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17D-012 (72) 491 BRIDGE RD BP-2022-0116 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-012 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-2022-0116 Project# JS-2022-000205 Est.Cost: $616000.00 Fee: $431.20 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: DICKY MATOS 105917 Lot Size(so. ft.): 1169150.40 Owner: MEADOWBROOK PRESERVATION ASSOCIATES LTD PARTNERSHIP Zoning: URB(100)/WP(28)/ Applicant: DICKY MATOS AT: 491 BRIDGE RD Applicant Address: Phone: Insurance: 23 HADLEY MILL RD (413) 530-5335 WC HOLYOKEMA01040 ISSUED ON:8/2/2021 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. Cgl • Certificate of Occupancy Signature;` • FeeType: Date Paid: Amount: Building 8/2/2021 0:00:00 $431.20 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner r11�cF � I VFO The Commonwealth of Mass ch f • • ©�1 Office of Public Safety and Inspecti om_ 1Oc t J/ Massachusetts State Building Code(780 CMR) Nq1'n� nniSp Building Permit Application for any Building other than a One-or Two- a ' g 5Q (This Section For Official Use Only) Building Permit Number:OP"2 2--I(W Date Applied: Building Official: SECTION 1:LOCATION yq i [�r�clge, Rr1 Ftorenc�- , MA ©tOha, Meadowbrook Acrtr}mel tS No.and //Street Cit./Town Zip Code Name of Building(if applicable) 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 Repair 11 Alteration 0 ' Addition 0 Demolition 0 (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy 0 Other 0 Specify: J Are building plans and/or construction documents being supplied as part of this permit application? Yes ® No ❑/ Is an Independent Structural Engineering Peer Review required? Yes 0 No Si Brief Description of Proposed Work: Tear off- CO[5-F 1 cep CAC€ W 1-4•h n-euj roof eelyielke GI( --hicas k onctGZebriS \l1Sk-c i Ptrc\n\-*e.c*urG\ Shy ack!-e S ) to -t-- - of lct off► Wc7rrer GcNrri€r Oir\CX, Sy t C urNCa-erkeyrn•€ft - • 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) ❑ 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 0 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❑ I-3 0 I-4❑ M: Mercantile 0 _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 ❑ IB 0 HA 0 IIB ❑ IIIA 0 IIIB 0 IV 0 VA10 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 0 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 Mtiac�ow brook. Lig t P)ric C4-. mad r lorence MA 010(0.), Name(Print) No,orntnts No.and sTreet City/Town Zip Property Owner Contact Information: I\c Q Q\J rah NAk-5Vy- 7 590 - - in(iverOtGop0 1C-OrnrnkAtS. Title Telephone No.(business) Telephone No. (cell) e-mail address c,0 i-n If applicable,the property owner hereby authorizes: Licii Boacc2 12ocd rko r µO 610 c, . Name Street Aildress 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 1 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 1 Com an I N e Nccto e-p (I3 L c"0OC C, P Y 'D C_V-1 tkAoS . CS -- l 0 5 g i t CS L Name of Person Responsible for Construction License No. and Type if Applicable c S mote\ e\-I HAI 12.a 4 ok'4 a k--e. RA C o 1(0 Street Address City/Town State Zip Lit. -5310- 11/L10 9i3 -530-5335) .. mroo'ftri3@ lc loud -Corrl Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11: WORKERS'COMPENSATIQN 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 0 No 0 SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ t I I Co 0° 'o0 Building Permit Fee=Total Construction •st x (Insert ere 2.Electrical $ appropriate municipal fact. _ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ .. . i cipality) 5.Mechanical (Other) $ 4 Enclose check payable to 6.Total Cost $ (O 1,(,00 .00 (contact municipality)and write check number here 161 N SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. c-. .ncxkos ?..00.6 ( ci y kit ) o>,, ner 413 -536-53 l i gia l Please print and signname 1 Title Telephone No. Date C �Hill •-•Wlov__e Mci Otbc 6 _(__ook 91@)ic(OUd•QLl Street Address City/Town State Zip Emai Address Municipal Inspector to fill out this section upon application approval: 8-Z"zoai Name Date CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: N/A REAR YARD SIDE YARD SIDE YARD t FRONT SETBACK FRONTAGE Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the ninth edition of the .• Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Date:' Property!Address: Project: Check(x) one or both as applicable: New construction Existing Construction Project description: I MA Registration Number: Expiration date: ,am a registered design professional,and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerningl: Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that to the best of my knowledge, information, and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that 1 (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1 Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent comments,in a form acceptable to the building official. Upon completion of the work,I shall submit to the building official a'Final Construction Control Document'. Enter in the space to the right a"wet" or electronic signature and seal: Phone number: Email: Building Official Ws Only Building Official Name: Permit No.i Data Note 1.Indicate with an'>t project design plans,computations and specifications that you prepared or directly supervised If'other'is chosen,provide a description. Version O1 Ol 01S • Appendix 1 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing(include local connections) 9 Gas(Natural,Propane,Medical or other) 10 Surveyed Site Plan(Utilities,Wetland,etc.) 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review(521 CMR) 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation ' 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date - - Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. City of Northampton `oaYx'Nro\. 5...'`.. S ;, •!- Massachusetts mow? " !<< `cC :i• ' U DEPARTMENT OF BUILDING INSPECTIONS a t f;; IA ,� ;y-': 212 Main Street • Municipal Building "" 'K Northampton, MA 01060 'P.P."- -0 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: 1 C)C VACAVO 5-k- ukyak� , MA O'O yQ • The debris will be transported by: Name of Hauler: D Q W S1fE ci-av U'S Li c_, 4 Signature of Applican . - 0 Date: a _ The Commonwealth of Massachusetts a_. ,Jr, Department of Industrial Accidents r — i :gnu= ' 1 Congress Street,Suite 100 1 ;;� Boston,MA 02114-2017 •''•, i-e wwwcntass.gov/die 'awes 11 utters'Compensation Insurance Affidavit:Builders/Contractors/ElectriciansiPlumbers. —to HE FILED WITH TIIE PEK.MITI'ING Alf 1'HORlTT. Annlicant Information ' Please Print Leeiblv Name IHusuuas:Or a za atndividuao: JJ1( t HCS 2 X I 103 TAC Address: c9 \ocaVe' A \\ R; \-\ciyntR.. Ma City/State/Zip:_ V\a1_‘tiJ Kk V kc 0 I(t--tn Phone#t: - IA -S 3 0 -5 3 a 5 , Art am en employer?Climb the appropriate bad: Type of project(required): 1.E6 1 am a employer wain__.a__emptuyees(foil andlor part-times.' 7. 0 New construction =C3 I am a sole proprietor ur pattaouhip and have no employees working far um iu K. O Remodeling any sty.[Nu mutters'comp.i.staaaeae required-1 30 I am a lammuw nee doing all wank myself.(No madamewop tnrece d s .imr r ttptal.l• 9. 0 Demolition 4.0 i am a hwesa,wsacr arid will be Melee americium to aoudadall work un row property_ 1 will 10 CI Building addition aware that all cvatrac-tems either leave workers'crraparratiwr inseam.ur.rc auk I I.Q Electrical repaint or additions proprietors with au anpl.'yeo, 12.0 Plumbing repairs or additions 50 l mu a generai cwatraotur and I have hired the sub-a ulnae fuel un the.nachcd abed. 13.dRowCrepeln These iuh-m.tractum hoe employees wed have workers'rump.insurance.• 6.0 We arc a cwpuraium and its talkers have exercised*nit right of exemptiun per M .GL c 14.LOti er 152.014 L and we have nu eraphoy eea.)No worked'comp.insurance regarrwl.) 'Any applicant that chocks bus.I was ads ftU oat die scenes below sluts ing their*utters'cumperamius policy information. ttuseteuw lets who wham this afthirvit iaelicating they ate doing aft work and tbca hire outside c,moas'aors mast submit a new affidavit i.dimelem suck j;t untraderes that check den butt must auacchad an additional sham dancing the name of the ai .etarrsc4xs and Gate whether ur nut douse entitaes have .anepluyem. U die mils-evWractura have empluyaxs.they mud provide their wutkas•comp.policy ameba. I awe an employer that is providing workers'compensation insurance for my employees. Below Is the policy and Job she infraration. Insurance Company Name: ptc,G -Amen c Girt i r iroc c — Policy#or Self--ins. Lic.#: (pS(n a,u 2) Pa S (7ay(D Expiration Date: j—16`d.Cl(a� Job Site Address: 1"t GI I 1Jr I aye. ea City/State/Zip: Attach a copy of the workers'compensation polka declaration page(showing the polity number and expiration date). Failure to secure coverage as required wider MGL c. 152,§25A is a criminal violation punishable by a tine up to S1.500.00 andd'or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator_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 Ip/ains and pen of perjury that the Information provided-above is true and correct: Signature: �L C`` — Date: 1`CJ'r 1 l al phunc c: LA1,2,- G1 -S 0 - Official use only. Do not write in this area.to be completed by city or town official. City or'Iowa: Permit/License N Issuing Authority(circle one): 1 I.Board of health 2.Building Department 3.Cityfrowa('krk 4.Ekctrkal Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: /VA , HEi ��� o- w ^dry * 23 Hadfey MIA Rd { "h • 9 � n e ; ;, .: HblifQke, Ma Q104q,.. 00 , S isib "" v ei e :418� 5313,5,, 0,4;;- 0-7, >ta g to 1 t ¢ Y +"�j , DeMw262000,0° 21 qb DICKY MATOS RJ() ENI:; : , . s R.O. "'r Terms Bill To Meadowbrook Apartments Ship Via ATTN:Maya Rivera 413.584.7690 EXT.5269 Ship Date 491 Bridge Road Florence,MA 01062 mrivera@a poahcommunitfes,com (sty Oescriotion Unit. 130 NEW ROOF 400.00 52.000.00 7L&7R. Tear off entire roof Inspect plywood(If any damage will be an additional coat of$90.00 per sheet 1/2 inch and$90.00 per sheet 3/4 inch, Install ice&water barrier 6 ft and valleys Install synthetic underlayment to rest of the roof Install limited lifetime warranty architectural shingles Install 8"ddp edge Install a Tamko Rapid Ridge Vent Seal all pipes and vents Remove all trash and debris Building Permit included 24 NEW ROOF 400.00 9,600.00 TOWN ROUSE 1201-1202 Tear off entire roof Inspect plywood(If any damage will be an additional cost of$80.00 per sheet 1/2 Inch and$90.00 per sheet 3/4 Inch. Install foe&water barrier 6 ft and valleys Install synthetic undertayment to rest of the roof Install limited lifetime warranty architectural shingles Install 8"drip edge Install a 7`drnko Rapid Ridge Vent Seal all pipes and vents Remove all trash and debris Total(184) 581,600.00 Page 10l 1 / 1 ® DATE(MM/DD/YYYY) A G D CERTIFICATE OF LIABILITY INSURANCE 04-14-2021 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: CHI INSURANCE AGENCY PHONE (FAX 17 COLLEGE ST (A/C,No,Ext): (A/C,No): E-MAIL SOUTH HADLEY, MA 01075 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC INSURER A:ACE AMERICAN INSURANCE COMPANY INSURED INSURER B: DICKY MATOS ROOFING INC DBA INSURER C: DMR ROOFING 23 HADLEY MILL RD INSURER D: HOLYOKE, MA 01040 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MWDWYYYY) (MM/DWYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE LI OCCUR DAMAGE TO RENTED $ PREMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY I _ I PRO- [ I LOC PRODUCTS-COMP/OP AGG $ _.., JECT OTHER $ ' ' AUTOMOBILE LIABILITY �OMaccident)BINED SINGLE LIMIT $ (Ea 'ANY AUTO 4 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accioent) $ HIRED NON-OWNED PPgOPERTY pAMAGE $ ' AUTOS ONLY AUTOS ONLY IF�er accWentl $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB -CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION I PER I 1OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/ N/A E.L.EACH ACCIDENT $$100,000 EXECUTIVE OFFICER/MEMBER 6S62UB 03-16-2021 03-16-2022 EXCLUDED? 5R818246 E.L.DISEASE-EA $$500,000 (Mandatory in NH) EMPLOYEE II yes,describe under E.L.DISEASE-POLICY $$100,000 DESCRIPTION OF OPERATIONS Delow LIMIT • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) CERTIFICATE HOLDER CANCELLATION DICKY MATOS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 23 HADLEY MILL RD BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE HOLYOKE,MA 01040 DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • • Commonwealth ot Massacnusetts • Division of-Professional Licensure Board of Building Regulation"and Standards Constwitt*%iipfrvisor CS-105917 * fit,opires:03/30/2022 DICKY MATgA 'fit 3 GLEN STREJT ••. ter • ? HOLYOKE MA:2„ ' i - 2 Commissioner duia K. B'Fn.hz/ Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Ma achusetts 02118 Home Improvement,Contractor Registration Type: Corporation Registration: 198417 DICKY MATOS ROOFING,INC - Expiration: 04/27/2022 23 HADLEY MILL ROAD - -_• - _ HOLYOKE,MA 01040 =- Update Addrsas and Return Card. :A 1 O 20M-05/11177 ✓/kt C7I/!l/!2I//1uiC4.!!/i(!�✓G'Oa:41aUK�Jd4 Mee ot Consumer Male&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYpf";Corporation before the expiration date. If found return to: Exoi� iration Office of Consumer Affairs and Business Regulation 17,,.. 04/27/2022 1000 Washington Street -Suite 710 * = Boston,MA 02118 DICKY MATOS:E3 �1C DICKY MATOS -- 23 HADLEY MILL ROAD " Not valid without signature HOLYOKE,MA 01040 Undersecretary S DATE(MM/DD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE th.......---. 04/06/21 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 CON1NAMME: Hannah O'Shea PHONE Bresnahan Insurance Agency,Inc. ovc,No.Ex(): 413-536-0536 (A/C,No): 413-534-4291 100 Whiting Farms Road E-MAIL hoshea@bresnahaninsurance.com Holyoke,MA 01040 ' INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Atlantic Casualty Ins Co, INSURED INSURER B: Mapfre/Commerce Insurance Co. Dicky Matos Roofing,Inc. INSURER c: Nautilus Insurance Co. 23 Hadley Mill Rd. INSURER D: Holyoke,MA 01040 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. TR TYPE OF INSURANCE INSD Jy1/D POLICY NUMBER (MM/DD/YYYY) (MFF OM/DD/YYYYCY Y) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE a OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A Y M271000234 02/25/21 02/25/22 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY n J'r n LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED AUTOS ONLY AUTOS ULED y RZV182 03/13/21 03/13/22 BODILY INJURY(Per accident) $ X HIRED x NON-OWNED PROaccdant)GE $ AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 C X EXCESS LIAB CLAIMS-MADE AN101325 02/25/21 02/25/22 AGGREGATE $ 2,000,000 DED RETENTION$ $ WORKERS COMPENSATION OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVEI N/A E.L.EACH ACCIDENT 5 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) Proof of Coverage 't 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. Dicky Matos 3 Glen St. Holyoke,MA 01040 AUTHORIZED REP ATIVEI diJgd3 ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD