24A-093 (4) 26 DICKINSON ST BP-2019-1151
GIs 9: COMMONWEALTH OF MASSACHUSETTS
Man Block: 24A-093 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 s BP-2019-1151
Proiect4 JS-2019-001870
Est. Cosi $18511 00
Fe $40.0o PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VISTA HOME IMPROVEMENT 111478
Lot Size(so.ft.): 4748.04 Owner. Colee Curtis
Zoni=URA(100)/ Applicant: VISTA HOME IMPROVEMENT
AT: 26 DICKINSON ST
ApplicantAddress: Phone: Insurance:
2003 RIVERDALE ST (413) 382-0249 WC
WEST SPRINGFIELDMA01089 ISSUED ON:4/19/2019 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 Sienature:
FeeTvpe: Date Paid: Amount:
Building 4/19/2019 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
1=
Departmerd use only
City of Northampton any F�
-� ..� Building Department _ �L 'Ee)MR
212 Main Street Sewer/Septic AvallabN
{ Room 100
Northampton, NIA 01060 ct
phone 413-587-1240 Fax 413-587-12-12 PbUSIts Plans
Dow PECTIONS
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: ab/ .��Gfr�9�Ssr1 Sf This section to be completed by office
NO��hp fan 41y pla�C Map a vA Lot 013 Unit
Zone Overlay District
Elm Sl District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: COKE C 461
2< �r�4f,%iSort S/ !✓o/fha dplol7 MA olWo
Name(Print) Current Mailing Address:
- L&e Telephone X4/5) 374E-7�
Signature
2.2 Authorized Agent:
p<ao kudd �09� r�vu�lc✓c s¢ wes �r�ngre�d_ 141,4
Name(Print) Current Mailing Address:
.Lgf.GA2 (41�) 3A.1 —gig?
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
Completed by Permitapplicant
1. Building �0 ,S/ (, 7a2 (a)Building Permit Fee /yQ Od
2. Electrical (b)Estimated Total Cost of ``77Cp r
Construction from 6 O5)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2 +3+4+5) Check Number
This Section For Official Use Only
Building Permit Numb r: Dale
Issued:
Signature:
Building Commissionedinspector of Buildings Date
@ �l��fiG11lYVLQ IvY1nr��xr�L�►t rCoVI
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
Tho,column a be filled in by
Buildin,Department
Lot SIZe
Frontage
Setbacks Front C—
Side L:L= R:� L: R:L-
Rear
Building Height
Bldg.Square Footage
Open Space Footage
Lm arca minus bldg&raved
arkln
#offaarkin S alta
Fill:
(volume&location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO & DONT KNOW O YES O
IF YES, date issued:�I
IF YES: Was the permit recorded at the Registry of Deeds?
NO (?f DON'T KNOW O YES O
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO v DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
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 O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicablet
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing 2r
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0l Other[O)
Brief Description of roposetl
Work: S+r_n� in=? ice wL�er Uhd2//c�n7CI1 / OG Sv Gess
Alteration of existing bedroom_Yes No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga.If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other
It. 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 allached?
h. Type of construction
I. Is construction within 100 N. 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
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property \ 1,�^^ (� }
hereby authorize V J t �7t'1 V y Lp LJ� 11�V-e,i' p Al 1
to act my behalf, in all matters relative to work authorized by t is budding pe mit appli atn.
1,09
Signature of Owner J
1 --II 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.
Si under the pains and pena sof perlury.
h
Print Name
Signature of OwnerlAgenl Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor': I Not Applicable ❑
Name of License Holder: dd► Alta c571(l47?
License Number
go Mf 5100
Address V Expiration Date
Signature Telephone
9.Realstered Home improvement Contractor: Not Applicable ❑
\l1 �fiCI 11 0 � m oYAo � Ito r� S�
Co Name T Registration Number
G � i2lUPrG�OAPp ST 1- � � l
Ad ress ///��� I/� (� /j Expiry io ate
0( c, V-K u) W.0 a cis % Telephone
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....... No...... ❑
City of Northampton
Massachusetts F= >•- <<
c
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northa ton, MA 01060 JSYrr. \fie
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC').
M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by reeistered contractors.
Note:if the homeowner has
��contracted with a corporation or LLC, that entity must be registered
Type of Work: V g - 1 g Est. Cost: ���', $��, 7,2
Address of Work:,2o� P,--k 'II SOlt /H/ Tolc/0
Date of Permit Application: t'{�j1//9
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
Job under$1,000.00
Owner obtaining own permit (explain):
_Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS W ITH 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:
1 hereby apply for a building permit as the agent of the owner:
al is � \() vmrc� Rpa-OS S
Date Contractor Name 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
s �
� ...t - Massachusetts
DEPAETNENT OF BUILDING INSPECTIONS
212 Main Street aNnnicipal Builtling
Nertln m ron. NA 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:
1l 9 ( �C�11S�r1 S1
(Please print house number and street name)
Is to be disposed of at:
CGk
(Please print name and location o facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
J� Ad I y1 ( r') IC)
Signature of Permit 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
a 7 Congress Street, Suite 700
Boston, MA 02174-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING.AUTHORITY.
Applicant Information ePlease Print Legibly
Name (Busincss/Organirailon/Individual): six��
Address:(] t-Llq `1 ��U-Q V, do t S�
City/State/Zip: ClPhpne#: 'A
I�trey nemploy Checkthe.ppruprimebac Type of project(required):
naanploy its _._employers(mlland/ur panaimcp 7. []New construction
2 F l am a sole pwprecomorpanncrship and have no employees working tbrdem $. E] Remodeling
any eopaeit, [No workers comp.mamancc requiredl
3F1 I am a homcowner doingII work myself No wader comp-insurance required.] q- ❑Demolition
n
oo 5 I 9uirc I'
1❑I am a homemvnemnd will be hinn6 wnoaemrz m conduct ell work on my property. I will 10 E] Building addition
ensure mal all contractors either have workerscompensation insurance or are sole 11.❑Electrical repairs or additions
pmpricmrs with no employee,. 12.E]Plumbing repairs or additions
5. I am a neral comerand I have hired' the sub-coatr l ntmenolison the sheet.
❑ general mro13.[-]Roof repairs
These sub contractors have employees and have workers'wrap,insurance:
fl❑Wc arca cooperation and its officers have exercised mMcuright ofexcntptionperMa.c. 14-�er
152,d 114),and we have no cmployces.[No worker'compinsurance required.l
'Any appliennuhin checks box a I must also till out the section below,showing their workers-compensation policy inrnrmmioa
t Homaowoers who submit this aridavit indincon. they am doing all work and then hire outside contractors must submit a new affidavit indicating such.
tcoutmemrs that check this box must attached an additional sheet showing the name or the sub-contractors and state whether or not those entities have
employers. Ifdm sub-contactors have employees.Ihcy must provide their workers comp.policy combo.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
�7lInsurance Company Name:
Policy#or Self-ins..Lic.#: ,j /
Ensptmt.i(on-j Date:
Job Site Addrew, l) Z:*aArN _\ ( \ City/State/Zip: ✓V�U ,,r\
+Lx rYr(4
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 51,500.00
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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
7 do hereby cer fy under the patns a penaltiesrl/of perjury that the information provided above is true and correct.
Sgt ,-,- \-A/ ( es1 Date' L41 Is
Phone# , 1 " I q
Oficial 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 Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Page 1 of 7
2097 Riverdale Street MA Lic# 162058
West Springfield, Vista}. CT Lic# 0621848
Ph 01089 V GE.
xoe IMPR l.aexovcmenr vistahomm
eimproveent.com
Phone: 888.597.2323 m
Fax: 413.382.0241 ROOFING CONTRACT
All home improvement contractors and subcontractors must be registered and any inquiries about a contractor or
subcontractor relating to a registration should be directed to:
Office of Consumer Affairs and Business Regulation Ten Park Plaza, Suite 5170
Boston, MA 02116 Phone: 617.973.8700
Customer Information
Colee Curtis coleeasia@gmail.com Date: 04/05/2019
26 Dickinson St (413)374-7809 Rep: Steven Wakefield
Northampton MA 01060
Roof Specifications
Owens Corning Roof Systems Standard Roof Systems
Color Onyx Black
Drip Edge Color white
Number of Layers 1
Attic plywood
Location Main
Underlayment Pro Armor
Ice&Water Shield 6feet
Supply and Install Ridge Vent yes
Vista Home Improvements agrees to do the following:
Acquire all permits for roofing work Yes
Supply Dumpster Included
Dumpster location Tbd
Inspect Decking for damage Yes
Ice and Water all valleys, penetrations, eaves and chimneys Yes
Supply and install pipe boot flashing Yes
Total Job Clean-Up Yes
12" Chimney Relead 1
I, Colee Curtis, have read the terms stated herein, they have been explained to (me/us), and (I/We) find them to be
satisfactory and hereby accept them.
Page 2 of 7
Roof Sketch / Photos
L
L
l
Steven Wakefield,Authorized Representative Colee Curtis
04/05/2019 04/05/2019
Date Date
Page 3 of 7
Homeowner's Association NO
WORK SCHEDULE
Contractor will not begin the work or order the materials before the third day following the
signing of this Agreement, unless specified herein. Contractor will begin the work on or about 05/05/2019
Barring delay caused by circumstances beyond Contractors control, the work will be completed by 05/05/2019
WARRANTY
The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship
for the period stated below following completion and shall comply with the requirements of this Agreement. In the
event any defect in workmanship or materials, or damage caused by the Contractor, its subcontractors, employees
or agents, is discovered after completion of any job, Including cleanup, the Contractor shall, at its own expense,
forthwith remedy, repair, correct, replace, or cause to be remedied, repaired or replaced, such damage or such
defect in materials and workmanship. The foregoing warranties shall survive any inspection performed in connection
with the agreed-upon work.
Warranty Period Lifetime
Measure Section
Measure Set With -- Rick
Total Contract Amount (All Discounts Applied) $18,511.72
Pa ment
Amount Due Upon Signing Contract (1/3 Maximum) $6,170.57
Amount Due At Start $6,170.57
Amount Due Upon Completion $6,170.58
Form of Payment Upon Signing Credit Card
Credit Card Visa
Credit Card Number 4147-4002-4641-4633
Expiration Date 10/2023
Credit Card CCV 456
Name as it appears on card Coles Curtis
Payment Form At Start Credit Card
Payment Form Upon Completion Credit Card
Acceptance of Proposal I have read both sides of this document and accept the prices, specifications and
conditions stated. I understand that upon signing, this proposal becomes a binding contract. You are authorized to
do the work as specified. Payment will be made as outlined above.
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the
Seller, which may be his main office or branch thereof, provided you notify the Seller in writing at his main office or
branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day
following the signing of this agreement. Please refer to the Notice of Cancellation below contents of which are
referred to above and incorporated herein by reference.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
NOTICE OF CANCELLATION
Page 4 of 7
YOU MAY CANCEL THIS TRANSACTION, WITHOUT ANY YOU MAY CANCEL THIS TRANSACTION, WITHOUT ANY
PENALTY OR OBLIGATION; WITHIN THREE BUSINESS DAYS PENALTY OR OBLIGATION; WITHIN THREE BUSINESS DAYS
FROM THE ABOVE DATE. FROM THE ABOVE DATE.
IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS
MADE BY YOU UNDER THE CONTRACT OR SALE, AND ANY MADE BY YOU UNDER THE CONTRACT OR SALE, AND ANY
NEGOTIABLE INSTRUMENT EXECUTED BY YOU WILL BE NEGOTIABLE INSTRUMENT EXECUTED BY YOU WILL BE
RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING
RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE, RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE,
AND ANY SECURITY INTEREST ARISING OUT OF THE AND ANY SECURITY INTEREST ARISING OUT OF THE
TRANSACTION WILL BE CANCELLED. TRANSACTION WILL BE CANCELLED.
TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED
AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY
OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO: VISTA OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO: VISTA
HOME IMPROVEMENT, 2097 RIVERDALE STREET WEST HOME IMPROVEMENT, 2097 RIVERDALE STREET WEST
SPRINGFIELD, MA 01089 NOT LATER THAN MIDNIGHT OF SPRINGFIELD, MA 01089 NOT LATER THAN MIDNIGHT OF
THE THIRD BUSINESS DAY FROM 04/05/2019 THE THIRD BUSINESS DAY FROM 04/05/2019
Vista Home Improvement Vista Home Improvement
2097 Riverdale Street 2097 Riverdale Street
West Springfield, MA 01089 West Springfield, MA 01089
NO LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY NO LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY
FROM THE DATE OF THIS CONTRACT. FROM THE DATE OF THIS CONTRACT.
I HEREBY CANCEL THIS CONTRACT. I HEREBY CANCEL THIS CONTRACT.
BUYER'S SIGNATURE DATE: BUYER'S SIGNATURE DATE:
Buyer(s) Acknowledge Receipt of the Cancellation Notice
Colee Curtis
04/05/2019
Date
Page 7 of 7
Contractor will be responsible to Owner or any third party for any property damage or bodily injury caused by itself,
its employees or its subcontractors in the performance of, or as a result of, work under this Agreement. Contractor
agrees to carry insurance to cover such damage or injury.
Construction Related Permit Acquisition:
Contractor, under provisions of Chapter 142A of the Massachusetts General Laws, is required to apply for and
obtain all construction related permits. Contractor shall not be deemed responsible for delays in the work described
in this agreement caused by regulator, permit granting or inspectional agencies, authorities or individuals.
NOTICE: If Owner obtains his/her own construction related-permits for the work described under this
Agreement, Owner is hereby advised that in the event of a dispute, judgment and non payment of Contractor,
Owner will not be entitled to make claim to or collection from the guaranty fund established in M.G.L. c. 142A.
Modification:
This Agreement, except as to concealed conditions or delays occasioned thereby or by restarts, cannot be changed
except by a written statement signed by both Contractor and Owner. However, cancellation by Owner is allowed in
accordance with the Notice of Cancellation. Owner hereby grants Contractor a limited Power of Attorney to
complete incomplete documents on Owners behalf.
Completeness of Contract for Execution:
Owner is hereby advised not to sign this Agreement unless and until all blank sections have been filled in or marked
as void, deleted or not applicable, and until all exhibits and related or referenced documents that are incorporated
herein are attached hereto.
Attorney's Fees/Casts
Owner agrees to pay all costs of collection, including reasonable attorney's fees, cost and expenses. Furthermore,
interest shall be charged at the highest lawful rate of interest on any and all overdue payments.
Copy of Agreement to be given to Owner:
This Agreement is governed by the laws of the Commonwealth of Massachusetts. It must be executed in duplicate,
and an original, signed copy hereof given to the Owner at the time of execution. No work under the Agreement shall
begun prior to thye�signiinngg\of f the
Agreement and transmittal to the Owner of a copy therefor.
Coles Curtis
04/05/2019
Date
Steven Wakefield Authorized Representative
04/05/2019
Date
Joie Frr�riiiii�rireaa / rz�uzu�e
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Mas`Sachusetts 02118
Home ImprovemBnt Contractor Registration
Tyle: LLC
Registration: 162058
VISTA HOME IMPROVEMENT Expiration01/02/2021
2097 RIVERDALE ST
WESTSPRINGFIELD,MA 01089
Update Adurass and Return Caret.
$GP1 O aIR 11/
OMca W Cone—AMha L&uinaa Repulxaon
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:LLC Before the expiration data. If found return to:
Reol,dralMn
Expiration office of Conaumer AHalrs and Business Regulation
11120.59 01/02@021 1000 Washington street-suite 710
VISTA HOME IMPROVEMENT Boston,MA 02110
BRIAN RUDD ' p /
2097 RIVERDALE ST ,41:..�--- MCGh.RBV S�kUY
WEST SPRINGFIELD,MA 01089 U
Undersecretary Not valid without Signature
CERTIFICATE OF LIABILITY INSURANCE I
DATE(MM/DDIYYYY)
FICATE IS ISSUED AS AMATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE THE CERTIF
IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policyRos)must be endorsed. KSUBROGATIONISWAIVED,subfectto
the terms and conditions of the policy,certain policies may re0uim and endorsement. A statement on this certificate does not confer rights to
the certificate holder in lieu of such endorsemen s.
PRODUCER CONTACT
NAME'
SOFT[FA INS AGENCY INC PHONE FAX
P 0 ROX 100 (AIL,No,ER): (AIC,Nok
E-MAIL
SOUTIIWICK,MA 01077 ADDRESS:
28TKC INSURER(S)AFFORDING COVERAGE NAICi
INSURED INSURER A: I RAt'ELERS PROPERTY CASUAI T(OkiPW Y OF ANIERIC
SAMBRICO LIC DHA VIS FA HOME IMPROV EMEN I INSURER B:
INSURER C:
INSURER D:
2097 RI VRRDALE S TREE I mSURER E:
WEST SPRINGFIELD,MA 01089 INSURER F:
COVERAGES CERTIFICATENUMBER: REVISION NUMBER:
THI T IFY TNAT THE POLICIESOF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTANTHSTANMNG ANY REQUIREMENT.TERM OR CONp9ON OF ANYCONTRACT OR OTHER DOCUMENT WITH RESPECT lO WHICH THIS CERTIFICATE MY BE ISSUED OR MAY
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND ODIU TNTNS OF SUCH POLICIES, LIM"SHOWN MAY
HAVE BEEN REDUCED BY PMD CLAMS
INDIA ADO SUB POLICYEFFOATE POLN:YEXPDATE
LTR TYPEOFINSURAMCE L R POLICY NUMBER IMMAGYYYYI IMSMPYYWI LIM"
GENERAL LIABILITY ACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
CIAIMSMADE OOCCUR. REMSESGE ORENTED(Eacc $
urerm)
ED ESP(AMone person) $
ERSONAL S ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $
POLICY ❑PROJECT OLOC RODUCTS-COMWOP AGO $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANT AUTO LIMIT OR accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEOULEAUTOS (Per person)
HIRED AUTOS BODILY INJURY $
(Per ni)
PROPERTY NONOWNEDAUTOS DAMAGE $
(Perersoudemaenq '
UMBRELLA LIMB OCCUR EACH OCCURRENCE $
EXCESS UAB 01-AIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ '$
A WORKER'S COMPENSATION AND X I W03TATUTORY OTHER
EMPLOYER'S LIABILITY YM US-2EO72183-19 0311212019 03/12/2020 LIMITS
ANY PROPERITOMPARTNER1.-Ur UTNE O VIA E.L.EACH ACCIDENT S 500,000
OFRCdor,InA NER ExCLuoem E.L.DISEASE-EA EMPLOYEE $ 500,000
11.'E"FEMIn NH)
1"..—Me¢oder EL.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATOrvs eeldr
DESCRIPTION OF OPERATION&LOCATIONSNEHICL WRESTRICTIONSMPECIAL ITEMS
THIS REPLACES d\Y PRIOR CIER UNIT ATE ISSLI ED TO THF CFR I Ir ICA FE HOLDER AFFF(TII W'ORkERS COMP C OVFRAGF.
CERTIFICATE HOLDER CANCELIATION
TOWN OF WEST SPRINGFIGI.D SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
26 CEN I RAL STREET IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORMEDREPRESENT VE � (
WEST SPRINGFIELD.MA 01089 �U[,µ'
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1888-2010 ACORD CORPORATION. All rights reserved.
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