Loading...
23D-029 (2) 460 ELM ST BP-2020-1181 GIS#: COMMONWEALTH OF MASSACHUSETTS Map-Block:23D-029 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categ-ory: ROOF BUILDING PERMIT, Permit# BP-2020-1181 Proiect# JS-2020-001986 Est.Cost: $7800.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sa.ft.): 12588.84 Owner: LEOPOLD REBECCA A toning_URB(100)/ Applicant: SEXTON ROOFING CO AT: 460 ELM ST Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 _ WC' HOLYOKEMA01041 ISSUED ON:5/2912020 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 5/29/2020 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 Northampton a of Permit: Building Department t/Driveway Permit 212 Main Street Sr tic Availability Room 100 'yet �9 Wat eI)l4vailability Northampton, MA 01060 r ?%, c wo S s�dtructural Plans phone 413-587-1240 Fax 413-587- �� ot/SiteTans y�A 9,�� Ot Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVA,J DEMOLISH A ONE OR TWO FAMILY DWELLING i SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office _ Map Lot 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: Telephone Signature 2.2 Authorized Agent: Name(Prin Current Mailing Address: 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 77 2. Electrical (b) Estimated Total Cost of Construction from 6 _ 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) (/ 5. Fire Protection 6. Total=(1 +2+ 3+4+5) Check Number 19 7 n This Section For Official Use Only 6�,_ �� 6 Date Building Permit Number Issued: Issued: Signature: Z y. 26 Z Building Commissioner/Inspector of Buildings n Date V EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[o) Other[CI] Brief Description of Proposed y /1 Work: U(-Pl •t I'Z�` ���— 5� ! I/t ��S G�✓ �1�.F}.ti `'� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in(eaamily unit: Number of Bathroo c. Is there a garage aftd. Proposed Square fonew construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Complianc Masscheck Energy Compliance form attached? h. Type of construction i. Is construction withi 00 ft. of wetlands? Yes Is construction within 100 yr. floodplain Yes No j. Depth of base nt or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR) CONTRACTOR APPLIES FOR BUILDING PERMIT I, k_6-eC-_ Le 9' L as Owner of the subject property hereby authorize �J I 1 L �— 5l to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date as Owner/Authorized Agent hereby declare that t e statements and information on thb foregoing application are true and accurate, to the best of my knowledge and belief. TSad under th pai nd penalties of perjury. LI) Prin N me Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: License Number �O CP 3 1 / a - r-- z / Addr Expiration Date Slgriature elephon 9. Registered Home Improvement Contra or: Not Applicable ❑ // Y7- 39 Com N� ame Registration Number 4ess Expiration Date Telephonef Z 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....... UK' No...... ❑ City of Northampton Massachusetts s ' DEPARMENT OF BUILDING INSPECTIONS z 212 Main Street • Municipal Building �Jr CDS Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: 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 building permit as the agent of the owner: 1 2, /-Z. 6 Zz, Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature i • �1, m ., a ''�+ .} t '+ •i,.f if,1s'. . F. 't .Yd4.fc. .. S �:.'ti•,,.,.....r.,....,.....,._..,s,. ....'....�w.�.. :.- :.,..:sass- ...1.«:..�,.- ...,..,.w .�.m ... r.wwy_...:.,;R.wnww_r.�.-w.`...a; ` I, ,t'=,i �) fi,yt s.:t'Y,s �'t� � Yd �✓sr{� X,��1.�f"� �{� f•.. %.� n. 1S�`'i �4't�,t' •r" �.. •�; !f k'R �Y..9d�.,' l �..f°,.... yJ x � _.'�+'�'f[(?��1'� ,fi�.� v °��:;F'E.�►% .st.i[�,` 'y ,!'} 31��;.C�c .. 4r :DY:�YI? F:. 'r"•'1. 7I=* ° e',:f,y}7��. f 44,0 ' � , :?`{.p.�,�) !",t�{.3 it ti',�-S1c ,��X' s:i i•1 •� .'.i�y+� .. t .1.i.�_ ,�Yf� �„i.8i;1� S "��r.�7_i'S �. t.3�Y ���..''�J•`f.e�%. > � ..�.� ' e'• 7C jC " .`i�C:f�l r:.IN 0 .:f t iii '.3 i' t �M+.' ?. �ti_Pli� �: � �• �, �:. s�D � �t i i S���Jci�. �� '+;tj;s•" . r'�P.y, t,�t9 J' �y�:"'t iii} �.:i-? •.'1. . ,.n t'. ;l:P f � '.��`•rf t .. �`�t �..�.; f•r+fi4�.' { 'i. .�.•;.: - wol I __. I 3 r r 'ra 17' i i t a L{q tl r U. ;. 1�;C •9..• .e.c...r:M _ '.:1f ..;°,,:, ,',#a, —til t.�:�,,, `.. a, ;� {Ci's' ;' ^'���:, 1.• '.,`tet' -.� .'1. .1•. . :Ka: �`:V ��... `N .1;r .Sa.'.• '��.Q1, .'.r: .1.j. ,!'-. . tii'.et ,�4 'a. .',,�-. i t'. . .."y t�'Y�/�� ,,1:;'.. .'4. .•! #' LS S .- i .y�,f/".�S,l � �.tl:. r ,s" is5,t.,, ,� ���s' ..•Y 1. . .. ; !.,ti•. .. 'j� �' f fi -�t;�l�x �1 f .. s 1•E�r;�a•re t.," p�:; •.S •a :4 . t U' ....et. .ltj+%+ _ ..i�.`�_t_ti+,!J'• t ..+,'. 'a ;! r•_ , ''' Z'!'�'+i:` .'? .... �S s.._ .;i• ' , ,t'. "�1�`...,,. _ _. ,IJ,t-..:):e r. �j1 ,t.,tib. ." a:is.=j. '7,'t"t,.,f.._. �j.r'J,.i _ ;l� , :rZ:, � �• !'.'h ;d ' ,�Qtt rt�iit.,i: �:'y�..t"• ytr1 �itr •�xaiiy , City of Northampton Massachusetts -� � DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building yJti a r 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: 7U0 r,A (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: .'OkiZ � i " 6_JX_(k (Company Name and Address) ZO ignature of Permit Applicant or Owner Date c�- 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. Proposaf SEXTON ROOFING AND SIDING INC www.sextonroo in of P.O. ]Box 6327 Settin_the Standard Holyoke, A1A 01041 gyp. 413,534.1234 f. 413.539.9906 MA HIC# 118239 sextonroofingga hotmail.com SUBMITTED TO Rebecca Leopold PHONE 658-5875 DATE 5/7/20 STREET 460 Elm St. JOB NAME Upper Main Roof 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. (811) 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. 1,it-4;,0&,k -8) Install IKO Architectural style roofing shingles as per manufacturers' specifications. >e. 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. -! , garage roof We Prropose hereby to furnish mater/a/and labor- coma/ete In accordance with the above speciflcations, for the amount of, -Seven Thousand Eight Hundred DOLLARS [$7,800.001 PAYMENTS rO BE MADE AS FOLOWS: 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 Signature deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.DAMAGES TO BUSHES AND OTHER VEGETATION'MARKS ON HOUSE MAY Note: This proposal may'1ie withdrawn by us if not accepted BE UNAVOIDABLE AND WF.ARE HELD HARMLESS. Not Iesponsible for water within(14)days. damage during construction. Owner to pay responsible legal-fees for non- payment,and applicable interest. Rcceyrance of Proposal The above prices,specifications and conditions are satisfactory and are hereby accepted. You Signature are authorized to the work as specified. Payment will be made as outlined above. Signature Date of Acceptance. r The Commonwealth of Massachusetts Department of Indms&hd Accidents O_jjcce ofbwesfigadons 600 Washington Street U9 Boston,Masi 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly Name(13asirK=vorgart;zalionawuYwuaal)_Sexton Roofing & Siding Inc Address P_O. Box 6327 City/StatelTp:Hofyokeh Ma. 01041 pboIIe4.413-534-1234 Are you an employer?Check the appropriate box. Type of project(regnk-ed): 1_L I I am an employer with 4.A I am a general contractor and I 6_Ll New construcem employees(full and/or part time)_* have hired the sub-contractors 2_^ I am a sole proprietor or partner- listed on the attached sheet_ 7.['Remodeling ship and have no employees These sub-cont actors have 8.CJ Demolition working for me in any capacity- employees and have workers' [No workers'comp_insurance comp_insmance.i 9_Cl Bunldulg addition required] 511 We are a corporation and its 10_U Electrical repairs or additions 3.! I am a homeowner doing all work officers have exercised their 1 I_C'Plumbing myself [No workers'comp_ right of exemption perm MGL or additions insurance required]t c_152,§1(4),and we have no 12_XRoof repairs .employees.[no workers' 13_ P Other comp.insurance required_] •Any app6caut that ebecks box;l mast also 1111 Got the sceflea below slowing tbeb warkers'eompcnsation potiey mformatiod I Homeowners who submit this at5dwit indicating they are doing all work-and then hire outside cautz ctors mit submit anew affidm it indicating such- .Contactors that check this boa mast attach an additional sheet showing the name of the sub-cootractms and state wbetier or not these entities have employees if the sub-coutrulm have employees,they most provide their workers'camp_poLcy number. I am an emp/nyer that is providwiQ workers'compensation insurance for my employees Below is the policy mrd joh site b7iror"tafiam Travelers Property Casualty Company of AmericaInsurance Company Nme: Policy#or Self-ins-Lic-#:UB-OG078982-19 Expiration Date-06/04/2020 Job Site Address: City/Stabr&ip: 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 an or one year im­pn—wW—n-en-t as we as ciw es in the of ren of a STOP WORK ORDER arld al ine of $250.00 a day against violator_Be advised that a copy of this statement maybe forwarded to the Office of Investigations ofthe DIA for coverage verification_ I do herby certiJy�e pains and penalties of perjury that the information provided above is true and correct signature: Date. Print Name: � ATL' �c,�4 s c�� Phone 9- L/ ! Official use only Do not write in this area to be completed by city or town official City or Town: Permit/Reense#: Issuing Authority(circle one): 1-Board of heath 2. Building Department 3.City/Town Clerk 4_Electrical Inspector S.Plumbing Inspector 6.'Other Contact person: Phone • 1 s �,: • .F, l ,'R• -FV[r!, ;,I't"'.a � .:1YL �.. t" .3'))� .i'.'e' '��raGl^`•1::7C••5,'1 g.{._. - ,�I v r,: rl""•���' „+`?r'•.. �•`� � .. t•�.,; i) '��". '' '.. ..�S;.L" f`>��. ;:�•i :� _��1h+r '33r , t"'ri'.it;ti`xy • - • ;\ c_''I.-�'E R:.yr. .,.Sa`'•�ari^N::;,�\^.�:. ,,rrl!i fit.' '�:•; ,. .�,j,T�y�.'c.` rs:\,'J„��';,, .r'#',;.,4' - ' • - �l'c r k' � 1 :f 2 t ".. :}tea ...,�y� e'�. 1•t f,R:""jvy� pix r�y\i��Z:3:.Y rt t. a ,. Y r�Xk✓#"�a+'�j,Yi •t + Z 4s: •' .. '.',�t': tC.,. '_anl, ._ •,• . ,. :r�r, y�:A. .' ' :i +r�.r,;A.fi'•: ',1�'° .�++' �;,aF'+!.i t r it "S,.r. �, y�• �.a:ti!.F".D`i .:.;$ '• 5..�:r.:'',{. :t.ii�A..:"?i. �i!Fd #ityf• '�, 't.:a;."� � �at:"FL'.x.•-t•k "w'. r'�eit;G.'..J ,' �" 71t • •.��.!!� ,'�,+r#::•'.1',". i t is '•.. .. � , ' .Ot. y r'., ,q A .rw'..'�"^ i-13'f.... -.[,: '•j•,,+..:�',�'.� ':� ,+!,� .. .t.^ ?�;" L'.��i.,i..,`w 1 :.fit,-. - . n tx+�: ..ass.:•;.'- _<r' + .,,it;_ ..c..I,�Cx,£" '3.i.;, rr„y7'Y r�xryn''S�" _ y•�, "7C ..,�I.,r .:.•cr•qtr• ;ua r'r .:CC•..s'�t 2'-:rfIR'.1rit.i}4Js ',x. - ec+4. 4a:l.xta.tv::# ;:. r6�' nh, *' .•.,us:, ��tr.ae roa.,R'-.: z .a :i:.� ' r{,.;. I 1::'�-. '.C. yt rye' :9}::'8 ��P"Ai;+Ae •u'.?►. •i'�e.:d ;Yes , ""J..# '.•ws+�rY..• .. , . " ,,. ..r ��:zfCf{1' - - (•'kCi:'v�rlt� ... 1. � � �� -,y4...,1;F'11'7. '�^t,+��,st1:. ._x'r ...,. �':'•tC'ry•",'7 Y� rr .e 1 .r',.,J•S.*.+'-{q;" T.hi�•'^ 1...Yv-.r ' l.': � ,e'ti �.,Y..,. :.. __„ .. � ;: .. , r r�.- 'an ' ^fctx t • a•{F i a�' 't�. y;'X. a� V,,YY cW Y. - f �p pI■�}}}}/-.sd: k Ir } _ .yk �.1 •;�,.�'����F�...�k*r li•.. il#J'1.' 1'x}'1 �.,W,%,.�.:Ss'{�.w Y7i �iA yy>y,:,Y,. CERTIFICATE OF LIABILITY INSURANCE DATE' 10/20/fyr1r' 19 TULS�TiFICATE IS ISSUED AS AiNATTER OF B�ORuATiON ONLYANI)CONFERS NO R1GKTS UPON THE CERTIFICATE HOIDEfL 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),AUTHOR®REPRESENTATIVE OR PROD AND THE CERTIFICATE HOLDER- IMPORTANT. OLDERIMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the poGcy(tes)must he endorsed_ U SUBROGATION IS WAIVED,SUW"d to the nns and conditions of the policy,certain policies may require and endorsemenL A statemerit on this certificabe does not confer rights to the certificate holder in lieu of such endorsemen s. PRODUCER CONTACT NAME ORMSBYINS AGCY PHONE FAX PO BOX 713 (VC,No,Ex* (AIC,No): E49AIL WEST SPRINGFIELD,MA 01090 ADDRESS: 286TF INSURER(S)AFFORDING COVERAGE MAIC# 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 R COVERAGES CEmnF1CATE NUMBER REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE-LISTED BELOW NAVE BEEN ISSUED TO THE YISURED NAIL ABOVE FOR THE POLICY PERIOD INUIC LTID.NOTWITHSTANDING ANY REQUI[Rt1MENT;TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRH RESPECT TO WHICH 7M C13ZMCATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES OFSCRIBED HERM IS SUWEC`TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LWTS SNOYIH MAY HAVE BEEN REDUCED BY PAID CLAIMS MISR kDOL am POLICY 1}F DATE POLICY ETP DATE LTR TYPE OF INSURANCE am WVD POLICY NUNME R (IBAIDDIYYYY) (NWDEAYYYY) DACES GENERAL LWHArfN OCCURRENCE ;S COHRIERCIAL GENERAL LIABILITY GE TO RENTED S CLAIMS MADE r--j OCCUR- NU3MSES(Ea AED EXP(Airy one Person) S ERSONAL&ADVINJURY GEN'LAGGREGATE LIMIT APPLIES PER ENERALAGGRCGATE !S POLICY Q PROJECT F--j LOC ROOUCTS-COMP/OP AGG S AUTOMOBILE LIABILITYCOMBINED SINGLE �S ANY AUTO LIMIT(Ea acodent) ALL OWNED AUTOS BODILY INJURY y5 SCHEDULE AUTOS Per Person) HIRED AUTOS BODILY INJURY 'S NON-OWNED AUTOS ROPERTY DAMAGE ;S Per ac-dent) UMBRELLAL1AB OCCUR EACHOCCURRE3NCE �5 EXCESS L.IAB Lj CLANS-MADE kGGREGATE S DEDUCTIBLE RETENTION$ S A WORKER'S COMPENSATION AND g ANC STA WTORY OTHER EMPLOYER'S LIABILITY YM UB-0GD7W82-19 06/0412019 (16/042020 UNITS my PROPewroRRARTTEaIDXECUTruE �INA E.L EACH ACCIDENT j$ 1,000,000 OFFICER/MEMBER R E MUDED? ( Y EL DISEASE-EA EMPLOYEE i S 1,000,000 It yes,desaihe under E -ION OF OPERATIONS� L DISEASE-POL CY L®qT 'j$ 1,000,000 DESCRIPow DESCRIPTION OF OPERATIOiNS1LOCA PEDAL ITEMS TIDS REPLACES ANY PR10R CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS CONIP COVERAGE THE INSUREDS MA WORKERS COMPE7SATION POLICY 4ND ITS LudETID OTHER STATES ENDORSEMENT AUTHORIZES THE PAYWE vT OF EIENE TI TS FOR Ci AM4S MADE BY THE DISURED'S MAEMPLO1TFS IN STATES OTHER THAN M4 NO AITIHORTZATION IS GIVEN TO PAY CLAMS FOR BFMTM IN STATES OWER THAN MA EF TEES INSURED IMES.OR RAS EEIRED E PLOYIFES OUTSIDE OF MA TATS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA- CERTIFICATE ACERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIDID POLICIES BE CANCER L rn BEFORE THE EXPIRATION DATE THEREOF,NOTICE WRL BE DFL IVFRFn IN ACCORDANCE WEEH THE POLICY PROVISIONS AUTHORIZED REPRESENTt ACORD 25(2010105) The ACORD name and logo ars registered marks of ACORD 1988-2010 ACORD CORPORATION- All rights reserved. `'`:.s �a,}a 1{►.;;' .nt '1/� 1 ",.,� :r '�.� 4tr s J2. : +�2 •.r T�.c! �s R�l' - .�xa� �4• ..;'i:ttWtdb -1 , — ,F.r•r:;.�.f.;t+t£'t=r ip..�?e!1' :ar.l w.+,. :i. s*:a1.#"i,�E�Y 1:,.:. ,;j�e�:5.. . 1 � s' Z,i 1rtiA.*.�W llYSr:lIE :+r• j+ �'!: � ., 1 >il'9t'k'rr:Tl'tt.^ _ - .., ....w.. .w-w�.. y s.. •.•t........x.w+ ♦ .r w vw^Aaow :.•...Mwu. ...a.. • i .. . .,...l,•. ... u.Y.._. ;- r :+. ' - ,.. M...i . _ _. .. r 'd' - ..... f" ��¢, ;c :,riy.:f ` ,v�-tl��.:..- jiskir.'.t' i ,'7y.,r 'c'�f" '.?}L _. . . •�'�• .S, rY:_ ... .i♦ �'f1�'!B t �,. - .. `i ... :.E L'. > .'� :�tt.� `a'�'.:'I��T.$,;.,r Pl.,t`r�/ .. ,•,..' ( 4. ? ',-1 �.{,'a'M•a Y.f' .9'r...'�+t ' � t c . ' 'CtJ x. ��Y` { 3r r' -.d•.Qi = :�!. r K :w � �° '�t'te'�i, � � , j 7.4 t } .! r ,`" w w..ILX'+4••.},,....._ ... - T,i#.�"hS't ., Amity V g ',�,tt,,,l„>_. Rr .'.J A i �� �". ��� ,. ..._, .+ ' .. ,. .,_ °'i .. �rC'1.:,` �,,F':4tir ' r i .., �.22t" ,1- ,, ,e:;._.ugg ,,t J:4Crek,{, :,!'" .y.H . . ::. 7 ✓. .t x he i k n ai. ' O +-,r Lfe { , e', r v+r. �4t � *YJ(La:Y,�ltt`•*3i. :lfs`is� / ?: ,a}].� .Y.l' aF 4' v Jil r .,. �« '1 n "'z.�.f�/_�i"'7Lw ✓�s�.. .,.�°�.w..:o .w�. - �..T "'•h• µms.•.• «.�j :3+ �`,.,..,... � ....�. ,. >;�. d#l4f.:,t`�'�y� µ� •� � iti • , - .:LC K rs. ;.. a,-1 { d'.-i a -.... V'v,• •.'� .moi r�,','`�i(:.iY y. : •_w 5 wf•P'14f ..i1t hs^i li r't`:t°'F - a t..zy},a':..R _ (:' -...ta.y _ 'vr'"�''rtic.",. •r, Of -ctr,�.• .r r ...} ...x. Vto .:•?,*ql3ZW "'�f:+xx•, .i.; , ri• :(c�1:�r�'C Gx .w;,7•t .:; :; sS wsM, '- P - ,..«�.—....y,�.rt iV!:G ` f-' -«r.•.,,.e.• \ ! .•:a!•1+�a5 t. i•.JI:,vYP :. -ix s}lr:.n... f C'"t ,k.. .. .�`1 f firxri !'teal ' a ,+J:t'I i t � a f '� :„!,/tr-�h.°. r d143•.J ?1 R c' aG'�' .*t rt�Y R 'k�.tet`t' .,1 �'�i�'S�' �i"� � j1:N: if At y;•' 3 ':7+ - is .,�.. :..�Y ^o`. n ,�_a.. ..� Mri� �� �+ ' .. P +wr..•�,,���?d)'l.ylfr s; ar~ c .s. 3 ^'• - .w qr. l t J�} .S••.x. a.. .t s U..IS •,r•�..wT 1�".J+IY J!°s +'.,. r .''q. tr 4V;' SEXTO-2 OP I R AC4R0' CERTIFICATE OF LIABILITY INSURANCE DATE("MMWYM �%� 1 07/10/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEIRL THIS CERTIFICATE DOES NOT AFFIRMATTVEL.Y 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 INSURERS), AUTHORED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pokcy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the pokey,certain policies may require an endorsement A statement an this certificate does not confer rights to the certificate holder in Heu of such endorsement(s). PRODUCER 413-737-0300 T ANTACT Eric Dembinske Ormsby Insurance Agency,Inc. PHONE 413-737-0300 FAIL 413-737-0617 698 Westfield St PO Box 798 wwt_No,EJ*� Wc,No West Springfield,MA 01090A cod erlelxN Eric Dembinske -- AFWIWBG COVERAGE MAIC# INSURERA:COlOnY InSUf2nCe CO. - 1N ® Roofing 8:Siding,Inc. iNSURMB:�cy Mutual Fre Insurance 15067 - Sexton PO Box 6327 INsur+3t C. Holyoke,MA 01041 INSURER o: INSPIRER 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 NAND ABOVE FOR THE POLICY PERIOD INDICATED_ NOTIMTHSTANDING 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 I LTRTYPE IN5ISU1�11NCE KDDL BR ,NUMBVD ER POLICY EFF POLICY W M A X COMMERCIALNAENEItALLYIBLITYI EACHOCO s 1,000,000 aAWSMADE FX OCCUR IOIGLOO2159903 061Z5(2019�06120f202D DAMAGE TORENFTED e $ 100,000 MND EXP �,e S 5,000 _ PERSONALaADVOLIURY S 1,000,000 GENT AGGREGATE L9AFr APPLES PER: GENERAL AGGREGATE S 2,000,000 POLICY❑JPE LDC i PRODUCTS-COMP/OP AGG S Z,{IOO,000 OTHER s B I CONBMH3 SINGLE Lour s 1,000,000 AUTOMOEILE LIABI ITY ANY AUTO AFV206561 051151201910SM-512020 BODILY INJURY(Perpeson) $ SCHF OWNED AUTOS ONLY x AU70.SU� I i BODRY IIN.RRTY S X NAUrOS ONLY X AUTOS ONLY NED PROPERTYraidw� L ± __ --- S ---.. —- --— � s UMBRELLA A IAS OCCUR I EACH OCCURRENCE S EXCESS LMB CLAINSMADE I AGGREGATE $ DED I RE"11 ON i S INORR6LS COMPENSATTON PTA OTH AND ENWIDYErt^LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YOBE SENT SEPERATELY EL EACH ACCIDENT S — (Ma Cndrtrnj�in NH)EXCLUDED? N/A -- F-L,DISEASE-5A EMPLOYEE S_ Ifyes.desa- under DESCRIPTION OF OPERATIONS below I EL DISEASE-POLICY LINFT DESCrJFrION OF OPERATIONS I LOCA71ONS 1 VEHICLES(ACORD 101,A ddNb"Remarks an e&dp,wy be alfadled V nae spare's 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 VATH THE POLICY PROVISIONS. AUTHORIIED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved_ The ACORD name and logo are registered marks of ACORD j*=i'7►'L4't�,f.f Li9MSS�"11T2!t j,L{�^r't; ��tf?jr9nYi(} yaxat ti'y,Vr"l+ a 'X.� v ,, ,: + .j����x.�+4,�:+Iir�r�Clc� :"k'Si.�)`�.i,�i: v 'Y ��►y'„�=r„ ,r} f +..'i�.r+�h� ..':k't .f7`C.'s �1YFf+Ci' +It4fr.+�' "#l.. +f` r`,.�.�",'♦CSAy("'�tP, .. j � ,L``kyy,�r�y-a2A'f�,�.•�.,' . 'r# '�'tk:{�^• `'•:t 3t-�t '?►' �`'`s! ,r ' -. � • ` a 0. Yt�:l l.na a+7�. N(Y .J't��.. .�-+�5� ��Y �t��L' � + �,. :4_ tf��t�`d�►i.t __. ..... �.__.--,.`,,, ._., " �_.._ •...., - .. ' �. _ �� .�/...�s�lt� �?L'..(3t.. ,.1 1�u rKi�.t� it., hie ro�4+svc< . ,rs�...�.._ er.'�:^t +°`Y'_.,.,„ r,ae M_ .« ,......,....�_... •,......,«.. __-" t ` -. ' ' _ � r-. ...,...�11•.._3.._.. ... _ _ �.+,:...«.. .. -., a.....�.-.i.i..,......r.b„�l.'►:'�'.i:+' Jr'P�,.shirr' Y ..._�.,..._. ._ ....}' .. �! 9 ` rat �p r•._.-.,i � � .11/ ... t - t.f d � -y �' �'..'41i?`::1 �i}�+d::.:�.i+.:�r^;.lr.`"=Et:s'' r• �:.1 :x +.•, u• _-. .. .:- .. r Yiw. . k .,. t-.• .. .:}pi 1.1 .y..(�.3d r^!.: � i+'�ja+Y t" CR'Y '� _ t�J wo ' { ai ,'.• I.lb.?'.L,�1Wr lid"*''P.S. ,x'p� .` "n _.. � ';»gig.'! b-' l..' .. . , .. ...... _ .p...,. _ M4 p '.lY.r at t %'E•E+-irF.rT tr..''''l�' °'r','AUZM:%,M1�Frk.(P.".. { t r.'i.ri�!l_. � "r..r •'` Y r s4;, -� ,.(J �RI�C r tr'a t�i+E �... `�3-d�k' '1ti9fv`' t'i••: e'f?.i�t`,1..:'sV f41 .9..}Str ?i+.' a1�+...-i.i+. . � V. a rl_.ifY �S ) - i J.1,S, dw'r '?w +ti.?i"�'!4xt'grE:T'Vi "." 1 �lft� �*` 7� t} a� i >t: ..r._1 .�. ♦�"P t s.:C+'W4+��+� i Fl}d�">'�I�it.l:fr�, - '' -..._. $1i.7'!.'Y: • ,_ .,.,_ v\i-':a2.:,;..'�-.!��IP4:''L•ar' •'ifr►C`K r, ... ... _ - t•'i:` 'y • ..11 14* '�-�`Z'.� ! nth. r'. .,,�.,��e-�',,y+Vtik •�+c .. � �'..tifi��l4�Ltly.�.�IF:..a.+..�.... .�..> ..».._ ,,.. .. «... ...r..__ ., ......�, ix. t�aY a.F.lt?tir �,'..�' �i Y:IYiFllt:a })Yt (Sqa+. rrr t..:FSJ♦ Yr'$x+W '+'�'rt✓ b r •:, a 6 + d �"g11'MSy ,f.tig- A. �'�Cy Ci•+;a'4i1,+ t .4'�r'E kti.8. 1.fin.{, 9 - .+}Y'xc• eLip}' �tY-� t +.'Mx i Y' Y>-.rif S,[t�$ u�1Yt �,It°r1_t >�i��1Ys�a-�&� �t a ., y 1': rt n z 1 ,� J•2 at y�ii:.s +_ :xi, tau1�t111• l6Tl:p,Cf{{ iG �Y/PrC*4. nx .ecwan�aKt w4rt ,+N�.si 1liirl�d�Y'�y► T• 1 •t t+i� tt.� � (FI' �� "`e � s r. `,.'S 'L t1Fi ��.�.1\� •. �ll�;�:�?f Fi•�j}-vic-i IV, E>�i:•.o t? �R.'�d��'tls.:+ � ,3e;19�..�'1'#�.f+.' .I, �ti . ➢KL'• ctt�vic.1,;r c '" =>�►t Gk J ir�v, s. ; a:3ltv1tM3 S;@r�+'F_a!ti3tFi `' 'Rt :�P"'}I�Sd �:� i ,ti .: .t"¢t, i3'.�kt ►1;13 tr'LItiC err' ` . :tis yYa:>t1�s.T :#tG�,` 3!S;�s F . t Zfftrf< a9G`J Sr�rOL i AfF:. 'A +t �:'ulL� ^ 'rr ,' x r„ moi'�,�, °,s7i..11Qs.Jl-�.. �.l��� s r..�'2.a r vi-1`: :�'i}+c.:•�+•r .•5/•aT YA+' T'�, f+Y:R WltJ.�14� The Commonwealth of Massachusms Deparinvent of IndusVialAccidems I Congress Stree4 Suite 100 Boston,MA 02114-2017 www.rnasxgov/dra Ww*ers'Compensation Insurance Affidavit:Builders/Contractors/ElectdcianstPlumbers- TO BE FILED WrrH THE PERIIITTi1G ALTHORM. gl2tican information i Please Print l ibh Name(Business.Or,—anuationln(frvidual): /W /tt, � �.;t�, {l;c=_tom'✓ h CityiStateiZip: 1661 16 r. /tib. Q j r L7 Phone#: Are you an employer?(%- eck the appropriate trey t T}pe of project(required): ❑t am a cmployc-r.mb +.cmplwces(full and/or part-titre).' ` 7. ❑New construction 2.Q I am a;ole propnttor or partners)up and have rro emplotiees worLing for mo in g t Z Rig am•c,pecay.lNonorkers'comp msumme required-] L! 9. ❑Demolition 3 Q t am a hurrxowrierdartgali�vorl:mysdf(Novxxkers'comp.ttisuraricetegiurea.j' Q 4E] ni I am a hoe�aw�ncrald aiH be hiring contractors to conduct all work an>t>1 property. twill I0 Building addition ensure that all contractors atter hsvr workers corrpctsatiori msrtaice or am sole � 11.[]Electrical repairs or additions pmPnctors with no employees 12.0 Plumbing repairs or additions 5 El t am a ger-rw contracw xw 1 have hired the sub-contractors listed on the attached sheet These sub-ermtrmcxs hsVr empb)res and lnve uvulas-comp inst n=e-_ { 13.❑Roof repairs 6.0 we are a corporation amd ds oRcas have ncarciwd their nglit of ecemption per MGL c 14. � — -- - --- .. 151..§t(4).and we have no cmployees f No uw-ers'comp.i su rmm require&) i 'Alin applicant thtat eliecks bee I mast also fill out the section bdowr strowi their workCes'ooetpasatien policy urferarwon t liono"mmers%im submit this affidavit ind=*mgtheey ae docigall-awk and then him outsidecontrictors must submit a new affidavit indr 2nng such =Contraaors that clinch this boy must attached an addiwaW shcrt shm ing the narie of the sub-connators mid state utrc,heror not three cmiks haw crrTlo%ves If the sib-coir=wm have arrplmees,Obey must Mvide thctr workers'comp policy number. lam an empleTer that is providu►r)r workers'compensadon insurance for my rmpfoyees. Below is the poficy and job site informadolc _ 4 \ Insurance Company Name: 1A4,-"vt7� Ft i:cI LX -S j�Ut S e Policy or Self'-ins.Lic.;?:__ F�/ l7 Expiration Dater Job Site Address:— City/Statetzip: Attach a copy of the workers!compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to 11,500.00 and/or one-year imprisotmienL as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to x250.00 a da}'against the violator.A copy of this statement enav be forwarded to the Ogee of hwestigadons of the DIA for insurance coverage verification. I do hereby certify under the pains and pesalde^s of perjury that the iaformeaion provided above a tree and cornet Ii _�wr .iii' -`✓�� — St e: _lL1LL ' ��, , Kid' [?ate L) Official use only_ Do not write in this arra,to be completed by city or tower officiaE City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector '6.Other Contact Person: Phone#: K�'�.. , -:i:' ,.. �'�4:.' ....�7,.:.'�'� �. �..�•.c.xX.'�. Rwt.„1;7C...r.. � . -.may w�-.. ..... ...'1 9'"�.-. c r x •�y � �1I � .+'':. A ` x �-i:RLt.^. �-:s t^ �c�t�.c� .a'.S.° :,�„.'h.j�h 'r ';5„!.-a+ +ib< l' - �+ v'L.+`G'•dfj,S6':.., + y rr' ��L: •.��- 'f'•a. r•Ylk:.• r - L�'-�,.bl '►,, e- ss r(... .. ".lM. .� :.i`ef •!}ft LSvfi., 'S�,'ci'LY�S'.Lt,.,::?F.. :. -.7 • w rd L "ri ti�aV .t, "Sw'?'+ k.$� is �k % fr;e •)t�, rri; 'SL n }J6" ¢i;,{,,i t"'I Sa' ,. P _ _,f ?2"f.,a`. y"t; n .�: L k:.:,iL,. S"x.i. '.xfe. �n7 fis' t�. ..,ily�,�y} \_.:5.�. e..� e R r k•'i�` ''kt#y*Y'_ .iX•r f �� L it ' �s♦ •4l rr'�i�jt�i. 1 a. � •�• r�'- f.T"' t:r.x a�t3V t:'�`(}; >�' ,. .�, :?:"-, — _ ... r �. .. - � - A\.� t. ,j ....�.F.: .�s �..... •j.-.r }. �.Zt'1' .s:lnr••..w.•= .,.*i,'.....:-a,.-M..,.y.--.. _ ..- w!?.r �r'J.irr�,. ;�, _ ,ti,.P"" : . t rt` •. ` - - ,� .^'!b\ '�`�• ��y k9;e. „''1.! .. � ;,-fi �-Jva�4j +'az'�"': ;•� it 7fX.. � iL' ',�, ♦ �fy'r t�'� tT'y ;.:. r J 4".':', iti, . . .. - ,-�-.e w .a'Y4 .3 AF::+'.,."1-..-""T« fir.:•' r ..ri. + .TjG�`. x_"Jo._.YhA'i.+#C'i1.�'t','alC"...'MZ,,;,:. y"K,'tiLt.:.�'..,.Z':: � ,I c � r 1 .Ti r'• y Yf.' ./' ,`�. �i 'Cr•'�+ t,:. �r l .�Fil!•sl •' .. e+t s �Rf� /,K s .t ,r. .. ,r: �.+�' Ir fir' � .�,. `,. ...`.' 4y ' �+~� .. r .. .. �.x.7{ "�'x'C� .. E', `kR''p'ir. r.'{1�IY�lG•i'�r y�.,'._�' t i• =r++L:4 F i'.-'M°y{` � . �.�... ... ............. ' '� �, ..y{..4 x .'dens� „..%,'• s ,�.da..4 r t;, wP`ftp'".µ �" �"�'Y'�l.','4- - .,, _I.- •. � Kr r+"!i 2. „ � .x '-:�otrrt'{31R•..::.1 .. .+1:itx'p' }i;.. .. + Zr4r4 r, J4 ;t. - ,r r. ,.w[ r?'. .r„'," 4i _ P v +ly»n i. f "'aP.: r• �tr, +r ti,;5 ..., „G PA Aw ow ji NNiti � �,,', ; +-s': f{ 's2. < ,, + ^ �� .... _ ,.,,.....^ .� tet_ ... •` .� '4` v ' i..�' _jS1t .S r�.t'i,CS•.R' t- .lrF ..,.. ns' Fts.� lt,^ ...l. ' �; Z K,../ ' ' r yr-1 ;•.;#. .,._.X�1}+:.}� ^r:8� ... '3 :''�£ r. ,}.� �ajlF/-•.r s y .. _ CERTIFICATE OF LI ABILITY INSURANCE °"-M peNoo^ THIS CERTIFICATE IS ISSUED AS A MA CERTIFICATE DOES NOT AFFIRMATIVELY TIER OF FORGATIV)RATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER 19 BELOW_ THIS CERTIgCA fE OF INSURANCE CE DOE SANOT COELy�TtnJND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE OLDER CONTRACT BETWEEN THE ISSUING INSU IMPORTANT: If the ce RER(S), AUTHORIZED the terms and conditions mho is AD �L INSURED,the polityGes)must be end certi5cate holder in lieu of terry.cerin Policies�Y"Liffe an endorsement d If SUBROGATION IS WAIVED,subject to such endorsemerrt{s� A statement on this certificate does not confer rights to the PRODUCER CT ONE FAMILY INSURANCE AGENCY LLC " 'ort Calvllo P1+oNE tom)403-5942 FAX -- 1 Main St Suite 15 AODpF!gs: a<ahr1710128- hoo cam Lunenburg MG INSURED _ MA 01462 > A: HARTFORD UNDERWRIT(gS INS CO NAac MNP CONSTRUCTION INC a c 30104 wsur:>iaz C.* 45 EXCHANGE ST APT 3E INSURER D: MILFORD INSURER E COVERAGES MA 01757 rNsuRERF THIS IS TO CERTIFY THAT THE POLICIES pFI1NSURpN78475 �M8D4BgOW HA1JE BEEN INDICATED. NOTWITHSTANDING ANY REOUIRSUURA REI�SION NUMBER: CERTIFlCATE tNgY gE ISSUED OR MAY PERT T OR CONOtT10N OF ANY CONTRgCOOR INSURI=D NAMED ABOVE FOR THE POLICY PERIOD INSREXCLUSIONS AND CONDITIONS OF SUCH POLJC�IEN$ LIMITS SHOWNCMAYHAVE�BY T){E OTHER DOCUMENT WfT})REgpEC f TO WHICH THIS TYPE OFrttSURAE BEEN REDUCED Y PA DECLAIMS- HEREIN IS SUBJECT TO ALL THE TERMS, CONMH2gALGBdFRALIJggITJTY O1 POUCYNUAra6Z POLA.YFFF POULYpIp CUUMS-MADE OCCUR EACH OCCURRENCE S 1 � oAMA T PREMISES crenae s GENL AGGRErz/{TE L1LQT j NIA f MED EXP(Ary ane ) S AppUESPr ; PERSONAL&AOVULAJRY S POLICY C,� n LOC �- , GBJERALAGGREGATE OTHER: PRODUCTS_CoIY�I�AG� S -- AuromostLEL1ABRrry S ANY AUTO Jj I SR1GLEl1Mri S ALL OriNED SCHEDULED i I _ AUTOS _ AUTO NIA j BOOBY INJURY(Par pwmp) S HIRED AUTOS AU i II BODILY IKAIRY(P- S -- PROPF�i'ty U11WR3LA UAa OCCUR S 17rCE55 LIAR - _— CLAlUS-MADE WA EACH OCCURRB�ICE S DED F RE'TBJTM')wl S j 1 M AGGREGA WORKERSTE 5 AND OI�B�64T1O �1 I — ------ s - -—-- -- LIAsury ) S �tARTNEPJEXEcurnVEYIN X S RRME OTH_ A EREuDE NIA NIA WA � Ify 'd demy=ft under 6S60UB1K70970619 11/162019111/16202o ELEACHACCIDENT $ 1,000,000 If yes,describe tinder I DE SCRXPnnmOFOPERATIONSbeb. E-LD1SEASE-EAS 1,00'000 J jEL DISEASE-POLICY LNur s 1,000,000 1 WA ------ DESC ---- - RIPr1pN OE OPE7RAMONS I LOCATIOMIV@ICL.ES pIcORD tot,Adti6oaaJ tRnoarla - Workers'Compensation benefits vAn be paid to Massachusetts em mYbO2 dodffmorespw is',7ifed) claims for benefits to employees in states other.than M employees only_Pursuant to Endorsement VIlC 20 03 06 B,no a assachusetts if the insured hires,or has hired those employees ac00 is given to pay This certificate of- P oYees outside of Massachusetts_ issue date of this cer�5ficattee o policy in force on the date that thiscertificate�hued(unless the expiration date on the above c Search toot at www- insurance)_ The status of this coverage can be monitored daily by arming the Proof of Co P �'Precedes the mass_govAwyworkers--compensationrinvestigabons/. Cover -Coverage Verification CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE SEXTON ROOFING SIDING INC THE "O" DATE THEREOF, NOTICE Y"LL BE DEUVERED IN S ACCORDANCE WITH THE POLICY PROVISIONS.S102 PINE ST AUTHOR RBpRES@lrATME HOLYOKL MA 01041 Daniel M.CmG/tey.CPCU,vice President-Residual Market-VCRIBMA ACORD 25(2014101) The ACORD name and logo a ©1988 M14ACORD CORPORATION. All re re rights �� ered marks of ACORD •. - . .y ,�y�,.,, .�. •orf rj>(of r.-' a ,/}'� y y� ,�q�- �y , C3'Y f `�.�f!.3' /i -fn{•-k*Rw t. ,�t'jfY .. - ..r.. � ,��*r•.}'�`}N, t.tiN i�^'t yts_"T_,y /��.C't}�»s -. ._ 71 �" •. 111 .��+ ;YrF »it4 f?��",. ,.m 4:l j^.J:f's�+�t'4�t` wd .. :nlTy-t ;'rL'@c�,t]Y':. M9s.:S< {�+�.�'Nilt=!$ �`i3<<s• �- `t =�1Cei6''J 1fY:L, r� d"t.th is(?'i?+ �•, r, '. :.£ irk a i b' zl td�1jp 4'�+1 :ir,.,,•1 '7r.A r�'%: � .. �Tft tr,•, s �, ;� 3n6 , y _ t fi r r ri''u, �•,��/y �a,�; 1, =t y':I:R a9 ��ti ` �:4 ., yc�,y:;R: X1:,+.3-t!'ll.. J! +fir.;rtl;;:.{.,r.r.. },!(}•'�' t .. - .rtw f -3,' '"!`i•.'..'< t'tfl':T,, t res fk � - y� y .��r:_. i:'•�^tt+F�ai'!",� ♦ a.�.^'+ r y v P",'.. _I'`F.v1 .r i�•'* }u:V,�;2 �t1 F�' 14 s• s +$eP3t'S'dE.�.+e ..� ,,:+M�,�4'�y may''Ic eevlltvr,.t' e. tY+r'e{k w .'�6 _.,_ ..... ,p. ! +r'y.',,,{ zt;14 k +Y•'#7Y�1t'Li"':q' r J_`A' _ ,.. .. ...^, t .,. � � _ ., f t" - ,."v:iw - . •4' 'r � "�r.^,. � q+a ., r a � e � tt++sa ah. t•ElIK.Jr -C 4WT mry ' +�' v � ! ! rs>�+aii'R`):K.;,'?2� 41!'-",,L, , , fln ,, r (:�' ter is .• .._'+-.. .1 - .• OGla t • ! i�� e .. .. . . .t tAs f f ,�d::•_f�t'•'"�,Tia'i,ai.ti` ... .. _.. -3 4 i'? A 'tt� Ct _ . tl�,wtaa ,ter '' k !. l ♦,.to. � l ,� T_!' - ����,h, - :.F+(,�n�}b'.. �.sTy3f}TAyiY- W 940 V'. •� 'r`-� -,mss:, 3{R.. .. ..wt's 14..." a fd �'-'�^ •• t4•T.� B=e }+.-_ Y.�: e„C>.` F i"a�. xj t-t +: .} � t r 'may � + � •, (: t r.�r:�>� � }+tri 4' 'r f`' , t �,e►1fi}' i�'�" ,,;,. _.._, _.. _..�,' _ �.x..y �}f''14 i•c�,+'I�'.fY.'t ,.... .. :. a{.• to t��: �_� �; � .,,., ...•s., ...... 'r y ? Olt .i., '';�Y It�i [.:: t,t 'V'J. a,�, f 'R Y>`'"r°s,Afxl't�i' t'9tkt'S+OF.6tli:�tK"-y`fti r- t a -ass ,i:3�;S J -i?�" - -✓'�� ♦ u, ' i J. it '�+"� lots r..y r '1 �4. �.,k;�Y..�}.,t�='i- 'T.•��� .. _'4 X ,. ...-. e ten. •fat .+. p'c�',LL, .3 fry �. .... .. -._.,.e..- I ' r rw ,'H w 'fC� .'� ,r s ,., a ; r t;a '�"�y"�tt-. .ft'+.c; r•.. �ta'"fAZa s ► nKl,r 3 �! itillt } 4:;a1i. :., •t> ` s y }§: t��jt A i:.kSr ;t"L t + � +:t' F.W et•, R u':.zL3' +: t� 3'sa:#::: ''� '� .. . , 'VIE L„..,. .tyy pp�tt�; +1P�+�� .ror,_���aX��t�j��PitF,+vF.� i,a:.._'�2tiry•YdA}yh. .A: • ♦ Y l tip.X'�Y�4.�.r �* �CO� J�. CERTIFICATE OF LIABILITY INSURANCE DATE I�DD/YYYY) 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 CONSTRUTE 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 CONTACT NAME Art Calvillo One Family Insurance PHONE E>a. 978 40 Lunenburg,MA 33942 FPS Ho_ 878 A03-5943 Ma 1 in St 5ui01462 15 ADDSt_ : arlfamilyinsurance-corn INSURETR(S)AFFOR004G COVERAGE NAIC A INSURERA- Evanston Insurance Company INSURED INSURERB: MNP CONSTRUCTION,INC. INSURER C_- 45 EXCHANGE ST APT 3E MILFORD,MA 01757 eNsuRER D IINSURIE R E: INSURER F COVERAGES CERTIFICATE NEER 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 ALLTHETERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES-LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. FA TYPE OF INSURANCE . POLICY NUMBER POLICY EFF EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADEOCCUR pREipgg S 100,000 ►ED EXP ane ) S 5,000 Y Y 3ET9385 11103MS 11/03120 PERSONAL a ADv miuRY s 1,000,000 GEWL AGGREGATE UMIT APPUES PER- GENERAL AGGREGATE S 2,000,000 POLICY �T El F-1 LOC PRODUCTS-COMPIOPAGG S 2,000,000 OTHER: S AUTOMOBILE 1.114iMM Y COMBINED SINGLE LMOT S ANY AUTO BODILY WURY(Perpermn) S OIVNED SCHEDULED BODILY KAJRY(Peracddw* S AUTOS ONLYAURIS_ HIRED NO" M DAMAGE AUTOS ONLY AUTOS ONLY EROacsidenl S $ UMBRELLA LIABOCCUR EACH OCCURRENCE S EXCESS LIAR HCLANS-MADE AGGREGATE S DED I I RETENTIONS S WORKERS COMPENSATION AND EMPLOYERS LLA LI[Y YIN STATUTE EER ANY PROPRIETORIPAKIT CUrIVE❑ NIA EL EACH ACCIDENT S OFFICFRlME1418FR IXCLl1DED? (Mandatory in NH) EL DLSEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below El DISEASE-POLICY LorIT $ n®CFW=M CWOPH M014S/LOCATIONS I VEHICLES(ACORD 101,Ad&fia 9 Pz u Sehedale,wW beaftd"8 mom space IS mquJmM CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DEUVERED M SEXTON ROOFING&SIDING INC ACCORDANCE VW H THE POLICY PROVISIONS. 102 PINE ST P.O.BOX 6327 AUTHOR>?]ED RIEPRESENTATIVE HOLYOKE,MA 01040 ART CALVILLO ©1988-2015 ACORD CORPORATION. All rights reserved ACORD 25(2016103) The ACORD name and logo am registered marls of ACORD ' a F 4awct SY;fid` I VC t')l' ���y 4 ,� ;,firtI}a�td1i`{ 4:t�r4VY 'rt � :.�•itMF'31:bY?%,'k t'�.!,rER'hi.'�::'a"t>r":'x::aQ'!SZ.`�Ga;w;i•,Y"":,firii,.'tF+�.' .. �- . -,:s} n•,r.k,1R.f"15-.>'i". '.,riY� .' r E.'1,!'..R f'3Mfif.,y y�.ayMt- :�1• -rt attlaaCi..r ...a,treaF r,�a -,, i- r <:,a, r 'fit '+ -. F:i• "S i• ( 'I7 1;M 1' � 7 { w :»,,.. y� ..,.,..... .,. .a... �'h: ; ;'�y }:1"". 1.(.t d2:d'ir�.i x.%;e.,y� =t,„ .�. � a* •'b�'9�..yr'r . - b . ff) ' t ,.. 7.x,'.rot'YI�": t r. YJb: ✓ro'R'�111 Yuyv�ta0rta.t '.... .i c wti•-arc- �r �.:. z 0 �• '• _. _.... \.. ._.. .....- ... r I. r r .i�.f.1'�.1( - s. :W,lr i .:aQ},:;'.ri} ✓+IrIM.'�i Ks�: '_'•qt.. t: mm� -#pi.y�.tyt a3t FtA : � ,YN3tA .',3"!yY(n t">r: ,c` J ) j t a �`��"'"'"'?' �'T �_ .t=•(�� . �:t�f t. f qn. t .'`' •_• 4A1.4ii," �y•�tY'7 ..s. } , �,�fJaat - k-041P ., t r t!!'ai ,,t v E.,.!r �h i a '°'riM.r t a :r c �t.l� � �.d �,li•;,+}.r ,vitt� i a$''�..1 L '�� L.r't-'`..�t�" '(JL "t't i?J,4 - � ,ti .t'4 i t; 1WF.} t - S -'e, r ,r�}; r a Sf' { :faJft 41 l Z.a %a`-t,• ��r �? , i r'rie.l a +Ytt�;,ys 'itir*�S$Lt' '►`L�:>ie gGrt. r. �Ja*I - 00 Ulf am), .,tAt�6.iP•Saf f;:t�+ir'ty 4. � '�`hp sitFik'�i r }, s"t7Rt"y L tHr : }-`s� �'iatri '�t�iizt'�.'t`�'t^ �'• 'r�. y.,t: r.-� 1 "f a��t:'r5 w'4iR o#° ig t,'" � .�- .a...�'rw.'.,�.« �.v7.+M4.�. � .atMary t'*"<� • 544.•_1.�:"4• .•'i ifi`1'y��y"�TJ, moi. ':\` � f T"'Y! ( y,� In ' 1 00ashinReguIa6_on Hon3e Bot-31-0r,Ir�CV Mac to Q2778 "afar Z tiTTG SIDBVGfl17C _ - = F: _ ty#1L-- Com} �J SEXt3J�.j SI? PO BOX 6327 AO�E j1VjpR0 j -'10-t '0 P. ICONTRACTOR J s i'ON SR HOS_ it�$$•�'��tit. S p , A _=24u RT`'`�RppG Bc Cp r ITIC-0605383 SIGNED _ - u/30/2�2� AMF Commomvealth of Massach - Division of P usetts Board rofesstonal Licensure or Bu$d-ing Regulations and Standards Canstructio0t*' r Specialty CSSL-099689 J -; E-Jcpires=10105/2021 �DCi'OA1 "'�� ' 'r - PO BOX 6327 HOLYOKE MA. 01041 Commissioner