23A-185 (4) BP-2024-0832
160 SOUTH MAIN ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
- 23A-185-001 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-2024-0832 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF 2024 Contractor: License:
WILDE HSE LLC DBA SEXTON
Est.Cost: 7845 ROOFING 106265
Const.Class: Exp.Date:03/08/2027
Use Group: Owner: E ODEA MICHAEL F&RENEE
Lot Size (sq.ft.)
Zoning: URB Applicant: WILDE HSE LLC DBA SEXTON ROOFING
Applicant Address Phone: Insurance:
45 OLANDER DR 315-569-7761 6HUBOW55113923
NORTHAMPTON, MA 01060
ISSUED ON: 07/03/2024
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:
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
VCr)
IL, The Commonwealth of Massa us s JUN
Board of Building Regulations Sta dards '8 242Q FOR
M ICIPALITY
Massachusetts State Building C e, 7t30- _r ulln USE
Building Permit Application To Construct, Repair, RenOva> ( r, ' Re ised Mar 2011
One-or Two-Family Dwelling r "q 01060 , s
This Section For Official Use Only
Building
Permit Nuuber: Q/0>'N ` ' j� Date Applied:
/Sau, / 7 7 7-320Zq
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: I (20 S.tr. ►1' ST. 1.2 Assessors Map& Parcel Numbers
fLoCLF,( C,F I mk 0 t blo a.
1.1 a Is this an accepted street?yes f 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.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private CICheck if yeses` Municipal l'fOn site disposal system 0
SECTION 2: PROPERTY OWNERSHIP'
(�,p N
2.1 e Record:
�� C3& _L0CLEA C_E 1(�tt \ 01 °Lo
Name( nt) City,State,ZIP l
IG0 S. (-1k%� -f. (L/,3) 31- aiz Rya'al cpmckss-t T
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building Owner-Occupied DTRepairs(s) 121I Alteration(s) 0 Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': Ve 1
itcliESM -bE V36 tlt:\s-r
g‘p t- z T 1 C. U..NOW-12... \ VaZii• `T', l S i-fa Li R.Ciri l 1 F.r—U a : R FI L`L)
1 wS:S -n.\. ., it.la eL,_ F,. -v
SECTION 4: EST ATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 1-7 8 iS co 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 11 u ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. a-`1- eck Amount: t) Cash Amount:
6.Total Project Cost: $?7I 0 i c' 60 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
7
j\s t L��, License Number Expiration Dat
e
Name of CSL Holder ��
� _
List CSL Type(see below)
No.and Street Type Description
t7It N [� l 0(1 l_J U Unrestricted(Buildings up to 35,000 Cu.ft.)
f t�T� R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
a'). S�k.;,D•ts, I Insulation
Telephone Email address tnt1/4) cA D Demolition
5.2 Registered Home Improvement Contractor(HIC) l 9C% / 7C)
�S�i 013 QIc 1 +.)& Gi S 1 )({ '1 HIC RegiWstrahonLNumber xpirat on Date
H_ IC�Companiameor�F�ll_C Registrant�]ame
Land Street N_ Yx-rhia.c'i a CFFl�C inAlL.OM
,,`(Q b L 7 fV"1 j n� /N� 040 bi'3)c3V-10.3 Email address
City/Town,State, P I t t 1 lephone — —
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 Issuan f 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 PER 11T
1,as Owner of the subject property,hereby authorize )V `TO . ( ( *) )ci.
to act on my behalf,in all matters relative to work authorized by this building permit application./�}�-1
a l
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.
Print Owner's or Authorize Agent's Name(Electronic Signature) to
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
\v IA.nma;,govloca Information on the Construction Supervisor License can be found at www.mass tips
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. II.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halflbaths
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
r " Massachusetts ��? '�!<<
t .
,�� DEPARTMENT Cr): UILDING INSPECTIONS ?s f;�
f 212 Main Steet • Municipal Building V�,k .C'
�--- Northampton, MA 01060 ` i ar,•
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:--b1k,,,,,` 5-
Location of Facility: (362 4i4
,71 , F4/2 A .)f
The debris will be transported by:
Name of Hauler: ASY„dC/4/CPU/./idJ n/6 41.66;,_c' /AIC.
Signature of Applicant: /��/-�iGc) Date:
The Commonwealth of Massachusetts
Department of Indu.+trial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
t•,. _ wwventass.gov/dia
al
lsorkers' Compensation Insurance Affidasit: Buildersl('ontractorsiEkctricians/Plumbers.
1t)BE.FILED NTtll tHE PER%iI rl INC AUTHORITY.
Applicant Information Please Print Lettibth
Name IBusinc Organization Individual l:5 O%3 G C l�`j / Sib,OC-1
Address: l{S p2P1/4 t i .
City/State/Zip t ' E ititettlion< ::: 46).5.4.5v:125v
%rr von an eymployee cheek the appropriate iron: Type of project(required):
.0 I am a employer with employees(full andoe put-timed.• 7. a New construction
20 I am a sok proprietor or partnership and have no employees working for m<in 8. 0 Remodeling
any capacity.[No*otters'comp.insurance required.)
30 lam a homeowner doing all work myself.[No workers'comp insurance nyuuetil j"
9. ❑Demolition
10 0 Building addition
4.0 I am a homeowner and will be hiring writ/actors to conduct all work on tin property 1 wall
ensure that all contractors either have workers'ccrnpensatxm insurance or are sole I I.a Electrical repairs or additions
pi eturs*nth no employees. 12.0 Plumbing repairs or additions
c I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13 f repairs Thew subcontractors employees m ontractors has.: and has c workers'cop.insurance.:
L-"
6.0 We are a corporation and its officers have exercised thru nghi of exemption per►KiL c.
14.0 Other
152,§1(4►.and we have no employees.[No waken'camp.insurance required]
•Any applicant that checks bon•1 moat also fill out the section below showing their workers'compensation policy information.
*Homeowners who submit this a(fidas it indicating they are doing all work and then hire outside contractors mast submit a new atYidas it indicating such_
:Contractors that check this box must attached an additional sheet show inn the name of the sub-cunttacturs and state whether or not those entities hase
employee, It its sub-contractors have employees.they must pros adc the a 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: 1 RAV EU.4. —
Policy#or Self-ins. Lie. #: 6 14(k8 O 1,0 Ss-7 1 3 q al . Expiration Date: &Won_
Job Site Address:/4 I 5'1H//1/ 4577 CityrState:zip:J/ �� O1 U0�
Attach a copy of the workers'compensation policy declaration page(showingthenumber and ex irat�.
P? IK P P 8 policy P
Failure to secure coverage as required under MCA.c. 152,§25A is a criminal violation punishable by a tine up to S1,500.00
and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
ecis came v eri tication.
i do hereby cerl fl'and•r the pain_ and pe rlties of perjury that the information provided abate i true and correct.
Stcnaturc: /,/-/ flit: (�1 �
L
Phemc : . ti,4),1-4y0--/.0,731
Official use on!r. Do not write in this urea. to he completed by city or town official
( its or-fo++n: Permit t.icense 0
Issuing authority (circle one):
I. Hoard of Health 2. Building Department 3.('its`Tossn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone 4:
AC�® DATE(MM/DDIYYVY)
CERTIFICATE OF LIABILITY INSURANCE 06/05/2024
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 Kathi Hutchinson
NAME:
ORMSBY INSURANCE AGENCY PHONE (413)737-0300 FAX
(A/C•No.Ed); (NC.No):
EMAIL hl t khucnsonp ,s
ADDRESS: bins.com y
P 0 BOX 718 NSURER(S)AFFORDNOCOVERAGE NAIC#
WEST SPRINGFIELD MA 01090 NSURERA: TRAVELERS INDEMNITY CO OF AMERICA 25666
INSURED INSURER B:
W ILDE H SE LLC INSURER C
INSURER D
45 OLANDER DRIVE INSURER E:
NORTHAMPTON MA 01060 INSURER F:
COVERAGES CERTIFICATE NUMBER: 1014749 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.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUER POIJCY EFF POLICY EXP
LTR TYPE OF INSURANCE Mg0 IAND pq•ICY NUMBER IMIUD MMIDDIYYYYI LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S
—DAMAGE To RENTED—
j CLANS-MADE OCCUR PREMISES jEa eoeierenos) S -
MED EXP(Any one parson) $
N/A PERSONAL&AW NJURY $
-GENE AGGREGATE LIMIT APPLES P GENERAL AGGREGATE $
ER:
POLICY PRO- I LOC PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOMLELMIBLITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Pon person) $
OWNED —SCHEDULED WA BODILY INJURY(Per soddenly $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY (Per accident)
S
USIBR8.LA LNB OCCUR EACH OCCURRENCE $ _
EXCESS LWB C S-MADE N/A AGGREGATE S
DED RETENTIONS S
WORKERS COMPENSATION X STATUTE PER FOR
AND EMPLOYERS'LIABILITY
A OOFFFl ERRNEMBERREXCLUDED ECUTIVE Yn WA WA 6HUB0W55113924 06/01/2024 06/01/2025 El.EACH ACCIDENT $ 1.�,�
(Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 1=000
If yes,describe under
DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY EMIT $ 1.000,000
N/A
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addlttonal Remarks Schedule.may be attached H 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-
compensationhinvestigations/.
Continuation of above Named Insured:DBA SEXTON ROOFING&SIDING
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Northampton ACCORDANCE WITH THE POLICY PROVISIONS.
212 Main Street
AUTHORIZED REPRESENTATIVE
Northampton MA 01060 CA_):`
Daniel M.Cro I y,CPCU,Vice President-Residual Market-WCRIBMA
CO 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
AC EP CERTIFICATE OF LIABILITY INSURANCE DATE(IA MrDDYYYY)
Of d)3,2U24
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 Amanda Cordeirc
NAME:
Clayton Insurance Agency,Inc. PHONE
o,Ea): FAX
(413)536-0804 F No): (413)534-7874
1649 Northampton Street E-MAIL acordPirr@rlaylnntnsttranrn.npt
ADDRESS:
INSURERS)AFFORDING COVERAGE NAIC
Holyoke MA 01040 INSURER A: Submissions
INSURED INSURER B: Safety Insurance Company 0014
Wilde HSE LLC,DBA:Sexton Roofing&Sidinc INSURER C:
45()Lander Drive INSURER D:
INSURER E:
Northampton MA 01060 INSURER F:
COVERAGES CERTIFICATE NUMBER: CL246306545 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOC
INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIE
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 AUDL-SUBR POLICY EFF POLICY ExP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDIYYYY) (MMIDD/YYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000
GE TO RENTED
CLAIMS-MADE XI OCCUR PR M Soc
currence)
ES Ea S 100,000
MED EXP(Arty one person) S 10,000
A BND0016953 05/30/2024 05/30/2025 PERSONALSADVIwuRY 5 1,000,000
GEM.AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE 5 2,000,000
POLICY PRO 2.000,000
JECT LOC PRODUCTS-COMP/OP AGG $
OTHER S
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
ANY AUTO BODILY INJURY(Per person) S
—B � OWNED SCHEDULED 5935264 05/30/2024 05/30/2025 BODILY INJURY(Per accident) $
AUTOS ONLY X AUTOS
HIRED Ne NON-OWNED PROPERTY DAMAGE $
X AUTOS ONLY X AUTOS ONLY (Per accident)
Medical payments S 5,000
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
-
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DED RETENTION S ,S
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANY PROPRIETOR PARTNER.EXECUTTVE NIA E.L.EACH ACCIDENT $
MEM D OFFICER/MEMBER EXCLUDE
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
!HE CITY OF NORTHAMPTON ACCORDANCE WITH THE POLICY PROVISIONS.
212 MAIN STREET
AUTHORIZED REPRESENTATIVE
NOR I HAMPTON MA 01060 ,/71- i' 1-7 22:2
I
Cc)1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
6/25/24,8:36 PM IMG20240510065637.jpg
The Commonwealth of Massachusetts
►` —ffi Department of Industrial Accidents
:=.T,fi�! :
;in,_ a 1 Congress Street,Suite 100
?�j= * Boston,MA 02114-2017
r\--ti.,�;. ac wwmassgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leelbly
Name(Business/Organization/Individual): t`A A GiDe&62 CATASkits A- Cody
Address: to Ohs - q
s ,P}• �. �1
City/State/Zip: IA J,1'yr4 KA d t')S 1 Phone#: tit,9 1110 3440
Are y an employer?Check the appropriate box: Type of project(required):
I. am a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 t am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity.[No workers'comp.insurance required.]
3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]/ 9 Demolition
10 0 Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors i.ithvr have workers'compensation insurance or arc sole 1 1.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.DRoof repairs
These sub-contractors have employees and have workers'comp.insurance?
6.p We arc a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,11(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'compeatation 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.
tContractors 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 sutb-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: 'rnbmeAces -Propsdd C IZS Cr Qv. AM
Policy#or Self-ins.Lic.#: I311S 4 Expiration Date: e{13n 12_0).5
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 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 under the pains and penalties ofperjury that the information provided above is true and correct.
$iznaUue: ` Date:a,/o y / W 21f
Phone#: t'/0 i-y fe 314 N#
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#:
' s :
^
,.air
https://drive.google.com/drivelfolders/1 ZyXGHtu68J3njf9-oHbp9M-yfWgOXr9u 1 1
Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
05/09/2024
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 GUILHERME CAMOSSATO
NAME:
I-INSURANCE GROUP INC IPi4H/cNE (978)645 6996 we No).
799 GORHAM ST-UNIT A EESS: info@i-insurancegroup.net
ADDRLOWELL.MA 01852 INSURER(S)AFFORDING COVERAGE NAIC X
INSURER A: ATLANTIC CASUALTY INS CO
INSURED INSURERS: TRAVELERS PROPERTY CAS CO OF AM
MJA GENERAL CONSTRUCTION CORP INSURERC:
6 OTIS STREET INSURER D:
APT 2 INSURER E: _
MILFORD MA 01757 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 ADDLSUBR POLICY EFF POLICY EXP
TYPE OF INSURANCE
LTR INSR WVD POLICY NUMBER •(MM/DD/YYYY) (MM/DD/YYYYI LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00
X COMMERCIAL GENERAL LIABILITY PREMISES(EaaE�rrence) $ 100,000.00
CLAIMS-MADE X OCCUR MED EXP(Any one person) S 5,000.00
A L261008542-0 05/03/2024 05/03/2025 PERSONAL a ADV INJURY $ 1,000,000.00
GENERAL AGGREGATE S 2,000,000.00
GEN•L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ 2,000,000.00
7 POLICY n JECT n LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per acolderrt) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per accident)
f
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE S
DED RETENTION$ _ $
WORKERS COMPENSATION WC STATU• OTH
AND EMPLOYERS'LIABILITY Y/N TORY I IMITS ER
B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000.00
N
OFFICERIMEMBER EXCLUDED? N/A ASSIGN#1397554 04/30/2024 04/30/2025
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEES 1,000,000.00
II yes,describe under 1,000,000.00
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addldonal Remarks Schedule,If more space Is requked)
General Liability:for regular and usual jobs.Worker's Compensation. MA employees only.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Wilde HSE,I I C DBA Sexton Roofing and Siding Co THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POUCY PROVISIONS.
45 Dander Dr
Northampton MA 01060 AUTHORIZED REPRESENTATIVE
GUILHERME CAMOSSATO
1
ACORD 25(2010/05) n 1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Licensee Details
Demographic Information
Full Name: SASHA MARIE WILDE
Owner Name:
License Address Information _
City: NORTHAMPTON
State: MA
Zlpcode: 01060
Country: United States
License Information
cense No: CSSL-106265 License Type: Construction Supervisor Specialty
rofession: Building Licenses Date of Last Renewal:
Issue Date: 7/6/2023 Expiration Date: 3/8/2027
icense Status: Active Today's Date: 7/7/2023
econdary License Type:
oing Business As:
tatus Change Reason: License Issuance
Prerequisite Information
No Prerequisite Information
No Available Documents
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
Home Improvement Contractor Registration
-fit
t=- , Typo LLC
!' ' _._ = Regstradon 205470
sE SEXTON
C I. - Exp.rabon. 04 312025
4 BA SEXTON ROOFING`SIDING ,,` =
45 OLANOER DR I.v3RTP4MAPTON MA 03104 L
update Address and Return Ca-d.
THE COMMO+AY ALTH or MASSACHUSETTS
Offiu of Consumer Affairs I business Reputetlon RpletrNlon veWtd for individual use only before t+e
HOME IMP tOVEMENT COfiTRACTOR osWroden dole. II round tsturn 1o:
TYPE, .LC Moe of Consumer Affairs and 6ueMess Regulation
I 000 WeM+olpton street ii Suite 710
NIXEC2C2S WEOen,MA 02116
WOE►SSE,LC
DIVA SEXTON ROOFING A SONO
S OuutDt DR 4,40.v4 i reNnA �t i�"—ttu/K/�`i—
~ MA Unpfy Not valid without signature
AUTHORIZATION PAGE
Architectural Shingle System S7,845.00 Name: Renee Odea
Address: 160 S. Main St., Florence, MA
NOTE:Quote valid for 30 days from date of estimate.1/3 deposit due at signing via cash,check,ACH deposit or Credit Card.Credit
transactions subject to third party fees.
Description Line total
❑ Gutter Installation. I noticed excessive wetness and rot at the base of the garage from water $860.00
backsplash. Help protect the wood by shedding water away from the foundation with a new K-style
gutter
❑ Gutter Guard Installation: Installation of new guards to prevent debris accumulation $580.00
Final Price $7,845.00
Customer Comments / Notes
Renee Odea: `Bulge OD ea, Date:6/24/2024
Timothy Wilde: ,Mina-dj 7 Wt.(h Date:6/25/2024
ARCHITECTURAL SHINGLE SYSTEM
Description Line total
Architectural Shingle Replacement
1.Strip and remove existing shingles and dispose of in proper landfill. $7,845.00
2.Inspect roofing deck and replace as needed
@$100 per sheet for 1/2"
@$125 per sheet for 3/4"
3. Install new metal edging to rakes and eaves of roof.(white/brown).
4. Install leak barrier protection on eaves(6'),vent stacks, in valleys,chimney,at intersecting roofs.
5. Install roof deck protection on remainder of roof.
6. Install new flanges over existing vent stacks.
7. Install starter shingles on eaves and rakes of roof.
8. Install IKO Architectural style roofing shingles as per manufacturers'specifications.
9. Install new cap over ridge vent.
10.Warranties:
Manufactures Lifetime warranty
SRC 10 yr.workmanship warranty
Quote subtotal $7,845.00
Total $7,845.00