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31A-291 BP-2024-0473 20 WASHINGTON PL COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31A-291-001 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-2024-0473 PERMISSION IS HEREBY GRANTED TO: Project# ROOF 2024 Contractor: License: WILDE HSE LLC DBA SEXTON Est. Cost: 18000 ROOFING 106265 Const.Class: Exp.Date: 03/08/2027 Use Group: Owner: S WADE ROBERT N&AUDREY Lot Size (sq.ft.) Zoning: URB Applicant: WILDE HSE LLC DBA SEXTON ROOFING Applicant Address Phone: Insurance: 45 OLANDER DR 315-569-7761 6HUBOW55113923 NORTHAMPTON, MA 01060 ISSUED ON: 04/19/2024 TO PERFORM THE FOLLOWING WORK: STRIP AND REROOF 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: 772. Fees Paid: $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner The Commonwealth of Massachusetts c, Board of Building Regulations and Standards FOR Massachusetts State Building Code 780 r1VIR,4p .(°) �, ,,'� JNIGIPALITY 7 /� USE Building Permit Application To Construct,Repay-,R-,y., ate Or Dlniil R`evise('Mar 2011 One-or Two-Family Dwelling ,;^a,A i This Section For Official Use Only rH,ii;, /NG1 Building Permit Number: ���" L7 Date Applied: M�yboioN� / 4,0 &055 //L '```J 14-1q-20z11 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1Property Address: Op ' �5 f It evroN Pk3.2 Assessors Map& Parcel Numbers 0 cktVtA Arn.,PT'b 1 MA O I n(pO 1.1 a Is this an accepted street?yes vno Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Wate Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private 0 Zone: _ Outside Flood e? Municipal Errn site disposal system 0 Check if yell SECTION 2: PROPERTY OWNERSHIP' 2.�l qwneri of Record: `,L6Ca:, VV �- Z_,.. n p_d lv, WI. . 6 )OLIO Name ) 2.i State,ZIP ao Li; h1�s 14 IL1Cc� btl Q1•PL 962 ►\1,k No.and Street elephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building Er. Owner-Occupied f Repairs(s) tar"Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. ❑ Number of Units Other 0 Specify: Brief Description of Proposed Work2:Rc iwE i.0 1 s'rrOA So,'xis S, g.Epboc,F A al/ ]2 6/i Ei N$i A Ll A>L cN►T F,c i'Lt(L.A L S'114 I►J(ej LI S, 1 l S`f{ijit. ILeY5 V JI CA") ittfq.AVA c1k tn"taL o. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ I 9 er p '" 0D 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ { 0 t V� 0 Standard City/Town Application Fee 0 Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No.a.10 I Check Amount:* Cash Amount: 6.Total Project Cost: $ /Qr coo ,00 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor LicenseLA) (CSL) k5�� Na_i_i__ 1 L ,hE L: ense Num r Expiration Date7 Name of CSL Holder � List CSL Type(see below) �L�t Yo.and Street Type Description ,�I ]'� U Unrestricted(Buildings up to 35,000 Cu.ft.) ai kM (�1 U'`r `YW-k �'V R Restricted 18c2 Family Dwelling City/Town,State,ZIP 1 M Masonry RC Roofing Covering WS Window and Siding C�, SF Solid Fuel Burning Appliances 713),5'3 H./3ii V_to1JobF ln I Insulation Telephone Email address G gn j Lc q1 D Demolition 5.2 Registered dome Improvement Contractor(HIC) CR Q�, ` 70 CNI b_ L \')C HIC Registration Number E piration Date II Company Name or HIC Registrant N 4,ame �.J�2s S QLk0 oirt- • f> >L C4$4 .and Street 0 11/3 a Email address City/Town,State,ZIP Telephone SECTION 6: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 ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOr BUILDING PERMIT I,as Owner of the subject property,hereby authorize` 0 E _ [,ii4 f/ to act on my behalf,in all matters relative to work authorized by this building permit application. /Ale;/ Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this a plication is true and accurate to the best of my knowledge and understanding. / �/� IZZ-Zt-- P�•wner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.govidps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton Op'Y M M-?u,. 5 s �' • Massachusetts ���5�40* - 'c,�` I ( .i DEPARTMENT OF BUILDING INSPECTIONS j,° J CD ♦ 3t f 6 212 Main Street • Municipal Building y ,Northampton, MA 01060 'Ps' ��`'Njy 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: --fps i Location of Facility: 3�a 1 'QL,6ia,NU 5-S N .L4) . ' ki\ o/1 OS— The debris will be transported by: Name of Hauler: ASSOG/ f p gilippip, pi / c Signature of Applicant: - g.J.,4 �-e�Clz Date: /A1,-, The Commonwealth of Massachusetts Department of Industrial Accidents Elf § I Congress Street,Suite 100 Boston,MA 02114-2017 ,��� www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibiv Name(Business/Organization/Individual):Sexton Roofing and Siding Address:45 Olender Dr. City/State/Zip:Northampton,Ma 01060 Phone#:413.534-1234 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. []New construction 2.1:1 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property_ I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.01 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet 13.E Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑ cmption ht of We arc a corporation and its officers have exercised their rig ex per MGL c. 14. Other 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contmctots mast 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 Policy#or Self-ins.Lie.#:6HUB0W5.'511113923 Expiration Date:6/1/24 y V Job Site Address:as As )tJthTaA) PL E City/State/Zip:�Qrr ulpft,, `A O)t O 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$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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce ' under a pains and penalti of perjury that the information provide a is ue and correct Signature:,. Date: Phone#: 413-534-1234 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ' 1 ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 09/12/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Kathi Hutchinson NAME: ORMSBY INSURANCE AGENCY (A/C,No Ext)c (413)737-0300 FAX No): E-MAIL hi t ucnson s ADDRESS: kh C�«mbins.Com Y P 0 BOX 718 INSURER(S)AFFORDING COVERAGE NAIC$ WEST SPRINGFIELD MA 01090 INSURER TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER 8 WILDE HSE LLC INSURER c: INSURER D: 45 OLANDER DRIVE INSURER E. NORTHAMPTON MA 01060 INSURERF: 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP UNITS LTR INSD WVD POLICY NUMBER (MM/DDIYYYY) (MMINY/DYYY1 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ — DAMAGE TO CLAIMS-MADE OCCUR PREMSES(EaENTED occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEM AGGREGATE LIMIT APPLIES PER: GENERAL.AGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE t: DED RETENTION$ $ WORKERS COMPENSATION 1 OTH- X PER UTE ER AND EMPLOYERS'LIABILITY ANYPROPRIETOA OFFCER/MEM ERREXCLUD D?ECUTIVE N/A NIA WA 6HUB0W55113923 06/01/2023 06/01/2024 E.L EACH ACCIDENT S 1,�.� (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ 1.000,000 Ii yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 1.000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space 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.gov/Iwd/workers- compensatioNinvestigations/. 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 ACCORDANCE WITH THE POLICY PROVISIONS. 210 Main Street AUTHORIZED REPRESENTATIVE 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 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). PRODUCER 413-737-0300 CONTACT Ormsb Insurance Agencyy Inc. NAME:_. 698 Westfield St PO Box 718 PHc,No,Ext:ONE 413-737-0300 I No):413-737-0617 West Springfield,MA 01090 Eric Dembinske INSURER(S)AFFORDING COVERAGE NAIC/ INSURER A:Northfield Insurance Company INSURED INSURER S:The Travelers of MA 10647 _ SextoHRo finLL dba Commerce Insurance Co. 34754 Sexton Roofing&Siding INSURERc: 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. N/SR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF ' POLICY EXP LIMITS 1 T! INSD WVD IMM(DD/YYYY1 IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMCLAIMS-MADE X OCCUR WS556514 05/30/2023 05/30/2024 So(ERaE ) $ 100,000 MED EXP(My one person) $ 5,000 PERSONAL A ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY j LOC PRODUCTS-COMP/OP AGG $ 2,000,000 I OTHER: $ C AUTOMOBILE UABILJTYJEa COMBINED t SINGLE LIMB ; 1,000,000 ANY AUTO L11219 06/30/2023 06/30/2024 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSRR�E�� ONLY X AUTOS BODILY INJURY(Per accident) $ X A�TOS ONLY X AUUTOS ONLYY (Pe►o Y ntD1AMAGE $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LII18 CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION X SPUTUTE OTH- AND EMPLOYERS'LIABILITY ISSUED SEPARATELY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/NI E.L.EACH ACCIDENT OFFICER/MEMBEREXCLUDED? NIA andatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more 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 ACCORDANCE WITH THE POLICY PROVISIONS. City of Northampton 210 Main Street Northampton, MA 01060 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts `,��`i►j Department of Industrial Accidents 1 Congress Street, Suite 100 = :is -" Boston, MA 02114-2017 www.mass.gor/dia 0.1 Workers'('ompensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers, TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print l,e>Ubh :�aplicant nation Name (BusinessECA GENERAL CONSTRUCTION INC Organizationrindividuat): --- — Address: 8 Otis St Apt 1 City/State/Zip: Milford, MA 01757 Phone#: 508-498-8870 .ore you a mployer?Check the appropriate box: Type of project(required): I. am a employer with 1-"A employees(full and:'or part-time). 7. ❑ New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] q. ❑Demolition 3E3 lam a homeowner doing all work myself.[No workers'comp.insurance required.]' 10 ❑ Building addition 4.❑1 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 1 1.0 Electrical repairs or additions proprietors with no employees. 12.[�Plumbing repairs or additions 5.0 I am a general contractor and i have hired the sub-contractors listed on the attached sheet I 3.2Ttrot repairs These sub-contractors have employees and have workers'comp.insurance.: 14 DOthef 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 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 arc 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 hether 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. AIM Mutual Ins Co Insurance Company Name: -- Policy#or Self-ins.Lic.#: VWC10060260282024A Expiration Date:02/11/2025 Job Site Address:c7/l.)WArld6fill1/- City/State/Zip: Attach a copy P of the workers'compensation po t icy declaration page(showing the policy number and e. piratio date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a tine up to S 1,500.00 andior 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the in formation provided above is true and correct Signature: ,1-•.,�Z.7lera . Date: 0 3 6)/ — ` �l Phone#: _. pfciai use only. Do nut write in this area, to he completed by city or town official City or Town: Permitll.icense # issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other f'nntart Person: Phone#: i Aco1?1_) CERTIFICATE OF LIABILITY INSURANCE DA E(MM/DD/YYYY) 02/29/2024 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 CONTACT BRUNO ROZEMBARQUE NAME: POINT INSURANCE INC (A/C,N0.Ed): (617)783-1160 jAIC,No): ADDR bruno@poirtinsure.com ADDRESS: "�� 1103 COMMONWEALTH AVE INSURER(S)AFFORDRAGCOVERAGE NAIL* BOSTON MA 02215 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B E C A GENERAL CONSTRUCTION INC INSURER C INSURER D: 8 OTIS ST APT 1 INSURERE: 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. NSR TYPE OF INSURANCE (MM ADDL SUBR POUCY EFF POLICY EXP LIMITS LTR MISD WVD POLICY NUMBER DDIYYYY) (MMIDDJYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCED $ RED CLAM c CLAIMS-MADE OCCUR PREMISES SES AGE T(Ea ocurrence) $ MED EXP(My one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED ^ SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ ,DED RETENTION$ $ WORKERS COMPENSATION X p AND EMPLOYERS'LIABLITYY STATUTE ER A FN CER/MEM ERREXC UD D?ECUTIVE WA N/A NM VWC10060260282024A 02/11/2024 02/11/2025 EJ_EACH ACCIDENT $ 1.� O ��0 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 1.000.E IF yes,describe under 1.000 000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space 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.gov/Iwd/workers-compensation/investigations/. 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 REPRESENTATIVE Northhampton MA 01060 CL 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 3/19/24,8:07 PM LP Baruch WC Affidavit.jpg The Commonwealth of Afassachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.stass.gor/dia Workers'Compensation Insurance A16dasit;IluildersJ('ondractors/FaecarieiansiPlumbers. 1'O BE FILED WII'H'1'lIP PERMITTING AIJTHOItI"Il'. Ant►)icant Information Satre Print Ltuibls Name 11usiness'O gamratikn Individual): L I y,sct d1 "Inc, Address: (Dal tZ.,Ah'h,, 14 4v a City(State/Zip: T Phone#: _ Are you as rmpl..er'clerk din appropriate boa: Type of project(required): 1.T I am a employ is with L-n,losvei(Full amlar pans-omen 7. 0 New construction I am a sole pnlpnetkr or tarn-nhlp and have nu employees working fur me in II- 0 Remodeling any capacity.[No workers'curtly.insurance nequiro ) 9. ❑Demolition 10 I am a hannnorier doing all work myself.[No wurkem curry_lawman/De wqunnal.]' 10 Q Building addition 4.0 I am a homeowner and will be hiring m ntration to conduct all work on my property_ I will ennui'that all contractors citla a have worker-oorrlpen atiun insurance or are sole 1 10 Electrical repairs or additions proprietors with no ernployets. I2.0 Plumbing repairs or additions 51 I am a ernual crunuactur and I have bired the sob-eunuzctun listed Lin the an shed sheet I j altS These sub-contractors love c employees and base workers'comp.insurance.: 14_El Other ei.CI We are a corporation and its offrcen have exercised their right of exemption per ktraL c. 152_21 tot.and we base nu employees.[No workers'comp.Insurance requa•d.j 'Any applicant that checks box al mint also fill out the section below showing their worker'compensation policy information_ t h omeownns who subalit this alti alit Indicating Lk"are doing all work and then hue outside -u ntraatots mutt submit a new afftdas it indicating such. ;Contractors that cheek this boa must attached an arishtivaal skeet show ing the name of the sub-coMrators anti Aare whether of not those alums have employee if the sub-contractors hose employees.they is ice 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 slit information. Insurance Company Name: — Policy ti or Self ins.Lie.#1 5 le)aU(itA ©1Vq a�3 Expiration Date: 011 IA .1+V2y Job Site Ad fir-Viiit tr // P4' CityiState Zip: 4 /1/a Attach a copy of the compensatiioa policy dedaratior page(showing the policy umber and a lion te). Failure to secure.coverage as required under MGL e.152,§2SA is a criminal violation punishable by a fine up to S1300.00 attd'or one-year imprisonment,as well as civil penalties in the form ot'a STOP WORK ORDER and a fine of up to 5250.00 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 c veider the palms and penalties of perjury that the information provided above is brie and correct. / � Signature: Date: //, P I /7ez'3 )'hone t:. ., Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License it Issuing Authority(circle one): I.Beard of Health 2.Building Department 3.Cicy/lawa Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Plow IS: https://drive.google.com/drive/folders/1 EJlauznxk442ABFg7A82m8pToYeiOXwe 1/1 ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYYYV) 08/15/2023 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). PRODUCER CONTACT BRUNO ROZEMBARQUE NAME: POINT INSURANCE INC PHC No Est); (617)783-1160 1 FAX — (A/C,No): E-MAIL ADDDRESS: ran��b ntufsUIe.Com A 1103 COMMONWEALTH AVE WSURER(S)AFFORDING COVERAGE NAIC• _ BOSTON MA 02215 IIISURERA; ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: L P BARUCH INC INSURERC: INSURER D: 637 RATHBUN ST APT 2 INSURER E: _ BLACKSTONE MA 01504 INSURER F: • COVERAGES CERTIFICATE NUMBER: 921636 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO $ _ —1 CLAIMS-MADE L_ )OCCUR PREMISES(EaRENTED occurrenCe) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO _ JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (E accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER Y/N ANYPROPRIETOR/PARTNERIEXECUTIVE E.L EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6S62UBOW59692023 07/11/2023 07/11/2024 1,000,000 (Mandatory in NH) E.L DISEASE-EAEMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ N/A DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space 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.gov/Iwd/workers-compensation/investigations/. 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. 102 PINE STREET AUTHORIZED REPRESENTATIVE HOLYOKE MA 01040 Daniel M.Cro I y,CPCU,Vice President—Residual Market—WCRIBMA 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Licensee Details Demographic Information uII Name: SASHA MARIE WILDE Owner Name: License Address Information City: NORTHAMPTON State: MA Zipcode: 01060 Country: United States License Information License No: CSSL-106265 License Type: Construction Supervisor Specialty Profession: Building Licenses Date of Last Renewal: Issue Date: 7/6/2023 Expiration Date: 3/8/2027 License Status: Active Today's Date: 7/7/2023 Secondary License Type: Doing Business As: Status Change Reason: License Issuance Prerequisite Information No Prerequisite Information No Available Documents THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration r. ... Typo .LC V�'�DE► .LLC R straoon 2061)0 • =.1» Exprobtat 04104025 D'`!A SEXTON ROOFING 0 ttpiti ;+ } AS WADER OR NJRTNAM.PTON MA 03104 «-' rr. Yodels Addroso and**turn Caro- ME CONNION*EALTN Of MASSACHUSETTS O .of Conaufna/Affaba I Swims**Rsgu a lOn RaaNrmeii robd tar k dtviduai user only Wore e. HOME IMPROVEMENT CONTRACTOR tapirollon MM. V%wild rsaum to TYPE-.LC Moo M Can&Mare surd SUWma Ragurat on tON SWIM •OWN 711 EesMr4 NAMIS MOO►OE.Lt.0 OS'A SEXTON ROONNO I SO'J3 S OLANDER OR �.w.r/.! a/4.A ,loRTww»roN,MA alter unosneorriory ���V Not valid without signature WILDE USE. LLC SEXTON ROOFING AND SIDING www.sextonroofing.com p. 413.534.1234 info@sextonroofing.com VINO 45 Olander Dr. Northampton, MA 01060 Setting the Standard MA HIC#208470 r )0 f /)1,0 SUBMITTED TO ( G• 0�, PHONE ?�/ ( DATE _ (/ STREET r li(ft j A c EMAIL CITY,STATE,ZIP Special Requirements: SEXTON ROOFING HEREBY SUBMITS SPECIFICATIONS AND ESTIMATES FOR: r- [§"S'trip and remove existing shingles and dispose of in proper landfill. IC]Jpspect roofing deck and replace as needed @$ , per sheet. -�-' nstall new metal edging to rakes and eaves of roof. (r rn v7* Qi Color:� � ,-`t D 5 in E8in Qinstall ice and water shield on eaves(6'),vent stacks,in valleys, chimney,at intersecting roofs. a4nstall synthetic roofing underlayment on remainder of roof. ra4rItall new flanges over existing vent stacks. Q.lnstall starter shingles on eaves and rakes of roof. ELM' IKO Architectural style roofing shingles as per manufacturers' specifications, I-$Yfstall new ridge vent cap over ridge vent. I ,,Reflash chimney D' upply manufactures warranty 0-Supply SRC 10-year workmanship warranty. +-Sexton Roofing shall apply for all permits. Shingle: J B r), 6r S Color: /r+'' ' 1."4P r_D 16.,,.1 j` - I We propose hereby to furnish material and labor-complete in accordance with the above s pecifications,for the sum of Total Due$ ` ' e )[� 0" 1/3 Down Payment S '! ' r Balance due upon completion$ Acceptance of Proposal The above prices,specifications and conditions are satlyfactory and are hereby accepted. You are authorized to do t work as specified. Payment will be made as outlined above.Unpaid balances shall accrue interest at 1896 expenses and reasonable attorney's fees incurred by Wilde HSE,LLC OBA Sexton Roofing&Siding to recovere any sumsdue u dersthisll copay for ntractall co • Customer Signature: // K.2 Date: . t.. 1 Authorized Signature: z Date:/1/ ATTENTION HOMEOWNERS:Please cover all person belongings in the attic,garage,or storage areas due to possible roofing debris or dust coming through cracks of wood decking,All Material is guaranteed to be as specified. All work to be completed,n a workmanlike manner according to standard deviation from above specifications involving extra costs will be executed on uponenorders,and will becomepractices.ndaboveArty heestima oa . DAMAGES TO BUSHES AND OTHER VEGETATION'MARKS ON HOUSE MAY BE UNAVOIDABLE AND WE ARE HE DHARMLESSr Not responsible for water atc damagedurk^t construction.