Loading...
30B-091 (4) 66 FEDERAL ST BP-2021-0986 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:30B-091 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-2021-0986 Project# JS-2021-0016.86_ Est.Cost: $10800.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sq. ft.): 23086.80 Owner: O'DONNELL GREG Zoning: URB(I13)/WP(102)/ Applicant: SEXTON ROOFING CO AT: 66 FEDERAL ST Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 WC HOLYOKEMA01041 ISSUED ON:3/9/2021 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. I I: • I • Certificate of Occupancy Signaturt., FeeType: Date Paid: Amount: Building 3/9/20210:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner ♦ The Commonwealth of Massachusetts • Board of Building Regulations and Standards '`F"OR �_ " Massachusetts State Building Code,-780 CMR,7th edition MUNICIPALITY USE TY Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised January One—or Two-Family Dwelling 1,200E— This Section For Official Use Only Building Permit Nu er: igif,—c).I e q g(, Date Applied: 1'-- o (� �� a- U D Signature: •• • _D:20Z ( N n s Bui ding Commissioner/Inspector of Buildings Date " ' SECTION 1:SITE INFORMATION L =ter 1.� /,P perty Address: I,2 � qrs Map&Parcel Numbs 1.1a Is this an accepted street?yes no Map Number ParcelNumber G c 1"Y" r 1.3 Zoning Information: 1.4 Property Dimensions: . Zoning District Proposed Use __ Lot Area(sq 11) Frontage(ft) 1.5 Building Setbacks(ft) , Front Yard Side Yards Rear-Yard • Required V Provided Required Provided Required Provided . 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Selvage Disposal System: Public❑ Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' �Z. Ortner'ofRecord: 6 Ad-5l �_ f C O. �rJH�• A dress for Service: . )L°'. 'ru,f14- ,` / • el'.,„-.3 /1 2fr9 400Hn e l/ TA '7 ' Signature Telephone .9s.,tiGt:r, • SECTION 3:DESCRIPTION OF PROPOSED NN'ORK2(check all that apply) New Construction 0 Existing Building l vner-Occupied £24 Repairs(s) ❑.'Alteration(s) 4 Addition 0 Demolition 0 Accessory Bldg.❑ • Number of Units / Other 0 VSpecify: Brief Dcescription of Proposed Work2:— e - ),-i S .. -1,--r./ St1 e ,tz----k&-' • SECTION 4:ESTIMATED CONSTRUCTION COSTS. • Item Estimated Costs: • Official Use Only (Labor and Materials) • 1.Building $ 1. Building Permit Fee:$ Indicate how fee is detennined: Ti standard City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier_ x 3.Plumbing $ 2. Other Fees: $ V 4.Mechanical (I3VAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ 4Suppression) `, -Check No Cheek Amount: l Cash Amount: 6. Total Project Cost: $w( Lt "_ 0Paid in Full El Outstanding Balance Due: p SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1(�/ U/Cf 9 4f S FI ere II.�e ! )f') License Number te Name ? }of CSL Holder/ ^} �/ j�, V �OK C0,3 J7 List CSL Type(see below) i) i t J No.and Street / Type Description !!O/,reKe !1)/')UI U Unrestricted(Buildings up to 35,000 cu.R) t-JU CAI c/ ! R Restricted 1&2 Family Dwelling CityMinsn,State,Zip M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation _ _- - Telephone Email address D Demolition �5.2 Registered Home Improvement Contractor(MC) p� 1 J 3 ,37xJnn. &64r anc/J/r,/% n( I I�a 3 9 `� MC Registration Number Expiration Batc HIC Co any Name or Registrant Name ' No.and Street //I Ohotmal/e.c"'/ Fil address F/'/a7)fie, 17?F9 Gc/6)5(/ L/3—534-1 / CityJT4wn,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE A}"F'IDAVIT(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 ' 'ti} ' No .Cl SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ( I,as Owner of the subject property,hereby authorize��)( (%f 1 (,��`7/,JG , i/7lf' LnC to act on my behalf;in all matters relative to work authorized by this building-fiermit applicationtJ eOn/TOr i iehe / 5 /Z/c' Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this plication is true and accurate to the best of my knowledge and understanding. MUST BE SIGNED by Owner or Authorized Agent 1c /e NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will p[have access to the arbitration program or guaranty ford under M.G.L.c.142A_Other important information on the HIC Program can be found at www.mass_gov!oca Information on the Construction Supervisor License can be found at w >tiy_tnas�.zovic_kis 2. When substantial work is planned,provide the information belovr_ Total floor area(sq.ft.) (including garage,finished basementfattics,decks or porch) Gross living area(sq_R) Habitable room count Number of fireplaces_ Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system • Enclosed _Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" z C. .'TON ROOFING AND SIDING INC www.sextonroofmg.com WOP.O. Bow 6327 Holyoke, MA 01041 Setting the Standard *M , sab,awn mom 4 t 3,539.9906 MA HIC# 118239 sextonroofing@hotmail.com com SUBMITTED TO Greg O'Donnell ' PHONE 413-923-1128 '! DATE 2/22/21 STREET 66 Federal St O'Donnell.gregorvfagmat7.coin CITY,STATE,ZIP Northampton,MA 01062 SEXTON ROOFING HEREBY SUBMITS SPEt7NCATIONS AND ESTIMATES FOR: 1) Strip and remove existing shingles and dispose of in proper landfill. 2) Inspect roofing deck and replace as needed Via. S75.00 per sheet. 3) Install new metal edging to rakes and eaves of roof.(8") 4) Install ice and water shield on eaves(6'), vent stacks, in valleys, chimney, and at intersecting roofs. 5) Install#15 synthetic roofing felt on remainder of roof. 6) Install new flanges over existing vent stacks. 7) Install starter shingles on eaves and rakes of roof. 8) Install IKO Architectural style roofing shingles as per manufacturers'specifications. 9) Install new counter flashing on chimney. 10)Install new cap over ridge vent. 11) Supply manufactures Lifetime warranty and SRC 5 yr.workmanship warranty. **PLEASE ADD S1,800.00 FOR GARAGE ROOF We Propose hereby to furnish material and labor-complete in accordance with the above specifications.for the amount o4 Ten thousand eight hundred DOLLARS ($)10,800.00 PAYMENTS TO 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 ( 2 /11 workmanlike manner according to standard practices. Any alteration or Signature 1 { �'W 11,K, 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.DAMAC.S'IOBUSHES AND OTHER VEGETADON'MARKS ON HOUSE\t‘\" Note:This proposal may be withdrawn by us if not accepted BE I'NAVOIDABLE AND WE ARE HELD HARMLESS.. Not responsible for water within(14)days. damage during construction. Owner to pay responsible legal fees for non- .ayment,and applicable interest. ileggitkures 4-total The above prices,specifications and conditions are satisfactory and are hereby accepted. You are Signature 1$ authorized to the work as specified. Payment will be made as j outlined above Signature q�1 �� �Date of Acceptance_ l"1("-) � ; �`e'4 I \ r Department of Industrial Accidents 9 .-,-, ,a 71 y Office of Investigations % 0Lafayette City Center l 2 Avenue de Lafayette, Boston,MA 02111-1750 ‘W�! 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): I. 1.El I am a employer with 4. I am a general contractor and I 6. 0 New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. [1]Remodeling . 2.LI I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. 0 Demolition workingfor me in anycapacity. employees and have workers' p ty 9. 0 Building addition [No workers' comp.insurance comp. insurance.t required.] 5. 0 We are a corporation and its ' 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.111 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 13.0 Other employees. [No workers' 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 anew affidavit indicating such. ,t-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:614/21 Job Site Address: C A.,-e.)-- .. City/State/Zip: 7 /1� -1Z /`�1 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. . Trance coverage verification. . I do hereby certify under t ins and penalties of perjury that the information provided ove i true and correct. Signature: - Date: 3 02 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): 10Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5Eklumbing Inspector 6.0Other Contact Person: Phone#: (MWDLI A�D DATE 06/09/2020mrY) , CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER . IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed_ If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME Kathi Hutchinson ORMSBY INSURANCE AGENCY PHONE FAX {Ajc,No.Ems): (413)737-0300 (Ac,No): E-M AIL khutchinson@onnsbyins.com P 0 BOX 718 INSURER(S)AFFORDING COVERAGE NAIC# WEST SPRINGFIELD MA 01090 INsuRERA: TRAVELERS PROPERTY CAS CO OFAM 25674 INSURED INSURER B: SEXTON ROOFING&SIDING INC INSURER C:' INSURER D: PO BOX 6327 INSURER E: . HOLYOKE MA 01041 INSURERF: • 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.' POLICY EFF. POLICY DIP 'LTR TYPE OF INSURANCE VYVD POLICY NUMBER (MM/OD(YYYY) (UMID LYYYY) LIMITS COMMERCIALGENERALLIABILHY , ' EACH OCCURRENCE S _ DAMAGE TO RENTED I CLAIMS-MADE OCCUR. PREMISES(Eaocnmen®Z S MED EXP(Any one person) S N/A PERSONAL&ACV INJURY 3 ' • GEN'L AGGREGATE UMRAPPLIESPER: . GENERAL AGGREGATE 3 POLICY( I jEa ( LOC • PRODUCTS-COMP/OPAGG S . OTER: . S AUTOMOBILE LIABILITY COMBINED SINGLELJMIT $ _ (Ea accident) _ANY AUTO -. .BODILY INJURY(Perperson) S ALL OWNED SCHEDULED • • _AUTOS _AUTOS N/A BODILY INJURY(Per accident) 3 HIRED AUTOS NON-OWNED. PROPEKIYDAMAGE $ AUTOS (Per accident) S . UMBRELLA L(AB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A . . AGGREGATE S . • DED RETENTION$ • . $ WORKERS COMPENSATION X ATUTE OTH- ER . AND EMPLOYERS LIABILITY Y/N . • ' ANYPROPRIErOR/PARTNIRJEXECUnVE EL EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A] N/A N/A 7PJUBOG07898220 G6/04/2020 06/04/2021 •(MandatoryNH) ._ - EL DISEASE-EA EMPLOYEES m 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY UMIT $ 1,000,000 — N/A • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD lei,Addationd Remarks Sc de,may be attached]`there 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..govilwd/workers-cDmpensation!Investigations(. • 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 . • n,_ I Amherst MA 01002 L Daniel M.Crogey,CPCU,Vice President—Residual Market—WCRIBMA • ©1988-2014 ACORD CORPORATION. All rights ite erved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ACO D® DATE(MM/DmrrY) CERTIFICATE OF LIABILITY INSURANCE DATE • THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. This CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 'CONTACT NAME: Ormsby Insurance Agency,Inc. I M E=p. (413)737-0300 FAX (A/C No); (413)737-0617 698 Westfield Street E-MAIL ADDRESS: West Springfield,MA 01089 INSURERISI AFFORDING COVERAGE NAIC S INSURER A: Colony Insurance Company 39993 INSURED INSURER B Sexton Roofing and Siding Inc INSURER C: 102 Pine Street -- INSURER D: Holyoke,MA 01040 INSURERS: INSURER F • COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE US)!L)BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDInON 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. LLIR TYPE OF INSURANCE INSD I wVO POLICY NUMBER POLICY EFF POLICY DIP LIMITS {MImIYDD/YYYI) (MM/DDfYYYY) A X COMMERCIAL GENERALUABIIJTY 101PKG002159905 6/25/2020 6/252021 EACH OCCURRENCE ; 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) S 5,000 PERSONAL B AOV INJURY I$ 30,000 GENL AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY JET ( LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER _ 5 AUTOMOBILE LIABILITY COMBINED SINGLE LIMB (Ea arced ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPNI IYDAMAGE S AUTOS _ (Peraccident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S _ EXCESS LAB CLAIMS-MADE • AGGREGATE S DED I RETENTIONS S WORKERS COMPENSATION I ETATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? I I N/A (Mandatory in NH) EL DISEASE-EA EMPLOYEE$ myyes,desmDe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY UMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD d01,Add Tonal Remarks Sdredule,Wray be attached if more space is required) 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. AUU�)T..HORRED REPRESENTATIVE t ©1988-2014 ACORD CORPORATION_ All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD The Ceona ansealtkof ' 1 as meg,Suite I O • - Boston,MAOW4-2017 Workers'C. (rnfo\-1--ije,41-)o Ina. Addresw 4 fl Q ' city/slam/rap: -111\koAsn phone#:33 -cn Asa•matli!es'!cxaaYlrrieappcapddteieot= - TYPe or (rellairedx_ 1-12'ramaeaci yerwith - employees : , 7 0New consinudion 2.0iataaaoicpe otlorar a+d]iancapaacio godcias farmca g_ Q Day aptly.pia Inaba'camp.imams= 3 3.Dlaaboo:craardoingailinatnelfPioarorlas' r It Eloa 4,0 Tmakaeeoraeraral sal I=l i cvvmckossosmdorsaHvaicmmo•pmpas_Irk 10 QWeldon mace amm000rceither asearadmms irtri* or air sale I LEI Elechical=paisora iB paaapoetea aarti no employees. adcritions - 5.0Iamz eal oradIlaaeta dgae sEstedaait=•,. .a.rrr 1 �Q U� These sab-aortndoalametaa piap=saibase arackeinp.insasance? I3-12Irrepairs Other 6.9Wcweacc porationsad inotrcashavecceSitca tiSei rink ofaciwolat perMGI.c. 14.0 I52.OKaodsae hex so esapioyecs.[Na aaaizre camp_iaaaamctmp ii _ _ *Aa]yap¢uettaltb�slsiYaasts �aettesetiioabricar aowig> rmarbas' - a brfurmpm. Homaasrseasvin 'sd ftilitya edoiaggivac mode a assidecaotagoassam[ as ICasmctoasfnreiterkibis box m atameiedanadd'mmadsi eliboacia zdmmac ft csab-matiacteissad staielevesiemarmtSoleasal brace earplaseQ WtbesabemlaamaL tbayaoast waken"amp.poncyaaaab¢ I ton a nragplayer isprowitlingmrlere conspensokoriosurnerzfor�employees Below istimpoti ranifobske c )s6 LLndQr10r1 3 _h „M 00 Policy#orsaf—.>e. cc SICC)tte)1 10q1 WO EapiFisooD4= 111 a101 ) Job Site Addres= CitV8tatetax Ate a copy of the workers' poN4y declaration page( the peaty masher and eXpiraticat date). Failure to secure coverage as required tmdetMGLc.152,§25A is a criminal viol»p le by orate-up ID SI,500.00 audios-onoyearimpasonsoett,as nett as civil pena sin the loon afa STOP WORK ORDER and afineofapto 3250.00 a clay against the violator-A copy of this statement may beIto the Office ofiavtstigatioos aftiienaA for i am= coverages I do r _ •tie: •% :�penn +ofperjrrygtettitc panrri letIaw 'strafe mmtcamect Srgaa= j£/a ' - _' rbtt i I [i fO I /A Phone#: , OP- 9 ` 7-g 7 7 6 Officiolnwonly.. Do,sat>t eisthsarea,tohe completed fry city or town drzcial City or Toler PermitILic se# _ Issaiag A (c o I_Board alleath 2. Departiaeut 3LStyITown Clerk 4. Inspector 5.P Iftspect nr F 6.Other i ' &onset Pawn- Phone ik . ' - a1 A Rom CERTIFICATE OF LIABILITY INSURANCE Dare(YM/DDIYYYI') 11/13/2020 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. tf 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 CNAIite Edson DeSouza MAYFLOWER INSURANCE GROUP INC No EA, (774)773 s702 FAX ADOE 6S: Edson@mayflowerinsurance.com 299 Court Street INSURER(S)AFFORDING COVERAGE NAIC It Plymouth MA 02360 INSURER A: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B: MNP CONSTRUCTION INC INSURER C: INSURER D: 45 EXCHANGE ST APT 3E INSURER E MILFORD MA 01757 INSURER F: COVERAGES CERTIFICATE NUMBER: 595621 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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. INSR TYPE OFIHSURANCE POUCY NUMBER IY ADOL SUBR-_--- POLICY EFF POLICY EXP LIMITS „— LTRINSD WVp (MM7DDYYY) (MI� DI DYYYYI COMMERCIAL GENERAL LABILITY • EACH OCCURRENCEDAMAGE TO RENTED S _ CLAIMS-MADE _ OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENrL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY sE-r LOC PRODUCTS-COMP/OP AGG $ OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE UMIT $ (Ea accident) lANY-AUTO BODILY INJURY(Per person) $ ALL OWNED — SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS UAB I CLAIMS-MADE N/A AGGREGATE $ IJED RETENTION$ — _ _ WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY • ANYPROPRIETOR/PARTNER/EXECUTIVE YIN EL EACH ACCIDENT $ 1,000,000 A OFFICE7/MEMBEREXCLUOED? N/A N/A N/A 6S60UB1K70970620 11/16/2020 11/16/2021 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 1,000,000 It yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY OMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may 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 acce ing the Proof of Coverage-Coverage Verification Search tool at www.mass.govllwdlworkers-compensationfinVestigations/_ 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 THEPOUCYPROVISIONS. 102 Pine St AUTHORIZED REPRESENTATIVE Holyoke MA 01041 Daniel M.Crorey,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 • AWREII CERTIFICATE OF LIABILITY INSURANCE DATE(YYlDDlYYYY) --'�y 11/24/20 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 CONSTTTUTE 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 WANED,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 Calvitlo One Family Insurance PHONE FAX (Arc,No Ent): 978-103-5942 (A/C,No): 978-403-5943 1 Main St.Suite 15 AIL DAD : artg1famayinsurance.com Lunenburg,MA 01462 E NS/IRER(S)AFFORDING COVERAGE NAIC It INSURER A Evanston Insurance Company INSURED INSURER B MNP CONSTRUCTION,INC. INSURERC: 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 US I EU 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 ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (YY/DD/YYYY) (MYTD/YYYY) LIMITS X COMMERCIAL GENERALLIAB'L1TY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A Y Y 3ET9385 11/20120 11/20/21 PERsoNAL a ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY PRO- ELT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accientd S _ AUTOS ONLY AUTOS ) HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) S UMBRELLAL1A8 OCCUR EACH OCCURRENCE S - EXt.t,55 LIAR CLAIMS-MADE AGGREGATE $ DED J RETENTION$ $ WORKERS COMPENSATION PER OTii- AND EMPLOYERS LIABILITY STATUTE ER Y!N ANY PROPRIETOR/PARTNER/EXECUTIVE N/A EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) - EL DISEASE-EA EMPLOYEE $ I yes.describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY UNIT $ DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES (ACORD 1111,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER - CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCFI I FD 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 AUTHORIZED REPRESENTA HOLYOKE,MA 01040 + � ©1988-2015 ACORD CORPORATION_ All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD