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36-141 (2)
BP-2022-1216 286 BROOKSIDE CIR COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 36-141-001 CITY OF NORTHAMPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-1216 PERMISSIONIS HEREBY GRANTE I TO: Project# ROOF Contractor: License: Est. Cost: 7437 RHINO BACK ROOFING LLC 106183 Const.Class: Exp.Date:05/26/2023 Use Group: Owner: A JOHNSON RICHARD E& SHIRLEY Lot Size (sq.ft.) Zoning: URA Applicant: RHINO BACK ROOFING LLC Applicant Address Phone: Insurance: 532 HOPMEADOW ST STE 4 860-438-6158 6S62UB-2E33572 SIMSBURY, CT 06070 ISSUED ON:09/26/2022 TO PERFORM THE FOLLOWING WORK: STRIP AND RE-SHINGLE 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 VIOL TION OF ANY OF ITS RULES AND REGULATIONS. Signature: 3-'! • Fees Paid: $40.00 2 l2 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner /'--- , Cp, - The Commonwealth of Massachusetts/ /nOt ' ,' Board of Building Regulations and Standards' 0ep Massachusetts State Building Code, 7,00 CMR. �� 7CIPIITY 'nj"Building Permit Application To Construct,Repair,Renovate Or IenLolish a d011 One- or Two-Family Dwelling ..,c This Section For Official Use Only 1 c%-/%, / Building Permit Number: 6(9 •71- j M(j Date Applied: VE-VIO , / (4. 26'zoZz Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Proper Address: 1 1.2 Assessors Map&Parcel Numbers .g?� f6r)0I( Sirk- CG1 .1 r p `7 I 1.1a Is this an accepted street?yes 7 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 i 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❑ Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2. O ner'off Recordd: 1 f r-i ala ra ,A o h n S o n O r 1Y1 tt_.im,ptOYl YYl A O l d(a 02_ Name(Print) City,State,ZIP a127c0 grnoksid,?_- Circle, 141:3 -6ai--limo 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 Id Specify: pot-i(1 Brief Description of Proposed Work2: V Q.MDAj& -ex S-kin 'roD Shi liStrytre re_uji 1 SCI.tarf_ 04) OffCi fCC 1Lr� 0 ' ha + S h i�lc bwi n C D Q- ar\c r,n • Ve own n en l60S_an*-kiI iC and Loa_ o + L) allal M'` �l�l vn M ei-t,.b cane, -rzi p' a'(l dl a cG( �S e e rns Q (vt , 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 Cost (Item 6)x multiplier _x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:,j `(l l Check No.(,l Check Amount:[ Cash Cash Amount: 6.Total Project Cost: $ 1i ,] 3.-- 0 Paid in Full 0 Outstanding Balance Due: City of Northampton ?43 , c Massachusetts ��S�s `� ' TT W. DEPARTMENT OF BUILDING INSPECTIONS \ai.Y,�1y 212 Main Street • Municipal Building 0.• Cam- Northampton, MA 01060 PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW 1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES, FENCES, GROUND MOUNTED SOLAR, ETC. I. 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. Site plan with location of proposed structure(s) and set backs. 4. Construction Debris Affidavit filled out and signed by applicant. 5. Worker's Compensation Insurance Affidavit filled out and signed by applicant. 6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance. 7. Energy Conservation Compliance Certificate (new/ replacement windows). 8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable). 9. Note any Conservation and/or special permit requirements (if applicable). 10. Driveway Permit (if applicable). 11. Proof of Water and Sewer entry fees paid (if applicable). 12. Trench Permit - public land by DPW / private land by Building Dept. 13. Stretch Energy Code - all new construction will require a HERS Rater Affidavit to be submitted with permit application before issuance of permit. 14. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton. L w SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) t (As, 13 3 T;ni License Number Expiration D e Name of CSL Holder �-1'1 d I l l�0 0 Q�(. List CSL Type(see below) C.S S L epp n k No. and Street r- Type Description JL��to f� 0 rp U U Unrestricted(Buildings up to 35,000 Cu.ft.) el , J 1-� R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry w_S c^S L 11D19 I t (kbj Roofing Covering C WS Window and Siding SF Solid Fuel Burning Appliances OGO-SIB—0131 mn 61410•6 t/Piatkii I Insulation Telephone Email address CO D Demolition 5.2 Registered Home Improvement Contractor(HIC) I 416 Dc? Daly( C.- 1l) QCl(t g co.ci Ay. , Lk-C. • HIC Registration Number Expiration Date HIC Cos'••'y Name or IIIC RegisName t_ 5302 .r MCLI U� �$�- l tilt*. 4 f e r w i i S L.rhl l op r)Uc l rot ► J. e 0�l ND.and Street Email address itrtSbttrq CT otoY-d 8loc�- 38-�is� City/Town,S te,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 Issuannce of the building permit. Signed Affidavit Attached? Yes 52' No ❑ 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 no Qack eo L-�—C to act on my behalf,in all matters relative to work authorized by this building permit applicagion. (Z�chcirot hnson glaa ja a, Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. caradh it'rd i di A.Cen1 a 9I.2 a1 a a, Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths _ Type of heating system Number of decks/porches Type of coolingsystem Enclosed Open YP Ys _ 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE . The Commonwealth of Massachusetts kir'-;�__-�1 Department of Industrial Accidents " l Congress Street,Suite I00 �IL,` : Boston. '►f.-1 02114-2017 t . • tvw tr.ntass.govidia 41 to kers' ( ompt�USA tiun Insurance.UITtdat,it: BuilderslC:ontractorxiElectricians Iiuinhers. it) lil•-1 I I.k.1)Si I 1"H I III.P!•:RMIITING AIJTNOlK111. .kpplicain Information (n1, Please Print l.e_ibls Name(dusincss.Organtzationandividual): I�' no 'sack- �09A � -r._• . ._ Address: 6'39. S1-1 cgi r CT0 0`-f'U �D��fY1eL(c�vl.0 �.� � MS y� City/State/Zip: S irA,S19lArtii CT O1D0 W Phone#: 8 tot)" 4 38" (o l 6 8 Are you an enipluyer?('peek the apprttp We boa: Type of project(requi red): 1.Q 1 ant a employer with employees(full antlor part-time).* 7. 0 New construction 2ln t am a wile proprietor or partnership and have no employees wurkuny fur me in B. Q Remodeling story capacity.[Nu workers'comp.msuranz n-yuinaL] .30I ant a humuownet duint all work myself.[No wurltiaa. com p,nixle ui urce regional.] 9. ❑ Demolition 4.0 lam a'wimpy,net and w ill be hiring evntracturs to conduct all work on my property- I will 100 Building addition ensure that all contr"actun either!tame workers"campers abut insurance or an wile 110 Electrical repairs or additions prupnetors with nu employees_ 12.0 Plumbing repairs or additions 5/Yam a general contractor and 1 lase hired the lib-contractors listed un the attached sheet. These sub-contractors have employees and has a workers'comp.insurance.- 13 f repairs 6.0 we an:a corporation and its officers have exercised then right of exemptionper ltKiL C. 1 4 0 Otllet 152.i 1t 4).and we have no employees.[Nu workers'comp.insurance required.] *Any applicant that chocks lox a 1 must also fill out the section below showing their workers'compensation policy information- +Homeowners who submit this atiulav it utdicutnst they arc doing all work and then hue outside contractors must subnut a new affidav it indilatmg such. iCuntntcturs that check this box must attaehed an additional shoat showing the name of the sub-contractors and state whether or nut those tannic.hale employee, If the sub-contractors has employ ces.they must pros ide their workers-comp.policy number. I cm an employer that is providing workers'compensation insurance.far my employees. Below is the policy and job site information. roe Insurance Company Name: JJ p Pro�r l 1.tS0.Q �� SsLC. .,.V t�-- — Policy#or Self-ins.Lic.#: Ni U)C — 100—( ()a 4 a R 5- a 04: ,c2A• Expiration Date: 0 f3 I ai I a D a 3 Job Site Address: 07 SL9 &'DOVS)(IL U rtVe-- City/Statei Zip: Not-Oloitpion, mil o 1 w&o a, Attach a copy of the workers'compensation policy declaration page(showing the polici number and exp ration date). Failure to secure coverage as required under MGL c. 152, *25A is a criminal violation punishable by a tine up to Sl 500.00 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 4.1f this statement may be tin-warded to the Office of Investigations of the DIA f r insurance coverage verification. I do hereby certif•wider the pain.%and peoulties of perjury that the information provided uboi a is true and correct. ytm.ttt:: G (�. �� Dale: ?1942-1-Ra% 1 Pbt)nti : 66710 -' 113,8 10I5-6 Officid list'Wily. Do not write in this area.to be completed by cite'or town official ('it% or"]-own: PerniitlLicense A Issuing Authority Icircic one): I. Board of Health 2. Buildin4 Department 3.City(limn Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: City of Northampton Massachusetts ��? tiV): DEPARTMENT OF BUILDING INSPECTIONS 7: r4 `\.��; � 212 Main Street • Municipal Building sJ'•., Cam 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: (' ')L, kn Si-- ‘ tfoI - i m A DI Dy b The debris will be transported by: Name of Hauler: OCI-Saia- Signature of Applicant: t,,'Iq,k_, airi,J.„ Date: aa- 09/13/2022 w BA- Rhino-Back Roofing Claim Information RHINO DN �'■■ 532 Hopmeadow Street Bunker Hill ROOFING Suite 4 Claim Nun)ber:357502151875 Simsbury CT 06070 John Jarzabski Phone:860-217-1424 (857)443-5807 jjarzabskif plymouthrock.com Richard Johnson Job: Richard Johnson 286 Brookside Circle Northampton, MA 01062 (413)627-9606 Full Main House Roof Replacement Acquire Building Permit as Needed Dumpster- 12 Yard-Approx. 2 tons of Debris Remove,Tear Off, Haul and Dispose of Shingles-Laminated or Equivalent up to 2 layers tear off included at no additional charge.Additional layers will be charged at$.31 per square ft per layer 2 layers Inspect, Prep and Repair All Sheathing. Re-Nail Loose Decking. Install 4"wide strips of polymer-modified-bitumen membrane on all roof decking seams. Sheathing Rot Replacement As Needed At An Additional Charge Of$98.00 Per 4x8 ft Sheet/$9 per board ft. Using high quality CDX 4ply plywood.We never use low grade OSB pressboard for structural roof sheathing R&R Flashing- Pipe jack-3"-4"-black 1 Pipe Boots Replace Ice&water shield »Owens Corning »Weatherlock Matte 6 feet(2 full rolls)up from all eaves.Also to be applied in all valleys,all low pitch planes,around bases of skylights and chimneys,and other high risk areas Replace Synthetic Underlayment»Owens Corning>>ProArmor Non-Water Absorbant ACM Aluminum Drip Edge-F8 1 1/2"(10') Replace Starter Shingles»Owens Corning»Starter Strip Plus Shingles(1000LF/BD) Replace Shingle-Laminated-Standard»Owens Corning>> Duration TruDef>>Color TBD Replace Ridge cap-dimensional shingles»Owens Corning>>ProEdge>>Color TBD R&R Chimney flashing-small Complete re-lead Warranty-Owens Corning backed lifetime Shingles Defect Warranty.15 years Workmanship through Rhino-Back Roofing. Terms 1 By signing this proposal the Customer agrees to,and accepts the terms and conditions here in,including but not limited to the"Scope Of Work"and"Payment Terms",and authorizes the the work to be done by Rhino-Back Roofing(CT reg#0641824). If"Payment Terms" are not met a service fee of 1%per month(12%APR)will be applied to any overdue amounts.The Customer shall also pay all costs of collections including, but not limited to, reasonable attorney fees on overdue payments.This agreement will be officially entered into on the date of the signing of this proposal by the Customer.The Customer also grants RhinoBack Roofing permission to use photos and reviews in print and digital marketing. 2 Rhino-Back Roofing, upon notification to,and authorization from,the Customer, may make changes to the"Scope Of Work"due to the Customers'request for additional work,or unforeseen conditions that existed, but were not detectable by visual inspection prior to the project start.Any such"Change Order"will first be authorized in writing,or by email, by the Customer prior to any additional work being done.The Customer agrees to pay any increase in cost to the project as a result of authorized"Change Order"(s). (As an example, rotted sheathing replacement would fall into the"change order"category.)Additional work will be billed in a separate invoice. 3 Pricing may increase due to additional items billed to the insurance company with no out-of-pocket cost to the homeowner. (As an example, permit costs are billed to the insurance company after job completion).All additional supplements will be billed and due following project completion and after the homeowner has received the additional funds of the supplement from the insurance carrier. Payment Payment 1: 1/3 of total contract price due upon authorization of project $2478.85 Payment 2: Due upon start of project after material delivery(Balance of ACV+Deductible) $2223.24 Payment 3: Balance due upon substantial completion of project(Depreciation, Building permit, PWI's Supplements) TOTAL $7,436.56 ACCEPTANCE OF PROPOSAL: By signing this proposal the Customer agrees to,and accepts the terms and conditions here in,including but not limited to the"Scope Of Work"and"Payment Terms",and authorizes the the work to be done by Rhino-Back Roofing(CT reg#0641624). If"Payment Terms"are not met a service fee of 1%per month(12%APR)will be applied to any overdue amounts.The Customer shall also pay all costs of collections including,but not limited to, reasonable attorney fees on overdue payments.This agreement will be officially entered into on the date of the signing of this proposal by the Customer.The Customer also grants RhinoBack Roofing permission to use photos and reviews in print and digital marketing. You the buyer may cancel this transaction at any time prior to midnight on the third business day after the date of this transaction,which is on or before ( )Saturday is considered a business day in Connecticut. See the attached Customer's Right to Cancel for an explanation pf this right. CHANGE ORDERS AND ADDITIONAL WORK: Rhino-Back Roofing,upon notification to,and authorization from,the Customer,maylmake changes to the"Scope Of Work"due to the Customers's request for additional work,or unforeseen conditions that existed,but were not detectable by visual inspection prior to the project start.Any such"Change Order"will first be authorized in writing,or by email, by the Customer prior to any additional work being done. The Customer agrees to pay any increase in cost to the project as a result of authorized"Change Order"(s).(As an example, rotted sheathing replacement would fall into the"change order"category.) e-Signed by Melanie Stachowicz 09/13/2022 Company Authorized Signature Date e-Signed by Richard Johnson 09/13/2022 Customer Signature Date Customer Signature Date Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC Registration: 196409 RHINO-BACK ROOFING, LLC Expiration: 08/11/2023 532 HOPMEADOW ST SUITE 4 SIMSBURY, CT 06070 Update Address and Return Card. Office of Consumer Affairs &Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE: LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 196409 08/11/2023 1000 Washington Street - Suite 710 RHINO-BACK ROOFING, LLC Boston, MA 02118 MICHAEL TROUERN-TREND 532 HOPMEADOW ST a,(/(ede-4,- SUITE 4 Not valid without signature SIMSBURY, CT 06070 Undersecretary /'1 RHINBAC-01 ELENACHURCHILL ,4c0/2a CERTIFICATE OF LIABILITY INSURANCE DATE{M 4.,......---- CERTIFICATE 2 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 CONTACT Mareigh Moon NFP Property&Casualty Services,Inc. NAME:N 100 Great Meadow Road (A//C,No,Ext):(562)215-2767 (A/FAX No): Suite 705 E-MAILDESS:mareigh.moon@nfp.com Wethersfield,CT 06109 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:The Cincinnati Specialty Underwriters Insurance Co 13037 INSURED INSURER B:Arbella Protection Insurance Company I 41360 Rhino Back Roofing LLC INSURER C:The Cincinnati Casualty Company 28665 532 Hopmeadow St Suite 4 INSURER D:ACE American Insurance Company I 22667 Simsbury,CT 06070 INSURER E:Associated Industries of Massachusetts Mutual Insurance Compan 33758 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 ADDL SUBR POLICY EFF POLICY EXP LT[_, TYPE OF INSURANCE INSD lAVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR CSU0117828 7/15/2022 7/15/2023 DAMA SESO(Ea occu ence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PEA LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Employee Benefi $ 1,000,000 B AUTOMOBILE LIABILITY COMBINED accdentSINGLE LIMIT) $ 1,000,000 X ANY AUTO 1020118135 01 7/15/2022 7/15/2023 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY {Per accident) $ $ C UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 X EXCESS LIAR CLAIMS-MADE CSU0163811 7/15/2022 7/15/2023 AGGREGATE $ 1,000,000 DED RETENTIONS $ D WORKERS COMPENSATION X SEATUTE EOTH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 6S62U B-2E33572-5-22 7/15/2022 7/15/2023 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? Y N/A 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT_$ E Workers'Compensatio VWC-100-6024295-2022A 8/29/2022 8/29/2023 Employers'Liab. 1,000,000 i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) General Certificate of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Rhino Back Roofing,LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 532 Hopmeadow St,Suite 4 Simsbury,CT 06070 AUTHORIZED /REPRESENTATIVEjSj�( ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD