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Pt ._ Office of Cow { r; u, ,�ess Regulation
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_ ._ Bo-s7o , n, 02116
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• -Hone T-rn_D�.oT,��iL C _ LO Regis LL ation
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1 = Reais _�orL 1'18239
Type: DB„ .•
- =- -�ir_ton 2/15/2015 Trg 207886
SEXTON ROOFING CO - __ - "
•
EVERE I T SEXTON = _ __—
P.O. BOX 6327 -__- =
HOLYOKE, MA 010 — =—
• __�=�__- -E--,_=; 4 tea—T =`? "zr— c3 -=�
PS-CM co 56M-04/04{101216
k� Massachusetts - Department of Public Safety
`� Board of Building Regulations and
Construction Super isor Specialtl Standards
License: CSSL-099689
EVERETTJSEXTON
PO BOX 6327 .:; -
HOLYOICE MA 01041 i
9::/....,
,.
�� Expiration
Commissioner 10/05/2015 -
t
The Commonwealth of Massachusetts
Department of Industrial Accidents
Fa -�i. (,
'' '4 Office of Investigations
—� y 600 Washington Street
s 1-- ,, Boston,MA 02111
t, -y� , -
--=7 �- www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information n Please Print Legibly
Name(Business/Organi�ation/Individual): L� 01,on3-�ru C un Tr('
Address:OA Qiou -0Ln
City/State/Zip: t 00 (e 93 r 0,3\ o4Phone#: L.Q\ri - 9L3 -q5 qc
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
g y p 9. ❑Building addition
[No workers' comp. insurance comp.insurance.t
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number,
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. _ n
Insurance Company Name: I,.'1 I i, in U A0 ,iJ wranc. 1 /U _L,,,
Policy#or Self-ins.Lic.#: VL0e-1 Q0-,`DUI -e9013 8s Expiration Date: .7 3l +
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: itili?Ai Aims Date:
Phone#: ton- 1 - V I`73 `9599
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#:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Office of Investigations
1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Sexton Roofing Co.
Address: P.O. Box 627
City/State/Zip: Holyoke, Ma. 01041 Phone #:413-534-1234
Are you an employer? Check the appropriate box: Type of project(required):
1.[1] I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees , These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp.insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as-required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone#: 4135341234
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
-� �_����
A division of Sexton Home Improvement Co.
MIS.
K4AH|C #118239
--~�~ ^ CTH|C #O605383
www.s8xtOO[0OfDg.00m
Since 1985
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-' �JOB Locm�mm | .
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Proposal to furnish and install the following
R R �~'�^
a' uo/ .="^OM ��NitanHnwue � Garage Shed
Complete Roof Preparation f-e'= 1'1
Homo exterza to he protected by tarps end plywood , "/� ''/
/ Shmby. landscaping, trees to he protected /
ex/�mgoohnymaoeha/tubemmnvedtoex��n9 decking. |o�udingUaoking. gz � � ^ �'^'' ` ^/
be cleaned everyday with m|l magnet debris removed at projec completion
.r Deteriorated existing decking replaced et S250 per ag.ft
� aU 'levy decking/type:
drip edge installed eaves and rakes -1--F-8 F'5 Rake Edge
/CitewOaskingwill he installed where necossary (see Special Requirements)
/ns,o: new pipe boot flashing .s -rhmom Exhaust Vent
Rehashohimnny new lead /~-'
��
We shall ouquima|| appmpna1e permits permits etc.for alt roofing work
Complete Roofing System
_V Leak Barrier installed at all eaves to protect from ice dams (and meet codes in the north) a 3 -r�.
Leak Barrier installed at valleys, a/oundpeneiuginnsandchimneysxzpmtecx -ii-
areas
a( /ostaxRoof DprkUrdedaymentoo remainder of roof e15 Felt
-4— gynMa|tcFa/t
Shingles
!KO a GAF Ce,,ainTepd 50 year -~~Ekyime Color
|ns/ai/ Attic venn/aoonsystem a Cap ever Ridge Vent �'1RnofLouwers
Warranty Options ~-
-if vvegua:an,eedovrwn,xmunnhiphzr25bUyeam
t hereby to furnish material aid | plete in accordance with t e above specifications,'=-
the our
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' .�°°����~��~,����,��, - - -Authorized
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Aomtaoon(Proposal Tie a " -----'mc*----�=======
um",nvoev.ypevmoo«nn nnxcommmms
are �°� �m�
� are accepted aumonzeo /uuo /np
wwxayspp'«.el povnwn outlined&Dove a /\
s�r�vn `~ � _ _. ` �_� '
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. El Demolition ❑ New Signs [D] Decks [p Siding[CI] Other[D]
Brief Description of Proposed /
Work: �� CI(,'1SIM S1/ ✓l fi eCl
Alteration of existing bedroom 6 Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building :One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft, of wetlands?, Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, )4 " - v� ��tC- ` ,as Owner of the subject
property
hereby authorize —Y_-1Z6U oo 11,1_,c. Cc)
to act on my behalf, in all matters relative to work authorized bytthis building permit application.
Signature of Owner Date
I, cox- L`.) GC 1,-1,1 , 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 t ns and pen (ties of perjury.
Print Name
/ 7/
Signature of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
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/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained l Obtained
, Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
• Department use only
F-------- -. City of Northampton Status of Permit:
-- Building Department Curb Cut/Driveway Permit
,ii
1 i j , , . ! I 212 Main Street Sewer/Septic Availability
Li; NOV 2 I 2013 1,,[-; Room 100 Water/Well Availability
I _44 •rthampton, MA 01060 Two Sets of Structural Plans
p
Electric. ; r7�,;r Ga . oil t-587-1240 Fax 413-587-1272 Plot/Site Plans
Ncrth�.;7,rtcn, MA 01060 Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
L
7 ( c j ' l Map Lot Unit
? Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
()a on e d lA IA 0 1 1c 5 c) s /V,6 4-CdAt-
Name(Print) Current a ing Address:
CCM.4,1ct el--4 4,A1-e-EID.k
Telephone
Signature
2.2 A thorized Agent:(Rock.cl-q Cc ' (c).0 D- ( tx. Co "'S,) 7 )-(61-t/CM /444
Name(Pri Current Mailing Address:
Z/as3y /z-3
Signature Telephone
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) LPf M Check Number 1913 / 036_
This Section For Official Use Only
Building Permit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
42 JACKSON ST BP-2014-0643
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A- 181 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-2014-0643
Project# JS-2014-001091
Est. Cost: $6800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEXTON ROOFING CO 99689
Lot Size(sq. ft.): 9234.72 Owner: HARRISON MARGUERITE I&PAMELA J PETRO
Zoning:URA(103)/ Applicant: SEXTON ROOFING CO
AT: 42 JACKSON ST
Applicant Address: Phone: Insurance:
P O BOX 6327 (413) 534-1234 WC
HOLYOKEMA01041 ISSUED ON:11/21/2013 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 11/21/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner