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29-110 (7) r PEPIN ROOFING & SIDING CO. Page No. 1 of 1 1, Pages MA HIC #107104 54 West Street PROPOSAL EASTHAMPTON, MA 01027 All home improvement contractors and subcontractors 527 -3640 engaged in home improvement contracting, unless • specifically exempt from registration by Provisions of Submitted ;/ i 1 Chapter 142A of the general laws, must be registered with J To: Ay _j a l _; - - - the Commonwealth of Massachusetts. Inquiries about c registration and status should be made to the Director, 1 Home Improvement Contract Registration, One Ashburton '}' \'1 \A- c )\ r _ Place, Room 1301, Boston, MA 02108 (617) 727 -8598 JOB NAME / NO. PHONE DATE J013 LOCATION `1;'°' . ARCHITECT DATE OF PLANS , > ", We hereby submit specifications and estimates for work to be performed and materials to be used - n 4 - f 1 / 4 .-"\ , C 1 .._-__ L'1 �___-�Y0.. - - ` -C�_ _ .,, -_V ) C..� � .(. ,,L- , c 1 , , \) t ._- • , ^__b `�' ,'�_ 4 \ _ ` \ .__ :. vr'.1`-Q 6 , t ` r& +""'P" t j \� (\ R\ ` a s i • ' \ S tom , 'A F \ ___nw.____ ___ _ 1 a;__. ? -" __ - V. S.1 " - -_ r • -( -- :> _ - _ . _i C v i s 1 ,, +. t—) y . ') ) J ,, �s � � At z r e . . ) e . . ) C d i r - _ \ i ( � L\ :_. j \ s ,,p, � \` r , a . A ,,` , n C - onstruction relat permits t _ is t n . 5.. '_ t_ :: : , .1.:_ .. _-_ ° "" ___� � �' - ' F - " Lx _"� - - ' ',y _ a _ . __ t 1 �� _ - _ _ - -_ . s ''s ` ) - . I . 4 :' ,.3 `. , � .,4'�... - -'� ! ti,�1. ,\ ..._. - -_ _"__ 3 ` \r,,,,,-- e\ i 1 ' -- "' L t" L } Lfi k tt r , I c, \ 1\ ,I 4. "� t \C t { ', \ 4 r \ , r. r/ R 0." C. A ; , a ■ l <:-.> P. v a 5 ? �, }..:..7 \\ e m : , N, i :::),A Sc > WORK SCHEDULE Contractor will not begin the work or order the materials before the third day fallowing the signing of this Agreement, unless specified herein writing. Contractor will begin the work on or about (date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed by (date). The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that stjch delays that are not avoidable by the contractor shall not be considered as violations of this Agreement. WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects in material and workmanship for a period of following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job, including clean up, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired, or replaced, such damage or such defect in materials or workmanship. The foregoing warranties shall survive any inspection performed in connection with the agreed -upon work. We Propose hereby to furnis material and labor — complete in ccordance with above specifications, for the sum of: ,, f ,k,)... „.. \...,) 0 v , 0 A, c()J.I \_\..,....,....,..9,,,_, . gC_,. :4 , \) ec -� :. dollars ($ \ i,...).__1 ....1 ) . Payment to be made as follows: i t 1 . Ut ' ($ 4 ` ") upon signing Contract; � - Na of \ ntractor /Designated egistrant \i ($ ) upon completion of r4 1, ,i0 4-),-.5 :: I Street Address t .� * % ($ ) upon completion of Fs,,.-, t ' ; (, -w isv- a -"k V r i ' C}D City /State \ Phone (, ( _ , ,� ($ (0 () ) shall be made forewith upon \On, t (0 L co- C "‘ 1 as p corn letion of work under this contract. Registration No. Social Security No. .) kc_tet• Notice: No agreement for home improvement contracting work, shall require a down Name Salesm n 4 / payment (advance deposit) of more than one -third of the total contract price or the y .,. t t _ r , total amount of all deposits or payments which the contractor must make, in advance, q(ithor ed signature to order and /or otherwise obtain delivery of special order materials and equipment, i whichever amount is greater. Note/f'his proposal may be withdrawn by us if not accepted within G `� r days. Acceptance of Proposal I have read both sides of this document and accept the prices, specifications and conditions stated. I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date cif this transaction. Cancellation must be done in writing. n BLANK SPACES. � G 1 . O N CONTRACT T IF THERE ARE ANY SIG THIS C 1 Signature ” I t Date Signature_ Data / IMPORTANT INFORMATION ON BACK ' , t - - HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two -year period shall not be considered a home owner." The building, department for the City of Northampton wants person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper jermits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made l; understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to Date Address of work location T . The Commonwealth of &fassachusetts -- Department of Industrial Accidents r, - t Office of Investigations = a _ 600 Washington Street • a r = *' Boston, MA 02111 , � ; www.mass gov /ilia • -Workers' Compensation Insurance Affidavit: Builders /C ontractors /Electricians/PIumbers Applicant Information Please Print Legibly Name ( Business /Organization/Indivirimt):. 3VQ L f\ �v a - Address: SL-( W Q 3 ` -6 ,,„„ City /State/Zip: oss\ 1/4A.. \ VA A , Phone. #: L *C3 —5D —3 L N a Are you an employer? Check the appropriate box: Type of project (required) : / 1.0 I am a employer with 4. Q I am a general contractor and I 6. ❑New construction employees (fall and/or part-time).* have hired the sub - contractors 2.,n, I am a sole proprietor or partner- listed on the attached sheet: 7. ❑ Remodeling ship and have a?o:loyees These sub - contractors have:. 8. ❑ Demolition wor • for me m any � enplo_yees and have workers' _ - king y capacrt3' 9 • QBuilding addit fin [Ne workers' comp: insurance _ r equir ed: 5. 0 We are a corporation and its 10. Electrical repairs or add'iti'ons � • 3.0 I am a homeowner doing all work officers have4xercised their . 11.0 Plumbing repairs or additions m elf N o workers' comp. right of exemption per MGL 11;5 Roof repairs . ce required] t . c. 152, § 1(4), and we have no I o workers' 13.0 Other employees. [N comp. insurance required.] . • • *Any applicant that checks box #1 must also fill out the section below showing their workers' -comp sation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside -contractors must submit anew affidavit indicating such. =contractors that check this box must attached an adtiitionat sheet showing the name of the sub - contractors and state whetheror not those have - employees. If sub - contractors have employees, they must provide their workers' comp- policy number. I am an employer that is providing workers' compensation insurance for my einployees 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 the policy number and expiration date). Failure to secure coverage. a§ required under .Section 25A ofNIGL c. 152 can lead to the niiposihon of crimusa 1 penalties of a fine 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 fine of up to 525000 a day against the violator Be advised that a copy of this statement may be forwarded to the Office of Investieations of thh DLA for ir'isura cce coveiiie verification _ , . -: _._ . v . . _ /do hereby certi tin the p d en of perjury that the information provided.abave _ar d comer( _ Signature: / • Date: 5 , Phone #: - Official use only Do not write in this area to be completed by city or town oj7cciaL City or Town: Permit/License # _ Issuing Authority (circle one): .1.. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6.Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Pe-w---1 IL-IL 1 / / es 4/907V License Number SV yes / s/, ee fpm,) P 0 (0 a7 9/2/9/62i/ Ad Expiration Date (17 2--&- _CO ? -36 YO Signature Telephone 9. eaiaierefl3Nt i Mlirttlrcivimen btiSc bi g4rMW "VES M , Not Applicable ❑ 1 0 7 /0 Company Name Registration Number rZP.,.> ,P_�r< 1 d- J cI 7 — 47-C31a Address /, / �/ Expiration Date SK i iI .S� >��Sf - -. f'hmJ /�"e-. Telephone �� -31° tf7 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 ❑ The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (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 two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws 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 0 Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks (C7 Siding [D] Other [CO Brief Description of Proposed i Work: Sdr �. <1 n l h SVGA U` 41 Alteration of existing bedroom Yes No Adding new bedroom Yes 7C No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll - Sheet ea >'�ir ��� fir r���ln � .��i�e"e,.t�ltt�iri'�: 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 . 1 Septic Tank City Sewer Private well City water Supply SECTION la OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, C's " o 4 , as Owner of the subject property hereby authorize ` Q `._Li\ Q ° o c \-`� to act on my behalf, in all na tters relative to work authori d by this building permit application. Signature of Owner Date t. c.:30 �"� , as Owner /Authorized Agent heret3y declare that the statement nd information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. `` Print Signature of Owrle 1 gent Date N c a o i , 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 i 1 1 b } k $ Frontage L 1i Setbacks Front 1 i 3 Side L:4 ? R:l I L:? R:` . Rear I g 4 j Building Height e ---- r Bldg. Square Footage r ---- 1 n ' % t Open Space Footage % (Lot area minus bldg & paved 1 1 I ! { parking) # of Parking Spaces , , ' M...... Fill: ..v.... ' r , w _ ,. i . _ - E �,�.�.,. --- . ' - (volume & Location) t A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:; 1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book 3 Pagel and /or Document #i B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ,Date Issued C. Do any signs exist on the property? YES 0 NO 0 _ I IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES I NO Q 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ' - i r r `" ' t City of Northampton = Building Department $: N K, , off 212 Main Street -72 " Room 100 \J ,Northampton, MA 01060 £1 ' phone 413 -5$.0 -1240 Fax 413- 587 - 1272 "a APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: �Q 511‘t ‘. 0, ` Map Lot Unit Zone OveflayDrstnct Etm St District CB. Dis trict SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ,_Sf - � �' —`A 1 d b t\ e-A SLI wieg sl• . 0_,(4 -- kit A- A"t -ovt Ai w . Name (Print) Current Mailing Address: ©i 01,-1 Telephone L1 ` 3 - S - 4 Signature (: ),"1 2 "�( v 2.2 Authorized Anent: t�� S `4`Df'CS e t -- 4. czooc...„... Na . /t) Current Mailing Address: Signatun Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS \a ( �I �I O 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) Check Number �� ` This Section For Official Use Only Date Building Permit Number: Issued :. Signature: Building Commissioner /Inspector of Buildings; Date BP- 2010 -1000 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNRE 9 ISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -1000 Project # JS- 2010- 001470 Est. Cost: $12470.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PEPIN ROOFING & SIDING CO 049074 Lot Size(sq. ft.): 22520.52 Owner: O'BRIEN GEORGE & RUTH Zoning: URA(100) / /WSP II Applicant: PEPIN ROOFING & SIDING CO AT: 584 RYAN RD Applicant Address: Phone: Insurance: 54 West St (413) 527 -3640 EASTHAM PTON MA01027 ISSUED ON: S /10/2010 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 5/10/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo