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17A-248 (8) 98 LAKE ST BP-2017-0410 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-248 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categprv: ROOF BUILDING PERMIT Permit# BP-2017-0410 Project# JS-2017-000682 Est. Cost: $5500.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SEXTON ROOFING CO 118239 Lot Size(sq.ft.): 16552.80 Owner: BROWN MAREN T&PATRICIA ANN MORRISON Zoning: URB(100)/ Applicant: SEXTON ROOFING CO AT: 98 LAKE ST Applicant Address: Phone: Insurance: P 0 BOX 6327 (413) 534-1234 WC H O L Y O K E M A 01041 ISSUED ON:9/27/2 016 0:00:00 TO PERFORM THE FOLLOWING WORK:REMOVE & RESHINGLE ACCESSORY ROOFS 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: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Sienature: FeeTvpe: Date Paid: Amount: Building 9/27/2016 0:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-0410 APPLICANT/CONTACT PERSON SEXTON ROOFING CO ADDRESS/PHONE P O BOX 6327 HOLYOKE (413)534-1234 PROPERTY LOCATION 98 LAKE ST MAP I7A PARCEL 248 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Bee Paid LG� Building Permit Filled out Fee Paid TypeofConstruction:_REMOVE&RESHINGLE ACCESSORY ROOFS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 118239 3 sets of Plans/Plot Plan THE LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF MN PRESENTED Approved ATIOAdditional permits: required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received& Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demo "on Delay .(I// _�(/(/l , ' /P 027-o?o/(P Signature fB ding 0 Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. Department use only -:� City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit - � 212 Main Street Sewer/Septic Availability �(�\ Room 100 Water/Well Availability \..............„..c..._ yV-1 Z8' s Northampton, MA 01060Two Sets of Swctural Plans .,c,�, � 413-587-1240 Fax 413-587-1272 Plot/Site Plans c.sv. ;e'u n.' Other Specify vs oR''"PLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: qyL/41c Si Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: l4f(n 3e a (4-'3 Q F L is sr r/cfc Ac e f 7 New(Print) Current drQ P Q 7 ail/ad -4111.41- -/( Telephone Signature 2.2,puthorized Agent: jth PO (7A9 z) - tou 6 s3-c Holyu4i (AAA NaCurrent Mailing Address: -- (90Y a Se 7 ) Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+q+5) 5/ 5ry i — Check Number /66 7 50 This Section For Official Use Only Budding Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing �s -r Or Doors CI Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [D Siding[0] Other[O] Brief Description of Proposed work: Yenobe Aft el )4pi7c12- r4CC Pssc/Sy Rcc0Cs 04, ac r) Alteration of existing bedroom Yes_No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sail New and or addition to existing'housing',complete the following: a. Use of building : One Family _ Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Igloo) " i66u& ,as Owner of the subject property (\� �_ �� �{' hereby authorize �- K at) I\0 o{( 1,10/ to a n my behalf,in all mattrer�� sre�lat�ive to work authorized by this building permit plication. Signature of Owner Date f9 I, &V XrjZ,- FC(1(77 0 cl ,as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Pnnt Name 9/a / //4 Shire o Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder / / , +:�/� .N"T Qom✓ '79.6 yq License Number ea -sD 1- (yo 69/ /o- r—/ "7 Address Expiration Date cl9C(/'cs) '7/75— Signature Telephone 9.`Registered Nome improvement Contractor: Not Applicable 0 (Y} L IN FOC( /Com n Name / Registration Number Address --.., Expiration Date ) l? 4 4 t ltitA ©/o T(/ ( Telephone 537`/)? SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 GI/ngNo 0 11.- Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellines of one(I) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner:Person(s)who own 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 homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be responsible for all such work performed under the buildine permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances.State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: 9y 4 A ke_ 51 - The debris will be transported by: nai p"eJ D 1 3/03 A-c The debris will be received by: 06-7,1'le i es'. -c Building permit number Name of Permit Applicant lead(by • I4 Date Signature of Permit Applicant tiroposat SEXTON ROOFING AND SIDING INC www sextomroofing com roil MASTER Setting the Standard L,Zra��a�kr. be maiii t P.O. Box 6327 p. 413.534.1234 Holyoke, MA 01041 f. 413.53),9906 MA 1110 # 118239 ����_ scxtpnrooflnIwhotmail com ____ St10aII'rfED TO Marco Drown __I1_ ___._ _._ ._ Pt10Nt_Srb.:Q4Dl I)ArF ai .tn MEET_ 9g Lake 5.. 14@ yAAfE Shed. side ILn and back sAinak roC f• _ - CITy:STATF/ZIP Florence, Ma. I JOB LOCATION SEXTON ROOFING HEREBY SUBMITS SPECIFICATIONS ANDESTIMATES FOR • • 1) Strip and remove existing shingles and dispose of in proper landfill. vs. (r.aau*d 2) Install new decking as follows;flat roofs 'i"4 ply plywood, back low pitched roof bC'plywood,replace as needed shed roof and upper back shingle roof(attached to low pitched section) at$65.00 per sheet. 3) Install new metal edging to rakes and eaves of roof. (8') 4) Install ice and water shield to entire back shingle section. 5) Install starter shingles on eaves and rakes of roof. 6) Install synthetic roofing felt on shed roof. [[ �Lt 1 7) Install fully adhered EPDM membrane to flat roofs.(S4�j 14 t di;MIX)/I"frill �7'e f 8) Install IKO Architectural style roofing shingles as per manufacturers'specifications. C Maartefi 6.hs y 9) Supply manufactures 50 warranty and SRC 25 yr.workmanship warranty shingle warranty, 15 year in house warranty on flat roofs. ALL CONTRACTS INSURED WITH PROPERTY LIABILITY AND WORKMANS-COMPENSATION. ALL PERMITS APPLIED FOR BY SRC. tde*repose hereby to furnish material and labor-complete in accordance with the above specifications,fot the sum of Five Thousand Five Hundred(55,500.00) Payment to be made as follows:u mpletion Wl Maenal is guaranteed to be as parted AR sunk to be completed in a Authori3 A�'j�-/ - workmanlike anlike manna meadow to standard;swam Any aihranoa or Signature dnaauon from above>Pmfications involving extra comwig be executed only upon wham orders.and will become an extra charge over and above tee estimate An awn contingent upon strikes,accidents or delays beyond Note:This proposal may be withdrawn by us Snot accepted our control. Not raponubk for water damae during coosmaum. Owner within(14)days. :. to pay rw.om.t*kgai fm fot nonpayment,and applicable mutat Saes=of awns! The above prices.specifications and conditions are satisfactory and are hereby accepted. You Signature arc authorized Co the work as specified. Payment will be Signature made as outlined above. Date of Acceptance. __ _ The CommocitieuPF q`_Massachsue as Dep art-noni ofIndusichalAcciclent Office of 1-....TesTigaziorLsr '� I Congress S: u�, Sk._e 100 3csion '±CA n1774_1017 iv1w:-rnass_dav/die Workers' Comt ersationlnTuft asce[-`.ffidawit. B iders/ContractorsiIiectricianslPlnmbers 3pv$canf J!fo_Li 1Iation - - Please Print dbly haine oros-ceslor onrdinow]). Sexton Roofing & Siding Inc . cHirers. P . O . Box 6327 iSt_,eIL,_ Holyoke , MA 01041 Pea'_#_. 413-534-1234- ��r 2Ly ? C* _zth F oy b :r✓e of ] ' eq..veip . ✓tea r _ -3 z '..r , d_ a'os es Cfil] ans/spa- )' tape hr dhestip-sort-actors c. Li-New con_�iyroa IIS in _KMm:Cie 2r tn.iar or rre-= s+a ds3 mt I 7. ❑ StrZzmodeasrz are,Ila oyplosees o& c_ s Sava 8Dencon These ' ❑ ,n :� :c.ra is )'cis-Yy.. 1 ..=s Eadh s workers' III P r - ..r= corer a;�zace ❑_call E15_42-tion 9 reroti d - 5 ❑ V accrp e_on caths III 1OJ Elacs..a,r.yo—� o. addifiou _.E. era alaDraeOveter longzilwari dw `esP et II 11 PFans- epees r addtans r-- L e _yo s _ f exe.eco n Tom,, — -2 as 11 ._s ice s - 5 oll', _w Even I era Errioyees )No salsa ]L.i Tfler _ -' _ _ ) 'I227-347 _mce Ezu;_e3j 3✓ =iy' ]. -m b *_=.tYv _ne se: O sass yr:.acy xtiaa Essace WAC wi o stesttseaSe T in ane O.. F all esons ald lenLte t COlarrasursnust ra:rriat anew a dtht d o gsuccs Desktau DOS`SIL. Tana e. n ilLtanal Sec rt6LOgra toenZnc sift:RhLOLha[.ID ane sirs Lew s r -'h e ea±resb ay: entecytes est s0-:on v ors bats c=„eloteses, sisstitseAsesem Vex..-.' ., oeSsy .sabEH aest etriesSst_ 7:0037-3-132g330-33/703°carr_ C :.s'a^ crmy empLoyeas do: the;Oi 3c job ste. rr=-z=_ C ort Nanjo: - J7.31±:y# r_ S6_±. a #_ "rp`=_aonDiia. :Co Sitz?_Mess. - `Asst A±4e1e sett, e_ries _ .- CI=trSatI0070F1. yne.]zdonp -e rracermg.n Pc 7 zun-her �i date)_ Failure scone age =retarer ane:Soo or peal o 12 cmlez -Ie.yros-i of c—nnel a aseCe 3 13 c 1 one-teuz so-mss y .reL es carreirerreirres mons font of a STOP r 0'P3 CRSEF nol a'fre ortr.tor _2•15n .11.1 >agentta N a or. Be alerder'c.. _copy steteresztrorobErforceter L 2ao Cwcs4rerci .. _kaon ripe._i_for rcirerace cove—et y°•--carica y- ereCti ce Re JC Cd p 21:7E f p , aset,i a orrovitief aloottsSTrize rod sore= Simms_. - Date. _ --__a. 4135341234 Cfficin2 itse crus Do xo!wrue a this area to be comp Bred by city or town cffi Bci C y 07 ro—.a- I Permitilicense issuing Authority Ccice one)'. Board ofEarlffi 2.Dialer glOtnerent 3. Cisyriste Clerk 4.Elec-.icalinsgector 5 Plnhtg Tropertut I6Other _ - Coa Person: Weeps-4t Deprterteiseor -•.iu - 'c J 7. -jilt-IP - Cfie. I revert n, - - IU•_...-1 �) 500 ,Vasnit:on Sire e. Bos:om4fA' 0?t_11 W1-1):42 aia Workers' Couip ens atop Insurance Affidavit: Builders/Ccn-actcrs/Elecfrieiansi?lumbers '3oulicant hforciadonPlease Print Le iLly Naddre (BtsineslOrgr-tioniadividua): ✓aacZ Cnio,=-1/#:ur„-i e;_> i1C A]2e5s: /t (. Cr/AQL ' cc/G /l City/Staled/Zip: C ; l^LLQ U u:? n sucker`: 9 - V5 - Are yrn an ..ployer? Cheekthe2 appropriate be l Type ofo oJe t(receiredh 11_Tattoo aup.c"with . °. ❑ far a noneral confront=andI opio ees(rad c b ve�_dhe cA ,.c_m.,rc C. ❑>v w �ptir Ilion e ro Dart ani et' 2.❑ _ sole yr t_ o, v=r"er- hooted Oa he ato cher sheet 7. 1 Aero reiias ship =±Mars MO employees These sorb-con a have r ;' ❑ Demo i4'ca orlaag for ME in my napacioy employeesand r°'_n' o. FA Buidirip. ad Gan [No workers' comp.insurance ❑ Catto ins.r:aace.7 90e. -ate _ a cerooradcn and id 10_❑Election]repairs or adoatoes - � 3_0I aM"mown doing ad work en have ea es ss :1.❑Plianhing T.T.FLES or addidoas r a :enpror, De 12.L'Roo ot repairs✓ I ITow ries coca. insurance required.]t e 1 2 g,(4) thea hen employees [No workers' 13. N Other 5 comp. rzsurance raq_ired_] 'Any app ucant thatchee'rs box g}most also fill out Gc scud on below showing thin work^r,'eonpcnsao'on poky iota_nn;a Horth cwnas who submit this vii davit indicating they ere doing al work and Lam hire outside cot omnis court su:mi!a new a_rtan.indict'apush _ etantactors Nat ehecl:this box mess attached an add thing]sheet showing tthe nam_of the sub<cntadms and cute wh zthe or not those en ides haw: mployes. If the sub<nctacmr have cmptorees,they must provide their wo is r.'comppolicy number I am an flnpGryer the:is pro vidlne workers' comper:ration Insurance jar fry employees. Below is the policy ce d job sire htjormalion. lav_=ce CC=yy N=ee: 4/A1 (4 bi g( thus . Petry a - Lia : Yw tailG11Q90c2OIL- A ExpioninaDae ,51It//7 Jon Site Address: Ciy%5¢le/Zip: Ermch a copy cf the workers' compensation policy den:a-atica page (shorting the policy number and a:opirztlon data). Bohm,to encore coverage as required under Section 25A or r!CL c_ 152 CM 1226 to the nposiddca of crinainal Dec des of a Coe op to 51,560.20 angor one-yea in:provent as well as oir-J pe lf_s 0 Me form of a S1'OE PORK ORDER and a fine of up to $250 DO a day agatt the violator. Be advised thin a copy of this statement maybe forwarded to the Office of_ Lvesdaadons of the DIA for inso ante oovcEa ge veddcador I de hereby cerary ander the hats and perci:ies o,'"Aeriu.ey!,h a.'.the Info rat dict:provided ehcvc is true mad correct. Sla-enti e' � a . Data Phone di /.- I i - r'.(l2 • 0 �9� 1,1 Official ase cry. Dan of write in Jas aren, Lo be cornoieted iy chy or torn o isiOL City or Town: Pe spit/Licanse Issuing Authority (circle one): L.Board ofEath 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector G. Other Contact Person: Phone k: • l 6 DATE lmWotw»'Y ACORD CERTIFICATE OF LIABILITY INSURANCE %.../ 03/18/2016 THIS CERTIFICATE IS ISSUED AS A MATER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT L NAME: eandro GUlmaraa5 UNIVERSAL INSURANCE AGENCY {WI. Em: (508)752-9333 I FAX No): ADDRESS leandro)Tuniversalinsagency.com 374 BELMONT ST. INSURERS/APPORDINGCOVFFRAOE I NAIL# WORCESTER MA 01604 INSURER A AIM MUTUAL INS CO 33758 INSURED INSURER B: ALG CONSTRUCTION INC INSURER en i INSURER D: 116 CHAPEL STREET [INSURERE: - - 1 CHERRY VALLEY MA 01611 I INSURER F: I COVERAGES CERTIFICATE NUMBER: 38399 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 CONE TIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR Litt TYPE OF INSURANCE ADDL Lett POLICY EFF POLICY EXP ' SO WVD POLICY NUMBER IMMIDOIYYYYI IMMIODIYYYYI LIMITS ' I COMMERCIAL GENERAL LIABILITY_ I EACH OCCURRENCE I S I I PREM4 cYURENPI„Eu b L�IM6dMOE '. OO CJR PREA115E6/d ncel I • MED W(Any one person) I F NIA PERSONAL aADV INJURY I s GIGOT AGGREGATE MILT APPLES PER. GENERAL AGGREGATE , i i PDIc 1jr-_RCTni LOC • rPRODUCTS-COMPIOP AGO S OTHER I 'S AUTOMOBILE LIABILITY 1 I COMBINED SINGLE LIMIT $ AN'YAUTO ' BODILY INJURY(Per person) IS A — ALL r.SCHEDULED N/A BODILY INJURY(Per acddenp E AITO6 �NONOSWNED PROPERTY aDAMAGE S HIRED ALTOS AUTOS UMBRELLA LIAB I I ocodRI EACH OCCURRENCE S I EXCESS LIAB I 1 CLAIMS-MADE' [ N/A AGGREGATE S I DED ' RETENTIONS IS I WORKERS COMPENSATION • :XI STATUTE ERH I AND EMPLOYERS'LIABILITY - A IANYPrTJoRIETO ARTNPLNI:X-GUiIVE VIN, 1 EL.EACH ACCIDENT S 1,000,000 OFFICERIMEMBEReXC.uDED? I NIA i NIA I NIA VWC 100601 0 9 9 5 201 oA 10311212016.. 03112/2017 - (ManOaYorylnNNl • I E.L.DISEASE-EA EMPLOYEE S 1,000,000 �pr geydeeadoeunder li sGRlrnoN D=oPErw-IDvs celo+ E.L.' DISEASE PounuMIT is 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES )ACORD IDI,Additional Remarks Schedulemay be attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 D6 B,no authorization is given to pay claims for benefcs 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 dale of certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.massgov/Iwd/workers-compensationlinvestigalions/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SEXTON ROOFING ACCORDANCE WITH THE POLICY PROVISIONS. 102 PINE ST AUTHORIZEDLRREEPREESSENTATIVE HOLYOKE MA 01041 Daniel M.CroWjey,CPCU,Dice President-Residual Market-WCRIBMA ©1958-2014 ACORD CORPORATION. All rights reserved. •,....,r.+C r+"r Atn4 r ThP ACORD name and logo are registered marks of ACORD /..9 SEXTO-2 OP ID: ER a�o CERTIFICATE OF LIABILITY INSURANCE GATE(M""°" ' 07/01/2016 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 CONNAME; Eric Dembinske Ormsby Insurance Agency,Inc. E. 698 Westfield St PO Box 18 (EA/ Hoc Nrio Ea1:413-737-0300 I FWD,Nog 413-737-0617 West Springfield,MA 01090 E-MAIL Eric Dembinske ADDRESS. INSURER(E)AFFORDING COVERAGE NAIL 8 I INSURER A'.Atlantic Casualty Ins.Co, INSURED Sexton Roofing&Siding, Inc. INSURER B:Quincy Mutual Fire Insurance 1115067 PO Box 6327 Holyoke,MA 01041 INSURER C: INSURER D: INSURER E'. i INSURER F COVERAGES - CERTIFICATE NUMBER: REVISION NUMBER: I 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 W SrnR NND 5� POLICY EFF POLICY EXP TYPE°FINSUPANLE SD VIVO POLICY NUMBER /MMNDnTWI (M M/DDM'YY) LIMITS A '�'I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE E 1,000,000 CLAIMS-MAD=_ I� O=UR •101 GL002159900 06/25/2016�06/25/2017 p Isrs°Eao 1 100,000 1 MED EXP(Any one cersnnl IE 5,000 PERSONAL a ADV INJURY $ 1,000,000 GENE AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY aE°r LOC ! PRoouas-conn/OP AGO $ 2,000,00C �� COKER- I E 1 E AUTOMOBILE LIABILITY I COMBINEDSING:c LIMIT $ 1,000,000 B !(Ea INN ANY AUTO I AFV206561 1 05115/2016 05/15/20171 BODILY INJURY(Per person) I$ ALL OWNED X LE SCHEDUC I BODILY INJURY P e AUTOS AOTos GE - =nn!s I AUOS NON-OWNED I PROPERTY DAMAGE-m HIRES AUTOS AUTOS (Pe.accident) E IE UMBRELLA LIAB 1 I OCCUR .EACH OCCURRENCE IE 7. EXCESS LIAB I CLAIMS-MADE. • AGGREGATE I$ I DED I •"RETENTION$ S WORKERS COMPENSATION I I PCR 0TH STATUTE AND EMPLOYERS'LIABILITY V/II ISR I i ANY PROPRIEBOR E/EXECUT'.VE I � 1 EL EACH ACCIDENT I8 OFFICER/MEM EXCLUDED? IiN/AI ._. !(Mandatory in N181 I 1 IE_DIGEASE-EA EMPLOYEEIE III yes.tlIPTIONes-wipe ncle- DRI4TIONOcOPERATIONSbelow ! E.L.DISEASE-PODGY LIMIT • • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD.IM,Additional Remarks Schedule,may be attached it more space Ie required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Everett Sexton ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Eric Dembinske • B1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 7/177. J �C2 L-- 5-55 T55.05rn c._ r- Eng 51151 Bo��n,-- -r 2=1:G a-trbn_ 1 Iff1252.9 - D - - - — _ - 2/15/17 237086 11Vf:1 ) rLHG HFH I I SEXTON - BG_, _ — _ H0L 0 Hi= \' 010=11 »� Na ch' settsGpatme ni o, PubicS-fiery Board of auHing'ng gurarons f.fnd f ntlards License- CSSL-0996 9 -I EVE30X63 SEXTON PC 30X 5327 - 7147:17;:11.:11" HOLYOKEMAU)0Ct = °aoiraJ_r Corn..:Rede er 10'05'2017