23D-027 (2) Vropoal
SEXTON ROOFING AND SIDING INC*
{413) 534-1234 P.O. Box 6327
FAX (413) 539-9906 Holyoke, MA 01041
sextonroofing@hotmaii.com Ir CT HIC #0605383
MA HIC #118239 www.sexton roof ing.Gom
Since 1985
SUBMI7TED TO C PHONE DATE
STREET L G' ? ,j JOB NAME
CITY
STATE ) ° r JOB LOCATION
ZIPCODE 'W b?e/� h
Proposal to furnish`and install the following EMAIL
❑ Re-Roof Near-Off in House ❑ Garage ❑ Shed
Complete Root Preparation
(Y—Home exterior to be protected by tarps and plywood
drubs, landscaping,trees to be protected
;�;,"A!6tire existing roofing material to be removed to existing decking,Including flashing,etc.
d-Site to be cleaned everyday with roll magnet debris removed at project completion cc� j fir,
!Weriorated existing decking replaced at$2.50 per sq.ft
❑ Install all new decking/type:
A hit rown metal drip edge installed at eaves and rakes 6,ie-8 ❑ F-5 &,J:3aketdge
,a,44 6w flashing will be installed where necessary(see Special Requirements)
&L:. tall new pipe boot flashing ❑ Bathroom Exhaust Vent
❑ Reflash chimney with new lead
e shall acquire all appropriate permits etc.for all roofing work
Complete Roofing System
yak Barrier installed at all eaves to protect from ice dams(and meet codes in the north) ❑ 3' ❑� �
4' Leak Barrier installed at valleys,around penetrations and chimneys to protect critical areas
X Install Roof Deck Underlayment on remainder of roof ❑ #15 Felt ynthetic Felt
Shingles
TKO ❑ GAF ❑ CertainTeed ❑ Tamko / ❑ 30 year ❑ 50 year ifetime Color
stall Attic ventilation system 21' Cap over Ridge Vent ❑ Roof Louvers
Warranty Options
e guaranteed our workmanship for 25 full years
Ne?or 00 hereb o furnish majerial and labor-complet in accordance with the abov specifications,for the sum of:
dollars($ 66�� )
PAYMENT TO BE MADE AS POLLOW „ G`= 1 �.
y
A aterlal is guarame as di . 11 to b led in a workmanlike me ner Autho zed
according to standard a s. Any alteration or deviation from above specifications involving
extra costs will be execu only upon written orders,and will become an extra charge over and Signature
above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control. Note:This proposal may
Not responsible for water damage during construction.Owner to pay responsible legal fees for Withdrawn by us 9 not accepted within days.
non•a ment n applicable i t re t Qf ilt%per month.
11cuptanre of Prop0941-The above prices,specifications and conditions Signature r
are satisfactory and are hereby accepted.You are authorized to do the
work as specified.Payment will be made as outlined above.
Date of Acceptance Signature
-••�•all narsonal belongings in the attic,garage or storage areas due to the possibility of roofing debris or dust
- -••
.,t hP responsible for debris or dust in the attic or storage areas.
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: LI�4 k�� -5�
The debris will be transported by: Oeo'la l z6ff a,wb2q
The debris will be received by: aLa X-h 19194- L
Building permit number:
Name of Permit Applicants 14 a
Date Signature of Permit Applicant
The Cor7rnorayve,t_,Uh of 1Ylassaci>usea`ts
e a trraerat of fndAstTialAccidents
Office of Investigations
600 Washington Sheet
Boston, MA 02111
5� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
'Name (Business/Organization/Individual): A n Csn—)-jm Q-16 o n Too—
Address: U 0 Inc,-n°� :�T` -FLJ
Ci tY/M ate/Zi p: , 1 uq,�) o � o - n A 0 I bI l Phone#:
Are you an employer? Check the appropriate box:
,-�� 'Type of project(required):
1.L I am a employer with 4. ❑ I am a general contractor and I
6. F1 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:$ 2. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp. insurance.' 9, ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t 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.
TCoatractois that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp:policy information.
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.#: ��I���t,� � ���� �0 ���1 ��'��� _� Expiration Date: j (D� (o
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (sho-ding 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 undeake_pains and penalties of perjury that the information provided above is trite and correct.
Si afore: — Date: U "�
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
City'or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Eealth 2. Building Department 3. City/Town Clerk 4.Electrical Inspectot• 5.Plumbing Inspector
6. Other l
i
Contact Person: Phone#:
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations.
1 Congress Street, Suite 100
Boston,AIA 02114-2017
Workers' Compensation lw ranceAMdavil: Builders/Contr act ors/Elec-tdcians/Pl-umbers
Applicant Information Please Print Le2-ibly
_ Name (Business/organization/Individual):
Sexton Roofing Co.
Address: P.O. Box 627
City/State/Zip: Holyoke, Ma. 01041 P hone#:41-3-534-1234
Are you an employer? Check the appropriate bog:
Type of project(re
4. ri contractor and am a general contracto and I quired):
1.F-1 I am a employer with g
employees (full and/or part-time).T have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner-. listed oathe attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have ' S. ❑Demolition
working for me iu any capaciy., employees and have workers' 9. ❑Building addition
[No workers' comp.insurance comp:in aMcO
regi ired.l 5. We are a corporation and its 10. Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Phinbing repa s er additions
m ,elf. o workers' com . right of exemption per MGL
Y, [N P 12.D Roof rep airs
insurance required.] t c. 152, §1(4), and we Dave no
employees. [No workers' 13.[1 Other
comp.insurance required.]
-A❑y applicmtthat checks box4l must also fill outthe section below showingtheir workers'compensationpolicy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicatiTig such
tContractors that check this box must aftached as addi-clonal sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they mustpiovide their workers'comp,policy number:
I am an employer tizat is providing workers'compensation insurance far my employees.. Below is the policy and job site
information.
Insurance CompwiyName:
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 leadto 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 fo=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 maybe forwarded to the Office of
Investigations of the DIA for " ce coverage verification.
I do hereby certify and the Rs and penaZties of perjury that the inforrgation provided above is true and correct.
Si afore: Date:
Phone#: 4135341234
Official use only. Do not write in this area,to be completed by city or-town off ciaZ.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Tlealth 2.BuildingDepa tmeat 3. City/Tovm Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor- Not Applicable
j❑
Name of License Holder: �l'e .Q !?!2,4 O
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
3Cf
ornoanv Name Registration Number
Address `` Expiration Date
i[b Telephone-5-3 Z
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
114 -Home Owner Exemption
The current exemption for `homeo "was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeo r to engage an individual for hire who does not possess a license,provided that the owner acts
as su ervisor.CMR 780 'xth Edition Section 108.3.5.1.
Definition of Homeowner:P son(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or wo family dwelling,attached or detached st tures accessory to such use and/or farm
structures.A person who constr is more than one home in a ar eriod shall not be considered a homeowner.
Such"homeowner"shall submit to a Building Official, orm acceptable to the Building Official,that he/she shall be
res onsible for all such work ver fo ed unde uildm ermit.
As acting Construction Supervisor y ence on the job site will be required from time to time,during and upon
completion of the work for which t ' e it is issued.
Also be advised that with ref ce to Cha er 152(Workers' Compensation) and Chapter 153(Liability of Employers to
Employees for injuries resulting in Death of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perfo ork for you under this pe it.
The undersign homeowner"certifies and assu s responsibility for compliance with the State Building Code,City of
Northampt Ordinances, State and Local Zoning L s and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [❑ Siding[0] Other[CQ
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. !f New house and or addition to existing housing, complete the f d1mina:
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 ne onstruction. imensions
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 1Xfloorbelow lands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or hed grade
k. Will bui lding confor o 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
as Owner of the subject
Property
hereby authorize
to t on my behalf, in all matters relative to work authorized by thi building permit application.
Sig on
of Owner Date W16^
as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing a ioation are true and accurate,to the best of my knowledge
and belief.
Siaaed under th pates and penalties of perjury.
Print Name
Signature of Owner/Agent ate
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 °o
(Lot area minus bldg&paved —
parking)
#of Parking Spa s -
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW (7f YES Q
r1F YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Cr YES Q
IF YES: enter Book Page; and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW CKYES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO
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
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.
City of Northampton s
Building Department `
212 Main Streetg` ` 4
r/ Room 100 t* x
f Northampton, MA 01060
;1 phone 413-587-1240 Fax 413-587-1272 t �
4;
PLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map lot Unit
Zone Overlay District
�p Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) 9 Current M�n Add
Telephone
Signature
2.2 Authorized A ent:
Name(Print) Current Mailing Address:
535- e 3 y
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit a licant
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) ws, Check Number
This Section For Official Use Only
Date
Building Permit Number: sued:
Signature:
Building Commissioner/Inspector of Buildings Date
468 ELM ST BP-2016-0443
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D-027 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-2016-0443
Project# JS-2016-000732
Est.Cost: $6825.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEXTON ROOFING CO 99689
Lot Size(scp 111 6795.36 Owner: RODGERS KEITH
Zoning URB(100)/ Applicant: SEXTON ROOFING CO
AT: 468 ELM ST
Applicant Address: Phone: Insurance:
P O BOX 6327 (413) 534-1234 WC
HOLYOKEMA01041 ISSUED ON.1012120-15 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 10/2/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner