36-127 (6) 271 BROOKSIDE CIR BP-2020-0019
GIS u: COMMONWEALTH OF MASSACHUSETTS
Map:Bl0ck:36- 127 CITY OF NORTHAMPTON
Lot: PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category, ROOF BUILDING PERMIT
Permit tt BP-2020-0019
Proiect# JS-2020-000020
Est.Cost:$7976.00
Fee:$40.0o PERMISSION IS HEREBY GRANTED TO.-
Const.
O:const.Class: Contractor: License:
Use Group: VISTA HOME IMPROVEMENT 111478
Lot Size(so. R.): 26528.04 Owner: MIGLIORE HOLLY A
Zoning: Applicant: VISTA HOME IMPROVEMENT
AT: 271 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
2003 RIVERDALE ST (41 3) 382-0249 WC
WEST SPRINGFIELDMA01089 ISSUED ON:713/2019 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 signature:
FeeTYpe: Date Paid: Amount:
Building 7/320190:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
r
po Department use only
City of Northa ptoFiECEI V� rmit:
Building Depa met CuIriveivay Permit
212 Main S real JU` Se r/SicAvailabilitRoom 1 0 _ 3 2019 We er/ AvailabiliNorthampton, 0 060 T Sef Structural Plans
phone 4l&587-1240 ax49r8- rn ,rnsPEc Sitans
NOmN4MPtOrAApfrSdy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 7 -SITE INFORMATION 6p—t4— //
1.11�P•rop llAddress: N` 1�.{n . /This section to be completed by office
I•�� f I � I �� CA �' " map Lot /-) 7 Unit
MRDI Ud'L Zone Overlay District
Elm SL Dishict CBDistrict
SECTION 2-PROPERTY OVIINERSHIPIAUTHORUED AGENT
caner of R
�,'� I �15d(J\k��dQ Gree
e riot) urmnt Mating
Tel
Signature
2.2 Authorized Agent;
I Qq n2111,0rr,bk S)
Name( 'ni) (Lurrenelling Atltlres Jill
hfyy
Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
completed bpermit applicant
1. Building (a)Building Permit Fee O
2. Electrical (b)Estimated Total Cost of
Construction from 6
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
Date
Building Permit Numb Issued: ��nn
Signature: 7. 3 -Z61 Ip
Building Commissionerllnspeotor of Buildings Date
�11��� C_ � VIStr, !-1mnc.im�rr�VPrv�n+. Com,
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
This column to be filled m by
Building Department
Lot Size O O O
Frontage 0 0 0
Setbacks Front O O O
Side L:= R:= L:= R:0
Rear 0
Building Height O O O
Bldg. Square Footage
Open Space Footage O O / O
(l,ot aminus bldg&paved
#ofParking Spaces O
Fill:
Ivolume&Location
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 F Page and/or Document#�
B. Does the site contain a brook, body of water or wetlands? NO O 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: F
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 i acre or is it part of a common plan
that will disturb over 1 acre? YES O 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 Alteratlon(s) ElRoofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs (O] Decks 1Q Siding 101 Other(Cj
Brief De option of Proposed
Work: 1t I►[J,yn� ` //ll ��
Alteration of existing bedroom Yes Adding ne oom Yes No
Attached Narrative Renovating unfinished basement __Yes No
Plans Attached Roll -Sheet w
on.If New house and or addition to existing housing, complete the following. t
a. Use of building : One Family Two Family Other
b. Number of rooms in each family uni . Number of Bathroo
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? 'replaces or Woo
oodstoves Number of each
g. Energy Conservation Compliance. Mas eck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 Zand
Yes No. Is construction within 100 yr. floodplain_Yes No
j. Depth of basement or cellade
k. Will building conform to thgulations? 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
+inI, as Owner of the subject
property
hereby authonze
to on my behalf,in ma ere relative to work authorized by this building emi application.
Signature of Owner
I, .as Owner/Authorized
Agent hereby declare'1115t the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
S' oder the pains and penaltif perjury.
it) 17
id
Print Nam
l I
atu er/Agent Date
SECTION 8•CONSTRUCTION SERVICES
8.1 Licensed Construct n Su a visor: /Not Applicable ❑
Name of License Holder: ( S � ) �--'
tense Number
q9 r
Adre Borallon Dale
I An ell
Si Telephone
9. Reaistered Home Improvement Contractor. Not Applicable ❑
�� � i M tau �t
C a Name eglstration Number
Sr
dress 6l atAe-
LkLykb Telepho / I 5 3 ao 61
� l
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...... ❑
• i
City of Northampton
P P
Massachusetts
0 R OF BUILDING IN
S NS
212 Win Stut .Mieipsl 6ullanq
i
NorNe ton, M 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111. S 150A.
The debris from construction work being performed at:
2-n 1 -1iM lCo- GY1L
lease print house number and street name)
Is to be disposed of at:
N
L
(Please prim name And location of fa lity)
�r will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
(,— n of Permit Applica r ate
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 Comtnonweahh ofMassachmsetts
Department of IndustrialAccidents
I Congress Street,Smile 100
Boston,MA 02114-2017
www.massgov/dia
Wil.irkers'CompensiMion Insurance Affidavit:Builders/Contraetors/Elmrieions/Plumbers.
TO BE FILED WITH THE PERMITTING At THORITY.
Aoolieent Information Please Print Legibly
Name(Business/Orgmizati NIndiddua0t vista home improvement
Address:2097 retardate street
City/State/Zip:'"'est spnngfield ma Phone#:4133024740
Art yeas so enpkwM.Cbeca the tppmpritle hos:
Type of project(required):
I.EJ I min.employer with 9 employeos(full allNor pan-time)• 7. ❑New construction
2.❑l am a sole proprietor orparmership and have no employees working for me in g. ❑Remodeling
atMoraicity.INoworkers comp.insur. emitted
❑3 I am a homeowner doing all work myself[No workers comp.insurance reauird9. Demolition.l'
4E I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10❑Building addition
ensure that all contractors either have workers adeacrsaion insvramaor are sole II.❑Electrical repairs or additions
proprom a with no employees. 12.❑Plumbing repairs or additions
5[:]I am a general coarmoor and I have broad the sub<anmwmrs hold on Ne aaached shat. 13❑Roof repairs
These sul.cantractors Tuve emr'employees and have workers comb.insurance
6.❑Weare.ca tionand its omcerahmeexeeteithnr rihtofexem i 14.QOtherrero0f
ryore g pl on ter MGI,c.
152,11141.andwe have no employeos.INo workers'comp.insurance reyuired.l
'AM triturated that checks box#1 must also fill our the section below showing their workers compensation policy infomution.
I Homeowners who submit this affidavit indicating they are doing all work and men hire outside eulnractols must submit a new affidavit indicating such.
:Contmetors that check this box must atschd an additional sheet showing the name ofthe subcontractors and slate whether or not these entities have
employees. If tM1e subcontractors have employes,they must provide their workers'comp.policy number.
I am an employer that is providing workers'rompensadon insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:soutlamCk insurance agency inc
Policy#or Self-ins.LLii�c.#:ub2u072183-119 �1 Expiration Date:03/12/20 (/�/�
Job Site AddressrJi" I V F•+c�1 c. _ \ r(—U City/State/Zi�'Q1 �Q ' , IA
Attach a copy o they workers'compensation policy declaration page(showing the policy number and expiration date).O t W
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 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.
/do hereby 'y under the pains and ¢s of perjury that the information protideedd�above is nue and correct.
Si t� Date'
Phone#:
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):
I. Board of Health 2.Building Department 3.CityrFown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
M \ J i
Page 1 of 7
2097 Riverdale Street Vista MA Lic# 162058
West Springfield, CT Lic#o6218a8
MA 01089 ® �LA `I N li h1
IMPROVEMENT vistahomeimprovement.com
Phone: 888.597.23239-01WE
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
HOLLY MIGLIORE hnmig@comcast.net Date: 06/24/2019
271 Brookside Cir Mobile: (413)695-6362 Rep: Murray Fanning
Florence MA 01062 Home: (413)584-2172
Roof Specifications
Owens Corning Roof Systems Preferred Roof System
Color Quarry Grey
Drip Edge Color white
Number of Layers 1
Attic plywood
Location Partial
Underlayment Deck Defense
Ice &Water Shield 6feet
Supply and Install Ridge Vent yes
Vista Home Improvements agrees to do the following:
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
Cut In New Braun Vents 1
I, HOLLY MIGLIORE, 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.
This space tentionally left blank
Page 2 of 7
Roof Sketch / Photos
I
Murray Fanning, Authorized Representative HOLLY MIGLIORE
06/24/2019 06/24/2019
Date Date
This space intentionally left bunk
Page 3 of 7
Homeowner's Association NO
WORKSCHEDULE
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 07/24/2019
Barring delay caused by circumstances beyond Contractors control, the work will be completed by 08/24/2019
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 -- Call To Confirm with customer
Total Contract Amount (All Discounts Applied) $7,976.00
Pa ment
Amount Due Upon Signing Contract (1/3 Maximum) $2,659.00
Amount Due At Start $2,659.00
Amount Due Upon Completion $2,658.00
Form of Payment Upon Signing Credit Card
Credit Card Mastercard
Credit Card Number 5243-6620-1930-2515
Expiration Date 01/2025
Credit Card CCV 662
Name as it appears on card Molly Migliore
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
Thk space '3 on[iona`ly ler[ Mall.
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 06/24/2019 THE THIRD BUSINESS DAY FROM 06/24/2019
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
�
Y
HOLLY MIGLIORE
06/24/2019
Date
This space Intr:ntio nally left blank
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/Costs
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
begin prior to the signing offtthe
� Agreement and transmittal to the Owner of a copy therefor.
HOLLY MIGLIORE
06/24/2019
Date
Murray Fanning Authorized Representative
06/24/2019
Date
This space intentionally lett blank
r
IFFCmRrpnwealtn of Massachusetts
Division of Prolessummi Lcensore
Board of Building Regulations and Standards
COnstrUCHOn Supervisor
CS-111678 r Expires:D112112021
BRIM
FEEDING
in
115 COYOTE CIRCLE
FEEDING HILLS Meq 01050
CommisOroner
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CERTIFICATE OF LIABILITY INSURANCE °"Hose""'D
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THIS CERTIFICATE Is ISSUED AB A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON TIRE CERTIFICATE HOI.OER THUS
CERTIFICATE 00E6 NOT AFFIRMATIVELY OR NEGATIVELY MEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTINICATE OF INSURANCE DOES NOT CONSTITUTE A CONTAl BETWEEN THE ISSUING INMIRER(B), MTHOREEEO
REPRESENTATWE OR PRODUCER,AND THE CERTIFICATE HOLDER.
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CERTIFICATE HOLDER CANCELLATION
VISTA ROME IMPROV EW
2003 RIVIORDAL6 91REBT SHOULD ANY ON THE ABOVE DESCRIBED POLICIES EE CANCELLED BEPORE
THE EaA.DOH DATE DEVELOP. NOTICE PALL BE OELNEAEO IN
WIST S%tINGFIELD NA 01aS9 ACCOROWCEMMTNEPOLICY PROVISIONS.
quixCalrSTxPrP x:AneE
WISMM10ACOR000RPOMllIX AIN9MareesmD.
ROUND IS(2010)03) The ACOROnsmee:Mle9oece A0lsbre Fad ACORO
I
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Mos'3achusetts 02118
Home ImproverRent<Contractor Registration
Type: LLC
Registration: 162058
VISTA HOME IMPROVEMENT Expiration' 011022021
2097 RIVERDALE ST
WEST SPRINGFIELD,MA 01089
xA i a zoR-mn f Update Morass and Return Card.
gl C Mna n
HOME tMPIRDVEMENT CONTRACTOR
eMe expirldfordate. dual only
TYPE:LLC Offlbefore. Meexpirationdeb. R feantl return to:
BeEsroSs O 01,02Q021 100D aConsumer AffaiStreet
and Business Regulation
1620.5E 01Al2rzOt1 100D Washington MA 0ton sveat.gui4 Pto
VISTA HOME IMPROVEMENT fimton,MA 02118
BRUIN RUDD Sab�
2097RDSr �,♦:,Cc{,,,a-- IYMf.{M1R-e'V
WEST7 SPRINGFIELD,
ELD,IAA 010ss Not valid without signature
Undersecretary
CERTIFICATE OF LIABILITY INSURANCE I
DATE tMNJDOIYYY 1
nvigonig
TlIfILCEI(TIFICATE 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
CMFICATE HOLDER
IMPORTANT:If Ne certificate holder Is an ADDITIONAL INSURED,the policy(ies)must tMI endorsed. If SUBROGATION IS WAIVED,sublectto
the torms and conditions of the policy,certain policies may requlm and endorsement A statement on this certificate does not confer rights TO
the certificate holder In lieu of such endommen s.
PRODUCER CONTACT
NAME:
SOUTHWICK INS AGENCY INC PHONE FAx
P O BOX 100 I=.No,END IAIC.Nol:
E-MAIL
SOUTHWICK.MA 01077 ADDRESS:
28TKC INSURERIS)AFFp1Daq COVERAGE NAICH
IIBIIAED INSURER A: IR.%%FI LRS PROPERTY CASUALTY COMPANY OF AMERII'
SAMBRICO LLC DBA VISTA HOME IMPROVEMENT INSURER B:
INSURERC:
INSURER D:
2097 RIVERDALE STREET IxauaER E:
WEST SPRINGFIELD,MA 01089 Ix3URER F:
CtTMEA s CERTIFICATE NUMBER: REVISION NU ER:
FS OF INSURANCE LGTED FELON HAVE BE"ISSUED TO THE INSURED IMMED ABWE FOR THE POLICY PEWDINtlCATED
W WRNBT.MMID ANY REQUIREMENT,TERMOR CONMTION OF ANY CONTRACT OR.T.ER U.NT WITH RESPECT TO NMICH THIS CERTF.TE MAYBE ISSUEDOR MAY
PERTMN THENWMNCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALLTME TERMS.ELCLUSADNSAND COND ONS OF SUCH POLCfES, LIMITS SHOWN MY
HAVE BEFN REWCED BYPMDCLAIMB
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GEN'L AGGREGATE LIMIT APPLIES PER: ENERALAGGREGATE 3
POUCY []PROJECT[]LOC RODUCTS-COMP/OP AGO 3
AUTOMOBLE UABARY COMBINED SINGLE IS
ANY AUTO LIMIT(Ea amanll
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(Per NKddent
UMBRELLA LMBOCCUR EACH OCCURRENCE s
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EMPLOYER'S LMBXT' YM UB-2EWNBSIB 0911/2019 OL1Yl020 LIMITb
ANY PROFERiiOPNPRTUDED,` GJIIVE OMA E.L.EACH ACCIDENT E 500,000
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THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THECERTIFICATE HOLDER AFFECTMG WORKERS COMPCOVERAGE,
CERTIFICATE HOLDER CANCELLATION
TOWN OF WEST SPRINGFIELD SHOULD ANY OF THE ASOVE DESCRIBED FOUCIES BE CANCELLED
26 CENTRAL STREET BEFORE WE EXPIRATION DATE THEREOF,NOTICE WILL SE DELIVERED
IN ACCORDANCE WITH WE POLICY PROMSIONS.
JAUTHOFUZEDREPIUESENT
WEST SPRINGFIELD,MA 01069
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