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22B-109 (10) 199 PINE ST BP-2022-0086 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:22B- 109 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-2022-0086 Project# JS-2022-000152 Est.Cost: $17600.00 Fee: $126.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RCI ROOFING 074334 Lot Size(sq. ft.): 203425.20 Owner: MATT&NICK LLC Zoning: SI(92)/WP(73)/URA(19)/URB(2)/ Applicant: RCI ROOFING AT: 199 PINE ST Applicant Address: Phone: Insurance: 6 LINE ST (413) 527-4775 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON:7/26/20210:00:00 TO PERFORM THE FOLLOWING WORK:NEW ROOFING ON LOADING DOCK AND FRONT & REAR BUILDING BRIDGES POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. I . • I Cgi Certificate of Occupancy Signature:+ • FeeType: Date Paid: Amount: Building 7/26/202I0:00:00 $126.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner , 176\ 0 (.* V/� 6.;()b9� T►e Commonwealth of Massachusetts r ticti Office of Public Safety and Inspections �I l I A_S'Oc Massachusetts State Building Code(780 CMR) n 1-: Per , t Application for any Building other than a One-or Two-Family Dwelling a QQ(( (This Section For Official Use Only) Building Permit Number' + at Date Applied: Building Official: /if/7 SECTION 1:LOCATION 199 Pine Steet Florence 01062 No.and Street City/Town Zip Code Name of Building(if applicable) 22B 109 Assessors Map# Block#and/or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here 0 or check all that apply in the two rows below Existing Building 0 Repair is Alteration 0 Addition 0 Demolition Cl (Please fill out and submit Appendix 2) Change of Use 0 Change of Occupancy 0 Other 111 Specify: roofing replacement Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No # Is an Independent Structural Engineering Peer Review required? Yes 0 No 0 Brief Description of Proposed Work: install new roofing system on loading dock and front&rear building bridges see attached for additional detail SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0 Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 0 A-2❑ Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0 F: Factory F-1 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional I-1 0 I-2 0 I-3 0 I-4 0 M: Mercantile❑ R: Residential R-10 R-2 0 R-3 0 R-4 0 S: Storage S-1 0 S-2 0 U: Utility 0 Special Use 0 and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 0 IB ❑ IIA 0 IIB 0 IIIA ❑ IIIB ❑ IV 0 VA 0 VB 0 SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal: A trench will not be Licensed Disposal Site O Public 0 Check if outside Flood Zone 0 Indicate municipal 0 required 0 or trench or specify: Private 0 or indentify Zone: or on site system 0 permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: _ Special Stipulations: Design Occupant Load per Floor and Assembly space: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Matt&Nick LLC 85 Hillcrest Place Amherst 01002 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Andy Klepacki,Director of Operations _ _ 413. 214. 2338 Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: RCI Roofing LLP 6 Line Street Southampton MA 01073 Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here IBC Otherwise provide construction control forms(see section 107 in the code)as required. 10.1 Registered Professional Responsible for Construction Control (the professional coordinating document submittals) - Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes IF No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)=$ 17,600 1.Budding roof repair $ 17,600 Building Permit Fee=Total Constructi• os I Insert here 2.Electrical $ appropriate municipal fact,r)=$126 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ 100 (contact municipality) 5.Mechanical (Other) $ Enclose check payable to City of Northampton 6.Total Cost $ 17,600 (contact municipality)and write check number here 3 17014 SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the ins and penalties of perjury that all of the information contained in this application is true and accurate to the best of owled e and understanding. Mark Delisle Partner _ 413 _ 527 _ 4775 4ry..2.04014 Please print and sign name Title Telephone No. Date 6 Line Street Southampton MA 01073 mdelisle@rciroofing.com Street Address City/Town State Zip • Email Address Municipal Inspector to fill out this section upon application approval: 7 Z3-2O1/ Name Date From: RCI Roofing LLP 6 Line Street Southampton MA 01073 To: Jonathan Flagg Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 The Massachusetts Building Code, section 107.1 allows for an exclusion from requirements for construction control in certain situations. In accordance with code section 104.10, I request that you grant a modification to waive the requirement for construction control of the project at 199 Pre 5-1- fr I brtnce. !Y A- because the work is of a minor nature,will not affect structural elements, health, accessibility, life or fire safety, and will be done in accordance with the prescriptive requirements of the code. Thank you for your consideration. Respectfully, Mark Delisle City of Northampton //,pp Massachusetts i 1 ?•E DEPARTMENT OF BUILDING INSPECTIONS 1 4 212 Main Street • Municipal Building Jt �ro Northampton, MA 01060 Est y�" i.\` 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: Shoham Road,East Windsor CT The debris will be transported by: Name of Hauler: USA Hauling&Recycling Inc Zo Signature of Applicant: Date: �- 'Zdzl The Commonwealth of Massachusetts Department of Industrial Accidents 1 ±( Office of Investigations _.( . Lafayette City Center -= 1-0) f/ � 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): l.© I am a employer with 13 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. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.* 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.0 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 12.0 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: 199 Pine Street 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 coverage verification. I do hereby certify under the pains and penalties o ury that the information provided above is true and correct. Signature: '- Date: 1—20'Zd 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): l❑Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.1:3Other Contact Person: Phone#: RC Roofin gu.r 6 Line Street,Southampton, MA 01073 Phone:413-527-4775 Fax: 413-527-8469 May 6, 2021 Mr. Andy Klepacki Pioneer Valley Books 155A Industrial Drive Northampton, MA 01060 Re: Roof Replacement Estimate Loading Dock & Bridge Roofs 199 Pine Street Florence,MA Dear Andy; Thank you for the opportunity to provide the following estimate for the above referenced property. Our scope of work is outlined below. Bridge Roofs Scope of Work: Furnish & install wood blocking as needed to match new insulation height Furnish&install 2" polystyrene flute fillers Furnish & install 1.5"polyisocyanurate continuous insulation mechanically attached Furnish&install .060 EPDM membrane fully adhered Furnish & install all related EPDM flashings and terminations Furnish &install .040 Aluminum edge metal Provide owner with manufacturer's 20-year membrane warranty Provide owner with RCI Roofing 5-year workmanship warranty Existing 5K gutters and downspouts to remain Loading Dock Roof Scope of Work: Furnish & install wood blocking as needed to match new insulation height Furnish& install 1/2" HD coverboard insulation mechanically attached Furnish & install .060 EPDM membrane fully adhered (2) Furnish& install all related EPDM fleshings and terminations Furnish& install .040 Aluminum edge metal Provide owner with manufacturer's 20-year membrane warranty Provide owner with RCI Roofing 5-year workmanship warranty Existing 5K gutter and downspouts to remain Price for Front Bridge Roof: $ 6,300.00 Price for Rear Bridge Roof: $ 1,500.00 Price for Loading Dock Roof: $ 9,800.00 Total Price: $17,600.00 Notes: RCI Roofing will provide crane as needed RCI Roofing to obtain building permit All work installed to manufacturers standards RCI Roofing employees are OSHA 10 certified. Terms: A 50% payment due at time of material delivery. Balance due upon completion. Warranties will be issued after final payment is received. We hope that you select R.C.I. Roofing to do this work for you.To accept this proposal, please sign and return a copy to us. We will obtain required permits and notify you when we plan to schedule the work. Dana Painchaud Estimator, Commercial Accounts 16, 2021 Accepted by Date July Commonwealth of Massachusetts • st� Division of Professional Licensure Board of Building Regulations and Standards —••••------�-------------.•-----.•— Coitstrui11/tyrtt1`lpirvisor �/2,0 CrumYreu,vverit'A tela ar✓rmat: Office of Consumer Affairs&Business Regulation CS-074334 Expires:05/03/2022 HOME IMPROVEMENT CONTRACTOR MARK THOMAS DELiSLE TYPE:Partnership 32 OLD COUNTY RD Registration 6117/fLon t26'235 06/17,12022 SOUTHAMPTON MA 01073 RC'ROOFING,LLP cal MARK•f.DELISLE "'Commissioner u, F ekrik. 6 LINE ST �4,»atc3,kr/. =•.r:. SOUTHAMPTON,MA 01073 Undersecretar} 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 -'" -.. -1---/-*----:1,,...._ 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)727-3200 or visit www.mass.govldpl • STATE;OF C©NN ?CTIGUT cOMMONWEALTH OF MASSACH ETIS ;* PROFESSIONAL 1. E-• , ;,f,EP4�t7 imNT of CONSUMER PROTECTION . BOARD Or HOME IMPROVEMENT,CONTRACTOR SHEET METAL WORKERS R t; I HOOFING LIT THE FOLLOWING LICENSE 6I.INL ST BUSINESS }" I SOUTHAMPTON,MA•,01073 I MARK T DELISLE 1„j s '? RCI ROOFING LLP u - .__.._ . 6 LINE STREET RcRistratiaa _ —Effective' ` ---" -" Expisntion -_ EASTHAMPTON,MA 01073 HIC.0624741 0 '''' 11/30/2021 SIflNED `" 601 0913.S0 2023 88810 AC� DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/09l2020 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 Banas BANAS & FICKERT INSURANCE AGENCY lacC.No.Extl: (413)527-2700 FAX Nor E-MAIL G� ADDRESS: so@banasinsurance.com 63 MAIN ST INSURER(S)AFFORDING COVERAGE NAIC EASTHAMPTON MA 01027 INSURER A: 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. INDDL LTR TYPE OF INSURANCE INSD swvo POLICY NUMBER UBR POLICY EFF POLICY EXP LIMITS (MMlDDIYYYY) (MMIDDIYYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&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 X STATUTE PER OTH- ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? WA 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 I 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.CroGf ey,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 AC( c CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/Y1 YV) 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 CUNTACI NAME: Michael R.Banas Banas&Fickert PHONE 413-527-2700 FAX Insurance Agency E MAIM°'EMI' (tvc,No): 413-527-0849 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 AUULSU IW POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMM/DD/YYYYUMM/DD/YYYY)_ LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 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&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X PECOT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY (Ea aBINEDll SINGLE LIMIT $ 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 RETENTIONS 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE(( N/A 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 I 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 WITHTHE POLICY PROVISIONS. AUTHORIZED REP F S IVE S - .s...............----r 15 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD