Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
30B-005 (2)
57 NORWOOD AVE BP-2021-1530 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30B-005 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-2021-1530 Project# JS-2021-002544 Est.Cost: $19000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RCI ROOFING 074334 Lot Size(sq. ft.): 17293.32 Owner: MCDONALD DOUGLAS S&DEANNA COOK Zoning: URB(100)/ Applicant: RCI ROOFING AT: 57 NORWOOD AVE Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:6/24/2021 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. • >2 7), Certificate of Occupancy Signatur I I I FeeType: Date Paid: Amount: Building 6/24/2021 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner I' RECt �/c1 -_ The Commonwealth of Massach setts C D Board of Building Regulations and 'and ds 1): F R Massachusetts State Building Code, 80 lWN iIIReMar M IC P/RALITY Building Permit Application To Construct,Repairen ate Or De 2011 One-or Two-Family DwellingThis Section For Official Use Onl�AMpTON t,,,\ r NS Building Pe it Number• 5/^2 6 3v Date Applied: -- �vi l)145 Z/� l! Zy 2ozj Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 57 Norwood Avenue, Florence MA 30B 005 1.1 a Is this an accepted street?yes x no__ Map Number Parcel Number 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 v 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' 2.1 Owner'of Record: Douglas& Deanna McDonald Florence MA 01062 Name(Print) City,State,ZIP 47 Norwood Avenue 413-362-5224 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) IN Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: remove existing slate roof,install 1/2"olvwood over existing decking. install new shingle roof SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.B(tikiix Roofing $ 19,000 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire A in Suppression) Ni$ Total All Fee i � Check 7 ieck Amoun : Cash Amount: 6.Total Project Cost: $ 19,000 0 Paid in Full 0 Outstanding Balance Due: ;•rt� tt r _ __.. III rj .. _. i .. •_ i 'RO t r's.'.LC�t 1_. �. - .... r`r SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-074334 05/03/2022 Mark Delisle License Number Expiration Date Name of CSL Holder U 32 Old County Road List CSL Type(see below) No.and Street Type Description Southampton MA 01073 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-527-4775 mdelisle@rci-roofing.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 126235 06/17/2022 RCI Roofing LLP HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 6 Line Street mdelisle@rci-roofing.com No.and Street Email address Southampton MA 01073 413-527-4775 City/Town,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 0X 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 RCI Roofing LLP to act on my behalf,in all matters relative to work authorized by this building permit application. see attached 040 O Z.(ZOZ/ 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 enalties of perjury that all of the information contained in this application is true and accurate to the be my knowledge and understanding. RCI Roofing LLP O(./ZS/Zo2./ Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. 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 not 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 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 cry--,., ; r f • .r r Massachusetts ��?ss N. t, .A (.4 4. ,,. *# 1, DEPARTMENT OF BUILDING INSPECTIONS y j r• - 212 Main Street • Municipal Building J,, fib-, Northampton, MA 01060 �fW 3 w ) �' - 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: Shoham Road, East Windsor CT Location of Facility: The debris will be transported by: Name of Hauler: USA Hauling & Recycling Inc ---t.i. c...... o6i21i2o21 Signature of Applicant: Date: . . ,. 1 Jt.% is • �r . v( • �F xy ._, c ;r• • i;Ts: '�4 .°.?4tarC4;:• 1 .Y4 'co..., , to t • , The Commonwealth of Massachusetts Department of Industrial Accidents 9 —1 Office of Investigations _ • III , , Lafayette City Center I2,1 * 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): RCI Roofing LLP Address:6 Line Street City/State/Zip:Southampton MA 01073 Phone#:413-527-4775 Are you an employer? Check the appropriate box: Type of project(required): I.0 I am a employer with 11 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have . 8. 0 Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.: ❑ 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 11.0 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.❑ 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:AIM Mutual Insurance Co Policy#or Self-ins. Lic. #:VWC10060226472020A Expiration Date:10/05/2021 Job Site Address: 57 Norwood Avenue City/State/Zip: Florence MA 01062 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 insurance�n coverage verification. I do hereby certify under the pa7fts snd penaltie erju that the information provided above is true and correct. Signature: Date: O(0 r Z I /ZO Z/ Phone#: 413-527-4775 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 21:1Building Department 31:City/Town Clerk 4.❑Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: • • • • • tC. is ".C '.1.1nI)'fii. ,J�SJ; 1 GC.%i- _ CI. �(1 Ft-. ..:.1 .� :�?t?:T�+.. "... ,, . s - _ - - - -, .0 6! RC.I. Roofing Estimate Date Southampton,Ma.01073 5/28/2021 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location Douglas &Deanna McDonald 57 Norwood Avenue Florence, MA 01062 Terms Rep Description Total Remove existing roofs. 18,000.00 Furnish&install 1/2"plywood over existing decking. Furnish&install aluminum drip edge,pipe flashings,chimney flashings(if needed)and step fleshings. Furnish&install CertainTeed Winterguard ice&water barrier along eaves and valleys. Furnish and install synthetic underlayment. • Furnish and install Lifetime CertainTeed Landmark Series shingle. Furnish and install CertainTeed approved ridge vent. All exterior roofing related debris to be removed by R.C.I. Roofing. All work will be performed according to manufacturers'specifications. Lifetime CertainTeed material warranty included. All related permits will be obtained by R.C.I.Roofing. ` �,C0C.op <<(c u<4-V-• t(uti` WE LOOK FORWARD TO DOING BUSINESS WITH YOU. ap ('( CCC Total $18,0'.00 TERMS OF PAYMENT 5%Deposit Customer Signature: Balance upon completionKiJ Registration# 126235 Date: 6'!' .G2i Construction License#074334 Insured by Banas&Fickert Ins. Shingle Color Selection: -� ,,,jj (413)527-2700 g G ectr_"(G`v,n Gc p I "R rotA NA CD I D•,.( vmrfelp, exi f ids CoR Commonwealth of Massachusetts 1 l Division of Professional Licensure • Board of Building Regulationst and Standards •-••• _- -- --- — __�._. Construr't )i�i' }S rvisor irorrmcumeerfkii riOlttraviar/ray f/.3 I Office of Consumer Affairs&Business Regulation CS-074334 6itpiresspires 05/03I20,' HOME IMPROVEMENT CONTRACTOR MARK THOMAS DELISLE TYPE:Partnership 32 OLD COUNTY RD , r Registration Expiration1 / 22 SOUTHAMPTON MA 01073 ": 126235 !}E;Ji7!202F L w RCI ROOFING,LLP • nn c�.,!/ MARK'I DELISLE ''Commissioner ciaXL1 f i)tr 6 LINE ST e;4—' ' ;,;>' r:,x,I, tCU SOUTHAMPTON,MA 01073 Undersecretary Construction Supervisor Unrestricted -Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed Registration valid for individual use only space. before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 Failure to possess a current edition of the Massachusetts Not valid without signature State Building Code is cause for revocation of this license. For information about this license Call(617)7273200 or visit www.mass.govldpl o COMMONWEALTH OFAS,AC11U5ETT a U.ARD ... SHEET SMETAL`JVOR`r.;ERS ISSUES THE FOLLOVa`INC LICENSE Pd,> . u BUSINESS i STATE OF CONNECTICUT f tARK T DELISLE1,, n it • 1),C.AAIITM1SNT OF CONSUMER'PROTECTION .`RCI ROOFING LLP HOME IMPROVEMENT,CONTRACTOR LIN E STREET R( I LINE$T ROOFING LI::P EASTHtAMP1 ON;-NIA�01073 S 6 LINE: €01 09/09/2021 714002 1 SOU'1'IIAMPTON,1VIA',0]073 i , r41.1,f zi cilI l , i+.P 7ait I.f f.�.:�rT fF[i2i 1T:i a Registration if 8ffective �--tap' iratiun HIC.0624741 0 11/30/2021 SIGNED ` • • ' , r •• . . • • r . • • r;• oz,, • • , . ' .• - _ • - .--_----.-.- . ' ',+.:•;t:(,. •" ii" .1 .7 ."1 • • . -..".• r. • -4 •. . . . . • • AC O ® DATE(MMIDD/YYYY) ��.. CERTIFICATE OF LIABILITY INSURANCE 10(MM/2a2o 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: Michael Banes BANAS & FICKERT INSURANCE AGENCY (A/C,No.Exth (413)527-2700 FAX (A/C,No): E-MAIL @ ADDRESS: so@banasinsurance.com 63 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC a EASTHAMPTON MA 01027 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURER B RCI ROOFING LLP INSURERC: INSURER D: 6 LINE STREET INSURER E: SOUTHAMPTON MA 01073 INSURER F: COVERAGES CERTIFICATE NUMBER: 583626 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR -INSp INVD POLICY NUMBER (MM/OD/YYYY) IMM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y I NER •ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A VWC10060226472020A 10/05/2020 10/05/2021 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Reference Copy ACCORDANCE WITH THE POLICY PROVISIONS. Reference Copy AUTHORIZED REPRESENTATIVE Reference Copy MA 01027 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 DATE(MM/DD/YYVY) ACORDf CERTIFICATE OF LIABILITY INSURANCE 03/09/21 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: Michael R.Banas PHONE 413-527-2700 FAX Banas&Fickert IA/C,No,Ezt): (A/c,No): 413-527-0849 Insurance Agency E-MAIL 63 Main Street ADDRESS: mb@banasinsurance.com Easthampton,MA 01027 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Admiral Insurance Co. 24856 INSURED INSURER B: Safety Insurance Co. 39454 RCI Roofing,LLP INSURER C: Admiral Insurance Co. 24856 6 Line Street Southampton,MA 01073 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE 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 AUULSUHR EFF POLICY XP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER .(MM/DDY/YYYYL LMM/DD/YEYYYL LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO REN fED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 50,000 MED EXP(Any one person) $ 5,000 A X CA000020963-07 03/04/21 03/04/22 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 JE POLICY X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B OWNED X SCHEDULED X 6207761 09/30/20 09/30/21 BODILY INJURY(Per accident $ AUTOS ONLY � AUTOS ) X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 C EXCESS LIAB ,CLAIMS-MADE X . GX000000385-05 03/04/21 03/04/22 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION f PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below +_ E L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) ROOFING CONTRACTOR. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Reference Copy *"• ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPFl SI IVE I 15 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD