46-036 (2) SEXTONROOFING AND SIDING CO .
www.sextonroofing.com
#to MASTER
Setting,the Standard
P.O. Box .7
p. 413.534. 1234 Hol-voke, Nk!A 01041
MA HIC# 118239
SUBMITTED TO Stanley Yurgiewlewicz PHONE 727-2939 DATE 5-5-15
Sandra Clark I I
STREET 4 Ferry Ave. JOB NAME
crry/sTATE/zip Northampton,Ma. JOB LOCATION
SEXTON ROOFING HEREBY SUBMITS SPECIFICATIONS AND ESTIMATES FOR:
1) Strip and remove existing shingles and dispose of in proper landfill.
2) Install new decking (7/16 OSB)
3) Install new F8 metal edging to rakes and eaves of shingle roof and C-6 on flat.
4) Install ice and water shield on eaves of roof, (6 )over vent pipes, at intersecting walls, in valleys and around
chimney.
5) Install synthetic roofing felt on remainder of roof.
6) Install new flanges over existing vent stacks.
7) Install starter shingles on eaves and rakes of roof.
8) Install new step flashing at intersecting wall.
9) Install IKO Architectural style roofing shingles as per manufacturers' specifications.
10)Install new metal flashing on chimney.
11) Install new cap over ridge vent.
12) Supply manufactures Lifetime warranty and SRC 25 yr. workmanship warranty.
13) Install fully adhered EPDM membrane roof in flat sections. (15 yr. SRC warranty)
ALL CONTRACTS INSURED WITH PROPERTY LIABILITY AND WORKMANS-COMPENSATION. ALL PERMITS
APPLIED FOR BY SRC.
We Propoor hereby to furnish material and labor—complete in accordance with the above specifications,for the sum of
Ten Thousand Eight Hundred Dollars. ($10,800.00) Payment to be made as follows:kyue in full upon completion
All Material is guaranteed to be 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
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 All agreements contingent upon strikes,accidents or delays beyond Note:This proposal may be withdrawn by us if not accepted
our control. Not responsible for water damage during construction. Owner within(14)days.
to pay responsible legal fees for non-payment,and applicable interest.
&rqtanre of jkopogal The above prices,specifications
The Commonwealth of Massachusetts
_ Department of Industrial Accidents
Office of Investigations
t 600 Washington Street
Boston,Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print]Legibly
Name (Business/Organizabon/Individual):
Address: (vhQ n�e
City/State/Zip: ()10 1 Phone#: (� - q 1-�'3 i:�, �I'
Are you an employer?ChecK the appropriate box: Type of project(required):
I. J I am an employer with 4. = I am a general contractor and I 6. New construction
employees(full and/or part time).* have hired the sub-contractors 7. - Remodeling
2. L I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. i Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp.insurance. I 9. ,Building addition
required] 5.-J We are a corporation and its 10. Electrical repairs or additions
3. C I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions
myself [No workers' comp. right of exemption perm MGL
insurance required]i c. 152, § 1(4),and we have no 12. Roof repairs
employees. [no workers'
comp. insurance required.] 13. Other
`Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
i Homeowners who submit this affidavit indicating the} are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContactors that check this box must attach 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. /II
Insurance Company Name: I i , , _ �i �'�U l)a x'1 o n}) L,;
E � _
Policy#or Self-ins.Lic. #: V MCI (j I W Q-,�)o)q k Expiration Date:
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 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
$250.00 a day against violator.Be advised that a copy of this statement maybe fonvarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: '-- t / Date.
Print Name: Phone+:
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 Heath 2. Building Department 3. CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact person: Phone#:
t
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
_ a I Congress Street, Suite 100
Boston,MA 02114-2017
wwvv mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name (Business/Organization/individual):
Sexton Roofing Co.
Address: P.O. Box 627
City/State/Zip: Holyoke, Ma. 01041 Phone 4:413-534-1234
Are you an employer? Check the appropriate bog: Type of project(required):
1.❑ I am a employer with 4. 0 I am a general contractor and I
6. E]New construFtion
employees (full and/or part-time).* have hired the sub-contractors
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
employees and have workers'
working for me in any capacity. 9. ❑Building addition
[No workers' comp. insurance comp:insurance.t
required.l
5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plurhbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.[] Other
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box 41 must also fill outthe 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: —
Policy#or Self-ins.Lic.#_ Expiration Date:
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 ofthe 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: Date:
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 Supervisor: Not Applicable ❑ f�
Name of License Holder: 4V 22C
License Number
3 ,rU -s
Address Expiration Date
Signature Telephone
Reoistared Home Itrracnvement Contractor: Not Applicable ❑
Com ame Registra ion Number
Address Expiration Date
Telephone-6-3 Y-%J 3 '71
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....... No...... ❑
11. - Home caner Exetnyfi9n
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 applicable)
New House F-1 Addition F1 Replacement Windows Alteration(s) ❑ Roofing
Or Doors 1711
Accessory Bldg. ❑ Demolition ❑ New Signs [0) Decks [M Siding [[3] Other[0]
Brief Description of Proposed ' G /
S4/Work: iie_ A
Alteration of existing bedroom Yes `'�No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
6a.If New house and or addition to existlnsa hour na, complete the`followinu:
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
OWNE AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize
to act on rmy behalf, in all matters relative to work auth rized by this building permit application.
Signature of Owner Date
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 ins and penalties of perjury.
Print Name
_AG
Signature of ner/Agent Date
- � City of Northampton
psi Building Department
212 Main Street
Room 100
1, rthampton, MA 01060
&
Gp nspectio a rf n a" a c a4a
plumb+n9 �e -587-1240 Fax 413-587-1272
O�tn Northampton,M _ 1
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
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
51AlvN ur2 CA ieVJ ICd )L)o zx frPTrt/ 4k-ef ti'8jqPVT
Nam�(Print) I Current Mailing Address:
Ir�f A 4 ��.e� Telephone _a �
Signature
2. Authorized Acient.
L PC) cL (�
Name(Pri C rrent Mailing Address:
6-3V-/23 V
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted 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=0 +2+3+4+5) (, Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
4 FERRY AVE BP-2015-1146
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:46-036 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-2015-1146
Project# JS-2015-002156
Est.Cost: $10800.00
Fee:$35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEXTON ROOFING CO 99689
Lot Size(sq. ft.): 7013.16 Owner: YURGIELEWICZ SANDRA
Zoning: Applicant: SEXTON ROOFING CO
AT. 4 FERRY AVE
Applicant Address: Phone: Insurance:
P O BOX 6327 (413)534-1234 WC
HOLYOKEMA01041 ISSUED ON.512012015 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & 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 Signature:
FeeType: Date Paid: Amount:
Building 5/20/2015 0:00:00 $35.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner