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15-010 (2)
BP-2023-0869 392 CHESTERFIELD RD COMMONWEALTH OF ASSACHUSETTS Map:Block:Lot: 15-010-001 CITY OF NORTH MPTON Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2023-0869 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2023 Contractor: License: Est. Cost: 14500 DICKY MATOS 105917 Const.Class: Exp.Date: 03/30/20 4 Use Group: Owner: RE OLDS TIMOTHY G& RACHEL A MAIORE Lot Size (sq.ft.) Zoning: WSP Applicant: DICK MATOS Applicant Address Phone: Insurance: 23 HADLEY MILL RD (413)530-5335 6S624B6R37184722 HOLYOKE, MA 01040 ISSUED ON: 07/03/2023 TO PERFORM THE FOLLOWING WORK: STRIP AND REROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: �� YJ( Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: ( 13)587-1272 Office of the Building Commissio er ,(511,....., 1(6m J .,,,-- — RECEIVED r' j---,c,L-..:; ; g, The Commonwealth of Massachusetts // 414r - 5 r JUL - 3 2023 B3ard of Building Regulations and Stat/darda IC PRALITY M ssaciusetts State Building Code, 780 C1�I �naFot,� 1 PSI USE ' PT OF ��. ncorkPpli�ation To Construct, Repair,Renovate Or i-niolis '-1, ti sed Mar 2011 One-or Two-Family Dwelling _ This ction For Official Use Only Building Permit Number: 60",•01.3'' 9 D to A lied: �C We°c� e 7.3ZoZ3 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Prokerty Addreess j 1.2 Assessors Map& Parcel Numbers 1.1a Is this an accepted street?- yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public kZone: _ Outside Flood Zone?Private 0 Municipal On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Leo W kWkonl No ompj0,/1 1 liT)Icl (Di 0 Name(Print) City,State,ZIP 3c a c} 1--(e\c` Oct 412-24o-(410- admin@ rnu . uS No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building/( Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition. 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: Q.(Y)O . e.. \3\lt^c► shvAlo-S (kw\ -1/40 c1.Q(L, 9.2 0q\\ a \5�. 0 00a- xr ll �Xo JJ5 co Ct d we c 51�1e.1d, a1W �.,�.1.er 1 kr>Al. zoWdel a h� 51-hf e I, SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1 LI spo (p 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Appl cation Fee 2.Electrical $ ' ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Flip (� tJ4 Check No. '�G Check Amount:_L�!! Cash Amount: 6. Total Project Cost: y�(� . 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS— Iq 1-1 a�a?y Ci M S License Number Expiration Date Name of Holder C2 2 ��`� M'i11 Ra List CSL Type(see below) No.and Street �, Type Description 1 I V C_ m 0 (� U Unrestricted(Buildings up to 35,000 Cu.ft.) CO N 1 `iv R Restricted 1&2 Family Dwelling City/Tow State,ZIP M Masonry RC Roofing Covering WS , Window and Siding SF Solid Fuel Burning Appliances CI 13-530-5a3.5 1 n-�0Qcdm r\0C . 0 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ' qg y t, a 01(A 03 HIC Registration Number Expiration ate HIC Co y Name or HIC a trait Name (Q3 ad1e.L. M\\� ink® 6mc\r\c, °col No.and Street Email address 1( - omA olouo Q13-530 6335 City/Thwn,State,ZIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDgVIT(M.G.L.c. 152. § 25C(6)) l 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 .0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By enter'. I my e below,I hereby attest under the pains and penalties of perjury that all of the information conta' ed in this a.pli • ;. is tr - . . : c • - o the best of my knowledge and understanding. </a7aoa.3 Pri or Authorized Agent's Name AO 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 cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton off,"� -w. s..+..:..si 1A' - Massachusetts � f . ••., j . ' �'- ki • C. a w? w ;% 4<it` i t ,•;f d. DEPARTMENT OF BUILDING INSPECTIONS 0: j; : ' 212 Main Street • Municipal Building vb,• _Ca ry _ Northampton, MA 01060 'r•�'`yti,..• �10 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: C'nnccr OIJ.a lnAl is-AT 1QS 6loor111•a1C k cr The debris will be transported by: Name of Hauler: O'n'1R (j3 QS,\-Q_, 34QCU\C5 Signature of Applicant: Date: '"- The Commonwealth of.thwssuchusetts is Deportment of lntlustriulAccidents I ''1.t 1 Congress Street.Suite 100 to>., Boston, .11.-1 0211 4-201 )von. muss.gorltliu tit a,,kers'( uny)cnsation Insurance.lffidax it: Iluilders;('untractursiElectriciain Plumbers. 1(1tit 1-tt.k_I)%%1111 t111. I'I R111I I1\(:. ( UIOKII . %milk:int Information n Please Print I.r•gibls N...tliu.autca,t)a t./m.raia n.1ndividual): ' t (t IG( t C l / Address: c m 1\� C'ity'St le Zip: } L Ol�� Phone#: U 13 sJ.9 0--s3-3_S Are you an employ Irv?Chock sippnapriatt hot: -1-,"pr of project(required): l.,ni.i.aaµaluy►t lkt[h / id piss[-tomet.• 7. D New construction .-,,D J am a auk proptaetutos p annithipaid Vve no employees.v.Luling tut teem a. 0 Remodeling any e:apaaeats-1Nu madame amp.indiniet nyou.d.l 30 I ant a t eoanrr doing all work ansxll.I a oti..T.'cumin.uuurance rcyaaued.l t 9. ❑ Detnolition aLn 10[J Building addition 4.01 am a humaawner and will be home.vrtttu.aut,to conduct all work on nay property. l wall anon:that all contra-tun either Lac widen:.usulaeuiaatuusa uwuran.e or an:'ale I I.L Electrical repairs or additions prupneton with no employee. 12. Plumbing repairs or additions SCI Eau a gemred smutscsur and I has a hued the sub-eunttaeton hated on the attached sheer. 13 Roof repairs !hest et !true cmployeca and has a%Laken'cuing.insurance-- a.0%cte :Ind a a aoporanaun usuttieen base.untaxed then nght of exemption pet AKiL.. 14.0Oth0 152,f 1(4),ird we Luse no employcsa.1No w taken'e.anp.maurmr.te.p and.l *Amy omplitat dirt db.xi%box?1 rnue alai till out the toctaata below show Inc then lkotka a polies uafurtnatwao. t 111002 U1I s 1Mhu saalarmi tfua all ids.d uidwanng they are dutng all wink and then here uniii_- sow w%ubu a new atiad ss illati[tp indi sudsommis r tint cheek the box mutt attached an additional%Moen%hulk mg the mine ut the aid stale tirdhet arttut tause ualdaca luxe minezeIf tlu:. h:.veit..,:t as lase.•curio}...coo.tics mutt ptLc alc their voLnler. comp,pulics nurilt. — I am an employer that is providing,t oriters'compensation insurance Or nil employees. Below Is the policy and job site information. Insurance Company Name: C Q. ( K Y1Q r 1 CCi!1 T Y)__ J rC1 n Cf2 ICJ. Policy 4 or Self--ins.Lic.#: CSC,_ a y (;� f �-) ) 7(47,9A Expiration Date: Job Site Address: 3 a C.1'1P_%le_c1 e\Ci 1 Citytstatc.!_ip:_J�_ YD}' PIyn Attach s copy of the workers'compensation policy declaration page(showing the polio number and expiration ate). Failure to secure coverage as required under NIGL e. 152.*25A is a criminal violation punishable by a titre up to$1.5(K1.00 :stator one-year impnsonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine 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 lac insurance costraec xer►licattun. I do hereby certify ' flue - . .that the information provided above is true and correct. Signature: � Dale ' //nl-� Phone g: '// S?o � �y Official*se only. Do not write in this area.to be completed by city or tuisn official ( its ur Toss a: Permit/License t+ Issuing.tutlturits (circle one): I. Board of Health 2. Building Department 3.('it yjoist'clerk 4. Electrical Inspector 5. Plumbing Inspector (i.Oilier ( unlact Person: Phone#: • • • a II P Commonwealth of Massachusetts 1: Division of Occupational Licensure Board of Building Regulations and Standards 5 Constron Srvisor CS-105917 1 ,,kw ; A pires:03/30/2024 DICKY MAT4 '.G * 4 P 3 GLEN STRgET( off. t-, O HOLYOKE N*01049 4OILVa:�') Commissioner e , t K. +ckra, $ 1 THE COMMONWEALTH OF MASSACHUISFrrc Office of Consumer Aff. a•� Business Regulation 1000 Washing:3.: �; - Suite 710 Bosto ,.;.:,--t - ,. - •--.--? 118 Home Im ro ,, • m. ;;z�'-_e istration • Type: Corporation DICKY MATOS ROOFING,INC rn �* • ation: 198417 23 HADLEY MILL ROAD 1 ......d» E j ation: 06/01/2024 HOLYOKE, MA 01040 '{ -- 1 w 1,4 , IX j't t \,...--... * P:sj -� ,r Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Aff*jss&Business Regulation Registration valid for individual use only before the HOME IMPROVE�NF�ti cONTRACTOR expiration date. If found return to: TYPE Corp&r ti Office of Consumer Affairs and Business Regulation n 1000 Washington Street -Suite 710 Boston,MA 02118 DICKY MATOS ROOFtr D � - ,1 -,...:, ' '.----:::- - 177_:.7 :,:, =1,,,,,) DICKY MATOS 're/ 'fir:�- I ,.� � f 23 HADLEY MILL ROAD yr`_ ' G am""' 4,....4 ////n Th_Slle_itk_JL.A HOLYOKE,MA 01040 , ACO. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/O6/23 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 NAME: Denise Blais Bresnahan Insurance Agency,Inc. A/CONr o Ext): 413-536-0536 (Arc,No): 413-534-4291 100 Whiting Farms Road ADDRESS: dmblaist bresnahaninsurance.com Holyoke,MA 01040 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Penn America Insurance Co. INSURED INSURER B: Pilgrim Insurance Co. Dicky Matos Roofing, Inc. INSURER C: XS BROKERS INSURANCE AGENCY,INC. 23 Hadley Mill Rd. INSURER D: Holyoke,MA 01040 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDLSUBR POLlCYEFF POLICY-EXP ' LTR TYPE OF INSURANCE INSD WVD, POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR I DAMAGE TO REND EDI 1 OO,000 PREMISES(Ea occurrence) $ MED EXP(Any one person: $ 5,000 C PAV0432616 02/25/23 02/25/24 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 1 GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOG PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY J COMBINED SINGLE LIMIT ' $ iEa accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ - $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ `~ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'UABILITY Y I N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory In NH) EL.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Proof of Coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Dicky Matos Roofing,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 23 Hadley Mill Rd. Holyoke,MA 01040 AUTHORIZED REPRESENTATIVE /711,4 tWails e c. ©1988-2015 ACO D CORPORATION. All rights reserved. kCORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:47B8B5FA-ECD5-49E8-8D41-A524F2AC86FB DICKY MATOS ROOFING/DMR CT 23 Hadley Mill Rd Holyoke,MA 01040 US4 1.*:11 +1 4135305335 info@dmrinc.org DICKY MATOS ROOFING Estimate ADDRESS Leo William 392 Chesterfreid Rd Northampton,Ma ESTIMATE# DATE 842 03/24/2023 DATE SCOPE OF WORK Remove existing shingles down to deck. 28 500.00 14,000.00 - Re-nail any loose wood. If bad or rotten wood is discovered,it will be replaced at a price of$85 per sheet. - Install 6'of IKO Ice and Water shield at all gutter lines and valleys. - Install IKO Stormtite Synthetic underlayment to keep your roof dry. - Install IKO Leading Edge Plus Starter Shingles along all gutter lines and rake edges. - Install IKO Cambridge Lifetime Dimensional Shingles per specifications using I ''A"roofmg nails. - Install IKO Hip and Ridge Shingles - Install new ridge vent. - Install all pipe and vents - Clean up all job related debris - They will perform a 10 point clean up when the work is done. -Install new pipe boots constructed of aluminum abd rubber for proper soil pipe seal. -dumpster included and it will safely place on board to protect drive way ( non dumpsters operation available please inquire with owner or manager Permit fees included. INSTALL ICE WATER BARRIER TO WATER PROOF AROUND CHI EY 1 500.00 500.00 INSTALL NEW 5X7 STEP FLASHING INSTALL NEW 12"LEAD FLASHING SEAL ALL WITH GEO SEAL You,the buyer.may cancel this transaction at any time prior to midnight on the third TOTAL $14,500.00 business day after the date of transaction. , —/D�ocu�Siignned by: Accepted By t/"" "-t`^^ cuti —790867CCE3DC40E... Accepted Date 4/23/2023 Page 1 of I l ® DATE(MM/DDIYYYY) ACC,REP CERTIFICATE OF LIABILITY INSURANCE . 03/1312023 kir. 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 NAME: Abi Fontanez CHI INSURANCE AGENCY DBA CHAFFEE HELLIWELL INSURANCE AGENCY PHONE 413)315-5181 FAX (p�c.Ne.Exn E-MAIL ,_,ADDRESS: afontanez( ChIagGnCY.COm 17 COLLEGE ST INSURERIS)AFFORDINGCOVERAGE 1 NAICtl_, SOUTH HADLEY MA 01075 INSURER A: ACE AMERICAN INSURANCE CO i 22667 INSURED INSURER B: ..-......._.. DICKY MATOS ROOFING INC INSURER C: ___ _ INSURER 0: —. ..........._._..- 23 HADLEY MILL RD INSURER E: -_. HOLYOKE MA 01040 INSURER F: COVERAGES CERTIFICATE NUMBER: 870257 REVISION NUMBER: 1 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. TR 1 COMMERCIALMADE GENERAL LIABILITY JNBII{S1HVO POLICY N Y I POLICY EFP POLICY EXP � m TYPE OF INSURANCE UMBER IMMODlYYYY) IYNNIDDIYYYY.LE LIMITS I I EACH OCCURRENCE I S C.AIMS- L I OCCUR ; PR_EMfS.5.1 Pmtrence $ MED EXP(Any one person) S i N/A 'PERSONAL&ADV INJURY $ GEM AGGREGATE LIMIT APPLIES PER: I - GENERAL AGGREGATE l$ t.._�— )'i PRO- 1 I .__. 1 POLICY i JECT I LOC PRODUCTS COMP/OP AGO $ OTHER: i �a_ �. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ __ 1 .I.Ee�t .4n1) 1 ANY AUTO I BODILY INJURY(Par pawn) 4$ OWNED SCHEDULED AUTOS ONLY AUTOS N/A BODILY INJURY(Per accident) $ HIRED NON-OWNED (PROPERTY DAMAGE '$ , AUTOS ONLY _ AUTOS ONLY �,jPgr acCidpnt} ,_,,,,,,,__„ UMBRELLALIAB OCCUR l' EACH OCCURRENCE $ EXCESS L.tAS CLAIMS-MADE N/A 'AGGREGATE 1 $ DEO i 1 RETENTION$ i I $ WORKERS COMPENSATION X1 STATUTEPEE 1 1 AND EMPLOYERS'LIABILITY i __ A 1 ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N I E.L.EACH ACCIDENT f$ 100,000 OFFICERiMEMBEREXCLUDED? N/A WA :I WA 6S62UB6R37184722 03/13/23 '03/13/24 3(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 It yes,describe under :DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 i N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,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/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Dicky Matos Roofing Inc 23 Hadley Milt Rd AUTHORIZED REPRESENTATIVE Holyoke, Ma 01040 Daniel M.Crojy,CPCU,Vice President-Residual Market-WCRIBMA O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD