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17B-008 www.sextonroofing.com MASTER Settim.,the Standard Certified Roofing Contractors MA HIC# 118239 CT HIC #0605383 SUBMITTED TO Shang Deane PHONE r.{ Ll _ DATE 7-21-14 STREET JOB NAME Rental Property/Dormers CITY,STATE,ZIP Sunderland,Ma. JOB LOCATION 444 Bridge Rd.Northampton,Ma. 1)Install a 1/2"fiberboard mechanically fastened with corrosion resistant fasteners. 2)Install a fully adhered EPDM .060 fully adhered single ply roofing system as per manufactures specs. 3) Counter flash walls and install proper termination. 4) Install .019 metal edging and counter flash. 5) Install new EPDM boots over existing vent stacks. 6)R/R shingles at 2 intersecting roof with ice and water shield, and shingles. 7)All work carries a 10 yr. warranty. All contracts fully insured with workers comp. and liability insurance. Ve J)rOp09;e hereby to furnish material and labor—complete in accordance with the above specifications,for the sum of: Three Thousand Six Hundred Dollars($3,600.00) Payment to be made as follows: Due in full upo&-completion All Material is guaranteed to he as specified. All work to be completed in a Authorized workmanlike manner according to standard practices Any alteration or Signature deviation from above specifications involving extra costs will be executed only f upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond Note:This proposal may bewithdtawn by us if not accepted our control. Not responsible for water damage during construction. Owner to within(14)days. pay responsible legal fees for non-payment,and a livable interest. Z1cteptanU Of VrOpOSai The above prices,specifications and conditions are satisfactory and are hereby accepted. You Signature are authorized to the work as specified. Payment will be made as outlined above. Signature Date of Acceptance. -V Y�i�/ �fr/�J���FL�7P t�[l'J Cr•��.� V � - Office of Cons ci= r' s "Id 1 si-ass Regulation 10 PaE!�P��- -Stite 517 0 B onto-:, _Nila_ssa-p�ztts 02116 Home L .o,--.-.mz�_=i 06 for Registration ReaistaborL 118239 Type: DBA E--iraaon: 2/15/2015 Tr 207886 SEXTON ROOFING CO EVERETT SEXTON P.O. BOX 6327 HOLYOKE, MA 01041 PS-CA1 C� 56M-0404-101218 y., . Board t�f Suiltlin� Rc,'t�l;atiilns antl �rantlarrl �—, , Ci3r i qua=t'i-. - -----� - - License: GS SL 99689 Resiric,ad to: = EVERE TZ SEXTON i - PO BOX 6327 ----i H OLY OKE,MA 01041 ---- 10/5/2015 --� Tr--: 7523 — DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 41 �1 , RTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS :ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES B ELOW. AS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE )R PRODUCER AND THE CERTIFICATE HOLDER.. MPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the erms and conditions of the policy;certain policies may require and endorsement. A statement on this certificate does not confer rights to the ;ertificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: BRESNAH.Ai'N INS AGCY INC PHONE FAX 100 WHITL-iG FARMS RD (AIC,No,Ezt); (A C,No): E-MAIL MOLYOKE,i4lA 01040 ADDRESS: 2STY-NI INSURERS)AF FORDINGCOVE RAG E NAIC 9 INSURED INSURER A: TRAVTT..,IRS INDENT N-IT'Y COMPANY OF AN ERICA ; SEXTON.EVERETT J SR DBA SEXTON ROOFING&SIDING INSURER B; INSURER C: INSURER D; PO BOX.6327 INSURER E; HOLYOKE,MA 01040 INSURER F: COVERAGES CERTIFICATE NUMBER; REVISION NUMBER: THIS LS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED HNAED ABOVE FOR THE POLICY PERIOD INDICATED. NOTYATHSTANDING 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 I3 SUBJ ECT TO ALL THE TERI-IS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES- LIArrS SHOWN MAY HAVE B EEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE. LTR TYPE OF INSURANCE L R POLICY NUMISER (MM�DD`NYYY) (hI1d,DDwYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE ;$ CO,NIMERCIA_GENERAL LIA51'.ITY DAMAGE TO RENTED $ C!-AIMS MADE F—]OCCUR. PREMISES(Ea occurrence) I DIED EXP(Anyone person) is PERSONAL&ADV INJURY I$ GEN'L AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE Is 0 POLICY PROJECT❑LOC PRODUCTS-CCMP/OPAGG $ AUTOMOBILE LIABILITY CONiSINEDS[NGLE S ANY AUTO' LIMIT(Ea acciderr) "L,-OWNED AUTOS BODILY INJURY S SCHEDULE AUTOS (Par parson) BODILY INJURY S HIRED AUTOS (Per accfderr) NON-CViNED AUTOS PROPERTY DAMAGE $ (Par accident) UMBRELLA LIAS OCCUR EACH OCCURRENCE _ S EXCESS LIAR EJ CLAIMS-MADE AGGREGATE DEDUCTIBLE $ $ RETENTION $ A WORKER'S COMPENSATION AND X J WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN J3 5B522Q55-14 04106(2014 G4''06 261a LIMITS ANY PROPER ITOR/PA8TN ER.!=XECUTIVc a rA E.L.EACH ACCIDENT —�$ 1 oo,ODO OFFICERRttE1MBER EXaLUDED7 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 Ityot,describe under E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPE AT;ONS below DESCRIPTION OF OPERA-IONS/LOCATICNSNEHiCLESwRES7RIC71ONSISPEC1AL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTrRCATEHOLDER AFFECIMNG WORKERS COh1F COVERAGE. TFiE WORKERS'COMPENSATION-POLICY DOFS NOT PROVIDE COVERAGE FOR SEXTON,EVERE'IT J SR, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WI?H THE POLICY PROVISIONS. AUTHORIZED REPRESENTty VE ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2070 ACORD CORPORATION- Ali rights reserved. � CERTIFICATE OF LIABILITY INSURANCE r�TE(MM�/3a) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER TWS 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(tes) 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). PROCUCER CONTACT NAME: Bresnahan Insurance Agency Inc PHONE FAx 413) 536-0536 N -4291(413) 534-4291 100 Whiting Farms Road, E-MAIL ADDRESS: Holyoke, MA 01040 INSURE!(S)AFFORDING COVERAGE NAlC C y INSURERA:ESSex Insurance LURED I NSU R ER 13: Sexton Roofing & Siding INSURERC: P.O. Box 6327 INSURER D: INSURER E: Holyoke, MA 01041 INSURER F: — COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTE0 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 WIT H RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTA.6'N, THE INSURANCE AFFORDED BY TI-E POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDI T IOINS OF SUCH POLICIES.LINIFS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN ACOL SUBR P LiCY EFF PDl1CY EXP LTR TYPE OF INSURANCE INSR YWD POLICY NU MS ER (Mfi+t117?+YYYY MM(701YYYY LIMITS A GENERALLIABILITY 3DU8067 6/25/14 6/25/15 EACH OCCURRENCE I S 1 ,000,000 DAt.14GETORENSEO[Ea=tt pr E RALLILITY 50,000 COtrvERCwLG CLAMPS=BADE DX OCCUR ME EXP(Aryone Persrn) S 1,000 PERSONALSADVINJURY S 1,000,000 I — GENERAL AGGREGATE S 2 000,000 i GEN'LAGGREGATELUITAPPUESPER PRODUCTS-COMP/OPAGG 5 1 ,000,000 I X POL ICY F-1 P COT L OC $ AUTOMOBILE LIABILITY j NE7lr SINGLE LVv R a ac;.:der# S ANY AUTO BODILY INJURY(Per,parson) $ ALLOWWO SCHEDULED BODILY INJURY(Per acc:aent)S AUTOS NON-OWNED PROPERTY DAMAGE S HIRED AUTOS _ AUTOS cP er acc dart S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS UAB CLAINIS-LACE AGGREGATE 5 OED RETENTION 3 3 IN7RKERS COMPENSATION WC S7ATU- DTH- T v � AND EMPLOYERV LIABILITY YIN ANY PROPRIET011IPARTNER/EXECUTNE N/A E.L.EACH ACCIDENT 5 _ OFF,CE RAE tABER EXCLU']ED? (Mandalory in NH) EL.DISEASE-EA EN'PLOYEE, S N ea,describe under DESCRIPTION OF OPERATIONS below E-L.DISEASE-POLICY LN11, 5 DESCRIPTION OF OPERATIONS/LOCATIONS/YEW CLES (Attach ACORD 101,Additional Rermrks Schedule,if more space is regii red) Roofing and siding contractor CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Sexton Roofing & Siding ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 6327 Holyoke, MA 01041 AUTHORIZED REPRESENTATIVE fcl 14RR�n1n erncn rneono�-nn►I wn.:..ti,..�,---.--+ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Sexton Roofing Co. Address:P.O. Box 627 City/State/Zip: Holyoke, Ma. 01041 Phone#:413-534-1234 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 3/4 4. E] I am a general contractor and I employees (full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. $ 9. E]Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.Rq1Gof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 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 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 Insurance Co. Policy#or Self-ins. Lic.#:U/B-513922059-13 Expiration Date:04-06-14 Job Site Address: / 6��_ � �G� . City/State/Zip: /wa• r 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-yeas 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 ' urance coverage verification. I do hereby certify under a pains andpenalties ofperjury that the information provided ab ve is ue and correct Si ature: Date: l Phone#: 4135341234 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#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction S/uppeervison Not Applicable/❑ Name of License Holder: License Number Addres Expiration Date G V-a�-� _ Signature Telephone 8.R"istered Home Im rovement Contractor Not Applicable ❑ :K;� V�ZLL� ) 1�� rc 1/ 8 , 39 Co a `` Regi tration Number Ad re Expiration Date Telephor►e_O!-/2—2,ce—, 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....... If uis 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aw)licable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks (❑ Siding[O] Other[a Brief Description of Pro po ed t° Y C/✓� / 1V` 1L0Q �Work: Alteration of existing bedroom Yes V No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes L--No 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 �1 4rir 4, 3 l/'c.=� as Owner of the subject property hereby authorize 4- to a n my behalf, in all matters relative to work authorized Y y this building per raft application. Signature of wner Date 1 as Owner/Authorized Agent hereby decla a that the statements an information on the foregoing appliGatiT are true and accurate,to the best of my knowledge and belief. Signed under the pains an enalties of perjury. Print Name Signature o ner/Agent Da 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 Fronta e 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 ® DONT KNOW ® YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW © YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 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 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ' Department use only D T ity of Northampton Status of Permit: c uilding Department Curb CuUDriveway Permit J 212 Main Street Sewer/Septic Availability 222014 Rpom 100 Water/V1IeII Availability Elect , --N rthampton, MA 01060 Two Sets of Structural Plans Norf r"�'10 �' i 41 -587-1240 Fax 413-587-1272 Plot/Site Plans ha rpt�n. h7 Ions A 060 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 (ILI /311/4�1 �', '/ Map Lot - Unit T n Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: StIAN A Oe cn e._ Grybkv cagskF Na a(Print) j Current/aij a Adt�ress: Telephone ignature Authorized A ent: Name( tint) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit 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+4+5) Check Number This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner/Inspector of Buildings Date 444 BRIDGE RD BP-2015-0099 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17B-008 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2015-0099 Project# JS-2015-000166 Est. Cost: $3600.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sci. ft.): 135036.00 Owner: DEANE SHANA Zoning: RI(100)/RR(100)/ Applicant: SEXTON ROOFING CO AT: 444 BRIDGE RD Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 WC HOLYOKEMA01041 ISSUED ON:712412014 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL NEW EPDM ROOF OVER REAR DORMER 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 Signature: FeeType: Date Paid: Amount: Building 7/24/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner