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10B-107 24 AUDUBON RD BP-2021-1310 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 10B- 107 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-2021-1310 Project# JS-2021-002171 Est.Cost: $8000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sq. ft.): 16596.36 Owner: COHEN BARRA Zoning: URB(100)/WP(94)/ Applicant: SEXTON ROOFING CO AT: 24 AUDUBON RD Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 WC HOLYOKEMA01041 ISSUED ON:5/11/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE REAR 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 C:f ` Certificate of Occupancy Signatur• � • �r • 'I • • FeeType: Date Paid: Amount: Building 5/11/2021 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner . iZ., The Commonwealth of Massachusetts 1. • ' ' Board of Building Regulations and Standards tv11JI.ICOPAi.1Tlr ''�W/ Massachusetts State Building Code,7S0 CMR,? edition USI :L_ Building Permit Application To Construct,Repair,Renovate Or Demolish a Revis�,Ja►1p9--� One-or Two-Family Dwelling f 20 04\'(' t Thisr�Section For Official Use Only �, `��� Building Permit N ber: -'4I�� v Date Applied: / 41,k Ll1 • . 5-11'26Z ^'T • Signature: ,.,/ � _ � � o�� �Q� i Building Commissioner/Inspector of Buildings - Date • \`��7 v1Zn ,�/f,r'b� : t SECTION I:SITE INFORMATION �. :o 1.1 Property Address: 1.2 Asses ors Map&Parcel Numbers 6o�oys `i �2 y ,D i etiA" P-1) - )0 f • . • 1DZ MapNumber Parcel umber ' l.la Is this an accepted street?yes no .; 1.3 Zoning Information: 1.4 Property Dimensions: . Zoning District Proposed Use ______ Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) • • Front Yard - • Side Yards Rear•Yard 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 ID Private 0 Zone: ^ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ • SECTION 2: PROPERTY OWNERSHIP' 2(], o24 • f r ofa. CRecord: ? ;J 1. r,it Q(SG'ill y% 3 A/ "L 'ilm, /" _ 'V • Name(Print) Address for Service: 0tgn4- I f il a. - .73(-- '7/u . • ature Telephone • • SECTION 3:DESCRIPTIONON OF PROPOSED WORK'(check all that apply) Cif New Construction 0 Existing Building Owner-Occupied 0 Repairs(s) 0 1 Alteration(s)"4 Addition 0 Demolition 0 Accessory Bldg.0 . Number of Units,� Other 0 'Specify: Brief DescriptP•-.M n of Proposed Work2: . • to i t 19/4 -A d r )'f.-/ -i y g{a-/- (�Q tl ' ' SECTION 4:ESTIMATED CCINSTRUCTION COSTS, • • Estimated Costs: Item .. ' Official Use Only (Labor and Materials) • 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ - 0 Total Project Costa(Item 6)x multiplier . x 3.Plumbing $ ' • 2. Other Fees: $ - 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees: Suppression) _— Check No. (-Cheek Amount: ash Amount: 6. Total Project Cost: $ �� 0 Paid in.Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 996 C Q - +rJ - Ekerei-f,_9e,tion / ' License Number �rraRasi Date Name of CSL Holder ) n/C f�, ?O /1OK f 7 List CSL Type(see below W No.amend Street (��y�/J j� (� Type Description !!Ueicei e e , //7, 0�(/ /J 13 Unrestricted(Buildings up to 35,000 cu.rt.) R Restricted 1&2 Family Dwelling Cityll'. ,State,ZIP _ M Masonry RC Roofing Covering WVS Window and Siding SF Solid Fuel Burning Appliances I Insulation -_ - Telephone Fm,il address 13 Demolition .___- J 5.2 Registered Home Improvement Contractor(HIC) I /!� - 3 n pI 11 J 3 3PXTtf got`n and`-fit-'�m7 -rng- HIC RegistratioonNumber - Expiration Date HIC Co arty Name or egistrant Name .-/ 1' lynx 62.3.E7 ,3uarral2W )hvfm(?i/,({OJ77 No.and Str=t address {-ftIc.fe Je, 7)7/9 G)/(i-V/ 4/3 a34/a.3 il City[l wu,State,ZIP Telephone SECTION.6: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 ' 'I?'`' No ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT '1 I,as Owner of the subject property,hereby authorize 3e h i?i (2./620 dinq _Ln- to act on my behalf,in all matters relative to work authorized by this butlditiaemtit application.L contra r 07i d eI!fir' . /4/49-/ Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNERS 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 plicarion is true and accurate to the best of my knowledge and understandinn g 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 tug have access to the arbitration program or guaranty fiord under M.G.L.c.142A_Other important information on the HIC Program can be found at wtvw.mass_gov!oca Information on the Construction Supervisor License can be found at vavw_rnass^ovidos 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 ..... 15. s) Massachusetts zs: c.e\ !isof f DEPARTMENT OF BUILDING INSPECTIONS ►'My 212 Main Street • Municipal Building SJ ate' Northampton, MA 01060 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: ' ii /4 ) A)/y-41-( The debris will be transported by: Name of Hauler: cOc_laAT��� �/ its ?cf � J Signature of Applicant: Date: Proposal SEXTON ROOFING AND SIDING INC www,sextonrooling.com liMOP.O.Box 6327 Setting the Standard � ,.. Holyoke,MA 01041 1/111 law AV AIMIIF gal ��. p.413334.1234 f.413539.9906 MA HIC# 118239 sextonroofing@hotmail.com SUBMITTED TO Barra Coles/ARK Olson PHONE 336-7144C374-452-3855 DATE M28RI STREET 24Aaibon Rd barracohen@gmail.com/alizolson@yahoo.com CITY/STATE/ZIP Leeds,Ma, JOB LOCATION Rear roof SEXTON ROOFING HEREBY SUBMITS SPECIFICATIONS AND ESTIMATES FOR: 1) Strip and remove existing shingles and dispose of in proper landfill. 2) Install new decking (r "CDX 4 ply) 3) Install new metal edging to rakes and eaves of roof.(White) 4) Install ice and water shield on eaves roof.(6') 5) Install starter shingles on eaves and rakes of roof. 6) Install synthetic roofing felt on remainder of roof. 7) Install new flanges over existing vent stack. 8) Install IKO Architectural style roofing shingles as per manufacturers'specifications. 9) Remove chimney to roof level. 10)Install new cap over ridge vent. 11)Supply manufactures 50 warranty and SRC 10 yr.workmanship warranty. ***Covering valuables and Attic Cleanup responsibilty of homeowner*** aVk i •g42 j61 We Propose hereby to furnish material and labor—complete in accordance with the above specifications,for the sum of: ( Eight Thousand DOLLARS($8,000.00) Payment to be made as follows:upon completion All Material is guaranteed to be as specified_ All work to be completed m a Authorized workmanlike manner according to standard practices. Any alteration or Signature deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond Note:This proposal may be withdrawn by us if not accepted our control. Not responsible for water damage during construction. Owner to within(7)days pay responsible legal fees for non-payment,and applicable interest. s Department oflndustrialAccidents 9 �iy Office of Investigations ki,l Lafayette City Center r/ 2 Avenue de Lafayette, Boston,MA 02111-1750 P 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 anycapacity. employees and have workers' P tY 9. ❑ Building addition [No workers' comp.insurance comp. insurance. 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.[I Roof repairs insurance required.] t c. 152, §1(4),and we have no . employees. [No workers' 13.0 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. 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.#:7PJUB0G07898220 Expiration Date:6/4/21 Job Site Address: /y ' f.€- �ow City/State/Zip: n(,if 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 t ins and penalties of perjury that the information provided above is true and correct. Signature: - Date: �� /)._/ • 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): rr- ��., 10Board of Health 2❑Building Department 3❑City/Town Clerk 4.❑Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: • A�� CERTIFICATE OF LIABILITY INSURANCE DATE aE(MMIDo o Y THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER Mils . 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 time Kathi Hutchinson ORMSBY INSURANCE AGENCY PHONE ,: (413)737-0300 FAX E-MAIL : khutchinson@otmsbyins.com P 0 BOX 718 INSURERS)AFFORDING COVERAGE NAIC# WEST SPRINGFIELD MA 01090 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED • INSURER B: SEXTON ROOFING&SIDING INC INSURERC:f 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 9Y PAID CLAIMS.' . INSR TYPE OF INSURANCE ADDL wvoUER POUCYNUMBER MIDJDIYYYYYY)'(MMMIDC Y ECP LTR fNSO 4WD D,YYYYI IiMns LT . COMMERCIALGENERALLIABILnY EACH OCCURRENCE $ • DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ . MED EXP(Any one person) $ N/A • PERSONAL F.ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: • GENERAL AGGREGATE $ POLICY JET LOC • PRODUCTS-COMP/OP AGG $ $ ' OTHER AUTOMOBILE LIABILITY (Ea accident)SINGLE LIMIT $ ANY AUTO -• .BODILY INJURY(Perperson) $ - ALL OWNED SCHEDULED• NIA BODILY INJURY(Per amdent) $ • _AUTOS -NON-OWNED ' PROP Litt Y DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ • UMBRELLALUAB _ OCCUR • EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE 5 DED RETENTIONS OTH- ER• S WORKERSCOMPENSATION X ATtfT'E AND EMPLOYERS LIABILITY Y/N • ANYPROPRIETORIPARTNER/E7(ECUTNE EL EACH ACCIDENT $ 1,000,000 A OFFICER/MEMOEREXCLUDED? NIA NIA WA 7PJUB0G07898220 06/042020 06/04/2021 E.LDISEASE-EAEMPLOYEE $ 1,000,000 (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY UNIT 1,000,000 - - WA • • DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Ad Mional Remarks Schedule,may be attached rAwre 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/Iwdlworkers-compensationfinvectigations/. • 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 • 1 Amherst MA 01002 Daniel CC�r> ve Iy,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 AW E CERTIFICATE OF LIABILITY INSURANCE DATE 2`" °"Y ' ' 6/26/7_0THIS 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 1NSURER(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. PHONE E<tl. (413)737-0300 FAX No): (413)737-0617 698 Westfield Street E-MAIL ADDRESS: West Springfield,MA 01089 INSURER(5)AFFORDING COVERAGE NAIL# INSURERA: Colony Insurance Company 39993 INSURED INSURER B Sexton Roofing and Siding Inc INSURER c: 102 Pine Street INSURER D: Holyole,MA 01040 INSURER E: INSURER F: - COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CBE!IFY THAT THE POLICIES OF INSURANCE US I t LI 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. LTRLTR TYPE OF INSURANCE INSD I I�NVBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS(MNWDlYYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY 1DIPK0002159905 6/25/2020 6/252021 EACH OCCURRENCE $ 1,000;000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR - PREMISES(Ea commence) $ 100,000 MED E) (My one person) $ 5,000 PERSONAL&ADV INJURY S 30,000 GEN'L AGGREGATE LIMIT APPLES PER �' GENERAL AGGREGATE $2,000,000 X POLICY jEo- LOC PRODUCTS-COMP/OP AGG $ Z000,000 OTHER: S • AUTOMOBILE LIABILITY COMBINED SINGLE LIMB S (Ea accident) ANY AUTO BODILY INJURY(Per person)_ALL S AUTOOS NED AUTOSUt En BODILY INJURY(Per accident) $ NON-OWNED PROPtx I Y DAMAGE HIRED AUTOS _ AUTOS - (Per accident) • S UMBREL.AIIAB _ OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DID RETENTIONS $ WORKERS COMPENSATION I STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y IN ANY PROPRIETOR/PARTNERIC(ECUTNE OFFICER/MEMBER EXCLUDED? N/A EL EACH ACCIDENT S (Mandatory in NH) EL DISEASE-EA EMPLOYEE$ If yes,describe tinder DESCRIPTION OF OPERATIONS below - EL DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/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 ACCORDANCE WITH THE POLICY PROVISIONS- AUTHORIZED REPRESENTATIVE 1.11 V c ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD f ;,= ef - i I C esStreet Smite 109 MA 4 2 17 Name 03eziacmdafgazindoldhafividtz*:- in c'j Aftesw 46-e02026q_3\-- t\pk- ibE - Areye tas apb+d!CkskI cappcopa`wteT - TYPe of 1_ waastoopioyear,ai •' employe=galtaadiforpect-lins** 7 0}few 2.0I Boa aoirlooPndoratp sral®g formcn , S. El g mg plolsorlxtecawap..Inman=>--i 0 Dcznadion , r 3_01tmaboaeoeaerdoegaihrottra selfPioaocters'comp_iosurarrcespoiaij+ 4.�Tanabomeoearraad+rlibckiing a tocandoctsHaikannyp !InaQe__!Ina IQ D cos=tbataHmomciorse> skim wake&wmpaaatioammaszaccaraQsoit ILO Elestsica. 1=pailstu aftlitionS - no coployess additbns i, Ialaateocalcoococfait>odli etaesithc fistedoedica sbras 10 Pbunbingrepairs� �7�Seseb-�mdoalmaet opi�¢sazlbasc uoktis} ameaeec=, I3_ I�tts fi.1:3 _viorecaeorpo_ __dasolf shaz____dtbeaneztofaamgtiamperMli.c I4_0Qther Is2,11(41 and weiaevens PDio neap_immixe�l - *Airy Apricot-flit s sbaa-Sl nassralsoilliortgcsectionbelow cmgsta impo&T isiosuation. thou ourneatrfa i' ticyaoodosgairciScaodtheshimotasi$etoo�oas�t aner sffiireliAtacaliowlach. Iran cacires Ike cieskttistary aetattaebod=Wai gel ssieetsloeieg the maw of state uhetierarnattdcierdities bate raiapt:gets.If thesabsonsesiassimeremployees,lisymostprovide>l aoadaese comp.paricy►sambx I ass eaag er ssprar:efig +rreaumpar i a_elaray employees. Below isthe,port rm i sRe Insurance CcrinpanyNam= Job Site Addrem _ Atta&a copy oftbe workers'eanipentationl page( ■i gibe pow number andel/Anti=date). . Failure to scare covrsace as raged underlAGLc.752,§25Ais ambling vio rpwiisbailie by a take up Os$I,500_40 andier onayearibiprianntaist,aswellmarl sin be fain Dia STOP WORK ORDERand afmcofupIn$250.00a day against the violator-Atpyof may fOrarardOtothe Office offav s ofibeDIAforinsuraace coverage wirfficaiica. I do harelip feerftfy sr tie -andpeasigesofpesjerrylitatiteinfemuliowtprevidedshove is tear and correct Sim f-`4l e" Mae- i I [1 Es 1 i 0 Wye.'d sseordye. Don twillehe this area,to he cempleted byeay orA'wn oreciA t City or Town Perzallakense# Issuing Antionly(emcee on* L.Board of Health 2.ButithRg epa rtment 3_City/Town Clerk 4_Eleetsiad Inspector 5-Pintnbing Inspector 6.other i - Contact Pena_ Phoneil: .._ . - 9 AWE L) DATE(rJI1/DonrYYY) CERTIFICATE OF LIABILITY INSURANCE ��n3DDIYY 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 Edson DeSouza MAYFLOWER INSURANCE GROUP INC PHONuktc,No mil; (774)773 9702 FAX WC,No): ADDILF : Edson@mayflowerinsurance.com DDR 299 Court Street - INSURER(5)AFFORDING COVERAGE NAM C Plymouth MA 02360 INsuRERA: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B: MNP CONSTRUCTION INC INSURERC: INSURER D: 45 EXCHANGE ST APT 3E INSURER E: MILFORD MA 01757 wsuRERF: 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 CONDITIONS OF SUCH POLICIES_LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADOL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE MSD WVD POLICY NUMBER (MMIDDIYYYY) (MMIDD!YYYY) LIMITS • COMMERCIAL GENERAL WIBIUTY • EACH OCCURRENCEDAMAGE TO RENTED S CLAIMS-MADE 1 OCCUR PREMISES(Ea commence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATEPRO- S POLICY JE r LOC PRODUCTS-COMPIOP AGG S OTHER_ S AUTOMOBILE LIABILITY COMBINED SINPJ F Limn- $ (Ea accident) ANY-AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED NIA AUTOS AAUTOSI BODILY JURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per amdenI) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE N/A AGGREGATE S DED RETENTIONS WORKERSCOMPENSATfON - X PER OTH- /� STATUTE ER AND EMPLOYERS'LIABILITY OFF EE � EL EACH ACGDINr $ 1000,000 A oFICEERMEaBERExaLD WA WA WA 6S60UB1K70970620 11/16/2020 11/16/2021 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPF_RATIONS below EL DISEASE-POLICY LIMIT $ 1,000,000 NIA OF S"RIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Addtional Remarks Schedule,may be 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 ddte on the above policy precedes the issue date of this certificate of insurance)_ The status of this coverage can be monitored daily by arrpssing the Proof of Coverage-Coverage Verification Search tool at www.mass.govflwd/workers-compensationfirnestigations/. 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 AUTHORIZED REPRESENTATIVE ie Holyoke MA 01041 CL4 Daniel 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 /��O DATE(MM/1OI/DO/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/24/20 DL 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 endorsecL 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 Calvillo PHOAX One Family Insurance ( N+.Exti, 978-403-5942 (Aic,No): 978-403-5943 1 Main St.Suite 15 AIL DAD : art@lfamilyinsurance_com Lunenburg,MA 01462 INSURER(S)AFFORDING COVERAGE NAIC I INSURER A: Evanston Insurance Company INSURED INSURER 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 US I EL)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 PLR I AIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.OMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- INSR ADDL aUBR POLICY /DB (M�plP LIMITS LTR TYPE OF INSURANCE p WVDUBPOLICY NUMBER ryyyYP X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CI AIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A Y Y 3ET9385 11/20/20 11/2_0/21 PERSONAL&ADVINJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY _ PERO�- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S . (Ea accident) ANY,AUTO BODILY INJURY(Per person) $ OWNED -SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) S UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION PER OTT+ AND EMPLOYEES'LIABILITY STATUTE ER YIN ANY PROPRIETOR/PARTNER/EXECUTIVE N 1 A EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (MancLatory in NH) EL DISEASE-EA EMPLOYEE $ If describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POUCY 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 AUTI+oR®REPREsarTA HOLYOKE,MA 01040 + . fir, ©1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD