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42-061 930 WESTHAMPTON RD BP-2020-0338 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 42- 061 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-2020-0338 Project# JS-2020-000574 Est. Cost: $8700.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sq. ft.): 43995.60 Owner: ROMANOS JOSEPH Zoning: Applicant. SEXTON ROOFING CO AT. 930 WESTHAMPTON RD 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 EXISTING 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 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 only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit z" 212 Main Street Room 100 R E C ability 1 Northampton, MA 01060 Two Sets of Stru tural tans phone 413-587-1240 Fax 413-58 -1272 Plot/Site Plans SEP oll,4 4A APPLICATION TO CONSTRUCT,ALTER,REPAIR,R NOV TE OR DEMOLISH OR O FAMILY DWELLING DEPT.UF UUILIJIN(i INSI'tUtIONS NORTHAMPTON.MA 01060 SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot lJ"� � Unit Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: fR / /� l �161-enc'kq­ Name Sae K O wi �rJ6S 05,-) (�t/'-PS��tik(Print) Cure My'l7 Address (§-4 Ili/ &' 4 Telephone 2o t6 Signature 2. uthorized Agent: Name(Pri Current Mailing Address: 2 S-3 V /23 SigAefure Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building , n 1�— (a)Building Permit Fee 2. Electrical CJ (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee f j'� (� 4. Mechanical(HVAC) ,`TV,0 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number p� This Section For Official Use Only Building Permit Nu er: Date Issued: Signature: 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/Varian a/Finding ever been issued for/on the site? NO O DONT N W O YES IF YES, date issued: IF YES: Was the permit corded the Registry of Deeds? NO ® DONT KN W O YES IF YES: enter Book Page and/or Document# B. Does the site con ain a brook, body of ater or wetlands? NO © DONT KNOW ® YES O IF YES, has permit been or need to b obtained from the Conservation Commission? Needs to a obtained O 0 ined © , Date Issued: C. Do any s' ns exist on the property? YES NO O IF Y S, describe size, type and location: D. Are there any proposed changes to or additions o igns intended for the property? YES ® NO IF YES, describe size, type and location: E. 1lkill the construction activity disturb(clearing, grading, excav tion,or filling)over 1 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 m the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 5�r— Or Doors ID Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[d] Brief Description of Proposed, �� � / ` / � Work.- 1J .lp_ �/' r/l�� Alteration of existing bedroom Yes "'No Adding new bedroom Yes No Attached 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 PQroily Two Family Other b. Number of rooms in each ily unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new con ruction. ensions 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. etlands? Yes No. Is struction within 100 yr. floodplain Yes No j. Depth of basement o ellar floor below finished grade k. Will building form to the Building and Zoning regulations? Yes No. I. Septic nk City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,�W. [/— (L M -3 as Owner of the subject prooperty ? hereby authorize R to act on my behalf, in all aiatters relative to work authorized by this building permit appli tion. Signature of Owner Dat I, �� l✓ , as Owner/Authorized AgentTiereby declare that the statements and information on the foregoing applicatio are true and accurate,to the best of my knowledge and belief. Si d under the p ins and penalties of perjury. i Print arae Signat of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Constructi n Su ervisor: Not Applicable ❑ Name of License Holder: 9g 6 a- License Nu b r Ad&ess Expiration Date Signature Telephone S,Beaistered Home Improvement Contractor: Not Applicable ❑ / -Uo--RtQnV Name Registration Number A ress Expiration Date Telephone-1 ��--3 y 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....... 1�5' No...... ❑ City of Northampton Massachusetts .A DEPARMUM OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 � rees .rC AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application T 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, modemization, 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 enti4,must be registered Type of Work: t Est. Cost: Z) 70-D Address of Work: 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 buildi permit as the agent of the owner: � � 7 ate Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS . t_�g3y 212 Main Street *municipal Building Northampton, MA 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: 0 3� ���� (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: (Company Name and Address) Signatur( of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. �'. } .•� .. :\• . 1 r ! _.� ` Z . . � 09109/2019 10: 33 4135843260 FL',' B`r' HIGHT PAGE 01/01 _Proposal SEXTON ROOFING AND SIDING INC www.sexton roofi ng.com &OSTE'R Setting the Standard B p. 4'13.534.1234 P.O. ox 6327 f. 413.539.9906 Holyoke, MA 01041 MA HIc# 118239 sextonroofin hotmai1.com SUI3MITTEU TO Joe Romanos PHONE 281-7267 DATE 8118/t9 STRt ET 930 Westhampton Rd. JOB NAME CITY, STATE,ZIp rlorartce, Ma. SEXTON ROOFING HEREBY SUBMITS SpECIFICA JOB LOCATION TIONS AND ESTIMATES FOR_ 1) Strip and remove existing shingles and dispose of in proper landfill. 2) Inspect roofing deck and replace as needed @$75.00 per sheet. 3) Install new metal edging to rakes and eaves of roof. (8") 4) Install ice and water shield an eaves ( 6'), 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. 10)Supply manufactures Lifetime warranty and SRC 25 yr. workmanship warranty. We Propose hereby to furnish material and labor—complete fh accordance with the above specifications, for the amount of Eight Thousand Seven Hundred Dollars$8,700.00)Payments to be made as follows: Due in full upon co m letion All Material Es guaranteed to be as specified. All work tot}e completed in a Authorized workmanlike manner arrording to atandard practices- Any alteration or deviation from above specifications involving extra costs will be executed Signature only upon written orders,and will became an extra charMC3 over and above the estimate- All agraaments contingent upon strikes,accidents or delays beyond our control- Nnt responsible for water damage during Note: This proposal may be withdrawn by us if not accepted Construction. Owner to pay responsible legal fees for non-payment,and a plicable interest- within (14)days. Acceptance of Proposal The above prices, specifications and conditions are Satisfactory and are SignatuI hereby accepted. You are authorized to the work as specified. Payment will be made as outlined above. ogle of AQwPtdnr_,e. 1 � iSignature - i r _ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busirwss/orgmizatoro"vidval):Sexton Roofing & Siding Inc Address:P.O. Box 6327 City/State/Zip:Holyoke, Ma. 01041 phonem:413-534-1234 Are you an employer?Check the appropriate box: Type of project(required): L l: I am an employer with __ 4.A I am a general contractor and 1 6. _1 New construction employees(full and/or part time).* have hired the sub-contractors 7. 1 : Remodeling I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees "These sub-contractors have 8. 1:Demolition working for me in any capacity. employees and have workers' 9. (; Building addition [No workers'comp.insurance comp.insurance.++ required] 5.i' We are a corporation and its 10. :; Electrical repairs or additions 3. 1 am a homeowner doing all work officers have exercised their 1 I. ! Plumbing repairs or additions myself [No workers'comp. right of exemption perm MGL insurance required]t c. 152,§ 1(4),and we have no 12.X Roof repairs employees.f no workers' 13- 1'Other comp.insurance required.] -- -- -- - *Any applicant that checks box#1 most also fist out the section below showing their workers'compensation policy information. (Homeowners who submit this atTidsrit indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating such. !Contactors that cheek this box most attach an additional sheet showing the name of the sob-contractors and state whether or not those entities have employees If the sub-coubvctors have empkryees,they mast provide their workers'comp,policy number. I am an em ptoyer that is proving workers'compensation insurance for my employees.Below is the policy and job site inf°rmadOrr' Travelers Property Casualty Company of America Insurance Company Name: Policy#or Self-ins.Lie.#:UB-OG078982-19 iration Date:06/04/2020 Job Site Address: �Q Gr/ City/StatdZip: �Jled/ C ` - -- -- - -— 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 herbycertifyder the pains and penalties of perjury that the information provided above is true and correct. 2 Signature: Date: Print Name: 9 L Cif Ejf J', r£�t-moo r, Phone#: Y /3 - '531Y J 2 :5 4 Official use only Do not write in this area to be completed by city or town official City or Town- Permit/license M Issuing Authority(circle one): !.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#• CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/1012019 TkLS,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 fNS AG('Y PHONE FFAXPO BOX718 (A/C,No,Ext} o): E-MAIL WES"F SPRINGFIELD,MA 01090 ADDRESS: 286TF INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA SEXTON ROOFING&SIDING INC INSURER B: INSURER C- PO BOX 6327 INSURER D: INSURER E_ IiOLYOKE,INA 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 I 4DDLUBR POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY mACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED j CLAIMS MADE a OCCUR. REMISES(Ea occurrence) — ED EXP(Any one person) 3 GEN'L AGGREGATE LIMIT APPLIES PER. ERSONAL 8 ADV INJURY ENERALAGGREGATE i POLICY PROJECT [:]LOG RODUCTS-COMP/OP AGCa S AUTOMOBILE LIABILITY COMBINED SINGLE i ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA L1AIIOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE .$ RETENTION $ ;$ A WORKER'S COMPENSATION AND WC STATUTORY OTHER' EMPLOYER'S LIABILITY YIN UB-OG078982-19 06/04/2019 06/04/2020 X I LIMITS ANY PROPERRORIPARTNFR/FXECUTIVL WA E.L.EACH ACCIDENT $ 1,000,000 OF FXCLUDED? El (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe urKler DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OP'E.RATIONS/LOCATE)NS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE, TITE INSUREDS MA WORKERS COMf*NSAT1ON POLICY AND FTS LIMITED OTHER STATES ENDORSEMENT AUTHORIZES THE PAYMENT'OF BENEFn's FOR CLAIMS MADE BY THE INSUREDS MA 0Lt WYFRSS IN STATES OTHER THAN MA NO AUTWRTZATION IS GIVEN TO PAY CLATM,S FOR BTINEFM IN STATES OTHER THAN MA IF THE tNSt RED HIRES,OR HAS HIRED EMPLOYEES OUTSIDE OF MA TRW 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. I AUTHORIZED REPRESENT E b�. ACORO 25(20ION" The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. SEXTO-2 OP I R ACOR,a CERTIFICATE OF LIABILITY INSURANCE FDATE("m"") 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 endorsement(s)- PRODUCER 413-737-0300 CONTACT Eric Dembinske NAME:- Ormsby Insurance Agency,Inc. 1 PHONE 413-737-0300 FAx 413.737-0617 698 Westfield St PO Box 718 ;puc,No,Ertl: _ -es Not_— West Springfield,MA 01090 E-MAIL ed&nbbrske@or Goin Eric Dembinske i ADDRESS: _--_--—------ --._ —_ -— --- . _._-- _-- INSURER A.ColorLMsuranw C& 1Nr12t18� glaw SURED YRM lee l ..._. Sexton Roofing&Siding,Inc. �NsuRERs° --,-- — --- _-- PO Box 6327 INSURERC_ Holyoke,MA 01041 — -- WSURER 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH -]His CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE FFRMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- _ INSR TYPE OF INSURANCE SUB R VJvDj POLICY NUMBER T POLICY EFF POLICY EXPLTR LIMITS A X COSINERCIAL GENERAL LIABILITY EACH OCCURRENCE _1,000,000 CLAIMS-MADE X j OCCUR I I DAMAGE TO RENTED 100,000 101 GL002159903 06/25/2019 06/20/2020 PhIISES fEa oow_ f MED 5,000 --- PERSONAL a ADV INA)RY s 1,000,000 2,0_00-,-0- 00GENtAGGR LIMIT APPLIES Pitt CTE PO $000,00P � E ��LOC PRODUCTS AGG s OTHER: B AVTOYOBILE LIABILITY COMBINED SINGLE LIMIT 1.0w1 ANY AUTO AFV206561 0511512019 i 0511512020 Bo_DIL_Y__INJLA _ OWNED SCHEDULED AUTOS ONI Y X AUTOS X AUTOS ONLY X AUTOS ONLY IP accident)PERTY DAMAGE $ _ UMBRELLALIAB L OCCUR EJ1CN_OCCURRENCE s EXCESS IIAB CLAIMS-MADE DED RETENTION S WORKERS COMPENSATION I PER OTH- AND EMPLOYERS LIABILITY AER YIN TO BE SENT SEPERATELY ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT _ s OFFICERIMFMBER EXCLUDED? [ NIA -- (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below -POLICY LIMIT S i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if 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 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD TJ:e Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston, 4 02114-2017 s wWW Mass govldia Workers'Compensation Insurance Affidavit;General Businesses, Astulieant Information TO BE FILED IVti7TH 7IiF PERMITTING AUTHOR(-Il. Please Print I e;thh Business/Organization Name:MNP CONSTRUCTION INC Address:45 EXCAHNGE ST CityState/7.ip:MILFORD, MA.01757 _ Phone#f:508-498-8870 - Are you an employer?Check the app]insurance e box: Business T — vpe(required): 1.eJJ t am a empiot er with 5 -___ yees(full and 5. ❑Retail -'•❑ or part-time).* 6. 0Restaurant Bar.,Eating Establishment [am a sole proprietor or partnershhave no employees working for me in anyity. ? ❑Office and•'ar Sales(incl.real estate,auto.etc.) [No workers'comp.insurance reqS. El Non-profit �.❑ We are a corporation and its office exercised 9. ❑Entertainment their right of exemption Pere. 152 ),and we have no employees.[No workers'comance required)= 10.0 Manufacturin, 4.❑ l}'e are a non-profit organization, by volunteers, 1 1.0 Health Care with no employees.f No workers• insurance req.) 12-Q Other CONTRACTOR 'Am aWwam that checks txpw 41 mu,t also fill out the section below shooing then corkers cort�es:vuton pones mtotmauon "1f dK ctvpmate offkTM has c cwempted themselves,but the on, should check 1xn�f ��'�`%`nom h��r empio�res a swrkets'campensatwn policy is rrgwrrd:uxf such an t ant an emplorer that is prnt•iding workers'compensation insurance or mr e f mplo}gees. Below is the pulid•information. Insurance Company 'game:HARTFORD UNDERWRITERS INS. CO. TRAVELERS-RMD Insurer's address:P.O. BOX 5600 City,-State.Zip: HARTFORD,CT. 06102 - Policy;:or Self-ins.I.ic.#IK709706 -- --- — -.._--- .__11!16/2019 Expiration Date: 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 c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 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. Be advised that a cop}of this statement may be forwarded to the Office of Investigations of the DIA for insurance co,.erage verification. !do hereby cern u^ pdr ialties of perju�n Ntat the in Prot ubnt a is:rue and c orrec I r Signature: } ! a " Date: f - Phone K:978-403-5942 Of use unit•. Do not write in this area,to be completed by city or town official Town: Permit/License;i:Authority(circle one): d of Health 2.Building Department 3.CitytTown Clerk 4.Licensing Board 5.Selectmen's Office r Person: Phone* w�aws,maws}tn Odra AC RD`s CERTIFICATE OF LIABILITY INSURANCE OATE(MMJDDfYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGI-,TS 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 BET.VEEN THE ISSUING INSURER(S), AUTHORIZELt REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT_ If the cerSfieate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. It SUBROGATION IS LyAIVED subject to the terms and conditions of the policy,certain policies may require an endorsement- A statement on this certificate does not confer right to the certificate holder in lieu of such endorsement(s). I-, ODUCER NE FAMILY INSURANCE AGENCY LLC Poo ECT {NAME: Art Calvillo JAM— Erif: ('978)403-5%42 _ FAX Ltain St Su'rteAnnE_nenburg - INSURSiIS)AFF ��_— -- - - MA Gi4o2 RlstLRERn_HARTFORD UNDERWRITERS INS- ------ 30104 AANP CONSTRUCTION INC 9: — C* -- 45 EXCHANGE ST APT 3E ;!E�R4�R°:MILFORD REtE- _ — COVERAGES MA 01757 INSURER F CERTIFICATE NUMBER: 401083 THIS is TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSU£D TO REVISION NUMBER: INDICATED- NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF THE INSURED AAM, CERTIFICATE ABOVE FOR TH.POLICY PERIOD CERTIFICATE MAY BE ISSUED OP MAY PERTAIN, THE INSUrZANC AFFORDED gY CONTRACT OR OTHER DOCUMENT EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN IV WITH RESPECT ALL WHICH THIS THE POLICIES DESCRIBED HEREIN IS SUBJECT TO A.LL 7Hc ,_RMS, 1 ---- HAVE BEEN EN REDUCED BY PAID CLAIhiS- LTR I TYPE OF INSURANCE ''� ( — - I t RAL LIA811ITY , POLICY NUMBER POLICY EFF POCDY IXPT._Di�4MERCIAL GENE Li1Nlt9 -- - 1 s-tiL:DE L—_CCCIIP ! 1 EACHOCCURRENC' S DAtaiac-�,E.TO - _ �PRE_AAM- fEa o �S — —-- — N/A { 1 UED EXP one oe+sanl i s - - GEN L AGGREGA,c UrllT tiIKI£S PE+2 IAL6 ADV 4YJ - !RM S ' EGET ` I LOC ! 1 1 GENERAL AGGREGATE--7 'RFOD ^ _-..._OTHPOAG S AUTOMOBILELIAWLITY i I Is -- ANY AUTO co` En smcLE wlRr, a ar�wv.tL i S r !ALL OWNED SLItEDIl•FD AUTO.; BODILY INJURY(Per Perses+) S ; AUTOS NfA I 5 -'-_- _I HIRED AUTOS ! { sOOEY p�.iU v d - ... 7' OS PROPERTY UgfkAGEa� I S � Is l tfBRELtJ111A8, � ----i "---�--��— _ _ { I OCCUR ] ! 1 S !E7tCESS UAS - ! ---_ - I CLAWSMIqE: f J NWA EACH R !s- OED 1 I RETENTIONS i ! AGGREGATE s WORK>_Ft5 CONpENSATION ) t I ---_— ANDE.'.1PLDYERS'UABILfN Y!N I {S IA-%-PROPRIZTCPPAR fIERIEXECUrIVc ! I X�SrATUiE ; ERS I A .O1FICcZ'M@J8ERFXCLUDFD? rN/A'NtA N/A 1 i if Yes deco to ra11 L 60t1B1K70370G18 1IIIW018�11/1612019 .�S 1.000.000 N Yes.desai N Over DISEASE-e SCRIPr1oN or DPERArcNs be!— ID- _n mtvLov�S 1.000,000 _ t 1 Z EL DISEASE-POUCYLNQT'S 1.000,000 i i NIA i I DESCRI?TION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 91T7,A2ditinryl RemarRs Sehedufe,rn I Workers Compensation benefits will be paid to Massachusetts employees be a °P"` "�ubca) claims for benefits to employees in states other than Massachusetts if the insured hires,or has Hared rimose employees AI tees only-Pursuant to Endorsement WC 20 03 06 8,nc authorization is given:o pay This certificate of insurance snows the policy p°yeQs outside of 1ti4assactlu e„ - tt issue date Of this e +cT in force on the date that this certificateoni was issued(Unless the expiration date cn the above Ocl" y 1 certificate Of insurance)- The status of this caierage can be monitored daily by accessing the Proof of Ccvera e-Cove; precedes t,e [Search tool at mvw.mass-govfAvdivrorkers-compensation(rnesligg6ons/. 9 age Verification CERTIFICATE HOLDER , CANCELLATION SHO LD ANY THE UEXPIRA OONH DASOVTHEREOFB NOTICE ED POLICIES VJILL CANCELLED DELIVERED BEFORE iN SEXTON ROOFING & SIDING INCTE 1Q2 PINE ST ACCORDANCE WIT. THE POLICY PROVISIONS. r�� HOLYOKEMA 01040 LDaniel M-Crowley,CPCU,Vice President-Residual Markel,-WCRIBrAA ACORD 25(2014101) 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation SEXTON ROOFING&SIDING INC - Registration: 118239 _� Expiration: 02/14/2021 P.O.BOX 6327 HOLYOKE,MA 01041 t ` F i SCA t O 2—.!-CS 17 Update Address and Retum Card. STATE OF CONNECTICUT i 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. ECTIVE EXPIRES HIC.0605383 /01/2018 11/30/2019 SIGNED Commonwealth of Massachusetts ® Division of Professional Licensure Board of Budding Regulations and Standards Construction Supervisor Specialty CSSL-099689 Expires: 10/0512019 of, ...' EVERETT J SEXTON PO BOX 6327 HOLYOKE MA 01041 Commissioner Cj—