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12C-030 (2) BP-2022-0388 242 SPRING GROVE AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 12C-030-001 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-2022-0388 PERMISSIONIS HEREBY GRANTED TO: Project# ROOF Contractor: License: Est. Cost: 14300 THOMAS MORIN 112460 Const.Class: Exp.Date:07/23/2022 MCPHEE LILLIAN E &D MCPHEE &K MURPHY & Use Group: Owner: L LAMICA & E COLES Lot Size (sq.ft.) Zoning: RI/WSP Applicant: VALLEY ROOFING AND RESTORATION Applicant Address Phone: Insurance: 162 PANDLETON AVE (413)230-8076 7PJUB6R27625422 CHICOPEE, MA 01020 ISSUED ON:04/15/2022 TO PERFORM THE FOLLO WING WORK: REMOVE METAL ROOF AND REPLACE WITH ASPHALT 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: , • if ' I Fees Paid: $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner /14, to., The Commonwealth of Massachusetts d of Building Regulations and Standards FOR assa husetts State Building Code,780 CMR MUNICIPALITY Bui1?? Pe 't A lication To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 117471/, One-or Two-Family Dwelling nf Sp ^'qocr This Section For Official Use Only Building Perm— ui er/ '31/ Date Applied: l4zv�t,� /2054 /47 y-15- Zozz Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors ap&Parcel Num�� 242 Spring Grove Ave. Florence, MA 01062 1.1 a 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' 2.1 Owner'of Record: Lauren Lamica Florence, MA 01062 Name(Print) City,State,ZIP 242 Spring Grove Ave 413-348-6834 lauren.lamica@gmail.com 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) ❑ Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other Specify: Roof replacement Brief Description of Proposed Work2: Remove metal roof and replace with asphalt shingles, see attached estimate if further detail is needed SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 14,300.00 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fee : II Check No-ja Check Amount: Cash Amount: 6.Total Project Cost: $ 14,300.00 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-112460 07/23/2022 Tom Morin License Number Expiration Date Name of CSL Holder lJ 162 Pendleton Ave. List CSL Type(see below) No.and Street Type Description Chicopee, MA 01020 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-230-8076 valleyroofingandrestoration@gmail.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 185148 08/08/2022 Tom Morin D/B/A Valley Roofing and Restoration HIC Registration Number Expiration Date HIC CompanyName or HIC Registrant Name 162 Penleton Ave. valleyroofingandrestoration@gmail.com No.and Street Email address Chicopee, MA 01020 413-230-8076 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 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 Valley Roofing and Restoration to act on my behalf,in all matters relative to work authorized by this building permit application. Lauren Lamica 04/12/2022 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Tom Morin 04/12/2022 Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) $14,300.00 (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" The Commonwealth of Massachusetts n - Department of Industrial Accidents i , 1 Congress Street,Suite 100 fl ( Boston, ,U-I 02114-2017 1..^,„ ,- .- www.mass.go►/dia 'J-t )luakers' ('onipensal- Insurance Affidasit:BuildersI('ont umbers. I O 111. 1-I I.F.1)sS I III I IIE PEItMI ITING AUTHORITY. .Applicant Information Please Print la-gilds Name I13usincss Oriani ataon lndi iJuat): Valley Roofing and Restoration Address: 162 Pendleton Ave. City'State/Zip: Chicopee, MA 01020 Phone#: 413-230-8076 Are inu an employer•I heel the appeepehee his: Type or project(required): 1 Q I am a employer with employees I lull and or part-saute 1• 7. 0 Neu construction :0 I am a soh:proprietor or txar,ner.hap.and hate flu eIi o t,rs working for m.an S. 0 Remodeling any capacity.(Nor workrn'comp uuuranex required_) 9. ❑ Dettsolition 30 I am a Iona owner doing all work myself.(No under..comp.insurance reunited.)' 10 0 Building addition 4.0 I anta!uanccvun.i and will Ise hiring.unir.setunto conduct all work tin my pnrperty. 1 wdl ensure that all eontractun either lute untie&compensation insurance w are sole I I Eleclrcal repairs or additions paopneturs w ash no employees_ 1 1_.0 Plumbing repairs or additions 5{11am a general contractor and I lure hired the subt.ntracturs listed tin the attached sheet Thai sub-contractors hose anplaytes and!use...rakers'comp uuurance 1314.E1RW repairs h.❑w e an:a corporation and its officer.hay.:exercised then neht of eYemptaorm per N1Gl_c. diet Roof replacement 15!;I1'11.and we hase no employees.[Nu%oilers'comp.msumance acquired l •A.ny applicant that chi els his.1 must at,...till OW Lib:section below show ma then w..,Lrs'compensation pulse!,ual.civaltOn 'lien somsnern who submit this atfasLas it utdocaunt they are doing all w utl and then hue oulsadc curmtra.tors must submit a new atlidx it mmhsatmg such. :Contractors that check this has must attached an additional sheet show tin,the name of the suh-ci draetun aorta state.a Nether Lit not those amities Luse employees It the sub-contractors his:curios ecs.th.i must manacle their wualer.'comp polies numnber. 1 ant an employer that is providing workers'compensation insurance fur my employees_ Below is the policy and job site information. Insurance Company Name: _ — Policy'#or Self-ins.Lie.#: — Expiration Date: Job Site Address: City State Lip: Attach a copy of the workers'compensation policy declaration page(shooing the policy number and expiration date). Failure to secure coserage as required under MGL e. 152. ;25A is a criminal 'iolation punishable by a line up to SI.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 iolator.A copy of this statement may be forwarded to the Office of Ins estigations of the DIA for insurance co%crat,e senlication. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct_ Siunature: Date: 04/12/2022 Phone�: 413-230-8076 Official use only. Do not write in this area,to be completed by cih,or town official ('ih or Town: Per-millLicense# Issuing:Authority (circle one): I. Board of Health 2. Building Department 3.t ih-fawn(leak 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone tt: City of Northampton - _ .�"• '` ~• Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 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: Casella Waste Systems 700 Main St. Holyoke, MA 01040 The debris will be transported by: Name of Hauler: The Barnish Companies Signature of Applicant: Date: vuf77111V11Wedlln OI MdSSdCI?'-+-_St•t IS Division of Prcfessional Licensure Board of Building Regulations and Standards C o n s t ratiCttb nt tSpe ry i s o r CS-112460 Expires: 07/23/2022. • THOMAS D MORIN • 162 PENDLETON AVE .� , CHICOPEE MA 01020 ti Commissioner //,ri:ur/re:,-/L: Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 185148 08/08/2022 TOM MORIN DB/A VALLEY ROOFING AND RESTORATION THOMAS MORIN • 162 PENDLETON AVE. CHICOPEE,MA 01020 Undersecretary ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD(YYYY) 09/30/2021 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 Chris Hess NAME: Southwick Insurance Agency PHONE (413)746-2822 FAX 413 746-2901 562 College HwyE HMCo,Ext1: (A/C,No): ( ) g E-MAIL s: chess@southwickinsagency.com ADDRE INSURER(S)AFFORDING COVERAGE NAIL p Southwick MA 01077 INSURER A: Crum&Forster Specialty Insurance Company 44520 INSURED INSURER B: Thomas Morin,DBA Valley Roofing&Restoration INSURER C 162 Pendleton Ave INSURER D INSURER E: Chicopee MA 01020 INSURER F COVERAGES CERTIFICATE NUMBER: CL2193003712 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.LI_twyTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR L POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD MM/DD WVD POLICY NUMBER { /YYYYj (MM/pDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) 5 5.000 A BAK-69939-2 09/25/2021 09/25/2022 PERSONALSADVINJURY 5 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE 5 2.000,000 X POLICY CrPRO- JE LOC PRODUCTS-COMP/OPAGG 5 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) OWNED SCHEDULED BODILY INJURY(Per accident) $AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) 5 UMBRELLA LIAB OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE 5 DED RETENTION S $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDE' N I A E L.EACH ACCIDENT S (Mandatory In NH) E L DISEASE-EA EMPLOYEE $ If yes,descnbe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached 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 City of Northampton Department of Building Inspections ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main St,Municipal Bldg. AUTHORIZED REPRESENTATIVE Northampton MA 01060 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD A�� DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02/24/2022 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 LEANDRO GUIMARAES NAME: POINT INSURANCE INC PH No,Ext) (508)552-8066 FAX No): (508)552-8065 424 BELMONT ST E-MAIL Iguimaraes@pointinsure.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# WORCESTER MA 01604 INSURER A: ATLANTIC CASUALTY INS CO INSURED INSURER B: CT HOME EVOLUTION LLC INSURER C: PO BOX 81328 INSURER D INSURER E: SPRINGFIELD MA 01108 INSURER F: COVERAGES CERTIFICATE NUMBER: Master Cert 2022 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 LTRINSD WVD (MM/DD/YYYY) (MM!DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PREMISESO(EaEN occu occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A L307001666 02/16/2022 02/16/2023 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- LOC PRODUCTS-COMP/OPAGG $ 2,DOQ000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY - AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ 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!LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached 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 Valley Roofing and Restoration LLC ACCORDANCE WITH THE POLICY PROVISIONS. 162 Pendleton Ave AUTHORIZED REPRESENTATIVE - Chicopee MA 01020 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Aco® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD YVYY) 02/24/2022 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: LEANDRO GUIMARAES POINT INSURANCE INC ((AHic No.Ext): (617)783-1160 F X,Nol_ E-MAIL runo _ ADDRESS: b CPOintinsure.com 1103 COMMONWEALTH AVE INSURER(S)AFFORDING COVERAGE NAIL BOSTON MA 022151111 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B: CT HOME EVOLUTION LLC INSURERC: INSURER D: PO BOX 81328 393 BELMONT AVE INSURER E: SPRINGFIELD MA 01108 INSURERF: COVERAGES CERTIFICATE NUMBER: 748131 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 SUER POLICY EFF POLICY EXP LIMITS LTRINSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/OD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO $ CLAIMS-MADE OCCUR PREMISES(EaENTED occurrence) $ MED EXP(Any one person) $ N/A PERSONAL$ADV INJURY $ GENt AGGREGATE UMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JPEC L_J LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMB $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OT PERTUTE AND EMPLOYERS'LIABILITY A OFFICER/MEMBER EXCLUDED?XECUTIVE E.L.EACH ACCIDENT $ 1,000,000 N/A N/A N/A 7PJUB6R27625422 02/16/2022 02/16/2023 (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 i I 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 VALLEY ROOFING AND RESTORATION LLC ACCORDANCE WITH THE POLICY PROVISIONS. 162 PENDLETON AVE AUTHORIZED REPRESENTATIVE CHICOPEE MA 01020 Daniel M.Croy,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 Valley Roofing & Restoration CSL#CS-112460 HIC# 185148 Please mail permit to: 162 Pendleton Ave. Chicopee MA 01020 or Email to: valleyroofingandrestoration@gmail.com *If you cannot do either of these can you call 413-230- 8076 so that we know permit has been issued Thank you ! Tom Morin 162 Pendleton Ave Chicopee MA 01020 (413) 230-8076 valleyroofingandrestoration@gmail.com