17C-187 (18) B P-2021-2332
62 CHESTNUT ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17C-187-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-2332 PERMISSION IS HEREBY GRANTED TO:
Project# TUB Contractor: License:
Est.Cost: 22425 SAMBRICO 111478
•
Const.Class: Exp.Date:01/21/2023
DELLA PENNA CRAIG P& KATHLEEN A GRIFFIN
Use Group: Owner: DELLA PENNA
Lot Size (sq.ft.)
Zoning: URB Applicant: SAMBRICO
Applicant Address Phone: Insurance:
2097 RI VERDALE ST (413)382-0249 UB-2E072183-21
WEST SPRINGFIELD. MA 01089
ISSUED ON:12/27/2021
TO PERFORM THE FOLLOWING WORK:
REPLACE TUB
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:
bod• - 9)-11
Fees Paid: $149.50
212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272
Office of the Building Commissioner
1 `--
/ ''b P.-
pep \ .,j 7
The Commonwealth of Massachus s 22 /
c� Board of Building Regulations and Sta dard , 2Q F a R
MUNI' IP TY
Massachusetts State Building Code, 780 CIVIko�r r>i,if USE
N'149n rNn
Building Permit Application To Construct,Repair,Renovate Or '4 ,0.., r •evi.ed M r 2011
One-or Two-Family Dwelling MA D7no�ONs
� This Section For Official Use Only
Building Permit Number: s ?I'� A►I,. ',/33 Date Applied:i
e o '. , , ' �►. . 1a/(317t/ ii
Buildin Oficial Name) Si ature I Da
g (PrintSignature
SECTION 1:SITE INFORMATION
1.1 Pro erty Address: 1.2 Assc stirs Map&Parcel Number
(9a � sr. \oc an l2,pM't- Uloipa C- (b
1.la Is this an accepted street?yes 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'
.1 l of Record:
' D 0(eR(4 Nk
CA o
ame 'nt) City,State,ZIP
s %-r. (.13-s-1~-aD- )
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. ❑ Number of Units Other ('Specify: V(l
Brief Description of Proposed Work2: etmUU . -I v o -- i p,1 cX ba CA- -i-u S dS .
4Su\ w i mod-• !c1s1-alU 01/4CR4'1 c.. StItoW..)(T bad- 4' (..-..)cu-!.
era? ricL. Q WMhgt -I'D 0 ulk -ly'�,►� ow,. aak-n*;4-.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ aaLka-S , OD 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Totai All Fees: $ 441,t/� 60
Check No:61e)1 Check Amount: ''I Is Cash Amount:
6.Total Project Cost: $ )(,gas .0 0 Paid in Full 0 Outstanding Balance Due:
City of Northampton
Massachusetts ^ ��
- 4. A.
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building yi
�� Northampton, MA 01060 3S't-Jy q,)%
PR• EDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 &2 FAMILY D . LING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
ENCES, GROUND MOUNTED SOLAR, ETC.
I. Building Permit Application signed by leg= owner and filled out by owner or authorized agent.
2. One set of plans and specifications of propo• -d work. (Digital and hard copy)
3. Site plan with location of proposed structure(s) - d set backs.
4. Construction Debris Affidavit filled out and signed • applicant.
5. Worker's Compensation Insurance Affidavit filled out - d signed by applicant.
6. Contractors must supply a copy of CS License, HIC Reg'.tration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new/ repla - ent windows).
8. Home Owner's License Exemption Form filled out and signe• •y Homeowner(if applicable).
9. Note any Conservation and/or special permit requirements (if a••Iicable). 10.
Driveway Permit (if applicable).
11. Proof of Water and Sewer entry fees paid (if applicable).
12. Trench Permit - public land by DPW/private land by Building Dept.
13. Stretch Energy Code -all new construction will require a HERS Rater t ffidavit to be submitted with permit
application before issuance of permit.
14. Please provide the appropriate fee in the form of a check made payable t.• The City of Northampton.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 1[0,11k
1I -' l I 'a2
r G� "a,Ul License Number Expiration Date J
Name of CSL Holder
n_ 1 l ` ' n: List CSL Type(see below)
No.and Street ,'1'` Type Description
` L �n\► ! ��b U Unrestricted(Buildings up to 35,000 Cu.ft.)
Restricted l&2 Family Dwelling
City/Town,Stat ,ZIP 1 `, t (, R
M Masonry
RC Roofing Covering
WS Window and Siding
1 q �± SF Solid Fuel Burning Appliances
"`�Ja'do �C1'1O�UI$�d�no► 2�wtfl)\/1ZN11�1� I Insulation
Telephone Email address v' D Demolition
5.2 Registered Home Improvement Contractor(HIC) 67 . `'a
0A HIC Registration Number Expiration Date
C ompany ame or HIC Registrant Name
n2b 1ihkU Q1OLRIL '• aft@�CS vi t Mcx1P� ameA
pjandStreet Email addressy/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 !8/ No .0
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 () V 'bf\
to act on my behalf,in all matters relative to work authorized by this building permit application.
C (Aarra -
Print Owners ame lectronic Signature) 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 application is true and accurate to the best of my knowledge and understanding.
GSS��
Print er'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
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
oSHAM'p\. ti • • t
' Massachusetts A4 "%.
F.
•.- • DEPARTMENT OF BUILDING INSPECTIONS
E �ti
212 Main Street • Municipal Building ��, a�
Northampton, MA 01060 J:f)'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:
Location of Facility: abC11 �``J 2'r St , PL\ - S IJC (�'��C � pi
\ 'i).\ 7O 0S.4,21" o 0( °P-Q5
The debris will be transported by:
Name of Hauler: S-\-c., A`^-Q- `
A ,_.
Signature of Applicant: Date: i . 1 I LR LDA
The Commonwealth of:'*fassachusetts
aaarr Department of Industrial Accidents
I Congress Street,Suite 100
z:� ice;-=- Boston, .NA 02114-2017
www mass.got/dia
11utkers' Compensation Insurance. fftdasit: Builder.'(`ontractor ElectriciansiPlumbers.
10 BE fll.k:I)11111I I Iih.1'1.K%II 1'1 I\(::11 1'HUKI fl
.lnniicant Inlurn1.u(14,11 Please Print l.reiblx
Name(Business Organization Individuall_
Address:02691
City.StatelZip S4' ,l161. 1 UV C t'httl)t• 3
krr,uu an cn1116) r:'l hack the appruprtan.Imo.: Type of project(required).
I.❑I am a cntphn aY v.,th ctry►loyce%r tall and or put-unit.' 7. Q Ness construction
:0 I am a>uk pNpnettx Vr partnt:ntilp and hasc no eraptu\R"1 M aiding tut MC rn 8. Q Remodeling
an\Lapit.lt'•r No Mutters'comp.(mummy nyuarul.1
9. Demolition
1.0 lam a home mane dung all work mysci.(No workers'comp.nbur.0 t.nquera i.l'
10 Building addition
4.0 I am a IitImeowm•I and will b.humg eonlraetor.to cuidud all wtxk puupeYty. I will
cnsurr that all cunuactum*idler hat.workers'cue uvw.jhc.n unurana:ex an mdc 1 I.O Electneal repairs or additions
pruprtctun w uth nu emplu)cta
12.0 Plumbing repairs or additions
5 am a itanral tunnactur oral I base hued the soh-cunuuctun hired on the attached died.
I e wh-Luntractun has.cttiplu�ccs and brie%oiker,'o*np.Inaunuu.. 13�Roof repairs
ies
h.a N. nt ate a corporatn and its utft.en tn ha,c cxi cd then ngla of caemption pet Mlrl.c 1 Eatthei
1'2. 1141.and we lust no anplu'..es.IN..Nurken'ctxnp.insurance required.
•An\applicant that elic ks box A I must atxt till out tilt'bectiun brio*shuwutg thou ltirL:T>'LVnipens.diun put it} info m:Hu t
'lloR t'ust,en who,ubmlt ihb atlidat it uuhcaling 141,are cluing all wank and slim tun:sitfatt•ctolua.tun tined,about a new atfidas it mtl.:illnit sut'h
(ontrac[tn that chuck this box must alis:lard an adahuonai sheet showing the name of the so coiutactort and state N het er to not those COMIC):ha,r
mhb ,_. It tl;.,_h, mir>cl:xn hiss*nine,een.thai nr.r-t pit,rJ_ta,is t ni si,'..a I, tvtl:t rt.:MINT
I ant an employer that is providing workers'contpemation insurance for my eneplo}'ees. Below its the policy and job site
in fOrntatian.
lnsutane Company Name:
Policy#or Self-ins.Lie. »: ,, \ l �� Expiation Date.
Job Site Address: /� cS f IO`►� �7 t City State Z.ip:k.gQJ
Attach a copy of the workers'compensation policy declaration page(showing the polio number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a line up to S1,500.00
and'or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a
day against the s tulator.A copy of this statement may be forwarded to the Office of Inv estigations of the DIA for insurance
ct's crag*s eri heation.
1 do hereb• rafi'under the pains d penalties of perjury that the information provided above is true and correct.
Signature: V Date: lc I L
Phone 1 13 v3a-( x-i.q
Official use only. Do not write in this Urea. to be t umpleted by city or torn odic la!
('its or Town: Permit%I.icense k
Issuing Authority (circle one):
I.Board of Health 2. Building Department 3.City r I own Clerk 4.Electrical Iuspctlur 5. I'luulhiu, luspettor
6.Other
( ontacl Person: Phone 4:
Page 1 of 8
2097 Riverdale Street MA Lic# 162058 Luxury
West Springfield, MA 01089 CT Lic#0621848
Vista ,...-�:-.--�-
Phone: 888.597.2323 HOME IMPROVEMENT vistahomeimprovement.com Bath
Fax: 413.382.0241
BATHROOM CONTRACT Technologies
Customer Information
Craig Della Penna (413)575-2277 Date: 10/25/2021
Kathleen Della Penna CraigDP413@gmail.com Rep: Kyle Matzko
62 Chestnut St
Florence MA 01062
All home improvement contractors and subcontractors must be registered and any inquiries about a contractor or
subcontractor relating to a registration should be directed to:
Office of Consumer Affairs and Business Regulation Ten Park Plaza, Suite 5170
Boston, MA 02116Phone: 617.973.8700
Wet Area
Item: Tub to shower any color and patterns Left or Right Hand Drain Right Hand
Color of Tub sandbar Wall Color canyon rock
Hardware Color Oil Rubbed Bronz Pattern on wall panels 12x12 simulated tile
Qty 1
Tub and Shower Doors
Item Cayman shower door Round Bar Type of Glass Clear
Qty 1
Pulse Showerheads and Spa
Item Qty 1
KAUAI III Kauai III Shower System ORB
if
k f:0 N®
) C CT
iiliiii.i; , 3
l
Bathroom add on's
Item Ceiling Panel Qty 1
Ceiling Color canyon rock
Soap dish and Caddy's
Item 3 shelf caddy
Qty 1
Page 4 of 8
Homeowner's Association NO
WORK SCHEDULE
Contractor will not begin the work or order the materials before the third day following the
signing of this Agreement, unless specified herein. Contractor will begin the work on or about 01/25/2022
Barring delay caused by circumstances beyond Contractors control,the work will be completed by 02/25/2022
WARRANTY
The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for the
period stated below following completion and shall comply with the requirements of this Agreement. In the event any defect
in workmanship or materials, or damage caused by the Contractor, its subcontractors, employees or agents, is discovered
after completion of any job, Including cleanup,the Contractor shall, at its own expense,forthwith remedy, repair, correct,
replace, or cause to be remedied, repaired or replaced, such damage or such defect in materials and workmanship. The
foregoing warranties shall survive any inspection performed in connection with the agreed-upon work.
Warranty Period Lifetime
Measure Section
Measure Set With -- Kevin
Notes for Measure Call if sooner availability/not avail Nov 1-5
Date Measure Is set for 11/19/2021
2 hour window Measure is set for 8-10am
Total Contract Amount (All Discounts Applied) $22,425.40
Payment
Amount Due Upon Signing Contract(1/3 Maximum) $7,475.00
Amount Due At Start $7,475.00
Amount Due Upon Completion $7,475.40
Form of Payment Upon Signing
Acceptance of Proposal I have read both sides of this document and accept the prices, specifications and conditions stated. I
understand that upon signing,this proposal becomes a binding contract.You are authorized to do the work as specified.
Payment will be made as outlined above.
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the Seller, which
may be his main office or branch thereof, provided you notify the Seller in writing at his main office or branch by ordinary mail
posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this
agreement. Please refer to the Notice of Cancellation below contents of which are referred to above and incorporated herein
by reference.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
NOTICE OF CANCELLATION
Page 8 of 8
Contractor, under provisions of Chapter 142A of the Massachusetts General Laws, is required to apply for and obtain all
construction related permits. Contractor shall not be deemed responsible for delays in the work described in this agreement
caused by regulator, permit granting or inspectional agencies, authorities or individuals.
NOTICE: If Owner obtains his/her own construction related-permits for the work described under this Agreement,
Owner is hereby advised that in the event of a dispute,judgment and non payment of Contractor, Owner will not be
entitled to make claim to or collection from the guaranty fund established in M.G.L. c. 142A.
Modification:
This Agreement, except as to concealed conditions or delays occasioned thereby or by restarts, cannot be changed except
by a written statement signed by both Contractor and Owner. However, cancellation by Owner is allowed in accordance with
the Notice of Cancellation. Owner hereby grants Contractor a limited Power of Attorney to complete incomplete documents
on Owners behalf.
Completeness of Contract for Execution:
Owner is hereby advised not to sign this Agreement unless and until all blank sections have been filled in or marked as void,
deleted or not applicable, and until all exhibits and related or referenced documents that are incorporated herein are attached
hereto.
Attorney's Fees/Costs
Owner agrees to pay all costs of collection, including reasonable attorney's fees, cost and expenses. Furthermore, interest
shall be charged at the highest lawful rate of interest on any and all overdue payments.
Copy of Agreement to be given to Owner:
This Agreement is governed by the laws of the Commonwealth of Massachusetts. It must be executed in duplicate, and an
original, signed copy hereof given to the Owner at the time of execution. No work under the Agreement shall begin prior to the
signing of the Agreement and transmittal to the Owner of a copy therefor.
G(60 6/11f14, ce.41KG,—ZIL e.-v—a--
Craig Della Penna Kathleen Della Penna
10/25/2021 10/25/2021
Date Date
JI ( iipiei
Kyle Matzko Authorized Representative
10/25/2021
Date
A o� CERTIFICATE OF LIABILITY INSURANCE DA TE IMM/DD/YYYYI
OB 02'2021
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 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 WM J MIS _
NAME. ..-__._. . . _..-.___ _ ._—....____.
WILLIAM MISS INSURANCE AGENT PHONE (41$ 568 6111 FAX (•••-•, 2-9191
IA/C.No,EMIL ) __ __ IA/C,NoJ;
156 ELM STREET E-MAIL ADDRESS: BILL//��@%BILLMISINSURANCE.COM
WESTFIELD MA 01085 INSURER(S)AFFORDING COVERAGE —_ _ NAIC K
INSURER A: NAUTILAS INS 66915
INSURED INSURER B _
SAMBRICO/VISTA HOME IMPROVEMENT INSURER C C.
INSURER 0
2097 RIVERDALE RD INSURER E:_
WEST SPRINGFIELD,MA 01089 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 EFF POLICY EXP- -- Ll�ltf'S
LTRINSR WVD POLICY NUMBER ' (MMIDOIYYYY) (MM W f00!YY)
GENERAL LIABILITY EACH OCCURRENCE S 1.000,000
DAMAGE TO RENTED 100.000
X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrencm-.._�f
X
CLAIMS-MADE , OCCUR MED EXP(Any one person) f 5,000
X G3679203 08/01/2021 08/01/2022 PERSONAL SADVINJURY S 1,000,000
GENERAL AGGREGATE s 2.000.000
3EN'L AGGREGATE LIMIT APPLIES PER. PROOUCTS•COMPIOP AGG S 2,000,000
POLICY PRO- X LOC , S
IFC7
A 0MOBILE LIABILITY COMBINED SINGLE LIMIT
u
(Ea aLvasn) _S -
_ ANY AUTO BODILY INJURY(Per person) S
ALL OWNED _ SCHEDULED
CHED LED BODILY INJURY;Per=dent) SAuTOS
HIRED AUTOS NON-OWNEDOS
T OPERY DAMAGE S
S
UMBRELLA LAB OCCUR I I _EACH OCCURRENCE S
-EXCESS LIAe.....__ 1 CWMS-MADE AGGREGATE S
DOD RETENTIONS FF' f
I
WORKERS COMPENSATION 1 ER�TQRYLIMITS I —'---_--�— -.._..PROPRIETOR/PARTNER/EXECUTIVE __-.
AND EMPLOYERS'LIABILITY
Y!N
ANY PROPRIETOR/PARTNER/EXECUTIVE I N!A I E L EACH ACCIDENT s
OFFICER MEMBER EXCLUDED' !
(Mandatory In NH) I
E.L.OISFA-¢F•EA EMPLOYEE S
If yes desert*under j E L.DISEASE•POLICY LIMIT S
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,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
ACCORDANCE WITH THE POLICY PROVISIONS. 11
AUTHORIZED REPRESENTATIVE
ACORD 25(2010/05) ID 1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DD/YYYY)
l 03/15/2ro1
TIAISaERTIFICATE 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:
SOUTHWICK INS AGENCY INC PHONE FAX
P 0 BOX 100 (A/C,No,Ext): (A/C,No):
E-MAIL
SOUTHWICK,MA 01077 ADDRESS:
28TKC INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
SAMBRICO LLC DBA VISTA HOME IMPROVEMENT INSURER B:
INSURER C:
INSURER D:
2097 RIVERDALE STREET INSURER E:
WEST SPRINGFIELD,MA 01089 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 4DDL IUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
-- CLAIMS MADE ED OCCUR. DAMAGE TO RENTED $
PREMISES(Ea occurrence)
MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL $
AGGREGATE:IPROJECT FLOC
E POLICY PRODUCTS-COMP/OP AGG $
$
AUTOMOBILE LIABILITY COMBINED SINGLE $
�^ ANY AUTO LIMIT(Ea accident)
BODILY INJURY $
OWNED SCHEDULE AUTOS (Per person)
AUTOS ONLY BODILY INJURY $
HIRED NON-OWNED (Per accident)
AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAB OCCUR EACH OCCURRENCE11
$
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED LIRETENTION $ $
WORKER'S COMPENSATION AND PER OTHER
EMPLOYER'S LIABILITY STATUTE
UB-2E072183-21 03/12/2021 03/12/2022
ANY PROPERITOR/PARTNER/EXECUTIVE YM E.L.EACH ACCIDENT $ 500,000
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) El N/A E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER •CANCELLATION
TOWN OF WEST SPRINGFIELDS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
26 CENTRAL ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
WEST SPRINGFIELDS,MA 01089
ACORD 25(2016/03)(Rev.09-18) The ACORD name and logo are registered marks of ACORD 1988- 15 ACORD RPORATION. nghts reserved.
12/13/21, 11:10 AM csl exp 2023.jpg
11.111.11101
c monweatth of Massachusetts
lip Division of Professional Licensure
Board of Building Regulations and Standards
t3nrs isor
. 1 1; " `R E pires 01 /21 /2023
RUDOoe
BRIAN '
tRc LE �" � "�
COYOTE :
FEEDING ML1 A 01030
/ �t :
commissioner - , , i, K biE4incitak.,
https://drive.google.com/drive/folders/1 VfNWnIS3Zffyk0ofd96Itst6AucA4eA2 1/1
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: LLC
Registration: 162058
SAMBRICO LLC Expiration: 01/02/2023
D/B/A VISTA HOME IMPROVEMENT
2097 RIVERDALE ST
WEST SPRINGFIELD, MA 01089
Update Address and Return Card.
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:LLC before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
162058 01/02/2023 1000 Washington Street -Suite 710
SAMBRICO LLC Boston,MA 02118
D/B/A VISTA HOME IMPROVEMENT
BRIAN RUDD
2097 RIVERDALE ST .dCG;2>4:
WEST SPRINGFIELD,MA 01089 Undersecretary Not valid without signature