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36-031 (3) 81 REDFORD DR BP-2020-0378 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36-031 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-2020-0378 Project# JS-2020-000649 Est. Cost: $11600.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEXTON ROOFING CO 118239 Lot Size(sq. ft.): 12980.88 Owner: KATHLEEN S KOCHAPSKI Zoning: Applicant. SEXTON ROOFING CO AT. 81 REDFORD DR Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 WC HOLYOKEMA01041 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: FeeType: 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 E�--11 , -- I --:: ' ( I ' t ` ) Department use only City of Nort amp on �'" Sfatus of ermit: �. Building De art ntSEP 2 3 Cub Cu Driveway Permit f212 Main,Stre t ?U? S er/S ptic Availability i + Room 100 W ter ell Availability Northampton, Mfgull n,rvr INSaF�T o Se s of Structural Plans TM phone 413-587-1240 FazF3-5 'i'- g2nAo,;. f�,Usit Plans Mer Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR(fTWO 2FAMILY DWELLING SECTION 1 -SITE INFORMATION �V -387 1.1 _Property Address: This section to be completed by office 2^ -0 2 Map�— Lot � 3/ Unit ,/ Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 0 MAI Name(Print Current Mailing Address: o, 4 Telephone Signature 2 Authorized Agent: O(�* t J r •C c (1 C� �—� Narne#rint rCurrent Mailing Address: /� C. � t6 - a� � � 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 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee �} 4. Mechanical(HVAC)v 5. Fire Protection 6. Total=(1 +2+3+4+5) dQ – Check Number 5^ This Section For Official Use Only Building Permit Number: Date Issued: Signature: ZJ- zo q Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) w Cx"-�i� w4 iU!t..A�'.i"..a'� i�.?�" '!3 5r{`:s...f - ♦..e. .�',G. i i�$4:.{( i,•4.«` x','16 L. 'Y-SI�� '„r :ti'}.t. c ice�� -'ns�rs�w+r.nM•t•+•-+a�aw••..,•w„irr4• a..•w__ .,,y,a,-.r.,..re.. .c..r..rµ.ouyur b.Yr.rw.wpv,.new �;'• 41 4 4 i�� ! .til ,...... �... .... .. ...w+ ._ '}Li S .• • xis. _ .+...-.w j` yy , EI Y.i'il�. ., / •.. �- 1�f2{ii,�l}t4� ;,�^�";1,��.mit' �'•'..•�' - !. r, , ` t - "I i J r.�t ? +'lt`'�� a�C;t �2 °;} ,�, w1' ._,�, r. `�s �;' �..:t�tr,l,G �t.`"; , ,•1 a , r•:'S�4'1,.M�'.?!x'>:aWr � �,�>" ;t rp�e'' .•.fine-• wr , � �, #+yt 4 IV 'Ai all T d{:fit°� tk-'1;1.G - 'ti 4. {3.'. i'P ,; 1-«.- Y, •r •. _ 3 Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This olumn to be tilled in by B ding Department Lot Size Frontage Setbacks Front l =� Side L•= R= L: R �7 { Rear �-- Building Height Bldg. Square Footage % i Open Space Footage % I (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Fi6ding ever been issued for/on the site? NO Q DONT KNOW/ O YES IF YES, date issued: IF YES: Was the permit record at the Registry of Deeds? NO Q DON KNOW 0 YES O IF YES: enter Book / Page at%1 or Document # B. Does the site contain a bro�k, body of water or wetlands? NO O DON7`�(NOW O YES O IF YES, has a permit b n or need to be obtained from the Conservation Commi ion? Needs to be obtaine O Obtained 0 , Date Issued: i r C. Do any signs exist onihe property? YES O NO O ./ ................ IF YES, describe stye, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O N O 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 O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aaalicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) El Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[d] Brief Description of Proposed 1 / Work: 01G /4 yt ✓2 �Gi r� lad Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa._I_f 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 const n. imensions e. Number of stories? I. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. TT Ma check Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of w ands? Yes No. Is construch within 100 yr. floodplain Yes No j. Depth of basement or cell oor below finished grade k. Will building confo o 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 JK sp c as Owner of the subject propbrfy o hereby au oriz _1J to act on y be alf, in all matters relative to work autholized by this buildind permitpplication. C t` Signature of Owner Date (4I. A/ O� ( as Owner/Authorized Agent hereby declare that the s atemen and information on the regoing application are true and accurate,to the best of my knowledge and belief. Sign under the in nd penalties of perjury. Prin ame Signature of Owner/Agent Dat SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: 1 Not Ap9plica(ble ❑ Name of License Holder / q� C� License Number ValbUA Address Expiration Date d 7S Signature Telephone 9.Re istered Home Improvement Contractor: Not Applicable ❑ CqMpany Name Registration Number , (5 ") _/y _z/ Address J Expiration Date Telephone_.5� /23 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 ! a C . ;jtu "+" }Lt:TJt.., 'J"F�'v 0411.j . . * t ft}I,3{,fl 14j;q,X'L" �'�r::� !i,t�:j}Y".3t �IC` i�S3' l�i::i �tl� 'i+'' �,(1a�� 2i i } f. , `.. . s':r c'�. . :�i:�!«'.�Ch��l.�;,+ ".v;+ a�;!;{`Sp�i'.'._ '.'Es:lt+?+l.�.f dh ': � dv. 1•:..� <«.... _.. ,_ .__ � .. • '! `Fy r �'• ' ♦ j Wit.. `. `� y'l1. --�. .� 'Y" _ r: _ �� ,. ..+,. �. -*�, i y ,'�'�'.'•�,a'� "�` e+ Ii'.'. s�tlf�Yv6,; f.'..,j 1�;i••1�. � !i_ ��,, City of Northampton Massachusetts : DEPARMINT OF BMLDZAG ZNSPECTZCNS 212 Main Street • Municipal Building �J, Northampton, MA 01060 rf 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 he registered Type of Work: Est. Cost: 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 he reb apply for a buildi rmit as the agent of the owner: 22,;Z.- y a e 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 I.x,Y -J.'!Zajr clj•, -r!i.rf � _,. 7. .a.:j `pd .. .. .1:1.>.•- 'i.Ji:Ar!: fit.t;iLY I -` -'''.r't tr�t{,�'7 1•.."� " ..�. .v.jr`t:: +`'i`• F,F '`: .7C':., `� t '.' "•i'S�r•r"s+' l,r ,r,?',.,' 'rr{ 7,r R,� 1 e;,t d�, �, ; � k tf J, t�}, !, a , 4 } '1.;r+ x s•' , + ` / 1. 4U, _ - ... � ,�.� '�'�. Fg�'}it �f�4 '!`ii .�2'i. .�x. :'�?2. f. ;{�v },� .+; f.,t°�#'1".1 V•, .�, ,�.•' f ,, c r,` `y tt (( M 4j ''♦ e' r M f� CNovr: ,. �.' h. � '+ 7;` J4 i�.'.f If.♦ . �q. ,. .,�''J'.fi.�C 1i 1l: 7 .... %� ,'; �?.�' ..���r�J''` l IS '`-t + ' . ir'' K.��'r ...K -M.l...,t,;' 'Y {;�«�..'•.iFi.. P. :'r. li�{'. •:'�� �1����#�.,�.'f'. }'y•�,Y.'. 'i tri�::'�,3. `` p�Sw ._. 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"l. si ... :?t`:_.?�' •J7"1�,f1 �- l:'ier(> t.�.'i.',:!!f. f•; xry�" . .. -!" f., Vropaga[- SEXTON ROOFING AND SIDING INC. (413) 534-1234 P.O. Box 6327 FAX (413) 539-9906 It e9!t Holyoke, MA 01041 sextonroofing@hotmal{.com CT HIC#0605383 MA HIC#118239 www.sextonroofing.com Since 1985 SUBMITTEDTo �a'r(`i h t)lC/ PHONE DATE cf STREET 2�4 V/t JOB NAME CITY STATE ZIPCODE !V° (. cQ JOB LOCATION Proposal to furnish and install the follow' EMAIL J Re Roof 3 Tear-Off l!' Main House *-Garage ;J Shed Complete Roof Preparation j ,!tome exterior to be protected by tarps J Shrubs,landscaping,trees to be protected /-Entire existing roofing material to be removed to existing decking,Including flashing,etc. J Site to be cleaned everyday with roll magnet debris removed at project completion Deteriorated existing decking replaced at$—_per sheet J lnst�ll all new decking/type: hit Brown metal drip edge installed at eaves and rakes U F-8 J F-5 J Rake Edge �N'ew flashing will be installed where necessary(see Special Requirements) )3' Install new pipe boot flashing J Bathroom Exhaust Vent -q'—Reflash chimney with new lead _4"�We shall acquire all appropriate permits etc.for all roofing work Co fete Roofing System eak Barrier installed at all eaves to protect from ice dams(and meet codes in the north) -1 3' d ; I.J/!teak Barrier installed at valleys,around penetrations and chimneys to protect critical areas Install Roof Deck Underlayment on remainder of roof with Synthetic Felt Shingles 2/1 O -1 GAF J CertainTeed Tamko / U 30 year r :damLifetime Color stall Attic ventilation system Cap over Ridge Vent Roof Louvers 4-c mu i %le"'guaranteed y Options our workmanship for 15 full years r0P05¢her by to furnish m rlal an bor-comp ete in accordance with the above specifications,for the sum of: +r dollars($ PAYMENT TO BEE AS FO OWS v All Material is guaranteed to be as specified. All work to be completed in a workmanlike manner Authorized aceordingtostandardpractices.Anyalterationordeviationfromabovespecificationsinvolvingextracosts will be without notice,and will become an extra charge over and above the estimate. Slgnatur Not responsible for water damage or damage to the house during stripping of roof during construction. Owner to pay responsible legal fees for non-payment and applicable interest of 11/2%per month- Note:This proposal may be Withdrawn by us it not accepted within day rEworkas Of Prop05al-The above prices,specifications and conditions Signature ctory and are hereby accepted.You are authorized to do the ecified.Payment will be made as outlined above.tance Signature C / ATTENTION HOMEOWNERS:Please cover all personal belongings in the attic,garage or storage areas due to the possibility of roofing debris or dust coming in through the cracks of the wood. Sexton Roofing and Siding will not be responsible for debris or dust in the attic or storage areas. City of Northampton Massachusetts �S H q� DEPARTMENT OF BUILDING INSPECTIONS �y r. m 212 Main Street •Municipal Building Jti 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: (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: i')5SA c(O-V 9-fl) ' (Company Name and Address) Signatu a 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. c : J t, f, a f`'•�?XtJ- %+ a'. i)�x !�' i'fi}lff�%1. j�F Z 'd iS�}1i - r r e,.1i�F x(j ,'lei � J � t C � ,�;� 'j;,' ') �.+,6:• 'i"v1,:� •''��t13.►�f�� �r=.S,' t '. .5C` �r.'...s'.i i a ro �, `.•P,. ^ AIX,, %aJ ,:K `=c:, a: 13�+� `; LSet y►'• t' r dRj: i. oJ.t.U ) •�• r ^s`x'.:'�t.l.C�'i;tiy� Fg��{ell,.�1la,_ 'i+..,fl"C.'j, � . �jR�� �ft,NS� ..C��it''�i ei.:7' ,��.� :a�3 �f... .. f .•:a��i"+ti,.3: ..-� ��! N d..,--� !��.^ .��}ei a .� J ,. '.}�'L.!a � {,j-it s.fir :i �t.*',?..{•� ,s:. o r,,:i, �' ��tl�'.�. , .s e-.�:.p�rt. F ,�. �,.� bny, er ,,�. yrL .0 p�...w .a•.a.c ;,.y 070 'g'."7C�.- .. e � w 4 e ..ria .. :: '.''1'i'j+1; f / �� ^�•"b . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizatiorOndividual)_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). 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_l;Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8.❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurancecomp.insurance. 9. !' Building addition required] S.n We are a corporation and its 10.Li Electrical repairs or additions 3.I'? I am a homeowner doing all work officers have exercised their 11.C 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_XRoof repairs employees.[no workers' 13. i Other comp.insurance required.] -- --- *:>n}applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information- 03, lomeowners who submit this affidavit indicating they are doing,all work and then hire outside contractors most submit a new affidavit indicating such. Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employem if the sub contractors- have employees,they most provide their workers�com�.policy number- - _ am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Travelers Property Casualty Company of America Insurance Company Name:__! us-oG078982-1 9 _ -_ -- -- - M/04/2020 -- Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address:_.( _ 4va City/State/Zip: uA 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 der the pains and penalties of perjury that the information provided above is true and correct - I Date: Print Name: IF1/���`Tf'" c Cit.-> Phone#: c/ / 3 . -e,i�` I ;Z. a 4' 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): I.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person- Phone#: h:. !'holt x, { ..A. ! ♦Ptf [ - r !•. 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[.a: t4�fi►';`l' 1a' rL:3 i•" '� a �,g' � �1 •i >ti t`4 �}k�l1�F*L"a� •r4113t d .. :,�ycltf' j;'� �2Ltt,.« �' t•:► l Y,cilCltSc�;��,1!',:.��, fil :.',.�,, SEXTO-2 OP IQ- CERTIFICATE :CERTIFICATE OF LIABILITYINSURANCE DATEfUWDDrrM) 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 Ormsby Insurance Agency,Inc. NAxIE _ 698 Westfield St PO Box 718 PHONE 413-737-0300 - 413-737-0617 West Springfield,MA 01090 -(AIC.N � N°.� -- _..!ON�k — ClRIbtTIS7C Eric Dembinske nnot:Fss: __ e�ORT1S;byNlS.cprtl -. tNSU"E RAFFORDINGC�_....-.. INSURERA Cobrlr Insurance Co.INSURED — exton Roofing 8 Siding,Inc. �NsuRatLs FIS IItBUranCE Holyoke,MA 27 01041 INSUREItc i— WSURERO• INSURER E• - INSURERF: -_ -- - - — - - 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 DOCUMEN I 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. MR - -r- --— - --- —-- TYPE OFINSURANCESIIBR POLICY NUMB9t POLICY EFF �POUCY EXP ---__.---- _------ - A X COMMERCIAL GENERAL LIABYJTY ' LIMPS EACIi occuRRENCE CLnIMsM1,000,000 ADE X�OCCUR 101GL002159903 0612512019 06720/2020 D ToRartED s — - '0 - -- - VED EXP(AmI ons s, s 1,�, Cm AGGRFQATE UNIT APPLIES PER: -AGGREGATE 2, ,POLICY POLICY[ ]JECT [ I L� oTHFJR: I ►RootlCTs-coL�ioP Alit s $000,000 B AUTOMOBILE UAORM COMBINED SINGLE LAW ---- s- 1,000, 00 OWNED 05/15/2019 051151202p FV2V6561 BODILY IWl1RYjPar_�ltyplt AUTOS ONLY L SCHEDULEDAIIrOS► Ep �4BODILY INJURY_P�isK---_.AUTOS ONLY AUTOS ONLY PROPER $ 4)VO REL1rJIRB OCCUR 1� EACH_OCCl1fCE s EXCESS LIAB CLAIMS MADE _RETENTIONS PEROTHRIETOWPARTNER/EXECUnyE YIN OBE SENT SEPERATELY - - OFFICERIMEM tER EXCLUDED? N/A E.L.EACH ACCIDENT (Mandatary W NH) If yes,describe under EL DISEASE-EA - DESCRIPTION OF OPERATIONS below - L DISEASE-POLICY LIMIT S i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it aaiintspace 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(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM1DD)YYYY) 0611012019 ALSGERTIFICATE 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 terns 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 ndorsemen s.PRODUCER CONTACT NAME: ORMSBY INS AGCY PHONE FAX PO BOX 718 (A/C,No,Ext): (A/C,No): EMAIL WEST SPRINGFIELD,MA 01090 ADDRESS: 286TF INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF AMER ICA SEXTON ROOFING&SIDING INC: INSURER B: INSURER C- PO INSURER D: 1�BOX 6327 HOLYOKE,MA 01041 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. W SR CkDDBRPOLICY EFF DATE POLICY EAP DATE LTR TYPE OF INSURANCE INSR WVO POLICY NUMBER (NM1DIMYYYY) (MRSMYYYY) UMITS GENERAL LIABILITY EACH OCCURRENCE s COMMERCIAL GENERAL LIABILITY ; AMAGE TO RENTED 1 s CLAIMS MADE OCCUR. REMISES(Ea occurrence) ED EXP(Arty one person) $ GEN'L AGGREGATE LIMIT APPLIES PER: ERSONAL&ADV INJURY $ ENERAL AGGREGATE s POLICY �PROJECT LOC RODUCTS-COMP/OP AGG s AUTOMOBILE LIABILITY OMBINED SINGLE y ANY AUTO IMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY s SCHEDULE AUTOS Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS Per accident) PROPERTY DAMAGE s Per accident) UMBRELLA LIAB B OCCUR EACH OCCURRENCE s EXCESS UAB CLAIMS-MADE AGGREGATE s DEDUCTIBLE s RETENTION S s A WORKER'S COMPENSATION ANDWCSTATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-OG078982-19 06/04/2019 06/04!2020 X LIMITS ANY PROPERITORIPXCLUDEDXECUTIVL El N/A E.L EACH ACCIDENT .$ 1,000,000 Of EXCLUDED" (__j (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS blow E.L DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIMS1LOCA7IONS/VEHICLES/RESTRICTK)t4&SPEC14L ITEMS TEBS REPLACES ANY PRIOR CERTIFICATE ISSUED TO TME CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE INSUREDS MA WORKERS COMPENSATION POLICY AND I73 LDM D OTHER STATES ENDORSEMENT TT AU7}IMEMS THE PAYMENT OF BENEFITS FOR CLAIMS MADE BY THE INSUREDS MA EMPLOYEES IN STATES OTHM THAN MA NO ALTMORIZATION IS GIVEN TO PAY CI ADDIS FOR BENEFTIS IN STATES OTHER THAN MA IF THE INSURED 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 REPRESENT J ..t ACORD 25(2010[05) The ACORD name and logo are registered marks of ACORD 9988-2010 ACORD CORPORATION. All rights reserved. The Comtnonr.•ealtlr of:Vus.vachusettc Department(?f Itrductrial Accide»ts I Cotrgress Street,Sttite 100 Bostotr, .11.4 02114-2017 y' tt wW trrass,sot/dia �i orkers'Compensation Insurance-affidavit:General Businesses. Applicant Information 10 BE F1 LED V,ITti 1 I I L PER�irl rl\t;:�CTH012IT1. Yiease Yrint I_e�ibly Business/Organization Name:MNP CONSTRUCTION INC .Address:45 EXCAHNGE ST f ityistate/Zim MILFORD,MA. 01757 _ Phone#:508-498-8870 - — Are you an employer?Check the appropriate box: Business Ty (required): -- — 1•Q i am a employer with 5 __--employees(full and 5• ❑Retail 2.❑ or part-time 1.* 6. Restaurant.gar;[;acing Establishment I am a sole proprietor or partnership and have no employees working for me in any capacity. 7• ❑O#3ice and-or Sales(incl.real estate,auto.etc.) [No workers'comp,insurance required] S. ❑Non-profit ,.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have no employees.['pro workers'comp.insurance required)*' 10.❑Manufacturing i.E3 We are a non-profit organization,staffed b_r volunteers, I I-El Health Care with no employees.[No workers'comp,insurance req.] 12.[Z]Other CONTRACTOR 'AM applica i that checks tk)X#1 must also till cwt the motion betms stxnsmg[[tele Markers'campettsation — ' ""the corpcxate affacrs tt n c exempted themsel,es•but the corporation has other employees,a workers c policy mfomiaucu mWiz ton,Jxwld check,box;i compensation policy is requtred and such an i am an emplot er that is providing workers compensation insurance or f ►n►'employees. Below is thepolicy 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.#1K709706 - 11/16/2019 Attach a copy of the workers'compensation policy declaration page(showing the polic- , number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition oferiminal penaltic,ofa fine up to S 1,500.00 and:or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDLR and a fine of up to$250.00 a da% against the violator. Be advised that a copy fthis statement may be forwarded to the Office of Imestigations ofthe DIA for insurance coverage verification. 1 do herebt c "f �, Iiec of perjure�Ihallke information at ided abore is true and coerce t. Si-nature: f L f ,/ f! .. Date:pri 3 Phone 978-403-5942 Official use onit: Do not write in thtc area,to be completed ln•vitt•or town nffr(•ia1. City or Tow n:_ PermitlLicense# Issuing Authorit- (circle one): I.Board of Health 2. Building-Department 3.Citv;Town Clerk 1. Licensing Board 5.Selectmen's Office 6.Other •Contact Person: Phone# cwsts m:; ^ov'dia AC RD`" �~ CERTIFICATE OF LIABILITY INSURANCE DATE�AiN.'Mr"yYI THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THF CERTIFICATE HOLDE-"101R THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGEAFFORDED BY THE POLICIES BELOW. THP5 CERTIFICAT] OF IN DOES NOT CONSTITUTE A CONTRACT HETtVEEN THE ISSUING INSURER{S), AUTHOfi1LED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICgTI HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pOhcy(ies)must be endorsed. !f SUBROGATION IS LVAiVED,subject to the terms and condi[ioru of the policy,certain policies may require an endorsement. A Statement on this certificate does not confer right-,to the certificate holder in lieu Of such endorsemeni(s). PRODUCF32 gh ONE FAMILY INSURANCE AGENCY LLC coNTACT — NAME: Art Calvlllo A7C,Npg E21Y. (978)403-5942 1 FAX .___...... I-1-14SURIER E53_aC2IViA01ZSeQ Yd}700.COri1 '-- LL��No1- 1 Main St Suite 15 -- Lunenburg - a!skU-R MDPT-FORI)NGCOVE-RAGE f - MA 01462 HARTFORD UNIJERWRfTERS INSCO_NsuRfD - — _ HARTFORD-- 30104 MNP CONSTRUCTION INC "�ll- --___ _F c45 EXCHANGE ST APT 3EMILFORD uRllt$: - - COVERAGES MA 01757 INsuRERF: -- ---- "— — � -- CERTIFICATE NUMBER: 401083 THIS is TO CERTIFY HSTA THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAf4REVISION D ABOVEFjjjj- OR�_POLICY PERI INDICATED. NOTVWTHSTANDIVG ANY REQUIREMENT, CERTIFICATE MAY BE ISSUED OP,MAY PERTAIN, THE INSURANCECONDITIONTERM OR OF BY TIANY KE pp�ES DESCRIBED HEREIN SCT OR OTHER DOCUMENT ITH RE SPECT TO To 7 RICH RTS D EX=SiONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE` >E BEEN THE BY PAID CLAIMS_ CTR. TYPE OFNSURANCE --—�A - —- f ---- POLICY NUMBER i .PRICY EFF ! POLICY IXP ----___------------ CCMTdERCiAL GENERALLIABILITY ° --�"---- i 1 EAC JJ CLA>^.:S►.IADE P. ' j YOCCURR7J�C`Dam LIM!5 ��. t! N/A ! I 1 MED ENP Wcy or`uers_n) — ;GEN'L AGGREGATE LRdrrA.-PLIES PFr I.W FPERSONAL 3 ADV URY _J 5 —_ _ ; ''O�y. i 1PERQ LOC ' I GE\�cRAt AGGREGJSTE' !5 I Orn—M I - t! PRODUCTS-COMPIOP AGG S LAUTOMOBILELIASnjTY +ANY AUTOCO:dBINED SIKGLE LIMIT SCHEALL AUTOS 'ED -1 AilTE�ED N/A Y INRI EY(Per persnf) AUi OS + i MLIIURY(Per acc;Ca HIREDF i AUTOS L►ROPIIiTYDAfkAGE----! � I I s F ELLA LIA3• t `— !_ I OCCUR + 1 S SS LdAB CtJ11TJ5-AAApE; — N/A j t J=C+1_-OCCt�RRENCE S I RETEr R IONSt i11AGGREGATECOMEMSATlON lYERS'LIA31UTy 1 �[ ($ ETORIP?;RTNER/EXECVrtVc ��Y)—�M��i� , I 1 x 5TAN7E.-41EREXCLUOcD? LTy/1�HIA i p/jL IMandzituy to NT1) _—��'� 6S6OUB1K70970618 11/16f2018I11/1612019 E'1'F� -__ S 1,000,000 „Yes.describe unser i j iDESCRIPTION OFOPERATIONS be!,. i ElD+sEASE-EAEmp OYES S 1,000,000 I I ELLkSEASE-POLICyLBYT i 5 1,000,000 ( I N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 107,Additional Remarks seheduie. ' I spas is requlrcd) Workers Compensation benefits vriH be paid Lo Massachusetts employees only_P rsuantt l Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those emPlOYees outside of Massachusetts_ This certificate Of insurance snows the policy in force on the date that this certificate was issued{unless the expiration date on the above f Sear date Of this certificate of insurance)- The status of this coverage can be monitored daily by 2ccessing the Proof of Coverage- SearCh tool at www .MBSS_gov/lwdlworkers-com°ensationfnvesiiga6onaL Policy Precedes 6.e g Coverage Verification CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCR)BED POLICIES BE CANCELLED BEFORE SEXTON ROOFING & SIDING INC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED (N 102 PINE ST ACCORDANCE WITH THE POLICY PROV151DNS- AUTHORIZED REpRESE&TATI VE HOLYOKE , .-a A 1A 01040 ( `� ':r- Daniel M_CrDiY}ey,CPCU,Vice Presiden(-Residual Market-WCR;BtrtA �ACORD�25(201�4101) ©9988,2074 ACORD CORAORATIpN. Aft rights reserved. The ACORD name and iOgo are registered marks o#ACORD ti 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 -, R� -- Registration: 118239 "f "` r +;� Expiration: 02/14/2021 P.O.BOX 6327 wi HOLYOKE,MA 01041 SCA 1 0 _ - Update Address and Return Card. OF CONNECTICUT EVERETT J SEXTON SR HOME IMPROVEMENT CONTRACTOR PO SOX 6327 EVERETT J SEXTON SR HOLYOKE,MA 01041 102 Pine St HOLYOKE,MA 01040-2411 SEXTON ROOFING&_SIDING CO CIC-1. REG—NO. —ECTIVL EXPIRES HIC.0605383 /01/2018 11/30/2019 SIGNED Commonwealth a�e hof Massachusetts Division of Professional Lxensure Board of Budding Regulations and Standards Construction Supervisor Spec,ai:,i CSSL-099689 Expires: 10/05/2019 EVERETT J SEXTON PO BOX 6377 HOLYOKE MA 01041 Commissioner V'r`"