29-043 firopo5at
A division of Sexton Home Improvement Co.
Tamko Roofing Systems .'w
•t r MASTER
Authorized I Cammrc4lA fl! tonboetw
= .`a
3r��a�i�a�1.
MA HIC #118239 CT HIC #0605383
www.sextonroofing.com
SUBMITTED TO rote ' C k/ & J (, {6't 1 ±1 PHONE ,f'" - G�,3 7 DATE & yy /f
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STREET y, fl ' 4 " ✓ - r + :'Z Yll..) f l a NAME /7 �-A /A.. j°=L '
CITY
STTE
IP A CODE -'L� ' d. L � O/t A . t JOB LOCATION
Proposal to furnish and install the following
u Re -Roof /'Tear -Off 1 Getter
Complete Roof Preparation
Home exterior to be protected by taros and plywood
jy'Shrubs, landscaping, trees to be protected
y" Entire existing roofing material to be - er~oved to ex's- -c decking. including flashing. etc.
Site to be cleaned everyday with roll I a:net deb s -em.c Jed at project completion
'Deteriorated existing decking r _c d at S2.50 c_ _ ft
It metal drip edge instare: at eaves e ^c akes
New flashing will be installed .here e:essary see Special Requirements
Pi Install new pipe hoot '',asni ng
' We shall acquire ail appropriate perry its etc. ft: all roofing work
Complete Roofing System
id Leak Barrier installed at all eaves to protect cm ice dams (and meet codes in the north)
Leak Barrier installed at valleys. around penetrations and chimneys to protect ciritcal areas
J 15 i,t,' reinforced underlay - Went installed over entire der_Yind
Shingles ££
A GAF Architectural 30 year 50'year Color t}f ric--d S
GAF ridge vent will be installed
Warranty Options
We guarantee our workmanship for 1C full years
age Propose hereby to furnish material and labor - compie'e accordance with the above specifications, for the sum of:
11E 7t /0.6.9/v zi /G /`1t dollars ($ S; 1 3 , -c - ••& )•
PAYMENT TO BE ":7A AS FOLLOWS /
f / �
All Material is guaranteed to be as specified. A oe completed it :rkmanlike manner Authorized
according to standard cra_tices. Any alteratg = acon from above ..,fications involving
extra costs will be ex _:;ted only upon written : and will become a «:-a charge over and Signature
above the estimate. Alagreeementscontinge = es accidents oree a s - eyond our control. Note:This proposal may be
Not responsible for matter damage during ... Owner to Lay re_ ;iole legal fees for
� / non- payment, and app, able interest withdrawn by us if not accepted within days
' ttrptiante of Vroposat - The above prices, specif cations and conditions Signature , �* ` , _ �1
are satisfactory and are hereby accepted. You are authorized to do the
work as specified. Payment wiii be made as outlined above.
\, Date of Acceptance . — . _ _ Signature (/
ATTENTION HOMEOWNERS: Pease 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 riahrfc a
The Commonwealth of Massachusetts
Department of Industrial Accidents
it ' Office of Investigations
4 = '== 600 Washington Street
w .....,...,-..., - B oston, M 4 0211 ,
ems+ ° www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A' .licant Information Please Print Le . 11 •
N ( Business /orgsni7ation/IndividvAi): �� ? '[ i, f J e)11,C7 L c -
Address: P O - 8 0 - y - ( . , . " ;19 1
City /State /Zip : ;4-0 i y 0 ki r , 0/2 4 Phone #: WS c ? y/' 3 9"
Are you an employer? Check t e appropriate box: Type of project (required):
1. [I am a employer with ✓ 4. Q I am a general contractor and I 6. ❑ New construction
employees (fill and/or part- time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub- contractors have 8. ❑ Demolition
working forme in any capacity. workers' comp. insurance. 9. [: BuilH in g addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs
insurance required.] t 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 their workers' comp. policy information.
1 am an employer that is providing workers' compensation_ insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 77? q R/f- L-S ,7' Ili, 3 C
Co
Policy # or Self -ins. Lic. #: /-" ('1 P 4//6, 4//6, 5 Pp G d -- 9 /2 Expiration Date: -� "i 3 / 1 J 3
r
Job Site Address: 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 insurance coverage verification. -
I do hereby certify 'der the pains and penalties of perjury that the information provided above is true and correct.
Sinrature: Date:
Phone #: y,/,_5_5 3
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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ( \ �,, / Not Applicable ❑
�
Name of License Holder : �!/ "e /� « '�i"� )(i t- o "� 196s- °7
License Number AO- s--ds,
PO ' e C) -- S -- r I-L.) I y 6 4 (414 Address Expiration Date
Signature Telephone
9. Re istered Home Improvement Contractor: Not Applicable ❑
\ I-1 • (I/ i p V' / /6 C'
Company Name 1 Registration Number
10 0 )\ C3 r7 °2— /5"°-'/
Addre Expiration Date
1 y a 1 4. , CAAk d dY ( Telephone 5 T /23 y
–
SECTION 10- 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 issuance of the building permit.
Signed Affidavit Attached Yes tl- No ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own 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.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Er
Or Doors 0
Accessory Bldg. ❑ Demolition 111 New Signs [O] Decks [E] Siding [0] Other [0]
Brief
Work: Description of Proposed ,F14 s //, 1 C in/4 / , c
Alteration of existing bedroom (/ Yes (�No /L Adding new bedroom /'" Yes L./"-- No
Attached Narrative Renovating unfinished basement Yes
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Fam " Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each _
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES CJ J , FOR BUILDING PERMIT
EE �" in C v , 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.
Signature of Owner Date
l/ S 243 1 "`( ` C , as Owner /Authorized
Agent hereby declare that the stateme is and information on the foregoing a plication are true and accurate, to the best of my knowledge
and belief.
Signed under the pain and penalties of perjury.
Print Name- -
Signature of Owner /Agent Date
r�,
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW ef YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW a YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW er YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO a
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO er
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
R C � C t "� Department use only •
G G V of Northampton Status of Permit:
B ildirg Department Curb Cut/Driveway Permit wit OC T 3 1 12 Main Street Sewer /Septic Availability
Fbom 100 Water/Well Availability
Ncrt am Eton, MA 01060 Two Sets of Structural Plans
pEPT. OF BUI�L� QIN�G��IN_SP€QT, �O
N .OFBU i -"240 Fax 413 - 587 -1272 Piot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
r! Map Lot Unit
iii f'' ��, �° /NC d Zone Overlay District
F/ e W v 4 ' Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
(-ero/yk) Sm14% (l 6 it /j//s 4 ift., or ,
Name Prin 1nt (/�,^� Current Mailing
L.1-. /
p" -0 I�-Q- �� / �-k �\.. 4 Telephone O 6, 6 3 `7
Signature
2.2 Authorized Agent:
3p isys' 10q Cc.., eo_ &)( co ,3 7 /4 /
Name (Pr Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 5 i O Check Number ie � "✓ 4fr/
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissionerllnspector of Buildings Date
1
41 PIONEER KNLS BP- 2013 -0512
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 043 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- 2013 -0512
Project # JS- 2013- 000818
Est. Cost: $5800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEXTON ROOFING CO 99689
Lot Size(sq. ft.): 11979.00 Owner: SMITH GERALYN M
Zoning: Applicant: SEXTON ROOFING CO
AT: 41 PIONEER KNLS
Applicant Address: Phone: Insurance:
P O BOX 6327 (413) 534 -1234 WC
HOLYOKEMA01041 ISSUED ON:10/31/2012 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 10/31/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner