 I.INE STREET INSURER E:
SOUTHAMPTON MA 01073 INSURERr:,
COVERAGES CERTIFICATE NUMBER: 322172 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENY,TERM OR CONDITI N OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFC RUED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM$,
EXCLUSIONS AND CONDITION$OF SUCH POLICIES,LIMITS SHOWN MAY H VE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE I U POLIC NUMBER MMLIC EF PM�GY LIMITS
COMMERCIALGENHRALLIABiLrY EACH OCCURRENCE S
CLAIMSMADE FJ OCCUR PR MIS 5 Ea o=nenft)
S
MED EXP WW one person S
N/A PERSONALBADVINJURY S
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL_AGGREGATE E
POLICY❑JECT LOC PRODUCTS•COMPIOP AGG S
THER:' S
AUTOMOBILE LIABILITY COMBINE SINGLE IMI S
Ea accld nt
ANY AUTO BODILY INJURY(Per person) $
ALL OWNEDSCHEDULED N/A BODILY INJURY(Per accident) S
AUTOS AUTOS
HIRED AUTOS NON-OWNEDRO R DAMAGES
AUTOS -CFO(eccideA
' S
UMBRBLLAUAB OCCUR EACH OCCURRENCE s
EXCEs3 LIAR CLAIMS-MADE N/A AGGREGATE $
DED I I RETENTIONS S
WORt(ERSCOMP6NSATION X T TOTE ETH
AND EMPLOYERS'LIABILITY
ANYPROPRIETO"ARTNER/EXECVrIVE YIN E.L.EACH ACCIDENT S 1 (100,000
A OFFICEWMEMSEREXCLUORO1 N(A NIA NIA VWC10060226472018A 10/05/2018 10/05/2019
(MandstoryinNK) E,L.DISEABe-EAEMPLOYEE 5 1,000,000
Ityee,desaibe under
DES RIPTION OF OPERATI NS below E.L.DISEASE.POLICY LIMIT S 1,000,000
N/A
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO 701,Addltlenel Remarks Se odula may b*attachad If mor*Space is recluim)
Workers'Compensation benefits will be paid to Massachusetts employees oily.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if 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 ce ificata 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 www.mass,gov/lWd/workers-compensationfinvostigabons/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OY THE ABOVE DESCRIIDED POLICIES BE CANCELLED aEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Proof of Coverage ACCORDANCE WITH THE POLICY PROVISIONS.
00000
AVTNORiZEO REPRESENTATIVE
C'\
00000 MA 00000 �-'—"
Daniel M.Cra_' )ey.CPCU,Vice President—Residual Market—WCRIBMA
Q 1988-2014 ACORD CORPORATION, All rights reserved.
AGORD 25(2014/01) The ACORD name and log i are registerod marks of ACORD
SCA 1 Co 2OMM-06/17
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Office of Consumer Affalr6&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:Partnership
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Commonwealth of Massachusett's '
MARK T.DELISL
6 LINE ST t�� :_ ~' �� �V�f/ Division of Professional Licensure
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SOUTHAMPTON, Board of BuildingRegulailons and Standards
MA"tf1:4r1'8' Undersecretary Consrttl, t'ft`'i�l�li rvIsor
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Registration valid for Individual use only ! :`' Y' in4 '
before the expiration date. If found return to: MARK THOMAS 094j``
Office of Consumer Affairs and Business Regulation 69 BRIGGS ST IE1 °
1000 Washington Street-Suite 710 EASTHAMPTO .p�`
Boston,MA 02118
Commissioner
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