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48-008 (8) 189 DRURY LN BP-2020-0339 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 48- 008 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-2020-0339 Project# JS-2020-000575 Est. Cost: $5800.00 Fee: $40.00 PERMISSION IS HEREB Y GRANTED TO: Const.Class: Contractor: License: Use Group: SEXTON ROOFING CO 118239 Lot Size(sq. ft.): 598950.00 Owner: LAVELLE JUSTIN Zoning: Applicant. SEXTON ROOFING CO AT. 189 DRURY LN Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 WC HOLYOKEMA01041 ISSUED ON:9/16/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE & REPLACE LOWER PORCH FLAT 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 9/16/2019 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use o �,;iGrrr City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability f '} Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans ��. 0 phone 413-587-1240 Fax 413-587-1272 to Plans ther pecify APPLICATION TO CONSTRUCT,AL ER, AIR, RENOVATE OR MO ISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION SEP 1 6 2019 1.1 Property Address: Th s section to be completed by office NORTH QINSPECTIU060S O� Lot /lJ, Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: j N Lv4 V L Name( res (Print) Current M in A s- ( `6001,41ZI-t �, Telephone Signature 2.2 Authorized Agent: Name(Prin Current Mailing Address: S3 y (Z3-f S nature 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 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) LAO .00 5. Fire Protection 6. Total=0 +2+3+4+5) r — Check Number This Section For Official Use Only Building Permit Num r: Date Issued: Signature: ' 16-2019 2019 Building Commissioner/Inspector of Buildings Date 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 in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Va nce/Fin ing ever been issued for/on the site? NO © DO KNOW YES IF YES, date issued: IF YES: Was the per it recorded at the R istry of Deeds? NO © DONT KNOW © YES IF YES: enter Book Page and/or Document# B. Does the sit contain a brook, body of water or etlands? NO O DONT KNOW O YES O IF YES, as a permit been or need to be obtain from the Conservation Commission? Nee to be obtained O Obtained O , Date Issued: C. Do ny 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 int ded for the property 7 YES O NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filli )over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO O IF YES,then a Northampton Storm Water Management Permit from the DP is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[IJ Brief Description of Propo�,%ee�d Work: GY�1:22 G61-e-- — Alteration of existing bedroom Yes ----ITO Adding new bedroom Yes ---'NoAttached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: 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 co traction. D �nsions� e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of ands? Yes Is construction within 100 yr. floodplain Yes No j. Depth of basement or cell floor below finished grade k. Will building confo o the Building and Zoning regulations? Ye No. I. Septic Tank City Sewer Private well City water Sup ly SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,�" ( i0 LA (/� �' � as Owner of the subject property / hereby authorize ( ( S,,/f to act on my behalf, in all matters relative to work auth rized by this building permit application. Ca'o4yz> , #x-- !?h(b g Signature of Owner Date I, J ltJ i J� ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing app ication are true and accurate,to the best of my knowledge and belief. Sign,ed under the pa� sand penalties of perjury. P/-e v Print Name 4 Sign re of Owner/Agent Dat SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su rvisor: Not Applicable ❑ Name of License Holder: 1 v �9�CP 0le2 License Number /j - S-- /� Address Expiration Date Sig unat re Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Comnanv Nam Registration Number `3 a -7 t-{ - /"( - Z / Address Expiration Date Telephone 53 V " Z 7 c./ 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.. -., — '� ,��, s' t .. .. �� _ .. __ •�� �I .� r;5".r,.. r �.. City of Northampton Massachusetts I� G I. DEPAR2MMT OF BUILDING INSPECTIONS x n, 212 Main Street • Municipal Building yJd OD1 Northampton, MA 01060 Jam , y'`�0 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 buildings'be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: Est. Cost: s Address of Work: /L(I Date of Permit Application: 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 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 perjury: I hereby apply for a bu'Iding permit as the agent of the owner: 4, �%ocjKr A ri &-- 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 :, ., y. :.� • ,.: �. �� � � a•"F'v.. t ., City of Northampton MassachusettsA. T2s i ' DEPARTMENT OF BUILDING INSPECTIONS 2 M 212 Main Street •Municipal Building �( Northampton, MA 01060 Js't• . , 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: (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: ,2SSacl�ssrc - (Company Name andAddress) Signature of Permit Applicant or Omirkr Dat 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. Proposal SExwrON ROOFING AN D_ MWNG INC . www.sextonroofino.com ' - —$1,C00 roc Setting the.Standard Certified Roofing Contractors i P.O. Box 5327 p. 413.534.123 Holyoke, MA 01041 f. 413.539.9906 Sextonroofing@hotmail.co M MA HIC# 118239 CT HIC#0605383 SUBMITTED TO Justin Lavelle PHONE Kevin:858.864-0165 DATE 8-1-19 STREET 185 Drury Ln. JOB NAME CITY,STATE,ZIP Northampton, MA JOB LOCATION 1. Strip And Remove Existing Roof Down To Deck, Dispose Of Improper Landfill. 2. Replace Decking As Needed @ $85.00 Per Sheet (first 3 sheets at no charge) 3. Install 1/2" Insulation Board Mechanically Fastened. (Meets Ma. Energy strech code) 4. Install Fully Adhered .060 EPDM Membrane Roof. 5. Install Metal Edging And Counter Flash 6. Install Proper Termination At Wails As Needed. 7. install new EPDM flange cover over existing soil pipes. 8. Supply Manufactures 15 year Material Warranty And SISI 5 Year Workmanship We Propose hereby to furnish material and labor—complete in accordance with the above specifications,for the sum of: �- Five Thousand Eight Hundred $5,800.00 Payment to be made as follows: 1/3 pa sc et9ule 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 involving extra costs will be executed r y only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. Not responsible for water damage during construction. Note:This proposal maybe withdrawn by us if not accepted Owner to pay responsible legal fees for non-payment,and applicable yyjthin(14)days. interest. Acceptance of Proposal The above prices, specifications and conditions are satisfactory and are Signature t, 1 s hereby accepted. You are authorized to the work as specified. Payment will be made as outlined above. Signature '?-'J Date of Acceptance. { r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street lug Boston,Masi 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/orga,;zationandividual):Sexton Roofing & Siding Inc Address:P.O. Box 6327 City/State/zip:Holyoke, Ma. 01041 Phone4:413-534-1234 Are you an employer?Check the appropriate box: Type of project(required): 1. L: I am an employer with__ __ 4.A I am a general contractor and I 6.!1 New constriction employees(full and/or part time).* have hired the sub-contractors 7.1'Remodeling 2. :' I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub-contractors have 8. L.;Demolition working for me in any capacity. employees and have workers' 9.G Building addition [No workers'comp.insurance comp.insurance.. required] 5.�: We are a corporation and its 10.11 Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. L Plumbing repairs or additions myself [No workers'comp. right of exemption petro MGL insurance required]t c. 152,§ 1(4),and we have no 12.X Roof repairs employees.[no workers' 13. 1'Other comp.insurance required.] --- 'Any applicant that checks hoz#1 matt also till ant the section below showing their workers'compensation policy information. tHomeowners who submit this aflplavk udicatinS they are doing all work and thea hire outside contractors mast submit a new affidavit indicating such. .+.Contactors that cheek this box mast attach an additional sheet showing the name tithe subcontractors and state whether or not those entities have employees. if the sub-contraders have emphopees,they mast provide their workers' number. I arm an engdoyer that is providing workers'compensation in=ranee for cry employees.Below is the policy and job site information. Travelers Property Casualty Company of America Insurance Company Name: Policy#or Self-ins.Lic.#:UB-OG078982-19 Expiration Date:06/04/2020 Job Site Address:_ - _--- �/- cy City/State/Zip= Y��'— -— Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration(date). Failure to secure coverage as required under Section 25a of MGL 152 can lead to the imposition of criminal penalties of 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 $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify ifder the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Print Name: �V� 77" T• ��' ���_.7 o c A Phone#: i}/3 1 17,' Official use only Do not write in this area to be completed by city or town official City or Town: Permit/license#: Issuing Authority(circle one): 1.Board of Heath 2. Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#: it CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDIYYYY) 06110/201-1) T(filS,GERTIFICATE 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 be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: ORMSBY INS AGCY PHONE FAX PO BOX 718 (A/C,No,Exl): (A/C,No): E-MAIL WEST SPRINGIFIQA,MA 010% ADDRESS: 286TY INSURER(S)AFFORDING COVERAGE NAIC# IISURED INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OFANIFRl(',1 SEXTON ROOFING&SIDING INC INSURER B: INSURER C: PO BOX 6327 INSURER D: INSURER E: HOLYOKF,MA 01041 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. WSR DD UBR POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDMYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY iACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY $ CLAIMS MADE OCCUR. AMAGE TO RENTED REMISES(Ea occurrence) ED EXP(Any one pe $ GEN'L AGGREGATE LIMIT APPLIES PER ERSONAL&ADV INJURY $ ENERALAGGREGATE E POLICY PROJECT LOC RODUCTS-COMP/OP MGG '$ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE $ LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY S SCHEDULE AUTOS Per person) HIRED AUTOS BODILY INJURY Is (Per accident) NON-OWNED AUTOS ROPERTY DAMAGE $ Per accident) UMBRELLA LIAB e OCCUR EACH OCCURRENCE ;5 EXCESS LIAB CLAIMS-MADE AGGREGATF $ DEDUCTIBLE $ RETENTION $ ;$ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY YM UB 0G078982-19 06/04/2019 06/042020 LIMITS ANY PROPERITORIPARTNERIEXECUIIVE Y NIA E L EACH ACCIDENT $ OFHCER/MEMBER EXCLUDED? 1.000.000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEIIIIIS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE INSURER'S MA WORKERS COMPE-NS.ATION POLICY AND ITS LOOTED OTHER STATES ENDORSEMENT AUTHORVES THE PAYMENT OF BENFFnS FOR CLAIIN.S MADE BY THE INSUREDS MIA EMPLOYEES IN STATES OTHER THAN MA NO AITI'HORIZATION IS GIVEN TO PAY CLAIMS FOR BENFFM IN STATES OTHER THAN MA IF THE LNSURED HIRES,OR HAS HIRED EMPLOYEES OUTSIDE OF MA THIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTA�PVE ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 198&2010 ACORD CORPORATION. All rights reserved. SEXTO-2 P I R CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 07/10/2019 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 may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such end orsement(s)_ PRODUCER 413-737-0300 CONTACT Eric Dbinske Ormsby Insurance Agency,Inc. NAME_ em _ 698 Westfield St PO 13ox 718 PHONE 413-737-0300 FAX - West Springfield,MA 01090 c,NO• — .413-737-0617 --- - Eric Dembinske Wns.COrn A"OROWGOWERAGE _ NAICi - - -_--.-- V!RR 4_ _ Insurance Co. tRoofing&Siding,Inc. !"URets Y�Fre Insurance 15067 Rx 6327 -- — --- --.---- _— —_ Holyoke,MA 01041 NSIlR6tC: _ NSURER D• —--- --_._.- ----— INSURER E• --—.-.___ 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 INSR _.—.— MAY_ HAVE BEEN REDUCED BY PAID CLAIMS. _ -- -- - __ — TYPE OF INSURANCE 6t19R p,OLJCy NUMB POLICY EFF POLICY ExpIMM - A X MMERCIAL GENERAL LIABILITY uleTs � QNyYY1 i : C� srI IMADF FACH OCCURRENCE 1,000,000 ( X occuR 101GL002159903 06125/2019'0612012020 DAMAGE TO RENTED — f 100,006 PREMI —" MED EXP Ww p m 5,009 cevLAG( TELIMrrAPPUESPet GBERALA GA7E — —2,000,000 OTHER: L ---- B AUTOMOBILE LNBIUry COMBINED SNGLE L1wItrT _ ANY AUTO i LE31 r* _-..__ }_ 1,��,000 OYIn'IEO SCHEDULED AFV206561 05/15/2019 05!1512020 BODavINJl1RY(Perperson� AUTOS ONLY X AUTOS I - —._-'— �{�R�� Tyyry BODILY INJURY(Per X AUTOS ONLY X ATO ONLY , accdelY PjZOd?AMAGE (rer 1 ILA LULB OCC( EXCESS LIAB (x/III&WOE AGGREGATE--_. DED RETENTIONS ---_. ... WORKERS COMPENSATION I PERAND EMPLOYERS,LIABILITY - MANY PROPRIETOR/PARTNER/EXECUTfVEIER YIN I TO BE SENT SEPERATELY - -- -- (IlarMat i-B NHj F �(CLUDED? N/A E.L.EACH ACCIDENT --_- If yes,describe under EL OISF_ASE-EA EMP_-_ DFSCRIPTION OF OPERATIONS bWow E.L DISEASE-POLICY IMIT I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) CERTIFICATE HOLDER CANCELLATION NONE-01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Everett Sexton ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE i ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD - The Commonwealth oflVassackusetts r' Department of IndustrialAceidents 1 Congress Street,Suite 100 Y Boston, MA 02114-2017 wwx:mass.gov/dia N�t)rkers'Compensation insurance Affidavit:General Businesses. :1 ) Iicant Inform—tiTO BE FILED NN ITH t-Ift.PI•:RMITFING AUTHORI"Il on Ylease Print Lenil�h BLisiness/Organization Name:MNP CONSTRUCTION INC %ddress:45 EXCAHNGE ST City/State/`Zip:MILFORD.MA.01757 Phone#:508-498-8870 - Frr�.,vi Vo an employer"Check the appropriate box: Business Ty I am a em lover with 5 5 Pe(required): p �___�employees(full and ❑Retail -'•❑ or part-time)." b. []Restaurant Bar.,Eatim,Establishment I am a sole proprietor or partnership and have no ` employees working for me in any capacity. 7• Dice and•or Sales(incl.real estate,auto.etc.) [No workers'camp.insurance required] g- El Non-profit 1 ,0 «'e are a corporation and its officers have exercised 9. []Entertainment their right of exemption per c. 152.510).and we have no employees.[No workers'comp.insurance required[" )0.[]Manufacturing 4.0 A'e are a non-profit organization,staffed by volunteers, 1 l.[�Health Care with no emplo.ees.[\o Workers'comp.insurance req.J 12.E]Other CONTRACTOR *Arn applicant that chet:ks hog 1 mint a6o till out the section belmt shen+mr thea uorkets etunp anon pottC►mfamautxt "ht t!e corporate offx cgs tett a estmpt<�them,eh es,btg the ctaporauwn has%Ftcr employees a workers'compensation Poi Ry is regetued anti six h an on_;mvation�ficnsl�chcc�i a�� h /ant an emplorertlratispruridin„wor/►ers'epntpensutiun i�r4rrrunc'efnr►m'eraplorecn. Brlmt•h th��pt�licl•in(urmutrun. Insurance Compan3 'dame:HARTFORD UNDERWRITERS INS CO. TRAVELERS-RMD Insurer's Address;P.O.BOX 5600 - City>StateZip: HARTFORD, CT.06102 Policy a or Self-ins.1.ic.:.1 K709706 A 11!16!2019 Expiration Date: Attach a copy of the workers'compensation policy declaration page(showing the polio number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 153 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and or one-year imprisonment,as Drell as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a da,, against the violator. Be advised that a copy of this statement may be forwarded to the Office of Imestigations of the DIA for insurance coverage verification. Iderbpjpu�r that the iajormation prorided whore is true and c»irecy: ! Date_ r /r Phone»:9703-5942 Eg only. Do not write in this area,to be completed bf•cih•or town official wn: _ Permit/License# thority(circle one): Health Building Department 3.Cite 'I-ott 11 E ierk 4.Licensing Board S.Selectmen's Office rson:- - -. Phorr u. — CERTIFICATE OF LIABILITY INSURANCE OATE(MMMD/YYYY) THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER_ THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGAEXTEND OS/70/2018 Y THE BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE,A CONTOIACT gE-R,VEEN g�INGFiNSDiIREC(S)INSURER(S).REPRESEATTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate hatder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. Jr SUBROGATION IS LNAiVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement On this certificate does not confer rights to t certificate holder in lieu of such endorsement(s)_ PRooucER 9 he I CU ACT ONE FAMILY INSURANCE AGENCY LLC i onF Art Catvllio _ a Pvc T;9 Exn (978)4035942 - f�-raAa 1 Main St Suiie 15acnRESs acafv7laca o12g�Tyahoc.Cam LunenburguisuR AFFORM- MA 01462 INSURED -- - ------__-.. _ f+suwER�_FIARTFORD UNDERWRITERS INS CO 30104 - MNP CONSTRUCTION INC u►sItRERs: ———--i—' — L45EXCHANGE ST APT 3ELFORD COVERAGES MA 07757 usuxERr, — —---. CERTIFICATE NUMBER: 401083 THIS IS TO CERTIFY THAT THE pp JCIES OF INSURANCEREVISION NUMBER: CERTINDICTED. NOTWITHSTANDING ANY REQU1RFMEN- TERM OR BELOW HAVE 8 EN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD CERT SIGN-c IvV+Y Bc ISSUED OP,MAy CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS DCCLUSSONSAND PERTAIN. THE INSURANCE AFFORDED By THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS OF SUCH POLICIES.LIMITS SHMVN MAy HAVE BEEN REDUCED BY PAID CLAIMS 1115((+"- LTRI TYPE OF INSURANCE ADDU$UBR'-- -----_.- -- C/M61ERMALGENERALLIABILITY RMQr PO'CY - j PO iciIL POIJCYD—m i--- -- -- --- _- UNITS 'CLAM M DE �'oCCVR 1 FACT'OCCURRENC` S f„--i NIA t 1 �PE.RSONAL 6ADV INJURY GENLAGGREGa lunar a=PLIEspFR — JECOT ___c LCC NERlL AGGREGATE 5 - OTY.^cR: t r t i PRODUCTS-CosdPlppqGGIs AUTOMOBILE LIABILITY 1 i 1 Is -- ANY AUTO t ± f S} E t.lblfi S i�---�ALL OWNED'AUTOSDlP�7 i ! ' '--a -...1 auTCs 1 I N/A 30D4.Y INJURY(Per person) S 'HIRED AUTOS VONO i l 800rr_V 011llRY - tr'eraadderry•S AUTOS ! 1 i I ' j � PROPERTY DM:AGE—'�-• - BRELtA L IAS i Il a¢dr.Cl I S .. ` 1 UM i f 1 —_' 7----- +OCCUR � s I —i EXCESS LIAB NIA I �E"c�'°�cu„REacE Is DED I j RETENITIt]T,S WORKERS COMPENSATION -- + 1 AND EMPLOYERS'L I BILITYt(S ANYPRDPRIZTORfP?ARTNER7EXZCUV,- YIN. I^.STATUTE E(= 7 K A .OfrICERIME`.tBEREXCLUDED? N!A NIA ? N/A 6 If yes. In NH) I S60U81 K70970618 JJ�!l/i6♦'�I18 1111SJ2019 I-= {��S 1,000 000 DYes.dUITION under i 1 I 1 EL a --- DESCRIPTION OF DP_RATiCNS De:hw , {{ SASE--A tpEAtPL NEE S 1.000,000 I {p ` I I E L o15EASE_POLICy LWT'S 1.000,000 _ I NIA ' i I l DESCRIPTION OF OPERATIONS!LOCATIONS r V=-HICLPS(ACO RD 701,Additional Remarks Schedule, I I , Workers Com ensat;on benefits vrili he aid to Massachusetts employeesoe �if mom space o"Aafrcd) D D claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired rimoseemployees only Pursuant to Endorsement WC 20 03 06 B,no authorization is given:o pay e of This cefti{lcate of insurance shows the policy in force on the date that this certificate was issued(unless the ex iration date on the bov policy p r issue dale of this certificate of insurance). The status of this Coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search too!at mvw_mass_govllwd/workers-compensaironrrnvestigations/_ policy precedes I e CERTIFICATE HOLDER CANCELLATION THOULD ANY OF EXPIRA71ONHDATEOVE DESCRIBED THEREOF, TICS POLICIES WILL CANCELLED DELIVERErJ BEFORE 1N SEXTON ROOFING & SIDING INC 102 PINE S? ACCORDANCE WITH 7}tE POLICY PROVISIONS_ AUTHORIZED REPTy, 7ATI VE HOLYO(E -NIA 01040 ^ ' LDaniel MCoCPCU,Vice President-Residua!cdarke -- t WCR;B Dr ACORD 25(2014103) The ACOR name and logo are registered marks of 014 ACORD CORPORATION_ Alt rights reserved_ r ` �%`1•FP (��fjl`j1�f?ll ff'f�/����. l'�«�11f1f`1ll�f'��1 Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration - ` ��3 .. �•,� Type: Corporation Registration: 118239 SEXTON ROOFING&SIDING INC e IR Expiration: 02/14/2021 P.O.BOX 6327 HOLYOKE,MA 01041 t-L� .a SCA 1 r, Update Address and Return Card. STATE OF CONNECTICUT EVERETT J SEXTON SR HOME IMPROVEMENT CONTRACTOR PO BOX 6327 EVERETT J SEXTON SR HOLYOKE,MA 01041 102 Pine St HOLYOKE,MA 01040-2411 SEXTON ROOFING&_SIDING CO LIC.!REG NO. ECTI—VE EXPIRES HIC.0605383 /01/2018 11/30/2019 SIGNED ® Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor Specialty CSSL-099689 Expires: 10/05/2019 EVERETT J SEXTON PO BOX 6327 HOLYOKE MA 01041 Commissioner L/""�