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32A-167 58 HAWLEY ST BP-2020-1077- GIS P-2020-1077GIS# COMMONWEALTH OF MASSACHUSETTS Map:Block:32A- 167 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-2020-1077 Proiect# JS-2020-001822 Est.Cost: $16400.00 Fee: $119.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: SEXTON ROOFING CO 99689 Lot Size(sg. ft.): 8015.04 Owner: WADE ROBERT N Zoning: URC(100)/ Applicant: SEXTON ROOFING CO AT. 58 HAWLEY ST Applicant Address: Phone: Insurance: P O BOX 6327 (413) 534-1234 WC HOLYOKEMA01041 ISSUED ON:4/27/2020 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 4/27/2020 0:00:00 $119.00 - 212 Main Street,Phone(4]3)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner V �ionl.�7CommercialBuildiPermit May 15,2000 Department use only City of No 1'n Status of Permit: Building Department Curb Cut/Driveway Permit - o� 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability 9T rO Northampton, MA 01060 Two Sets of Structural Plans >>^ter �oione,413-587-1240 Fax 413-587-1272 Plot/Site Plans 'off Other Specify APPLICATION; STRUCT, REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING S OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Is-if Map Lot 1 Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: w A D Baa n��� �,��� X14 rA� Name(Print) Current Mailing Address: nn /_ D o2 l � _C) 9�� Signatured'4rCe-C'(f-- �V � '' ` Telephone 2.2 AuthorizedAwn Name(Print) Current Mailing Address: 0?6 V - 1.) 1/? S-/-S 3 /Z -3 SignatureTelephone 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+4+5) U Check Number This Section For Official Use Only Building Permit Number Date P- 70- to -77 Issued Signat Buildinj Commissioner/Inspector of Buildings 9 Date Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑ Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ RoofinQ O Change of Use❑ Other ❑ Brief Description Entcr a brief description here. Of Proposed Work: SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ ❑ A-4 ❑ A-5 ❑ 113 ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F- ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 11-1 1-2 ❑ 1-3 ❑ 313 ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERG NG RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Prop ed Use Group: Existing Hazard Index 780 CMR 34): Propose azard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING OPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1 SI 2nd 2�d ! rd 3rd l 3 4'h 4n' Total Area (sf) Total Proposed New Construction(sf) Total Height(ft) Total Height ft 7.Water Supply(M.G.L. c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public E] Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑ Version].7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) ITK Independent Structural Engineering Structural Peer Review Required Yes O No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �� hw` Lu as Owner of the subject property hereby authorize S, ti ��c' ` `( �"� "i fi `Y to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date o 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 penalties of perjury. Print Name '212;, Signature of Owner/Agent Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ / L '7 / Name of License Holder U_ ►!'� T Cs� // License Number -7 Address Expiration Date Signature Telephone SECTION 13-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 buo ing permit. Signed Affidavit Attached Yes 0 No 0 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: G7,, The debris will be transported by: sSo c, ,--k t-, The debris will be received by: CA c.,/.a w� Building permit number: Name of Permit Applicant _ . o (c Z,6 ;5e L— Date Signature of Permit Applicant Version 1.7 Commercial Building Permit May 15,2000 SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor Not Applicable ❑ Company Name: Res nsible In Charge of Construction Address Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING 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/Findin /-ever been issued for/on the site? NO O DONT KNOW fQ� YES O IF YES, date issued: IF YES: Was the permit recor at the Registry of D ds? NO O D T KNOW O O IF YES: enter B Page and/or Document# B. Does the site cont n a brook, body of water or wetlands? NO O ONT KNOW O YES O IF YES, has permit been or need to be obtained from the Conservation Commission Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O 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 O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. T SEXTON ROOFING AND SIDING INC www.sextonroofing.com &ffjV0 P.O. Box 6327 Holyoke, MA 01041 Setting*the Standard p. 413.534.1234 f. 413.539.9906 MA HIC # 118239 sextonroofin hotmail.com SUBMITTED TO Robert Wade PHONE 218-0944 DATE 4/7/20 STREET 422 North Farms Rd JOB NAME Rental Property CITY STATE ZIP Northampton,Ma. JOB LOCATION 58 Hawley St Notham ton Ma. SEXTON ROOFING HEREBY SUBMITS SPECIFICATIONS AND ESTIMATES FOR: 1) Strip and remove existing shingles and dispose of in proper landfill. 2) Inspect roofing deck and replace as needed @ $75.00 per sheet. 3) Install new metal edging to rakes and eaves of roof. (8") 4) Install ice and water shield on eaves(61), vent stacks, in valleys, chimney, and at intersecting roofs. 5) Install#15 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 IKO Architectural style roofing shingles as per manufacturers' specifications. 9) Install new counter flashing on chimney. (1) 10)Install new cap over ridge vent. 11) Supply manufactures Lifetime warranty and SRC 5 yr. workmanship warranty. I We Prropose hereby to furnish materia/and labor-complete in accordance with the above specirmations, for the amount of Sixteen Thousand Four Hundred DOLLARD s16 oo PAYMENTS r0 MADEAS FOLOWS. due 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.DAMAGES TO BUSHES AND OTHER VEGETATION'MARKS ON HOUSE MAY Note:This proposal may be withdrawn by us if not accepted BE UNAVOIDABLE AND WE ARE HELD HARMLESS. Not responsible for water within(14)days. damage during construction. Owner to pay responsible legal fees for non- payment,and applicable interest. 2ueptanee of propagal 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. . I + ° Ti y. ' yr 'r"f �'.K`^.'a':.iW"1C,+ lhrCj.:A�Cx wf'+4'%.'�C.e•�cN!'°`�iY.,'�. '4�`. .�"'a�1�4i �P ° ,'i`.r ..d4 zv-if0 5��.','i�td �k` •.6 1v' a .,tom,,: •N i4 trot :i: ... 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The Commonwealth of Massach usetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass- 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/org-mization/Individual):Sexton Roofing & Siding Inc Address:P.O. Box 6327 City/State/zip:Holyoke, Ma. 01041 Phone#_413-534-'1234 Are you an employer?Check the appropriate box- Type of project(required): LL L I am an employer with _ 4.?t I am a general contractor and I 6_Ll New construction employees(full and/or part time)_* have hired the sub-contractors 2_ ' I am a sole proprietor or partner- listed on the attached sheet. �- =Remode{ink ship and have no employees These sub-contractors have 8.Cr Demolition working for me in any capacity. employees and have workers' 9.[l Building addition [No workers'comp-insurance comp_insurance. required] 5.TWeare a corporation and its 10_[:1'Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their myself [No workers'comp_ right of exemption perm MGL 11_ C'Plumbic repairs or additions insurance required]i c_ 152, § 1(4),and we have no 12_X Roof repairs employees.[no workers' comp.insurance required] 13_[ Other .Any applicant that checks box rl must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work-and then hire outside contractors most submit a new ata-idavit indicating such_ :,Contactors that check this box must attach an additional sheet showing the name of the sub-contrrctors and state whether or not those entities have employers 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 mrd job site Travelers Property Casualty Company of America Insurance Company Name: --- Policy#or Self-ins,Lie.#:UB-00078982-19 Expiration Dart;:06/04/2020 Job Site Address: �� /1 w�°� �'� City/StatelZip: U 64- - (/tl Ltvj — -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 152 can lead to the imposition of criminal penalties of a fine up to$1,500:00 an one year impnso"—nmen as�r as civil penalties m the form of a STOP WORK ORDER and aline of $250.00 a day against violator_Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verificatiorL I do herby cer"Jyder the pains and penalties ofperjury that the information provided above is true and correct Signahrre: / Date: 4-//-7/P_V r Print Name: ���.?"e~:r: G�r_'�.r'-�_`�,-� srya� Phare#_ Li Of 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): LBoard of Heath 2_ Building Department 3.City/Town Cleric 4.Electrical Inspector 5_Plumbing Inspector 6.Other Contact person: Phone#: CERTIFICATE OF LIABILITY INSURANCE DATE 6110DO1YYYY) 012019 TTIFICATE 1S 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- OLDERIMPORTANT_If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must he endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME ORMSBY INS AGCY PHONE FAX PO BOX 713 (AIC,No,Extr (A/C,No): E4NAIL WFST SPRINGFIELD,MA 01090 ADDRESS: 286TF INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVELFRS PROPERTY CASUALTY CON PANY OF AMERICA SEXTON ROOFING&SIDING INC INSURER B: INSURER C: INSURER D: PO BOX 6327 INSURER E HOLYOKE,MA 01041 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS tS 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 PAIDCLAIMS. INSR 4DD4UHR POLICY EFF DATE POLICY EYP DATE LTR TYPE OF INSURANCE INSR1WVD POLICY NUMBER (MMIDMYYYY) (FALMDDIYYYY) OMITS GENERAL LIABILITY CH OCCURRENCE COMMERCIAL GENERAL LIABILITY $ CLAIMS MADE F--1 OCCUR- DAMAGE ( RENTED $ REMISES(Ea occurrence) i ED EXP(Any one person) i$ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER ENERALAGGREGATE ig POLICY 0 PROJECT LOC DRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY is SCHEDULE AUTOS Per person) HIRED AUTOS BODILY INJURY ;5 Per acddent) NON-OWNED AUTOS PROPERTY DAMAGE !$ (Per accident) UMBRELLALLAB OCCUR EACH OCCURRENCE �$ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ f$ A WORKER'S COMPENSATION AND g WC STATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-OG078982-19 06/042019 06/0412020 LIMITS ANY PROPERRORIPARTNERIEXECUTIVE [71 UA E_L EACH ACCIDENT Is 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L DISEASE-EA EMPLOYEE,$ 1,000,000 (lyes,des be under E_LDISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS belox DESCRIPTION OF OPERATIONSILOCATIONSlVEL-IICLESIRESTRICTiONSISPECIAL ITEMS THIS REPLACES,ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE INSUREDS'MLA WORKERS CONIPE:NSATION POLICY ANND ITS LIMITED OTHER STATES ENDORSEMENT AUTHORIZES THE PAYMENT OF BENEFITS FOR CLAINIS MADE BY THE INSL='S tiIA L%PLOYEFS IN STATES OTHER THAN MA NO AUTBORIZA'IION IS GIVEN TO PAY CLAMS FOR BENEFITS IN STATES OTHER THAN MA IF THE INSURED HIRES,OR H-AS HIRED EMPLOYEES OUTSIDE OF MA. THIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR 12m REPRESENT ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION- All rights reserved. SEXTO-2 OP I R ACORL?" DATE(M MMD/YYY17 k. � CERTIFICATE OF LIABILITY INSURANCE 07/10/2019 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 413-737-0300 Na Enc-r Enc Dembinske Ormsby Insurance Agency,Inc_ PHONE 413-737-0300 FAx 413-737-0617 698 Westfield St PO Box 718 (Air,No,Edg I(ruc Nod West Springfield,MA 01090 IL esn�m5skei nsbyins_com - Eric Dembinske -- __ _ TSURER(S) _AFFORDING COVERAGE NAIC ii INSURER A_-COIOny Insurance CO. S(e�DRoofing 8 Siding,Inc. INSURER&:Quincy Mutual Fre Insurance 15067 PO Box 6327 INsuRER c: -- — Holyoke,MA 01041 INSURER D INSURER E INSURER F; -- - �— 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 . POLICY WVD POLICY EFF EXP IJMfTS VNSn POLICY NUMBER A X COMMERCIAL GENERAL LIABILITY � EACH OCCURRENCE $ 1'000'000 cu`I""sMADE CX)OCCUR j 101GL002159903 0612512019106/2012020 M,'GERENTED 100,000 ocamence $ MED EXP ane on S 5,000 PERSONAL&ADV INJURY S 1'000,000 GEN'L AGGREGATE LIMIT APPLIES PER. ! i GERAL AGGREGATE ; 2,000,000 POIJCY JECT U EN LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER S B AUTOMOBILE LIABILITY I COMBINED SINGLE LQeIR S.— 1,000,000 ANY AUTO AFV206561 05/15/2019 05/15/2020 BODILY IwURY(Per person s OWNED SCHEDULED — AUTOS ONLY LX AUTOS BODILY INJURY er accident SHIR�p NONWNED AUTOS ONLY AUTOS ONLY iper P L GE....___. S UMBRELLA LIAB OCCUR I I EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE 5 DED RETENTIONS S -- WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIAE fLrry Y/N � A ER ._-- ANY PROPRIETOR/PARTNER/EXECUTIVE O BE SENT SEPERATELY EL.EACH ACCIDENT 5 (Il a CCERIMEry in BE EXCLUDED? � N I A i i --- EL.DISEASE-EA EMPLOYEES If yes,describe under -____ DESCRIPTION OF OPERATIONS be1mv i EL DISEASE-POLICY LIMIT S i -- I DESCRIPTION OF OPERATIONS f LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER - CANCELLATION NONE-01 SHOULD ANY OF THE ABOVE DESCRIBm POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Everett Sexton ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION_ All rights reserved_ The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts �— Department of Industrial Accidents I Confess Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTiNG AUTHORITI'. Applicant Information Please Print Lezibly Business/Organization Name:MNP CONSTRUCTION INC Address:45 EXCAHNGE ST City/State/Zip:MILFORD, MA, 01757 Phone#:508 498-8870 Are you an employer?Check the appropriate box: Business Type(required): 1.Q✓ I am a employer with 5 employees(full and' 5. ❑Retail or part-time).* 6. E]RestauranL/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. E]Office and,'or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturinc, no employees. [No workers'comp. insurance required]* ` 11.❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees_[No workers' comp.insurance req.] 12•1D Other CONTRACTOR *Any applicant that checks box#1 must.also rill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves.but the corporation has other employees,a workers'compensation policy is required and such an organi-ration should check box a 1. I am an employer that is providing workers'compensation insurance for my employees. Below is the polig,information. Insurance Company Name:HARTFORD UNDERWRITERS INS. CO. TRAVELERS-RMD insurer's Address:P.O. BOX 5600 City/State/Zip: HARTFORD, CT. 06102 Policy#or Self ins.Lic_#1 K709706 q Expiration Date:_11116i2Q;kg) 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 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 _oLup_to-5750:00-a7dav-againstthe-violato —Beadvised-that a copy of ifiis statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby cern u� p t t! 'pities of perjury rhat the information provided above is true and correct Signature: /j Date: Phone n:9781303-5942 [EOther only. Do not write in this area,to be completed by city or town official. n: Permit/License# hority(circle one): Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office son: Phone#• ��ww.ntass.�ov/dia CERTIFICATE OF LIABILITY INSURANCE °A'E(M""°°"YYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER- 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 SUBROGA710N 15 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 ONE FAMILY INSURANCE AGENCY LLC PHONE NAME_—ArtCalvillo FAX E-yA NO Em. (978)403-5942 AIG No): 1 Main St Suite 15 ADDRESS: acal_villo128@yaho°_com - _LUnenburg _ - - INSURER(S7AFFORDING COVERAGE NAIC# INSURED -- ----.— MA 01462 INSURERA. HARTFORD UNDERWRITERS INS CO 30104 MNP CONSTRUCTION INC INSURERS___ -- INSURER C: -- 45 EXCHANGE ST APT 3E INSURER D: MILFORD INSURER E. - COVERAGESCMA 01757 1nsuRERF: - - ERTIFICATE NUMBER: 478475 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEVIED ION NUMBER: INDICATEDD A OVE FOR THE POLICY PERIOD . NOTWITHSTANDING ANY REOUIREMENT,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 REDUCE BY PAID CLAIMS. INSR —. LTR TYPE OFINSURANCE ADOL Su - HV D' POLICYNUMBER M p 'F POLICY EXP - COMMERCIAL GENERAL LIABILITY D LIMITS .— I { CLAIMS-MADE 11OCCUR ! i EACH OCCURRENCE $ I DANA ETTO—RENTED- ;-CEaoccurrece S { N/A MED EXP(Arty ane person) $ -- GEMLAGGREGATE LIMIT APPLIES PER, t j PERSONAL B ADV INJURY S POLICY C ]JECT n LOC 1 GENERAL AGGREGATE S OTHER- 4 PROOUCTS_.COMP/OPAGG S AUTOMOBILE LIABILITY ANY AUTO 1) COMBINED acgdent�-INGLE LIMn $ -- AUTOS AS5HOEDS ULED N/A I BODILY INJURY(Per person) $ALL ..—... '— NON-0WNED I BODILY INJURY(Per accident) s HIRED AUTOS AUTOS I PR-0PPE bAMAGE. . . S 1 UMBRELLA UAB �j S -- OCCUR i EXCESS LIAR I EACH OCCURRENCE s - —_.r_-. _-- CLAIMS-MADE + N/A f _ DED I RETENTION S I i AGGREGATE S WORKERS COMPENSATION ( $ AND EMPLOYERS'LUIBILITY I PER ANYPROPRIETOR/PARTNERIDCECLTTIVE Y/N I { ^� STATUTEER A OFFCER/MEMBER EXCLUDED' 1I — (Mandatwy in NH) N/A 6S60UB1K70970619 11/16/2019+ 11116/2020 EL EACH ACCIDENT S 1,000,000 It res, IPTIOeunder I EL DISEASE-E.o,EMPLO s 1,000,000 DESCRIPTION OF OPERATIONS below — +I EL DISEASE-POLICY LIMIT S 1,000,000 I WA __—.. DESCR1PT10N OF OPERAT1Dus I LOCATIONS 1 VEHICLES(ACORD 101,Additional Re Sctwchedule,may be attached drnoR space required) Workers'Compensation benefrts will be paid to Massachusetts employees only.PUTSUarit to Endorsement IWC 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-compensationfinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SEXTON ROOFING &SIDING INC ACCORDANCE WITH THE POLICY PROVISIONS. 102 PINE ST AUTHORIZED RFPRESENTATTVE HOLYOKE ,1 LL t P MA 01041 k--- -" Daniel M.C1 y,CPCU,Vice President-Residual Market-WCRIBMA ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD O�CORPORATION. All rights reserved. A�Q M CERTIFICATE OF LIABILITY INSURANCE DATE` DD,YYYY) 11/27/19 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 he 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 endomement(s). PRODUCER CONTACT NAME Art Calvlllo One Family Insurance PAIL,N Ela_ 978-03-5942 INC No: 978 d03-5943 1 Main St Suite 15 E-MAIL I Main St. it 05 ADDRESS: art@1familyinsurance.com LuneINSURERS)AFFORDING COVERAGE NAIC# INSURERA: Evanston Insurance Company INSURED INSURER B: MNP CONSTRUCTION,INC. INSURER C: 45 EXCHANGE ST APT 3E INSURER D MILFORD,MA 01757 INSURER E INSURER F: 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 POLICY EFF POLICY D(P LIMNS LTR INSD WVD POLICY NUMBER UM MMlD X COMMERCIAL GENERAL LIABJUrY EACH OCCURRENCE $ 1,000,000 DA100,000 CLAIMS-MADE X OCCUR PREMISES Ea occurrence S MED EXP one n) S 5,000 A Y Y 3ET9385 11/03119 11/03/20 PERSONAL s ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY F-1 PRO LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER t AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT f Ea accdent ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Peramdent) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY M DAAGE S AUTOS ONLY AUTOS ONLY acddenl S UMBRELLA LIMBOCCUR EACH OCCURRENCE S EXCESS LIAR HCLAIMS-MADE AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION SW OTH- AND EMPLOYERS LIABI ITY YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE❑ NIA EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatary in NH) EL DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMfT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Rem2dl6 Schedule,may be attached it 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 SEXTON ROOFING&SIDING INC ACCORDANCE WITH THE POLICY PROVISIONS. 102 PINE ST P.O.BOX 6327 AIITHORRED REPRESENTATIVE HOLYOKE,MA 01040 ART CALVILLO ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD offl ce a' and BuSineess Rjagulaijon 1000 Washir3 Mn Sb'eet-Suite 770 Harte �Mass [�18 �e� ucar O -�M27' u SIDING ltVC jy� 'n L10LYDK_MA _ a-P POSEZkTON SP AOME PRO Ifl irQg f3i£ BERET MElUT CON�RACTpR J sE TgIN SR HoLyQ�, oia�r�_24u SEXTON RROO, ING l"Geaaistrin# &M, °eC.o1-11C.06035g3 sIGNEp � 1/201 EXpirarion 11/30/2020 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstructiomS-4"e{,& Specialty CSSL-099689 Expires 10/05/2021 EVERETr J SEXTOf+11.4� PO BOX 63271 f��3 = C"y HOLYOKE MN 01047 Commissioner /�l � From: 10 I o To: Louis Hasbrouck Building Commissioner City of Northampton 212 Main Street Northampton, MA 01060 The Massachusetts Building Code,section 107.1 allows for an exclusion from requirements for construction control in certain situations. In accordance with code section 104.10, 1 request that you grant a modification to waive the requirement for construction control of the project at wleuC- because the work is of a minor nature,will not affect structural elements, health,accessibility, life or fire safety,and will be done in accordance with the prescriptive requirements of the code. Thank you for your consideration. Respectfully, L U&K c, f.J L+1J S