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12-022 (6) 31 COUNTRY WAY BP-2021-1311 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12-022 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-2021-1311 Project# JS-2021-002172 Est.Cost: $10230.00 Fee:$40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sq.ft.): 19994.04 Owner: HARD REBECCA Zoning: Applicant: SEXTON ROOFING CO AT: 31 COUNTRY WAY 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 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. j, d� 1 • Certificate of Occupancy Signatur 4 )2 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 The Commonwealth of Massachusetts Board 0 ^ ..� ,,ttu.%Err., of Building Regulations and Standards �`� s:'--_°ice, , i Massachusetts State Building Code,780 CMR 20 ' aza _ �`"' Building Permit Application To Construct, �' �ugloymmmosiniiiiiii .�.,:at. Repair, Renovate Or Demolish a One-or ��`-�y.,,,-•OK "'; Two-Family Dwelling �: /// ' This Section For Official Use Only ,Z,, #f� i Building Permit Number: a4 k i Date Applied: - L Building414-7Z5 Z'Z J 4,. Official(Print Name Signature '0 ) g1 J SECTION 1:SITE INFORMATION 4.k% ///, 1.1 Pe 'hi/A/e 1.2 Assessors Map& Parcel Numbers — �'q�,o_ �k 1.1 a Is this an accepte streetet?� no Map Number Parcel Number s. 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 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP` 2 ner`of Record: /�— !/( b e-€4. 4114 0 �1D MO Name(Print City,State,ZIP 31 o Gi - " ' /%f 4e 4Alt. (o No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: f �, 4.i2t-L- ,a•1/ ____ ApIG.c.0--- Cy. cS)1 .1,9 c_V i-4 y4> CZ et SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ Building Permit Fee:S 2.Electrical $ Fee schedule can be found on the Building Department page at 3.Plumbing $ Date Received 4.Mechanical (HVAC) $ 5.Mechanical (Fire $ Suppression) Check No. heck Amount. Cash Amount: 6.Total Project Cost: S C t j t•Z-3 6 ❑Paid in Fu I 0 Outstanding Balance Due: . 6 /6 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) (�/�/QQ /0/5-12 • Ye�eff-eA ion License NumberUu puatio_a)D�,atc Name of CSL Holder �J n/LW ?D fl�'t ` 1Z -� 7 List CH.Type(see below) L �LJ /l (9LI�J'` J No.and Street Type Description Pro ////'f 0 11/ IIco Unrestricted(Buildings up to 35.000 .ft.) R Restricted 1&2 Family Dwelling City![ tate,ZIP M Masonry RC Roofing Covering WS 1 Window and Siding SF Solid Fuel Burning Appliances I Insulation __--- - Telephone Email address D Demolition I 5.2 Registered Home Improvement Contractor(HIC) p� I d0X1�n. &cO n and cYiII7 _4n(7. ( spa q HIC Registration Number Expiation Date HIC Company Name or egistrant Name C,x 623,.4 ?..'' No.and Street � ,/ �1q PXfOn 1 / �� aC't lj�C0 E. yy�{ ! 7A7 G1l6)�/ 4/3-53'7 f.g3 F I address City/to n,State,LIP 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 0 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 3eth)/; C�!�I, d %�( fJ7 n( to act yow�n my behalf;in all matters relative to work authorized by this btuldittg.ilermit applicationL (�-'/1 Ira T t tar H e/i e/x /,=.7 / Print Owner's Name(Electronic Sipaat+ce) 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_ S � r MUST BE SIGNED by Owner or Authorized Agent ate 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 gpj 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 wzvw.rnass_govloca Information on the Construction Supervisor License can be found at}4�Wtiy_mast Gov=dpc 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.ft) 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 � wM ~ Massachusetts ` C, f DEPARTM:NT OF BUILDING INSPECTIONS 3` 212 Main Street • Municipal Building v , Ns, cs ' Northampton, NA 01060 s - 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: Loca tion tron of Facility: ��� 47,6-1 f'l � 8'4 The debris will be transported by: Name of Hauler: 4,1g-i/UIAcQ / l /i`Ly )i/" e kg; Signature of Applicant: / e: 1 Proposal SEXTON ROOFING AND SIDING INC www.sextoniroofipg. !JNO P.O.Box 6321 ti aaewn then oatamt =�..I Holyoke,MA 01°41 .1►' Sri ss- Ant most . p.413.534.1234 = f.413.539.990E MA MC#118239 sextouroofing@hotmait.com UBMITTED TO Rebecca hard PHONE 404-686S DATE 10n/20 111 STREET 31 Country Way tebeoeakeroWtacvurs CITY,STATE,ZIP Northampton,Ma. E.Sextoa/Roofr EXTON 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 @ 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 1KO Architectural style roofing shingles as permanuIacturers speetficaYtons. 9)Install new counter flashing on chimney.(Add S300.00 if needed) 10)Install new cap over ridge vent.(Add 5800.00 to replace 2 attic power vents,all electrical to be completed by borne owners own eletrican at their expense) 11)Supply manufactures Lifetime warranty and SRC 5 yr.workmanship warranty. 12)Install.060 EPDM membrane over low pitched section. 1 f �•:% We Propose herebeiejNrnirh material and labor-comoleteln acroedence whh the above. ailicutioi.!mike amoy,u pL Mae fliausana'flirec,YarrefrafOtItLrt'Rc(3Y,I1R.tc5l)'PAIIArEl4TSTIIII MADE AS FOLOWS: due In till upon completion All Material is guaranteed to be as specified All work to be completed in a Authorized ...tmlike matmer according to standard practices.Any alteratives or deviation Signature rbwr_sgxifscuirmaim:nkzmgvtra nus.ww. ,a/Wual.wlss'gnn.witten. order,,and will become an extra charge over and above the estimate.DAMAOES TO •USriES AND OTHER V&OE rATIDN'MARKS ON HOUSE MAYBE UNAVOR)Ate.R AND WE ARE HELD HARMLESS.Not responsible for water damage during construction. Owner to Note:This proposal m be withdrawn b us if not accepted pay respamible legal fees for non-payment,and applicable interest Prof may yp within(14)days. cceptance of Proposal The above prices,specifications and conditions are satisfactory and are hereby accepted. You are Signature authorized to the work as specified. Payment will be made as .utlined above. a ate of Acceptance. Signature Ck \( R 1 9 / • Department oflndustrialAccidents is . -,. Office of Investigations i,l Lafayette City Center I 2 Avenue 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. 4. I. I am a general contractor and I ❑ I am a employer P Yer with 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P tY 9. ❑Building addition [No workers' comp.insurance comp. insurance.t 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 11.0 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 . 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 anew 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. Tnsurance Company Name:Travelers Property CAS CO OF AM Policy#or Self-ins.Lic.#:7PJUB0G07898220 Expiration Date:6/4121 Site Address: ac„,„„..41,___ City/State/Zip:, / G2 )4-A"-- ' Job 1 /� Attach a copy of the workers' compensa policy de iml tio 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 ove is true and correct Signature: - Date: S �g / - • 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❑City/Town Clerk 4.111Electrical Inspector 5lumbing Inspector 6.0Other Contact Person: • Phone#: A�� ® 'CERTIFICATE OF LIABILITY INSURANCE DATE(FOADDIYYYY) 06/09/2020 THIS CERTIFICATE IS ISSUED AS A MA i 11 H 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 • NNAme Kathi Hutchinson ORMSBY INSURANCE AGENCY PHONE° 1: (413)737-0300 FAX ADD : khutchinson@ormsbyins.com P 0 BOX 718 INSURER(S)AFFORDING COVERAGE NAIC# WEST SPRINGFIELD MA 01090 INSURER : 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED 13Y PAID CLAIMS.' INSRLT TYPE OF INSURANCE ADDL SUER POUCY NUMBER (MM/DDIYYYY) (IYWOCOIYYYY) UNITS LTR NSA MD COMMERCIAL GENERALUABIUTY EACH OCCURRENCE $ _ • DAMAGE TO RENTED CLAIMS-MADE OCCUR. PREMISES(Ea occurrence) $ MED.E(P(Any one person) S N/A • • PERSONAL 8ADV INJURY $ GEN'L AGGREGATE LIMIT APPUESPER: " GENERAL AGGREGATE $ POLICY JEa LOC • PRODUCTS-COMP/OPAGG S - ' OTHER $ AUTOMOBILE LIABILITY _ (Ea SINGLE LIMIT $ ANY AUTO ,BODILY INJURY(Perperson) $._ ALL OWNED SCHEDULED AUTOS AUTOS N/A - - BODILY INJURY(Per accident) S NON-OWNED. PROPttcl YDAMAGE $ • HIRED AUTOS AUTOS (Per accident) $ . UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DID RETENTIONS OTH- ER $ WORKERS COMPENSATION PER X STATUTE AND EMPLOYERS'LIABILITY YIN • ANIPROPRIETORIPARTNER/Ea=CUTIVE EL EACH ACCIDENT s 1,000,000 A OFFICER/MEMBER/EXCLUDED? WA WA WA 7PJUBOGO7896220 06/042020 06/04/2021 ELEACHACCID DISEASE- EMPLOYEE S 1,000,000 {M�ndaroryinNH) If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POUCYUMfT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 1Q1,Ad EEonal Remarba Schedule,may be 411a..1- B`there space Is requioed) 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-compensationfinvestigations/. • • 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 REPRESENTATWE . � l • Amherst MA 01002 • Daniel Cr e 1 y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights Ieaerved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD A�� CERTIFICATE OF LIABILITY INSURANCE DATE 2`"I'o°°""�"'' 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 POUCIES BELOW. THIS CLRI'MATE 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. (A�ic°M )_ (413)737-0300 FAX NO)_ (413)737-0617 698 Westfield Street E-MAIL ADDRESS: West Springfield,MA 01089 INSURERS)AFFORDING COVERAGE NAIC# INSURER A_ Colony Insurance Company 39993 INSURED INSURER B: Sexton Roofing and Siding Inc 102 Pine Street INSURER C INSURER D: Holyoke,MA 01040 INSURER E: .. INSURER F: - I COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CEHI IFY THAT THE POLICIES OF INSURANCE Lis Iti)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 r so I wvu SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS{NtdNDD1YYYlT (MMlDDlYYYY) A X COMMERCIAL GENERALLIABILTIY 101PKG002159905 6/25/2020 6/25/2021 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR - PREMISES(Ea ocamence) $ 100,000 MED EXP(Any one person) s 5,000 PERSONAL&ADV INJURY I s 30,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE I$2,000,000 X POUCY jECOT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMB s (Ea accident) ANY AUTO BODILY INJURY(Per person) S_ • ALLOOSNED Al7TOSULED BODILY INJURY(Per accident) $ NON-OWNED ' PROPtrti Y DAMAGE s HIRED AUTOS ^AUTOS - (Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ _ EXCESS LIAR CLAIMS-MADE AGGREGATE S DED I RETENTIONS S WORKERS COMPENSATION I ETATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EJCECUTIVE EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) EL DISEASE-EA EMPLOYEE$ IDEf yyes,desaibe under SCRIP1IONOFOPERATIONSbelow EL DISEASE-POUCY LIMIT $ • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION 1111111 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�REPREESENT�ATIVE C yr IV ©1988-2014 ACORD CORPORATION_ All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD .C1, The CommoommedaTe eflifessechnsetie - {,= ��(+n, id Mecidefits - e Basita,MA0211Y40 TO BR MUD WITHTHE Name Oitosiote40FganizalioofhafivighoW in jup (I t.0 Of) 1:fi(1), 45- Q- " '5E ows.„,,,,,,xiatoc&ialLoasq Phone tf":3:) -Cr7 Amps aeearin±ta"Otedtaeapptopeintekex - TYPeef Prgiectftetiliredx_ t_�.ma employer..it aup.• per .= 7IINew 2.ElI elmaoiepeqiesororp rsteiF fat-mein 8. 0Reittoa mg ray cif wiry.llecraatkete coup.insannar icquited.] 3.01s nabootanonerdoingalitnoel;at�3f/Noaodra'comp.imaoe= ]* El 4,0 Ian a3ocneorneralwale- toem_cts�vadkmmfpcopr brai4D ga ton con=tatalknataaoaeitheriaeanniete corepeeration itatezneeOf=sale I I-E1 EIatoi=d rtpaits or adilitions pealstieloa.itbmempioyees 12.01Inabingtepaits or ' - S.QIama generalcocOmieramdlbasehriedtbesab•oo a&trdoaticaeacbodshas Then: abme iopersattl a:evad +v.iekp.a am:EA -EtCwflePaim6.0 We steasoqwticetaxlits cases here e their light �aftiesprrMt1.c. MO Other 152,1t(4),and welsmeao us-[No-maim'coop_imaceneete ] _ - - *Aay ap¢canttotr2rr]cx6arg1 mszabnlinontiliCsrrtian bdotr aba ioa. tHomeorrnea>ko salaniatessifidentiouicatingditymedoingsElmotkaoddra taotsidctaotaaoennent iss>fffie.3ierScatitgma- :Canin.r>atb tebeekthsbacmetMactaedaaaetifitionatsieetaionigtineaaacofIhc coatoctmsadstateabetberarnotdos-eonii<slane e iopkryees WthescirctessaccestieremployeesAryma tpnwidei imam'cawpartepauebrs l ems an etaphyerikatlsprlo 7galarkere comapersatioalasanateefar agp employees. Below I e awl/aa37le r1V-01c--"\-----N-6. 0nd-QV MilkPr j . OD Policy#ors-3ns.lie.# ( t0(119)111i O 11 Df 0 ExpiFfiaa Dal= 111 gal CR) Job Site Adchem CityiStateMin Attack a copy of the workers'courpe onponey dedarafioo page(shooing the parsley number and date). Pall to secure coverage as refired underMGLc.152,§25A is at criminal le by afineup to 51,500-00 and/or way= $s Weil asritr11p in the form of a STOP WORK ORDER andafinsofupto5250.00a t ay against the violator.A copy of this statcancat may be forwarded to the Office of fnvestigatiens aftheDlA for insurance coverage - - Ido hereby e r to -and pe t safperj�rry&attire isfarzearsaaprnideli above istraea eafret:t Sty j el _ ; Dat t t Eo I i n, a tificial meanly. Da tmtwrsie FM Ara+ It be completed by ci tar lawn official. 1 City or Tess PenuitiLicesse# Issuing Authority(circle a I_Baird of Health 2-BcolaRugDepar 3.CityfrownClerk 4. Inspector 5_P Ipectnr i Cont:etPerson _ Phaue • ACORGP CERTIFICATE OF LIABILITY INSURANCE DATE" 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 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 Edson DeSouza MAYFLOWER INSURANCE GROUP INC ;ON rio.Exd): (774)773 97D2 FAX Hoy E-MAIL m awerinsurance.com ADDRDREss: Edson@mayflowerinsurance.com Court Street INSURERS)AFFORDING COVERAGE NAIC n Plymouth MA 02360 INSURER A: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B: MNP CONSTRUCTION INC INSURERC: 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 LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICAILU_ NOTW1THSTANDING 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 CONDinONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADOL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDIYYYY) MMIDDIYYYYi COMMERCIAL GENERAL LIABILITY • EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea oazmence) S MED EXP(My one person) $ N/A PERSONAL&ADV INJURY $ GFTtL AGGREGATE liMIT APPLIES PER GENERAL AGGREGATE S POLICY f_J,rE T LOC PRODUCTS-COMP/OP AGO $ OTHER S AUTOMOBILE LIABILITY COMBINED SINE,I F LIMIT $ (Es accident) ANY-AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Peracdderd) $ NON OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE N/A AGGREGATE S DED RETENTIONS OTH- ER S WORKERS CONPENSATION X STATUTE AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOPARTNER/EXECU IVE RI EL EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCUIDED? WA NIA WA 6S60UB1K70970620 11/1612020 11/16/2021 (Mandatory in NH) EL DISEASE-EA EMPLOYEES 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S 1,000,000 WA DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD let,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 atA. sling 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 THEPOLICYPROVISIONS. 102 Pine St AUTHORIZED REPRESENTATIVE Holyoke MA 01041 )" Lt Daniel M.Crow 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 ACORD, CERTIFICATE OF LIABILITY INSURANCE DATE(IOIIDD/YYYY) 1 u2412o 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 ADDRTONAL 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 NArhNE= Art Calvillo One Family Insurance "py,et 978-403-5942 (iuc,No): 978-403-5943 1 Main St Suite 15 EMAIL DAD , artglfamTyinsurance.com Lunenburg,MA 01462 INSURER(S)AFFORDING COVERAGE NAIC# 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 Ill 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 ALIULJUUR POLICY EFF POUCY QP LTR TYPE OFINSURANCE ns POUCY D WVD POCY NUMBER (MM/DU/YYYY),(MMJDD!YYYY) LIMITS ' X COMMERCIAL GENERAL UAHdITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED C'I AIMS-MADE X OCCUR PREMIbr s(Ea occurrence) $ 100,000 MED SW(Arty ma person) $ 5,000 A Y Y 3ET9385 11/20/20 11/20/21 PERSONAL a ADV INJURY $ 1,000,000 c' GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JE LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILYINJURY(Peracddent S AUTOS ONLY AUTOS ) HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ — UMBRELLA LIAR —OCCUR - EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ BED RETENTION$ $ WORKERS COMPENSATION PER AND S PLOVERS YIN LIABILITY ER STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ If yes,desae under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 1 DESCRIPTION OF OPERATIONS!LOCATIONSI 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 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 AUTHORIZED REPRESENTA HOLYOKE,MA01040 +dor ,. I 01988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD