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23A-087 (3) 14 PLYMOUTH AVE BP-2020-0380 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A-087 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Building BUILDING PERMIT Permit# BP-2020-0380 Project# JS-2020-000651 Est. Cost: $2599.00 Fee: $40.00 PERMISSION IS HEREB Y GRANTED TO: Const. Class: Contractor., License: Use Group: SURGE HOME CONCEPTS LLC - DAVID WOELPER 110193 Lot Size(sq. ft.): 8537.76 Owner: GARTLAND AGNES E Zoning:URB(100)/ Applicant: SURGE HOME CONCEPTS LLC - DAVID WOELPER AT. 14 PLYMOUTH AVE Applicant Address: Phone: Insurance: 66 SOUTH BROAD ST SUITE E8 (413)454-2154 WC WESTFIELDMA01085 ISSUED ON.9/23/2019 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: FeeTvpe: Date Paid: Amount: Building 9/23/2019 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Y j — Department use only i City of Northa ptorR E ;E v i s I rmit: Cf, y '^° Building Dep met Civeway Permit *� 212 Main St eet jer/ c Availability '�. ,. Room 1 t SEP 2 3 201 r/ AvailabilitNorthampton, A 01 60 SeStructural Plans phone 413-587-1240 F x 4 R itns — - NORT!-JA14PTON.�MA0�1(TTher Sfy APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING -dd' 3�0 SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office FIIv2 Map X3/9- Lot /'S� 7S Unit q Pl/lAtctt Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 4!?1) c5 Cur+Iao P� y�����I ate Name(Print) Current Mailing Ad ress: uta ) Sg , a ) �S Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: C;--z NO) 3 LO -15 ,YS Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building �, `�t //�� (a) Building Permit Fee 2. Electrical "i (� (✓ (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total = 0 +2 + 3+4+ 5) `1 ,L�U ---- Check Number L This Section For Official Use Only Date Building Permit Numb r: Issued: 1--� Signature: q- 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/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO '* DONT KNOW Q YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 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 acre? YES O NO 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 Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [0] Other[t:] Brief Description ofPrQposed Work:_ `v O"'B r�L�J `�4,,%t 6,S P cj+a.) view o"%6 / Alteration of existing bedroom Yes I/ No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes _J/ 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 construction. Dimensions 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 wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, A 5)1&Js CQ r J 1 (4 nd as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date l CcJet) 0-tai as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under theains and penalties of perjury. Print Name (Act Signature o caner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Pf- ,�Uy ae(p er ( 10/c(3 License Number Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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....... 4/ No...... ❑ City of Northampton ' Sys..,- S•� • Massachusetts � G �. DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building 9v� Cam 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 Type of Work: 1\VUC; N-, Est. Cost: s q efi 00 Address of Work: I q Ply i*&(w4 h Gly e Date of Permit Application: C1 a U 1 C7 1 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 building permit as the agent of the owner: III �(Acl (k,«'� Wo e fo�er [ F5&LI r 3 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 City of Northampton X Massachusetts DEPARMENT OF BUILDING INSPECTIONS 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: Iq ? I V "I ouftl Wit, e (Please print house number and street name) Is to be disposed of at: GO (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: C6 se((zi VV.1i)te ),w � e c- (Company Name and Address) Signatbre of P rmit 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. MA HIC#186413 -- MA CSL#110193 Date:8/9/2019 CT HIC#0655970 .. U R�G� E HJ n'- ' M E "' D N CE P T ESUS! (413) 342-1585 - SURGEHOMECONCEPTS.COM Residential and Commercial Roofing Systems Customer:'A►emas Gartland Phone: �GNt5 Address: 14 Plymouth Ave Email: tom.gartland@comcast.net Florence, MA 01062 Roofing Proposal Provide permits for work on property Provide Dumpster to haul-away all roofing debris Strip 1'floor front porch roof faces to existing sheathing Inspect sheathing and roof framing for damage If more plywood is needed the additional charge will be$75/sheet installed If more work has to be done a quote will be provided immediately Install F8 drip edge around all eves and rakes of roof faces—Color: Install Ice and water barrier 6' up(two courses )from eves on all roof face Install ice and water barrier around each post for solar panels Install all new pipe flashing boots Install synthetic underlayment on remain roof faces Install starter shingle along all eves and rakes of roof faces Install architectural shingles on all roof faces Install rolled ridge vent Install matching cap shingles Additional info: j I Install shingles where missing on rear southern side of house Shingle color may not match Provide roof tune up to entire existing roofing system Seal all exposed nail heads on roof with clear silicone Seal all visible roof cracks with clear silicone Provide multi-point roof inspection Price includes all materials, labor, taxes and permit fees. Your Project Manager: Shingles will be Atlas in color: All applicable shingle accessories to be Atlas brand Includes 25 year craftsmanship warranty from Surge Home Concepts Includes Atlas Signature Select warranty Start Date: Includes 3M Scotchgard lifetime stain warranty Completion Date: Attention homeowners:Please cover all personal belongings in the attic,garage,or storage areas due to the possibility of roofing debris or dust coming through the cracks of the wood.Surge Home Concepts will not be responsible for the debris or dust in the areas mentioned.Homeowner must remove valuable items from walls to prevent damage during siding projects.Also SHC is not responsible for gaps from siding on home and roof line due to multi layer roof strips.A 3.5%fee will be added if payment is made via credit or debit transaction.Ali material is guaranteed to be as specified.All work to be completed in a workmanlike manner according to standard practices.Any hidden conditions are not covered under this document and may become an extra charge. Any alteration or deviation from the above specifications must be made in writing on an addendum contract and may become an extra charge over and above the amount stated herein.This agreement is contingent upon delays beyond our control.Owners to carry fire,tornado,and other j necessary insurance.Our workers are fully covered by Liability and Workmen's compensation insurance.Homeowner agrees to pay for all work as set forth in this document.If the homeowner defaults,homeowner agrees to pay all costs of collection,including reasonable attorneys fees,in addition to other damages incurred by contractor.An 18%per month service charge will be assessed for all payments not made within 10 days of due date per the schedule below: j We purpose hereby to furnish material and labor,complete in accordance with the above specifications, for the sum of: $2599 Said amount shall be paid as follows: j Down: $1000, Start:$1000, Completion: $599. i Note:This proposal may be withdrawn by us if not accepted within_3-days. YOU,THE BUYER,MAY CANCEL THIS TRANSACTION ATANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DAY OF THIS TRANSACTION.THIS SALE IS SUBJECT TO THE PROVISIONS OF THE HOME SOLICITATION SALE ACT AND THE HOME IMPROVEMENT ACT.THIS INSTRUMENT IS NOT NEGOTIABLE. Signature of contractor or authorized mprosentative: '(I/We)have read the terms stated herein,they have been explained to(me/us),and(Uwe)find them to be satisfactory and hereby accept them.Signature of Homeowner: X� s Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC SURGE HOME CONCEPTS, LLC + t Registration: 11/0 13 66 SOUTH BROAD ST l� ~-- Expiration: 11/07(2020 SUITE E ' WESTFIELD, MA 01085 SCA t 8 200.05/17 Update Address and Return Card. Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 186413 11!0712020 1000 Washington Street-Suite 710 SURGE HOME CONCEPTS,LLC Boston,MA 02118 DAVID WOELPER l� 66 SOUTH BROAD ST C� SUITE E Undersecretary Not valid without signature W ESTFIELD,MA 01085 Massachusetts Department of Public Safety ® Board of Building Regulations and Standards License: CS-110193 Construction Supervisor , DAVID WOELPER 115^ RDEN ST- -T WEST SPRINGFIELD MA 01089 �Z;7 (LA— Expiration. Commissioner 02x091020 The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www,mass.gov/dla Workers'Compensatlon Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Apaltcant information Name(Business/orgaanizationalec/indlvidualj: GL J Addresr J �� l9 cy& ep%,OC S'D City: !� State: MA Zip:_ GLOSS Phone: q(3342-1925 IAre 0 an employer?Check the appropriate box: Type of project(required): 1. 1 am an employer with 1 employees(full and/or part time)' D 7. New construction ❑2. 1 am a sole proprietor or partnership and have no employees working for me in any Q S. Remodeling capacity.(No workers'comp.Insurance required.) 9. Demolition ❑3. 1 am a homeowner doing all work myself.(No workers'comp.Insurance required)t F110. Building addition ❑4. 1 am a homeowner and will be hiring contractors to conduct all work on my property. ❑11. Electrical repairs or additions 1 will ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. ❑12. Plumbing repairs or additions a 5. 1 am a general contractor and I have hired the sub-contractors listed on the attached ❑13. Roof Repairs sheet. These sub-contractors have employees and have workers'comp.insurance.t �6. We are a corporation and its officers have exercised their right of exemption per MGL. E.4. Other c.152,§10),and we have no employees. No workers'com .Insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit Indicating they are doing all work and then hire outside contractors must submit a new affidavit Indicating such. tContractors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that Is providing workers'compensation Insurance for my employees. Below Is the policy and fob site information. insurance Company Name: ( " JJL`Q�-S Policy#or Self fns.lie,fi: (� q013'-) }-1$Z3 G Ito I I Expiration Qate: 1Z. v Job Site Address: ' vh Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL.c.1:2,§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 statement may be forwarded to the office of investigations of the DIA for insurance coverage verification. I do hereby cert*under the pans and penaltles of perjury that the Information provided above Is true and correct,and that clicking this cheekbox and inp my name In thfe.file d below will act as my signature. ' Name: s" Date: q: ' �� Email: Phone r'o co° CERTIFICATE OF LIABILITY INSURANCE °"'�( 'ry" 04128!201612019 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 poilcy(les)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 endorsemartt A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER NAME:CT Gloria Lk1Zi Bates Fuliam Insurance Agency,Inc ,PH N NB . (413)737-3539 (413)7314M55 975 Elm Street ADDRE . glinzi®bsteafullarrL om INSU AFFORDINGOOV8RA08 NAIL/ West Springfield MA 01089 INSURER A: Western World Insurance Co INSURED INSURER a NGM Insurance Company 14788 Surge Home Concepts,LLC INSURER C: Nautilus Insurance Co. 88 So.Broad 8%Unit E8 INSURER D: Ohio Casualty Insurance Company 24074 INSURER E: Westfield MA 01M IN URER F: COVERAGES CERTIFICATE NUMBER: 1S-19 GL,XS,IM,SA 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. NOTVNTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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. I.TR TYPE OF INSURANCE POLICY NUMBER MMIOPNYM (MMIDDNYYYI LIMITS COMMERCIAL GENERAL LIABLITYEACH OCCURRENCE i 1,000,000 100,000 CLAM.MADE ©OCCUR 3156(ES 90MM11941 Is MED EXP one 5,000 A X $NO Ded Per Claim NPP8526290 12/21/2018 12/21/2019 PERSONAL 4 ADV INJURY i 1,000,000 GIBMAGGREGATE LIMITAPPLIES PER GENERALAGGREGATE 2,OOD,000 ICY PRO- LOC PRODUCTS•CCMPI1OPAGG S 11000,000 i OTHER: AUTOMOBILE LIABILITY denn i 1,000,000 ANYAUTO BODILY INJURY(PW Person) Is B OWNED SCHEDULED MIP9684G 05/04/2018 05/04/2019 BODILYINJURY(Per saddent) e AUTOS ONLYAUTOS HIRED x NON-OWNED AUTOS ONLY AUTOS ONLY e UMBRELLA UABHCLAIMSAIADE SUR EACH OCCURRENCE i 1,000,000 C EXCEsaLue AN061397 12/21/2018 12/21/2019 AGGREGATE 1,000,000 DEO I I RETENTION i i PER WORKERS COMPENSATION A R AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE [7 NIA to be Sent Separately E.L.EACH ACCIDENT i OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE (Mandatary In NH) Ir yea,deauibe under E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS below Leased Equipment $76,000 D INLAND MARINE BM0584S7311 12/22/2018 12/22/2019 Deductible $1,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached I more space Is required) Construction Management for Resldential Propeuties, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL Be DELIVERED IN Mm Fuller ACCORDANCE WITH THE POLICY PROVISIONS. 17 Mockingbird Lane AUTHORIZED REPRP.BBrITAT1Va Waffield MA 01085' ®1988.201$ACORD CORPORATION. Ali rfphts reserved. ACORD 25(2018103) The ACORD name and logo are registered marks of ACORD DATBIMMIDD/YYYY1 Co. CERTIFICATE OF LIABILITY INSURANCE 04/26/2019 THIS CERTIFICATEATTR OF INFORMATION ONLY AND CONFERS NO SGHTS UPON THE CERTIFICATE HOLDER. THIS NOTUA AFFIRMATIVELYE NEGATIVELY AMEND, EXTEND OR ALTER TIHE COVE CERTIFICATE DOE RAGE 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:and condltionsfof the policy,certain carte nDpo IlcOlesAmaY requlNSURire e�an endo—the PClrse(ment A statement on this certificate does not conterDrights to the the terms a certificate holder In lieu of such endorsement(s). Sonia Per PRODUCER A E' FAX PHONE 413 737-3539 BATES FULLAM INSURANCE AGENCY INC -MAIL s e batesfullam.com _ INSURE S AFFORDING OVERAGE NAIC9 975 ELM ST SU 25666 WEST SPRINGFIELD MA 01089 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA INSURER B: INSURED SURGE HOME CONCEPTS LLC INSURERC: INSURER D 66 SO BROAD ST UNIT E8 INSURERS: WESTFIELD MA 01085 INSURER P: COVERAGES CERTIFICATE NUMBER: 395313 REVISION NUMBER: HIS IS o CERTIFY TivS NOTWITHSTANDING ANYIREQUIREMENTNTERM OR CONDITION TION OF ANY CONTRACT OR OTHER DOCHAVE TO THE INSUREDNUMENT WITH ERESP CT TO WHICH THE poUCY PERIOD 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 PAPID CLAIMS. LlMlra INSR TYPE OF INSURANCE pQLICYNVMBER EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY S CLAIMS-MADE 0 OCCUR MED EXP An one rson f N/A PERSONAL&ADV INJURY $ GENERAL AGGREGATE S GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGO S POLICY❑JECOT• F�LOC i OTHER: N i AUTOMOBILE LIABILITY BODILY INJURY(par person) f ANYAUTO BODILY INJURY(per soddent) S ALL OWNED AUTODULED N//>, R P G i AUTOS NON-OWNED HIREDAUTOS AUTOS i EACH OCCURRENCE S UMBRELLAUAB OCCUR AGGREGATE f EXCESS LIAR CLAIMS-MADE N/A S DED RET NTION I X T WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN E.L EACH ACCIDENT i 500,00 ANYPROPRIETORtPARTNERIEXECUTIVE NIA WA NIA 6HUB7H82361618 12/21/2018 12/2112019 E L DISEASE•EA EMPLOYEE i 5001000 A OFFICERIMEMSEREXCLUDED9 (Mandatory In NH) E.L.DISEASE•POUCY LIMIT S 500,000 Ites describe under D SG�RIPTION OF OP RATIONS below NIA DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(ACORD fol,Add{Uonal Remarks Schedule,may be attached K more apace Is required) is Workers,ms for enefits to employees Instatesother thansachusetts Massachus employees f the Insured hires,or has.Pursuant to Enhirred hose employees outside of Massacdorsement WC 20 03 06 B,no husettsven to pay as This certificate of Insur mate of insuthe rance)!ICTIn hefstatus of his coverage can eon the date that this fimote was nitoredissued daily by accessing thless the e Proon date on the of of Coverage-Coverove ige Verification e issue date of h Search tool at www.moss.gov/lwd/workers-compensaUonlinvesugauons/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXP NE W TH THE POLICY THEREOF,PROVISIONS, NOTICE WILL BE DELIVERED IN ACCORD Kim Fuller 17 Mockingbird Lane AUTHORIZED REPRESENTATIVE Westfield MA 01085 c Daniel►el M.C��y,CPCU,Vice Preside11 nt—Residual Market—WCRIBMA ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD