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BP-89273 Permit No. BP-s9273 BUILDING PE. MIT y GIS#: 9411.00 Comoro w Itu or Oiassa• chusetts Map: 0139 _ TOWN OFDARTMOUT i Lot: 0091 :400 Slocum Road,Dartmouth,-,MA_ 02747 Sub-Lot: 0000 Phone;(508)9101820 t.iax 508l 910 1838 • - Category: RE-ROOF __ Project# ` JS-2019-000230 PERMISSION IS h EREB'GRAFTED TO: Est.Cost: $10000.00 Contractor: Eicense Phone#� Fee: $75.00 JASON 0 COUTO C�*6628 (50:8)509-4414 Const.Class: 41-:65756 - Use Group: R3 Engineer: _ , Licetts x':`�.� = Phone# ; Lot Size(sq.ft.) 8000 Zoning: GR Applicant: y Pho e• it Aquifer Zone: N/A - • . Flood Zone: ZONE X COUTO CONSTRUCTION INC z ;($08 ,09-4414 New Const.: N/A OWNER: SALVADOR STEFAN ' Alt.Const: N/A _ - -‘,._-,;2. ---,T;.- rr, _-:,-,,,j- -..,.:,:-.- -,--,--,... -,, , :, ..:- Date Typed: 07-24-2018 DATE ISSUED: TO PERFORM THE FOLLOWING WORK: Strip/re-roof residence 111 oject Location: 16 PIKE ST Approved/Issued By: • !1 / DAVID BRUNETTE,LOCAL INSPECTOR All work shall comply with 780 CMR 9TH Ed.(MGL Chap.143)and any other applicable Mass.Laws or Codes and plans on file. Schedule appropriate inspections as required. Upon completion,final inspection is required. I hereby certify that the proposed work is authorized by the owner of record an I have been authorized by the owner to make this application as his agent and to receive this permit,I further understand other agencies may have rea on to STOP WORK if items under their jurisdiction are not met, of m , n withstanding the issuance of this Bull _ tying Pc it. Signature of Owner/Agent: i' i • "Persons contracting with unregistered contractors do not have access to the guaranty fund(as set forth in MGL c.142A)" Inspector of Inspector of D.P.W.Inspector Building Inspector Inspector of Gas Fire Department Plumbing Wiring Water Service#: Footings: Underground: Oil: Underground: Service: Foundation: Rough: Smoke: Rough: Rough: Sewer Service#: Rough Frame: Insulation: Final: Final: Final: Cross Connection Final: Final: Board of Health E-911 Additional Comments: Planning Board Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary inspections signed off. Department phone numbers are listed on the white"Required Inspections"document provided with the issuance of the building permit. POST CARD SO IT IS VISIBLE FROM THE STREET 0,), TOWN OF DA. TI UTHz.zUILDING DEPARTMENT RECEIPT : ? ,if. 3 'R E 508 9101820 FAX 00 0-1838 fiF, /lry 3 ' /i v i C Name: �./. b1 (1*-{ jibed e U 7 v j: , Property Owner: ,,, �c//�+`/ ...e,}f'' Date Job Location: At) f 1 t -- t Map:__al__ Lot: 9 1 1 Description *OF DART General Ledger#'s Ref. # Amount Building & Buil disc jp �Qby 01000-44105Ruir-6 # - , -— Electrical 1000-44106 JUL 1 2 2018 NO Plumbing & Ga 1000-44107 Trench Safety Oil,,. 6 LE0,(1Q. 01000-44129 B ETTE R M ENTS TcoL Other Department Reve 01000-42420 White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy Building Department Received Bys' 1-4,-.7,1(,/,41 THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS RESIDENTIAL ❑ Phased Approval(R106.3.3) $25.00 APPLICATION FEE IS NON RE-FlPFTIOABLE &NON-TRANSFERABLE DATE RECEIVED „-f �l~. ' - Qot.9 : DARTMOUTH BUILDING DEPARTMENT A-C ... X 400 Slocum Road � r' Dartmouth, MA 02747 Phone: 508-910-1820 Fax: 508-910-1838 www.town.dartmouth.ma.us APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING nx.Jb. iB4:^k. .i•.'^v .f..;3. �....'tK�A.u�. .v\ 1 x t 'r—'w� +' ��,:R..�`uT.t.S- i .3 'tJ'G Y .�LAM - v.�R.Jn r�z*��-;,'�^•`,"r'i y:,�i:�": "�i'. < t ;� s ''W.c' .` gtO „'�,�S'� .a"x'�q'Wr '.•i t 'ittig "�:r-. - �'S .�'�e�., '�v�;:��Jn;:�3,'�n:;_ v•�t�•- - nz:; 7'�-.�,��f��.p�� `T-a '�a � w��-r �- �-.`�� �a` '`ic � �s 'a a -s'.h �. t * _ -.k r .r^.r, S'mr:.,Y-•E:.., J Uc e z kg"c .'z���'�-•�Y�ry�'?l z _ i'1'a9 � ± •F"l�_si'��r ti ?}f�.,'� �'�ikiir•�c. P,., 3r �riin, �• t ^§ram,.i-5 � rti S a ��,#S^Y�'{�,� - "°`. � _ .: ,, 1"^ ' T t 4 _ y �r h Y - TAT+.Eai� CFh+>•G j �Th� �T �'W 'a SfIG1elJ �` tli▪ ir• t:iA �t PI WferZane ""1 _s' r 1 e s '`-ffa�esT' ..v, a`a' S4.C_. S \ t S• v. f `, .l e FOLt*V1,6!',G!.0E DIES SHflUL�b,4 4t 3T1 E M1t K r �� t Q�.qgi l of t gpacd of Q Cohs O Planning f^ ❑Aldress £ Engineering Cj CroSs ;A peas Health Go is o �Oard Connecfion D lie ❑Gas ❑Etectr1p Li Other k: D WaterC•ard ❑Sewer Card E PDF- r Cr efi C.iit Off FCtUt Of>' Cat Off Cut Off • 4 ¢ 1 ti i- • ..J s• '.`^ 1 ..4.+ .7...Lar ' r..b. w.i. �s 2.�`C_ ._.t .Y� - c x�- r.,k tni t.:.g 4'�", .l x. r I 4 ttegic t TATtAP1? O t tr" R K- - Board of Health: Signature: Date: Conservation Commission: Signature: Date: D.P.W.: Signature: Date: Fire Chief: Signature: Date: Other: Signature: Date: Brief description of work being performed: S- %tQ 1ZL 2_003 / 9 se -.J .} �•,. Y -fh '�.- Y S�� 3:\ gesi:�4,i''r.�.d'i„'�q•-•A S� `Z�.ty,.*r,�e.. i T.,pi- `t'. c s;��"'=3 t`r m=k�-'`.i pi t, .n ti i. �FH� y '�(ol, c- ,{liC�►n��" �'o;.a:.r ya .ti`a .7*r �:� x� -a;:- 1 5 .,..-s�J-u l_'!t��.3f.;'::`�-��"`i.�.s.s.•'s±xr,�,:,�,r.�.,_ {,+,"?.Jtn-.:c-.i:�:.ir�...�=+-ek�.�� „� �� 1�,. ��!�F����t..l�r..A�S+•�F�Q�•`. �.:. � <Xc,,,s.^ a�-.v+._ ,....a.. `' n z a S.y:>�s;a 6`�.-•>�-:. J-�3�..�*nt'-3•ro�L�..r.� -i"t;;::�.. �..ne-:.s�.�.. 1.1 Property Address: I L �t YL- J� 1.2 Assessors M :8,,.!..ot Number: Contact Person: 5c__ ,Th \‘)Ct&O Map LotgI Phone Number: SC�g - I - 1-2 Z(0 1.3 Historical District ❑ Yes 0 No Year Built 1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System: Cl Municipal 0 Municipal 0 Altering more than 25%per side of building ❑ Private Well 0 On Site Disposal System Has application been submitted to the Historic Commission? ❑Yes ❑ No Date: Li 1.4 F'/5 Ri'fbit' evised 5/13 El CONSTRUCTION PLANS SITE PLAN ENERGY REPORT I IitlitIMIY1IIL . 2.1 Owner Record: S-EIcAc c.t 1 N)a ocz_- I Co Di V__E Si 5c ? g1-7.- 722in Name(print) Contact Address Phone Number • 2. O h�ori'ed Age t:0. 4 Q u o() 9 `4 ?9 1rl LS\ �* /\\ELt &-are_ Name(print) Contact Address Phone Number .il r^ itt : e.3geM gi �-FO ONSIi PatgaragarganiMSZERI 3.1 Licensed Construction Supervisor/Specialty License: License Number: OC (o to a Company Name/Contractor Name: 0 exit-{0 COYlS-\120,C `1i-1 o1c). /4 I 6 /1 t° I Go 576 Co Address: a Qx- , -;_ S-*- Expiration Date: -5- lei'- 18, Signature: G(� Telephone: 4,�D6�-ft-/(y ' -Z)-2.0 3.2 Homeo ner Exemption-One&Two Family Only Section 110.R5.1.3.1 Exception: FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section;provides that if a Homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor. For the purposes of this section only,a"Homeowner"is defined as follows: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures: A person who constructs more than one home in a two-year period shall not be considered a Homeowner. If you are applying under this section sign below: . Signature: • !,. 7 1 C MKL � g�`` W e M47: l"StiUr. ..n..-�j,�i,��.2�Cf..�"�,�i�c t. w h..,.s"��;�'_'nh��f.++1.'S''�r a;`L _ 7. i� � E171 � _y � � � -`'"' ��"�i=�.�"'�u ..ice``. . Worker's 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 0 No 3" �.A M �- 'z - } ' T ��. rK( (err;�..-� O ��74� } 1; CdF7� {�,x- 'a- ' vim'` . W elate' s� _....__��3 x..��_Y.. .{x�Y--�. s.-��:i ��Y��F�S������`r_�.Y�-'+'��-�'+sti'�=�-��� � i�..R,.ul_��i� ..i � 1.y� _ t..�' � .a�,.s-_. ❑ Deck - 0 Pool ❑ Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove ❑ New Construction* 0 Accessory Bldg. ❑Addition BDofing/Siding 0 Replacement window/door (Energy report required) (Shed/Garage) (Energy report required) No.of windows Doors r QEMOLITION (specify): A-E Location of debris removal (per MGL C.40 Sec 54):� id umpster on/site C] Dumps�ter�On Street Facility Name: �� (.6 °� v�t�� U` Cts- E Location: 1 \\ , 1 d ( r C *If new construction, please complete the following: Single Family: No. of Bedrooms No.of Baths Two Family: No of Bedrooms Unit 1 No.of Baths Unit 1 No of Bedrooms Unit 2 No.of Baths Unit 2- ❑Furnace(hot air)-fuel gas(natural or propane),fuel oil,electricity,other(specify): ❑Boiler(heating)-fuel gas(natural or propane),fuel oil,electricity,other(specify): ❑HVAC(combined unit)-primary fuel,natural gas,propane,electricity,other(specify): ❑Air conditioning-(separate unit) ❑ None of the above to be provided 0 Hot Water: Gas Electric Fuel Oil Other � Item Estimated Cost($)to be completed by permit applicant 1. Building 2. Electrical 3. Plumbing ' 4. Mechanical(HVAC) -21 '(Please Print C)L%,-N as Owner of the subject property hereby authodze &,)LcV3 06mAet to act on my behalf,in all matters relative to work authorized by this building permit application. SigneturoW Owner Oota �� ''\ L \ �m' .00 Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best ufmy knowledge and belief. Signed und e pains n penalties of perjury. & --* - 16)- I r, aer Signa of Owner/Au orized Agent Date Less AppUcoUonFee:$25.00 Remaining Balance: Toto Ponn�Feo� � ^^ �~� Other$Amount$ ^ GmoeArna-NowConutructiontotal oq.ft Gross Area'Alteration total sq.ft. Permit Issued to: . ` ��. .^�] , \ ` ^ � � N� LUG emg ! vti 1-9* (\lif4 /f,16-) Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-096628 Construction Supervisor JASON O COUTO • 23 HIGH HILL RD DARTMOUTH MA 02747 Expiration: Commissioner 08/19/2018 (0±14 Wo4i4...„,a Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation Registration: 165756 COUTO CONSTRUCTION INC. 24 ERNEST ST. Expiration: 03/21/2020 NEW BEDFORD,MA 02745 Update Address and Return Card. 1 a: 20M-05/17 r.17, `6(,),/mmrei/wry///!I t/- 7413,rldmir/7; - Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 165756 03/21/2020 One Ashburton Place-Suite 1301 COUTO CONSTRUCTION INC. Boston,MA 02108 JASON COUTO 24 ERNEST ST. [� NEW BEDFORD,MA 02745 Undersecretary � ', Not va d without signature The Commonwealth of Massachusetts _* r Department of Industrial Accidents = 1=1411= 1 Congress Street,Suite 100 .,�;1til ,t Boston,MA 02114-2017 _ . www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): CcLv O C ��Q i_XC .0` \ i 1 C Address: J q ECZY'lE_` -V 1- t- City/State/Zip1 1�..L.Lkt t c t � "`one#: JOct- 609 (4 Ll I Lj Are you an employer?Check the appropriate box: Type of project(required): Iral-am a employer with �#__ employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. EJ Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13 oof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.❑Other 6.ElWe are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'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: Ac G-q OC.ism . Policy#or Self-ins.Lic.#: (.42 ( p( &`I `1 og RaoS)6 Expiration Date: ) I " l q Job Site Address: )(n (Dl )L- S*2.) £_-# City/State/Zip: t?A-inelLA . MC( lC( 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 er t ejainsl nd penalties of perjury that the information provided above is true and correct �i -7 g Signature: Date: T' ( o ` O i Phone#: 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#: , o ._7/7-7771 _ 24 Ernest Street i 1 1 7 0 New Bedford,MA 027415 Phone Number:508 509 4414 Fax Number:508-858-5048 oINIE cam■ ■ ir7. oE5 • Email:Coutoconstruction9@gmail.com Purchaser(s): Home Phone: Cell Phone: Skrcin SCf)v4k so?-Ed 7-7? Mailing Address: City: State: Zip: 16 f )L-e St Sdo± ow ,y? Put A7z/e Job Address: / City: State: Zip: I t� t c Q Strip off up to 2 layers of asphalt roof shingles from roof surface of house /'}/ [✓7Replace up to 64 Sq.Ft.of sheathing as needed for a sound nailing surface (�( L Install F8 8 inch drip-edge to all roof edges ©Install Ice&Water Shield along first coarse and penetrations Manu: 06 pe: W?4/fl'r Pei( []Install underlayment to remainder of roof deck surface Manu: aL Type: ' 0104 ur F✓ Install Starter Shingle(LF) Manu: 0 C Type: O /C. Q'Hurricane nail asphalt shingles to entire roof surface Manu: 0(, Type: `74 .✓a_+1 tI [Install new self-sealing pipe flanges to vent pipes ❑Install new lead around chimney Quantity: Cut roof deck at ridge and install Ridge Vent Manu: dG Type: V❑�Cap off all peaks with hip&ridge caps Manu: 06 Type: [ C can all debris made on site,roll yard&drive way with magnetic roller All permitting Included ❑Other ventilation Manu: Type: ▪ CU,r?ice' <Si yA4-14Fr:;nr srgy, ❑• Vr� vril?Skr n Pf U(Vay #i r d1 ivitkr nP.44'J Other/notes/Sp�l1ecial instructions:�h > rci rf l i r7 7N� r'tly coot!yr, -I-r- 0 I,V Pitched Year Labor Warranty ( Year Manufacturer's Warranty Slb it Flat Year Labor Warranty Year Manufacturer's Warranty All material is guaranteed to be as specified.All work to be completed in a workman like manner according to standard practices.Not responsible for any engineering if required by local authorities.Any alteration or deviation from the above specifications involving extra costs,will become an extra charge over and above estimate.All agreements are contingent upon the absence of strikes,accidents or delays beyond our control.Owner is to carry fire,tornado or other necessary insurances upon above work.Worker's Compensation Insurance and Liability Insurance will be provided. We do not assume responsibility for any additional wood sheathing needed for a solid nailing surface;if needed,additional sheathing over the allotted amount specified will incur additional costs for each additional layer.Price includes removal&disposal of asphalt/fiber glass roofing only,for quantity of layers specified,any additional layers found will incur a charge.Price does not include any removal or disposal of asbestos roofing.Contacting neighbors&obtaining access to neighboring properties to execute work will be required from homeowner,in the case that encroaching or access is needed to perform work.Access to electricity on site to run power tools,etc.must be provided by property owner.Also not responsible to vacuum/clean attic areas of roof granules. Written dollar amount s Dollars $ Payment Terms: Deposit $ 1110111110111Check# 2nd.Payment on Start/Delivery of Material $ ❑ Credit Card 3rd.Half Completion $ I I Cash Final $ 1.11 ,F Financing '■ ACCEPTANCE OF PROPOSAL .� Purchaser(s)Signature:� ,�-�s�?_— � 6141116...._ Date: Purchasers)Signature: Date: Representative Signature: f Date: 6 WH —CORP YELLOW—PRODUCTION PINK—CUSTOMER Acd® CERTIFICATE OF LIABILITY INSURANCE I DATE(MMIDDIWYY) ��. ouos/zD1s _ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Lisa Souza au: — Branco Gardner Insurance PHONE 508-990.7367 (arc,Not. 508-999-9621 (AIM No.E 48 State Road E-M LSS: Tina@brancogardnerinsurance.com INSURER(S)AFFORDING COVERAGE _ _NAM X North Dartmouth MA 02747 INSURER A: Western World Insurance Co INSURED INSURER B: Safety Insurance Co INSURER c: Ace Insurance co Couto Construction Inc INSURER D: 23 Ernest St. INSURER E: _._..._ New Bedford MA 02745 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, TIC 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 TYPE OF INSURANCE AD61-SUER POLICY EFF POLICY EXP LIMITS LTR INSO YND POUCY NUMBER IMMIDDIYYYY) IMMIDDANYYI XCOMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 DAMAGE TO RENTED 1,000,000 CLAIMS-MADE N1 OCCUR PREMISES(Ea occunence) S - MED EXP(Any one person) s 50,000 A X X NPP8326735 02124/2018 02/24/2019 PERSONAL B AOV INJURY s 1,000,000 GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2.000,000 PRO- PRODUCTS-COMPIOP AGG S 2.000,000 OTHER: S ` X�POUCY�JECT �LOC AUTOMOBILE UABIUTY Eaac tleDDt]SINGLE LIMIT S 1,000,000 ANY AUTO BODILY INJURY(Per person) S B _____ALL OWNED X SCHEDULED 623482 09/25/2018 08/25/2019 BODILY INJURY(Per accident) $ _ NON-OWNED PROPERTY DAMAGE S HIRED AUTOS — AUTOS IPeraccident) _ "" S UMBRELLA UAB OCCUR EACH OCCURRENCE S — EXCESS UAB u CLAIMS-MADE AGGREGATE S DED RETENTION S _ S WORKERS COMPENSATION 1 STATUTE I I W- AND AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE i l N/A E.L.EACH ACCIDENT ___ S IM OFFICEREMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S Ir yqesSGI dePT)ON scnbe wider OPERATIONS below El.DISEASE-POLICY LIMIT S DERI - DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space's required) CERTIFICATE HOLDER _CANCELLATION Town of Dartmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 400 Slocum Road ACCORDANCE WITH THE POLICY PROVISIONS. Dartmouth, MA 02747 AUTHORIZED REPRESENTATIVE Lisa Souza I ©19B8.2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD "--i ® DATE(MMIDDIYYYY) A�n CERTIFICATE OF LIABILITY INSURANCE 01/10/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT lina rein PRODUCER NAME: BRANCO GARDNER INSURANCE PHONE 508 990-7367 FAX No): PHONE o.Ext): ( ) E-MAIL ADDRESS: lina@brancogardnerinsurance.com 48 STATE RD INSURER(S)AFFORDINGCOVERAGE NAIC# N DARTMOUTH MA 02747 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURERB: COUTO CONSTRUCTION INC INSURERC: INSURER D: 23 ERNEST ST INSURER E: NEW BEDFORD MA 02745 INSURER F: COVERAGES CERTIFICATE NUMBER: 228450 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. ILTR, TYPE OF INSURANCE INS)SUBR POLICY NUMBER (MMIDDIYYYY) (CY EFF MMIDDI Y EYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADVINJURY $ GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY LOUJECOT PRODUCTS-COMP/OP AGO $ OTHER $ AUTOMOBILE LIABILITY COa aBINEeDtSINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULEDAUTOS _ WA BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) S UMBRELLA LIAB OCCUR - EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY Y I N A E.L.EACHACCIDENT $ 100,000 OFFCER/MEMBEREXC EXCLUDED? N/A NIA N/A 6S62UB4567P26318 01/21/2018 01/21/2019 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 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/lwd/workers-compensationflnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Dartmouth ACCORDANCE WITH THE POLICY PROVISIONS. 400 Slocum Road AUTHORIZED REPRESENTATIVE Dartmouth MA 02747 Daniel M.Crgy,CPCU,Vice President—Residual Market—WCRIBMA I I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 000 0 o 0 0 0 0 o V o o .. ,; o 0 Doo o ,, = 0 0 0 0 ,-' � o 0 Q NON rl' 0.4 "1 N O; l� N �r>- a 01 C*4 rc-5 ::..„.,; ,.,_ ..,.„.,, z ._., • ,L,,,...,„ . • CA Vzgg M uu kQ •V, wfl: F., 7 0 O O Z •�O00 O a q res' co y .�(- Li N d 'V 0 000 V CC �. W y A 000 Ok� tl �OON .� O O . � 00M,..: M tl , i 3 b�v o H C ° o00 0 P Q , n O M 3 N aD n '- 500 oar: y d W Cq d so as N N Q �. d e•+ N Y" 7 MI cd y .,.:. t [fr,�000 u as J •• yes .' : () V OOO QM,)~ N.0 a. 0. LS-, 6. U cd 7 E"▪'i .., ::c3:00Mcl.‘ — ?;, x J `lr a. 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