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23D-201 118 HINCKLEY ST BP-2021-1184 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23D-201 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-2021-1184 Project# JS-2021-001979 Est.Cost: $15800.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sq.ft.): 32931 36 Owner: DEBORAH B KALLMAN Zoning: URB(100)/ Applicant: SEXTON ROOFING CO AT: 118 HINCKLEY ST Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 WC HOLYOKEMA01041 ISSUED ON:4/14/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:ST RI P & 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: l�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. y9 c10 Certificate of Occupancy Signature: I i FeeTvpe: Date Paid: Amount: Building 4/14/2021 0:00:00 $40.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner aZ., The Commonwealth of Massachusetts • ' .. ' Board of Building Regulations and Standards Massachusetts State Building Code,-780 CMR,7 edition USE MUNICIPALITY Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised January One-or Two-FcmtilyDwelling 1,2008 This Section For Official Use Only Building Permit Num r:�j/7-'421.'// f9 Date Applied: )/) -7� -- n r-- -- nQ re: . // ' . '_/". /`7'GUZ 1 . 0 -+ Boil ing Commissioner/Inspector of Buildings Date i. IT]. - SECTION 1:SITE INFORMATION irb c per ddress: 1.2 Assessors Map&Parcel Numbers n z N T,].a-I$this an accepted street'1"yes no Map Number Parcel Number • a m r.21 $14aning Information: 1.4 Property Dimensions: o� w NArming District Proposed Use ____ Lot Area(sq ft) Frontage(ft) } 1.5 Building Setbacks(ft) - Front Yard Side Yards Rear:Yard f Required - Provided Required Provided Required Provided . 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public CI Private Cl Zone: _ Outside Flood ZoneT Municipal 0 On site disposal system 0 Checl;if yes0 • SECTION 2: PROPERTY OWNERSHIP' . 1 Owner'of Record: �2-1,04.1-61 . tip, ?,�. ' <!4 1 J44 4-k)• Ada ess rce �/ Name(/Priint),� // ' /, p _ ✓1 r` l I-1 4 Telephone - OC 3 F Signature • SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building t4Owner-Occupied 1 Repairs(s) ED AIteration(s) 0 Addition C Demolition D Accessory Bldg.CI Number of Units / Other 0 Specify: Brief Descyigtion of Proposed Workk: i . • ' SECTION 4:ESTIMATED CONSTRUCTION COSTS, • • Estimated Costs: Item . Official Use Only (Labor and Materials) 1.Building $ I. Building Permit Fee:$ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ . ❑Total Project Cost'(Item 6)x multiplier - x_ 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees: Suppression) Check No. OLI L heck Amount;/if 1 Cash Amount: 6. Total Project Cost: $ h je — 0 Paid in.Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) G. 3 2 Name of CSL Holder //��_I o ?0 OK 00-7 List CSL Type(=below) adJ No-and Street Type Description J l O e `` V- /)�j�./� 11 Unrestricted(Buildings up to 35,000 Cu.ft.) /U! n //' L/ (J r R Restricted 1�42 Family Dwelling City/T State,ZIP M Masonry RC Roobng_Covering WS Window and Siding SF Solid Fuel Burning Appliances T Insulation - - -Telephone Email address D Demolition r l , 5.2 Registered Home Improvement Contractor(MC) (7l 1 3 joxf�n�� c�d�in sr5n�. I 1?a 3 9 N_- � I HIC Registration Number - Expiration DateHIC HIC Coma Name or IW_ftegistrant Name r x 623 t 7 ,)exfo'ralli 17 No.and Street address IMJgc KC, P7A 6)//)3/ Cityr4-n,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AIF"FIDAVIT(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 ' ' t[ ' No ❑ 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 3 id v1 l ,h'7 a dJthi j to act on my behalf,in all matters relative to work authorized by this btttldinaermit application-Li C0/2/-r g I c Leh / 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 petjury 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 Date 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 nal have access to the arbitration program or guaranty fund under M.G.L.c.142A Other important information on the HIC Program can be found at www•.mass.govinca Information on the Construction Supervisor License can be found at ws31v_tttass.govldips 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,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" City of Northampton Massachusetts ?S' "!<< d- 4 ( 4 DEPARTMENT OF BUILDING INSPECTIONS ,�. 212 Main Street • Municipal Building �'N Northampton, Ma 01060 " 46° CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40,S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: /1Z m/4 pt) $'% /74// 4.4. The debris will be transported by: Name of Hauler: GC /A 4///dlG 14.4/er / f' Signature of Applicant: Date: "7/4 ! l SEXTON ROOFING AND SIDING INC www.sextonroofing.com ' KOP.O. Box 6327 Holyoke, MA 01041 Setting the Standard I. �7► �s•a p. 413.534.1234 f. 413.539.9906 MA HIC# 118239 sextonroofing(a hotmail.com SUBMITTED TO Debbie Kaltman PHONE 335-0638 DATE 4/10/21 STREET 118 Hinckley St dbkallman3(agmail.com CITY, STATE,ZIP northampton,Ma. roofr 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 a $95.00 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 cap over ridge vent. 10) Reflash chimney as needed @ $350.00 11)Supply manufactures Lifetime warranty and SRC 5 yr. workmanship warranty. We Propose hereby to furnish material and labor-complete In accordance with the above specifications.for the amount of. Fifteen Thousand Eight Hundred DOLLARS ($15.800.00) 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 y} workmanlike manner according to standard practices. Any alteration or Signature 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.DAMAGES TO BUSHES AND OTHER VEGErAT1ON'MARKS ON HOUSE MA', Note:This proposal may be withdrawn by us if not accepted RE UNAVOIDABLE AND WE ARE HELD HARMLESS. Not responsible for water within(14)days. damage during construction. Owner to pay responsible legal fees for non- payment,and applicable interest. "fee lrwwee pimfomal The above prices,specifications and Signature conditions are satisfactory and are hereby accepted. You are authorized to the work as specified. Payment will be made as Signature outlined above. ,7 f /1 J�� ��� Date of Acceptance. ` Department of Industrial Accidents iv I c Office of Investigations % 12) Lafayette City Center 'r/ 2 Avenue de Lafayette, Boston,MA 02111-1750 sue;- 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 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling . 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9 El Building addition comp. insurance.t [No workers' comp.insurance 10.❑ Electrical repairs or additions required.] 5. ❑ We are a corporation and its ' 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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 13.111 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 a new affidavit indicating such. tContractors 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: 0 11/NC�-/- _ j City/State/Zip: Jw", i -V 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 i trance coverage verification. I do hereby certify under i ins and penalties of perjury that the information provided above is true and correct Signature: - Date: � ?Jei Cs, 7.4-- . 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): 1❑Board of Health 2111 Building Department 3.111City/Town Clerk 4.111 Electrical Inspector 5.aIumbing Inspector 6.0Other Contact Person: Phone#: Ac0 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDEINYYY' R 1..-- 06/09/2020 THIS CERTIFICATE IS ISSUED AS A MA►I EH' 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 micN o.Exc): (413)737-0300 FAX (A/C,No)_ • oneness: khutchinson@ormsbyins.com PO BOX 718 INSURERS)AFFORDING COVERAGE NAIC# WEST SPRINGFIEiD MA 01090 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED ' INSURER 8: SEXTON ROOFING&SIDING INC INSURER C: INSURER D: • • PO BOX 6327 INSURER S: 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 "ILTR TYPE OF INSURANCE !NSA WVD POUCY NUMBER POLICY EFF. -POLICY EXP LIMITS (MMJDOIYYYY) (NMIDOlYYYYJ COMMERCIAL GENERALLIABILJTY EACH OCCURRENCE $ DAMAGE TO RENTED l CLAIMS-MADE OCCUR PREMISES(Ea occurrence) S MED.EXP(My one poser) S N/A PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ . POLICY JEI° LOC • PRODUCTS-COMP/OP AGG S OTHER:. $ " AUTOMOBILE LABILITY COMBINED SINGLE LIMIT S (Ea amde tt) -ANY AUTO - .BODILY INJURY(Perpetson) 3 • ALL OWNED SCHEDULED N/A BODILY IWURY(Per amde • AUTOS AUTOS r) S HIRED AUTOS NON-OWNED. - PROP titlYDAMAGE $ AUTOS "(Per accident) S . ` UMBRELLA n UAB _ OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE N/A • AGGREGATE S DED RETEN110N$ _ S WORKERS COMPENSATION 'N.,"^ PER OTH- STATUTE ER AND EMPLOYERS LIABILITY YIN ANYPROPRIETOR/PARTNER/E ECVE UTI EL EACH ACCIDENT S 1,000,000 A OFFICER/MEMBEREXCLUDED? N/Al NIA NIA 7PJUBOG07898220 06/042020 06/04/2021 (Mandatory in NH) - E.L DISEASE-EA EMPLOYEE S 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY UMrr $ 1,000,000 N/A DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(ACORD 1ui,Additional Remarta Schedule,may be attached SIhore 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/Iwd/workers-compensationhnvestigations/. • • CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE • THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE Will-I THE POLICY PROVISIONS. • • AUTHORIZED RS,RIESENTATIVE 1 Amherst MA 01002 �" C Daniel M.CI rley,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 • O�® DATE(MM/DWYYYY) AL -G CERTIFICATE OF LIABILITY INSURANCE 626/2020 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(es)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. PHONE 413 737-0300 FAX 41 (A/c,Na.E,d): ( ) (A/c,No), ( 3)737-0617 698 Westfield Street E-MAIL ADDRESS: • West Springfield,MA 01089 INSURER(S)AFFORDING COVERAGE WIC$ INSURER; Colony Insurance Company 39993 INSURED INSURER B Sexton Roofing and Siding Inc INSURER C: 102 Pine Street - INSURER D: Holyoke,MA 01040 INSURER E: INSURER F: - 1 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CEN t IFY THAT THE POLICIES OF INSURANCE US I Ei)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. LLTTRR TYPE OF INSURANCE IN lSO I�YVq POLICY NUMBER . POLICY EFF POLICY EXP LIMITS (MWDDIYYYY) {MMIDDlYYYY)_ A X COMMERCIAL GENERAL LIABILITY 101PKG002159905 6/25/2020 6/252021 EACH OCCURRENCE y 1,000,000 DAMACLAIMS-MADE X OCCUR PREMISES (Es o ID 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) S 5,000 PERSONAL B ADV INJURY I s 30,000 GEML AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE I S 2,000,000 X POLICY jEa LOC PRODUCTS-COMP/OP AGG $ 2,000,000 • OTHER S AUTOMOBILE LIABIL rr COMBINED SINGLE LIMB (Ea accident) ANY AUTO BODILY INJURY(Per person) S • ALL OWNED SCHEDULED BODILY INJURY(Per accident) S • AUTOS AUTOS - S AUTOS D PerraccidlerY-dDAMAGE HIRIDAIIfOS AUTOS • S • ) UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DID I RETENTIONS WORKERS COMPENSATIONOTH- AND EMPLOYERS LIABILITY YIN - I STATUTE ER ANY PROPRIETOR/PARTNER/EIECUTNE N/A EL EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? - (Mandatary in NH) EL DISEASE-EA EMPLOYEE$ I{yes.de unaer DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD la-L AWNona]Remarks Schedule,may 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_ AUTHORIZED REPRESENTATNE t ©1988-2014 ACORD CORPORATION_ All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD g __ = BOSOM, IT : svt d tsasas�,gsa " Worizes'easupeusstrws Insnrance.Affidinit - - - infaramarmsa N Aunties* rn}c' u.LL l� ���� p(� 00 1- 11( Addlcsm 46-evbc4nVi_Dcp\- '5E city/staer,palogi _ phonek.3:23 -cri ArtYet>:at+i•!ea-' dctieappiopreie>= - T *fx Pretieet#egldred 1 2<ciaemploy rr►iitt - eopioyex a$ p s 2.01seta:soi:paopuetororpmeeasdy workingpia S- II Remodefing - mg ►.plb a] 3_01aatabooararserd �oingmave tdf!Nounitedcaagi- sc 11 n� Baffin rdifition 4.0 Ian alaooroeacrad�be:lwoeg dcro . fostodoxailvastypmfamIrk I0` l east=tatancmtacaoaeieher brae madame compensation kanrsoce or= oie IIOF. xep sor aderetions pi alati l=anikialamQiolces S.Q lam i�connaca and imef trsabta�rsomfosiedmdc'`+r.4t.,t rr. Q 'oia�di�ns Tbese hnecmpio!a saodiroemmifz� .ios:mance? 13- €.9wesa ccaptratimanditso�c�baees their tofccomr perMli£.e. MO a • 152,§]Ftk nod welamenoe o iasees..[13oviodax'eomp"insamoceiegaired.] - .Aa]'aFP tbats itt a stalso� �orsectioaWm-sta viogtimirwodaecs laioom ion. tHoc eownees>dso -- aoeaoi+gaibraE n d aansideu>tomams ecs amersslliimal sor3_ :Caatadoefrccionek sbasm statncriedanadditionisiceisioairgsteaysoftlic -.=,dslatxhtimerarnot lmseant6eslime erurtloyea irlbesan-cononocostutremapimiess,theymostprogiie their lyobuecow.Arley I tars anea ijierthai s -tassim'sanrp aly employees. Below is Ike paEcjd absite Insurance Comprmy Nam=\---6-Aw6, Ondo-On'VP),...) 1 41:5 eto Podi or Lie- Site A ,c , Attach a copy of the workers'earapeasttionporm3r declaration page(showing the p rnnumbacand eviention. Failure to sea=c ovcagc as ramrod inx MGcLo_152,§25A is a criraireal i by afiaeup to S1,500.00 mileramyl=imprisomere,as welt swirlpain the form pia STOP WORK ORDER dafneofuptinS25OAOa day against the vitlator.Acopyofthis statement may befrerwmd d to the Office ofluvestigatiOns oftheDIA for insurance coverage verb' . - Idahereby cern Age - aadpeteabssafp litateke iiiisnraaarsastpropilied:ber eristraeasaiearrect Similar= j V - , rkttr- I ( ! I G j 5 A Phoneif: ,5'07' r-M ?2d Official use ots t. Do natalnle he this area,ta be caiapkted by 'city e►Erma(Oast" City or ToCity ar Minn PermitiLkense# Author-By(tittle on I.Board ofIteafth 3.Bea Dgmrtment 3.City/Town Clerk 4.Ele tri r 5-Ple tl ied r 6 Other 4 Cootaet Peron _ Phone ik AC ORE) CERTIFICATE OF LIABILITY INSURANCE DA;(NI 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 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 CONTN E., Edson DeSouza MAYFLOWER INSURANCE GROUP INC PHONfAtc.No mil_ (774)773 9702 FAX Noi, __. ADD : Edson@mayflowerinsurance.com 299 Court Street INSURER(S)AFFORDING COVERAGE NAIC# Plymouth MA 02360 INSURER A: HARTFORD UNDERWRITERS INS CO 30104 ENSURED INSURER B: MNP CONSTRUCTION INC INSURERC: INSURER D 45 EXCHANGE ST APT 3E ENSURER E: MILFORD MA 01757 INSURERF: COVERAGES CERTIFICATE NUMBER: 595621 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 CONDf1lONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ INSR ADOL SUBR POLICY EFF POLICY EXP TYPE OF LTRINSD WVD POLICY NUMBER (MMIDDIYYYY) (MWDDtyYYY) UNITS COMMERCIAL GENERAL LIABILITY • EACH OCCURRENCEDAMAGE TO RENTED S CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENII.AGGREGATE IJMrT APPLIES PER GENERAL AGGREGATE $ PRO- POLICY , a LOC PRODUCTS-COMP/OP AGO S OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY-AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Peracdderd) $ NON-OWNED ROPE DAMAGE HIRED AUTOS S (Per accident) S UMBRFI I A LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE N/A AGGREGATE S DED RETENTIONS $ WORKERS COMPENSATION PER OTH- ER X STATUTE ER AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTN /EXECLITWE Y/N E2 EL EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBERE7XC UDED? WA WA N/A 6S60UB1K70970620 11/16/2020 11/16/2021 (Mandatory in NH) EL DISEASE-FAA EMPLOYEE 1,000,000 If yes.describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY DMrT S 1.000,000 N/A DFsr'RtP11ON OF OPERATIONS!LOCATIONS!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 accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensationfirrvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Sexton.Roofing & Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS_ 102 Pine St AUTHORED REPRESENTATIVE Holyoke MA 01041 Y Daanieliel M.C y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD a ARE) CERTIFICATE OF LIABILITY INSURANCE DATE (I& 'DD' 'T' 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 CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Art Calvillo AX One Family Insurance Nj,o.tel: 978-403-5942 {A/C,Noy, 978-403-5943 1 Main St Suite 15 AIL DAD : art@lfamlyinsurance.com Lunenburg,MA 01462 WSURER(S)AFFORDING COVERAGE NAIL al` SURERINSURERIN BA:: A:: Evanston Insurance Company INSURED ' 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 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 WfTH 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.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AUULSUUt POLICY TYPE OF INSURANCE p y POLICY NUMBER IDDm (MmDIT yyyL LIMITS X coMMERctALGFENEZALuAEulrr EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea on ) $ 100,000 MED EW(Any ono person) $ 5,000 A Y Y 3ET9385 11/20/20 11/20/21 PERsoIAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: , GENERAL AGGREGATE $ 2,000,000 POLICY jE LOC PRODUCTS-COMP/OP AGE $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILYINJURY(Peraaadent $ _ AUTOS ONLY AUTOS ) HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) S — UMBRELLA LiAS OCCUR - EACH OCCURRENCE $ EXCEL LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION I STATUTE OERTM AND EMPLOYERS'LIABILITY Y IN ANY PROPRIETOR/PARTNER/EXECUTIVE NIA EL EACH ACCIDENT - $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL DIcFaSE-EA EMPLOYEE $ lI yes desnibe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may 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 SEXTON ROOFING&SIDING INC ACCORDANCE WITH THE POLICY PROVISIONS. 102 PINE ST P.O.BOX 6327 AUTHORITY REPRESENTA HOLYOKE,MA 01040 + �? l 0 1988 2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD