24C-129 e 1
No. 1
PEPIN ROOFING &SIDING CO. of a Pages
MA HIC#1071 PROPOSAL
54 West Street t
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 - + < �
Chapter 142A of the general laws,must be registered with
To:._:-_ ?__ , z `_-r_ _-____ the Commonwealth of Massachusetts. Inquiries about
registration and status should be made to the Director,
�;- —_tom— ____t. :v ! J --
Home Improvement Contract Registration,One Ashburton
L \,,:j.,,,,s 1's'„" ('-'s ' )I` Place,Room 1301,Boston,MA 02108 (617)727-8598
JOB NAME/NO.
,,
PHONE DATE JOB LOCATION
t_ 7 1 - _ C -c__ tt;_y -1 `-
1
1
• ARCHITECT DATE OF PLANS
We hereby submit specifications and estimates for work to be performed and materials to be used:
U
\� �,. t. E
„I•
Construction related permits:
•
>
-- ---- -
WORK SCHEDULE
Contractor will not begin the work or order the materials before the third day following the signing of this Agreement,unless specified herein writing.Contractor will begin the work on or
about t,'= (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 such delays that are not avoidable by the contractor shall not be considered as violations of this Agreement.
WARRANTYI
The Contractor warrants that the work furnished hereunder shall be free from defects in material and workmanship for a period ofTk <',1 C. 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 furnish material and labor-complete in accordance with above specifications,for the sum of:.
\ . _ _ �` dollars($ )•
Payment to be made'as follows:
%($' tit• )upon signing Contract: t C�> __. _..-.. _-
NameofC`tractor/DesgnatedR gistrant
1
%($ )upon completion of S_ /- \ I C -, =-
' L'-,- -
Street Address
A A r t-- —r - 7 c- -_
($ )upon completion of : ...A._.u_ - -_._Phone v _.-J�
Ciry�State
Iy
( shall be made forewith upon _ - - ---
$- )completion of work under this contract. Registration No Social security No.
// -1 + 1 ,
Notice: No agreement for home improvement contracting work shall require a down Name of Salesman ,�
payment(advance deposit)of more than one-third of the total contract price or the I I I ,-1'
total amount of all deposits or payments which the contractor must make,in advance, Authorized Signature
to order and/or otherwise obtain delivery of special order materials and equipment,
whichever amount is greater. Note:This proposal may be withdrawn by us if not accepted within 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'of this transaction.Cancellation must be done in writing.
DO N .J,OT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Signature ' , ' Date Signature '' Date
IMPORTANT INFORMATION MATION ON BACK l
A.
SH ...
City of Northampton
Tea
/r ` Massachusetts w�S' _ •:.c}�
! * o e\
Jolt
r
t °4 DEPARTMENT OF BUILDING INSPECTIONS y;
\7,-, ' 212 Main Street • Municipal Building v� A Sb'
Northampton, MA 01060 st'Pt RIO
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 any 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 permits 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
I, 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 me.
Date
Address of work location
The Commonwealth of Massachusetts
it—
Department of Industrial Accidents
Office of Investigations
'= j° 600 Washington Street
tv
�.a
Boston, MA 02111
mormimor
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /9 Please Print Legibly
Name (Business/Organization/Individual): i/ C� Roc.)r f ea
� J
Address: 5,2 t`v/ i)e .S/ . f'd, r f tasl�r"7c49_✓ ,;"/ o/ '17
City/State/Zip: Phone #: ,1)7—J `lO
Are you an employer? Check the appropriate box: Type of project(required):
1.El 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 AI 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.❑ 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 12.0 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.
tHo meowners 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: ° 7‘--i i''c.✓ Date: `/—
Phone#: (/ t�t2 7 —f yO
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#:
SECTION 8-CONSTRUCTION SERVICES v V°‘
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder: �,` �/ J ��i, /t�-r L f G(7 C License Number
S �e c�-le /-� Sow/, ��-,�0/ J rl•�c, 0/ )477 S /3 AGO
Address-) Expiration Date
-Sv7 x'J
Signature Telephone
9 Registered Home Improvement Contractor mm .w„ „ Not Applicable £
A/2,.49 20 c��i,v .•S,c%�J G� /off/L,Y
Company Name Registration Number
e'��l��e /. GAGr/ LGi .�,f� ,� /—i`. Q/Q.77 7'-19
Address Expiration Date
Telephone
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 £
11 Home Ownei I emption
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 m ay 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.
r-
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) • '
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing rgi
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [C] Siding[0] Other[0]
Brief Description of Proposed Z o[ O �r r re e 4c 9 SI C rr Dl u)O0cl
Work: ( cJel � �c �L: D ___541-/-�S Z iS � .y
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.'If>New house'"and:or'additon to°'existinghousmq carnplete 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
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
CC.•"( ✓1. i°(.ek 1 /CO��f♦,s F 1;e1 ,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 the pains and penalties of perjury.
//ems
Print lama
S71 /I
Signature of wner/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 . .,_.._.___ _._i ' --- _71 ..... , .. _.7._ ......... ,..
t ' t. .-. 3
Frontage .............___._.__._...._........_._...__.._..._____. ._ ,_._...._._..___............._....._.__...._._......_.__._....._..._. .. .._..............._.__......_.._._........_...__...._....__........)
Setbacks Front ET
Side L:[T _ R:= L:(. R:= El= . . _
Rear _..........1
€I
.
Building Height
Bldg.Square Footage F .- -1 1 % ;_...._....-_...1 ...._
Open Space Footage % 1
(Lot area minus bldg&paved . __ .__,,,, „,-1 ? 1
parking)
#of Parking Spaces I I
Fill: jµ...:.._ w.....�.,
(volume&Location) " --- ^. --- _. ---- ----°
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES 0
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 _... _,,i Pagel J and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
•
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urb Cut/D s re t v a aliDPeermari#tm enue n}
i 'dW t . mo nS x Hl City of Northampton Status::',Jqta:,:taCqraf,trMelealpOnteiNpatilIghtligarilipf.2013 Building Department
4uG 212 Main Street s01er/Septicgyaiia411�tyh'
pEP.OF BUILGiPaG MA 010610 NS
Room 100 Wat�erIWe�lf Availability
NORTHr�MFTON, Northampton, MA 01060 Twi'Sets of S#ructural Pans
phone 413-587-1240 Fax 413-587-1272 Ptof/Site Plans ` t
Other Specify , `
k 1
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
Map Lot Unit
/H, p kJ).`ti7 c
1 Elm St District. CB District
SECTION 2'PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) ✓ Current Mailing Address: Jac 3 44s
Telephone
Signature
2.2 Authorized Agent:
QoGJ S 41` j ,tr./7 -)4 3 tic.Gf,3 e e
Name(Print)) Current Mailing Address:
J--27—Y6 `t'a
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
.2jw
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) 2700 Check Number g 142. 3c5
This Section For Official Use Only
• Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
21 WESTERN AVE BP-2014-0115
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C- 129 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-2014-0115
Project# JS-2014-000222
Est.Cost: $2700.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PEPIN ROOFING & SIDING CO 049074
Lot Size(sq. ft.): 11020.68 Owner: YOUNG ELISE G
Zoning:URB(l00)/ Applicant: PEPIN ROOFING & SIDING CO
AT: 21 WESTERN AVE
Applicant Address: Phone: Insurance:
52 COTTAGE ST (413) 527-3640
EASTHAMPTONMA01027 ISSUED ON:8/1/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE ROOF OVER 1 LAYER & 4 PLY
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 8/1/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner