32C-309 (8) 21 HENRY ST BP-2019-0332
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-309 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2019-0332
Project# JS-2019-000539
Est. Cost: $13800.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: SEXTON ROOFING CO 118239
Lot Size(sq.ft.): 12196.80 Owner. ROUMAY SUE
Zoning:URC(100)/ Applicant. SEXTON ROOFING CO
AT. 21 HENRY ST
Applicant Address: Phone: Insurance:
P O BOX 6327 (413) 534-1234
HOLYOKEMA01041 ISSUED ON:9/16/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE AND REPLACE EXISITNG SHINGLES
ON MAIN FRONT
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 Signature:
FeeType: Date Paid: Amount:
Building 9/16/2018 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
kj-
City of Northampton Status of Permit:
Department use only
. - Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
�I Room 100 WaterNVell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,A EMO ISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION �! 1q-3
1.1 Property Address: 20-18
T iiiis section to be completed by office
Lot S09 Unit
t"-1 lv'r y S DEPT OF BUILDING INSPF-TIONS
NORTHAMPTON,P 01060 Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2. Owner of Record:
'r- 't� 2
bI aV
r
Name(PrinIT Mailing Addre s:
11lkCL' Telephone
Signature
2,2 Authorized A ent:
Nam (P Current Mailing Address:
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 !l
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+ 3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: _ C�/� lt--"
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
33� ;
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing LAA
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other[0]
Brief Description of Proposed
Work: 4',t/ '�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house 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 c`7ttion. Dimensions
e. Number of stories?
f. Method of heating? Fir aces 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 wetland Yes No. 11-7 uction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor elow 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, /Y`A as Owner of the subject
grope
hereby authorize /'►
to on my behalf, in all matters relative to work authorized by his building permit application.
Signature of Owner Date
/_1 .4-JI, / L/C as Owner/Authorized
Agent hereby declare t at the statements and information 6n the foregoing application are true and accurate, to the best of my knowledge
and belief.
S.igned under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
f '
,�
a-
1 � .:[S
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: 1� Not Applicable ❑
Name of License Holder:
License Number
Address V Expiration Date
o � �
Signature Telephone
S-Reoistered Home Improvement C tractor: Not Applicable ❑
t vL- d c . JQV_l 1-k 3 a
omDanV Name Registration Number
0 -
Address Expiration Date
Telephone 53Y,/23--v
SECTION 10-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....... No...... ❑
i
., :yam.:. t . ••�r. ,,,
City of Northampton
' Massachusetts
c
I JL. 3
DEPAR"MENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building yeti Oa
•
Northampton, MA 01060 rst 3 7`�0
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L. Chapter 142A requires that the"reconstruction,alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building" be
done by registered contractors.
Note.If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work:2 ac 612 c;t Est.Cost:—/ 3 k-t'2)
Address of Work:
Date of Permit Application: S /
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
_Job under$1,000.00
Owner obtaining own permit(explain):
Building not owner-occupied
_Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a buildin ermit as the agent of the owner:
i � 3,Cjd1
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts
5. DEPARTMENT OF BUILDING INSPECTIONS z
-+g 212 Main Street •Municipal Building
Northampton, MA 01060 stayj��
Debris 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.
The debris from construction work being performed at:
(P ea a print house nuinber and street name)
Is to be disposed of at:
i' Ik 0k r 44
(Please print name and location of facilit
Or will be disposed of in a dumpster onsite rented or leased from:
V
S t4
(Company Name and Address)
Signat re of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
Proposal
SEXTON ROOFING AND SIDING INC
vywW,sextonroofing-coni
P.O. Box 6327
VIA Holyoke, MA 01041
,Soiting dw Standard
5,34. 1234
.l 13.539.9906
MA 1110 # 118239
se xtonroofiniz(a-41 ail.coni
1 DATE 9. 5 18
site 248-225-5291 1
JOBNAM.E UPPER MAIN AND FRONT PORCH ONLY
qTATKZjjl Not-thamplon, Ma. J-QB LOCATION
It tN P()()I-I M; I I kRH5Y StJ13MITS SPECIFICATIONS AND ESTIMATES FOR-
j.) Strip and remove existing shingles and dispose of in proper landfill.
wI Itist,ill new decking ( '/z"CDX 4 ply))
Inst ill new metal edging to rakes and eaves of roof. (8')
4) Install ice and water shield on eaves roof. (6')
Install-,.ta.fter shingles on eaves and rakes of roof.
ljj4t�j11 synthetic roofing felt on remainder of roof.
Install II(-w flanges over existing vent stack.
s) Install !KClArchiteotiral style roofing shingles as per manufacturers' specifications.
,)) listed( new It-ad flashing on chimney.
it)) Install new vap over ridge vent,
I I) Sliplily mantifactuteS 50 warranty and SRC 25 yr. workmanship warranty.
I'l.f PROPERTY LIABILITY AND WORKMANS-COMPENSATION, ALL PERMITS
h( t-hy 1,)I'toni-;h material and labor --complete in accordance with the above specifications,for the sum of.
I hisict-n I housindj.--ight Hundred(S 13 800.00 Payment to be made as follows: upon Completion
All work to be complmd Ln a Authorized
()TdtrX to standard pmcftces Any alwatton or
11volicAtIfin5 Invol"14extra costs wit!beexecutedonly Signature
all CXtrA charge over and above the
"n""'gent"Pun$EnkL
*s-accidents Of decays beyond Note:This proposal may be withdrawn by us if not accepted
Ate'.dames
dur'ng comtrumm ovVfYCT iwithin(14)days.
q2ayment and )wAble it tsett
`Vckcjytiincrofl?ropotsal The above PliCCS,specifications
md,onditions Siguture
air s"t"dZU'Wry and are hereby accelftd, You
,w-.iuth1)rtzv.d 10 flit work 83 sMificd, Payment.WiUbe
f'�Adv,iti rwutlined above Signal=
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Warkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Oro nization/individual):Sexton Roofing&Siding Inc
Address:P.O. Box 6327
City/State/Zip:Holyoke, Ma, 01040 Phone#:413-534-1234
Are you an employer?Check the appropriate box: Type of project(required):
L❑I am a employer with employe0s(full and/or part-time).* 7, E]New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in g. ❑Remodeling
. any capacity.[No workers'comp.insurance required]
3.F�I am a homeowner doing all work myself[No workers'comp.insurance required]t 9. ❑Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I wrll 10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole I LF]Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.[D I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance_$
6.n We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required]
*Amy applicant that checks box 41 must also fill out the section below showing their workers'compensation policy informafioa
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such
:Contractors that checkthis 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.
I am an employer that is providing workers'compensation insurance for my employees. Belaw is the policy and job site
information.
Insurance Company Name:Travelers Property Cas Co of Am
Policy#or Self-ins.Lic.#:7PJUBGo7898212 Expiration Date:6/4/19
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 MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office-of Investigations of the DIA for insurance
coverage verification.
I do hereby certify u the pours andpenalties ofperjury that the informadon p rovided above is true and correct
Simature: Date:
Phone S^3y
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
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#:
i
The Commonwealth of Massachusetts
' Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02112017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Elech idans/Plnmbers.
TO BE FILED WITH THE PERMITTING AUTHORTI'Y.
Applicant Information Please Print IMJbly
Name(Business/Orpau:ationllndividaal):LDG Homes,Improvement Inc
Address:18 Spring St. 1 st floor
City/State/Zip:Milford, Ma.01757 Phone#:(774)214-6239
Are you as employer?Check the appropriate box: Type of project(required):
1_�✓ I am a employerwith 5 employees(full and/orpart time).* 7. ❑New construction
2❑I am a sale proprietor orparincrship and have no employees wodoug forme in $ []Remodeling
any capacity-[No workers'comp:insurance 'required]
3.[:]l am a homeowner doing all work myself[No workers'comp.insurance required]t 9. ❑Demolition
4.❑r am a homeowner and will be being contractors to conduct all work on my.property. I,,v l 10❑Building addition
ensure that all contractors either have workers'compensation insuraoce or are sole 11-E]Electrical repairs or additions
proprietors with no employees_ 12.❑Plumbing repairs or additions
5_❑1 am a general contractor and I have hard the sub-contractors Iisted on the attached sheet
These sub-cant actors have employees and have workers'comp.incur P* 13.oRoofrepairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c_ 14.❑Other
152,§1(4),and we have no employees_[No workers'comp_inmira,cerequired]
*Any applicant that chi box#1 must also fill out the section below showing thea workers'compensation policy information.
t Homeownen who submit this affidavit indicating they are doing all wodc and then hire outside,contractors must submit a new affidavit indicating such_
4Contractois that cher-k this box must attached an additional sheet showing the name oflt a 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.
I am an emplayer that is providingworkers'compensation insurance for my employees Below is the policy mid job site
information.
Insurance Company Name:TravelersIndemnity Company of America
Policy#or Self-ins.Lic.#-UB-1 K196202-18 Expiration Date:02/21/19
Job Site Address: City/stn zmp:
Attach a copy of the workers'compensation policy declamfion page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00 .
and/or one-year imp... ent,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 vialJor.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage veribcati
I do hereby cc the pains and penalties of perjury that the information provided above is true and correct
Signature: Date:
Phone#: 1 239
Official use ono v Do not write in this area,to he completed by city or town o flderL
City or Town: Permit(License#
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#:
® CERTIFICATE OF LIABILITY INSURANCE DATE(M23f201 YYI�
TkLS.CEi2TIFICATE 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:
OLDERIMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the poficy(ies)must be endorsed_ If SUBROGATION IS WAIVED,subject to
the terns and conditions of the poficy,certain policies may require and endorsement A statement on this certificate does not confer rights to
the Certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME
A COSTA INSURANCE AGENCY PHONE FAX
2 FRANKLIN COMMONS (AIC,No,Ext): (AIC,No):
E-LWL
FRAMINGHAK MA 01702 ADDRESS:
783BY INSURER(S)AFFORDING COVERAGE MAIC#
INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA
LDG HOMES IA PROVEMENT INC INSURER B:
INSURER C:
INSURER D:
18 SPRING ST 1 ST FL INSURER E:
MILFORD,MA 01757 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE 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 DESCRIED HEREIN IS SUBJECT TO ALL THE TERNS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY
PAID CLAIMS.
INSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (WdIDDIYYYY) (LOADMYYYY) UNOTS
GENERAL LIABILITY EACH OCCURRENCE I5
COMMERCIAL GENERAL LIABILITY
TO
CLAIMS MADE F-1OCCUR-
REMIE6AIESES( RENTED ) 5
Ea occurr
ence
EXP(Any one person) 15
PERSONAL&ADV INJURY Is
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S
POLICY F-1 PROJECT F-1 LOC RODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea aeadent)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (P-Peen)
HIRED AUTOS BODILY INJURY $
(Per aoodent)
NON-OWNED AUTOS PROPERTY DAMAGE $
(Per accident)
UMBRELLA L1ABe OCCUR EACH OCCURRENCE I$
EXCESS LJAB CLAIMS-MADE AGGREGATE 4$
DEDUCTIBLE 3
RETENTION $
�$
A WORKER'S COMPENSATION AND X I WC STATUTORY OTHER
EMPLOYER'S LIABILITY YIN UB-1K19&202-18 021212018 =112D19 LIMITS
ANY PROPERFTORIPARTNERID:ECU LVE
OFFTCEPJMEAABER EXCLUDED? NIA E L EACH ACCIDENT Is 100,D00
(Mandatnry in NH) E.L DISEASE-EA EMPLOYEE $ 100,000
If yrs,describe under
DESCRIPTION OF OPERATIONS belvv EL DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERAl70NSILOCATTONSIVEHICLESIRESTRICTIONSISPECWL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTI NG WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
SEXTON ROOFING&SIDING INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLBEFORE THE EXPIRATION DATE ED
102 PINE ST N L ACCORDANCE WITH THE POLICY P THEREOF,NOTICEWILL BE DELIVERED
PO BOX 6327 AUTHORIZED REPRESENT
HOLYOKE,MA 01040 Jl~ z t
ACORD 25(20111/05) The ACORD narne and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved.
it
I
• �
• •
A�o CERTIFICATE OF LIABILITY INSURANCE DATE 6262018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
EATIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW
-
THIS CERTIFICATE OF INSURANCE DOE'S 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(es)must be endorsed.If SUBROGATION IS WANED,subject to the
erns and conditions of the policy, certain policies may require an endorsemelR A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT NAME-Kathi Hutchinson
Ormsby Insurance Agency,Inc. PHONE(A1C,No,Ext: 413)7374300 FAX(AIC,No):
PO Box 718 E-MAILADDRESS:khutchinson@ormsbyins-=n
West Springfield,MA 01089 INSURERS AFFORDING COVERAGE NJUCX
INSURED INSURER A:Colony Insurance Company -39993
Sexton Roofing and Siding Inc INSURER 6:
PO Bax 6327 INSURER C:
Holyoke,MA01041-637J INSURER Ch
INSURER I_
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 REOUIREMENT,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.
POLICY EFF POLICY EXP
INS7 AD0"L SUER DATE DATE
LTR TYPE OF INSURANCE NSRD WVD POLICY NU16SER IDD I.IMOD LIMITS
A COMMERCIAL GENERAL LIABILITY IOIGLOD2159903 62-52018 625/2019 EACH OCCURRENCE S1.DDO,ODO
X
CLAIMS MADE0 DAMAGE TO RENTED OCCUR PREMISES Oc=rrence) 5100,OD0
MED EXP(Any one person) SS.DDO
PERSONAL E.ADV INJURY S1,DD0,0W
AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE SZ.DDO,ODD
Y POLICY N ZE T' N❑LDC PRODUCTS-COMP/OP AGG SZOOO,OOD
OTHER:
COMBINED SIGNED LIMIT S
AUTOMOBILE LIABILITY (Ea accident
ANY AUTO BODILY INJURY(Per person) S
ALL OWNED SCHEDULED BODILY INJURY(Per 5
AUTOS AUTOSaccident)
HIRED AUTOS NON-OWNED PROPERTY DAMAGE S
AUTOS (Per accident)
5
MBRELLALIA6 CCUR EACH OCCURRENCE S
CESS LIAR MS MADE AGGREGATE is
ED I kETeMON S s
WORKERS COMPENSATION AND
EMPLOYERS LIABILITY YIN NTE
ANYPRDPRIETORIPARTNER/DG=CUTIVI= EL EACH ACCIDENT S
OFRCERIUEMBER EXCLUDED? NIA
(Mandatory in NH) EL DISEASE-EA 5
IF yes,describe under EMPLOYEE
DESCRIPTION'OF OPERATIONS below EL DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,ilmore space is required)
CERTIFICATE BOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 13EFORE.THE EXPIRATION DATE
THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25(2014101) 01988-2014 ACORD CORPORATION.All Tights reserved.
The ACORD name and logo are registered marks of ACORD
i
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: Corporation
Registration: 116239
SEXTON ROOFING & Siding Inc Expiration: 02/14/2019
P:O. Box 6327
Holyoke, MA 01041
Update Address and return card. Mark reason for change.
r7 r n+
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Constructiorr511pefvtsor Specialty
CSSL-099689 rz fir,; Expires: 10/05/2019
EVERETTJSEXTOf'1; tads'
PO BOX 6327%
HOLYOKE MA 01_041
i tl•.�'1 ih�
Commissioner
HOME IMPROVEMENT CONTRACTOR
EVERETT J SEXTON SR
102 Pine St
HOLYOKE,NIA 01040-2411
SEXTON ROOFING&SIDING CO
LIC./REG NO. EFFECTIVE EXPIRES
HIC.0605383 12/01/2017 11/30/2018
SIGNED