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24C-182 (7) BP-2024-1242 212 CRESCENT ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24C-182-001 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-2024-1242 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2024 Contractor: License: WILDE HSE LLC DBA SEXTON Est. Cost: 4924 ROOFING 106265 Const.Class: Exp.Date:03/08/2027 Use Group: Owner: LOWRY NANCY N REVOCABEL TRUST Lot Size(sq.ft.) Zoning: URB Applicant: WILDE HSE LLC DBA SEXTON ROOFING Applicant Address Phone: Insurance: 45 OLANDER DR 315-569-7761 6HUB0W551 13924 NORTHAMPTON, MA 01060 ISSUED ON: 09/25/2024 TO PERFORM THE FOLLOWING WORK: STRIP AND REROOF PORCH ONLY POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring U.P.W. Building Inspector t,ndcrground: 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: 72. Fees Paid: $60.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner l� Cl�� The Commonwealth of Massachusetts fr- ;a Board of Building Regulations and Stan.= ds Sep �1y 'z I Massachusetts State Building Code, 780 k R"kor 1lfvise1ar �IU` IT Building Permit Application To Construct,Repair,Renovate • �lo �' < . ' a 11 Ai One-or Two-Family Dwelling ^"'�1r,�Ns This Section For Official Use Only ."'4oao,(s. Building Permit Number: 60- 4 r 1 -c-/Z. Date Ap'lied: / Building Official(Print Name) "gnature Date SECTION 1:SITE INFORMATION 1. Property Address: a ( �C, T $1 1.2 Assessors Map& Parcel Numbers 1\\b CZ v` ' kiNQii ,�'D , MA O I tii2.0 1.l a Ts this an accepted street?yes ,/ no Map Number Parcel Number 13 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.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public li Private❑ Zone: _ Outside Flood e? Municipal ErOn site disposal system 0 Check if yes SECTION 2: PROPERTY OWNERSHIP' 2.1 Owne 'of Record: k)6K71-k+Qh.15.--bdIatA 0 ia(20 Name(Print) l' City,State,ZIP (9ia ( sc l ter. (/l3o.-�a3( iLo�ftA&sue. . P.D14 No.and Street Telephone Eilail Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building e- Owner-Occupied ar Repairs(s) ( Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2:fa(Ayr Po(ZCik Re,R. - 1`fi»i V Ex tsFi p)r-i, S 1Af 5, t� t^ik 1 . £R..t�e mau , `i1 7T*LL AZ.�bt t T ECi'u4st,L �Ci 11 A�h lit s/ �. (I-`g.,-1- -i C-\ d3VicA..A_F* fjOATC,E,R53 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ / afc fl 0 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ Z �� ❑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.'�-�' Check Amount. Cash Amount: 6.Total Project Cost: $ Xr07/a2 ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) /D)_ / t--+ 5fkS-? i L ), License Number Exp ratio Date Name of CSL Holder �/� OLt. 1 , - List CSL Type(see below) l� No.and Street Type Description m lV ��,n/�\ ry O r Unrestricted(Buildings up to 35,t)DO cu.ft.) 11�� 1U1 Restricted 1&2 Family Dwelling City/Town,State,ZiP I M Masonr y RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances ,c q-iob/ i insulation elep one Email�ada� migt L•Cr. D Demolition 5.2 Registered Home improvement Contractor(MC) 07 8-yZ q��+ A( 1 t\ e• S I)11VC1 HiC Registration Number 4E p� i7aie iC Company Name or HiC Registrant Name o.and Street (11 -- ^3,l Email address City/Town,State, IP elephone �( Y 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 of 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 1,as Owner of the subject property,hereby authorize (i, Q// CF/ 7l o i 0 i"Lo to act on my behalf,in all matters relative to work authorized by this building permit application. 0/eh, Print Owner's Name(Electronic Signature) Date 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. l 5/M14 Ztk,i) 11//:Xoti r/ Print Owners or Authorized Agents Name(Electronic Signaturc) Date 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(MC)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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov'dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,fmished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half7baths 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 0 // • '� t_ Massachusetts �" c. N: i DEPARTMENT OF BUILDING INSPECTIONS y, �. ti` r. 212 Main Street • Municipal Building v PD 4 Northampton, MA 01060 Js'NfY � 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: Location of Facility: 5S a, 16,,l)mp3 ��_ Fc l�i� . ipftO )1 The debris will be transported by: Name of Hauler: ,4Sc 76/4f 7 �T1/'l/,��i4/6 1 tJiirdie5�Signature of Applicant:, �Q�!� Date: ? l�o2 5/ g p p &.44_, l f% The Commonwealth of Massachusetts = l 1, Department of Industrial Accidents C 1 Congress Street,Suite 100 Boston,MA 02114-2017 .�.> www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMUTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Sexton Roofing&Siding Address: 45 Olander Dr. City/State/Zip: Northampton, Ma 01060 phone /#: 413-534-1234 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I 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. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.] 9. El Demolition 10❑ 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 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. l 3 Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 1a 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. l 4•['Other 152,111(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 polity and job site information. Insurance Company Name: Travelers Policy#or Self-ins.Lic.#: UB-0W551139-24 Expiration Date: 6/1/25 Job Site Address:212 Crescent St. City/State/Zip:Northampton, Ma 01060 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 cert. 1'under the pains and penalties of perjury that the information provided above is true and correct. Signature: 4L.0 c - Date: 9/1 / Phone#: 413-534-1234 Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# issuing Authority(circle one): 1.Board of llealth 2. Building Department 3.Cityfl'own Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDrYYYY) 06/05/2(124 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 EAU (413)737-0300 —1 FAX No). ADDRESS: khutchinson@ormsbyins.com P O BOX 718 INSURERS)AFFORDING COVERAGE NAILS WEST SPRINGFIELD MA 01090 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B WILDE HSE LLC INSURER C: INSURER D: 45 OLANDER DRIVE INSURER E: NORTHAMPTON MA 01060 INSURERF: 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR TYPE OF INSURANCE ADOLtSUBR POLICY EFF POLICY EXPL�8 LTR NSD 1Afl/D POLICY NUMBER IMMIDO/YYYY) (MWDOSYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCED S AGE TO RENTED CLAIMS-MADE j OCCUR PREMISES(Ea occurrence) S - MED EXP(Any one person) S N/A PERSONAL&ADV INJURY S GENL AGGREGATE LRifT APPLES PER: GENERAL AGGREGATE S POLICY plJECT I I LOC PRODUCTS-COMP/OP AGG S OTHER: S AUTOMOBILELIABtnY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED N/A BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED PROPERTY DAMAGE AUTOS ONLY _ AUT NON-OWNED (Per accident) S UMBRELLA LMB OCCUR EACH OCCURRENCE S EXCESS LYE CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ l $ WORKERS COMPENSATION X STATUTE I 1 ER AND EMPLOYERS'LIABILITY ANYPROPRIETOA OFFICERIMEM ERPEXCLUDED5ECUTNE N/A WA WA 6HUB0W55113924 06/01/2024 06/01/2025 EltJ1C11ACCDBIf $ 1.000.000 (Mandatory in NH) EL DISEASE-EA EMPLOYEES 1.000.000 If yes,descnbe under 1.0�,�0 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LBMT = N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule.may be attached if more space 1s 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 stales 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.govflwd/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 L Daniel M.CroJvley,CPCtJ,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 CC DATE(MM/DD/YYYY) ACORE. CERTIFICATE OF LIABILITY INSURANCE �� O6/03/2024 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 Amanda Cordeirc NAME: Clayton Insurance Agency,Inc. (NCO,No,Est) (413)536-0804 AX 1 No): (413)534-7874 1649 Northampton Street E-MAIL arnrdeirn@riaylnninsurance rip] ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 0 Holyoke MA 01040 INSURER A: Submissions INSURED INSURER B: Safety Insurance Company 0014 Wide HSE LLC,DB&Sexton Roofing&Sidinc INSURER C 45 Colander 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 THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,TILE 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 ADDL'SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MARL X OCCUR PRA M SESGEO ro(Ea occurnce) S 100,000 MED EXP(Any one person) S 10.000 A BND0016953 05/30/2024 05/30/2025 PERSONAL a ADv lwuRv $ 1,000,000 GENE AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2.000,000 POLICY n J,ECt7 n LOC PRODUCTS-COMP/OP AGO 5 2,000,000 OTHER S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED s.' SCHEDULED 5935264 05/30/2024 05/30/2025 BODILY INJURY(Per accident) 5 AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE 5 X AUTOS ONLY X AUTOS ONLY (Per accident Medical payments s 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE S —~ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RI_tENIION S S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR PARTNER/EXECUTIVE NIA EL.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S I1 yes.describe under DESCRIPTION OF OPERATIONS below El.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached i1 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 lb THE CITY OF NORTHAMPTON ACCORDANCE WITH THE POLICY PROVISIONS. 212 MAIN STREET AUTHORIZED REPRESENTATIVE NORTHAMPTON MA 01060 i I C 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 9/17/24,3:51 PM IMG20240510065637.jpg The Commonwealth of Massachusetts l' - "-!!l. Department of Industrial Accidents I Congress Street,Suite 100 :/ g ';_igil-l=e� Boston,MA 02114-2017 ' ,,1"' www mass.gov/dia a,.„i., Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): tut Tik GeAern.J COaS +t--KM Co Address: to Oh $) -S a 9 City/State/Zip: M kk!'at jk 10 (\t151 Phone#: tier 1 410 ?Li to Are an employer?Check the appropriate box: Type of project(required): Liam a employer with 5 employees(full and/or part-time).* 7. 0 New construction 2_p I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 9. 12 Demolition 3.Dm 1 a a homeowner doing all work myself.[No workers'corm.insurance required.]t 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 either have workers'compensation insurance or arc sole 11.p Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E1Cof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We arc a corporation and its officers have exercised their right of exemption per MGL a 14.Q Other 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: ali15 { Expiration Date: 0 Job Site Address:020 C4E,5 CI Y City/State/Zip: d )4 j 44 O1 d Attach a copy of the workers'compensation policy declaration page(showing the policy number and expi ion ate.r. 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 of perjury that the information provided is //above true and correct. Signature: o�puo, Date:OS/O 1 / W 2# Phone#: Cfo i-y 9O 3gc9 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#: https://drive.google.com/drive/folders/1ZyXGHtu68J3njf9-oHbp9M-yfWg0Xr9u 1'1 Ace`� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDO/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 PHONE (978)645 6996 FAX (A/C.No Eriy IA/C,Not: 799 GORHAM ST-UNIT A ADDRESS: info@i-insurancegroup.net LOWELL,MA 01852 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: 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: MII.FORD MA 01757 INSURERF: 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 TYPE OF INSURANCE ADDL SUBR p01 ICY NUMBER POLICY EFF POLICY EXP UMITS LTR INSR WVD (MMIDD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 DXX COMAGE MERCIAL GENERAL LABILITY PAGETO REM REMISES EaENTED occurrence) $ 100,000.00 CLAIMS-MADE OCCUR MED EXP(My one person) $ 5,000.00 A L261008542-0 05/03/2024 05/03/2025 PERSONAL&ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000.00 —7 POLICY JE f n LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUI O BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accdenl) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEO RETENTION$ $ WORKERS COMPENSATION WC STATU OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000.00 oFFICER'MEMBER EXCLUDED? N N I A ASSIGN#1397554 04/30/2024 04/30/2025 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE\S 1,000,000.00 If yes,duscnbe under 1,000,000.00 DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) 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,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 ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Licensee Details Demographic Information ull Name: SASHA MARIE WILDE r Name: License Address Information ity: NORTHAMPTON tate: MA 'code: 01060 untry: United States License Information ',License No: CSSL-106265 License Type: Construction Supervisor Specialty Profession: Building Licenses Date of Last Renewal: Issue Date: i 7/6/2023 Expiration Date: 3/8/2027 cense Status: Active Today's Date: 7/7/2023 Secondary 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 Typ• CLC Rogistrabor 206470 WIDE MSE..LC Esprat,a+ CW301025 D'd'A SEXTON ROOFING&SONG AS OLANDER DR NORTHAMPTON MA 03104 Up4als Addrsaa and RMurn Cud THE COMMO$MIALTM Or MASSACHuSETTS O1Rca of Cow/mot Athos I Own***Rapulanen Regletration v.Md for Mdivlduol too only Galore Poi ►sO11E MPROVE WENT COMIRACIOR 040Ma11416 daa. N%%rid ralwn Is: TYPE...0 011ao of Conourwsr Alwlro swr losiosso Ropdseoe /OM Vfoolinpb Suds 710 Same •S 710 �� Swam MA MI IS A"tDE 4SE.LLC DoWA SEXTON IIOOP010 S 60 Np SAS►1A Ws DE j es ot/WOER OR i,`.../A i/..46.4 201--411d�— NORTIIAAAPTON,tNA 0l1W undersecretery Not valid without signature SEXTON ROOFGUARD Description Line total Sexton RoofGuard: Front Porch Roof Front Porch Roof: $3,694.00 Set up heavy fabric tarps to direct debris away from house. Set up plywood barriers or other systems to protect delicate vegetation Laydown plywood on decks or other sensitive areas to limit damage from falling debris. 1.Strip and remove existing shingles and dispose of in proper landfill. 2. Inspect roofing deck and re-nail any loose decking. If replacement is needed due to rot, de-lamination,or damage,the following prices will be charged: @$80 per sheet for 1/2"CDX @$105 per sheet for 3/4"CDX 3. Install new F8 metal edging to rakes and eaves of roof.(white/brown). 4.Install leak barrier protection on entire porch roof 5. Install starter shingles on eaves and rakes of roof. 6. Install IKO Cambridge Architectural roofing shingles as per manufacturers'specifications. 7. Re-attach and secure gutters Warranties to be provided after final payment: IKO Lifetime warranty including 10 years IronClad SRC 10 yr.workmanship warranty 8. Replace up to 5 wood siding shingles and stain $250.00 Estimate subtotal $3,944.00 Total $3,944.00 AUTHORIZATION PAGE Sexton RoofGuard $3,944.00 Name: Tom Lowry Address: 212 Crescent St., Northampton,MA NOTE:Quote valid for 30 days from date of estimate.1/3 deposit due at signing via cash,check,or ACH deposit. Description Line total © Replace fascia boards around entire porch roof $980.00 Quote $3,944.00 Options $980.00 Final Price $4,924.00 Customer Comments / Notes Tom Lowry: .grumtas I-L Lacuryc Date:9/12/2024 Tim Wilde(SRS Rep): .0 7Wi,Ctl2 Date:9/12/2024