38B-045 (2) 145 SOUTH ST BP-2019-1280
GIs# COMMONWEALTH OF MASSACHUSETTS
Man:Block: 38B-045 CITY OF NORTHAMPTON
LO-1--Q-01- PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category, ROOF BUILDING PERMIT
Permit# BP-2019-1280
Proiect# JS-2019-002071
Est Cosr 2460000
Fee $4Q_00 PERMISSION IS HEREBY GRANTED TO.
Const.Class: Contractor: License:
Use Group: PHIL BEAULIEU & SON HOME IMPROVEMENT 062638
Lot size(sa.fl.): 6664.68 Owner: ZGRODNIK PAUL I M. PAMELA B
Zoning:URB(1 W)/ Applicant., PHIL BEAULIEU & SON HOME IMPROVEMENT
AT.- 145 SOUTH ST
Applicant Address: Phone: Insurance:
217 Grattan St (413) 592-1498 Workers ComRLasation
CHICOPEEMA01020 ISSUED ON:5/14/2019 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 n Foundation:
Mfi,away Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oi'1:, Insulation:
Final Smoka; Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature
FeeType: Date Paid: Amount:
Building 5/14/20190:00:00 $40.00
212 Main Sweet, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
• ,r�
- _—' City of Northampton Status Department use only
it a Perm
,r Building Department Curb Cutmdveway Permit
/, �:, 212 Main Street Sawer/SepgA
cfallabgRy
... (.Il: Room 100 Water/WellAvellebitly
Northampton, MA 01060 Two Sets of Structural Plana
phone 413-587-1240 Fax 413-587-1272 Pagel Plana
OUMr Spec*
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TAO,FAMILY DWELLING
SECTION 1 -SITE INFORMATION 0,' I _I /a D/O
1.1 ProoerN Address: Th' section to be complsbtl yoflice
Map Lot Unit
H55aU}h S}. Zone Overlay District
J J Elm S4 Blstrkf CB Bbeicr
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Napam l (odniK
e 2l) C In1ailin@ gtleress'.
L42--4A
d9000al
Televnone
s. amm
2.2 Authorised A e = Phil Beaulieu&Sons Hone Imp.,Inc.
217 Grattan Street,Chicopee,MA 01020
HI REG 4100073 Exp.6/7/20 t Malting geeres -
rvamelPrmq CSL 4CS62639 Exp.6/13/19 -
Alain Beaulieu
BgnaWre PIL0l3)592149fl;Fox:(413)594.6t(A
SECTION 3-ESTIMATED CONSTRUCTN)N COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
coin Intetlb ermita licant
1. Builtling 1a 00.ne (a)Building Parmit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plum an, Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total-(1 +2+3+4+5) 1p 0.0 Check Number
This Section 1�7tu
I l Use Onl
Building Permit Nu er. — ed:
SigneWre:
Building Commiseemo rlloaWtor of Buildings Dale
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR C NT EI VED
I
MAY 1 3 2019
-'T O�51lIL DINE INSPECTIONS
O'iiys",,ON.IAA 01090
Section4. ZONING All Information Mot Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Ibiswlumn to be filled in by
Building Dcommrn,
Lot Soon
road age
Setbacks Front
Side L - R-.-- L. R'
Rest
Building Height
Bldg,Square Footage - -
Open Space Footage
ILm arta min-bldg&oacud
akin
dmf Parkin $ ac
Fill:
lvd ami&Locmim
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT 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 Q 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 7 YES O NO O
IF YES, describe size, type and location:
F, Will the construction activity disturb(clearing.getting,excavation,or filling)over t acre or is it part of a common plan
that will disturb ever 1 aae? YES NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteratlonls) ❑ Roofing 171
Or Doors O
Accessory Bltlg. ❑ Demolition ❑ New Signs Int Decks IQ Siding lo] Other[0]
Brief Description of Proposed
Work: SM',P al 12405 Of mC fn'� nSbl u /ImW 1 arre•Yerh,ml Sh'n /erg
Alteration of existing bedroom_Yes J No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement _Yes No
Plans Attached Roll -Sheet
W.If New house and or addition to existing housing-complete the following:
a. Use of building:One Family -1Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
o Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance, Masseheck Energy Compliance form attached?
In, Type of construction
i. Is construction within 100 f1.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 Buildilg and Zoning regulations? Yes_No.
I. Septic Tank_ City Sewer_ Private well_ City water Supply_
SECTION Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,roperty Y 0 f 0 3K as Owner of the subject
p 'O
hereby authorize O � P HO P ImOfOJPm Pni
to act on my behalf,in all matters relative to work au odd by this buiitling permit application.
S1 (' 1/9
SlghatureMOwn Date
1 //) �J as OwnerlAuthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the beat of my knowledge
and belief.
Signed undW pains and penalties of perjury.
Print Name
Signature of OwoerlAgent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Not Applicable ❑
Nama of Liean '��yy�� Phil Beaulieu&Sons Home Imp.,Inc.
317 Grattan Street,Chicopee,MA 01020 License Nomp r
HI REG#100073 Exp.6/7/20
CSL#CS62638 Exp.6/13,19
Address Alain Beaulieu Explosion Date
PH_(43592.1498,Fax'.1413)594 d008
Signature Telephone
B.ReRlebrstl W^�'•^^^••�•••�^'�^^'^^'^� Not Applicable ❑
resil Phil Beaulieu&Sons Home Imp.,Inc.
gagtg1nXNamteeeYRYe217 Gashes Street,Chicopee,MA 01020 Registration Number
HI REG#100073 Exp.6/7/20
CSL#CS62638 Exp.6/13/19
Address Alain Beaulieu Expiration Date
PH_(413)5921498 Fax:(413)594.6008
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....... lil No._... 0
City of Northampton
+' Hassachusetts
( DEPARTMENT OF BUILDING XASPECTIONa
313 Win 9tt 0 Municipal BuilEng
navNiu ¢ton,
as 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,demontim,or construction of an addition to any pre-existing owneroccupied building containing
at least one but not more than lour dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:Lf one homeowner has contracted with a corporation or LLC,that entity must be registered.
Typeof Work: 900{ E9LC06C o2 y1 100006
Address of Work: X15 ,500A Sil
Date of Permit Application:
I hereby certify,that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
Job under S 1,000.00
_Owner obtaining own permit(explain):
Building not owneroccupied
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 pedury:
I hereby apply for a building permit as the agent of the owner:
Date Contractor Name HIC Registration No.
Phil Beaulieu&Sons Home Imp.,Inc.
OR: ZA 217 Gmtmn Street,Chicopee,MA 01020
HI REG#100073 Exp.6/720
Notwithstanding the above CSL#CS62638 Exp.6/13/19 owner of the above property:
AI Beaulieu
PI 1'.(413)5921499,this(413)594 6008
Date Owner Name and Signal=
RI Bequileu �"
City of Northampton
Massachusetts
OFPMTNNNT 010 OF BUILDING INSPECTIONS
\ 213 Mein txeet • Hun Building C
Nor[t�emp<on, MA 01060
Massachusetts Residential Building Code
Section I IO.R5.L2
Homeowner: Person (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. A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section I IO.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR I I O.R5, provided that if a homeowner engages a persons)
for hire to do such work,then such homeowner shall act as supervisor.
Such homeowner shall submit to the Building Official,on a form acceptable to the Building
Official, that he/she shall be responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to
time,during and upon completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(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 liable for person(s) you hire to perform work for you
under this permit.
City of Northampton
t4assachusetts
D212ft xn S OF meaIH DZNGnici INSPECTIONS
212 Main Stb a aM�aicipal enilGinq s
1\ " No[N�[oq rq 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:
195 50oh 5F
(Please print house number and street name)
Is to be disposed of at:
All lfdasle Rfmodo.t
(Please print name and location of facility)
Or will be disposed of in a dumpsler onsite rented or leased from:
All Wa5fe Remoyat
//((CCoompa'ny Name and Address)
Signature of Permit Ap Ii nt 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 ss IndustStreet,
Suit ccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gouldia
Workers'Compensation Insurance Affidavit:Builders/Cont rad ars/ElectriciansMambers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant InformationPhil.m. ee Sons Home Imp.,IncPlease Print Leeibly
.
-ZA
Name(BusinesyOrgavizeuonnndivid� 219 Grown
mtmn St Street,Chicopee,MA 01020
HI RAG k100073 Exp.bq/20
Address: CSL NCS62638 Exp.6/13;19
Alain Beaulieu
City/State/Zip: P11'.14131592-1498/Fax:14131594.6008
rare You..empmYer^Cheat m.appropriate bac Type of project(required):
I.dlamaemp(oycrwas 11 can.. tu'll notc."an-tim ) ], ❑New construction
?�lemas.lc pmp-mror petwohipand have noemPloycce wo, ing for me In 8, 0Remodeling
ah,char 'uy.lNo w acem'com, a stairs re,ancol] q. ❑Demolition
[,me hemeawner doing all work my-hr[No workav'comp.imumma required.]'
a.[]lama haachmnerand win m hiring ren mon-mconow— nwY prvC+9' (will
ok-in 100 Building addition
-
.remaul)eamnaor.caber nave workers eompensafon inaatante or me gale IL[]EIecMcal repairs or additions
proprielan with no employees. 11Q Plumbing repairs or additions
501amageneralmmwhe and I have random sebmnlnctars lured on the amchedshed. 13 Roof trying
nccsesubcentnrtorshaveemployeesandhavcwrken comp-anichnee
4�Wem o corporation and Iu o1Fvn have exe.iad their riQM1t o[aonplion per MCL c. 14. Other
152.Mal.a.d we hwe.a employees tso warken'wmp.is angwr o s it]
^A.yapnlicentthar,wrk,Mxcl maxi a Lo all,whir-arenb .. fi—m their work,, wlerwinat npolity Inromerma
^Ilomc o.whmot this allidav indicating nee re doing all enhance then hire cid— submitewalfidar mh
no—ting e .
,me cars@at check this box wit attached w iddhawi
onal sheer shaw the name uftfi—alb monal and state whether or not th—entities have
e.ployves-Ifthefuhwn ctonh,,eemployee,.theymonpmvW,leir workers'wmp.Policycamber
I am an employer that is providing workers'compeasanon insurance for my employees. Below is the policy andjob site
alternation
Insurance Company Name: A (h
Policy a or Self-ins.Lia N: VV('((7 XQO��SO Expiration Date' d .d5 I
Job Site Address: N5 SOUfh S4- Cdy/State/eet, 0(th6
Attach a copy of the workers'compensation policy declaration page(shoring the policy number and exp rafion date).
Failure to secure coverage as required under MGL a 152,425A is a criminal violation punishable by a fine up to$1.500.00
and/or ono-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 Qo herehp cerfiry an(rf I spa' enables ofperjuq�that the informadonprovided above�is/trJ/fepoadcorrect.
Sienature: f//E,4/S`/J s Data /C2/
Phone k' /f tell
Oficial use only. Do not write in this area,to be completed by city or town oJjcial.
City or Town: Permit/License k
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone g:
Information and Instructions
Massachusetts General Laws chapter 152 rtyu ns;all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as". encry person in the service of another undu any want of hire.
express or implied,oral or written,"
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in aimed enterprise,and including the legal representatives ofa deceased employer,or the
receiver mousey mine individual,partnership,association or other legal entity,employing employees. Howeverthe
owner ore dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.'
MGL chapter 152,$25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to uperato a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.'
Additionally,MGL chapter 152,p25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the Incriminate of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority"
Applicants
Please fill out the workerscompensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),addresses)and phone numbers)along with their certificates)of
insurance. Limited liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
embers or partners,are not required to carry workers'compensation insurance- If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation ofinsurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retained to the city or town that the application for permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
onnpamostme policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and pointed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the peva it/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)cud order"Job Site Address"the applicant should write all locations in (City or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit ism file for future femurs or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
rx a dog license or permit to bum leaves etc)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel.#617-727-4900 ext 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.inas"s.gov/dia
City of Northampton
Massachltsettas cr
DNPAafN6N9' tlF BUILDING INSP£CTION3 = px
'L 312 Na— at., uunicfpal euildlvq C
uoxsn.�ton, uA 83060 Y `J
LOUIS HASBROUCK
BUILDING COMMISSIONER E1facYIY@duly 1,2615
Phone: (413)587-1240
Fax: (413)5117-1272
Residential One and Two Famiiv Building Permit Fees
her I/ rth t O02IB 'Id' D rt t
Fees for work not listed..be determined by the Building Department
Any work beginning before a permit has been issued is subject to double fees and a stop work order removal fee
Hours of operation are typically Monday thru Friday 8:30 to 4:30,Walk-in hours are closed at 12:00 pm Wednesday
Permit Fees are pad to the CRY OF NORTHAMPTON CHECKS OR MONEY ORDERS ONLY:NO Cash or Credit Cards
Checks or Money Orders Must Be Submitted with the Apoflc Pion or H will not be acted upon
To 8e Processed,Applications Must 80 Complete and Include ALL Required Attachments
All Applications Are Subject To Zoning Review,The Weekly Filing Deadline is 12:00 pm(noon)on Wednesday.
Building applications-Require a plot pian,floor pians.elovations,structural and energy information as appropriate
Sign applications-Require a photo of the existing elevation and a photo shopped placement of the proposed sign
Applications may be subject to Central Business.and or Historic and Demolition Delay reviews
It is the Owner's rosincra biiity to verify property bounds and conservation issues
COMPLETE DEMOLITION Accessory Structure -- - - --- - --- -----.—$30.00
One or Two Family House--- --- -- ----- -- -- ------$75,00
NEWCONSTRUCTION All Occupied Floors per sf--- ---- --- -- --- ----..,.$,50
Floors,Walk-in Attics, Basements, Garages per ai------- - ----- -$,20
Decks,Porches,Canopies,Porticos per sf --------- - ---------- —$,20
NEW ACCESSORY SLR CTU Free Standing Decks---------------------$20 per sf,Minimum $50.00
Shed up to 200 sf zoning review._..._.___........_.....___...__........_.__$30.00
Shed over 2005f.........._—...._..__._....__....--$20 per sr,Minimum $35.00
Tent over 200 sf ___..... -....._- ___.._.......--$30.00
Above Ground Swimming Pool ------- ------ -----$40.00
In Ground Swimming Pooi......_._......___.....__..._..____...____..___._.$75.00
REPAIR RENOVATION ALTERATION$6.50 per$1000 of estimated cost(rounded up)— ------Minimum $65.00
SIONS Wali Sign for Home Occupation- ------... _.__
SPECIALTY PERMITS Ro@Ong_.......... __._. ......_ ...___........._..$40.00
Siding...__-_.. _........_.__- __....__ __......-_-.. __...-..$60.DO
Non-Structural Door&Window Replacement $40.00
Solid Fuel Burning Appliances- ------ — ----$40.00
Sheet Metal- ---- --$25,00 with building permit on site;Otherwise $50.00
S LAR Roof Mount.... _.....- ....___. ......._.$75.00
Ground Mount up to 8kw or 100%of demand--__..._._-_..._—_.....__._.$75.00
Ground Mount up to 200%of demand----- ----------- -----$100.00
Ground Mount over 200%-- ----- -----Use the commercial rate Calculator
OWER SERVICES Request For Zoning Determination - -----------------------.......$30.00
Home Business Review&Registration-------------------.- --$30.00
Replacement Permit _..._ .._._ .....___...._.._..$30.00
Contractor Change ___....... ___....._. _......_...... . _.__.$30.00
Temporary Certificate of Occupancy..._.__...__.........-.__..___._.........._$75.00
Additional or Requested Inspections----- ----.---- ----- -----$75.00
Removal of Stop Work Order..___......___.....__............__._...__.._......$75.00
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: Corporation
73
PHIL BEAULIEU&SONS HOME IMPROVEMENT,INC. Re xpiration: 06/012
217 GRATTAN STREET Expiration: 06/0712020
CHICOPEE,MA 01020
Update Address and Return Card.
MeeatL`onsumeiAf(aii�a 9uir�¢si�e,julalbn
HOME IMPROVEMENT CONTRACTOR Reglatrabon valid for individual use only
TYPE:Coroara0on before the expiration date. If found return to
Reafstralion Ex,lotion Mee of Consumer Affairs and Business Regulation
100073 M0712020 1000 Washington Steel-Suite 710
PH IL BEAU LIEU&SONS HOME IMPROVEMENT.INC. /Bosstttoo/nMAAA 002113
ALAIN M.BEAULIEU
217 GRATTAN STREET U
CHICOPEE.MA 01020 Undersecretary Not valid without signature
PHILBEA-01 CHRISTINE
TE CERTIFICATE OF LIABILITY INSURANCE DA
A311312019rY1
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: H the certificate holder is an ADDITIONALINSURED,the policy(iss)musthaye ADDITIONAL INSURED provisions or Endorsed.
If SUBROGATION IS WAIVED. subject to the terms and conditions of the polity,certain policies may require an endorsement. Astatement on
this certificate does not confer rights to the Dertfipate holder in lieu of such endorsement(s).
PRODUCER ACT Christine Sullivan
Phillips Insurance Agency,Inc j x.Exrl:(413)594-5984 �(413)592-8499
97 Comer Street
Chicopee,MA 01013VSs.chdstine@phillipsinsurance.com _
IXSURENS FORDINGCOVENAGE MAIC/
I, NSUPER A'.Ohio Security Insurance Cc _ _ - 24082
INSURED �wsuPER e:Ohio CasualfV 24074
Phil Beaulieu B Sons Home Improvement Inc. SURER c A.I. M.Mutual Ins.Co. 33758
Phil Beaulieu -
217 Grattan Street INSURER o_ -
Chicopee.MA01020 INSURER E: . _
IN$VRERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 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 SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -
NUR ttIN OF INSURANCE ADOL SUBR POLICY XYMBER PCLICY EFF POLICY E%p UNITS
PIND
A LX COMMERCIAL GENERAL LPSUORTY EgCX OCCURRENOE 1'000'800
DAMAGE TO RENr ac 300,000
CWMSANDE ,X CUP jB KS58415578 W2512019 . 2/2512020 1$E,S�--I $
MEDExP(ArIne IYAAL i . 15,000
PSNSONGL&ACA/INJUFDFd1
1'000'000
GEHL AGGREGATE LIMIT APPL $PE
IER: �ENERAL AGGREGATE s 3,000,000
X POLICY` PET LOC PRODULi$ COMP/OP AGG�$ - 3'000.000
OTHER'.
A c�MawEO SINGE LMIT 1,000,000
wroxoea TLuaunr a311-YI_y
ANYAUTO I � BA5584155T8 925/2019 925/2020 eoDILV INJuxvL�ni E _
OWNED -x $GHECULEL
AUgTCOn$ONLY X 'AUTTO$$ BODILY INJURY(Perarci I) j _
AUTOS ONLY X AVTOS ONLYY a�ccWmen GE--$
B X UMBRELLA LIa X OCCUR EACH OCCURRENCE $ 1'000'000
!�ExcTsss u�ne CwMs#1AOE U5058415578 212512019 92512020AGGREGATE 7,000,000
DEO X 1 RETCH ON 10,000
C WORNERa COMPENSATION X Pc_TUUUTE Q,
AND EMPLOYERS'unaalTv /x WMZ-800-62052019A 92512019 92512020 1,000,000
FF PROPRICTOR/PARTNERIE%ECUTIVE EL FALX ACCIDEM $ _
p ICE�LM��ExmuOED± x1A _ 1,000'000
IMdn0a1 EL DISEASE-EA EMPLOYE S
NYmea,'"N""Eer iEL.OI$EPSE-POLICY LIMIT 1'000'000
1E$CR110.OF OPERATION$N.—
p Equipment Floater BKS58415578 92512019 92512020 ILSONSIM,Equipment 200,000
DESCRIPTION OF OPERATIONSI LOCATIOXSI VEHICLES IAEORD 101.Asur r—I FU—M,RIASII .mey0e aIUCM1M X mo a e0a[a b rpun.)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25(2016103) / m 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
® Commonwealth of Massachusetts
Drvlslon of Professional Licensure
Board of Building Regulations and Standards
Constructlon Supervisor
CS4162638 4,pires:01,11312019
M EEAU
217 GRAT7AH-STREET
CHIC 010
CHICOPEE MA 01/020 n
Commissioner
Construction Supervisor
Unrestricted-Buildings of any use group which contain
less than 15,000 cubic feet(661 cubic meters)of enclosed
space.
Failure to possess a current edition of the Massachusetts
State Building Cade is cause for revocation of Mis license.
For informatim about this 0cense
Call(617)727-3200 w visit www.mass.gov/dpi