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25A-085 (6)
BP- 022-1252 359 BRIDGE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 25A-085-001 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-2022-1252 PERMISSION'S HEREBY GRANTEa TO: Project# SIDING/WINDOWS/DOORS Contractor: License: Est. Cost: 41820 PHIL BEAULIEU 62638 Const.Class: Exp.Date:06/13/2023 Use Group: Owner: J. CUNNINGHAM, MICHAEL Lot Size (sq.ft.) Zoning: SC/URB Applicant: PHIL BEAULIEU & SON HOME IMPRI VEM ENT Applicant Address Phone: Insurance: 217 Grattan St 413-592-1498 WMZ80062050 CHICOPEE, MA 01020 ISSUED ON:09/30/2022 TO PERFORM THE FOLLOWING WORK: RESIDE FRONT OF GARAGE ONLY, INSTALL 22 WINDOWS, 4 DOORS 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 VIO ATION OF ANY OF ITS RULES AND REGULATIONS.. Signature: I. • � I Fees Paid: $100.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner rr t�. The Commonwealth of Massach setts SEP 2 trO i.., Board of Building Regulations and tan ds 20�2 F R Massachusetts State Building Code 780 I TY \, NpF 81 SE Building Permit Application To Construct,Repair,Renov � 0�(;,I,•tifikEbri evise Mar 2011 One-or Two-Family Dwelling • A oros�s This Section For Official Use Only Buildin Permit Number: `Sn-)+I.•I)-$3- Date Applied: 1 L-v14-3 `Kos, ///7g" - ZOZZ. Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assess r Map& Parcel Number 351' taxi d jc S+ruk- Nvr-1-►1 n !- 63 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 CI Municipal_ Outside Flood Zone? Municipal❑ On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP1 1.4 Owner'ofRecor1/411 ^ NQd4 a.,MP+ef) t �Pi OI Qi00 ame(Print)) City,State,ZIP 359 Bri le S-I fi (A1- 951- 0422, mCunnin22 Q9rnai I. No.and Street Telephone Email A ess COM SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied le Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other LlSpecify:SCial,VJiaclOw.lfd0of5 Brief Description of Proposed Work2: S•i-r'1I h. re5i ctQ 9n f of �qo"a on I SnS+a,l1 22 w winolOS f'n oo re- 4- Jar ace, Ingi-c ll `I do s SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 91 , 20.00 I. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x l 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: _ 5. Mechanical (Fire $ — Suppression) Total All Fees: li ‘,1Check No.111f ' Check Amount:I60 Cash Amount: 6.Total Project Cost: $ (4 1 i S(ZI)70 Paid in Full 0 Outstanding Balance Due: — SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-0c02c93S (9• 13.23 Phil Beaulieu&Sons Home Imp.,Inc. License Number Expiration Date Na . 217 Grattan Street,Chicopee,MA 01020 ff � HI REG#100073 List CSL Type(see below) V` Nc CSL#CS-062638 Type Description Alain Beaulieu PH:(413)592.1498/Fax:(413)594.6008 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 qa3 SF Solid Fuel Burning Appliances 912-1`f'W fl beA,u.IitA b 2 i Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 1 000-73 ` • 7 . 24 HIC s• ��. Phil Beaulieu&Sons Home Imp.,Inc. HIC Registration Number Expiration Date 217 Grattan Street,Chicopee,MA 01020 No.ar HI REG#100073 rnbCC L&I I , 4 Pg CSL#CS-062638 Email address City/ Alain Beaulieu Telephone PH:(413)592.1498/Fax:(413)594.6008 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 Issuan a 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 1,as Owner of the subject property,hereby authorize Phi/ &a u/i_ t Sons Hemp_ Tin p ro ten&t to act on my behalf,in all mattersrelative to work authorized by this building permit application. M I ck O 1. nr n ' _/ -2 3 -2 2 Print Owner's Name(Electronic Signaturc 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. Ph%l/3eauire441 sons Herm Tt p rovtm ef)t- 9 . 2 3 . 22- 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.) (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 f 1.G DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building -, Northampton, MA 01060 �f'F-,y 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: -1 5 MI,cikc? Act/ fd 0/7 The debris will be transported by: Name of Hauler: IA CA- (4a.,t,th P G /1 Signature of Applicant: '`-' Date: 9/2 lZZ- • Your Proposal has been Approved! Phil Beaulieu & Sons Home Improvement, Inc. 217 Grattan Street 11102\1116 Chicopee, MA 010 Phone: (413) 592-14 8 Fax: (413) 594-60 8 Be- aillieu HOME IMPROVEMENT, INC. 41822 Print-data 8,27-2022 Michael Cunningham 359 Bridge Street Northampton, MA 01060 Cell: 617-957-0428 mcunning22@gmail.com Garage Siding Strip the existing siding on the front face of the garage only-dispose of all debris Wrap with house wrap and tape seams Furnish and install Norandex Cedar Knolls D4 siding-Body color:White/Corner color To match the body or 4"white Cover all fascia and rake tnm with brake formed aluminum-Color White Cover all soffit-Color White Cover and flash all window and door casings with brake formed aluminum-Color White Install new garage door weather stripping—Color:White $5.975.00 Windows Garage Windows Remove and dispose of the existing windows Furnish and install six(6)Harvey Slimline double hung replacement windows 7/8"Insulated glass(non Energy Star glass) White interior/white exterior Half screens No grids between the glass Manufacturer lifetime warranty Build a new buck jamb for the windows as needed Cap exterior casing with brake formed aluminum-Color.White Insulate and caulk the perimeter of windows Interior to remain unfinished Wire brush the steel headers and paint gray $6,150.00 House Windows Remove and dispose of the existing windows Furnish and install fifteen(15)Harvey Classic double hung replacement windows Furnish and install one(1)Harvey Classic double hung-picture-double hung replacement window(1/4-1/2-1/4) Energy Star glass/Insulated glass/LowE glass/Argon gas .27-U factor/North East Climate Region White interior/white exterior Half screens on double hung windows No screen on picture window No grids between the glass on thirteen(13)windows 6/1 grids between the glass on the two(2)double hung windows and the double hung-picture-double hung window Tempered glass on one(1)double hung window Manufacturer lifetime warranty Cap exterior casing with brake formed aluminum-Color White New clear interior stops if needed-To be painted or stained by others Insulate and caulk the perimeter of windows $16.950.00 Continued on to 2nd page Beaulieu 111'\II I\II•klI\1'II\1.1\1 Entry Doors Remove three(3)existing doors-dispose of all debris Furnish and install three(3)ThermaTru by Reeb S255-FXG-LE entry door systems Sizes:36x80 driveway side and front/32x80 rear Energy Star glass Factory Finish:(Two colors)Paint Interior-Color:To be determined/Paint Exterior-Color:To be determined 4 9/16 jamb depth built in(front)/5 1/4 driveway side/6 9/16 rear White cap stock composite jamb Mill finish threshold/Light cap Swing LHIS front and side/RHIS rear Schlage Georgian knob standard lockset and deadbolt-Hardware Color.Oil Rubbed Bronze Hinges to match the lockset as close as possible 2W clear colonial interior casing-To be painted or stained by others 908 PVC exterior casing Insulate and caulk the perimeter Complete finished carpentry inside and outside Specifics Re-install the existing storm door on the driveway side only Total $11,550.00 Front Storm Door Remove and dispose of one(1)existing side storm door(driveway side) Furnish and install one(1)36x80 Andersen 8-series full view white side storm door with retractable screen Traditional Handle/Color Oil Rubbed Bronze/Handle Location:Right $1.195.00 General Includes removal and disposal of all debris Any rot found during the project is to be repaired or replaced at a rate of($185.00)per hour+materials+15%of material Payment Schedule Siding-$500.00 deposit at signing:half the total price due upon the start project:$5:000.00 midway;remaining balance due upon completion Windows and Doors-1/3rd deposit at signing,half the total price due upon the start project:remaining balance due upon completion Total: $41 ,820.00 Legal Price Escalation: In the event of significant delay or price increase of material,equipment or energy occurring during the performance of the contract through no fault of the Contractor, the Contract Price. time for completion of contract requirements shall be equitably adjusted by change order. A change in price of an item of material, equipment, or energy will be considered significant when the price of an item increases twenty percent(20%) between the date of this Contract and the date of commencement of work. Work Schedule: The anticipated work commencement date will be determined and communicated to Homeowner at signing, but not to exceed nine months from signature.with substantial completion within 45 days after commencement. Contractor to notify the Homeowner if factors outside our reasonable control require any material changes to this time frame. Substantial Completion: To the extent that work has been substantially completed, but certain materials need to be replaced or repaired by an original manufacturer or third party supplier(the cost of which does not exceed 10% of the overall Contract price), the remaining balance shall still be due and payable minus the commercially reasonable cost of such items,which may be held back by Homeowner until such items are replaced and payment hold-back shall then be due. Beaulieu_ HOME IMPROVEMENT,INC. Change Orders: To the extent that Homeowner requests and/or agrees to the addition or removal of products and/or services after the execution of this Contract.the Homeowner shall sign a change order specifying the changes in the scope of the Contract and pricing,which shall modify such provisions of this Contract but otherwise incorporate all provisions of this Contract as if fully set forth therein. Finance Char9e: 1%%monthly(ANNUAL PERCENTAGE RATE OF 18%)will be added to the unpaid portion of the balance due.Homeowner agrees to pay these charges. In the event of default of payment. Homeowner agrees to pay reasonable Attorney's fees& court costs. This agreement does not constitute a release of liability. By Homeowner's signature below. Homeowner acknowledges and agrees to the above. Arbitration: Contractor& Homeowner hereby mutually agree in advance that, in the event either party has a dispute concerning this Contract, either party may submit a dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs & Business Regulation and each party shall be required to submit to arbitration pursuant to M.G.L.c 142A.§4. Contractor Obligations: All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.Alterations or deviations from above specifications involving extra cost will be executed only upon written orders. and will become an extra charge over and above the estimate.All agreements contingent upon strikes.accidents or delays beyond our control.The Home Improvement Contractor Regulation Statute,M.G.L.c. 142A gives you certain warranties and homeowner's rights thereunder. Contractor shall inform Homeowner of any and all necessary permits, and it shall be the obligation of the contractor to obtain said permits.If Homeowner secures his/her own permits, he/she will be excluded from the guaranty fund provisions of M.G.L.c.142A. Registration: Contractor to have all registration.license number and insurance required by the state.Contractor to be registered with the Director of Home Improvement Contractor Registration.Certificate of Registration#100073.Any inquiries about Contractor relating to registration should be directed to the Consumer Hotline at (617) 973-8787. Contractor to carry commercially reasonable insurance.Contractor's workers are covered by Worker's Compensation Insurance. Customer Acceptance of Proposal: Upon signing. this document becomes a binding contract under law. The above prices. specifications and conditions are satisfactory and are hereby accepted. Contractor is authorized to do the work as specified. Payment will be made as outlined in the payment schedule. Contractor may withdraw this proposal at any time prior to signature by Homeowner.Homeowner may cancel this Contract without penalty or obligation within three(3)business days from the date signed.Contractor may withdraw this proposal if not accepted within 30 days. Customer Consents: Contractor is authorized to use media for promotional purposes. Contractor is granted permission to access property after signing until project completion. Homeowner's signature grants permission to Contractor to obtain all necessary building permits. IJ lQ� Goode p Beaulieu :- k ) e 0 •Stay Connected with our social media and helpful links above Proposal Date'August 26.2022 Revised From:July 25 and July 14,2022 Estimate Date:July 11,2022 PBHI Representative Cameron Beaulieu Authorized Signature I confirm that my action here represents my electronic signature and is binding. Do not sign this contract if there are any blank spaces. ird/) (1-j Signature: Approved by: *Michael Cunningham Date: 8-26-2022 6:22 PM Commonwe Mcsion of Professiofonalassa Licensure • Board ofDivi Building Regalthulations arid Standards �� Construct t�ii0 parvisor CS-062638 Expires:06/13/2023 ALAIN M BEAULIEU 217 GRATTAN STREET CHICOPEE MA 01020 (i1/Sc I Ills Commissioner cad K. S'&1 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Cpntractor Registration \ _ ($a H — Type: Corporation PHIL BEAULIEU & SONS HOME IMPROVEMENT, INC.- `Registration: 100073 217 GRATTAN STREET Expiration: 06/07/2024 CHICOPEE, MA 01020 \'` r r •._, Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Corporation Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 100073 06/07/2024 Boston,MA 02118 'HIL BEAULIEU&SONS HOME IMPROVEMENT, INC. / Oki LAIN M.BEAULIEU 2 17 GRATTAN STREET i' 1:% „„.efGL. /zG'is4 HICOPEE, MA 01020 �%�._`c37 I . _5 Undersecretary Not valid without signature PHILBEA-01 CHRISTINE ACORD- CERTIFICATE OF LIABILITY INSURANCE DAT/18/2D!YYYY) `.--� 2/1 s/zo2z 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 c%N�Acr Christine Sullivan N M Phillips Insurance Agency,Inc. PHONEI 97 Center Street (a/c,No,Ext):(413)594-5984 lac,No):(413)592-8499 Chicopee,MA 01013 christine@phillipsinsurance.com INSURERS)AFFORDING COVERAGE NAIC# INSURER :A.I.M.Mutual Insurance Company INSURED INSURER B: Phil Beaulieu&Sons Home Improvement Inc. INSURER C: Phil Beaulieu 217 Grattan Street INSURER D: Chicopee,MA 01020 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY1 (MM/DDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE n OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 78, n LOC PRODUCTS-COMP/OP AGG $ OTHER: $ LIABILITY COMBINED SINGLE LIMIT AUTOMOBILE (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $— OWNED SCHEDULED _ AUTOS ONLY _ AUTOS W BODILY INJURY(Per accident) $ _ AUTOS ONLY _ OS ONNLYEp ((P err acGdent)DAMAGE Fe $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A AND EMPLCOMPENSATION EMPLOYERS'LIABIILIITNY X STATUTE ER PER H ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WMZ-800-6205-2022A 2/25/2022 2/25/2023 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 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 Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DATE!MM1DDlYYYVi ACR©® CERTIFICATE OF LIABILITY INSURANCE o3roDD/Y 2/22 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 CONTNAME: ERIC ERIC MASON THE MASON AGENCY INC _JAM,No,Ecn: (413)569-2307 /A/C,No), (413)569-2308 504 College Hwy ADDRIEss: themasonagencyp_american-natlonal.com Southwick, MA 01077 INSURERS)AFFORDING COVERAGE NAIC II INSURER A: FARM FAMILY CASUALTY INSURANCE 13803 INSURED INSURER B: PHIL BEAULIEU&SONS HOME IMPROVEMENT, INSURER C: INC. INSURER D: 217 GRATTAN STREET INSURER E: Chicopee, MA 01D20 MA 01020 INSURERF: 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 ADDLISUER POLICY EFF POLICY EXP LIMITS LTRWED WW1, POLICY NUMBER IMM10AlYYYY1 (piNIDDNYYYI X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RENTED CLAIMS-MADE X OCCUR PREMISESO(Ea occurrence) $ 300,000 BUSINESS OWNER'S MED EXP(Any one person) $ 25,000 A x x 2001 X2810 02125/22 02/25/23 PERSONAL 8 ADV INJURY $ 1,000,000 GENII_AGGREGATE LIMIT APPLIES PER'. '� GENERAL AGGREGATE $ 3,000,000 X POLICY JEC LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER $ AUTOMOBILE LIABILITY i COMBINED SINGLE LIMIT $ Ma accident) 1,000,000 ANY AUTO �/ BODILY INJURY per person $ WNED A AUTOS ONLY AUTOSULED x 2001C7139 02/25/22 02/25/23 BODILY INJURY(Per accident) $ XHIRED v NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY I Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 A EXCESS LIAB CLAIMS-MADE 2001E1738 02/25/22 02/25/23 AGGREGATE $ 3,000,000 DED X RETENTION$ 11000 $ WORKERS COMPENSATIONOTH AND EMPLOYERS'LIABILITY Y 1 N STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N 1 A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CARPENTRY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE SAMPLE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRED REPRESENTATIV O 1988- 015 ORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Department of Industrial Accidents ,; ( Office of Investigations (..,, Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 %�_ r www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Phil Beaulieu & Sons Home Improvement, Inc. Address: 217 Grattan Street City/State/Zip: Chicopee, MA 01020 Phone #: 413 592-1498 Are you an employer? Check the appropriate box: Type of project(required): 1.Q 1 am a employer with 25 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. 0 Demolition working for me in any capacity. employees and have workers' 4Building additi n LNo workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.0 Electrical rcpai or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repai or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 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 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 mployccs. If the sub-contractors have employees,they must provide their workers'comp.policy number. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site nformation. nsurance Company Name: A.I.M. Mutual Insurance Company 'olicy#or Self-ins. Lic. #:WMZ-800-6205-2022A Expiration Date:2/2512023 ob Site Address: 3S 113 r)cl 5fi.. S +- City/State/Zip: 1 V e l'`fl cifi p Q 0 rk-A- lttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 7ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 if up to$250.00 a da/against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of th&,DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. ►ignature: 'l 30.4a Date: 1 I 2 3 /72 'hone#: 413-592-1498 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): 11:1Board of Health 20 Building Department 30Cityrl'own Clerk 4.❑Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: