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15B-041 I 204 CHESTERFIELD RD BP-2020-0248 cis#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 15B-041 �' 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-2020-0248 Project# JS-2020-000427 Est. Cost: $10405.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED JO.- Con st. O:Const.Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sq.ft.): 93654.00 Owner: BERGER JANEMARIE Zoning:RR(91)/URA(9)/ Applicant: SEXTON ROOFING CO AT: 204 CHESTERFIELD RD Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 1 WC HOLYOKEMA01041 i ISSUED ON:8/28/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF POST THIS CARD SO IT IS ISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector I Underground: Serviced Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: II 1 Rough Frame: Gas: Fire Deoartment Fireplace/Chimney: Rough: Oil: Insulation: I Final: Smoke•c Final: i THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. i Certificate of Occupancy Signature: _ f , FeeType: Date Paid: Amount: Building 8/28/2019 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner YOUF 4DepartmentM,-e only t ' City of Northampton status of Permit r°r *� a, Buikng Department �irllrb CiUt]DrIVeWayt Permit X 4' m ' �s ti ?fir2 ti d s ,t 212 Main Street Sewe%septic Availabtlity Room 100 Water/INeI1 Availability r } Northampton, MA 01060 TWO!,' ofStructural Plans ;Y ' phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,FREPAIR REN ATE OR DEMOLISH[A ONE OR TWO FAMILY DWELLING L® d �. y� SECTION 1 .SITE INFORMATION Q 4 his ectron to'be comptetetlby office 1.1 Property Address: I AUG Z 7 20�g f�S Z 1 Map Lot (Jolt !r /1 / J,oTB�i P C)' Overlay Distract Y C;/ j PJORTHAMPTON W 6j' EIm St Drstrrc CB Drstnct SECTION 2 .;PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 OwnerrofRecord: Name(Print) Current Mailing Address: / W5* ���r�- 9 13o la Telephone p Signature Authorized Agent: Name rink Current Mailing Address: �— Signature Telephone SECTION 3..-ESTIMATED:'CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only . completed by permit applicant 1. Building (a)Building Permit Fee I ' 2. Electrical ti Estimated Tofal Cost<of Gonstry on from;6` 3. Plumbing Building Peranit.Fee r 4. Mechanical(HVAC) r— �1 5. Fire Protection 6. Total=(1 +2+3+4+5) ; Check Number This"Section For Official Use:Onl Building Permit Number Dat e Issued.: OF 4. J . Buildmg Commissioner/inspector of Buildings Date V I ' I EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) I I SECTION 5. DESCRIPTION:OE PROPOSED.WORK.(check.all.aaplicable):' New House ❑ Addition ❑ Replacement Windows Alteration(s)i ❑ Roofing �-- Or Doors I—I i Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[d] I Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Ye f No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 1 saz}If.INew"houseFand`:or.adtlition#o.`existing,housmg,�c'omplete<tlie^following: i a. Use of building:One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. �ensions e. Number of stories? f. Method of heating? ireplaces or Woodstoves i Number of each g. Energy Conservation Compliance. sscheck Energy Compliance form attached? h. Type of construction i i. Is construction within 100 ft.o etlands? Yes No. Is nstruction within 100 yr. floodplain Yes No j. Depth of basement or c ar floor bl low finished grade f k. Will building conform to the Building and Zoning regulations? Yes No J I. Septic Tank City Sewer Private well City water Supply SECTION 7a=OV'IINER AUTHORIZI4TION TO BE'COMPLETED WHEN ;: j OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,���nn � T7�e- MA 44t e as Owner of the subject property hereby authorize K �(.., �, L✓! f � to act on my b If,in all matters relatilve w k authorized this building permit a p' ation. � Si ature of Owner Date i o f �9—going as Owner/Authorized Agent hereby declare that the tatements and informatioappligAtionare true and accurate,to the best of my knowledge and belief. Signe rider the pains and penal' of per]` ' Print Name _ Y Ic Signature of OWnirrrAgent Date Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Regtiired by Zoning This column to be filled in by Building Department Lot Size I Frontage ------- - -----I' l -------— — - Setbacks Front Side L:7-R: L: J R: --- Rear r I t f Building Height t Bldg.Square Footage % 1 Open Space Footage % (Lot area minus bldg&paved C I parking) �----� #of Parking Spaces 1---- Fill: g �� volume&Location s— i I A. Has a Special Permit/Variance inding e r been issued for/on the site? 1[/: W ® YES NO 0 DONT K IF YES, date issued: IF YES: Was the permit re#N-7r t the Registry of D ds? NO ® OW ® ES 0 IF YES: enter Bo k Page and/or Document# i B. Does the site contain al brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a per it'been or need to be obtained from the Consery 'on Commission? Needs to be o tained Obtained , Date ued: C. Do any signs st on the property? YES NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 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,ad re? YES 0 N0'0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION'& :CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: `��y • n �1/ License Number Z tg AMess Expiration Date Signature---- Telephone 9 R`e istered Homeslm rovemenf Gon ctor w �' a R w Not Applicable ❑ w y �-- 06ftipiriii Name tration Number Tr - tG�� ;> -1 Addr ss Fxpiration Date Q Telephone 7 SECTION 10-WORKERS'COMPENSATION INSURANCEAFFIDAVIT(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. j Signed Affidavit Attached Yes....... ' No...... ❑ i I I I I i City of Northampton _ r 5�.5' SICft ~ : Massachusetts DEPARTMENT OF IWILDING INSPECTIONS a' 212 Main Street •Municipal Building Jb� ram Northampton, MA 01060 stzy �1 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. i The debris from construction work being performed at: (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: zolke'z'o-led it 1.11114-'9' (Company.Name and Address) Si atur Permit Applicant or Owner Date 9 pP 1f, 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. I City of Northampton Massachusetts DEPARMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building vys rca Northampton, MA 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, 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 registered contractors. Note:If the homeowner has!contracted with a corporation or LLC,that entity must be registered I Type of Work: Est. Cost: Address of Work: Date of Permit Application: ! i 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 Others eci ( p fY): 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 RESPONSIBILTTES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties oflperjury: I here y apply for a building-Ipermit as the agent of the owner: / � I ZS ✓U f�i .< J(�� f Dae I Contractor Name VHIC 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 I SEXTON RO®FING AND SIDING INC www.sextoimroofing.com �O MASTER OAF1dC C�U.i•..1b.C.oVscln. Setting the Standard Ar P.O. Box 6327 p. 413.534.1234 Holyoke, MA 01041 f. 413.539.9906 MA HIC# 118239 sextonroqfiggAhqtLnajl.com SUBMITTED TO Janemarie Berger PHONE 5849130 1 DATE 6/28/19 STREET 5 Shepards Hollow [ a r I JOB NAME CITY STATE ZIP ce Ma. V 0 A I JOB LOCATION SEXTON ROOFING HEREBY SUBMITS SPECIFICATIONS AND ESTIMATES FOR: 1) Strip and remove existing shingles and dispose of in proper landfill. 2) Inspect roofing deck andlreplace as needed @$75.00 per sheet. 3) Install new metal edging to rakes and eaves of roof. (811) . 4) Install ice and water shied on eaves(61),vent stacks,in valleys,chimney, Skylights, and at intersecting roofs. 5) Install#15 synthetic roofing felt on remainder of roof. 6) Install new flanges over existing vent stacks. 7) Install starter shingles on eaves and rakes of roof. 8) Install IKO Architectural style roofing shingles as per manufacturers'specifications. 9) Reflash chimney with new lead flashing:(If needed) j 10)Install new cap over ridge vent. 11)Supply manufactures Lifetime warranty and SRC 25 yr.workmanship warranty. i We VVSPM;e hereby to furnish material and labor—complete in accordance with the abov specifications,for the amount of Ten Thousand Four Hundred� ollars(10,400.00 Pa ents to be made as follows ue in full upon completion All Material is guaranteed to be as specified. All work to be completed in a Authorized workmanlike manner according to standard practices. Any alteration or Signature deviation from above specifications involvinglextra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond Note:This proposal may be withdrawn by us if not accepted our control. Not responsible for water damage during construction. Owner within(14)days. to pay responsible legal fees for non-paymentl and applicable interest. t't C}1t81TtC Df PTDP95ai The above.prices,specifications and conditions are satisfactory and are hereby accepted. You Signature are authorized to the work as specified. Payment will be made as outlined above. Signature Date of Acceptance. 1 I j` The Commomvealth ofMassachusetis Depariment'of Industrial Accidents 4s Office dfbwestigadons 600 Washington Street Boston,Mass. 02111 wwfv mass gov/dia Workers',Compensation-Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(sus:ness,Organizatron iridi-viduO)- exton Roofing & Siding. Inc Address:P:;O. Box 6327 { City/State/Zip:Holyoke,-' a. 01 041 TPhone#:413-534-1234 Are you an employer?Check the appropriate boa: Type of project(required): 1.U I am an employer with . f 4.A 1 am a general contractor and I 6.Ll New construction. employees(full and/or part time).* have hired the sub-contractors 2_. 4 am a sole proprietor or partner- listed on the attached sheet 7.['Remodeling ship and have no employees These sub-contractors have 8_E,Demolition workingfor me in any capacity- employees and have workers' [No workers'comp.insurance comp_insurance.-+' 9_[i Building addition required] I;. 5_!l We are a corporation and its 10_[J Electrical repairs or additions 3.L] I am a homeowner doing all work' officers have exercised their. myself[No workers'comp_ right of exemption perm MGL 11.:f''Plumbing repairs or additions insurance required]t ', c.152,§1(4),and we have no 12_XRoof repairs, employees.[no workers' 13_Il Other comp.insurance required.] ' *Any applicant that checks box ift must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing alt work and then hire outside contractors must submit a new a8-idavitindicating such. ,Contactors that check this box must attieh an additional sheet showing the name of the sub=contractors and state whether or not those entities have employees. if the subcontractors have employees,they mnstprovide their workers'comp,policy number- X inn an employer drat is prmWdrrrbz workers'compensation vusurance for my employees Be["is t)repolicy anajab site Travelers Property Casual Corn ail of Arnenca : hisurance Company\Tame :.. p '`y p. y UB-06078982-19 a 06/04/2020 Policy#6r Self ins:Lic.#_ _ xp tion Date: . Job Site Address' City/State/Zip: Attach a copy,of the workers'I ompensation policy declaration page(showing the policy number and expiration(date). Failure to secure coveiage as required under Section 25a of MGL.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00and/or one year:imprlsonment as well as civil perialfies in the form of a STOP.WORK ORDER and a fine of $250.00 a day agalnst:violaior.Be advised that.a-copy of this statement maybe forty ded to the Office of Invest gations-ofthe DIA for coverage verification:. I do herby certify der the pains andpenalties ofperjury that the information provided above is true and correct }. Signairae: Date: . 1, PrintiVame: y ,' - Phone#: i Official use only. Do not write-in this area to be completed by city or town official City or Town: Permit/license#: I Issuing Al3thority,(circle one) ' . 1. doDepartment � - Boar f Heath 2. Building C epartment 3.City/Town Clerk 4.Electrical Inspector 5_Plumbing Inspector 6.Other _ Contact person-> Phone#: CERTIFICATE OF LIABILITY INSURANCE DATE(M1MD1Ymi) CTUIS AMF1CATE IS ISSUED AS A MA'ITER OF INFORMATION ONLY,AND CONFERS NO RIGHTS UPON,THE CERTIFICATE HOLDER THIS RTIFICATE 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 PRODUCE AND THE CERTIFICATEIHOLDER_ IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policypes)must be endorsed.if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement A sI ment on this cert ficate does not confer rights to the certificate holder in lieu of such.endorsemen s. PRODUCER CONTACT NAME I ORMSBY INS AGCY PHONE Fax PO BOX 718 , (A/C,No.Ex* , � (AIC,No): WEST SPRINGFI]EL D,MA 01090 E4dA1L DDRESS: 286TF INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA =- ON ROOFING&SIDING INC INSUREK B: INSURER C: PO BOX 6327 wsuRER D: HOLYOKE,MA 01041' INSURER E I ],A NSURER F: COVERAGES CFRTIICATE 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 PEiUOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDMON OF ANY60NTRACT OR OTHER DOCUMENT WfrH RESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAUL THE INSURANCE AFFORDED BY TRE POUCLFS DESCRIBED,HEREIN SUBJECTTD.ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - �. INSRi qDDL UBR POLICY EFF DATE POLICY EXP DATE LTR 'TYPE OF INSURANCE - .. NSR WVD 'POLICYNUMBElR .(MMIDMYYYY) (MMMMYYYY) LIMITS . GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY. CLAIMS MADE M OCCUR." AGE TO RENTED g REMISES(Ea occurrence) ED EXP(Any one person) Is GEN'LAGGREGATE LIMITAPPLIES PER: - ERSONAL&ADV INJURY is ENERALAGGREGATE �$ POLICY PROJECTE]LOC" , RODUCTS-COMPIOPAGG 'Is AUTOMOBILE LIABRITY OMBINED SINGLE i ANY AUTO LIMIT(Ea accident) i$ ALL OWNED AUTOS -' FBOD LYlNJURY ;$ SCHEDULEAUTOS erson) j HIRED AUTOS LY INJURY g NON-OWNED AUTOS ccident) j ERTY DAMAGE g cadent) f UMBRELLA LIAR8 OCCUR EACH OCCURRENCE .. i$ EXCESS LIAR CLAIMS-AMD AGGREGATE. ' 3S DEDUCTIBLE ig RETENTION is A WORKER'S COMPENSATION AND WC STATIJTORY OTHER EMPLOYER'S LIABILITY YIN UB-OG078982--19 06104x1019 06104/2020 g LIMBS y ANY PROPERROR/PARTNERlEXECUTIVE $ OFFICERMIEMBER EXCLUDED? Y I_ NIA ELEACH EICCIDENT' I 1,000,000 (Mandatory in NH) E.LDISEASE-EAEMPLOYEE 1,000,000 byes,describe urider ; DESCRIPTION OF OPERATIONS below, EL'DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERKTDONSILOCATIONSIVEHtCLESlRESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTII7CATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE INSUREDS MA WORIUM COMPENSATION POLICY A\'D 77S LIMITED OTHER STATES ENDORSEMENT AUTHORIZES 173E PAYAIENI OF BENEFITS FOR CLAIMS MADE BY THE INSURED S ti1A LMPLON EES IN STATES OTHER THAN MA.NO AUTHORIZATION IS GIVEN TO PAY CLAIMS`FOR BENEFITS IN S.TATESOTHER THAN MA it THE INSURED HIRES,OR HAS HIRED E PLOYEES OUTSIDE OF MA.THIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA . CERTIFICATE HOLDER' �. CANCELLATION - i SHOULDANY•OFTHE'ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WMi THE POLICY PROVISIONS. U _ ' A THORLZ>�REPRESENT f ACORD 25(2010105) The ACORD name and logo are registered"marks of ACORD 7988-7010 ACORD CORPORATION, All rights reserved. i The Commonwealth ofMassachusetLs L Department of1H&MtrialAccidents t I CongressSZW4 Suite 100 Boston,MA 02U4-2017 j �. www.massgov1dia W'orkere Compensation Insurance A$ndavit:Builders/Coniiaclors/Piechicians/1Phimbe TO-BE FILED WITS THE PERMR-MG AIDTHORTFY• ApalicantInformaiion 'Please Print Legibly NaMe(Bus ne;s/OrganWon/lndiv dual):N.RG Construction Inc Address: 66 Water S#Apt 2 CJStat -Miilford,MeL 01757 Phone#:774-28711485 Are on an employer?Checkithe approp:i�te box_ I Type of project(required): Lor am a employerwith� employees(fila aua-part�ne)* ?�I f . . { .7, [�New construction am a sole proprietor•orparft=sVT andhmno employees woddng rarme in i 8.'❑Remodeling any�cit}r_[iso woflrers'COOP.ms�nce required.]. 3-❑Imm a homeowner doing a wor$mysel£[No worlx�s'cO 9- ❑Demolition Op.nnm�ce requueiL]t 4 Imnahomeowner,andwiDbe to-C3 BuiIdingaddition ❑ g co�aciorsio condor tall wt)&onmay property.I win ensure that an contractors eitlterhave workers'compeasaticmws;•a:m or are sole 114]EIeCLIICal proprietmswiih no em repairs or additions 12.[]P1umb1Ur6&repass or additions 570Iama gcDcZalContra r�ndll� huedthesub-conhact=Ustedonthe atiachedsheet 7Inese sub c�Radnrs have employees and havewO&Cre comp.iasor a 33.nRoofrepaIIs 5❑We areaooipOatinaand :niaccsbave e�rzsed then14_II0ther nglrtof-emptionperMM e 1 §1(4��dwe have no employees[No wod-e,comp.insurance regOned] *Any appIicantthat checks boxffl must also fiII outthe sectionbelovrsbowmO-gteirtvorms'comp®satiohpolicy Homeowners who srbmitthis afadavit mdratingtbey arrdoinga]IwarkandthenTiue ode contzacma mudsubmit anewal;rdavit idicatingsOch. $Contractors that chwkthisbox n staanadditionalsheetgwwiogthenameofthesvb- ors'andstatewhdherornotthoseenWcshave employeesIftlzwssbwarskavaempIopes,diet�FVvWe% -wodces - comp.po[icynimber .. lam an erirpirryer aiatisp _gavorkers'compensafn insurmuefarMY fit" 'a. Below is fTzepodicy mtdjob side informs o>a . Insrnance CorIIpany Name Atlantic Casua!(y Policy#or Self-ins-Iic- iF, R.'),Ui ed Expriation Date Job Site Address: Cr[y/Statel2w.rp: Attach n copy of the worktre compensation policy declaration page(showingthe policy number and expiration date FatZme to secure coverage as reg iced under MGL c_15%§25A is a cr®aI violation punishable by a fine up to$1,500.00 .and/or one-year kmprisoame4 as well as civil penalties in the foam of a STOP WORD ORDER and.a ime of up to$?50.00 a day ate'utast the piolator_A copy of this statement may Ile forwarded to the Of of hivestigations of tie DIA for insurance coverage verification_ r 1' 7 Ido hereby 'wdert�epdw mulperrzMes ofperftuy that the in_formation pmvM'71i. d arb a is hue and carred NiLmat e.tr { Zj Daw: Phone�:-i'742871485 � - •C flf}rcial use gaYy. 32o ptofwriteiis this arear,to be compieMdby city or towii ofjivarl City or Town• Permit/Ucense411 # IssuingAuthority(cird ones 1 l L Board of Health 2..Bid1 ` gDe Inspector, Inspector drub Department 3.CitylTowu Clerk 4_Electrical tor,5.Fiumb' 6 Other Contact Person: �: Phone#: I o CERTIFICATE OF LIABILITY INSURANCE DATEt (MMroD/YYYY) ;4 -A: .-Ro i. 1 08/20/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS'UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. { IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies mayf require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER NAMEACT ISABELE CORDEIRO Brazway Insurance PHONE978�455�991 FAX 978-455-9934 2 Courthouse Lane Unit 14 E 1�Ell: a No ADDRESS:info@brazwayins6ranceagency.com Chelmsford MA 01824 INSURERS)AFFORDING COVERAGE NAICS INSURER A:ATLANTIC CASUALTY NIF GROUP INSURED NRC CONSTRUCTION INC INSURERS•AMGUARD INSURANCE CO 118 E MAIN ST INSURERC: INSURER D: MILFORD MA 01757 INSURERE: INSURER F: 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_ ILiR TYPE OF INSURANCE fNSO W D POLICYNUMBER MSD EFF MMLICY EXP /DD RLIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000.00 CLAIMS-MADE n✓ PREMI OCCUR REMIDAMAGE TO RENTED PSES Fa occurrence $100000.00 A L30700022" 0812212018 08/2212019 MED EXP(Any one person) $5,000.00 PERSONAL BADV INJURY $1,000,000.00 GENT AGGREGATE LIMIfAPPLIESPER: GENERAL AGGREGATE $2,000,000.00 ✓ POLICY E]JECT nLOC I PRODUCTS-COMP/OP AGG $2,000,000.00 OTHER: $ AUTOMOBILE LU181LITYCOMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY er accident E UMBRELLA UAB OCCUR L EACH OCCURRENCE $ EXCESS LIAB Id CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION I ✓ P kTUTE ER AND EMPLOYERS'LIABILITY ANYPRE OPRIETOR/PARTNER/EXCUTIVE YIN EL EACH ACCIDENT $1,0()0,000.00 B OFFICER/MEMBEREXCLUDED? LY NIA (Mandatory In NH) R2WC050945 08/16/2019 08/1612020 E.L.DISEASE-EA EMPLOYE $1,000,000.00 If DESCes RIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $1,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)- i CARPENTRY,ROOFING,PAINTING. i CERTIFICATE HOLDER CANCELLATION SEXTON ROOFING&SIDING INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PO BOX 6327 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 102 PINE ST HOLYOKE,MA 01040 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD_CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Produced using Forms Boss Web Software.www.FormsBoss.com(c)Impressive Publishing 800-208-1977 SEXTO- , R AC R 2 ���D� CERTIFICATE OF LIABILITY INSURANCE 0 711 012 0 19 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 CERTIRCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATH/E OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is Ian ADDITIONAL INSURED,the poftcy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsemenL A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 413-737-0300 coerACT Eric Dembinske Ormsby Insurance Agey,Inc. 698 Westfield St PO Boxx 718 PHONE. 413-737-0300 arc Nol_413-737-0617 WestSEric ftked'NIA 01090 — ernTijps-Tce�a tTIlgFjylns,com ' IN AFPORDINGCOVE'RAGE NAICri �NsuRERA:Colon Insurance Co. �Ppi'g,nDRoofing&Sid-mg,Inc. INS,mER8;Quincy Mutual Fre Insurance 15067 Holyo�ce6MA 01041 INSURERC- INSURER D: INSURERE- INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: Ej 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 CONDMONS OF SUCH POLICIES.LIMffs SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR IYPEOFINSURANCE �' POUCYEFF POLICYEItP' i -- POLICY NUMBER V A X comuERcIALGENERALuABnmr MrrS 1,000000 CLAIMSMADE OCCUR EACH OCCURRENCE S 101GL002159903 06/2512019 06/20/2020 DAMAGETORH1TE°S100,000 ES rEa ocagw -1 S MED EXP ane $ 5,000 PERSONALBADVINJURY S 1,000,000 GEMAC LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POticr LOC PRODUCTS-COMPIOPAGG $ 2,000,000 OTHER- I B AUTOMOBiLELIABILFIYCOM®INEDSINGLE11Mrr $ 1,000,000 ANYAUTO 6561 _ S AUTOS ONLY X AAUTO$UULLEEOp OS/i512019 05/15/2020 BODILY INJURY ~Parson X. AUTOS ONLY X AUT ONLr BOOP YE INJURY DAMAGE�rd UMBRELLA LIAROCCUR EACH OCCURRHJCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERSCOMpg 'qON I $ AND EIHPI DYERS'LIABILITY PER OTH ANY PROPRIETORIPARTNER/EXECUTNE YIN O BE SENT SEPERATELY (M5W,MER EXCLUDED? N!A' EL EACH ACCIDENT $ Iryyes,describe under E.L.DISEASE-EA EMPLOYE S DESCRIPnON OF OPERATIONS beloCa E.L.DISEASE-POLICY LIMIT DESCRIFnON OF OPERA710NS l LOCA7IONS!VENCI (ACORD 101,AddWWnar Renwite Schedjd e,maybe attached Bmoie space is requr►ed) CERTIFICATE HOLDER CANCELLATION NONE-01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL. BE DEWVERED IN Everett Sexton ACCORDANCE WfIH THE POLICY PROVISIONS. AUTHORIZED REPRESENTAMVE ACORD 25(2016103) I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD name and logo are registered marks of ACORD i -�,¢,'- • , • � L G'r�/4�"VJ4 G`� I ^J(l (�(/�.faa VriG e.&D__ 1 Office of Consumer AfifY5 and Bwslo ReggWafifln 1000 WaWmgton Ste-Side 710 Win_"use '0211 a HOM.in4ND,Ve� or�tsaL%A FlOfMraftn 't'YP SEONROORNG&MVIGNG F.0 BOX Cid HOVY01M,AA DIM--1 - - - . _ IPA_ �y�- ����+ggaa��e ��r•77 _� H/te�L71t3.iCi aa��.. [��3 g 1F i P"ROVEM —F COMM&c o R Spo Xii3GJ .�3.G?' ..7. 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