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21-018 (5) BP-2022-0428 511 SYLVESTER RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 21-018-001 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-2022-0428 PERMISSIONIS HEREBY GRANTED TO: Project# ROOF Contractor: License: Est. Cost: 11000 THOMAS MORIN 112460 Const.Class: Exp.Date:07/23/2022 VACCHELLI ANTHONY A & DEBRA M Use Group: Owner: VACCHELLI Lot Size (sq.ft.) Zoning: RR Applicant: VALLEY ROOFING AND RESTORATION Applicant Address Phone: Insurance: 162 PANDLETON AVE (413)230-8076 7PJUB6R27625422 CHICOPEE, MA 01020 ISSUED ON:04/26/2022 TO PERFORM THE FOLLOWING WORK: STRIP AND RE-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: 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: Fees Paid: $40.00 212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner / r--- s------'.Z-s-..... ''""-^'..ti ''' ----'' APR 2 2 202� ThiCommonwealth of Massachusetts FOR v, Soard f Building Regulations and Standards -- 1 °,o;'`---- Massni huseds State BuildingCode, 780 CMR MUNICIPALITY 'or -R�UILDIN��In �� $ fiT . , ;1 ,fi ication To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 _One-or Two-Family Dwelling This Section For Official Use Only BuildingPermit Number: �- '` ylS j7D)te A plied: Ev,,-� 1�055 q-25-7.62.7_, Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 511 Sylvester Rd. Florence, MA 01062 0 1.1a 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: Tony Vacchelli Florence, MA 01062 Name(Print) City,State,ZIP 511 Sylvester Rd. 302-233-0672 avacchelli2014@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) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg.0 Number of Units Other Specify: Roof replacement Brief Description of Proposed Work2: Remove and replace 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 $ 11,000.00 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 Fe�e��s��++$ , `,1 Check No."t,1 Check Amount: a'(Li Cash Amount: 6.Total Project Cost: $ 11,000.00 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-112460 07/23/2022 Thomas Morin License Number Expiration Date Name of CSL Holder List CSL Type(see below) 162 Pendleton Ave. 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) Tom Morin D/B/A Valley Roofing and Restoration 185148 08/08/2022 HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 162 Pendleton 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 . IS' 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. Tony Vacchelli 04/18/2022 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 04/18/2022 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.) $11,000.00 (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" City of Northampton Massachusetts ^� ( t" l� 4 k DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Jj Northampton, MA 01060 SPW > 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: Casella Waste Systems 700 Main St. Holyoke MA 01040 Location of Facility: 413-306-3929 The debris will be transported by: The Barnish Companies PO BOX 201 Granby MA 01033 Name of Hauler: 413-537-5760 Signature of Applicant: Date: 04/18/2022 The Commonwealth of Massachusetts Department of Industrial Accidents _ sP Office of Investigations yam r= Lafayette City Center " =�: 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Valley Roofing and Restoration Address: 162 Pendleton Ave. City/State/Zip: Chicopee. MA 01020 Phone#: 413-230-8076 Are you an employer?Check the appropriate box! Type of project(required): 1.❑ I am a employer with 4. [am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 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 working for me in any capacity. employees and have workers' 9. El Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.1]ElectricaI repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12_0 oof repairs insurance required.]t c. 152,§1(4),and we have no 13.[ OtherRoof replacement employees. [No workers' comp. insurance required.] *Any applicant that checks box tit 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. :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. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 Investieations 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: I Date: 04/18/2022 Phone#: 413-230-8076 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--� 10Board of Health 20 Building Department laity/Town Clerk 4.❑Electrical Inspector SCPlumbing Inspector 6.❑Other Contact Person: Phone#: f c.unfhlotiWedlln Ui IVIdSSdCl,..Sir:CS f Division of Prcfessional Licensure Board of Building Regulations and Standards const,r40Mri it rvisor • r � CS-112460 yires:07/23/2022. THOMAS D MORIN 162 PENDLETON AVE CHICOPEE MA 01020 N` 'f)/Ss..1 10' c:,Commissioner ra_� .Tr munrnri ref//r/.liiay ezrAte4e//•: 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 � .; i fy 162 PENDLETON AVE. i CHICOPEE,MA 01020 Undersecretary ACO CERTIFICATE OF LIABILITY INSURANCE DATE(MM,DD/YYYY) �.i 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 (A/C,No,Ext): (A/C,No): 562 College Hwy E-MAIL S: chess@southwickinsagency.com ADDRE INSURER(S)AFFORDING COVERAGE NAIC# Southwick MA 01077 INSURERA: 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.LIIu]JTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IPOLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSDMM/DD Vyvo POLICY NUMBER ( /YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrences S 100,000 MED EXP(Any one person) $ 5,000 A BAK-69939-2 09/25/2021 09/25/2022 PERSONAL&ADV INJURY 5 1.000'000 GEN'L AGGREGATE LIMIT APPLIES PER• GENERAL AGGREGATE 5 2,000,000 X POLICY PRO PRODUCTS-COMP/OP AGG $ JECT LOC 2, ,000000 OTHER S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) S 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 S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED', N/A E L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S if yes.describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I 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 City of Northampton Department of Building Inspections ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main St Municipal Bldg. AUTHORIZED REPRESENTATIVE Northampton MA 0106C ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACO a DATE(MMIDDIYYYY) 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 IA/C No.Ext): (508)552-8066 FAX No): (508)552-8065 424 BELMONT ST EMAIL 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 IADDL NSD SUBR ( OLICY M/DDIAE�) I POLICY EXP) LIMITS TYPE OF INSURANCE POLICY NUMBER MM/DD MMIDD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTE $ 1,000,000 CLAIMS-MADE X(OCCUR PREMISES(Ea occur re $ 100,000 MED EXP(Any one person) $ 5,000 A L307001666 02/16/2022 02/16/2023 PERSONAL&ADvINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT PRO LOC PRODUCTS-COMP/OPAGG $ 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) 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 $ It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 Valley Roofing and Restoration LLC ACCORDANCE WITH THE POLICY PROVISIONS. 162 Pendleton Ave AUTHORIZED REPRESENTATIVE Chicopee MA 01020 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AC�0 DATE(MM/DDIYYYY) 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 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 CONTNAME: LEANDRO LEANDRO GUIMARAES POINT INSURANCE INC ,vHO No.E:g: (617)783 1160 I FAX (A/C, Aruno ntnsure.Com ADDDRDR bESS: @p0Ii _. 1103 COMMONWEALTH AVE INSURERS)AFFORDING COVERAGE NAICi1 ._ BOSTON MA 022151111 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER S: CT HOME EVOLUTION LLC INSURERC: INSURER D: PO BOX 81328 393 BELMONT AVE INSURERE: SPRINGFIELD MA 01108 INSURER F: 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 SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) IMM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ GE TO CLAIMS-MADE OCCUR PREMISES(EaENTED occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEM AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY JET LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (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 accdent) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PERTUTE ER OTH- AND EMPLOYERS'LIABILITY A OFFICER/MEMBEREXCLU EDXECUTIVE N/A N/A N/A 7PJUB6R27625422 02/16/2022 02/16/2023 E.L.EACH ACCIDENT $ 1,000,000 (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 DESCRIPTION OF OPERATIONS/LOCATIONS/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 L.S1k CHICOPEE MA 01020 Daniel M.Crowley,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 s Chicopee MA 01020 (413) 230-8076 valleyroofingandrestoration@gmail.com