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24A-050 (4) 137 BARRETT ST BP-2020-1133 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:24A-050 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 P E RM I T Permit# BP-2020-1133 Project# JS-2020-001372 Est.Cost: $9400.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sa.ft.): 11238.48 Owner:ELSON VICKI Zoning:URB(100)/ Applicant: SEXTON ROOFING CO AT. 137 BARRETT ST Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 HOLYOKEMA01041 ISSUED ON.511512020 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE GARAGE 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: FeeTvne: Date Paid: Amount: Building 5/15/2020.0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only - City of Northamgt -.%.� atus of Permit: few; ~ Building Departr49` Curb Cut/Driveway Permit 212 Main Street; �� s Sewer/Septic Availability Room 100 '��' ?.�j Water/V1/ell Availability w+y4 Northampton, MA 01060 0 Twe'Sets of Structural Plans phone 413-587-1240 Fax 413-5���� 72 Iot/Site Plans \o�.`�. Other Specify ,o APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office ,c�1� �-. I !- Map �� J Lot 6� Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: 3{.=9 - -3 -n 4 Telephone Signature 2.2(Authorized A ent: P-o- c� Name(Pnnt) Iturrent Mailing Address: 4s- 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) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number ,7 .l This Section For Official Use Only Building Permit Number: 6' RO^-1/✓ �_ Date Issued: Signature: Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Ft X'"W p.Y �iC�I«,Y C, <ig!;- .yf, y.yr �'�i..'f�• ... r ..a,'�! .'11. A;r. (:...' 4. too! .. ' r,... s•....: rv....:,r M-tliw..A.y.�wr.wdM;,..:...e-.:-,.>v... -.wer[.n�a'_ ,....,.��-�x..sr.�� t.�:.<•.+.r.sv...i.we �.�iRMM r'.. .-..�-.P--..Yk...a.+...._ ...�.�w� ..nv ......t.anT. . 1,7 So ,v n:.• .. .... 'a W...WyYrt.....-v AMM,.w..�,�ryr_. � _ ... .: V Y ♦ .� w f .. ... .. . SF1.. � � '� t�i 'i��.� r.... 'i i .. .r,' �.. +. if(I*., .. _,_",F. ;ti��t���a��•_•k . ., ' ,.r �lt, e• _:.. fir` � ..,aL _ t "�`.�A a �fi a x.• _�• .. ... � '. ee 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 b Building Department Lot Size Frontage -- Setbacks Front Side L: R: L: R: I 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/Vari nce/Find g ever been issued for/on the site? NO O DO KNOW YES 0 IF YES, date issued: IF YES: Was the per t recorded at the R istry of Deeds? NO O DONT KNOW O YES Q IF YES: enter Book � i Page and/or Document# B. Does the site ntain a brook, body of water or tlands? NO O DONT KNOW O YES O IF YES, h a permit been or need to be obtaine from the Conservation Commission? Needs be obtained O Obtained O , Date Issued: C. Do an signs exist on the property? YES O NO O IF ES, describe size, type and location: D. A there any proposed changes to or additions of signs inten ed for the property ? YES O NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, excavation, or fillin4over 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. 'f. : 1:� %�.' •• .c.: .r. ..,�.�..t•1„L c+t,r i„♦.+ ,'���:°'�C+i .. •:.4' - '?''•.t.t• �(���-l._..�♦�. ,. _ �t;. $,�.., "-�'L'4:4,+"� .�,��0. .':, .♦"�+4 tai. � � � � - .,,t '. ' �.r f'` 'Yj�: � 1�.. .J' ... $f,��f'C.-r'� '�A . ;;?4' �i:`l:; _Cxtl,,,�},l.r'.. "1 :s .. el �..�'��9��;• .n.J.._ �� ,� Y.`d*_. �`�? , 4i ,..ar• ft.J Ov `a:•a: ;L 3',t.r� .C). .,rl r -. � .,. rte♦ , ♦ t 1 ' � 'i-.•t::' � � tit[,s4♦' :C .♦�+ .A' _ -�,.;.,.,.hi.1 ' ,,fit sr;ri:;� .5♦�1!`�: .1 .r •Ni .i.�' c ...'.l:>'}*r.''t SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ' Or Doors l] Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [Q Siding[C] Other[CI] Brief Descrip' n of Proposed Work: Q 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 toNxisting housing, Com tete 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? Fir s or Woodstoves Number of each g. Energy Conservation Compliance. sscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of ands? Yes No. Is nstruction within 100 yr. floodplain Yes No j. Depth of basement or lar floor below finished grade k. Will building orm to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water S ply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Q✓IOas Owner of the subject prop hereby authorize k_') ton my behalf, in all matters relative to work authorized by this building permit application. (74 � �- !, S Signature of Owner Date as Owner/Authorized Agent TFereby declare that the statements and information on the foregoin application are true and accurate,to the best of my knowledge and belief. Signed der the pains an nalties of perjury. Print Name Z_ o Signature of Owner/Agent Date v t .... .. gyp;.. _ SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable/❑ Na License Holder: �/`�" �1 ✓V (v License N r 'X S-- z / Address Expirallon Date Signature Telephone 9.R641stered Hom Im rovement Contractor: Not Applicable ❑ �V h:kcl d Y, 1 // ? Company Name I Registration Nu ber Af e) /(� ) -7 -,-,-,/,/v res Exp ation Date B G t Telephone V/Z j 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.......Q�� No...... ❑ • l • r ''�ti � to i r�4c',... t .'.:.x4 ".•`''.ss a.�t�lal. �` •'• � ,.,: � +..t. r 't1� kr . }., r. ++',' ,s.. t• f{ :>. -<... ;t(t•- r.+ -�CRr .. .,f L'. :�Y,•' .Ery. tit}'.4 r,. t IC. j, s�' �.>', ti'- :! It J;`. ° i)`_:''/�}4Ar ".�!4.,� .•r}!?lR' •♦+C' _ !'' # �{ t(. • •t } >,s •1 "211. �, - , W.' in- r tie.' • ti ,�. ...� t��l'.7 hit!a?t t�vl:r�• ., �.1 � 1�r#{; b. +` .. i City of Northampton ( Massachusetts c DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building yeti Citi ,r Northampton, MA 01060 �Sp 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 stnictures 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 hereby apply for a bl permit as the agent of the owner: d Dae 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 A: "di ..�� to - , .. ... .y,�.r..•.v..a. .._,..w. w•✓+...r.n....y«..... :... .,a.-:..�-a:....,w..r.-. -... - w.....- ...•.Mw•.:.-•,.•.rn.•.�-n+w-.e..r.:...uv--n1.h♦..W'+"r.T•,.«s...- w...ae... 1� � ..;1 a1"3 ,�� i ti,t'. k{' 1 r' �• `! ,eta- t.;' •i7•' ' ; . ✓. - .. w-.aY.-mow... . iG>aY w.n ..wy. �r.f,,. ..nih ....,w. ....• .. .-....�..a. .� �..-..> 1wil.Yt...•.. d. ... .r-.v1a. ♦.aLw. ♦ -. •r� f'�•'RR .f.t- '� i�"�l:Ef�- n3�'" � .' fir. s � _ /. _ _, .. :r.*,ir.P { - �3. t.�.y ` :.:° ? ft '�' �i.. 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'11 City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS � x pyo ! I` 212 Main Street •Municipal Building D '� 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: (P ease print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: 14s67C 1,4_�4 P A/ /, cls s (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. 1 r,#^:'� �Ci; e� q`�s {, .i, jp�yic}b�•:wf4 t'i a�. ':r !2 1ST sy, ;;}"Yi'`,•: �j54.�,'." v .R C ii d i i AIV j r 3: { ;� .i• f v!l'1: }L'd li.. w ��.+LT y t i iAUE14`.1' C 1. ` `` � \• � _. t . _ E,itN, C:; 5 r.C. 'h„1;C,;n � ..,. + .ic��yi.� `?'i' .i ;;:.Lr�,e'�'+i ° ;�'� ' .fit ;r { �.; ` %`'•'�,' _ _�. :d' � u'C.�}�'�.' *:. 9�. ie:t�i'�,;�t•'.Si. r{ i .�.�+..3.{�''. ��, 't;`li y.':�!,?, E. ?�;e. ,t .�'r �{�i'-'?.:\.y ”: \'..+..:, +�° •�l4iz iv,},, y,�,• ,y f. 7 Q � t:.� ,�a•'.:'rKK'(y(ie" ' f , I'. _ ✓ 1 a� v.�.,'1w ,s,Yl S+' .}w+JrJ.<� .f�•.��. � I. S 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(Business/Orymizafion/Individual)_Sexton Roofing & Siding Inc Address.P.O. Box 5327 City/State/Zip:Holyoke, Ma. 01041 PhoIIe-9:413-534-1234 Are you an employer?Check the appropriate boa- Type of project(required): 1.C I am an employer with 4.;X I am a general contractor and 1 6.Ll New construction employees(fall and/or part time).* have hired the sub-contractors 7.[!Remodelin- 2.- I am a sole proprietor or partner- listed on the attached sheet- ship heetship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9.F Bwldin-addition [No workers'comp_insurance comp.insurance. required] 5_T1 We are a corporation and its 10.[11 Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. 1!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_ C' Other comp_insurance required.] *Any appticaut that check box r7 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a Dew affidavit indicatiug such_ 4.Contactors that check this box must attach an additional sheet showing the name of the sub-coutractors and state whether or not those entities have employees. If the sub-contractors have emplovees,they must provide their workers'comp.policv number_ I am an employer that is providbr,-workers'compensation insurance for my employees Below is the policy and job sire informatiom Travelers Property Casualty Company of America Insurance Company Name:- — - — — Policy#or Self ins.Lie.#:UB-OG078982-19 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 annd/or one year imprisonment as we as civil es 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 DtA for coverage verifzcation- I do herby certify a der the pains and penalties of perjury that the information provided above is true and correct Sidnature.- Date: Print Name: `T Phone#- i;' ; ,�u` cY 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): ].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 ITATE(MMIDDIYYYY) 0611012019 rTHIS rF TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS IFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW_ CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE RODUCE 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 CONTACT NAME ORMSBY INS AGCY PHONE FAX PO BOX 718 (A/C,No,Ext)-- (A/C,No): E-MAIL WEST SPRTNGFIELD,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= INSURER D: PO BOX 6327 INSURER E HOLYOKE,MA 01041 INSURER F= COVERAGES CERTIFICATE NUMBER: REVISION NUMBER- THIS IS TO CERTIFY THAT THE POLICES 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 WTTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN_ THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN LS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIDNS OF SUCH POLICIES_LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR IkDOL 3UBR POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (M1AWMYYYY) (MMMIAYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS MADE OCCUR_ $ REMISES(Ea occurrence) ED EXP(Any one person) ;$ ERSONAL&ADV INJURY {$ GEN'L AGGREGATE LIMIT APPLIES PER ENERALAGGREGATE is POLICY D PROJECT LOC DRODUCTS-COMP/OP AGG S AUTOMOBILE LIABILITY COMBINED SINGLE i$ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY y$ SCHEDULE AUTOS Per person) HIRED AUTOS BODILY INJURY ;S Per 2CCident) � NON-OWNED AUTOS PROPERTY DAMAGE S (Per accident) t UMBRELLA LIAB 8OCCUR EACH OCCURRENCE �s EXCESS LIAR CLAIMS-MADE AGGREGATE is DEDUCTIBLE 5 RETENTION 3 A WORKER'S COMPENSATION AND x WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-OG078982-19 06/0412019 06/042020 LIMITS ANY PROPERITORIPARTNERIECECUTIVE El N/A E L EACH ACCIDENT j$ 1,000,000 OFFICERVEMBER EXCLUDED? (Mandatary in NH) E_L DISEASE-EA EMPLOYEE�S 1,000,000 If yes,describe hider DESCRIPTION OF OPERATIONS belvx EL DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIRESTRICTIONSISPECIAL,ITEMS THIS REPLACES.ANY PRIOR CFRMCATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. TBE INSUREDS NLA WORTk-RS COMPENSATION POLICY.4,\TD ITS LIMITED OTHER STATES ENDORSEMENT AUTHORIZES THE PAYMENT OF BENEFITS FOR CLAINIS MADE Bl'THE INSUItED'S MA L•�IPLOYFFS IN STATES OTHER THAN NIA_NO AUTHORIZATION IS GIVEN TO PAY CLAR4S FOR BENEFITS IN STATES OTHER THAN MA IF THE INSURED HTR FS.OR ELAS HIRED 2i IPLOYEES OUTSIDE OF NIA- THIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA- CERTIFICATE ACERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS_ AUTHOR»REPRESENT ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION_ All rights reserved_ SEXTO-2 OP 10. ER CERTIFICATE OF LIABILITY INSURANCE -TE 07/1012019 ' 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 corder rights to the certificate holder in lieu of such erldorsement(s)- PRODUCER 413-737-0300 CONTACT Eric Dembinske Ormsby Insurance Agency,Inc. NAME_ 698 Westfield St PO Box 718 PHONE 413-737-0300 413-737-0300 FAX No):413-737-0617 (A1C.No,Ear West Springfield,MA 01090 E4WLtFffisTce-@&M�s ylns.com Eric Dembinske ADD __, INSURER(SI AFFORDING COVERAGE __ NAIC# INSURER A:Colony Insurance CO. 4NSUREDn Roofing 8 Siding,Inc. INSURER 1:Quincy Mutual Fire Insurance 15067 exto PO Box 6327 INsuRER c: -_--— Holyoke,MA 01041 W SURER 0: INSURER E' INSURER F: COVERAGES - 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. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS A )( COMMERCIAL GENERAL L1ABLLITY EACH OCCURRENCE $ 1,000,000 c'AI""sMA°E903 06125120191Ofi12012020 P° ❑X OCCUR 101GLOO2159ATORENTED s 100,000 �1 - t MED EXP one person S 5,000 tt ; PERSONAL&ADV INJURY S 1,000,000 GEN1-AGGREGATE LIMIT APPLIES PER: I fl GENERAL AGGREGATE E 2,000,000 POLICY JECO 1:1T- 11 LOO ` I PRODUCTS-COMPIOP AGG S 2,000,000 OTHER: B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 I I (Ea acadentl E_ ANY AUTO AFV206561 05115201910511512020 BODILY INJURY(Per�erson s OWNED SCHEDULED - AUTOS ONLY X AUTOS BODILY INJURY(Per accident S XR�E�Q� Nry-..Op I _.. _ . AIIJTOSONLY X. AUTOSONLLYY i LIRe.OraPca�derr�GE__ __- $ UMBRELLA LIAB OCCUR I EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE � J AGGREGATE s -- -- DED RETENTIONS WORKERS COMPEN7N� f j I PER OSTATUTE R- ANY PROPRIETORIPARTNER/F_XECUTNY!N E O BE SENT SEPERATELYI4 EL=EACH ACCIDENT OPRCERIMEMBER EXCLUDED? El NIA; 5nder (Mandatary In If yes,describe aundEL.DISEASE-EA EMPLOYEE_$ I I DESCRIPTION OF OPERATIONS below I EL DISEASE-POLICY LIMIT S i ----- ----- -- -- DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may he attached it more space is required) CERTIFICATE HOLDER CANCELLATION NONE-01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Everett Sexton ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR17_ED REPRESENTATNE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION- All rights reserved- The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts ��-- Department of IndustrialAecidents > 1 Confess Street, Suite 100 Boston,M,9 02114-2017 www,massaov/dia Workers'Compensation insurance Affidavit:General Businesses. TO BE FILED WITH THE PERyIITTi.NG AUTHORITI'. Applicant Information Please Print Legibly Business/Organization Name:MNP CONSTRUCTION INC Address:45 EXCAHNGE ST City/State/Zip:MILFORD, MA. 01757 Phone#:508-498-8870 Are you an employer?Check the appropriate box: Business Type(required): 1.[ I am a employer with 5 employees(full andi 5. ElRetail or part-time).* 6. nRestaurant(Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have.no 7. E]Office andlor Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp. insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees. [No workers'comp.insurance required]* 4.❑ We are a non-profit.organization,staffed by volunteers, 1 1.❑Health Care with no employees.[No workers' comp. insurance req.] 12.1D Other CONTRACTOR 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employers,a workers'compensation policy is required and such an organization should check box i. lam an employer that is providing workers'compensation insurance for my employees Below is the policy 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.Lic.#1K709706 [q Expiration Datej 111 6120k 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$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-ttday-against the-violator-Be-advised-that a copy of his statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification_ I do hereby cern u ` p r i�'tp[ties oJperjury that the information provided above is true and correct Signature: A/ Date: Phone x:9781103-5942 OJJecial use only. Do not write in this area,to be completed by city or town official City or Town: Permitf.License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: w�vw'.mass.vov(dia ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMUD"yyy) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER-/ 1THIS 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 terms and conditions of the policy,certain the Policy(ies)must be endorsed_ If SUBROGATION IS WAIVED,subject to 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 CONTACT ONE FAMILY INSURANCE AGENCY LLC P"H"ONE--Art Calmllo No Eet: (978)4035942 - E-MAIL 1 Main St Suite 15 ADDRESS: acalvillo128@yahoo.com Lunenburg _ INSURER(_AFFORDING COVERAGE NAIL# INSURED ----- ----- MA 01462 INSURFRA: HARTFORD UNDERWRITERS INS CO 30104 MNP CONSTRUCTION INC INSURER El --- — INSURER C•_ -- 45 EXCHANGE ST APT 3E INSURER°' MILFORD INsuR_ COVERAGES MA 01757 INSURER F: - CERTIFICATE NUMBER: 478475 THIS IS TO CERTIFY THAT THE POLICIES OF INSION NUMBER: URANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMREVIED 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 PAI INSR LTR TYPE OF INSURANCE ADDLSU D CLAIMS_ IN Di POLICYNUMBER POUCYEFF POLICYEXP - - COMMERCIAL GENERAL LIABILITY Mwu ; D LIMITS I 7 CLAIMS-MADE 1:1 OCCUR I EACH CCCURRENCE S — DAMA ETD RENTED PREMISES ocamence S I N/A MED EXP(Any one person)) S __---- GENLAGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY S 1 _ PODCY PRI JECT n LOC j GENERALAGGREGATE $ OTHER PRODUCTS -COMP/OPAGG S AUTOMOBILE LIABILITY ANY AUTO (E.acaderrt)SINGLE LIMITALL OS -- AUTOSWNED �HEDUI cn , N/A BODILY INJURY(Per Person) S i ---- NON-0WNm i BODILY INJURY(per accident) S HIRED ALJ AUTOS --- _ -- - 1 P accident AMAGE UMBRELLA UAB r S -- OCCUR EXCESS LIgB CLAIMSMADE N/A i EACH OCCURRENCE S -- --- DED RETFNT)DNS - - ----- AGGREGATE $ I — -- ----- --- .. WOR!¢FZ,$COMPENSATION I $ AND EMPLOYERS'LIABILITY OTH- ANYPROPRrETDR/PARTNER/EXECUTIVE YIN i X,STATUTE ER A OFFICER/MEMBEREXCLUDED? WA WA N/A EL FA ATUTE DENT (Mandatory in NH) 6S60UB1K70970619 11/16/2019 11/16/2020 - S 1,000,000 _ If yes.descnbe under I j Ei DISEASE-EA EMPLO $ 1,000,000 DESCRIPTION OF OPERATIONS below ! i ( EL DISEASE-POUCYLIMn S 1,000,000 i WA _.__. DESCRIPTION OF OPERATRONSiL.00ATIONS/VEHK;LES(AC.ORD101,Addtional Remarks SchedWe,may he attadmddmore Workers'Compensation benefits Will be paid to Massachusetts employees �e 1s resin) claims for benefits to employees in states other than Massachusetts if the insure hires,or has hired those employeesdorsement WC 20 036 8,no of Massachusetts, igiven to pay This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policyprece issue date of this Certificate of insurance)_ The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification des the Search tool at www-mass.govAwd/workers-r-ompensabon/investigations/_ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SEXTON ROOFING &SIDING INC ACCORDANCE WITH THE POLICY PROVISIONS. 102 PINE ST AUTHOR1gD REPRESENTATIVE HOLYOKE MA 01041 \� ``C Daniel M.Crow y,CPCU,Vice President-Residual Market-WCRIBMA ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORDORD CORPORATION_ All rights reserved. DATE(MMIDD/YYYY) ,4ou CERTIFICATE OF LIABILITY INSURANCE 11/27/19 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: OLDERIMPORTANT: 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 GUNFACI NAME' Art Calvillo One Family Insurance PACO N Fit): 978403-5942 Ass/�C No 978 03.5943 1 Main St Suite 15 E-MAIL Lunenburg,MA 01462 ADDRESS- art@1familyinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Evanston Insurance Company INSURED INSURER B: MNP CONSTRUCTION,INC. INSURJER C_ 45 EXCHANGE ST APT 3E INSURER D MILFORD,MA 01757 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 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR INSD 4WD POLICY NUMBER MM MM/D X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 100,000 CLAIMS�AADE X OCCUR DA PREMISES -R omim>ncz S MED EXP(ArTy one n) $ 5,000 A Y Y 3ET9385 11/03119 11/03/20 PERSONAL&ADV INJURY $ 1,000,000 nGE .T.,.- N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 JECT LOC PRODUCTS-COMPfOP AGG S Z,000,OOO POLICYEI PRO-- $ AUTOMOBILE LIABILITY COMBINEDaccident SINGLE LIMIT S Fa ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per acadrst) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY er acddenl S UMBRELLA LIABOCCUR EACH OCCURRENCE S EXCESS LIAB HCLAJM&MADE AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION SW OTH- AND EMPLOYERS LIABILITY YIN STAME ER ANY PROPRIETORIPARTNER/EXECUTIVE❑ NIA EL EACH ACCIDENT S OFFICFIbN�7dBER EXCLUDFIY? (Mandatory M NH) EL DISEASE-EA EMPLOYEE S If yes.descibe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS!VEiIICI FS(ACORD 101,Additional Remarks Schedule,may be attached if mare space is requved) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN SEXTON ROOFING&SIDING INC ACCORDANCE WITH THE POLICY PROVISIONS. 102 PINE ST P.O-BOX 6327 AUTHORED REPRESENTATIVE HOLYOKE,MA 01040 ART CALVILLO ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD office C"C�'nsLjmer / Grimm '���and Bminess Re9uIallon 1000 WashigMn meet-suite 7-le HomeIr 00r&�0211 or T OFt!dG SIDMIG WG6327 Rer fO�YOKI.�5tf�i fli0 r7cK2 ?1Z239 f2 - --1_ TT-.1.--c. C-d- PO-OX�02 7 SF HOME IMPRO , If3lyp ;A #31L4I L�'ERET CONTRALTO I SE$TO.V S$ R -" IOZ pie_ HOLYOI� �;010�02411 SEXTON $ snOIZ - F NG&OS ExzNG niCe'.0�0 C0605383 -...... SIGNED 12 1/201 Expirarioa 11/30/2020 �t Commonwealth of Massachusetts _� ' Division of Professional Licensure Board of Building Regulations and Standards ConstructiorrSe,jlsor Specialty CSSL-099689 ERETCJ Expires:10/05!202-1 SEX orq � r PO BOX 6327 *;, tr HOLYO a r�qen MLL 0104'L Camrnissionerc SEXTON ROOFING AND SIDING INC www.sextonro�.cOIm P.Q. Box 6327 Holyoke, MA, 01041 Setting the Standard p. 413.534.1234 f. 413.539.9906 MA HIC # 118239 sextonroofinhot-rnail.COM SSUBMITPED TO Vicki Elson PHONE 329-3778 DATE 3!20!20 STREET 137Barrett St JOB NAME CITY,STATE,ZIP Northampton,Ma. _ JOB LOCATION SEXTON ROOFING HEREBY SUBMITS SPECIp7CATIONS AND ES[IMATES FOR 1) Strip and remove existing shingles and dispose of in proper landfill. 2) Inspect roofing deck and replace as needed(a? $75.00 per sheet. 3) Install new metal edging to rakes and eaves of roof. (811) 4) Install ice and water shield on eaves(61), 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) install new counter flashing on chimney. 10) Install new cap over ridge vent. 11) Supply manufactures Lifetime warranty and SRC 5 yr. workmanship warranty. We Prrosw#e ►�'�!to Iur»!slfr nnaterlstwandlabo�cele accorr/sace twit!►the above srrereii9eatiotr�,!lav tlrs amount o/ N/ne Thovsend I�our.fiundrrwd Dt?LLAI�D 1 &4 ►OPI PAYMENT+ T(�BE MADE AS FDLDW _ due in full upon completion All Material is guaranteed to be as specified. All work to be completed in a Authorized workmanlike maaner according to standard practices. Any alteration or Signature deviation tiom above specifications involving extra assts will be executed only upon written orders,and will become an extra charge over and above the. estimate. DAMAGFs,rt)BUsttESAN'DODIER VEGAFTATI(Mr MARKS ON iloUSU MAY Note:This proposal may be withdrawn by us if not accepted Hr L NAVOIDABl_E AND WE ARF tJUD 11ARMC.t SS. Not responsible for water within(14)days. damage during construction. Owner to pay responsible legal fees for non. went,andawlicable interest. _ „ns ad The above prices, specifications and s l Signature ---�—•- conditions are satisfactory and are hereby accepted. You are authorized to the work as specked. Payment will be made as Signature outlined above. Date of Acae_ptance,