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30A-043 (3) 19 LEXINGTON AVE BP-2020-0431 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:30A-043 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-2020-0431 Project# JS-2020-000736 Est.Cost: $6300.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sa.ft.): 10410.84Owner: VON HARVEY SARAH Zoning: URB(100)/ Applicant: SEXTON ROOFING CO AT. 19 LEXINGTON AVE Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 WC HOLYOKEMA01041 ISSUED ON.10/9/2019 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 10/9/2019 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner r Department use only City of Naafi amptop Status of Permit: 'f=� Building Dep t ' Curb Cut/Driveway Permit . 212 Main street -' V �U Sewer/Septic Availability �1 RQOm 100 W er/Well Availability i �1r� Northampton, MA`tCIb60 3 T Sets of Structural Plans �. phone 413-587-�1240Fax 413-587- PI ttSite Plans her Specify APPLICATION TO CONSTRUCT,ALTER HFl"Rr�JB+9R D MOLISH A ONE OR TWO FAMILY DWELLING P- SECTION 1 -SITE INFORMATION au--Ly 1.1 Property Address: This section to be completed by office Map(3c/ c,( A Lot 1 _Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.&Owner of/Record:}, ze, k'/,q 7 / /l r "/ `7 X l�Z�`/' l "� N ie(Print) Current Mailing Address:,-j!/ ? 4 Telephone Signature 2a Authorized A ent: etv 0/ _� G Name(P /current Mailing Address: gnatu 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) �a 5. Fire Protection 6. Total =0 +2+ 3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: C Signature: �0 1 �� Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) '+1!'%��3Y �t`3;. .dd.'.P fl��.•rvf^'�1«...�,' �..t1`,r�,'.� �'?!�,ww"'.?�'i�'��.:1"4 ��`�? '�sS.'+''.m�P�l'l.r.d.`+':;�� ' ....,,.... .,...•�.ydr«w►. ... ,a.w,•.w...:x.w.• ,..-,.w...•..�.-w+wrw-°++wean.rw�.�-.wsa..�\.r.s+inrVw.se..r..w...•,.r.re+..,.r...y�ir...M+w_rsM w.\rr+awaw++W`w'..wwws+•w.wtia•. ..... w...,:w»..... r.,,. r.a»....,.. -.w,• +..c+...tw•,�r.�.s�+'NMMrw•'+�rw-+..+`l""aq"�1}r'"":m.:v...y..�te+o�rx..�r.w.»......_.,,, w,. , ....•,!/9r!'E aL•� Z;"`•�. '�.tr�i"ettGO.lsj1J':.�. - 'G-' _ "^,�'_.. _ 17 a},,,E .,. .__.....:' .. .._.. ..... _.. ._._... se.. .,.......t, ...awe+. I It t'. x , � P r ' �i a�:t F�:��'�'f a�..L.ttt(•i,,Si11 r 1wA.� :.:`,w ..�►.'��:w •ti.r�i.tiys,j,, 4 4 r ..i ' t... 1�:..W P. IN y;.� 1 P 1 P y � ;.� �9 ��° +` 't 6..Jf.�t..x . [ y�+y.. tp i 1 i � "s,: 4}�`.o'-"'�1 y..•; � +�L ! ��Y. � 1•'3 �f,.a at'.wA-• 4;;.�-w1e�:�,.i!i�S:.w..... .. .. ; .i.J $Fe •'"�.•: �, * r'/'4P ..l+..ti..� �o��. L"r.�} 4 l,',Rr•~, iS. � .,;„�.. L, )� "�'.v;��yl1 M fi'..G ...r .n +` C 5 t Cu' � 1 •!�. { ,.yt. j I SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) EJ Roofing ©� Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding[p] Other[O] Brief Description of Proposed Work: 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 existina housing, complete the following: a. Use of building : One Fami Two Family Other b. Number of rooms in each family it: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new constructio Dimensions e. Number of stories? f. Method of heating? Fireplaces oodstoves Number of each g. Energy Conservation Compliance. sscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is struction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor b w finished grade k. Will building conform to th uilding and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a WNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ffy f .64 f J�,CIM41 as Owner of the subject prope hereby authorize a-'V0 d ( > r to act on my behalf, in all matters relative to work autho zed by this buildingp6 app ication. �r Signature of Owner at I, �� i ! 12� as Owner/Authorized Agent hereby declare that the statements a d information on the fo oing application are true and accurate,to the best of my knowledge and belief. Sig under the pains and nalties of perjury. PrAt N Mel., G Sign of Owner/Agent Date . _ . .... .. , �,,,, t � � t i' ..1�' r' r;�'. b.-� d3. R ' ;;! Cl :i�h' ..rt::` ,. t+i' �t. _ a ^! ..t,`��.{� .. a._ .•F. • . . i . .. r i� �� dv'� .u. . x, ,�vf.9. y�r r' ::11'', •.�. a •'. x. ....._... ... ... . . . ...., __.. ..._ _.. .._. _ . . �. .. P. -i. � r '�r � .. � .. .. ... ... - -.. ...r. ... moi..... a.. .... _. .. .. .. ...-.r - -.a._ ... ....r..... .. ... ... .. .. � ' \� /. M ., yi. .» .. � _ � '!.. -���'.�`ct L'.Ca is1��f 4� •t1,[ ;t.i..'-3t�i1-. .. '�.... 1,� � . � f 5 ,`f .l' � i" �e.��'@ttr?t .:yq.VI ".l„a��rL, � i ' i t . 4 —.k a: �. _ r r: _ �' � _ r . �'.���' t y 7 }'�'Z Li •ta+l. •t t;. 'a r;�i�e,i ,�(',~ ,•w!eY��r ' « ���Z�'r .. a.'+.li^ :r.F.. ,,tt. ;+.t l`. - ......... ,.., ..................... ....,,.,,..„-,., ..-�..w.. �.+.-. � r t --__ .J Vit.1l:; �:_ �ti - .. _, __ .._� .._^n , _. �".. .-..1. .. �. ..,. .?) is °ti t•4 .4 �..�:... 7t��f�T'-�y'`yl� - , i t SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: ✓� c'� Licensee(Number �� c1 �L/ --5,— –) Ad res xpiration Date Signature Telep onh e b 9.AnIstered Home improvement Contracto . Not Applicable ❑ 1 Z/9 r) Commrw Name J (Registration Number AdFbr ss Expiration Date d Telephoney� 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....... Ef---. No...... ❑ City of Northampton Massachusetts Z�? '<<� D"ARMENT OF BUILDING I WECTZCKS -. x yJ �" 212 Main Street • Municipal Building �, O Northampton, NA 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"reconstnrction, 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 entity must be 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 by apply for a building permit as the agent of the owner: to 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 . l r t � .._.,.,.,,..ww+...,..,,...._ .-.�..w ..+w.-w.... _.... .. ..•,...•,.,.....•. ,.. ,.. s.-.w-,+wrn,.w......e...«., .:... "a ..._.+w.r,•,..., .........•..., w,•...�.w..,.»....rr,..... t' ,-'g_!, •�• �e; s, .. , r'•3�-'' �' �•La, r�y'r 7;t! {"g�X qPs♦iliF� '<; 't6; 'TP.',etg.` Ley.. r :ltr;', .. . t. t •.,,,'f�,•'��... . ,........w..x.,...^.:I.y.,....� «. ... R .,,.y+w-a�w..,......,.g.w...,+li.,.,.-r.. ..... ...-,o. ,..r..•.. .,. .,.,.,.rA .,. ., ,.....,. ,,,. " • � r to �11.�}i /�Yt�.�'{.1{ ... tt,..�� ea. e�: .,.t.�{'f.��s�• �ap:t; ��� � iT tr :i. +- -�"4 it'i'�'1 fY t�,f_iiGr•1�'Q gid•,si. 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(yit't'i�:i?t.U1. ,se+r,j•�L!;A,},r,3;.i#rti{!!i{�!,a-g.:b,-.4'.0.I.i::��}f3�1 t'_{•kt. .�'*'i.. - ;:ti: •4�'.:•n•• j �.n�,;., �' } a 'i.'"gFs i.g � �t,'�IsV 4•_ � •'"r b ". Y A��, � •rt'•'"{ •t1. ,•>.,, .� „�... r i�t:l{'"Fs'.'':a�.'. i �� "�g+Ft .�!} ,i. "«1.a •�•.''-1 :tt� _a,. t p N34J if.S t. !` ' �'•, 4 1` -. ' ��.:... Cj r.; {•i;s 1,.f,3,• #fy i.-,0}'N tcs :'j,l,'{".if, 1}• .�'�iW ,1'Y.t .-� ..l� l..s.:gz ;tt ..t J,}.1,4,'•l.�+��.yJ .urY . _..i , t''��"'.•.. i. --'aS•�,. ".i; ;�;, :t{ •t'n.-.3.is '.g'vf e�' (,t ;:ri!"!. .t R.tC rt* s:> �:.£: _'. 'i t�liw s.. (k.. oj. tA•'it1:: .tA'•t`PF,(T> l' •° t» .t �;.�. .. .;: t{;•' gf ^Ms!):",Eti T}''+�r}:. ;ia""i{' ' ,�t y:r✓ Fi.,P. _i ..:•` :i' "..; +;_St:'. ,k; -- '�bs2tii�2;C,t}I r.Ta�!{c ��y?..�rt 'J��e•c.�s ��.�' � r�d�1-rC�sll�e:•:IFti>-aSYt�%Itrk�,'�.r12!'s, •d'1"Y9. �`'oJz' 'i,F' '»{ r �' S r �•tii"�b'7C.�1'2t {. rf + .IN4, s _„•' �?• • i City of Northampton ria s Massachusetts aQ' q w DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street *Municipal Building yeti 7 �f 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: (Pleade print house numbier 9nd 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) Signature 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. Proposal SEXTON ROOFING AND SIDING INC www.sextonroofiniz.com 4"yo MASTER Setting the Standard 09C& P.O. Box 6327 p. 413.534.1234 Holyoke, MA 01041 L 413.539.9906 MA HIC# 118239 sextonroofin hotmail.com SUBMITTED TO Sarah Von Harvey PHONE DATE 9/12/19 STREET 19 Lexington Ave JOB NAME CITY,STATE,ZIP Northampton,Ma. JOB LOCATION SEXTON ROOFING HEREBY SUBMITS SPECIFICATIONS AND ESTIMATES FOR: 1) Strip and remove existing shingles and dispose of in proper landfill. 2) Inspect roofing deck 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 on eaves(6'),vent stacks,in valleys,chimney,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) Install new cap over ridge vent. 11) Supply manufactures Lifetime warranty and SRC 15 yr.workmanship warranty. We Propose hereby to furnish material and labor—complete in accordance with the above specifications,for the amount of Six Thousand Three Hundred Dollars($6,300.00)Payments to be made as follows:Due in full upon completion All Material is guaranteed to be as specified. All work to be completed in a Authorized workmanlike manner according to standard practices. Any alteration or deviation signature from above specifications involving extra costs will be executed only upon written 224 orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. Not Note:This proposal may be withdrawn by us if not accepted responsible for water damage during construction. Owner to pay responsible legal within(14)days. fees for non-payment,and applicable interest. Acceptance of Proposal The above prices, specifications and conditions are satisfactory and are hereby Signature accepted. You are authorized to the work as specified. Payment will be made as outlined above. Signature Date of Acceptance. r t r it.,.r .x' <.. • 1 YGf Of'IL ,.�..rd ii�,�'L ... lJtjri .:Q;lP �� .. ;I�.:'..,h,;.. • r�. ( �A: 'r.. . `i:.. tcca *el :!t f�. ..lyd}�.R}'z A� '7.0�"Y:.r '?!.. r�i.>& '•.$}: ^{Ei '',. ...r :t' _ ..s ., • 'Iia E: PSSe' :.{r:"r;.r;+1 i :.lr•i.`' 4A Ulf�ll ILI r ,;p. .rl ; „s1 L'•,'." ,. ';'7t i:l :!'. ,r.t.: � e' Y �s : ;'7 r'. .• C'-:i' •+,. a. - .dt '(e: t i` Y r e tti'If a6':. - bi .w� ,.�, `,1431;,?• fs - t' 1k 1 The Commonwealth of Massachusetts Department of Industrial Accidents m Office of Investigations 600 Washington Street Boston,Mass. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Name(BttsinLss/OrganizatioMndividual):Sexton Roofing & Siding Inc Address:P.O. Box 6327 - — -- City/State/zip:Holyoke, Ma. 01041 Phone#:413-534-1234 Are you an employer?Check the appropriate box: Type of project(required): 1.U 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-contractors7.1; Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8.1 Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurancecomp.insurance.::: 9.f Building addition required] 5. We are a corporation and its 10.[;Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their myself [No workers'comp. right of exemption perm MGI, 11.[i Plumbing repairs or additions 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 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 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 employees. If the sub-contraeto �-have employees,they must provide their workers'comp. oliev number_ — — I 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: Policv#or Self-ins.Lic.#:U B-OG078982-1 9 Expiration Date:06/04/2020 Job Site Address: City/State/Zip: 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: f 1i � Phone#: Y / 3 . 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#' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 06/1012019 T111LS .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 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 ndorsement s- PRODUCER CONTACT NAME: ORMSBY INS AGCY PHONE FAX PO BOJ{718 (A/C,No,Ext)_ (A/C,No): E-MAIL WEST SPRINGFIELD,MA 010% ADDRESS: 286TF INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVFTERS PROPERTY CASUALTY Y COMPANY OF AMERICA SFXTON ROOFING&SIDING INC: INSURER B: INSURER C: INSURER D: PO BOX 6327 INSURER E: 11OLYOKE,MA 01011 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. 1NSR MODL;UBRPOLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE INSRWV0 POLICY NUMBER (MNIIDDIYYYY) (MWDDIYYYY) LIMITS GENERAL LIABILITY CH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE [--�OCCUR. REMISES(Ea occurrence) ED EXP(Any one person) $ ERSONALBADVINJURY i GEN'LAGGREGATELIMIT APPLIES PER ENERALAGGREGATE S POLICY PROJECT a LOC RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE .$ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY s SCHEDULE AUTOS Per person) HIRED AUTOS BODILY INJURY �s Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR 8 OCCUR EACH OCCURRENCE $ EXCESS LIAB CI AIMS-MADE AGGREGATE i$ DEDUCTIBLE i$ RETENTION $ $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY YM UB 0GO78982-19 06/04/2019 06/04/2020 LIMITS ANY PROPERITOR/PARTNER/FXECUIIVE Q N/A E.L.EACH ACCIDENT $ 1,000,000 Of FICER/MEMBFR EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe urKW DESCRIPTION OF OPERATIONS belay E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/RESTRICTH)NS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE INSURSYS MA WORKERS COMPENSATION POLICY AND ITS LIMITED OTHER STATES ENDORSEMENT AUTHORIZES THE PAYMENT OF BENEFIT'S FOR CLAIMS MADE BY THE INSUREDS%1A ENHILOYEES IN STATES OTHER THAN MA. NO AUTHORIZATION IS GIVEN TO PAY CLAIMS FOR BENEFIT'S IN STATES OTHER THAN MA IF THE ENSURED HIRES,OR HAS HIRED 061PLOYEES OUTSIDE OF MA THIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA- CERTIFICATE ACERTIFICATE 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 REPRESENTt � ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 9988-2010 ACORD CORPORATION. Ali rights reserved. 'i of T�,lt'�'i •;ta f;,! .y{��� N ,jL.Ft(T:Y/tQ(C,l It:9 F3".{� :R✓"'1�i'� f k .�r�vn„•',.�.ti.� Mt+�`"O • R��., t��Ti'r��4 '��?,»;�P .°�h.y�jA.i' fEJc^7.`J;1�iC� V i�5`�'� r+'hlM,.tF it.. •?!!b IG^.lh7i�r,:Rr' e i.`\ q Pt+p?.+•t►�``}F.„`w 01'W VVI f rgk'Wl>!•'ti 11 6��,'i.'4if2.1P4kr Lir.,.;ty1s ",?:ilk.,�i::i,'•`SS O9-d»'Yyilt' '`I•ri:i1 ._ _j '� _ .• -.Lwr .Jr,.,....e.,. w...„+_..r•..IrY....sJe�wrw:..rbs4.wyrrnaJ..•l.+w.�•vs4...,.r.,lyr.r. ire-,.�+I�IM,...af,.w..a�•=n.J+i4w r...�.•-s-t'i� ti ,.-.. ...... .. .. ... .�a..t..-,'t ,.,.:._-. ...,.5,.... ...._. «y.. .r••+p.»+..T•}+•a,�,--.y.r...w. ..--.a«.r•......�'...a.ry,.w Y.+.+.,�..+.-....,.-.a.... .9„r:._...... .. .. , s- S”. ,.:t. ,Jr J•J i'Y ��• tt.,y-.,>�j::.t s^'J L.:=: �1' ,atfrxstr?,AMS.xWa.�'�S �d�'`k:'r •�-t°;xt� i �?a.m'is(�. ,�:7:;r:...'k?r a ' f,>t 'iK 3 JI7A4 iT. 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'�fi�� .,.x+.un+nM.ertx. +.ifwl-.,�,1,..»awe„rt..«4ww+:r+.wV+.+e,...w-+W.aoJ.:-a+Jikn•.,wwy.uw..►r1,.Yr.w.e,.rl.,.;r.wo.ew'. ,r,.t �l,tL`,! :'F' '>' SSc di^,'y1"�,�+= °X'$ �!bd3l�bc::,.eY•i.:'1^°tl�t:�'� �1,; it. tt,ECt'1;'*:,At' 'tyG�; [.r.R•e�. y�, 1:,.. .r..ia .:�:TAf7`,f;� .. :r. �.Jc -� �yC, i �y17v3SF�i�rs .y,M�•y.., 1�.6.}t T. :lr`•+W .,...-,y._...r•?J.i-1 .}.. E.1 ••, L! '�t'4�.'ilt .r1 j74 VT 3"t'. ^ •' 1✓c 1!ly'w 'M .J.M.:;Y'*.* . �.'r'!�+�j.�! P'•'fi%� "ir'A* ��P',1?., 'sit '1.tf� �r L\'f�_V, M1�svj • •MIw�-.µ,x- Jx+. .,e w Jlrp. - •N'MM A♦!Ir»»•r.w n .»� .pR^.v. .n... ..'•++• � 'ti�r�1 :�i�It (9'�.,�:.�►. i `�� `��i4� ✓.'s� DY,�:,=;'�E'',J3s� ' tip_i,a . e r SEXTO-2 OP II A`C�RO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDO/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,tate 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 ri hts to the certificate holder in lieu of such endorsement(s). PRODUCER 413-7376300 CONTACT Eric Dembirtske Ormsby Insurance Agency,Inc. NAMIL --- ----- .-- 698 Westfield St PO PHONE ox 718 (AIC,No413-737-0300 FAX 413-737-0617 West Springfield,MA 01090 Eric Dembirtske A - _ inszom __--- wB11Rt3iyS1 AIwG COMEpE s - ---—- MIII�IA:C lin � CO. NsuRED e.Quki y�Irrbud�e Insurance 15067 exton Roofing&Siding,Inc. O Box 6327 -- ---- -- -- Holyoke,MA 01041 tNSURetCc INMWER D• �tNSURERE7 � —.. --------- -�- INSURERF• - --- -_- -- COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE WSUftED 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 CLAW INSR _ -- --- - TYPE OFINSURANCE SUOR POLIC1/1Wl1EER POrJCYEFF ;—POUCYERP ---..- LIMITS A X COMMERCIAL GENERAL LIABILITY 1,000,000 1 CLAIMS-MADE X OCCUR EACHor_cURRENCE $ _ _ 1 101GL002159903 06/25/2019,0612012020 nAMAGETORENTED s _ -_100,000 _ --- _- - — - MEDEXP _ 5.6 — - - -- — i ►ERSONAL d ADV IL& s —-1 000,000 7AGGREGATE LWT APPLIES PE t AUT10F2,000,000r ]PRo (� s 2,000,000L_J JECTLACTIiER: , —MD691LE L1ABR W ANY AUTO n,O1�SNIME L WT - s— ,000, FV206561 05/1512019`05/15=20 BODILYrapIRyLRr�sat OWNEDSCHEDULED AUTOS ONLY X AUTOS I --- N�8pN ��pp I DOILY lwLIl1RY LPar rx AU1%ONLY X AUTO LY _. --..- HIR � OP�TY _ UMBRELLA WB OCCUR EXCESSLIAB p,AM$.MRpE EACFI.00Ct DED_ RETENTIONS - TION AND EMPLOKERS YEMRT NLIABRITY PER ,ANY PROPRIETORIPARTNERIEXECUTNE YIN O BE SENT SEPERATELY --- OFFICERIMFME3ER EXCLUDED? [ ] NIA EL EACH ACC®HfT (Marwlatory in NH) ---_If yes,describe under EL DISE -EEA _ _ J. DESCRIPTION OF OPERATIONS below EL DISEASi j 7 DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space m 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 i The Commonwealth of Massachusetts -- Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,-1f4 02114-2017 :yr wwK'Mass gov/dia Workers'Compensation insurance Affidavit:General Businesses. Applicant InformationTO BE FILED%ITH THE PERMITTING AI'THORITI'. Please Print L tbl� Business/Organization Name:MNP CONSTRUCTION INC Address:45 EXCAHNGE ST Oth;.Statef7.ip MILFORD, MA.01757 _ Phone 4:508-4W8870 Are you an employer?Check the appropriate box: Business Ty pe(required): 1•I 1 am a employ er with 5 employees(full and 's ❑Retail '•❑ or part-time).* 6. []RestaurantBar'Eating Establishment 1 am a sole proprietor or partnership and have no employees working for me in any capacity. ?• ❑Office and or Sales(incl.real estate,auto.etc.) [No workers'comp. insurance required] S. ❑Non-profit ❑ %Ve are a corporation and its officers have exercised 9. ❑Entertainment their right of'exemption per c. 152,ti 1(4),and we have no employees.f No workers'comp.insurance required]' 10-El Manufacturing S.E] ll'e are a non-profit organization,staffed!iv volunteers, 11.0 Health Care with no employees.[No workers'comp,insurance req.) 12.0 Other CONTRACTOR •.gym applicam that checks NA must also lilt out the section below stklwing their workrrs compensation polity mtommuin -- "!f the corporate offkcrs hal c exempted them,ches.but the ration has other em orgmzxion shxwld check ftiis�7 COQ° pknees.a workers'compensamn policy is required and such an /am an emplgt er that is proriding workers'compensation insurance for int!employees• Below is thepolicp information. Insurance Company Name:HARTFORD UNDERWRITERS INS.CO.TRAVELERS-RMD insurer's Address:P O. BOX 5600 City State zip: HARTFORD,CT. 06102 Policy;;or Self-ins.1.ic.x 1K709706 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 MGI_c. 152 can lead to the imposition of criminal penalties of a fine up to S 1500.00 and:or one-year imprisonment,as well as civil penalties in the form of a STOP NVORK ORDER and a fine Of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of tmestigations ofthe DiA for insurance coverage verification. !do herebe cern u r r�r Allies of perjurt•that the information proitided abore is true and correc7. Si ature: Phone-:9781403-5942 Official use anti. Do not write in this area,to be completed bt'cin or town offrcial City or Town- Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: sstiW mass eos dia 1 ACORZ7� CERTIFICATE OF LIABILITY INSURANCE aaTe(UwoorYY,rY) 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 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 It Catvilio ONE FAMILY INSURANCE AGENCY LLC A PHONE _ LAIC NO Ertl- 1978)�IG3-5 2 .—. 1 FAX 1 Main St Suite 15 A�nsrFss__?cafvi)ao128PYafioo-com pt _Lu _—....___-_ INSURER(5)AFFORDWGCOVERA_GE _____ NASC: -' _ MA G1462 ulsuRERAc HARTFORD UNDERWRITERS INS CO _ INSURED - `- — _ ---- -- - 30104 - MNP CONSTRUCTION INC '"-s"'—�R9' — INSURER c- _ --_---- -- 45 EXCHANGE ST APT 3E Il+suru_t Di- [MILFORDt!�E COVERAGES MA 01757 wsuRERF - CERTIFICATE NUMBER: 401483 THIS IS TO CERTIFY-i-HAT THE POLICIES OF INSURANCE LISTED BELOW HAVE REVISION NUMBER: INDICATED_ NOTWITHSTANDING ANY REOU;REMENT. TERM QR COIdDffION OF ANY COttTRgC7 OR OTHER DOCUMENT WTHE INSUREDiNAMED OT}I RESPECT TO WHICH THIS OR THE FOLIC. PERIOD ERTIFICA7e MAY He ISSUED OP, Iv MAY PERTAIN THE ItvSUPANC� ANY BY 7F)E POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.Lim SNOWLN h'.AY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR: TYPE OFINSURaN ;ADOUSUBR� ----.._ --__ f N POLICY NUMBER POLO EFF ' POUCYDCP COMlAERCIAL GENERAL UABIUTY 11Dp_1YYyy}: O5 - r ---. 1 f l+)c ! I EACH OCCURRENCE S PREMISE wA ------- ---I f s j `_FEiRSONAI bADV INJURY -- GEN'L AGGREGATE ll!AITA�PLIES PER: 1 ' ! i S - i _ POLICY�I JECOT LOC t GEVERALAGGREGAT_E j s 1 r I AUTOMOSILELIABILtry is '— -- l ANYAUTO { COldBINED SIIhGCE LIMtT L acrdeati s r ALL OWNED se AUTOSrsEaLr=a AUTOS NIA f BODILY INJURY(PerNON _ t ➢Mon S _f HIRED AUTOS AUT�YNcD 1 3OOL•Y INJURY(Fer accideny�S -- { ;?-OFER7Y L Pier artdenM �s UMBREU.A UA8 r :OCCUR 1 I T s - - F i EXCESS UAB i GH OCCURRENCE N/A DED i !RETENTION sORKERSCOMPENSATIONSNO EMPLOYERS'LIA3ICrrYPERPROPRIETOR/?ARTMERiEXECUTfvE YINFICERIVE-MBERFXCLUDED? �'ST?PI;E� I (Manrlamry In NH) �Wq I�NIA : WA' ES60UB 1 K7097061 S11/1612018111/1612019. E L EACH;,CCiDENT -- -_.- _— if 911962098 t9I?512019 = - i s 1,000,000 D Yes.describe Unser i ( I EL DISEASE.EAE LOYE_E S 1,000,000-- (DESCRIPTlON OF OPERATIONS below 1 _ EL DISEASE-POLICYLIM!T i S 1,000,OGO } I N/A ! i DESCRG*rION OF OFERATIONS 7 LOCATIONSf VEHK:LES(ACORO ids,Additional Remares Sehederte,m Workers'COmpensaLan beneli;s vrl1l be paid to Massachusetts employees only_Pursuant too Endorem�en WC 20 03 OE 8,n°authorizaLon is given:o pay claims for benefas to employees in states ocher than Massachusei*s if the insured hires,or has t fired those employees Outside of Massachusetts. This certi{Icate of insurance shows the policy in force on the date tt;zt this certificate was issued{unless the expiration date cn the above 1- y issue dale of chis cerufrcaie of insurance). Tne status of this coverage can be monitored daily by acre sing the Preof o.Ccverage-Cove age Verification Search tool at rvww_mass_gov/lwd/•workers-compensationTnvestigaGonsl. I� DTees the CER7IFlCATE HOLDER CANCELLATION SHO D ANY THEULEXPIRAOONHDAIEOV7NER>THEREOF, NOTICEPOLICIES YJILL CANCELLED CDELIVEREQ BEFORE iN SEXTON ROOFING SIDING INC 102 PINE ST ACCORDANCE WtT}I 7}IE POLICY pROVtSlONS_ ri. ZED REPRESchTATIVE HOLYOKE MA 01040 M-Crotiv�y.CPCU,Vice President-Residual Market-WCRIBMA ACORD 25{2014/)31} ©9988 2014 ACORD CORPORATION. All rights reserved. The ACORD name and Ingo are registered marks of ACORD i. yl, .'Taws.,. tilS+l i .. r I C./ / "��Y i. _ �• f,. i. ..'., wR��.- (w .. PE' '�«/�1�'�.'4�np�•.Jrafi;,.rra.'. � u, • 5.0 k�}Ff�' �+ �'� ? 1. # ,. "' f., t,,)} Lf S, i. C '�Pc .. #9'�a '} „ ." 'e`�•Y �� _.' Y�'f: `"fr�Y=k✓i:�v`"'.lxlt,.'°t"'� y`, ... ..::k..s.vrrr.• .rr�'°1«aR '�"�"'s$ V< .. .., .._. _ .t�..�..,5 .,.�.. Y+ •# ^P J'ti'•;"t' nt.k •key' � .i"` �},..;lr� 1� txi '�5f{"jx«.5 ,. 's 'aM^. a'•', �!t. 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