06-022-024 BP-2024-0412
46 EVERGREEN RD#208 COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
06-022-024 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2024-0412 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF BUILD B Contractor: License:
WILDE HSE LLC DBA SEXTON
Est.Cost: 51440 ROOFING 106265
Const.Class: Exp.Date: 03/08/2027
HAMPSHIRE PROPERTY MANAGEMENT GROUP
Use Group: Owner: C/O EMERSON WAY LLC
Lot Size (sq.ft.)
Zoning: URA Applicant: WILDE HSE LLC DBA SEXTON ROOFING
Applicant Address Phone: Insurance:
45 OLANDER DR 315-569-7761 6HUBOW551 13923
NORTHAMPTON, MA 01060
ISSUED ON: 04/09/2024
TO PERFORM THE FOLL O WING WORK:
STRIP AND REROOF BUILDING B
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:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
17/2.
Fees Paid: U
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
rAPR - 82024 g
The Commonwealth of lY1a '-_
,A �r I INSPECTIONS
a Office of Public Safety and InspecHrifigiAmrioN,MA01060
tw 3 Massachusetts State Building Code(780 CMR) -----
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(Thus Section For Official Use Only)
Building Permit Number:i L/' W Date Applied: Building Official:
SECTION 1:LOCATION
I o EVr k to hj RT). Lec s 0/053 YAM/it?. 1-1 ILL &A i t E
No.and Street City/Town Zip Code Name of Building(if applicable)
Assessors Map# Block#and/or Lot #
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building Br Repair id[Alteration 0 1 Addition 0 Demolition 0 (Please fill out and submit Appendix 2)
Change of Use 0 Change of Occupancy 0 Other 0 Specify
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No E(
Is an Independent Structural Engineering Peer Review required? Yes 0 No lid'
Brief Descri tion of Proposed Work
1 fV i
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0
Existing Use Group(s): Proposed Use Group(s):
SECTION 4 BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Boor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2 0 Nightclub ❑ A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational ❑
F: Factory F-1❑ F2 0 H: High Hazard H-1❑ H-2 0 H-3 0 H-4 0 H-5 0
L• Institutional I-1 0 I-2❑ I 3❑ I-4❑ M: Mercantile 0 R: Residential R-ID R-2 El"R-3 0 R-4 0
S: Storage S-1 0 S-2❑ U: Utility 0 Special Use 0 and please describe below:
Special Use Description.
SECTION&CONSTRUCTION TYPE(Check as applicable)
IA 0 IB 0 ILA. 0 MT 0 MA 0 InB rr IV D VA Cl VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public 12r Check if outside Flood Zone 5zrIndicate municipal EC A trench will not be Licensed Disposal Site 0
or trench or specify
Private 0 or mdentify Zone: or on site system 0
permit is enclosed 0
Railroad right-of w�j Hazards to Air Navigation: MA I Gstonc Commission Review Process:
Not Applicable lH Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No IY Yes 0 No 0
SECTION&CONTENT OF-CERTIFICATE OF OCCUPANCY
Edition of Code Use Group(s): Type of Construction:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space: J
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
likNx5iMal_12,4*E.rigt IfYINto,c,FinsAil Q.o .e-ox oksz JQrTitikih i, tm 0/6(Q0
Name(Plait) No.and Street City/Town Zip
Property Owner Contact Information:
VRoe -- Pik M)Aat , qI5 - 73--943g - - Jmt&E.EGtttMCJOL{o.ftVil
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes: r
S .)c.o+ c 45 Sin�tJ0Du t. zil1 • DES t ►'} 0)OcQ
Name Street Address City/TownState Zip
to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here ll_
Otherwise provide,-on'trcction control form::(see section 107 in the code)as required.
10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals)
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
f
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
g5 Du\mbaK (� . 02 i�l#�rvi ON MA,_ DID&C)
Street Address City/Town ( State Zip
Iee�-'t q-!a.3`1 - - 5-L,k Vkoinc I{C'\OCCq-)Ct. cli1fl'l\IL.0 11(k
Telephone No.business) Telephone No.(cell) e-mail address
SECTION 11:WORKEI_S LJJME'ENSA riUNIN$URANCE AH41DDAVI: (M.G.L c.152.§25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes —No D
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and f Materials) Total Construction Cost(from Item 6)=$
1.Building $�l/ t C c 00 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ _ appropriate municipal factor)_$,.1 01 .
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to 114 r 'IV DV IVeQ'04 A T tdi j
6.Total Cost $`17 /IVO,CO (contact municipality)and write check nun{ber here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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®nokowledge and understanding.
SIV-i/i /i/ZZle _,q4,d,Z s
owiv6A vzst5.33/44dy___/105/
Please print and sign name Title Telephone No. Date
�&- 02A4/9� Die Nal- /An/Rd / ,oieo Sr..rsnb tioiFF1cee6mtic.cs�r
Street Address City/Town State Zip Email Address
Municipal Inspector to fill out this section upon application approval: ,�r�/���-'` I-9.26 L f4
Name Date
City of Northampton
roc
- Massachusetts
,� DEPARTMENT OF BUILDING INSPECTIONS y fi
212 Main Street • Municipal Building v �D
Northampton, MA 01060 ss!p,Y
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: i p s'
Location of Facility: &cog_ e7A1v "61, (2-14\)(-,F-1 ), kft ill
The debris will be transported by:
Name of Hauler: A nedic fff) , Jc 1,..A. 2eicKet .S,
Signature of Applicant: , Date: I ��
�p _ The Commonwealth of Massachusetts
> sica ti:,`.�( : Department of Industrial.Accidents
=�'» -k1 Congress Street.Suite 100
Boston. !VA 02114-201
roils:muss got/dirt
11 ut kers'("ontpensation Iusurancr Af6das it:Builders:t( uutractur• Electricians Plumbers.
JO BE FILED II II II 1111:P1..10111 I I\G.kt I IIOKI I .
auplicant information Please Print i.et,ihls
t c
Name{13usta.�,(lrsarruati.�n 1lxlts taus l: ylr`� .._1(anRC C J l 0 1 0,
Addre Li S OL.p..,r�oe.g,_._. (
C'ity/State Zip:dDfcc-tki 1 l O'fJ i k O)Q(pD one m: Lq1 53(J /c23 q..... .._________
Inv you an easpluy sr?It'hawk the rppsupristr but
Tyi pr ofproject(required):
..1711.41,a_r:gtl..-j.:with cmpht)..s itult writ at p:a liner' 7. j Ness construction
.`.0 I Ant:r wit:pntpticLH tH Turin.bhip and hair iR..titployes,w otkrn tut as in B. 0 Remodeling
an.capacity.[Nit w tit ker.,.cHtq insurance- n:epued.
9. D Demolition
0 I an J hoer,..ow net dual_all work m),dl.[.'ve w,nka>'eurnp :nwrant."rrquu al.t.
10 0 Budding addition
4.0 I am a IaH nee acid w Ill tn.,:Mimev con duet to. de t dl w tNk on my prop ray I wsli
aatw
tt...J mastic that all l.nQtalGcs tirFwa lime worrier ccnnpert,anon insurance or arc sole 1 1.,C3 Electrical repairs or additions
ptu n.Wn with rn,emtployces.
1_.0 Plumbing repairs err atklitions
.' Am a genera:.oritz rtt.t and I E.t.."tiled th.sort-:uatta.-Eitn laerit ua the attached sheet
These>tdrr.mirx*.e,n Lti�tniphn.t.ant:ha::uuikir,'comp insurance. i; Wl repairs
14.D Othei
6.0 WC:UV a c n}tatutn and it,oi`.xas tome.\3.is.'d the right.,f e..mpu.Hi pet MU..
I�_. Unit.and w.hase no tanplot.es.INo wutkers'c..nip-amutance r.yui..d[
plat applicant that cheeks huk aI want also till till the section hektw show mg then wutka;,'compen>:flion policy utl.-rtremor&
-bknKo,.nets who MJ.'uiit this atiNlatat nicht:mine th..y at'dvang all a l rk and then hae outside e.nlra.l r,nest,ubnnl a r.e'atitdan tt trkh.aari:,u."h
'4 eganko 1Vh that ehi..b Iht,hue must ause/scd an.wlditiaiai,1t.ti shuwaii;Ebb;avant 01 tin:,ntr.1.4tt1a.1ar,and.:jr..I,ll.thKT eH not those 7tt:ik,lune:
employee, It Js soh:.a.::..iti,bane atgrt.n.es.the,octal pnnide thew worker, comp.pt'.ta r=umrbcr
1 am an employer that is providing worriers'compensation insurance for my employees. Below is the policy and job site
information.
insurance Ct.mrpauts Name: _ 1 R P..v 14Z. —
Policy#or Sell-ins.Lie. :_157 -0t `�- -. Expiration Date- (fj//
Job Site Address:q le 1;2V Beats_ ! .. - c 1t. State Zip: 5. (iiik O ias-3
Attach a ropy of the»corkers'compensation policy declaration page(sho»lug the policy, number and elpiration date).
Failure to secure cos erage as requit.J under MGL c. 152.§25A is a criminal s tolatton punishable b .1 tint:up to S1.500.00
and'or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a line of up to S250.0()a
day against the s rotator.A cope of this statement may be forwarded to the Office of Ins estigauon.s of the DiA for insurance
eineraue serilication.
1 do hereby certi I under the pains and penalties of perjury that the information provided re is true and correct.
/�t
S;Ln.it.itc:,4.-. L `�� I)ar.. `� ,.,/�
Platrc 0s S iTy/2)Y
Official use only: Do not write in this area.to be completed by city or town official
City or ['corm: Permitll.iceuse A
Issuing.luthoritq(circle one):
I.Board of Health 2.Building;Department 3.("its fo»n Clerk 4.Electrical Inspector 5.Plumbing inspector
6.Other
Contact Person: Phone a:
ACORO® DATE(YM(DDNYYY)
��- CERTIFICATE OF LIABILITY INSURANCE 09/122023
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 poticy(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 Kaihi Hutchinson
NAYS:
ORMSBY INSURANCE AGENCY I NC-Pla ENS (413)737-0300 4iAk.Y
ADDRE
ADDRESa: bIt11011inSOneomiS111
P 0 BOX 718 _ AFFORDING COMMON WWI
WEST SPRINGFIELD MA 01090 mum A; TRAVELERS INDEMNITY CO OF AMERICA 25866
INSURED tattittl IERS:
WiLDE HSE LLC MIB®t6:
N UNN'o:
45 OLANDER DRIVE INSURER E:
NORTHAMPTON MA 01060 INSURER F
COVERAGES CERTIFICATE NUMBER:929774 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.
Not — TYPE OFINSUR E yy o ESP
LTR POLICY eM I Yrn YseonYY
JSY)T MSS
COINS eRNL9IM.LIABany EACH OCCURRENCEDAMAGE TO R94TED
$
}CLAWS MADE OCCUR PREMISES exurrencW f
M®EXP(Any one person) S
WA P8t801N_a*Dv INJURY $
MIL AGGREGATE LIMIT APPLES PER GENERAL AGGREGATE $
J POLICY Lire,. ❑LOC PRODUCTS-COMPIOPAGO S
OTHER
AUTOMOBILE LIABILITY CA►EaSV SINGLE LMT $
ANY AUTO BODILY INJURY EIrpow) $
SCHEDUUED WA BODILY INJURY(Rs naleseS
_ AUTOS • AUTOS
H Y — NON4YMED PROPE3CtYDAV E $
AUTOS ONLY _AUTOS OILY Mee accident)
UNIMIELLALIM OCCUR EACHOCCtadIBICE _
Mass LIAR CIAatIIMADE WA AGGrEQATE $
DED I RETBITION; $
WORKERS COMPENSATION X
AIOBROMBNITtJAIRU Y Yin STATUTE ER
A n WA WA 8HU50W55113923 06/01/2023 06/01/2024 E I?11C11AOCEE4T $ 1,000,000
(Wyeei, rrylnNIS El DISEASE-FAEYPLOWE $ 1,000,000
R0ER TrGN OF mew
OPERATIONS beam EL D -MUM LIT s 1•000.000
WA
oEsaarnoN OF OPERATIONS!LOCATIONS!VEHICLES(ACORD IpI,Addaos!Renanis Schub%WS M eNer+rd if more IPew r r.plrred)
wormers'Compensation benefits was be pain to Massacrusetta employees only Pursuantte Encieresment WC 20 03 06 a,no autnonzation is given to pay claims for benefits to
erepioyeae In states other than Massachusetts if the insured hires,err has Hired those errlpbpettCUMde of Massachusetts.
Thiscertificate of insurance shows the policy In forte 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 iciww.inass.govithecttworkers-
compensationlinvesfigationeJ.
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
ACCORDCAN E WITH THE POLICY PROVISIONS.
210 Main Street
AUTHORIZED REDRESEMATNE
C
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
"....N WILDE-1 OP ID:KH
ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
�.--�" 09/12/2023
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).
413-737-0300 CONTACT
PRODUCER NAME:
Ormsby Insurance Agency Inc. PINE 413-737-0300 FAX 413-737.0617
W
698 Westfield St PO Box 71 to
8 C,No,Ex* puc_N
West Springfield,MA 01090 EMAIL LSS:
Eric Dembinske
Y. INSURER(S)AFFORDING COVERAGE NAIC 0
INSURER A:Northfield Insurance Company
IN URED INSURER B:The Travelers of MA 10647
Wide HSE LLC dba Commerce Insurance CO. 34754
Sexton Roofing&Siding INSURER C:48 Olander Drive
Northampton,MA 01060 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 ADDL SUBR POUCY EFF POLICY EXP
LTR TYPE OF INSURANCE NSD WVD POLICY NUMBER IMM/DD/YYYYI IMMIDDIYYYY) LIMITS
A I X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000
Li
(IAMB-MADE X OCCUR WS556514 05/30/2023 05/30/2024 DAMAGE S� oa� ) 5 100,000
MED OM(Any one person) S 5,000
PERSONAL&ADV INJURY S 1,000'000
GENT_AGGREGATE p LIM Q TAPP ES PER GENERAL AGGREGATE 5 2,000,000
II4 X POLICY L i J6f LDC PRODUCTS-COMP/OP AGG4$ 2,000,000
----OTHER: ----i s
C AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT 1,000,000
(Ea acadent)
ANY AUTO L11219 06/30/2023 06/30/2024 BODILY INJURY(Per person)IS__
OWNED X SCHEDULED
AUTOS ONLY ._ AUTOS BODILY INJURY(Per accident)._$
PROPERTY DAMAGE
X AUTOS ONLY .-X_AUTOS ONLY (Per accident) $
S
UMBRELLA A LAB OCCUR EACH OCCURRENCE S
ExCFCS LIAR __---CLAIMSi1ADE AGGREGATE
_--------_ ---I
DED RETENTIONS $
A WORKERS COMPENSATION X STATUTE _OTM- ---
AND EMPLOYERS'UABI ITY .. ER - }-
ANY PROPRIETORFPARTNER/EXECU IVE YIN- ISSUED SEPARATELY I
OFT ICERIMEMBER EXCLUDED? N/A E.L.EACH ACCIDENT_ _ C__ __
(Mandatory la NH) - E L DISEASE-EA E
Eyes dasvi0eonder .___—__—__.--_
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT I S
DESCRIPTION OF OPERATIONS/LOCATIONS/VEtBCLES(ACORD 101,Additional Romarks S hodula.may Eo attached if mono space is required)
Roofing&Siding Contractor
CERTIFICATE HOLDER _CANCELLATION
NONE-01
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.
210 Main Street
Northampton,MA 01060 ADTNORIZED REPRESENTATIVE
ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
. ,
The Commonwealth of Massachusetts
;e .__;_. Department of Industrial Accident.
I Congress ngress Street,Suite 1(10
-' Roston. MA 02114-2(117
www.mass.gov/dia
Workers'Compensation insurance Affidavit: Huitders/Contractor /Electricians/Piurnhers.
TO BE FILED WITH THE PERMITTING AUTHORITY
APolicant Inform/Mon
Print 4 e>iibit
NatTle(Business Organizationandividuali. ECA GENERAL CONSTRUCTION INC _ __ _
Address: 8 Otis St Apt 1
City/State!Zip: Milford.MA 01757 Phone#: 508-498-8870
4re you an employer?Cbeck the appropriate boa: Type of project(required):
i�am employer with t-1 employees(full andhor part-time).` 7. Q New construction
2.J I am I sole propnetor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'cuuti.insurance required.]
9. 0 Demolition
317.3 I am a homeowner doing all work myself.[No workers'comp_insurance required_]`
I0 Q Building addition
4.01 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 I 1.0 Electrical repairs or additions
{ proprietors with no employees.pip �oy' 12.❑Plumbing repairs or additions
50 l am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13f repairs
These sub-contractors have employees and base workers'comp.insurance• LL1
6.0 We are a corporation and its officers have exercised thew right of exemption per NW.c, 14_Q 4hher _
1 152.§1(4).and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information_
'Homeowners who submit this affidavit Indicating they are doing all work and then hire outside contractors must submit a new affidavit medicating 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 hat e
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: AiM Mutual ins Co _
VWC10060260282024A Expiration Dare 02/11l2025
Policy#or Self-ins.Lie.#: P
Job Site Address:*2 Eve4tEitzsisi RS)- C'ityiStatr/Zip:L.ExQ) O O 3
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 S 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 S250.00 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 ofperjury that the information provided above is true and correct
t
---
Sigttatur L,(11/ Date Q' C i I -- �t
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Coronet Porcrin! Phone#:
A G CERTIFICATE OF LIABILITY INSURANCE DA'o;,° `4'"'
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 poicy(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 REACT BRUNO ROZEMBARQUE
POINT INSURANCE INC PHON
i E Exit (617)783-1160 AX
,WC,Nol.
ADDRESS: brun0@pOlrltilstlre.com
1103 COMMONWEALTH AVE INSURERS)AFFORDING COVERAGE HAMS
BOSTON MA 02215 B16URERA: AIM MUTUAL INS CO 33758
INSURED _--�_---
INSURER 8:
E C A GENERAL CONSTRUCTION INC Itatiu tER C:
ASSURER D:
8 OTIS ST APT 1 INSURER E:
MILFORD MA 01757 INSURER F:COVERAGES CERTIFICATE NUMBER: 982472 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 ADM SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE NASD W VD POLICY NUMBER NIINDDiYYYY) (MM/DD,YYYY1 urns
COMASRCIAL GENERAL DABS TIY EACH OCCURRENCEDANAGE TO RENTED
i
CLAIMS-MADE I OCCUR `PREMISES Ma occurrence) $ _.
MED EXP(Any aria person) $
N/A PERSONAL&MN MJURY $
GENL AGGREGATE LJINT APPLES PER: GENERAL AGGREGATE $
POUCY Plen I LOC PRODUCTS-COIPIOPAGG $
OTHER: I $
AU rOMOBILELMBR.nY (EaCOMBINED SINGLELAST $
ANY AUTO BOOLY INJURY(Per peson) i
OwNED SCHEDULED
AUTOS ONLY ^AUTOS NIA BODILY"'JURY(Per acddMrq $
AUTHIREDOS ONLY ALIT PRCIPERTY DAMAGE - -- _-
UIBRHIALIAB OCCUR EACH OCCURRENCE _ S
EXCESS LIAS E G.ANSMADE N/A AGGREGATE $
DEO RETENTIONS $ _
WORKERS CO PENSATION X ME ERO 1-
AND EMPLOYERS'UABLITY
ANYPROPEIETORlPARTNE� Y/N EL EACH ACCIDENT $ 1.000,000
A OFFICERAA iEXCLWED? IBA NIA RYA VWC10060260282024A 02/11/2024 02/112025
!Mandatory h.MI) EJ-DISEASE-EA EMPLOYEE $ 1.000,000
If DEESCRIPTIONOF desaibe FO OPERATIONS below ,EL DISEASE-POLICY UNIT $ 1.000.000
N/A
)
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.Additional Remarks Schedule.may be attached if mom apace 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.govflwd/workers-compensationfinvestigations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Sexto Roofing and Siding Co ACCORDANCE WITH THE POLICY PROVISIONS.
45 Olander dr
AUTHORIZED REPRESENTATNE
Northhampton MA 01060 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA
B 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
Licensee Details
Demographic Information
uIl Name: -- — SASHA MARE WILDE
Name:
License Address Information
City: NORTHAMPTON
State: MA
Zipcode: 01060
Country: United Slates
License Information
nse No: CSSL-106265 License Type: e v Construction Supervisor Specialty
fession: Building Licenses Date of Last Renewal:
ssue Date: 7/6/2023 Expiration Date: 3/8/2027
tcense Status: Active Today's Date: 7/7/2023
Secondary License Type:
ving Business As:
tatus Change Reason: License Issuance
Prerequisite Information
No Prerequisite!damnation
I No A affable Documents
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
1000 Washington Street-Suite 710
Boston,Massachusetts 02118
Home Improvement Contractor Registration
Typt .LC
Flo9strabor za�in
_r -:- Ext,tata" O4•'112025
Uedata Adds..and R.}.,r-,Card.
'rit COW/C.004ALTN OF MtASSACnu5ETT5
OKcs of Consun+s►A►wierk&/twinsa►**twistzn Registration vatoA for individual AMP posy iasran''+s
riC7-1/f ifififiOVEfalii,CCtiTitACTOR lalitnf4n dot* If mold r.t.iry to
TYPE-.•L r_ Wilts of Consumer Affairs a^y Bus.nas s Ragu+at-cm
ktSaitgker Eati!IEiu itiX Waco-' 61 strsat •&Ate Tt:
rIf47: '.t's-. :;! Boston.VA D2114
•
<S Ct.At:aE R DR .rLn+t t. _ 'r fill:..— -
Unnowseveu , Not valid without signature
WILDE HSE,LLC
SEXTON ROOFING AND SIDING
www.sextonroofing.com
1 p.413.534.1234
info@sextonroofing.com , KO
�./' 45 Olander Dr.
Northampton,MA 01060 Setting the Standard
MA HIC#208 470
SUBMITTED TO HPMG PHONE ' 413-650-6010 _ DATE 03/08/2024
STREET PO BOx 686 EMAIL. I sbardwell@hpmgnoho.com
CITY,STATE,ZIP Northampton,MA 01060 jobsite:46 Evergreen BLDG B
SEXTON ROOFING HEREBY SUBMITS SPECIFICATIONS AND ESTIMATES FOR
I) Strip and remove existing shingles and dispose of in proper landfill.
2) Inspect roofing deck and replace as needed @$100 per sheet_
3) Install new metal edging to rakes and eaves of roof.(white/brown)
4) Install ice and water shield on eaves(6'),vent stacks,in valleys,chimney,at intersecting roofs.
5) Install synthetic roofing underlayment 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 cap over ridge vent.
10) Supply manufactures Lifetime warranty and SRC 10 yr.workmanship warranty.
AITENTION HOMEOWNERS:Please cover all personal belongings in the attic,garage,or storage areas due to possible roofing debris
or dust coming through cracks of wood decking.
Sexton Roofing shall apply for all permits.
We propose hereby to furnish material and labor-complete in accordance with the above specifications,for the sum of
Fifty-one thousand four hundred and forty dollars($51,440)
Payment due in full upon completion
All Material is guaranteed to be as specified All work to be completed
in a workmanlike manner according to standard practices. Any
alteration or deviation from above specifications involving extra costs Authorized � �
will be executed only upon written orders,and will become an extra Signature Jan."{rJ ee-
charge over and above the estimate.DAMAGES TO BUSHES AND
OTHER VEGETATION'MARKS ON HOUSE MAY BE UNAVOIDABLE
AND WE ARE HELD HARMLESS. Not responsible for water damage Note:This proposal may be withdrawn by us if not accepted within
during construction Owner to pay responsible legal fees for (30)days.
non-payment,and applicable interest
Acceptance of Proposal The above prices,specifications Jon McGee/Property Manager
and conditions are satisfactory and are hereby accepted. You Signature
are authorized to do the work as specified. Payment will be 04/02/2024
made as outlined above. Date