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13-080 (5) BP-2024-1465 48 ROCKLAND HEIGHTS COMMONWEALTH OF MASSACHUSETTS RD Map:Block:Lot: CITY OF NORTHAMPTON 13-080-001 Permit: Exterior Res PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2024-1465 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2024 Contractor: License: WILDE HSE LLC DBA SEXTON Est.Cost: 17473 ROOFING 106265 Const.Class: Exp.Date: 03/08/2027 Use Group: Owner: JORDA JANEL P& KARLA D YOUNGBLOOD Lot Size(sq.ft.) Zoning: RI/SR Applicant: WILDE HSE LLC DBA SEXTON ROOFING Applicant Address Phone: Insurance: 45 OLANDER DR 315-569-7761 6HUB0W551 13924 NORTHAMPTON, MA 01060 ISSUED ON:11/01/2024 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: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 172- Fees Paid: $60.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner Ss, The Commonwealth of assa husettsr 2024 W Board of Building Regulati'nsSt rds FOR Massachusetts State Buildi 8: _ .i epttlYO / MUNICIPALITY gh91,r�,misp&-CTl USE Building Permit Application To Construct,Repair, Renova - "t t o°l�ih a i Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 3/.9-'4A y' /40 Date Applied: < iQP(OZD Cam. /1 W Building Official(Print Name) Signature Dat SECTION 1:SITE INFORMATION 1.1 Property Address:LI S Kt)tr, 4tb t� NC i exkiTS1.2 Assessors Map& Parcel Numbers \ NA a I'Mik nitcoo R.O. 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) I 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 le Private 0 Zone: _ Outside Flood Z�ue`? Municipal*B�On site disposal system 0 Check if yesia SECTION 2: PROPERTY OWNERSHIP1 2. Ow ert of Record NF oR-c)-(1., 00( ---r\---t-k4.0(\kk» NI, 1' p)07,00 Name(Print) Ci State,ZIP o.g �'1--`Ako �1�=1 C�,- S (�fl_ �/13 I_ S" b "i C i 1 CS r Co rn and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building ve Owner-Occupied l'( Repairs(s) Eil Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work2: '` 5 \ ✓ t.t*N T-2 lam'0m 1) I:)s- cL AkC 11'trfl A r;\ L S+4 I Kei LFS, I `IN(L SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ /IT iftij�1 06 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ! /V 0 Standard City/Town Application Fee 0 Total Project Cost- (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $i it / Check No.�� Check Amount: LA Cash Amount: 6.Total Project Cost: $ J V 1/7 3" /0 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1062c2,4cA License NumberExpiration Date Name of CSL Ifolder Q /� List CSL Type(see below) P., 1\7 OL:fi k ".(2— '7c .1? .o.and Street Type Description q�Ni-‘3• , � QCAA, U Unrestricted(Buildingup to 35,000 cu.ft.) �1�j R Restricted l&2 Family Dwelling ity Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 6113).-$4-1 33 vj r r'Q\� i \tn C9 I Insulation Telephone Email address Clrn JL l'Q Demolition 5.2 Registered one ImprovemAe\nt(��C,ontactor(HIC) �'�, � � j H/D � jrn,�, )`\► � 11)I 1' l C Regist`rationn Number xpirat ootSJ�l7a�te IC Company Name or III Registrant Name . Ot_ t• Cir`� - rr*ACICF 1KY-i6-1C?>(�),6mfl)1_Coa‘ .and Street Email address City/Town,State,ZI Te ephone 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 Ie. 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 a 'R_ 1 3( -1- i k_ to act on my behalf,in all matters relative to work authorized by this building permit application. )0ASAV 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. J � iihq 4,:14. /.(jao /o% ___ Print Owner's or Authorize me Si ature Dat�A (ElectronicSignature) 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 IIIC Program can be found at v1\A v .rims .gov'oea Information on the Construction Supervisor License can be found at www.mas .gol. dps 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 ?oa<"`M;off s`s : : sin f �" e` Massachusetts �4,, 'e G � , .,, DEPARTMENT OF BUILDING INSPECTIONS s .- ,-r A 212 Main Street • Municipal Building . ca _.y=..% Northampton, MA 01060 ssfiy VD`,�o 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: ' fw.,c)5 Location of Facility: , 7),. t -P S t- Sv u (hk Q I /Pic The debris will be transported by: C 01/' af).:(1/7k5)/ 4/c? - Name of Hauler: ���5G/A/ OP') (tl�/ Signature of Applicant: a�� ij„/I Date:/6l�/ The Commonwealth of Massachusetts c* ;, !l, Department of Industrial Accidents _;�]= I) 1 Congress Street, Suite 100 =414_i Boston, MA 02114-2017 ,, _ 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#: 413-534-1234 Arc you an employer?Check the appropriate box: Type of project(required): ICI 1 am a employer with employees(full and/or part-time).' 7. ❑New construction 20 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3-0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 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. 12.0 Plumbing repairs or additions 5 a I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGI.c. 14.❑Other ---- 152,*I(4),and we have no employees.[No workers'comp.insurance required.) I *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t I lomeowners 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 policy and job site information. Insurance Company Name: Travelers Policy#or Self-ins. Lic.#: UB-0W551139-24 Expiration Date: 6/1/25 Job Site Address:48 Rockland Heights Rd. 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 certify under the pai s and penalties of perjury that the information provided above i rue and correct. Signature: L ,K itZoidDate: Mk' 7 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): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACOR� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYI'YY) 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 (A/C,No, Ext): (413)737-0300 (AX A/C,No): E-MAILkhutchinson©/, ,�rmsb ins.com ADDRESS: V" Y P 0 BOX 718 INSURER(S)AFFORDING COVERAGE NAIC# WEST SPRINGFIELD MA 01090 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: WILDE HSE LLC INSURERC: INSURER D 45 OLANDER DRIVE INSURERE: 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. INSR LI TYPE OF INSURANCE ADDL SUN. 00Y EFF POLICY EXP Vim$ LTR INSD WVD POLICY NUMBER (MM MI/DD/YYYY) (MDD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAMS-MADE r OCCUR PREMISES Ea ococcurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE $ POLICY JE a T� LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident)_ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE! N/A AGGREGATE $ DED RETENTION S $ !WORKERS COMPENSATION X PER OT TUTE AND EMPLOYERS'LIABILITY A OFFCER/MEMBEEXC E.LEACHACCIDENT $ 1,000,000 LUD D?ECUTIVE N/A N/A N/A 6HUB0W55113924 06/01/2024 • 06/01/2025 (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ N/A 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If 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.Crowley.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 ACC DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 06/03/2024 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. PHO No,Ext): (413)536-0804 (A/c,No): (413)534-7874 1649 Northampton Street E-MAIL ar:nrdeiro@daytoninsurance net ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC It Holyoke MA 01040 INSURER A: Submissions INSURED INSURER B: Safety Insurance Company 0014 Wilde HSE LLC,DBA:Sexton Roofing&Sidinc INSURER C: 45 Olander 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.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDffIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADDL-SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSD WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAGE TO CLAIMS-MADE X OCCUR PREMISES(Ea occuEDnce) S 100,000 MED EXP(Any one person) S 10,000 A BND0016953 05/30/2024 05/30/2025 PERSONAL&ADVINJURY 5 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) S B OWNED X SCHEDULED 5935264 05/3012024 05/30/2025 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS XHIRED X NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY _ AUTOS ONLY (Per accident) Medical payments S 5,000 UMBRELLA LIAB t_ OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION S S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORiPARTNER/EXECUTIVE piNIA E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if 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 THE CITY OF NORTHAMPTON ACCORDANCE WITH THE POLICY PROVISIONS 212 MAIN STREET AUTHORIZED REPRESENTATIVE NORTHAMPTON MA 01060 �' �' / �y�z��_ �l %<,I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 10/28/24,7:26 PM IMG20240510065637.jpg The Commonwealth of Massachusetts 1` E!1. Department of Industrial Accidents =aril "i 1 Congress Street,Suite 100 i.__ �_`__ �� Boston,MA 02114-2017 ,_ www mass gov/dia Corkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business!Organization/Individual): tJC,rfk Cnrev-J Coadvuaggt COI Address: la Ohs } a- 9 City/State/Zip: Mkkc'arA M41 \UJS 1 Phone#: 11('1 1470 3 L.i L9 Are yop an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with C employees(full and/or part-time).' 7. 0 New construction 2.0 I 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. I am a homeowner doingall work9. El Demolition myself.[No workers'comp.insurance required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. i will [0 Q Building addition ensure that all contractors either have workers'compensation insurance or arc sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 50 lam a general contractor and I have hired the sub-contractors listed on the attached sheet 13. OOf 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.El Other 152,§1(4),and we have no employees.[No workers'corup.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 policy and job site information. Insurance Company Name: --rrayecirs 17t`4 C ci Cr) (1V. AM _ Policy#or Self-ins.Lic.#: i3g15 Expiration Date: di(So 121)15 Job Site Address: gc,e',kLIAKi Auriirrsko. City/State/Zip: i A 0)O(Q0 Attach a copy of the workers'compensation policy declaration page(showing the policy n m r and expire n 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 of perjury that the information provided above is true and correct Signature: '4co Abe Date:05/O y / ' Phonc#: (/0i—v go-3NN9 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/1 ZyXGHtu68J3njf9-oHbp9M-yfWgOXr9u 1/1 A ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYY1� 05/09/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 7 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 PHC No.Ertl. (978)645 6996 FAX No): 799 GORHAM ST-UNIT A ADDRESS: info©i-insurancegroup.net LOWELL,MA 01852 INSURER(S)AFFORDING COVERAGE NAIC 0 INSURERA: ATLANTIC CASUALTY INS CO INSURED INSURERS: TRAVELERS PROPERTY CAS CO OF AM MJA GENERAL CONSTRUCTION CORP INSURER C: 6 OTIS STREET INSURER D: APT 2 INSURER E: MILFORD 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 SUER POLICY EFF POLICY EXPM/ LIMITS LTR INSR,WVD POLICY NUMBER (MDDIYYYYI (MM/DD/YYYYI GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 GE TO X COMMERCIAL GENERAL LIABILITY PREM PREMISES(EaENTED occurrence) $ 100,000.00 CLAIMS-MADE X OCCUR MED EXP(My one person) $ 5,000.00 A L261008542-0 05/03/2024 05/03/2025 PERSONAL&ADVINJURY $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 GEM_AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ 2,000,000.00 —I POLICY n JEC n LOC $ AUTOMOBILECOMBINED SINGLE LIMIT LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED ^1 SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS . NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ — EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY I IMITS ER B ANY OFFICER/MEMBERPEXCLUDED?ECUTIVE Y] N I A 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 If yes,describe under 1,000,000.00 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Addltlonal 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 POUCY PROVISIONS. 45 Olander Dr Northampton MA 01060 AUTHORIZED REPRESENTATIVE GUILHERME CAMOSSATO I 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 (Full Name: SASHA MARIE WILDE Owner 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: 7/6/2023 Expiration Date: 3/8/2027 icense Status: Active Today's Date: 7/7/2023 econdary License Type: Doing Business As: tatus Chan a 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 Typo LLC Roptstratlon 206470 Exptretlon. 0410/2025 011,4 SEXTON ROOFING&SIDING 4S OIANER DR NORTKAM.PTON MA 03104 UpdM.Addrss,and Return Cara. 'HE CONMtONVI ALT►t OF MASSACMU$ETTS Of►cs or Consveer Allen&$usinon Rspulstion Rspls1tMton v*$d lot IndNldual our only Were tns HOVE IMPROVEMENT CONTRACTOR saplratton dale. M found rotor'to. TYPE. Moo of Consw'ar ANNrs irid Business Regulation hasalarJan 1001 WSN+Inpton Street •subs 710 1 �Ei 5 Boston.WA 02114 WY4,0E HSE.L.0 OVA SEXTON ROOi4NG♦$t' 3 SASNA aV4DE <S OVERR OR f T Tom'MA 03104 Undersecretary Not valid without signature OPTION 2: REPLACEMENT - ROOFGUARD Description Line total Sexton RoofGuard Set up heavy fabric tarps to direct debris away from house. $17,473.00 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 8"Aluminum edging to rakes and eaves of roof.(white). 4. Install leak barrier protection(Ice and Water)6 feet up on eaves,around vent stacks, in valleys, around chimney and at all places where roof intersects with walls or other roof facets. 5.Install roof deck protection(Synthetic)on remainder of roof. 6.Install new flashing over existing vent stacks. 7.Install starter shingles on eaves and rakes of roof. 8.Install IKO Cambridge Architectural roofing shingles as per manufacturers'specifications. 9. Install new ridge vent and cap over ridge. Warranties to be provided after final payment: IKO Lifetime warranty including 10 years Ironclad SRC 10 yr.workmanship warranty Estimate subtotal $17,473.00 Total $17,473.00 AUTHORIZATION PAGE ❑ Option 1:Repair Ridge and Vent $2,244.00 Name: Janel Jorda © Option 2:Replacement- RoofGuard $17,473.00 Address: 48 Rockland Heights Rd., Northampton, MA ❑ Option 3:Replacement-RoofGuard $18,953.00 Premium NOTE:Quote valid for 30 days from date of estimate.1/3 deposit due at signing via cash,check,or ACH deposit. Final Price $17,473.00 Customer Comments / Notes Janel Jorda: 7 P. 7oa, Date:10/28/2024 Timothy Wilde: Tungy Wdh Date:10/28/2024