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Vll til l)tC+/)t bt(IltOnlin3 F .v "`".']'S" • '� s bt �.�i". 4i rllllll�f)a`..r olf lb'lII1InUl11S\ r` �'s "air �, vt Nllinbt.ritltrill fl!Ob1thS ,�^p`"I�''$`"1iif Y}}pbtUlt lit.{f111g ,Ystilnr ", i lumb4r:og�t,(9�t.k,(Iylr�h�s aE11t,10)4d�#'F+`v`' lki s y.• 'li ;5 .. �• rp- t K ' ��'bl • � '� �� w�` ap F, � +,'rl i" • ,� ) {Ill )f IIItII�ItIJtI[.1tIUI 11�IF I1u)Iltt.t,Ill ly bl ]llb,tlfllfL.N� YU4��*,,I ht III IIIIII��I( irit " r a � w'ti :_.�"� �'. 4bn6 �.{^.��.,' � •z k ak` � nay '8' c� A 4 '� w Y7r 1P; a� 0. 3' ?a?t" � x w+' n , t . xas v.. .�. ?`$,.s :'�9'n .� .m.'' s r�rx,",,.,. � �h �a- .►a > -r� `Cep >s"I FFe `�S tr �i �4. .i wFw�:.uar,Sm.L,�C The Cotnmottrvealtfr of tYlassacltusetis Department oflndustrial Accidents ( Office of Investigations 1 Congress Street, Suite 100 Boston, A14 02114-201' ��"-'.�A rvrnip.mass.gortdia N'Vorkers' Compensation Insurance Affida-tit: Builders/Contracto►•s/Electiicians/Piumbers Applicant Information Please Print Legibly Name (Busmess,organizationnndi�idual): Peter Ryan and Son hoofing, Inc. Address: 377 Lowell Street Cin'/State/Zip: Wakefield, MA 01880 phone 781-245-4900 Are you an employer' Check the appropriate box: Type of project (required): 4: I am a general contractor and I 1.❑ I mu a erployer uvith ❑ 6. ❑New construction employees (full and!or part-time).* have lurid the sub contractors 2.El am a sole proprietor or partner- listed on the attached sheet. ?. ❑Remodeling drip and have no employees These subcontractors have S. ❑Demolition working •for rue in any capacity. employees and have workers' Y 9. ❑Buildurg addition [No workers' comp. insurance comp. insurance.' required.] 5. ❑ we are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowaner doing all work officers have exercised thew 11.❑ Plumbing repairs or additions myself. [No workers' eonnp. right of exemption per TNIGL 12.❑ oat repairs insurance required.] ' c. 152. §1(4). and we have no employees. [N wor kers! 13. Other comp. insurance required.] `Any applicant that cbecks box:1 must also fill out the section below showing their workers compensation policy information. t Homeouuers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new afffida.it 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 tint an employer that is providing workers'compensation iasurenee for my employees. Beloit,is the policy and job site information, Insurance Company Niue: N/A (I am not required to carry W.C.as I have no employees) Please see the Sub-Contractor's W.C. Policy�or Self-ins. Lie..I_((::�N/A t Expiration Date: N/A p� r� Job Site Address_ I"i a1� G _ ]��__....:,, -__, _ ___ City;'State'z1K L A wu tl 1 Attach a copy of the workers' compe us lion policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of Mi GL c. '152 can lead to the imposition of criminal penalties of a fee tip 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 tip to$250.00 a day against the violator. Be advised that a copy of this statement clay be folivarded to the Office of Investigations of the DLk for insurance coverage verification. I do herebv t j under the pains and penalties of perjure-that the information provided above is true and correct. Si nahtte •_ Date: Phone 81-245-4900 or 617-571-9056 Official use only. Do not write in rhisarea, to be completed by ciny or town official. Citv or Town: Permit/License Issuing Authority(circle one): 1,Board of Health 2.Building Department 3. C:in Town Clerk 4.Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone '\ The Commonwealth of Massachusetts Department ofindustrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www massgov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. ADDlicant Information Please Print Legibly Business/Organization Name: WeatherTite Solutions Address: 79 Nashua Street City/State/Zip: Woburn, MA 01801 Phone#: 781-281-5782 Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail or part-time).' 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(met.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] S. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees. [No workers'comp.insurance required]** 11.❑Health Care4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers'comp.insurance req.] 12.❑Other "Any applicant that checks box#1 must also fill out the section below showing their workers'compersation policy information. ••If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#I. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Duffy Insurance Agency, Inc. Insurer's Address: 317 Broadway(Wyoma Square) City/State/Zip: Lynn, MA 01904-2602 Policy#or Self-ins.Lic.# V3 C5-3[S-3145* {- 01('( Expiration Date: 03—07 '2.01 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 insurance coverage verification. I do hereby certify, un the poi d pe d/ties of perjury that the information provided above is true and correct. Si afore: Date: Phone#: 781-281- 8 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia CERTIFICATE OF LIABILITY INSURANCE DATE (MWDD 6YY) 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((es) 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 Stephen Duffy, Sr Duffy Inaurance Agency PNONE , (781)593-1200 wn No:(781)593-7260 317 Broadway ADDREss:ste"@duffyins.com Wyoma Square INSURE S AFFORDING COVERAGE NAIC II Lynn MA 01904-2602 INSURERA3desa Underwriters Specialty INSURED INSURERB3.M Insurance Corp Weathertite Solutions INSURER C: c/o Richard Reynolds INSURER D: 79 Nashua Street INSURER E: Woburn MA 01801 1 INSURER F: COVERAGES CERTIFICATE NUMBERCL165600874 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 TYPE OFINSURANCE ADDL UB POLICY EFF POLICY E%P LTR POLICY NUMBER RP MMID LIMITS X COMMERCMLGENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ A CLAIMS-MADE OCCUR PREMI ET Ea occvEnence $ 100,000 $m002000500550 4/22/2016 4/22/2017 MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENT AGGREGATE UNIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ 1,000,000 R JECT OTHER' It AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ea aaWarA ANY AUTO BODILY INJURY(per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(per accident) $ HIRED AUTOS NON4WNED .. PROPERTY DAMAGE $ AUTOS ip.r.ccal t E UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LUIB CLAIMS-MADE AGGREGATE $ LIED I RETENTION$ $ WORKERS COMPENSATION PER TH- ANDEMPLOYERS'LIAaWTY YIN STATUTE ER ANY PROPRIETORRARTNERIEXECUTWE E.L.EACH ACCIDENT $ 500,000 B OFFICEWMEMBER EXCLUDED? NIA (Mandatory in NH) NC5-31S-345064-046 3/3/2016 3/3/2017 E.L.DISEASE-EA EMPLOYEE $ 500,000 tt yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space is required) C CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Peter Ryan and Son Roofing, Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 377 Lowell St - ACCORDANCE WITH THE POLICY PROVISIONS. Wakefield, MA 01880 AUTHORIZED REPRESENTATIVE j. P Diamantides/PETER ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r?D14o11 I�'I , Peter Ryan and Son Roofing,InC. Y , LICENSURE HIC License #: 178871 Exp. Date: 05-28-2018 "'°^" ��� � ��" �'sf77i License or registration valid for individual use only Omce or Coosamer Affairs&11 mess Reg laden before the expiration date. Iftoundretumto: ^`HbME IMPROVEMENT CONTRACTOR Orflce of Consumer Affairs and Business Regulation lReglstratlon 178871 Type lO Perk Plam Suite 5170 � Expuati n. Sr=018 Corporation Boston,MA 02116 r3 PETER RYAN&SON ROOFING;INC. V.1. - 7 PETER RYAN �- 377LOWELLST .,; . ..�1...---_ Asiro WAKEFIELD,MA01880 Undersecretary Not valid witM1ougnato ..rr..¢Rn,:'S Massachusetts Department of PublicSafety CS License #: 106054 Board of Building Regulations and Standards License: CSSL-108054 Exp. Date: 05-17-2019 Construction Supervisor Specialty PETER RYAN a 377 LOWELL STREE. ra _ WAKEFIELD MA 01 (�✓ZZK l Expiration: Commissioner 0611712019 c Peter ayaa aad Bea B00000,INC. I Waae0e14 M1101800 1 TeF.10M45-0900 I Elaalk OYaa0adSOUNMEeom www.0yaaMdSouRoofiag.eom "1�'' Offices: 377 Lowell Street, Wakefield, MA 01880pr"q PONE Tel: 781-245-4900 R"p pand sk Fax: 781-245-4999 11lIW www.PoterRyanAndSonloofing.com Submitted To: lob Location: Hector Ramirez 190 Loring Avenue 190 Loring Avenue Salem, MA 01970 Salem,IRA 01970 Phone;* unknown Email: H.1Ramirez86@gmail.com PrOP@S8l date: November 8,2016 We are pleased to hereby submit this proposal to furnish materials and labor,completely In accordance with the below specifications: (Additional charges may apply for any change's not included below in proposal either by request of owner, or ifPeler Ryan and Son Roofingfinds unforeseen circumstances that will affect the performance, quality or integrity of this job). In the event legal action is taken to enforce any provision of this agreement, the prevailing party shall be entitled to all its reasonable costs, including reasonable in-house or outside attorney's fees. Not responsible for debris in attic. Strip entire Mal to hare wood and re-Shingle: $111,1100.01111 • Strip existing shingles down to bare wood • Check for rotted wood and replace(at time&material) • . Nail down any loose wood • Install ice&water shield to first 6-feet,and in all valleys and around any protrusions iL • Install premium synthetic underlayment(inplace ofstandard 301b.felt paper) • Install all new 8"white drip edge on perimeter and step flashing,where needed • Install manufacturer suggested starter course of shingles Install GAF Lifetime/architectural shingles in color of your choice • Install ridge vent(only if soffit vents are present,per national roofing guidelines) • Cap ridge vent properly with manufacturers suggested cap(GAF Timbertex®),if applicable • Properly flash any protrusions and all new pipe flanges,if arty on roof Clean up: • Cover area with tarps to minimize debris and remove debris related to work • NOTE: Please cover any belongings in the attic,as they will get dusty,ifapplicable Is`payment due upon signing: $2,000.00 Total COSL $6,000.00 Total balance due upon completion: $4,000.00 Kindly remit payment to `Peter Ryan". Thank you! ReSpeCd011y Submitted by: Accepted by:� e� Our craftsmanship is 100%guafanteed a 10-years. A wartantees are through the manufacturer.All warGitintres i r I i job is not paid in full. Peter Ryan and oofing,Inc.License k178871 1 Thank you for letting us serve you!!! cc: Peter/Ricky