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36-097 (6) 997 BURTS PIT RD BP-2021-0122 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:36-097 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-2021-0122 Project# JS-2021-000195 Est.Cost: $6500.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sa. ft.): 16378.56 Owner: PORTER GAIL L Zoning: Applicant. SEXTON ROOFING CO AT. 997 BURTS PIT RD Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 WC HOLYOKEMA01041 ISSUED ON.8/3/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 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: 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 8/3/2020 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner � The Commonwealth of Massachusetts FOR - ------ W, n Board of Building Regulations and Standards MUNICIPA�ITY Massachusetts State Building Code,-780 CMR,7°i edition USI; oReZidedJa uaOBuilding Permit ApplicatioTo Construct,Repair,Renovate Or Demolish a 0 w One-or Two-Family Dwelling 4 This Section For Official Use Only G o Date Applied: Building Permit N bW: o -3"ZOZ10 Signature. - o(" ' Building Commissioner/Inspector of Buildings Date w° SECTION I:SITE INFORMATION o 1.1 roperty dre s: Q J� Q j� I.2 Asses ors Map 8 Parcel Number. �-�-- ! I''/ IN l.la Is this an accepted street?yes no um er Parceumbe Map 1.4 Property Dimensions: 1.3 Zoning Information: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Rem-Yard ' � Front Yard Side Yards Required Provided Required Provided Required Provided c.40,§54) L7 Flood Zone Inform9tion: 1.8 Sewage Disposal System: 1.6 Water Supply: (M.G.L Zone: _ Outside Flood Zone? Municipal D On site disposal system ❑ Public❑ Private D CM4,if yesO SECTION 2: PROPERTY QWNT RSHIPr 2.4 Owner'of ecor ��'� o /� r ' Address for Service: Name(Print) S." Telephone Signature z SECTION 3t DESCRIPTION Or PROPOSED WOW(check all that 213Y) 1 Owner-Occupied Repairs(s) ❑ Alteration(s)'Q Addition D New Construction❑ Existing Building Demolition ❑ Accessory Bldg.❑ Numberof Units_ Other ❑ -Specify: Brief DeFeription of Proposed Work1: 0111 1� 01' ( l HCl- SECTION 4:ESTDI ATEA CONSTRUCTION COSTS. Estimated Costs: Official Use Only Item (Labor and Materials 1, Building Peirnit Fee:$ Indicate how fee is determined: 1.Building $ D Standard City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ List: 4.Mechanical (HVAC) $ 5.Mechwiical (Fire $ Total All Fee Suppression) � CheckNo. Ch�k,gmount: Cash Amount: 6. Total Project Cost: $ 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES fName onstruction Supeervisor License(CSL) �i 67 1144e�,e17f .J - j,tai ���1< 0/5Y' License Number hxpiration Date of CSLHolder _PO 6L)/,�• _ /7 List CSL Type(see below) r� 1. No.and Street , � / —-_-- IlUe Description l alb) � _1 W 0/0 yI Unrestricted(Buildin s u to 35,000 cu.fl:)Ctryjr State,Z1P // Restricted 1&2 Famil Dwelling M onry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Telephone Insulation Email address Demolition 5.2 Registered Home Improvement Contractor(RIC) \ ''`.�L &;.3 9X61�6/� ��`%6L �n�any Name or H HIC CHIC Registration Number Expiration Date Company egistrant Name TVe,Al�3.27 0 0 �7 _ / I , No.and Street /� 11,-)A.e h rn� %/ )y it address Cin,State,ZIP Telephone SECTION-6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G_L.G 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 .-.......:12�' No...........0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i J 1,as Owner of the subject property,hereby authorize l'ah(l �w",L/1Q and 1_/J to act on my behalf,in all matters relative to work authorized by this building-O!ermit application. Punt 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 plication is true and accurate to the best of my knowledge and understanding. — MUST BE SIGNED by Owner or Authorized Agent D— ateite NOTES: l. 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 1ti21 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 �ti�;��.mass.t*o� itca Information on the Construction Supervisor License can be found at,.xv A.mass.anvidps 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 DEPARTIMNT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 sfyjY- `�0 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: ,A lh lS-� The debris will be transported by: Name of Hauler: 4�jS 6u ja-4d P3 u, (J( N-� �/ PC-4� z } Signature of Applicant: z Date: 7 7-4—/Z4 Propagal SEXTON ROOFING AND SIDING INC. (413) 534-1234 Aft P.O. Box 6327 FAX (413) 5399906 ' Holyoke, MA 01041 sextonroofing@hotmaii.com CT HIC#0605383 MA HIC#118239 www.sextonroohng.com Since 1985 SUBMITTEDTO wI_ PHONE -�} �s DATE ; STREET JOB NAME CITY STATE ZIPCODE £6 Qt) A JOB LOCATION Proposal to furnish and install the following EMAIL iJ Re-Roof 3 Tear-Off �AowMain House ❑ Garage J Shed Complete Roof Preparation Hom � e exterior to be protected by tarps I ii-Shrubs,landscaping,trees to be protected �e F4a( Entire existing roofing material to be removed to existing decking,Including flashing,etc. Site to be cleaned everyday with roll magnet debris removed at project completion 91"bleteriorated existing decking replaced at$ per sheet ,�C /ll ewdecking/typed � 'r ��*�'C�Q if '��� i Xeres hitef$rown metal drip edge installed at eaves and rakes uIF F8 IJ F-5 iJ Rake Edge �'- / ew flashing will be installed where necessary(see Special Requirements) E Install new pipe boot flashing IJ Bathroom Exhaust Vent -E—Reflash chimney-with4vew-lead We shall acquire all appropriate permits etc.for all roofing work Complete Roofing System 9 Leak Barrier installed at all eaves to protect from ice dams(and meet codes in the north) ❑ 3' CA V Leak Barrier installed at valleys,around penetrations and chimneys to protect critical areas , , 40,4!` ''Install Roof Deck Underlayment on remainder of roof with Synthetic Felt Shingles J" IKO _j GAF -i CertainTeedU Tamko / �j 30 year J 50 year s"Lifetime Color 4 Install Attic ventilation system 0 "Cap over Ridge Vent ❑ Roof Louvers Warranty Options f" We guaranteed our workmanship for 15 full yearsf � e J)rapoa hereby to furnish material and labor-complete in accordance with the ap°ve specifications,for the sum of: % 4?^c dollars($ �Zy FAYIIENTTo eE WDEAS FOLLOWS �"� All Material is guaranteed to be as specified. All work to be completed in a workmanlike manner Authorized accordingtostandardpractices.Anyalterationordeviationtromabovespecificationsinvolvingextracosts will be without notice,and will become an extra charge over and above the estimate. Signature Not responsible for water damage or damage to the house during stripping of roof dur;ngconstruction. Note:This proposal may be Owner to pay responsible legal fees for non-payment and applicable interest of 1 h%per month. Withdrawn by us if n,#t af cepted within Zttfptati[C Of�CUp05Rl-The above prices,specifications and conditions Signature are satisfactory and are hereby accepted.You are authorized to do the work as specified.Payment will be made as out above. Date of Acceptance Signature ATTENTION HOMEOWNERS:Please cover all personal belongings in the attic,garage or storage areas due to the possibility of roofing debris or dust coming in through the cracks of the wood. Sexton Roofing and Siding will not be responsible for debris or dust in the attic or storage areas. t l tie uommonweaun of Massachusetts ,q 5 Department of IndustrialAccidents Office of Investigations Lafayette City Center r/ 2Avenue de Lafayette, Boston, MA 02111-1750 =� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Sexton Roofing &Siding, Inc Address:P.O. Box 6327 City/State/Zip:Holyoke, MA 01041 Phone#:413-534-1234 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition woiking for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10 3. Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Travelers Property CAS CO OF AM Policy#or Self-ins. Lic. #:7PJUBOG07898220 Expiration Date:6/4/21 Job Site Address: Piz a City/State/Zip: ✓ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for ance coverage verification. I do hereby certify under t)i ins and penalties ofperjury that the information provided ove is true and correct Signature: Date: 2� Z C) Phone#: 413-5341234 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): 1❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5alumbing Inspector 6.❑0ther Contact Person: Phone#: ACO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 06/09/2020 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 CONSTRUTE 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 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 NAME Kathi Hutchinson ORMSBY INSURANCE AGENCY P, NN (413)737-0300 a No Ate ; khutchinson@ormsbyins.com P O BOX 718 INSURER(S)AFFORDING COVERAGE NAIC# WEST SPRINGFIELD MA 01090 INSURERA: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B: SEXTON ROOFING&SIDING INC INSURER C: INSURER D: PO BOX 6327 INSURER E: HOLYOKE MA 01041 INSURER F: COVERAGES CERTIFICATE NUMBER: 541733 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- 'N'R LAIMS. ILTR TYPE OF INSURANCE FNSD ADDLJWVD�� POLICYHUMBER MlEms- MMIOCY i- UMnS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ AMAO RENTED CLAIMS-MADE OCCUR PDREMISGE ES Ea occurrence) E MED-EXP(Any one person) E N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE b POLICY❑JET LOC PRODUCTS-COMP/OPAGG $ + OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea acrid ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS amdent)N/A BODILY INJURY(Per adent S NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Pet acddent S S UMBRELLA LIAB [d OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTIONS S WORKERS COMPENSATION X STATUTE EOTH- R AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETORIPARTNER/EXECUTTVENIA EL EACH ACCIDENT S 1,000,000 A OFFICER/MEMBEREXCLUDED? NIA WA 7PJUBOG07898220 06104/2020 06/04/2021 (Mandatory in NH) EL DISEASE-EA BAPLOYEE $ 1,000,000 Ifns,describe under OESCRIPTIONOFOPERATIONS below EL DISEASE-POLICY LIMIT S 1,000,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Scheduke,may be attached if more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only_Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/iinvesfigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR®REPRESENTATIVE Amherst MA 01002 D' 1 Daniel M.Cr nr y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD SEXTO-2 op in, CERTIFICATE OF LIABILITY INSURANCE °°0711 G19 n7�1a2o1s �;' 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, ECiEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW_ THIS CERTIRCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURIER(S), AUTHOR® REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER- IMPORTANT- OLDERIMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the poficy(ies)must have ADDITIONAL INSURED provisions or tie endorsed- If ndorsedif SUBROGATION IS WANED,subject to the Yemen 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 413-737-0300 E?m Eric Dembtnske Ormsby Insurance Agency,Inc PHONEE 413-737-0300 f�No)- West e�413-737-0617 698 Westfield St PO Box 718 W 0Springfield,MA 01090 A UL etn Ins nns ylns,com NSURERM AFFORDING COVERAGE NA1C-9 INzuRERA Colony Insurance Go. Seas ton Roofing S Siding,Inc, ,U,,,,-Quincy Mutual Fire Insurance 15067 PO Box 6327 INSUR82 C_ Holyoke,MA 01041 INSURER D: 94SUREi E 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,TERFA 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 TYPEOFILSURAHCE 151im POLICY NUMBER ��-JEFF POLICY EAP A X couuERC1ALGENERALuamu r EACH OCCURRENCE S 1,000,000 CLAM&-MADE ❑X OCCUR101GL0021599(13 06/25t2019�06/2012t12D °A""A�TOR5 F��� 5 100,000 y If MIDDY tAryr ane S 5,D00 PERSONAL a ADV INJURY S 1,000,000 GENt AGGREGATE LIMIT APPLIES PEZ ( GENERAL AGGREGATE S 2,000,000 POLICY E]JECT LOC I PRODUCTS-COLIPIOPAGG S 2,000,000 OTHER= I s B AU ONOBILELIABTLrrY I ( INEfS SINGLE LIMIT S 1 i ANYAU O 80DILY PLIURY S OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY erarSd 5 FpR� PROPERTY DAMAGE X AUTOS ONLY X ALTOS ONLY _---- S UMBRELLA e LIAB OCCUR I EACH OCCURRENCE S EXCESS LIAB CLAW&MADE ' I A13XIREGATE S DED I RETENTIONS ; S WORKERS COMPENSAWON I ' I PEZ OTH- AND EMPLOYERS'LUU38J Y A � Y r N 1 BE SENT SEPERATI3Y ANY PROPRI R/PACUSC 1E7CECUTNE ❑ NIA A i 7 EL EACH ACCIDENT 5 1CFFICERI&UDJGER` FJ�LUIIt� -ory Ini NIH) i EL DISEASE-EA EMPLOYEE 5 Ifye3, [vides - DESCRfPT10N OF OPERATIONS below I EL DISEASE-POLICY LIMIT S DESCRIRRON OF OPERATIONS 1 LOCA=NS 1 VE}nCLES(ACORD 101,Addl meal Remarks Schedide,maybe attached a mole space is requhied) CERTIFICATE HOLDER CANCELLATION NONE-01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE YPLL BE DELIVERED IN Everett Sextan ACCORDANCE WITH THE POLICY PROVISIONS_ - AUTHORIZED REPRESENiATWE ACORD 25(201&03) O 1988-2015 ACORD CORPORATION- All rights reserved_ The ACORD name and logo am registered narks of ACORD The Comrnonwettlih of Massachusetts _ Department of Industrial Accidents �j I Congress Stree4 Suite 100 Boston,M,4 02114-2017 c' = www_mas govldZa V-j iters'Compensation Inmrsnre Affidavit:Bntitders/Contractors/ElectriC=r--JPlumbem TO BE FILED RTIH THE PER-NWrMNG AV,MO ITY- -Apa is nt Information l P-teasc lomat Ie-M-bh', Name(Bu5-nes,`ort,aniza-on rnd vidual)_ / �1) Address. .s, 1{,�anc. +CittilStater'Zip_ W\,iY-1- XA A Cl i 7S7 Phone 4 _irt vov an emplmee Check the appropriate box: } T e 3T Of project(required): '. I am aemplovcrwith anplavees(fn i nndlorpctrt lime).: , —— ! 7_ New construction _ 2-Q I am a sole pmpnercr orparmer_,aupand leve no croploizcs x-Miing forme in s Remodeling i _ Q ling ; MY crpacrty.lNo workcrs'comptrsc¢arce required] F l } j ' 9. ❑Demolition f 3❑I am a 6omcownQdnrxtall(soils mvsdf[NotimrLas'coal_nma�tttegnszd]' I �i� m ` iii 10 Q Building addition -1 Ell l aa homtowncrand mil Ile�cork ict=to corduCt all-vi iic On my propertyI will msurethatallconirttorsedwrh�ruariers wrape>u3tioaa,am.,r�ur=csok- ! II E]Electrical repairs or additions } propnctors with noImxcs � � 12-[]Plumbing repairs or additions � 5 Q I am a gcra-l mrd actaemid i have hired the sob-rnnvciors listed on the ausched sheat 13.Q RoofuteFsairs Tncsesnb�ire��astrnshssccmpioSxrsandhave.� iam� s'caffLp. +n=,- (] j fi.❑�Vc are a cozporatnn and ids offrcas havc i�ercisrd their nght of memptian per MGL� I �� I�. 15'_§I(4),and ire l--s-e no employrc:-(No ernrl ens'comp,irswtnce requut d-I *Am applicmtthat checks box x I must also FLU out the=coon below sl�%ing dreir u=k='cumpcn=t m p dic7 mformaucm- t who submit this af5d2ru nxibcahngthcy zme doing all saml:mrd d,ert hat outside contrsctaa must stibunt a cess aff do it odtatting such :Cori(- o that ch,-:l this box must amche3 an addilaya l sbrzt shmving the name of the sub-canuaciorsad stac aihnccror not those cnbties ha%e rmplo;Ccs. If the sub-cn„ttracto•.shaVrctipbcees,tncvmistProvide their warkets'cvtnp.Policy number_ I aux an earrpioper that is providing workers'corapensadon iasuruncefor nzy emmpinyres. Below is the polieT and job site inform diox Insurance Company Name: S Policy T or Self-iris.Lim Expiration Date: i 3ob Site Address: CityfState/zip: Attach a copy of the porkers'compensation Policy declaration page(showing the policy number and expiration date)- Failure to sere coverage as required under MGL c.I5y§25A is a criminal violation punishable by a fine tip to S 11500-00 and/or one-year imprisonrncrtt,as well as civil penalties in the form of a STOP WORK ORDFR and a fine of up to V-50.00 a dad-against the violator_A copy of his statement may be forwzrded to the Office of Imestigations of the DIA for insurance coverage verification- I do hereby certify under the pairs and penalties of pts that the iaforrrzmfion provided above is"e gird correct -. 5iarin� JLF i lGt �Y�f L I/Lr`'�` �i� Date- 60k/_12 G ' Phone Ficial ase only- Ito not write in this area,to he completed by dz v or toren o iciaL City or Town: Permit/License ff Issuing Authority(wile one): L Board of Health Z_Building Department 3.City/Town Clerk 4.Electrical Inspector 5-Plumbing Inspector 6-Other Contact Person: Phone-I- ACOR,p® CERTIFICATE OF LIA131LITY INSURANCE DATE(MWDD^� THIS CERnFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CO 11/27/2019 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS $FLOW_ THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTEq�DRqALTER J B �E COVERAGE AFFORDED BY THE POLICIES REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. BETWEEN THE ISSUING INSURER(S), AUTHORIZED IMPORTANT: If the certificate holder is an AD the terms and conditions ofthe i ADDITIONAL INSURED,the PolicYGes)must be endorsed If SUBR�O.yG�ATION IS WANED,subject to certificate holder in Leu of ry'certain pOGcies may require an endorsement A statement On this certiircate PRODUCER SIICh erldOr52rnent(S). does not confer rights to the ONE FAMILY INSURANCE AGENCY LLC PNAAFE Art I Calvdlo No ExM (978)403$942 FA2 No- 1 Main St Suite 15 Aoo,z _- aC2lv;fl0128j hoo_Com LUnenburg 1NSU AFF-- -COVERAGE NAIC 0 INSURED MA 01452 INSiRH2A: HARTFORD UNDERWRITERS INS CO MNP CONSTRUCTION INC INsuRER a= 30104 INSURER C: 45 EXCHANGE ST APT 3E INSURERD: MILFORD INSURER E: COVERAGES MA 01757 RNSURERF- CERTIFICATE NUMBER_ 478475 THIS IS TO CERTIFY THAT THE POLICIES OF ItVSL1RANCE USTID BELOW HAVE B::: ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED- N REVISION NUMBER OD CONDTANDING ANY REQUIR1311E1,T� TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMEDJ CER ATE MAY gE ISSUER OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUS[ONSAND CONDtT10NS OF SUCH POLICIES UMTTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ��RESPECT TO WHICH THIS INSR LTR TYPE OFINSURANCE ADDU rN$pi POLICYNUR(eER POLrCY EFF I POUCY E)W COdMERCIALGENERALLIABILITY j UISp7'S 1 I CLANS-MADE ❑OCCUR I � EACH OCCURRENCE S DAMA TO RHYTED PREMISES omnm -S i NIA MED EXP(Airy ane person) S GEN'LAGGREGLWT PERSONAL&ADVINJURy S pODCY PR0. T�— f JECT l—J LOC IF>ZALAGCRECATE ; OTI-�t (I PRODUCTS-COMP/0PAGG S AUTOMOBILELIAB7IITY 1 I s ------i--- ANYAUro i COMBINED 5WGLE U+RT ALLS N�m SCHEDULED + wA j BODILY INJURY(Pc pe<sm) S HIREDAUrOSAUTOS orN4AUTOS m j �11 BODILY INJURY(Per a¢idenr) S _---.----- -- lij PROPERTY DAMAGE S UNMRIE 1 A UAg OCCUR EXCESS LLAS CLAIMS-MADE I MAL1 EACH OCCURRENCE S DED T RETENTION S - I f AGGREGATE S WORKERS PENSATION I —— ——— ----- -- -- AND>3rPLDYE];ET HILTIY 1 Xi PER OTT-4- S YIN i i STATUTE ER A �OEFIC�RI6AENYPR 6l��E�UnVE (NaadaGary in NH) NIA NIA NIA 6S60UB11Q0970619 - 11/16/201911/162020 F-LEACHACCit IDENT S 1,OOD,D00 OE CR O O F PERA-nGNSbe1m,es, uTxlerI jjj EL DISEASE-EA II $ 1,000,000 ( f EL OISEASE-pou—,-qT S 1,000,000 NIA DEScRaImAr OPERATIONS/LOCATIONS I V ER CL.ES(ACORD 1Rr,AddTffon-I Remad=S.N dWe,may be armed r7more Workers'Compensation benefits will be paid to Massachusetts em SPC.i5_qv�) claims for benefits to employees in states other than Massachusetts only_Pursuant to Endorsement WC 20 03 06 B,rro autho tion given to pay assachuseUs if the inlred hires or has hired those employes outside of Massachusetts.. This certificate of insurance shows the policy in forte on the date that this certificate was issued(unless thecy _ issue date of this certificate of insurance)_ The status of this coverage Can be monitored dal b a e>�Irati°n date On the above oli Search tool at wwwmass.govltwdMrOrkers-compensatiDrYnvestga TY y accessing the PmOf Of Coverage-Coverage Verification des e tion-:J- CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POIJGIES BE CpNCEI T Fn BEFORE SEXTON ROOFING SIDING INC THE �P1RPiON nATE THEREDF, NOTICE "'TTtL BE DELIVERED IN ACCORDANCE WtTt T THE POLICY PRp IIS1CIN5- 102 PINE ST AUTHORQ DREARESENTATNE HOLYOI� - - C- MA 01041w LL' Daniel M.CTow1y,CPCU,Vice President-Residual Market-WCRIBMA ACORD 25(2014101) ©1988-2014 ACORD CORPORATION_ All rights reserved The Al name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DA�`I�I�no�.Y' 11127,19 ` THIS CERTIFICATE IS ISSUED ASA 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 policy(ies)must have ADDITIONAL INSURED provisions or be endorsed- If ndorsedIf SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statanent on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s)- PRODUCER CONTACT NAME Aft Calvillo One Fatmly Insurance PACO N 978-403-5942 FAX No- 978403•-5943 1 Main SL Suite 13 E+ARIL Lunenburg,MA 01462 AODREss- arf@lfamRyinsurance-com INSURT M(S)AFFORDING COVERAGE NAIL S wsuRERA= Evanston Insurance Company INSURED INSURERS: MNP CONSTRUCTION,INC. INSURER C- 45 EXCHANGE ST APT 3E MILFORD,MA 01757 INSURER INSURER E_ INSURER F COVERAGES CERTIFICATE NUMBER REVISION NUMBER THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE USTFD BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIRBAENT,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 POUCIES DESCRIBED HEREIN IS SUBJECTTO ALLTHETERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES_LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ POLJ Y EFF POLICY EXP LTR TYPEOFINSURANCE INSD MND POLICY NUMBER wO LIMITS X COMMERCIAT GENERA LIAIDLTrY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE OCCUR PR6dI5E5 -g S 100,000 MM EXP One er5w) 5 5,000 A Y Y 3E-T9385 11/03!19 11103MO PERSONAL E ADV INJURY S 1,000,000 G-1VLAGGREGATE LIMIT APPLIES PET- GENERAL AGGREGATE S 2,000,000 POLICY❑JT n LOC PRODUCTS-COMPJCP AGG $ 2,000,000 OTHER: S AUTOMOBILE I IA6RITY COMHWdEmD 5AK3E LDAIT $ ANY AUTO BODILY INJURY(Perpersun) S AUTOSAUTOSSCHEDUI.ED BODILYffQURY(Psa�L) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY amdeni S UMBRELLA LLA13OCCUR EACH OCCURRENCE $ EXCESS LIAE HCLANS4AADE - AGGREGATE S DED I I RETENTIONS S WORKERS COMPENSATION LISTATUTE ER AND OWPLOYERT ASILnY Y I N ANY PROPRIETORIFARTM5R/EX�UTIVE❑ NIA E-EACH ACCIDENT S CF,10ERJFE&1EER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYEE S !lyes,destnbe tender DESCRIPTION OF OPERATIONS below IE1 DESEASE-POLICY LIMIT S DESCRIPTION OF OPERATION51 LOCATIONS I VEE=LES(ACORD 101,Adddlonal Renu*--ScAe4ule,t8y be altacbed if more space E regrmed) N CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUGIES BE CANCELLED BEFORE THE EXPIRATION DATETHEREOF,NOTICE WILL BE DELIVERED IN SEXTON ROOFING&SIDING INC ACCORDANCE WITH THE POLICY PROVISIONS. 102PINE ST P_O_BOX 6327 AUTHORIZED TZ7PRES@ TATIVE HOLYOKE,MA 01040 ART CALVILLO ©1988-2015 ACORD CORPORATION- All rights reserved- ACORD eservedACORD 25(20161(13) The ACORD name and logo are registered marks of ACORD office and f{ !� Business Regulaffon Boson_ � � Home ` � ag — �r-- ETT T SE$ a -g CT OR Hog-CV ?� &S� ._ = ZtG CO SC 0605383 SIGN 11/30/2020 ' Commonwean &,M"aches i Division of P alts rafessTona!licer� - Board of EI-TCU-9 Regulations and Stz,ndardS Canslructio � sRr Specialty CSSL-099689 ' 1;7cpires=1:0/051202-1 EVERE- r J S.EXro11k: ,-,g- f HOLYOKE _ 1 - Commissioner