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36-227 (5) 52 WINTERBERRY LN BP-2020-1288 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36- 227 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-2020-1288 Project# JS-2020-002161 Est. Cost: $5300.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sq. ft.): 60984.00 Owner: SPECTOR ABBY zoning: Applicant: SEXTON ROOFING CO AT. 52 WINTERBERRY LN Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 WC HOLYOKEMA01041 ISSUED ON.6/26/2020 0:00:00 TO PERFORM THE FOLLOWING WORKSTRIP & SHINGLE DECK 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 6/26/2020 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner at\ Department use only -'�-' City of Northampton ,\ Status of Permit: Building Department C{!Cut/Driveway Permit f 212 Main Street vG Sewer/Septic Availability Room 100 ���T. y�s WaterNVell Availability F 3` Northampton, MA 01, Two Sets of Structural Plans phone 413-587-1240 Fax 41 2 ` Plot/Sjtee Plans To,��, OtherSpecify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENO y MOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION / 1.1 Property Address: This section to be completed by office / ^ Map 30 Lot 'a i7 Unit 4) �0 )e4 ����� �/� ( Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: hone 7 > Telephone Signature 2.2 Authorized Agent: Name(P nt) Current Mailing Address: 53yiZ "3 y 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 4. Mechanical(HVAC) 5. Fire Protection 6. Total =(1 +2+3+4+5) �j < Zj Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: `, & &Zo Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) .. �s�'�r Y,�4'9.F�:I i. iY,1 y...1�2�C. �",, �3?�..5 '�.�ro`�,5�'�-/^�►s'r'=:h:.'cv'���¢�F'? �•c,*a'�'."t�Vf; ....e..w.....+....r�w,.....r«.,.aws.r�•�,w.,..,....w ww».wtnw..a�:,+.wo�wAw-•,s wurv'r.....»...w,.......a,,...na..r�wa.,pt.,.w:+rt,...•...�,....v+,.;:rr,.wW.t.kyr,r.r�..e..•+xw..n.r.tw.++ar••..wrAwra'r+.w.�s. - -.»..,..:.....+.. ..,-...w+»• 4:,..wn.nw.» •r'+'.x.+nl+r,...w.xw->:..:.�wb.tva.at�rr.'.x, ap�.s��yn,;-.,. .r-r...,n...-e...,.., r-'fwxrlNMN.w�.scn,v.,..-1srmW.kraM�ry......, '.un"t/h'�"p`°r•.d�w�*,.�.w. .,. J ........ ....,... ..:.. .. :.� ...t.,.. .. ,..._ .».., .tet.. ., ... .._. 3� r_r}n„'. L w...y '�, r7 J.x. ,� ' a..r'�• F p" I ..1 xv Ile- _ _ c t t •• 3 a ,. '�{ t.1S + r •fid_4,:'���'ai.:. ! ��. � � 1 t 1) fel. �^ �� Y•B d }�.��f " 0 'fir .•:y� V f-t w_[''I'�_ ,rt ..Y... - .,,� y d i i. ,.. .. .._...... .. .... .*...:;. ....... .n..y. ...W.......«. ...,....,�- ,._. •:.«..:.t.-�+.w- ,. .... .. ,.. .....,..�_ _ _.. .... .. moi'.. ___«.. ..... .......,.... }, ....,.,, ., ...1 . =a;.Jt°..i4 J s Y.XL'",...,� •''r„`iRiLt� k�+.»L,'x:1�af t`�r s '":•i`�'�+L{ K.e.'_��', i , r, I,.•�V i#�Y 41 �"1�' :u W:..;.I,.�'��.'.i�r��.+!j��..' Z ..> kf. 1Y'•� Au A c .art : r es i 5r'.a't' l t (. p •rf [.! f xC'' )lP .r R tt��, ti �, � w<'�y� � y:� ',t Y.. �'�c`•�f J �i�it .r� i Yf'`� rr+� i't F�!rw �*``•.'� "Sf'.`iw� I _... t t _ . Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Varia a/Finding ever been issued for/on the site? NO O DONT W O YES O IF YES, date issued: IF YES: Was the permit ecorde at the Registry of Deeds? NO O 1 DONT K OW O YES O b IF YES: enter Book Page and/or Document# 1` B. Does the site coain a brook, body f water or wetlands? NO O DONT KNOW O YES O IF YES, has�permit been or need t be obtained from the Conservation Commission? Needs to�e obtained O btained O , Date Issued: f 1 C. Do any sns exist on the property? YES O NO O IF Y6, describe size, type and location: D. Are ere any proposed changes to or additions f signs intended for the property? YES O NO O YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. tiC•$• syr. 'S'n t(' r ai2,1•f.' Y,-Z: .,:� r i ,8 .`:S.'w ,'L�iy h• Y�;.fit.f,i,.' ,. �,�• " � - 4 a � ^ �.. i.. � •,� t�,.' .. ,.. n°-�; •'}; p�Jl;:i� - a! .. C,.'�;'t_� rt ��f.'b+ �F•r?7e�.,: •'Id'. ..1:':,. - ¢i'.. r> i 77 • 3 , . . ..�. .,.. �'.4Y '•.gig. � � '- - .:ffii'r , i s, 4 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding[01 Other[U Brief Descri tion of Proposed Work: a 1-0.A-e D/'Q.C. �c_r!L PQ'z-�" Gc Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative vating 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 each family unit: Number of B rooms c. Is there a garage attached? d. Proposed Squ re footage of new construction. Dimensions e. Number of stories. f. Method of heating? X Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 . of wetlands? Yes Is construction within 100 yr. floodplain Yes No j. Depth of basement cellar floor below finished grade k. Will building co orm to the Building and Zoning regulations? Yes No . I. Septic Tarte+ City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Q(/�L/L/�� p �,�Zr� as Owner of the subject property / hereby authorize to act on my behalf, in a matters relative to work authonzed by this building permit application. 6),''1 (- ] ";� �'i'l/ %-Z Signature of Owner Dat I, /�`I z' L r' � - as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Sig under the p ns a nalties I perjury. Print Name Signature of Owner/Agent Date i �` 'i1orf '�cI�1�. , oX ,a ,,.. .. .,. ... ,+... .._.wt� .•+-roW54.+.+.wwr.Via* ..\,. .,,,„ ... _.... .._.....- . �, x'tr,,•�'� ''�, t,,d"' � :k't;\�`�:"-.�.r3b '"�-r`':l: � '' 'i!�"c?.� ,t�kP . ,. .\ .2.t ,'t�ti:�. r1 L ir _i;,-�W:� >r F..r+�Y r r :y'�" ,yY.�,�' i .;: ( ..y�• y '. .. ,. ..y+r.J^....(r>: ^�,'..b' ✓ `°"" ,Z,,, .. � .P 1, 4aJi +4 r„ .r. _ ,.,�'... _. J 'madgj - r l 4A.il 1�. y°'7'"\f,tert'. L46i'fipX�. .6 ,f:� �.A4c'.. �a:f l,i•• 'f r�'y*t�'. .� F - S yy� J '`Sc� ,,�••s�# .. ��kit..7rv;'.;Ei.s "'.� t E" �' , ;ik s;" #;;�£.�4'id .... �;;'�,6�1< s.,. {;\�>b tr.-i: i i + .M,z � �: >f j¢t1!t t �� 3 �•�t r Jlf:'i �'�E,.y •4' � �� aYNGti .l�ii4� � r � u,,S�.*t d�� � � j'' 1. ,_P.. u �f1.`tZll�i hS'i_l4r'`•" vA ��'M"..�xw-���.�.�-7.1•IiT �����p�� A ` P' + - .j yY SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: �u W /y 412) / License Number Address Expiration Date _ 6Y � Y � S Signature Telephone 9.Regisftired Home Imerovement Contractor: Not Applicable ❑ I)- ComRanv Name Registration Number VO L CU PL-/Lrr Z % Ad ess Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... Z/ No...... ❑ City of Northampton -00 ss f •''" Massachusetts �w� 'cmc DEPARTMENT OF BUILDMG INSPECTIONS x 212 Main Street • Municipal Building yvQ 4a' Northampton, MA 01060 fsNw 37��0 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, 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 hereby apply for a buildin t as the agent of the owner: 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 1, - .,... +a..,. .t.. ......e.,.y,..r�.. ,. w.,:r.�.4a,...r.....':�+i...,.a.. .w�w......ra...,.. .... ,«....+.•....+........�..w....w.w.a.w.....a.:..++,waaw..yr...a.r. ..•..«*..+�•r..ww,...r».w .°f� 41.: .. .,. «... ..«..-r.,rt•yyy.ww-.ur v..,... i ..� wrc wewnp W"+^"•' w. �,,J••.t.... ,n.s,...swww.-�r1.wNarm+.•w-..r.M•r-..aw-w+rrw.na..d....,4.+w..w:Na..M ....w....r.. '-.M.«...».N i 'p' a"T_ �'!'t l't. �r Ft:F ifLp��t �,Y�i.. `.X `4��a�f:C,1 �l'r il+.f PA,� �'Ar.3.� df .f Fa'J'"l.pf. 1 +43 ,;`iF,Ii M� ?i'.M`4.r.A":?M?:`�YV. .''if• ,_ :a a'}>Ys 'A e F�,v;'+�7a�`Y $�" F si, xv 4,��i�k+J�C}JR� •p'�Sya°�`� t' .'�-�s����6`,���� t♦v��S',+r..��cr'z�$t�� � �,�rr t f 3a� •.`!' "f�p¢'f���,;�`gP• 1 . .r•f{i/ll Y. [� 1s `?r.r if '1.�)q,.S �' .i i;'�if :+` "?C.�.►l'!}dW�'"y�g�i.t.Y.4.F�Fi i'+1 t_47.}!�f. .�`Yt k.Ap, i`gi*' 1. 1; a�4{t f.y ��r7 �Y:r T� ) i�. !�•�1_ll3ej a 14 sf!..�J lOOV ?Tr.}', All ;' .1-��,. .1��•�.°�4;r. '« �. �J."fib S'yk°, ii.v .rs .y �l:t k.i�.. , 5. aaA�I�I.�.t..3 '' '�.W"Cfif t.:; U - rat a .. • .. e. +`i.t.•i�� ._ .. ,.. r. pit' r, ., at '.iY.1:+h.5jt;t�}i.x.Vit• .1'�a ti`�;. ;�:t! :rf�;;Y; °ri,t.....,fhyt '`a .'�. h�tk ., ".c• 4�6i s7C 2.+>'e� ,;,"_y,}`t - a{"�;.:`,� age-r +',.:.'.J[','. ... •. .,.� �-' r;.r .:{j,:St;. ttd:. i�:i,...Z.l. 'bt,�-'N..'•t,.i![;:r: t.x.k,i-r:[;..., '[..:'--: ..ajii.•r,. + [ -fi<�."f'a4'�-� . �i� -' ,vhf.:,. ;r fCi .)�" ` ;s. •r ',�vt1,:}' !'r i...+'.'[�'.+a' i .. '3',y3`�int.:'r.:tf, ai'?c�� ;�.';311�'� ,;,fo ?..[ t`at d..tes., Vis.. ., e.{ �;. tii}.r" '.r.J, .ii" . i jL .t - [. . ,, .X_,,as ;i <..>i:ti:v�.� ,.. +t'S ia•: _ :'�. :1 t�: !r, ¢ir�,ytl� s ;t:�Eiy �:",. ,. . . 'f. i6o«e' .1J ..t: Lt .. ;�r� ;a.t.'Si: �r4 `.'>i" i• 7fae..f;,[7•: t. �i.'S1 7;''�`.��-' .�"Ll`,.� S:a .}.t d•: ll.,('{it �.: f• :it {r :1:.#r't{ cfilo; f ,j K 'tJetj'.t r' • - xit,'or gi1} m 4, '14rK, '•rY '1L`.�.F _ !S'�..:�7W.�hb:i'�.,:: ._... _. _4a.:�;�! �:.wdi".. - R'�•_4 + 4.� 'Ifr City of Northampton 2.-6 . . Massachusetts A� DEPARTMENT OF BUILDING INSPECTIONS rt. r� 212 Main Street •Municipal Building yJi :cs 9R+^s 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: 4 ( ease print house number and strdet 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: Id LAP et &i-j (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. ' •c\ ";yi .n �;,L.^•�✓ ,f:f;t'�aid � .tr C':.. ES,��.���' x:�,?`rt..i�.i 4.�;,�`S�Sr9� 'i�t';t �F� "8.x,7/.'..4`Ctt.^s i' i .. �''l� _'`>� t�' ?ca .,:r`.:�c"�' 'f t:'::T �i,:� :�tr:.�;�,'3'�Ci ��, �_ 'lt�.!y �C.�` �j,t3',�f �'r,ta,'^st: + � .,%�:4►Ix� ;*,$1? f,„;ti•ri"•.'`i y � .+:..-5 w )w', of f'$'3• �� Y 4's � f _; �. {i< 41.. ..1 6j °'A 4' ..f3 ri.Y•.� tivu l ;i-, Q+ i i y . !_^.¢i +Jt♦.is ...1 ,�1;.. �t.;��}�.� .a ;,1:�4A�(,, a� COW". .s..i�'�:s lN��lfi� ,•".S-x;•[;��1,:.1.�1.',,...::...� moi. .. - ' 1 utri{ , ,s.w. �°+a.y:.�`�- H'�'sr i:� '�.�.?�.F�t t'?,�. i...2�•�t�.��1:�'=�t?S�«g1{� :,F':'��,Mi,x;%'sC l'>t d�tr;',�, �` } l'f1�� a rs�.e.+f.:'q i''3��f ti. �r,'�::�':± e VIM Tabo Z. AT '�„;'�r" �i.:�.x lY iC,€$ .".!!►i)}'yzi{elr'` '.iti '�}�„►j':r ��' .�.7t'' # srK,.. .i';iIY�">~ T�C.(}#.Bili its' Y Y'p 1..r} .{i;3� -, xS{1'�rrie"d9 s`!€i.d`i '+P t'�rs,,,,�. ",:r,`a•;'k�1 7 ':t _.+ �,e �1 �'`:r re: " 1 fig c SEXTON ROOFING AND SIDING INC. www.sextonroofi ng.com P.O. Box 6327 Selling the Niam:ard y"t, MA 01041 Cerrtncd Rwnna�c i'natrn.tan p.413.534.1234 f.413.539.9906ssrxtornCo�ngt�a hotmail.Com MA HIC# 118239 CT MC#W5383 SUBMITTED TO Abby SpeetorP LONE 359- OATE '.x'7/20 tor* STREET 52 q intrrt►trry Or JOB'-4AAtE CM.ST,I7E.7JP lsrtbamptoo.Ata. JOB LOCATION side deet dormer flat roof 1. Remove deck ham roof and sct aside.(Nut responsible for damcgc during removal and reinstall) 2. Install mechanically faocncd.060 EPDM Membrane Roof. 3.Counter flash supports. 4.Install decal Edging tlnd Counter Flash 5.Install proper termination at walls. b.Reinsiall deck. 7. Supply I year warranty. 8. Install new hip and ridge cap on detached garage. ' %' a Propose hereby to furnish matcrial and labor-complete in accordance with the above specifications.for the sum of: Fie c-nuu,attd Thier lfundted Dollars(55.300.00) Payment lobe made as follows:in full upon eomptchon All llatc:ulisrsct.trst;rdtobc&4.s coif" AilwoAlobrcoap+lCled Aullmrifetl et a umr►rr3nitic meaner a.coatsap W stsssdard ptactun Any altcratsm.ce dc+ratiort frwn sbrsrr*PCV tfKaWAU unotcinb exaa case ,i;rnatutr will he cxc:wtJonly upon wnnen ordm—xW will hccow as tura :hagtr De rr sad ahu.e chr cstiraatr. Ail afire ea+rau:a ale at np:�r► Note:This pru4 ZY withdrawn by us if am accepted within(14) stales.accidents or dctays"vnJ oats control Not raivwihte rix water dinurc dura"tv;o w-tioa. Owner to pay rrvonsibic ktesl ices tlayS. for MM-rynrtscrt.sad aMiKibit tt:mco Acceptance of Proposal The above prices. specifications and conditions arc satisfactory and arc Signature hereby accepted. You we authorized to the work as specified Payment will be made as outlined above. Signature Date of Acccptawc. The Commonwealth of Massachusetts Department oflndustrialAccidents 92; Office of Investigations i Lafayette City Center -/ 2Avenue de Lafayette, Boston,MA 02111-1750 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):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.❑ I am a employer with 4. © I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. employees and have workers' Y P t3'• 9. ❑ Building addition [No workers' comp.insurance comp. insurance.1 required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.© Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:Travelers Property CAS CO OF AM Policy#or Self-ins. Lic. #:7PJUBOG07898220 Expiration Date:6/4/21 Job Site Address: Sl��U �� 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 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 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for 2ce coverage verification. I do hereby certify under t ins and penalties of perjury that the information provided above is true and correct. Signature Date: / /2 Phone#: 413-534-1234 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 1011oard of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5alumbing Inspector 61-10ther Contact Person: Phone#: AC"R"® CERTIFICATE OF LIABILITY INSURANCE DATEWAIDDIYYYY) as/as/2ozo 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 terns 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: Kathl Hutchinson ORMSBY INSURANCE AGENCY PHHII.N (413)737-0300 FAX No E-MAIL SS: khutchinson@ormsbyins.com P O BOX 718 INSU 5 AFFORDING COVERAGE NAIC# WEST SPRINGFIELD MA 01090 INSURERA: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B SEXTON ROOFING &SIDING INC INSURERC: INSURER D PO BOX 6327 INSURER E: HOLYOKE MA 01041 INSURER F: COVERAGES CERTIFICATE NUMBER: 541733 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ITR TYPE OF INSURANCE ADDL�� POLICY NUMBER Map EFF POLICY EXPINSID MM LIMITS COMMERCIALGENERALL1ABILITY EACH OCCURRENCE $ CLAIMS-FADE u OCCUR DAMAGE O R PREMISES(Ea occurrence) $ MED EXP(Any one person) $ _ N/A PERSONAL&ADV INJURY S GEN'LAGGREGATE LIMIT APPLIES PER: - GENERAL AGGREGATE $ POLICY D PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea acrid ANY AUTO - BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED ROPaRtDAGE HIRED AUTOS AUTOS er $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATIONV ERn OR- AND EMPLOYERS'LIABILITY Y/N X ANYPROPRIETOR/PARTNEI ILITIVEWA EL EACH ACCIDENT S 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A 7PJUB0007898220 06/042020 06/04/2021 (Mandatory in NH) EL DISEASE-EA EMPLOYEd$ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS Wow EL DISEASE-POLICY LIMIT I S 1,000,000 N/A DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(ACORD 141,Additional Remarks Schedrde,nay be attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only_Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay Claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance)_ The status of this Coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www_mass.gov/lwd/workers-ompensationfinvesfigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Amherst MA 01002 Daniel M.Cro vey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION_ All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD SEXTO-2 OP 1 - nATE(MMMDr rM CERTIFICATE OF LIABILITY INSURANCE 07110120151 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 AHEM, 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 poliicy(ies)must have ADDITIONAL INSURED prnvisions 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 Iiieu of such endorsement(s)- PRODUCER 413-737-0300 SME!-T Eric Demburske Ormsby Insurance AC.174 ency,Inc- (Asir-No.Er 413-737-0300 I�Nor 413-737-0617 698 Westfield St PO Box 718 West Springfield,MA 01090 AooADDRESS: em Iris Rns yins.com - Eric Dembiriske AFFORDING COVERAGE MAIC-X INSURERA-Colony Insurance CO. Acton Roofing&Siding,Inc, ITLSURERB-Quincy Mutual Fre Insurance 15067 PO Box 6327 Holyoke MA 01041 INSURER c INSURER D INSURER E: - IKSUf28Z 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. iLTR TYPE OF ITISURAHCE POUCYEFF POLICY EXP TNSD�EIR POLICI'NUMBER A X coQr�RRaALcaaslALUABnITY EACH OCCURRENCE s 1,000,000 CLANS-MADE ❑X OCCUR 101GL0021599030612512019(1612012020 ='---`ETO ,� s 100,000 ? { neEn o5,000EXPane s PERSONAL&ADV INJURY S 1,000,000 C$Jt AGGREGATE LIMIT APPUES PE' � � GENERAL AGC-SATE S 2,000,000 POLICY❑JJECT ❑LDC } I PRODUCTS-COWIOP AEGS 2,000,000 OTHER' I I S B AUTOpWUILE L1A81LDY I i C INEf15WGLE LIMIT S ANYAUTO 1 BODILY PUURY S OWNED SCHEDALFFOS ED BODRLY M.AIRY S AUTTJS ONLY Ix ALfTOS iXAUS ONLY AUTO ONLY i I 3 11MERI I A RIAS OCCUR I I EACH OCCURRENCE S EXCESS LIAR - CLAILISMADE 1 - _ AGS ATE S DED RETFMION$ S WORKERS C0I9PENSAI1ONAND EMFLOYEFZ I I PER OTI1- ANY R PFZIErORIPARTNHZfE7(ECUTNE YIN I BE SENT SEPERATFiY i A IOa daury in NU))EXCLIwt3P L _ ❑ NIA EEACH ACCIDEM S In NH EL DISEASE-6A EMPL S de�ON DES vr , ELDtSEASE-POUCYLIAUT S DESCRIPTION OF OPERATIONS belo DESCRIPnON OF OPERATIONS I LOCATIONS I VEHICLES(ACOR O 101,Add`rional Re ,its Schedide,r+y beaLtt-hed irmore spate is requaedl CERTIFICATE HOLDER CANCELLATION NONE-01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEII ED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN Everett Sexton ACCORDANCE WITH THE POLICY PROVISIONS. - AUTHORL!:ED REPRESENTATIVE ACORD 25(201 UO3) 91988-2015 ACORD CORPORATION- All rights reserved. The ACORD name and logo are registered manes of ACORD The Common vetdth ofMasachusevs Department of IndsmW&Atciden& _ I Congress Street;Suite 100 Boston,MA 02114-2017 www n=mgov/dra NK--r kers'Compensation lummuce AffuLw&.BuildersJContrador-vTAectsiet=s/Plumbers- TO BE FILED WITH TBE PER-NM-MNG AFMORFFI'. AI?pjic nt Information P!eane Print I&::iblc NBillZ(8usiness`Organization/Irtdvidual): / ,! L J k fu_t�,�, _ y h L Address: CiryiStatciZip: IA, o j -7 S? Phone#: ,ire col an emplmer?Check the appropriate boz l # Type of project(required): 1 a I am a employer R-uh_ __.cmploy=(ftr)l wd/or part-6=).- 7- ❑New construction 2.❑13m a sole proprietor orparmership andhave no emptotires cvorlcing forme in i $ Remode Qling arty crp2cr[y.[No norkas'comp.tnsurancc rr4ufied-1 i 3-Q1amahomrnwnerdomgall wmkmysdfLNowork-ets' 9. ❑�Iition rnmp insiaantercgmrzd_]' 10 Q Building addition DI am a hommwmermd 8711 be hmag ax&actots to conduct alt za dd an my prvpcty. 1,,,U r ventre ff=all contrstms eitherh3vcuvrkcm'wrepettsafioa i icor arc sok l ': Ii-E]Electrical repairs or additions proprietors with no emplo)xcs I 12-[]Plumbing repairs or additions_ 5 Q I atn a aeraal conwactoratd i have hired the sob�Iiseed on the attrshcd shod. 13.Q Roof retrans TheszsuL contradorshaszcmplo)resandtoreaarias'comp.ilsaance.= 6❑we area a porninn gad its flHicea ha,,a ccised their n,-Iu ofexemptioo per MGL c ! I S_Q Outer s.. 157-§3(4),and ti,6r Is vz no anployz,-s [No x%vz1- s'comp,irstrrance requirt&] `A mr appfic td=chcds box'I rmat also fill out the soctrou below slm%-cT xhm u=rkcs'aampcu=brm poise)mforn=W°. t ff, �who 7s. m this af6daru mdic.bmgd ey we doing alt Rei:and nccn h=outside conhzct=must subnat a rxw affidm:d Mdreanng such Contractors that cha:l:the bat must attached at addinano)sbcd shm%aT the game offt sub-conaact�saw state%Ax-t eror not those a>WICS base oTTID;�as_ Ifthesub-coirtrecto lm—,L cnplovets,lncy mtat Fur u+e 8mr workrrs'comp.policy nwuber_ t am an engWoyer that is providm,wort vs'congvwsadors insurance-for my employers. Bdow is the poffcy and job site informadom _ Insurance Company Name: N Y�r F0 l LkV',5 1�S Polite T or Self ins-E ic-r: Expiration Date: r� ✓, Job Site Address: cit-rfStne/zip_ Attach a copy of the workers'compensation policy dedarafion 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 tip 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 5250.00 a 'r!2�y against the violator_A copy ofdiis statement may be forwarded to the Office of investigations ofthe DIA for insurance coverage veri5cation- I do hereby certify under the pains=dpen&fies of pert'-u y that the injrarnzatitm pnnidJedfa`hove a tme and correct Siarra� �1 t C4� ` ..�f �� 2 � Date• Phone i✓z"J V k—0,::/- -Yr 7�1 C. Official use only_ Do not write in this area,to he complefed by city or town official City or Town_ Permit/Licensem Issuing Authority(circle one): 1.Board of Health 2.Building Department 3_City1rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6-Other Contact Person. Phone k, A4C"�REO® CERTIFICATE OF LIABILITY INSURANCE DATE(andvnorrYYY) =7f THIS CERTIFICATE IS ISSUED AS A IVIA 11/272D19 CERTIFICATE DOES NOT AFF(RMA77VE17Y OR NEGATIVME]Y AMEND. EXTEND OTION ONLY AND R ALTER THE COVS NO RIGHTS ERAGE E AFFOORDED 13y THE PO C IS BELOW_ THIS CERTIFICATE OF INSURANCE DOES NOT CONS REPRESENTATIVE OR PRODUCER, TATE A CONTRACT BETWEEN THE ISSUING INSURER{S), AUTHORIZED CER,AND THE CERTIFICATE HOLDER IMPORTANT_ If the certificate holder is an ADDITIONAL INSURED, the terms;and conditions of the the PC is es)must be endorsed If SUBROGATION IS WAIVED,subject to certificate holder in Tieu of sack endorsement(s�Lcies Tway require an endorsement A statement on this certify d PRODUCERoeS not confer rights to the CONTACT ONE FAMILY INSURANCE AGENCY LLC PN ' Calvrllo No (978)403-5942 FAX No 1 Main St Suite 15 AooREss acalvlllo1280)yahoo-com Lunenburg MSU—"S)AFFORDING COVETtA6E NAICtt INSURED MA 01462 INSURER A. HARTFORD UNDERWRITERS INS CO 30104 MNP CONSTRUCTION INC MSURPRB: WSUR£R c: 45 EXCHANGE ST APT 3E INSURER n: MILFORD INSURER E.- 'COVERAGES MA 01757 INSURERF: CERTIFICATE NUMBER- 473475 THIS IS 70 CERTIFY THAT THE POLICIES OF II7Sl1RANCE US7ID BELOW HAVE BEEN ISSUED TO THE INSUREDURED NAMREVLED ABOVE FOR THE POLICY PERIOD INDICATED- NOTWITHSTANDING ANY RE-gU1RHyIEN1 TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT T ED(CLUCERTIFICATEONS MAY O ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED By THE.POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, IXCWSfONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- �RESPECT TO WHICH THIS WSR LTR TYPE OFlNSl1BANCE ADQ " IVSD PoLICYNUMBER P011r.Y EFF POLICY EXP COM ERCIAL GENERAL LIABILITY j L1NI7�' } I CIAIMSWADE F-1 OCCUR ! EACH OCCURRENCE S li DAMA TO RBdTED PREMISES odzurremx S N/A [ MED ETP(Any ane GENNLAGGREGATEL=rAPPLIESPEiZ 1PFRSONALSADVINJURY s POLICY .-T LOC n LOC I GBdERALAGGRC-GATE j OTHER: -• J PRWUC75-COMPlOp AGG S AUTDMOBTLE LABn.DY ANYAUTO i COMBINED SINGLE LONrr S ALL AU`TpSS� }�U� BOOBY W.IURY 9-c person) S HIREDAUTTJS NOS o ED N/A BODILYINAIRY(Peragix" s -------- — Atrros � _ PROPETZTY DAMAGE 1 s UhmRa.LATIAB OCCURs D[C>351IAB CLAIMS-MADE IV/A ` EACH OCCURRENCE S DED I RETENTION S - I ; AGGREGATE_ _ _ S WORKESIRS COMB' -nONAND I I S --- -- -- LWOLrrr IN I v PER OT7-1- ANYPROPRRIEr0RipARTNERfD�CLmVE 1 XI STATUTE ER A tb 6E EXCLUDED NTA N!A N/A 6SS0tJB1K70970615 1 111 6/2 0 1 9+ 11116/2M ELFACHACCUDENT S 1,000,000 It demote 0 1 1 DESCSC RIPTOF ION OF OPERATIONS 6elnw 1 EL DISEASE-EA 8IPL S 1,000,000 E L-OISEASE-pauCY Lmrr S 1,000,000 WA -_ DESCRIPnONOFOPERA7WNS/LOCATIONS/VEHDCIES(ACORD701,AdMoro1Ra_.audk¢ Workers'Compensation benefits Inrlll be paid to Massachusetts employees fie,may be attached Nnmm spaces nNpAn dl claims for benefits to employees in states other than Massachusetts mp o the only- Pursuant to Endorsement WC 20 03 06 B,no authcF zation is gin to Pay hires,or has hued those employees outside of Massachusetts_ This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the Exp an date on the above policy issue date of this certifuate of insurance)_ The status of this Coverage can be monitored daily by accessing the Proof of Coverage- Searrh tool at wwwmass.govitwdhmrkers-com P cY Precedes the pensatio�nvesDgafons/- Ve>z9 Coverage Verification CERTIFICATE HOLDER CANCELLATION ATION SHOULD ANY OF THE ABOVE DESCRIBt�P0l1CtES BE CANCAD SEXTON ROOFING SIDING INC THE �cP►RATfoN DATE THEREOF "DTTC> WILL BE ACCORDA14CEVWTH(THE POLICY PROVISIONS. 102 PINE ST AUTHOR REPRESENTATr- HOLYOIk `11 MA 01041 S'w'FCrvy,CPCU,Vice President-Residual Market ACORD 25(2014101) ©1988-2014 ACORD CORPORATION- All rights reserved The ACORD name and logo are registered marls of ACORD CERTIFICATE OF LIABILITY INSURANCE °ATE``MDO`n`rr' 11/27119 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,subjectto the terns and conditions of the policy,certain policies may require an endorsement A statement on this cerfificaI does not confer rights to the certificate holder in lieu of such endorsement(s)- PRODUCER - CONTACT - NAME: Art Calvillo One Farrbly Insurance PHONE For 9M403-5942 FAX Na 978403--5943 1 Main St Suite 15 ADDRESS-Lunenhurg,MA 01452 = art@1famlyinsurance.com INSUREifS)AFFOAIHNG COVERAGE NAIC It INSURERA_ Evanston Insurance Company INSURED IIrSURER B: MNP CONSTRUCTION,INC. INSURER 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 MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUB,IECTTD ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OFINSURANCE TNSD WVD I POLICY NUMBER PJvDU EFF P'wDnN RP YID LIMITS X COMYERCIALGENERAL LIAHM Y EACH OCCURRENCE S 1,000,000 CLAOMSTJADE 1—1 OCCUR PREMSES omme S 100,000 MED EXP one person) S 5,000 A Y Y 3ETS385 11/03!19 11103MO PERSONAL EACV NJURY s 1,000,000 GEN*LAGGRECATELIMITAFPDES PER _�' GENERAL AGGREGATE S 2,000,000 POLICY❑JpE"C`T- El LOC PRODUCTS-COMPIOP AGG S 2,000,000 OTHER' S AUTOMOESLE I1-Rn.ITY COMBINEDSINGLELMT(E2 a—denn S ANYAUTO BODILY INJURY perpermrt) S OWNEAUTOS AUTOS LED BODILY ONJWY(Peracddrnt) S AUTOS ONLY AUTOS HIRED NON-OWNED PROP EI7TY DAMAGE S AUTOS ONLY AUTOS ONLY amdenll S UMERJE LA L1ABOCCUR EACH OCCURRENCE (CFS' S EJL1AH HCLAMS-MADE AGGREGATE S C® I I RETENTIONS S WORKERS COMPENSATION PER STATUTEER AND EMPLOYERS'LJABnITY YIN ANY PROPRIETORIPARTNERIEJ(ECUnVE❑ NIA EL EACH ACCIDENT $ OFRCFRINEMBH3 EXCLUDED? (Mandatory is NH) EL OLSEASE-EA EMPLOYEE S If yes.desaibe ranter DESCRIPTION OF OPERATIONS below EL 06EASE-POLICY LIMIT S 136CRIFnON OF OPERATIONS!LOCATIONS I VEtICLES(ACORD 101,Add600al Rertmarc Schedtde,may be dtached if more space is mgtmed) i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCR ISD BEFORE THE EXPIRATION DATETHEREDF,NOTICE WILL BE DELIVERED IN SEXTON ROOFING&SIDING INC ACCORDANCE WITH THE POLICY PROVISIONS. 102 PINE ST P.D.BOX 6327 AUTHOnz>zm REPFZsENTATNE HOLYOKE,MA 01040 ART CALVILLD ©1988-2015 ACORD CORPORATION. All rights reserved- ACORD eservedACORD 25(2016103) The ACORD name and logo are registered marls of ACORD 41 Office of Gorjs� Home ., 02178 � +iG�SIDIVGdtgC - = type- C _ QM 'moi o� �o� }�a3�I5� $� �gROEN3':.,CoCON �Fo � } .. EPEItET`t' RACTog J sEo S$ OZ InOg 0304(_ Il HIC-0605383 11/30/2020 CommomAealth at Massachus - _ -L 01vision of Professional Licensure Board of Btnf&-g Reguiations and Standards Cans-i�vcfro�rS'c `rr• IIPEs,4r Specialty CSSL-099688 pir 10105=2 Ev REIT J 4EXT01w PO BOX 63271 _ HOLYOKE M41 ------..-----.-__...._------- •(l. --- Commissioner