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10B-047
BP-2022-0413 27 RESERVOIR RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 10B-047-001 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-2022-0413 PERMISSIONISHEREBYGRANTED TO: Project# ROOF Contractor: License: PEAK PERFORMANCE ROOFING Est. Cost: 4400 LLC CS-103061 Const.Class: Exp.Date:09/21/2022 Use Group: Owner: P MARONEY ADAM Lot Size (sq.ft.) Zoning: URB/WP Applicant: PEAK PERFORMANCE ROOFING LLC Applicant Address Phone: Insurance: 1 LOVEFIELD ST 413-203-5888 R2WC202869 EASTHAMPTON, MA 01027 ISSUED ON:04/20/2022 TO PERFORM THE FOLLOWING WORK: ROOF MAIN ROOF ONLY 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: I Cgi I , Fees Paid: $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Buildi a Commissioner DocuSign Envelope ID:6DAOAC25-3FE8-4E75-AD1B-965F19B19CA1 i $2., s The Commonwealth of Massachusetts �,------ ': Board of Building Regulations and Standards FOR COI O 1::-` I�� Massachusetts State Building Code,780 CMR MUNICIPALITY USE o m 7 0 Building Permit Application To Construct,Repair.Renovate Or Demolish a Revised Mar 20I1 t 6 One-or Two-Family Dwelling o 2 co This Section For Official Use Only `" .iiu iPern>;tNumber. O �'y 1 cn� o B� �/J � Date Applied: ooG H LVi,��/ 1 y-ZC ZOZZ 0� 1, 6 i— -'Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 27 Reservoir Rd., Leeds 10B-047-001 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if yes❑ Municipal 0 on site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Adam Maroney Leeds, MA 01053 Name(Print) City,State.ZIP 27 Reservoir Rd 413-559-8069 apmaroney@gmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK?(check all that apply) New Construction❑ Existing Building I Owner-Occupied 0 Repairs(s) 1d Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other IJ Specify: Roofing. Brief Description of Proposed Work': Strip and replace asphalt on main roof only SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only .(Labor and Materials) I.Building S 4,400.00 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 0 Standard City/Town Application Fee 0 Total Project Cost'(Item 6)x multiplier x 3.Plumbing , S 2. Other Fees: S 4.Mechanical (11VAC) $ List: 5.Mechanical (Fire $ ,��// Suppression) Total All Fees:S N 6.Total Project Cost: $ Check No. Ydktheck Amount: 7D Cash Amount: 4,400.00 0 Paid in Full 0 Outstanding Balance Due: DocuSign Envelope ID:6DAOAC25-3FE8-4E75-AD1B-965F19B19CA1 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-103061 09/21/2022 James J. Flannery License Number Expiration Date Name of CSL Holder List CSL Type(see below) U No.and Street Type Description Holyoke, MA Al040 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/I-own,State,ZIP • M Masonry RC Roofing Covering WS Window and Siding 413-203-5888 peakperformanceroofingllc@gmail.cortt SF Solid Fuel Burning Appliances Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 183698 11/03/2023 Peak Performance Roofing LLC RIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 1 Lovefield St. peakperformanceroofingllc@gmail.com No.and Street Email address Easthampton, MA 01027 413-203-5888 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 1 this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes No ❑ 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 James J. Flannery/Peak Performance Roofing LLC to act on my behalf,in ail matters relative to work authorized by this building permit application. o«usronod by: 4/8/2022 Adam Maroney Q�M4'ew� Print Owner's Name(Elec 'c ggieaeo 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. James J. Flannery 4/31 z 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.ttov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 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" DocuSign Envelope ID:6DAOAC25-3FE8-4E75-AD1B-965F19619CA1 City of Northampton ' rir Massachusetts �,, '1 DEPii ARTMENT OF BUILDING INSPECTIONS �. �. 212 Main Street • Municipal Building yo'. rCl� 144;) Northampton, MA 01060 w»"�1� 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:Valley Recycling, 234 Easthampton Rd., Northampton MA 01060 413-587-4279 The debris will be transported by: Name of Hauler: Aaron's Roll-Off Service 413-529-1100 James J.of Applicant: Flannery Date: ACc CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD VYYY) �...� 05/12/2021 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 CONTACTE: g Adina Edgett,CISR NAM Webber&Grinnell PHONE (413)586-0111 FAX (413)586-6481 (A/C,No,Ext): (NC,No): 8 North King Street E-MAILESS: aedgett@webberandgrinnell.com ADDR INSURER(S)AFFORDING COVERAGE NAIC# Northampton MA 01060 INSURER A: Admiral Ins Co/BRECK INSURED PlymouthRockAssurance INSURER B: Peak Performance Roofing,LLC INSURER C: WCAR-Berkshire Hathaway GUARD Attn:James Flannery INSURER D 1 Lovefield Street INSURER E: Easthampton MA 01027 INSURER F: COVERAGES CERTIFICATE NUMBER: Exp 06/2022 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 LTR TYPE OF INSURANCE INSD WV DR POLICY NUMBER MM/DDYIYYYY POLICY EXP ( ) (MMlDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE XI OCCUR PREMISES(Ea occurrence) $ 300,000 MED EXP(Any one person) $ 5,000 A CA00003521803 07/07/2021 07/07/2022 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 XI POLICY JEa LOC 2,000,000 PRODUCTS-COMP/tDP AGG S OTHER: Employee Benefd $ 2,000,000 AUTOMOBILE LIABILITY (S& BONEEYSIHOLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ g OWNED x SCHEDULED PRC00001007091 06/27/2021 06/27/2022 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED \/ NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION XI STATUTE PER ERH AND EMPLOYERS'LIABILITY Y/N500000 C ANY PROPRIETOR/PARTNER/EXECUTIVE Y N!A R2WC202869 04/27/2021 04/27/2022 E.L.EACH ACCIDENT $ , OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 WC:James Flannery is excluded 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 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC PEAK PERFORMANCE ROOFING,LLC. Registration: 183698 1 LOVEFIELD ST. Expiration: 11/03/2023 EASTHAMPTON, MA 01027 Update Address and Return Card. SCA 14 20640517 Office/of oo}Consumer f•if///^/ ��i�;•i i�/..iJr//., 4rtairs R 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 183698 11/03/2023 1000 Washington Street -Suite 710 PEAK PERFORMANCE ROOFING.LLC Boston,MA 02118 JAMES FLANNERY I "'^� >,(� 1 LOVEFIELD ST. J EASTHAMPTON,MA 01027 Not valid without signature Undersecretary Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor Unrestricted-Buildings of any use group which contain ;onstryction Supervisor less than 35,000 cubic feet(991 cubic meters)of enclosed aC space. C S-103061 Expos:O4/211 ., • 41 JAMESJFLANNERY 1 WILLIAMS ST HOLYOKE MA 01040 Failure to possess a current edition of the Massachusetts Commissioner State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.govldpl 1 L( U.M/d 8 a 0-Ais 0(1l i Y1.� ck8.41.1 Ltd Ca Yd S DocuSign Envelope ID:6DAOAC25-3FE8-4E75-AD1B-965F19B19CA1 F ak P jfoimance Roofing LLC 1 Lovefield St. P E K Easthampton,MA 01027 413-203-5888 P E R F O R CE peakperformanceroofingllc@gmail.com ROOFING MA HIC#183698 MA CSL#103061 Contract ADDRESS CONTRACT# 10633 Adam Maroney DATE 04/06/2022 27 Reservoir Rd., Leeds,MA 413-559-8069 apmaroney@gmail.com DESCRIPTION -This contract is for the MAIN ROOF ONLY (highest peak roof) 1. Remove the existing roofing shingles 2.Inspect the sheathing for any rot or deterioration.Any new plywood necessary will be$80 per sheet installed.Any new roofing boards will be $6 per foot installed. (Wood prices subject to change based on market fluctuations) 3. Install six feet of ice and water shield on eaves,three feet in any valleys,and three feet around all penetrations 4.Cover remaining roof with synthetic underlayment 5.Install new 8" aluminum drip edge on all eaves and rake edges 6. Install architectural shingles by CertainTeed(Landmark) http://www.certainteed.com/residential-roofing/products/landmark/ Color Choice: Moire Black 7.Install Shingle Vent 11 ridge vent on peaks of roof(where applicable) https://www.certainteed.com/residential-roofing/products/certainteed-ridge-vent-12-filtered/ 8.Complete all necessary flashings including new LIFETIME pipe boots and base flashing around chimney Includes CertainTeed Lifetime Limited Warranty (Transferable) with 10 year SureStart period. https://www.certainteed.com/resources/Asphalt_Warranty_CTR3782_1912_E.pdf Remove all debris from premises,and throughout the job,continue cleanup and keep the premises undamaged.WE ARE NOT RESPONSIBLE FOR DEBRIS THAT MAY FALL INTO ATTIC.Please use reasonable caution during the installation process: do not walk or drive under active work,or on areas of potential roofing debris. Peak Performance Roofing will obtain the building permit. Installations are weather permitting; inclement weather will cause scheduling delays. DocuSign Envelope ID:6DAOAC25-3FE8-4E75-AD1B-965F19B19CA1 DESCRIPTION Total: Landmark shingles=$4,400 A one-third deposit of$1,400 will secure contract,permitting,material order,and priority scheduling. The balance shall be due upon completion,within 10 days of invoice. Accounts outstanding over 30 days subject to 2% finance charge monthly. Warranty confirmation shall be provided upon final payment. Installation and manufacturer warranties are not in effect until Paid In Full. TOTAL $41400.00 Accepted By ,—DocuSigned by: Accepted Date 4/8/2022 Qd awn At/WNW/ �5438C1370DEB48D. DocuSign Envelope ID:6DAOAC25-3FE8-4E75-AD1B-965F19B19CA1 Wlmw WILL MY 015774hL.tr471ON SE SC441 444:D? Your town must first process & approve the building permit (this can take 1-4 weeks, depending on the town.) We can't promise specific installation dates because there are several variables, the biggest being the weather. The safety of our crew is a priority; we can't install during rain, wind, or temperature extremes. Long stretches of inclement weather will cause delays for everyone. Once installation begins, our goal is to minimize disruption to you with an efficient installation. Our hardworking crew completes most residential installations in only 1-2 days. Do Immo O Da *got7na& Ta PeEPAtte As noted on your contract, we are not responsible for debris that may fall into the attic/interior. We do not go inside your home to lay tarps or clean inside the attic. Depending on the condition of the plywood, there may be little to no debris, or it could be more substantial. If you store items in the attic, we recommend covering with tarps or plastic sheeting. If you need help with attic cleanup, we suggest the cleaning and handyman service "Whatever You Need" in Northampton. 413-586-0678 www.whateveryouneed.biz Dar WEED TO NOTIFY MY WEI6 45O1S? If your home is extremely close to other homes or driveways, we may need to be on their property temporarily to lay protection or collect debris. If so, yes, please notify your neighbors ahead of time. Otherwise, it is a courtesy. Your neighbors will likely appreciate a heads up that there will be some noise & increased traffic. Ma traL DELIWAY Materials are usually delivered separately by a supply house. Materials often arrive the day before the scheduled installation. Materials are usually not large (only the size of a pallet), so it is unlikely that vehicles would need to be moved at this point. You need not be home to receive it, and no specific time will be given. Refusal of early delivery will incur a re-delivery fee. DVMPSITA DIELtWAY The dumpster will almost arrive the morning of, but in rare cases may need to arrive a day early (such as for a weekend installation) and vehicles may need to be moved at that point. We would notify you if the dumpster needs to arrive before installation day. Refusal of early delivery will incur a re-delivery fee. Do not add any additional items into the dumpster; it is intended specifically for roofing debris ONLY at the transfer facility. Pasua►r, lea lct s% f DeIVE&OW ACCESS On the day of installation, we ask that you move all vehicles out of all driveways, and away from the house, by 7am. This is to avoid any damage to your vehicles, keep you from getting blocked in, and for our access. HOW IMI.Y WILL My T Usually the crew will begin arriving approximately 7:00 - 7:30am. They may work until nightfall if needed. We aim to have the installation completed as quickly as possible to minimize disruption to you and your neighbors. Do my IADED a aitrcaL sums? It can be helpful to have an exterior outlet available, yes. If you don't have an exterior outlet, we may need to ask to access an interior outlet. If the property is vacant and no electrical service is available, please let us know so we can plan ahead to charge batteries and bring generators. —os Customer Initials: IZ�ti DocuSign Envelope ID:6DAOAC25-3FE8-4E75-AD1B-965F19B19CA1 Da I HEED lb sE 1411114E? If you are having skylights installed, we will need brief interior access. If you don't have an exterior outlet available, we may ask to access an interior outlet. Otherwise, it's up to you. Some customers like to keep an eye on what's going on. Others would rather not be home because of the noise. Be aware that roofing is loud (banging, nail guns, compressors, etc) so you may wish to make arrangements for residents, tenants, or pets. SAFETY Please use reasonable caution. Do not plan on outdoor activities while we are working. Do not walk or drive underneath areas of active work, or on areas with potential roofing debris. If you must walk or drive under an active work area, alert the crew or supervisor. Keep children inside. Keep pets inside, or on a leash away from active work. IAIRMESEEAI ISSUES Once we remove the existing roofing, we can inspect what's underneath. We will replace rotted plywood/sheathing as necessary as per your contract. If any serious problems are found, the project manager will contact you. There may need to be an upcharge on the final bill if additional issues are found that should be corrected. CLWJVP No way around it, roofing is messy work. Rest assured that when the job is done, we will pick up all debris and do magnetic sweeps. Since we may work until dark, the main crew may have to leave before a complete cleanup can be completed, or if the job ends midday, they may leave to start another job. If the main crew must leave before all cleaning is complete, a staff person will return for more cleaning later or on another day soon after. If your installation takes place when there is snow on the ground, we may need to return for another sweep once everything has melted. In this case, please alert us once your yard is completely clear of snow so we may return for more cleaning. I SEE Pant.M S LEFT O U, DID I e.tr oa* D Am nosy? Your job is accurately priced according to the measurements, but we always bring extra materials,just in case. You were not charged for these overage materials, and we will be collecting them. A staff person may need to pick up extra materials after the main crew is finished, usually within a few business days. MIEN WILL WE N/MPS1EIR 8E MOVED? The dumpster will be picked up the next business day after the main crew has finished. Weekends or holidays may delay pickup. The dumpster company should check for any debris left behind/underneath as they pick it up, but for safety please do a visual check before walking or driving over the area where the dumpster was located. T E 363 IS 1)6/4 8111"I UWE 3t 4E G S? Even after the main installation crew has left, that doesn't necessarily mean our job is done. Any final touch ups/cleaning/pickups still needed are usually completed within a few business days. The office will not send the final bill until receiving confirmation from the project manager that all is complete. If you receive the invoice and you feel something was missed, please contact us. If the job is substantially complete, but a touchup still needs to be coordinated with you or another contractor at a later date, we may send the bill, minus a holdback amount contingent upon the completion of the punchlist item(s). name You Fat 00651116 PEAK PE m s*MtE *.00AHA We will do our very best to make this major home improvement a smooth experience for you! Customer Initials: Q�l gZX The Commonwealth of Massachusetts r Department of Industrial Accidents "' Office of Investigations k a ti:. 600 Washington Street '1 slit Boston,MA 02111 '` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Peak Performance Roofing, LLC Address: 1 Lovefield St. City/State/Zip: Easthampton, MA 01027 Phone #: 413-203-5888 Are you an employer? Check the appropriate box: Typeof project(required): 1�� e9 1. I am a employer with 4 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.❑ 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 workingfor me in anycapacity. employees and have workers' p y 9. ❑ Building addition [No workers' comp.insurance comp.insurance.• required.] 5. [] We are a corporation and its 10.❑ Electrical repairs or additions 3.[1] 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.[1/�Roof repairs insurance required.[ ' c. 152,11(4),and we have no employees.[No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. +Homeowners who submit this atftdav it indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such. -Contractors 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. It the sub-contractors have employees.they must provide their uorkcrs'comp.pulley number - - - L - 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Berkshire Hathaway Guard Policy N or Self-ins.Lie.N: R2WC202869 Expiration Date: p 4/27/2022 lob Site Address: / I 1`�C l"�'�l lG2/�� City;State/Zip: K ,541- .6" 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 S250.00 a day against the violator. Bc advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: tit Date V/ Jz2 Phone#: 413-203-5888 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License ft Issuing Authority (circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: