24B-020 (2) BP-2023-0735
39 DENISE CT COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24B-020-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGI STERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2023-0735 PERMISSIO IS HEREBY GRANTED TO:
Project# ROOF 2023 Contractor: License:
Est. Cost: 13000 DUBAY BROTHER. ROOFING INC 100292
Const.Class: Exp.Date: 10/15/20.4
Use Group: Owner: COR N LINNE V&BARBARA SWEET
Lot Size (sq.ft.)
Zoning: URB Applicant: DUBA BROTHERS ROOFING INC
Applicant Address Phone: Insurance:
36 EDENDALE ST (413)781-2533 UB-1K82045
SPRINGFIELD, MA 01104
ISSUED ON: 06/06/2023
TO PERFORM THE FOLLOWING WORK:
STRIP AND RE-ROOF
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:
d • a' i )2
� •
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissi.ner
N S,
The Commonwealth of Massach ottr °Pa al
14
Wt Board of
Massachusetts Building
Regulations
Bu lding Code, 780 MR D°'1'.4 pFcT CIPALITY
o70 ipN USE
Building Permit Application To Construct,Repair, Renovate Or Demo a S Re.ised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: 8i-) ` 733 Date Applied:
4.s/Zs ///z 6-1 ZOZ3
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Co
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: A /
Name(Print) City,State,ZIP
35 p 71'7 e C,
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 0 Specify:
Brief Description of Proposed/Work2:
S kr`v p akC /'c h4 /Z! 99.4.i
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fee : 6
6.Total Project Cost: $ f�LyC�C�, cG Check No. � Ihec*Amount: r
0 Paid in Full 0 Outstanding Balance Due:
Iiiiiiiiiir
City of Northampton
(-r—" Massachusetts ,
r
T' _ DEPARTMENT OF BUILDING INSPECTIONS . `
1, 212 Main Street • Municipal Buildings-s ,C'A
'S(� t
Northampton, MA 01060 k4 , 1
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR WINDOWS,
DOORS,ROOFS,RENOVATIONS,ROOF MOUNTED SOLAR,ETC.
1. Building Permit Application signed by legal owner and filled out
by owner or authorized agent.
2. One set of plans and specifications of proposed work(Digital and hard copy).
3. Construction Debris Affidavit filled out and signed by applicant.
4. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
5. Contractors must supply a copy CSL, HIC, and proof of Liability Insurance.
6. Energy Conservation Compliance Certificate (new /replacement windows).
7. Home owner's License Exemption Form (if applicable).
8. Note any Special Permit requirements (if applicable).
9. Energy Code—all new construction (Gut/Rehab) requires a HERS Rater Affidavit
_10. Please provide the appropriate fee in the form of a check made payable to: The City of
Northampton.
SECTION 5: CONSTRUCTION SERVICES //5.1 Construction Supervisor License(CSL) I00 Z� Z, to-/S�7
I7r1 fJN.L $z License Number Expiration Date
Name of CSL Holder t
33 E2e /a= g Jam-- List CSL Type(see below) ',
No. Stree Type Description
/ rifh— oil 'f U R Unrestricted(Buildings up to 35,000 cu.ft.)
Restricted 18c2 Family Dwelling
Ci /Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
f !� z l SF Solid Fuel Burning Appliances
7 D/�y Z-Y� va $ /3 G hri I Insulation
Telephone Email address AC D Demolition
5.2 Registered/ Home Improvement Contractor(HIC) /S!7// v_2 Z -2 r
��/ �HL HIC Registration Number Expiration Date
HI Company N G orr / rant Name
No.and S t a( Email address
S it/, /7* 0/10 Y 7 g/ZS3 3
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 ii 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
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 a li 'on is true and accurate to the best of my knowledge and understanding.
j—s— .3
s or u>riz ent'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.cov/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"
eg..
_______ The Commonwealth of Massachusetts
sciern,1=1.71 Department of Industrial Accidents
1 Congress Street,Suite 100
911r
Sid 1,L 4.) Boston, MA 02114-2017
www.mass.govidio
11'i-is-kers'Compensation Insurance AlTidas it:Builders/Contractory'ElectriciansiPlumbers.
TO BE FILED WI III I III' PERMITTING AUTHORIIIi.
ADDliCallt 11110111A don Please Print Legibls
Name ililkiinCSSOrganization:Individual
Address: OS ,S7L-
&--c/rel del i e_
City/StateiZip:S/ (// /17,4-- 07/0, Phone g: 7 ,, /25g ,..5>
l '
Are_von an einpliocr?Check Hoc a pprupriair hot; Ty pc of project(required):
1 ';''' I ain a employer Art / erriployee (fa arakor part-nine t.' 7. 0 New construction
2, 4 I arn a sok prupnetur or purtnenhip and have no employees working for me In g.. 0 Remodeling
any careelty.,[NQ workers'corrop,insurance required]
9. 0 Demolition
.;...0 I am a homeowner doing Ali work myself.[No workers'comç.nisurance mimed.)
I 0 0 Building addition
(a I am a hornoirwner and will be hiring cuitractors to..-venhiet all work on in property I will
ensure that all eoritracturs either have svxnkers*LlImponalion ireninuacv or art sole 1 1 0 Electrical repairs or additions
pwonetois wail no,iivioycks,
12.0 Plumbing repairs or additions
51:1 I am a general contractor and I hze hired the sub-contracton,listed Ull the anaLheil sheet
I 3 Roof repairs
These sub-euratracton have employees and bav c woikers'k'oarip.,uhanince)
14_ - Other
L. We ate a LANTreirAIRA3 and its Tieers have exert:hal their right orcierraptionper VW&c
1!•2..,§1i41.and sA,e have coo ernploveva.(So worke.rs'cutup.irbUSallee TO1.141.11.411
•Ai y:mph,oil ittaz,liwks l.....s..1 rnizst also till out the vectron below,slioi.kina their worker,'cmlopero.ation pslivy infortisition
1-kmzeo%nem who siznonti this atraki.,A mho:atone they arc doing all work and own hose ouhode,...,oritractor.mum submit a new affidavit indicating Al.40:
Contractor%that cheek ibta box roust attached an additional sheet show ins the came Of the sith-eontracti.rs and stalk:Whelber Or nut thus,:ettlities 1411.4e
onployees. If the sub-L....morn-tors have einplovces,Ow!,IllUit provide their vvorken`coottp.policy number
- ..
lam an employer that is providing ovorkers'compensation insurance for my employees. Below is the policy and joh site
information.
Insurance Company Name: A ( 4/t L —
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 d8 required under NIGL c. 152,§25A is a criminal s iolanon punishable by a tine up to S1.5(X0.00
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 violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
/dr)hcreby eery: idler the pains a dso e u . 0 lnformalion provided above 1 I true and correct.
&vulture: Date: ee---5-2.-
Phone#:
Official use only. Do not write in this area,to be completed by city or horn official
City or To%n: Permit/License It
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#:
„ —
Pr
City of Northampton
Massachusetts w
": * ..
-
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: i/4/ 9 kir,
wit. 7�e .� /7v PS 1�t. 7�
The debris will be transported by:
Name of Hauler: J //�? D
L ' _
Signature of Applicant: / Date: g s
City of Northampton
Massachusetts
#- R DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building 0-
i z r "
Northampton, MA 01060 �t \�`�
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT
1, (insert full legal name), born_ (insert
month, day, year), hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or
work on a parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'
exemption, does not involve the field erection of manufactured buildings constructed in accordance with
780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one-or two-family dwelling, attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in
a two-year period shall not be considered a home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I
qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of
the project or work on my parcel, I am not engaged in construction supervision in connection with any
project or work involving construction, reconstruction, alteration, repair, removal or demolition
involving any activity regulated by any provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on
my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work.
Signed under the pains and penalties of perjury on this day of , 20_.
(Signature)
,4co d CERTIFICATE OF LIABILITY INSURANCE DATE(MMJDDrYYYY)
`� 5/8/2023
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 CONSTITUE 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 poiicy(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 an endorsement(s).
PRODUCER CONTACT
NAME:
MCCLURE INS AGENCY INC PHONE FAX
PO BOX 339 (NC.No.Ext.):(413)781-8711 (NC.No.Ext.):
WEST SPRINGFIELD,MA 01090-0339 E-MAIL
ADDRESS:
INSURED INSURER(S)AFFORDING COVERAGE NNC#
INSURER A:ACE AMERICAN INSURANCE COMPANY
DUBAY BROTHERS ROOFING INC
35 EDENDALE ST INSURER B:
SPRINGFIELD,MA 01104 INSURER C:
INSURER D:
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 NUMBER TYPE OF INSURANCE ADOL SUER MD
EFF POUCY EXP LASTS
LTR INSO D POLICY (MMIDDIYYYY) (MMIDDIYYYY)
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE OCCUR DAMAGE TO RENTED
PREMISES(Ea Occurrence) $
MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY n PROJECT l 'LOC PRODUCTS-COMP/OP AGG $ ,
OTHER
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Es accident) $
- BODILY INJURY(Per person) $
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Per accident) $
-
HIRED - NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY (Per accident) $
$
UMBRELLA LIAR OCCUR
EACH OCCURRENCE $
EXCESS LAB CLAIMS-MADE
_ AGGREGATE $
- DED RETENTION
- WORKERS COMPENSATION PER OTH
AND EMPLOYERS'LIABILITY YM N/A UB-1K82045-7-23 02/01/2023 02/01/2024 X STATUTE -ER
ANY PROPRIETOR/PARTNER/EXECUTIVE -
OFFICERMIEMBER EXCLUDED? Y
A (Mandatory In NH) E.L.EACH ACCIDENT $100000
If yes,describe under
DESCRIPTION OF OPERATIONS BELOW E.L.DISEASE-EA EMPLOYEE $100000
E.L.DISEASE-POLICY LIMIT $500000
$
$
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
CERTIFICATE HOLDER CANCELLATION
DUBAY BROTHERS ROOFING INC SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED
35 EDENDALE ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
SPRINGFIELD,MA 01104 ACCORDANCE WITH THE POLICY PROVISIONS
AUTHORIZED REPRESENTATIVE
01993-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/3) The Acord name and logo are registered marks of ACORD
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
1000 Washington Street-Suite 710
Boston, Massachusetts-02118
Home Improvement Contractor Registration
0Ii =r,r --- (.
TIMOTHY DUBAY �M1 Type: Individual
35 EDENDALE STREET (4i Registration: 181711
SPRINGFIELD, MA 01104 %; Expiration: 04/22/2025
"fit:
� � _
Update Address and Return Card.
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation
Registration valid for di use only before the
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual expiration date. If founn return
d return to:
Rears- tration Exni_�'ration Office of Consumer Affairs and Business Regulation
1000 Washington Street -Suite 710
181711 04/22/2025
TIMOTHY DUBAY Boston,MA 02118
TIMOTHY DUBAY
35EDENDALE STREET
SPRINGFIELD,MA 01104 i0r4-,
Undersecretary Not valid without signature
commonwealth of Massachusetts
Division of Occupational ande S an
lir e
Board of Building Regulations and Standards
Construc pe, ;(Specialty
CSSL-100292 _: pires: 1011512024
TIMOTHY J 6i.IBAY
35 EDENDAI f STREET _
SPRINGFIELA 01104
O�II
rt. .3 .
Commissioner a . f;. A+1' -
_____-1 DUBABRO-01 CMASCIADRELLI
AMMO"rCERTIFICATE OF LIABILITY INSURANCE b tizoi2o�ii
r
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 &re
McClure Insurance Agency,Inc. PNONE 413 781-8711 1(c N.:413)731-8548
103 Van Deere Ave. ( 'No, (
West Springfield,MA 01089 ADDRESS: ---- _- . ._ __ - -_-
___. -- wSURERIsl AFF9RIL(N�.C9MAG i - MICA _
INSURER A:Penn America Insurance Company 32859
INSURED INSURER B: —
Dubay Brothers Roofing Inc. INSURER C:
35 Edendale Street INSURER D: —--
Springfield,MA 01104
INSURER E --_--_---_.-__.
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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,
EXCLUSION SAND CONDITIONS OF SUCH POLICIES_UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. `_-_-_
I -POUCY op
LTR TYPE OF INSURANCE (INS°ilL sIN O POUCY NUMBER POUCY 9111INDINYYTY1 UNITS
A X coNNBIxaL GENERAL L tAelUT1f I EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR PAC7233432 7/22/2022 7/22/2023 DAMAGE RED 100,000
IEa orxlrrrelue) S _
_ MED ExP.(40Y-ne oerfc_01 - 5,000
PERSONAL INJURY s 1,000,000
E JL
GEML AGGREGATE OMIT APPLIES PEFt: ,_C+ENERAL AGGREGATE 1 2,000,000
X 1 POLICY[X l J r l WC PRODUCTS—COMP/OP AGG S 2,000,000
OTHER: $
AUTOMOBILE LIABILITY I COMBINED SINGLE WAIT
IEaacddent) 5----_-_-----ANY AUTO BODILY INJURY(ParencnL _-- ----_ ---
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY YIINJURY
jp_eer accident) $
—_AUTOS ONLY _ AU�LY 1 MP acrid U E >1-
$
UMBRELLA UAB OCCUR EACH OCCURRENCE- --_t$.
EXCESS UAB -CLAIMS-MADE AGGREGATE $ --- .-
DED RETENTIONS , $
WORKERS COMPENSATION 1 PESTAT J 0TH-
AND EMPLOYERS'LIABILITY Y/N
AA�FR�� NpRC�E fl 1 NJA -,EL EACH-ACCIDENT ,�-_ _ -- -_
(Mxaato�ry NI1) EL DISEASE-EAEMPLOYEE S
If descnbe uncle[ E.L.DISEASE-POLICY um' $
DscRIPTION OF OPERATIONS below
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
Cornerstone HouseLLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BuyingACCORDANCE WITH THE POLICY PROVISIONS.
1218 Westfield St.
West Springfield,MA 01089
AUTHORIZED REPRESENTATIVE
I
ACORD 25(2016/031 '"„"Info a........
v 7UOtt-LUTb AIAJPW CUKl OKAI ION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
DUBAY BROS. ROOFING INC.
CONTRACT
(413) 781-2533 •
Page No. of Pages
DESCRIPTION OF JOB
ARCHITECT DATE OF PLANS
PROPOSAL SUBMI i"I'ED TO:
JOB
IL)r+n e_ l_//7 a P iul o r t ADDRESS
q,} f{ elaSI°� (fc4rfL CITY STATE ZIP
/I PHONE DATE
r Q Y /'j G, ,1 ,/,
PWE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR: N
�) i/p / 7(nni✓e.-. 9 i Ail lei '4 /
( i- ' 4
f -c c few '�/ I0f
7 e/c.. jy' t
/�i ,,.f>j'.
I Ici, c WY/
,r^ f
, /.0.,
,.
,,,.),.., ,,,,,„6_,..,.. /......„
r�
C , I.
r C , , B lire's /
,e/(4-,i.' t:"..-c)c. r- ,5 0 el e i.---6,) k) ,, oe<>e
,f t
. A..re 0 le... Ai( . (,,, k--ce K-
F4-ici< Pk I 1., e c I; 4--)
We hereby propose to furnish material and labor, complete in accordance with ab v/e specifications, for the
sum of dollars $ `SG oe- o'O
I I
with payment to be made as follows: 0 °/'7 I i.
CC)/77/2 C ' ee)
All material is guaranteed to be as specified.All work is to be completed in a workmanlike
manner according to standard practices.Any alteration or deviation from specifications Authorized .�/
involving extra costs will be executed upon written orders, and will become an extra Signature a --'i" �Cte
charge over and above the estimate.All agreements contingent upon strikes, accidents
or delays beyond our control. Owner to carry fire, tornado and other necessary Note: This proposal may be withdrawn by us if not accepted
insurance. Our workers are fully covered by Worker's Compensation Insurance. within days.
Acceptance of Proposal - The above prices, specifications and condi-[
).
tions are satisfactory and are hereby accepted. You are authorized to do
the work as specified. Payment will be made as outlined above. Signature %'�' „�c. :_-.) (
,f
Date of Acceptance: - Signature_
k