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31A-072 (6) BP-2024-1165 222 ELM ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31A-072-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2024-1165 PERMISSION IS HEREBY GRANTED TO: Project# 2024 ROOF Contractor: License: WILDE HSE LLC DBA SEXTON Est.Cost: 4125 ROOFING 106265 Const.Class: Exp.Date: 03/08/2027 Use Group: Owner: ELENA SHARNOFF Lot Size(sq.ft.) Zoning: URB Applicant: WILDE HSE LLC DBA SEXTON ROOFING Applicant Address Phone: Insurance: 45 OLANDER DR 315-569-7761 6HUBOW55113924 NORTHAMPTON, MA 01060 ISSUED ON: 09/12/2024 TO PERFORM THE FOLLOWING WORK: PREP METAL& SILICON COAT FRONT PORCH AND REAR ENTRANCE ROOFS 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: :/i Fees Paid: $125.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner 1.1 C& SEP Cr,i2D�4 `n The Commonwealth $f chusetts ',. Board of Building R : •= ;i ns,arpd "?% FOR Massachusetts State Building • _78d' �^ MUNICIPALITY ��� "vs USE cj Building Pei udt Application To Construct,Repair,Renovate °t olish a Revised Mar 2011 " One-or Two-Family Dwelling This Section For Official Use Only Building Pi ii.1 NumberPgat4-1I(oS Date Applied: (2,5 q-B-Zait Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: ap 2.1..(Y\ �"1". 1.2 Assessors Map&Parcel Numbers U4.-ink o4l I DIVAN. 0lb Cap 1.1 a Is this an accepted street?yes ✓ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public CY Private❑ Zone: _ Outside Flood Zane? Municipal EKOn site disposal system ❑ Check if yesar SECTION 2: PROPERTY OWNERSHIP1 2A__Ownerl of Record: c� u� k)o •ftn1 frt3nl MA O10(p0 Namenn (Print)r �n City,State,ZIP aaa Ci1�11 1. (siipin_vottg? St f'rini14'.(Jot5TS1?]ESteho{4.0 %l o.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building tD" Owner-Occupied fY itepairs(s) i31 Alteration(s) ❑ Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2.12 eta fbRL+I �4.20a f.•EAm- *.t .. F. mP� L L Cfli/f G11U ( f.rv1,ov E. y,L k i ts-f 41�($c. L11.mi t3 tIACp i nlC t j tYriA1L L j St L.► ror.1 gasE Cam' ¢?o P Cofer D tl M& SLIT,P.t (lflrrs4A L F J to(AAA)t t3F1 t1 D6 E5 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building ,$ ,V j9s"� 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ `/ ❑Standard City/Town Application Fee ❑Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ '^� Check No.a.1 q1 Check Amour:(.,0 Cash Amount: 6.Total Project Cost: $ ///45-O 0 Paid m Full tl❑Outstanding Balance Due: cf'r. Pqz (0s— q/,0/ZV SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Iota it2s �' Lr License N ber Expiration Date Name of CSL Holder f� List CSL Type(see below) , No.and Street — Type Description to lV( C.1 kkQ�l6��� .\ n C)`C)(oO U Unrestricteds Restricted 12 Family up el 35.000 cu.ft.) t�m R Restricted i&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding 11 nn SF Solid Fuel Burning Appliances r.! I Insulation elephone Email address .� l(�,C,DAD Demolition 5.2 Registered Home Improvement Contractor 1 (HIC) Ot7S't 1 MC Registration Number xpiration .te. HIC Company Name or WC Registrant Name �' O( b(&. a a�1RaoFl -�eic 4L G_lMA1L .ca,� and Street (q )cij / Email address � (�[0100 City/Town,State,ZIIPP Telephone 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 Issuance 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 PERMIT I,as Owner of the subject property,hereby authorize'3� h w� �k t'l Si&Ts,1 N C1 to act on my behalf,in all matters relative to work authorized by this building permit applicati . 7%/f,' Print Owner's Name(Electronic Signature) Bate SECTION 7b:OWNER'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. er/fs or uthio�rtz dAcgent's m% (Electronic Signature) ate NOTES: . 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.govloca Information on the Construction Supervisor License can be found at u,V mass.gov~dam, 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 y'1��'"� Massachusetts �`�+S`s . r,�,'' w 't�. .1 ,i DEPARTMENT OF BUILDING INSPECTIONS a x. ' 212 Main Street • Nunicipal Building ii OD t Northampton, NA 01060 ems. ;)���� CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, 554, 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: ~ .)1/4,vti.pS-S-7.k Location of Facility: 3,..C-,2 ALlya t5 "Tr. Sr Lim. `MA, 011 D The debris will be transported by: Name of Hauler:i y/4% 'P g.,,,71.a16 ajae, ,/ /C,, Signature of Applicant:.SivrrjAy��, � Date: The Commonwealth of Massachusetts Department of Industrial Accidents ;; . 1 Congress Street,Suite 100 =t� Boston,MA 02114-2017 "MN/ 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): Sexton Roofing &Siding Address: 45 Olander Dr. City/State/Zip: Northampton, Ma 01060 Phone#: 411-534-1234 Are you an employer?Check the appropriate box: Type of project(required): t.O I am a employer with employees(full and/or part-time).' 7. Ei New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity,[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.] 9. 0 Demolition 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. 12.0 Plumbing repairs or additions 5.1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. ✓OROOf repairs These sub-contractors have employees and have workers'comp.insurance. 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.00thCI 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. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Travelers Policy#or Self-ins.Lic.#: UB-0W551139-24 Expiration Date: 6/1/25 222 Elm St Northamptn, Ma 01060 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,certtify under the pains and penalties of perjury that the information provided ab ve is true and correct. Signature:, Date: J /& Phone#: 413-534-1234 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#: ACORO0 DATE(MIMIDDNYYY) 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. It 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 Ka hi Hutchinson NAME: ORMSBY INSURANCE AGENCY ( NNQ ad): (413)737-0300 FAX No). E-MAIADDRESS: khutchInson@jormsbyins.com ADDRESS: t3'`^"'� yl PO BOX 718 INSURERS) wucs WEST SPRINGFIELD _ MA 01090 *IIumERA: TRAVELERS INDEMNITY CO OF AMERICA 25888 INSURED INSt1RER S: WILDE HSE LLC SNsURERC: INSURER O: 45 OLANDER DRIVE IiSURERE: 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. NSR ADDL SUs7F— POIJCY EF POLICY Elm _ - LTR TYPE OF INSURANCE ,1N3D WVD, POLICY NUMBER (MIN DO/YYYY IMMIDO/YYYY) LINTS COMMERCIAL.GENERAL LIABILITY EACH OCCURRENCE $ CLAMS-MADE OCCUR PR S(RENTED PREMISES(Ea occurrence) $ MED EXP(My one person) $ N/A PERSONAL&AM INJURY $ OEM.AGGREGATE LIMIT APPLES PER GENERAL AGGREGATE _ lPOLICY PRO LOC PRODUCTS-COMPIDP AGO $ OTHER: _ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ms=Mont) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY*WRY(Per acdd..) $ AUTOS ONLY AUTOS ---- 1 HIRED NON-OWNED O AUTOS ONLY _ AUTOS AUTS (Peroxides* _— -_ -- $ UMBREUALMB OCCUR EACHOCCURRENCE $ EXCESS UA6 S-PA N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X PSER UTE ERt'I' AND EMPLOYERS'LIABILITY Y/N A OFE � EXCLUDED? ACCIDENT $ 1'000'000 oi R/M� N/A NIA WA 6HUB0W55113924 06/01/2024 06/01/2025 (Mandatory in NH) ELL DISEASE•EAEIPLOYEE $ 1.000.000 II yes describe under 1 �0 DESCRIPTION OF OPERATIONS below El P'O DISEASE- LIMIT $ N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be allsciwd I 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/. 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 Daniel M.CTOWIy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACORN i CERTIFICATE OF LIABILITY INSURANCE DATE 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 Cordelrc NAME: Clayton Insurance Agency,Inc. PHONE (413)536-0804 FAX (413)534-7874 (A/C,No.Ert). (A/C,No): 1649 Northampton Street DRESS: Tc �nrrlair [iaytnnirmfranrR net INSURER(S)AFFORDING COVERAGE NAIL a Holyoke MA 01040 I SURER A: Submissions INSURED INSURER B: Safety Insurance Company 0014 Wilde HSE LLC,OSA:Sexton Roofing&Sidinc INSURER C 45 Olander Drive INSURER 0: INSURER E Northampton MA 01060 INSURER F: COVERAGES CERTIFICATE NUMBER: CL246306545 REVISION NUMBER: THIS IS TO CERTEY 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 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 NSR ADDL-SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLE NUMBER (MM/DDWYYY) (MMIDD/YYYY) WITS X COMMERCIILL.GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 E TO RENTED CLAIMS-MADE XI OCCUR PREEM DASES(Ea°caurenoe) S 100000 MED EXP(Any one person) S 10,000 A BND0016953 05/30/2024 05/30/2025 PERSONAL aAov INJuRY 1,000,000 GEM.AGGREGATE LTAPPLIESPER GENERAL AGGREGATE $ 2.000,000 M POLICY n JE.G7 LOC PRODUCTS-COMP/OPAGG f 2,000,000 OTHER. AUTOMOBILE LIABLITY • COMBINED SINGLE LIMIT $ 1,000,000 (Ea areidont) ANY AUTO BODLY INJURY(Pe parson) S g OWNED X SCHEDULED 5935264 05/30/2024 05/3012025 BODILY INJURY(Per accident) S . AUTOS ONLY AUTOS HIRED X NON-OWNED PROPERTY DAMAGE S AUTOS ONLY X AUTOS ONLY (Per accident) Medical payments s 5,000 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE S EXCESS LIMB CIA/OAS-MADE AGGREGATE S DED RETENTION S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTNE NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E:l.DISEASE-POLICY LMUT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remante Schedule,may be attached I more space Is required] CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELJVERED IN THE CITY OF NORTHAMPTON ACCORDANCE WITH THE POLICY PROVISIONS. 212 MAIN STREET AUTHORCCED REPRESENTATIVE I NORTHAMPTON MA 01060 4 ,7, ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 9/6/24, 11:02 AM 1MG20240510065637.jpg The Commonwealth of Massachusetts -- —!I Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit;inildera/Contractors/Electriclans/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ADotleit at lnform*tlou Please Print Le2lbly Name(Business/Organization/Individual): MIA LTsfierni coaskt aget _Coale Address: k0 Ohs S,4 Atpk City/State/Zip: M 404 t M1 (511 S 1 Phone#: ti L2 1 u 70 ?y to Are anemphayer?Check the appropriate box: Type of project(required):I.Iaam■employer with S employees(full and/or part-time).• 7. ❑New construction 20 I am a sok aici or or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance requited] 3.01 am a homeowner doing all work myself.[No workers'camp.insurance required.]? 9. CI Demolition 4.01 am a homeowner and will be hiring contract to cadet all work on my property. ]will 10 Building addition ensure tint all contractors either have workers'compensation insurance or are sole 11-0 Electrical repairs or additions propzietors with no employees. 12.EI Plumbing repairs or additions 5.0I am a general contracts and I have hired the listed on the attached Meet. 13.0R0of repairs These subconta tccs have employees and have workers'comp.nnsotaooe.t 6.0we are a oa ocatimi arced'its ocas have exercised their tight of exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No wad'gyp.insurance ] *Any applicant that checks box 61 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are dolug all work and then hire outside contactors must submit a new affidavit inatiesting such. teerarac$oes that check this box mast attached an additional sheet showing the mime oldie 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 Insurance Company Name: '1111.vLt((C 'Pt'K{j L QS Cr, QV A M Policy#or Self-ins.Lic.#: IS11564 Expiration Date: Job Site Address: t�Ca ;,6%7 ill City/State/Zip: Attach a copy of the workers'compensation policy der ar'atlon page(showing the policy a ber and exp tion date). Failure to secure coverage as required under MOL c.152,§25A is a criminal violation punishable by a fine up to S 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 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 coverage verification. I do hereby certify under the pains and penalties of pedury that the information provided//above is true and correct. Si¢Dature: v Alai Date:OS/O1 I phonok evoi_q z,Jggq Owl use only. Do not write in this area,to be completed by city or town official Coy or Town: Permit/License# fasting 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#: https://drive.google.com/drive/folders/1ZyXGHtu68J3njf9-oHbp9M-yfWg0Xr9u 1/1 Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/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 PMNE FAX t w (978)645 6996 F No): 799 GORHAM ST-UNIT A EMAIL SS: info@i-insurancegroup.net ADDRE LOWELL,MA 01852 INSURER(S)AFFORDING COVERAGE NAIC I _-- INSURERA: ATLANTIC CASUALTY INS CO INSURED INSURER B: TRAVELERS PROPERTY CAS CO OF AM MJA GENERAL CONSTRUCTION CORP INSURER C: 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. NSR ADOL SUER POLICY EFF POLICY EXP TYPE OF INSURANCE IN SR WVD POLICY NUMBER (MM/OD/YYYY) (MM/DD/YYYY) LIMITS GENERAL L IABIUTY EACH OCCURRENCE $ 1,000,000.00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100,000.00 PREMISES(Ea occurrence) S CLAIMS-MADE X OCCUR MED EXP(My one person) $ 5,000.00 A L261008542-0 05/03/2024 05/03/2025 PERsoNAL a ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 GENt AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000.00 I POLICY n 78, n LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT(Ea ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY FICCEER MEI B EXCLUDED?�U Yn NIA ASSIGN#1397554 04/30/2024 04/30/2025 E.L.EACH ACCIDENT $ 1,000,000.00 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 O RIPTION OF O 1,000,000.00 DESCRIPTION OF OPERATIONS below E.L.DISFAqF-POLICY LIMIT $ )EECRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (Attach ACORD 10i,Additional Remarks Seta/dub,if more space la required) General Liability:for regular and usual jobs.Worker's Compensation:MA employees only. :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Wilde ESE,LLC DBA Sexton Roofing and Siding Co THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 45 Olander Dr AUTHORIZED REPRESENTATIVE Northampton MA 01060 GUILHERME CAMOSSATO CORD 25(2010/05) ©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 ner Name: License Address Information NORTHAMPTON tate: MA '4.••• =: 01060 .untry: United States License Information License No: CSSL-106265 License Type: Construction Supervisor Specialty Profession: Building Licenses Date of Last Renewal: Issue Date: 7/6/2023 Expiration Date: 3/8/2027 License Status: Active Today's Date: 7/7/2023 Secondary License Type: Doing Business As: Status 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 Reglstra;lor Type :LC .;,E. cc _.` Rest straw, 2044Ts • Co' 9 A 5_x'C'i RC OFl G&S'Dl�G E>tpret•o� Oa YY?025 cSa.,A\:ERDR ► DRT•!040TO!, Iva 331CA Update Address and Return Card. 1st C040M0K stALTu OF MASSACHUSETTS Ofrt*or Consumer Armin&Bueinaas Regulsson R.Qletrettor vand for+redly dual uae only b.'ori t",e MOWE IM►ROYEMEkT CO%TRACTOR •aptraaen data. S found return to TYPE. _1.r Witt*of Conau+^w Attain a-.d Bus nose Regulat on t :a11z E�R1tman 1000 Ws,0.4 5 tan Street •Suite 71v :68477 1C2C15 Boston,MA 02t f1 e._:?E•-5E } SAS° A DER / 'l t:!XA•NDER OR y..r.: .N.w•t �--trb/lviti.--—— vORTriAf G. MA rJ11C4 uvsan.c awry Not valid without signature Ji CL iZOL -c � c�<,�� :� VAC\tc '� '� 11/4A-A'Z- SYSTEM Description Line total Front Porch and Rear Entrance Metal Roof Coatings 1.Strip and remove all rust and loose aluminum coating $4,625.00 2. Clean surface and prep. 3.Install liquid applied silicon(Roof X Tender 983)Base coat over entire metal roof, including edges. 4. Install liquid applied silicon(Roof X Tender 985)Top coat over entire metal roof, including edges. 5.Silicon will be applied using rollers with 3/"nap and will be worked into cracks and openings. 6.Supply manufactures Lifetime warranty and SRC 10 yr.workmanship warranty. Advertising discount(yard sign in front Sep-Dec) ($500.00) Estimate subtotal $4,625.00 Credit ($500.00) Credited subtotal $4,125.00 Total $4,125.00 AUTHORIZATION PAGE Architectural Shingle System $4,125.00 Name: Jessica Salloom Address:222 Elm St, Northampton, MA NOTE Quote valid for 30 days from date of estimate. Customer Comments/ Notes ---IL-4- (v--/ ( - ;-cf< 41--" Jessica Salloom: ( 7' Data: C)10 3 (202,e Sasha Wilde(SRS Rep): ..." (lye& Date: osio4/2°24 v CONSTRUCTION CONTROL WAIVER From. `` (n� / 1 LJ 0 L. N (Qb F,e... --UZ - To: Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 The Massachusetts Building Code,section 107.1 allows for an exclusion from requirements for construction control in certain situations. In accordance with code section 104.10, I request that you grant a modification to waive the requirement for construction ontrol of the project at ee 6/61/1/Wrf SI g/4 ()-2& because the work is of a minor nature,will not afff ctu/al elements, health, accessibility, life or fire safety, and will be done in accordance with the prescriptive requirements of the code. Thank you for your consideration. Respectfully,