29-407 .1/14/2012 10:06 4135726542 tO THE 1 -AGE 02 / ee
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SEXTON ROOFIN 'AND SIDING CO.
A division of Sexton Home Improvement Co,
Tarnkn Roofing Systems ..goli`
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M v thtelDSud r MIN lamer r, r
(413) 634 -1234 A.�. P.0. Box 6327
FAX (413) 539 -9906 fv1A HIC #118239 CT HIC #0606383 Holyoke, MA 01041
www, sextonroofii ng.. corn �
r SUBN TTED 1 "-" i4. *"'F . IONE f e' J 6 y i DATE A erb', / 2 ' !
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STREET $1,_./ � T N r 1�/ d? 42 i JOB NAME _ — _ —�_
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V ZIP A Cr1OE i' t�1LfC' � r_•a t.c c„-it7r,
Proposal to furnish and instal) the following
Re -Roof r13''"iear -Off za Gutter
Complete Roof Preparation
we Home exterior to be protected by turps and piywood
(Shrubs, landscaping, trees to be protectec
r, Entire existing roofing materiel to be removed to existing deck!ng, including fleshing, etc.
Site to be cleaned everyday with roll magnet debris removed at protect completion
Oeteriorate.d existing decking replaced at $2,50 per aa.fi far +0 4 S cz. 1u I
Tr White /Brown metal drip edge installed at eaves and rakers A' it
' ,/New flashing will be installed where necessary (see Special Requirements) / 'Le4L. c h✓ i4 nvxr,
ri Install new pipe bootftasning
e shall acquire all appropriate permits etc_ for ell roofing work
Complete Roofing Systern
' L k Barrier installed at alt eaves to protect from ice dams (and meet codes in the north) G r
iiri Leak Barrier installed at valleys, around penetrations and chimneys to protect cititcai areas
G2/16 Ib. reinforced underlayment installed ever entire decking
Shfngiaa I tMF�+trohitectural D 30 Clear GD Color Dr0A e ow w
..'"'eF ridge vent will be Installed
Warranty Options
C ` VOe guarantee our workmanship for 10 full years
F.-- r' e repeat befit hereby tC furnish material and 1 y r - complete in accordance with the�p ov ecifications, for the sum of: 1.
S ! f>~ J � 6 ^ - ;�_
ow _ W da!lars ($_ G r �" ) 1
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Ai1 Blatant1 iv guaranteed to be as epecdka. Ali work to be compianrd li a workmanPke manna- Authorized , N — 1
acnomg to sute pracdcea. A.n ekerptg n or deviatMr. frcr+ +x spec) I
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Rcre Cc wtl tar bO eY rtl OUtad to n Avrtltwn prderG, and wt F,MRnmo on a,c r� vh arpa o, •nA Signature _
ebav etnocarmete. MagreememeooMhtgent acc! denteOrdatfya beyn�,da�:roantrc! Nota :TN raportalrr �i��� �__ � ,,, } �
Nat reapcnafble for water damage airing eoratructim. Owner to FRY respari bte eon! Pass ter N°t oWh by U3 ` 1 rr 3CCe �°tl within I I
nen- uevm,�pgg, __ 97t. . ___ -� _ ■
_ _ dap _
pten t at *reppeet - The Above prices, speolficatlons and conditions - _ - -- — _ ,
$�gnoture
a re sstlataetory and are harrby accepted. You arr au thorized to do the S g 6 rsa
I
work as speoified. Pay l t8� be made as outlined atbove, 4
4 date of Accwptance _it '� y _ __ " i
Ark. _ m _ . w _
` ilii ,__ -.., -- [. _ -_ -rte- J �_
AYTENTioN HOMEOWNERS: Please cover all personal belongings in thm attic. garage or storage areas due to the possibility or roofing debris or the
coming in through the make of lhb ✓goad. $extrsn Roofing anq Siding will not be responsible for debris or dust in thn attic or staiege areas.
,,:...,\, The Commonwealth of Massachusetts
* * — Department of Industrial Accidents
r`
Office of Investigations ,
*; s 600 Washington Street
., i Boston, MA 02111 ,
-, -- .. 5�' www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Eleetricians/Piumbers
,Applicant Information Please Print Legibly •
Name ( Business /org l): ,,' /T()' f J nr1 C C(
Address: p - s„y Cc ..> --- 9 1
City /State /Zip: c ty (; k ;'- 1 t4 r Phone #: WS C 2 y/.2. 3 V
Are you an employer? Check t e appropriate box: Type of project (required):
1. [I am a employer with `7 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (fill and/or part - time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner - listed on the attached sheet. I 7. ❑ Remodeling
ship and have no employees These sub- contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3. ❑. I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs
insurance required.] t employees. [No workers' i3. ❑ Other
comp. insurance required.]
'Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. - Below is the policy and job site
information.
Tnsurance Company Name: 77? 0--- /4 .7J 4'. cc) .
Policy # or Self -ins. Lic. #: 6
J' J (/ ij y c7/46, • P? -- 9 - /; Expiration Date: 1 1 (^,-, I 1
F
Job Site Address: City /State /Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can Lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify trader the pains and penalties of perjury that the information provided above is true and correct.
Si:mature: . Date:
•
Phone #: 9/ ? 5 3 Y
1
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 #:
4 :.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
t � � //
Name of License Holder : [_.� 1 "!' f € ) - - ' X , L, 9 e 6 �" f'
?
License Number
Address Expiration Date
7
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
,S'7 x - 1,J Oa J ` , 7 l // t .1 3 �
Company Name Registration Number
p n 444- Ad ress Expiration Date
Telephone SS i /2 3 I
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 0' No ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two - year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
A
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [D Addition ❑ Replacement Windows Alteration(s) Roofing --
Or Doors E
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [0] Other [0]
Brief Description o j Pro p osed
Work: g /.e ',t/ "5t/.9f /e
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes �o
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building One Family ° Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 5 `- /C,4 ,+0 C 7 A- P e' C i.+.) s /C , as Owner of the subject
property
hereby authorize 3 „�� �Z - 7 ` / :1 0?”" i v< 4
to act on my behalf, in all mma'tterrs felative to work authorized by this building permit application.
S c_ A ffn.- //
Signature of Owner Date
1
I, rY � k IZ' /✓ c. , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
E ? £ h '
Print Name
/// Z, I
Signature of Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW a YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW ® •''VES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , Date Issued:
C. Do any signs exist on the property? YES 0 NO er
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO e
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO e
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
RECEIVED Department use only
City of Northampton Status of Permit:
,}}`�1r Building Department Curb Cut/Driveway Permit
i'r 11 V 1
212 Main Street Sewer /Septic Availability
_ Room 100 Water/Well Availability
DEPT. OF BUILDING INSPECTIONS ortham ton, MA 01060 Two Sets of Structural Plans
NORTHAMPTON, MA 01060 p
p one 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
�" r f
Map Lot • Unit
Zone Overlay District
7 f 1' V1 Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
/ fA A./ L2/3 pocc , S 4 4, // �Z i)
Name (Print) Current Mailing Address: / t
'k v'✓✓� r c f Telephone -
Signature
2.2 Authorized Agent:
c r = t x ,; s� 2�;n. �. 4= - /k /yoke, 14,0
Name (Pri ,,7 / Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 + +5) ,, f c7OO Check Number /010? 4535
This Section For Official Use Only
Permit Number: Date
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
81 SANDY HILL RD BP- 2013 -0561
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 407 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2013 -0561
Project # JS- 2013- 000901
Est. Cost: $6800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEXTON ROOFING CO 99689
Lot Size(sq. ft.): 20821.68 Owner: CZAPOROWSKI STEFAN
Zoning: Applicant: SEXTON ROOFING CO
AT: 81 SANDY HILL RD
Applicant Address: Phone: Insurance:
P O BOX 6327 (413) 534 -1234 WC
HOLYOKEMA01041 ISSUED ON:11/15/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: ST RI P & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Siunature:
FeeType: Date Paid: Amount:
Building 11/15/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner