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17A-173 (12)
40 HOWES ST COMMONWEALTH OF MASSACHUSETTS BP-2021-1765 Map:Block:Lot: 17A-173- 001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2021-1765 PERMISSION IS HEREBY GRANTED TO: Project# Contractor: License: Est.Cost: $16800 MARK DELISLE 074334 Const.Class: Exp.Date:05/03/2022 Use Group: Owner: BASSETT THOMAS A&BEVERLY A S Lot Size (sq.ft.) Zoning: URI3 Applicant: RC1 ROOFING LLP Applicant Address Phone: Insurance: 6 LINE ST (413)527-4775 SOUTHAMPTON, MA 01073 TO PERFORM THE FOLLOWING WORK: ISSUED ON:08/20/2021 STRIP AND SHINGLE 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. Signature: I �I• yQ IT) I Fees Paid: $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner The Commonwealth of Massachitisetts Board of Building Regulations an Stan :rds /r, FOR Massachusetts State Building Coe, 781 CM, +� ICIPELITY Building Permit Application To Construct,Re4ir, I ovate Or 11eeiojtsh a •vised ar 2011 One-or Two-Family Dw ng o� `0(9J This Section For Official Use Qu�� qt�Qi4'G Buildin Permit Number: 1512-W/-(16 C- Date Applied: TON i"SA Et111J /7/7Z- Mq oro of0"S 6-17 76zi Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 40 Howes Street, Florence MA 17A 173 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 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: Thomas Bassett&Beverly Shaw Florence MA 01062 Name(Print) City,State,ZIP 40 Howes Street 413-584-5399 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) l Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: remove existing roof and install new shingle roof SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Boiltitiog Roofing $ 16,800 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: _ 5.Mechanical (Fire $ Total All Fees: $ Suppression) Check No34440 liteck Amount. Cash Amount: 6.Total Project Cost: $ 16,800 0 Paid in Full 0 Outstanding Balance Due: _ — . • :.., + ;t# i L 1, ! 3,��..��. yI i. l w)al.<f.''�" • 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 I&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 D X No 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,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 $-/-Zv Z Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pain nd penalties of perjury that all of the information contained in this application is true and accurate t est y knowledge and understanding. RCI Roofing LLP g .1k Z02I Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. .\n 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. I42A.Other important information on the HIC Program can be found at \w ww.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. \Vhen substantial work is planned,provide the information below: Total floor area(sq. I).) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplace, _ Number of bedrooms Number of bathroom, _ 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" �ti_ City of Northampton fi. rr 5 r' • Massachusetts ham,, ! f ram' r Afk * - 4 DEPARTMENT OF BUILDING INSPECTIONS I x? v' 212 Main Street • Municipal Building 0_ Off` `' Northampton, MA 01060 -i')qk, .4..j\ 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: USA Hauling & Recycling Inc Name of Hauler: Signature of Applicant: Date: g"«"Zo Zt i y • 1.. `• f. . . - .•t •L 1 t • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations �-` Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 M / www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RC I 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): 1.0 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 .❑ 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 working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance. t required.] 5. ❑ We are a corporation and its 10.❑ 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 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp. insurance required.] _ *Any applicant that checks box#l 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. #:VWC 10060226472020A Expiration Date:10/05/2021 Job Site Address: 40 Howes 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 penult' per' that the information provided above is true and correct. Signature: Date: o (‘ 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): I❑Board of Health 20 Building Department 3ECity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: • .. t'f .._iJ ;. .fi t i.� 0 ,, .M v ,\ tVf 1 vi+ .-lf:. .... a 1• 1 ..)•' . ,. • t ... ti • • f , r. 1 .. ( . li ! .. .. .. - . 1... . t .. RC.i.. Roofingg Date Estimate Southampton,Ma.01073 7/28/2021 Phone(413)527-4775 Fax(413)527-8469 Name/Address Job Location Beverly Shaw 40 Howes Street Florence, MA 01062 Terms Rep Estimate valid for 30 days Description Total Remove existing roofs. 15,700.00 Furnish&install aluminum drip edge,pipe flashings,chimney flashings(if needed)and step flashings. Furnish&install CertainTeed Winterguard ice&water barrier,6 feet along eaves and 3 feet in valleys. Furnish and install synthetic underlayment over existing deck. 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. ***Due to fluctuating material prices,any wood decking replacement needed would be an additional charge based on the material price and additional labor at the time of installation. Gutters-additional fee for gutters on main portion of house only would be$1,100 .— 7 L 5 1 WE LOOK FORWARD TO DOING BUSINESS WITH YOU. Total $15,700.00 TERMS OF PAYMENT / > i 'i. / /�� 5%Deposit Customer Signature: Balance upon completion g• _ Registration# 126235censeDate: O)Jo1j04,1 Construction License#074334 Insured by Banas&Fickert Ins. 4(413)527-2700 Shingle Color Selection: /Lj®f ke ,, f ,, ,...j/kJ,,,,,L.,e_-. 1if ..- -. Commonwealth of Massachusetts • ilt Division of Professional Licensure / k-- Board of Building Regulations and Standards — — *— Co ivitrue.-41YSTYpp,rvisor (712e foonmo,fivoertill;c/01:4oieoke4611; 'I Office of Consumer Affairs&Business Regulation CS-074334 , E.:xpires:05103/2022 HOME IMPROVEMENT CONTRACTOR TYPE:Partnership MARK THOMAS DELISLE Registration Exoirstia0 32 OLD COUNTY RD , . 126235 06/17/2022 SOUTHAMPTON MA 01073 , ' RCI ROOFING,LLP < r '(,,i', MARK T.DELISLE 'Commissioner da8Q...i A.,', IDITotill.a... 6 LiNE ST SOUTHAMPTON,MA 01073 Undersecretary , --, Construction Supervisor Unrestricted-Buildings of any use group which contain less than 36,000 cubic feel(991 cubic meters) of enclosed Registration valid for Individual use only space. before the expiration date. If found return to: Office of Cortsumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 ---------- Not valid without signature Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpi STATE OF CONNECTICUT . - immo NWEALTH OF MASSACHUSETTS ONISION OF * - ....,2....,-..,-1.„- 11FPARTMENT 01;CONSUMER PROTECTION IBOARD of HOME IMPROVEMENT CONTRACTOR SHEET METAL WORKERS R C I ROOFING 1,1,P ISSUES THE FOLLOWING LICENSE z \\,.j E • 6 LIN ST BUSINESS SOU'llIAMPTON, MA 01073 I MARK T DELISLE / . ' RCI ROOFING LLP N\ ; 6 LINE STREET ——Regiiirratficii II l'ff"'"" Exphation _ ,j EASTHAMPTON,MA 01'073 . HIC.0.624741 'T/24410 11/30/2021 ‘,, 601 0'9,09)202a 68510 1 1 Za,L.L.112'''2111101-, .._ . _ ., • . • . '.',.i.,.-..;;?z?c.!•• • - •4, • _ . . . . _....... .... . , . •., . • • • • • , - -•• • • . . , : • • '" ,..• „ :'• • . _ •" . . . . . . A/"�® DATE(MM/DD/YYYY) V .. CERTIFICATE OF LIABILITY INSURANCE 10/09/2020 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 (arcC.No.Ext): (413)527-2700 FAX No): E-MAIL ADDRESS: so@banasinsurance.com 63 MAIN ST INSURER(S)AFFORDING COVERAGE NAICE EASTHAMPTON MA 01027 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B RCI ROOFING LLP INSURER C: INSURER D: 6 LINE STREET INSURERE: 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 LTR TYPE OF INSURANCE INSD SUBRwo POLICY NUMBER POLICY EFF POLICY EXP LIMITS IMMIDD/Y1'YY) (MMIDD/YYYY) 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 LOC PRODUCTS-COMP/OPAGG $ PRO- JECT 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 EOTH- R AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED7 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 j$ 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.CroWfey,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 ,... • „r AC'C7RD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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). CORI PRODUCER NAMEACi Michael R.Banas AX Banas&Fickert ( /CC PHONE.Ext): 413 527-2700 (NC,No): 413-527-0849 Insurance Agency E-MAIL mb@banasinsurance.com 63 Main Street 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 INSURER D: Southampton,MA 01073 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. TNSR AUUL'UB POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVD, POLICY NUMBER JMMIDDIYYYY)_fMMIDDIYYYY)_ X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE 1 O REN TED 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 POLICY X ECT I 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 OAUTOWNEDS ONLY AUTOS X SCHEDULED X 6207761 09/30/20 09/30/21 BODILY INJURY(Per accident) $ PERTY x HIRED x NON-OWNED ROr accident) DAMAGE $ AUTOS ONLY _ AUTOS ONLY $ 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 PER OTH- AND EMPLOYERS'LIABILITY YIN 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 I 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 REPR SI IVE l i 9 15 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD