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24C-183 Mar 13 1 1 06:37p david j harrison 044N0 /1 1 1 . 0 4 5 ( 978281 4363 p. ' 1ewEngland IN 2 LIFETIME ROOFING SYSTEMS Agreement Between ` 2 ' I ' INTERLOCK INDUSTRIES, INC. / / / - Fri 3 -7 •-t Ur it 7, 25 Walpole Park South, Walpole, MA 02081 J Massachusetts Home Improvement Contractor 'Registration #139640 (, r 7'3 I s? Customer Service: 1 -1366- 588 -ROOF (7663) a i r a44451 Name — 7 14 0N4 A - s ""P -s ("Buyer') Date 3_i i 1 Job Address 7- V A Cite-Se: a at- 61 ( "Premises ") City/Town I00(t}t4 M P1D N M Zip Code O( O19 0 Mailing Address E -Mail Work Phone (1'13) S'S - 04 1 11 Home Phone ( ) Cell Phone The Buyer is the registered owner of the Premises and hereby contracts with Interlock Industries, Inc. (the 'Contractor") authorizing the Contractor to furnish ail necessary materials and labor to install, construct and place the improvements according to the following specifications, terms and conditions (tt e'Specifications ") at the Premises: tease one). SHINNGL tyRS • SPECIFICATIONS Color(JJQ.Mil.QPILI • RA tt YES NO ROOFING MATERIAL YES NO OWNER WILL g IB Low Slop Roofing ✓ Supply adequate electrical power. IB Color U. Q ✓ Be responsible for all rot damage and other necessary Flash Skylights # ` roof repairs. (ie) roof decking, fascia boards, etc. Flash Vents • Roof repair work will be undertaken by Interlock _ Underlayment f tt T ) '*' f CC. ( 0 A... Industries, Inc. at a cost to be mutually agreed upon in Snow Guards # � O _ advance between the parties. Ridge Vent Iti..)' Proposed Start and Completion Schedule: ROOF REMOVAL Start Date: 2.- it tJS.a-e-ltS alt. SOONee, - _ t X Strip existing roof (cirdec ): Q2 3 layers Substantial Completion Date: 2_ ti- Wee QI'l 04 ?� _ Supply' /2 plywood LOCATION OF SHIPMENT: D2we.vum l )L — Haul away roof debris aid pay refuse fees. LOCATION FOR BIN: 1 Di .tV 4A.rlti 5194p PA c z t r AA 5(44-k Roofs A Fes- 5k.l 4 Pee (ivsI - ( ! ?poi j pi tjlrrib Fort Ak t nski(A - -(o, Pt-,s/4 1 n IP, hrt lC Lt,, 4l)Q, ..> 42, (-to s-�A -1 k a PIMA- Age-A- B € -h 470 c 6r1) 8 IV SAM/ / cis rim � c�t� -tc v r�l�� ) Pg-�e�e arm Stu I�r All P�i�.Mtf S z -el , L3 is Pw> L tiles - IS _ t F s P,e.Gf'- ( oe i ( d t S Al t cs 2-espoistki. Flip- AVDDi.0 cT- hostoortwlo- lo RAM- ofF FAat THIS CONTRACT INCLUDES: ( iQ (/11,4. pit- if. r..1 Z- It 4, Nt IP4 rot'- tic Mgopriv m- LIFETIME LIMITED WARRANT' TRANSFEF,ABLE, NON - PRORATED FOR MATERIALS MANUFACTURED BY INTERLOCK ROOFING LTD. PLUS 10 -YEAR LIMITED LABO IWARRANTY PROVIDED BY INTERLOCK INDUSTRIES, INC. SEETHE WEBSITE FOR WARRANTY TERMS. LIFETIME LIMITED MATERIAL WAR_RP),JTY FORS ROOFING, PROVIDED BY IB ROOFING SYSTEMS. Financing Requested Ye: I [ ~ No Sales Price $ ? jli (Gs-o Sales Tax $ l r - c (1/4/ rt. -0 Interest Rate: 11.9% to 14.9% Sub -Total $ _ >�y. Down Payment (not to exceed 1!3 �[ $ of total contract price) Payment not to exceed $ Total Balance on Completion $ '1111M. 7 O.A.C. (on approved credit) MAKE ALL CHECKS PAYABLE TO: INTERLOCK INDUSTRIES, INC. (FEIN 43479096) You may cancel this agreement if : has been signed by a party thereto at a place other than an address of the seller, which may be his main office or branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail . posted, by telegram sent or by del very, not later than midnight of the third business day following the signing of this agreement. See the attached nobae of cancellation form for an explanation of this right. f IN WITNESS WHEREOF, the Bur and Contractor have hereunto signed their names this _1 0 clay of P44K1 20_1 1 Do Not Sign This Contract If There Are Any Blank Spaces INTERL INDUST 1 S, INC. nit �,�l .. Signed I � OW 1)0 v 3 ' ( 1 I Per: "^' (.U. Buyer (Print name) b "- 11 Signed Unit 7, 25 Walpole Park South Buyer Walpole, MA 02081 HIC #' 13 )640 This Agreement is a binding agreement and contract between the parties. This Is not a credit transaction and will nol be finencod by the Contractor. If financing is required, the Buyer hereby authorizes the Contractor to obtain credit information and the Buyer hereby agrees to provide and sign all necessary documents required by any third party finapcial Institution to complete the financing, immediately on request. The Buyer hereby acknowledges receipt of this Agreement. See reverse of Agreement fo additional terms and conditions. All surplus material is the property of the Contractor. CRSC MA 0710 1' • A CERTIFICATE OF LIABILITY INSURANCE 2,1,20 DATE (MM of11 THIS CERTIFICATE I5 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 pollcy(las) must 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 LOCKTON COMPANIES, LLC-1 KANSAS CITY CONTACT 444 W. 47TH STREET SUITE 900 (A/C, rla Ndl KANSAS CITY MO64112 -1906 (816) 960 -9000 MSS: INSURERISI AFFORDING COVERAGE _ NAIC # INSURER A : National Union Fire Ins Co Pittsburgh PA 19445 INSURED INTERLOCK INDUSTRIES, INC. INSURER B 1333138 UNIT 7, 25 WALPOLE PARK SOUTH INSURER C: WALPOLE MA 02081 INAI IRER D : INSURER E _INSURER F : COVERAGES E8 CERTIFICATE NUMBER: 11146434 REVISION NUMBER: XXXXXXX 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. INS R T YPE OF INSURANCE IN YNO POUCY NUMBER tM /DJYY YYI (MM I LIMITS A GENERALUABILITY N GL5836199 2/1/2011 2/1/2012 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY p FMI ( occurence $ 500,000 CLAIMS -MADE El OCCUR MED EXP (Any one person) 3 50,000 PERSONAL &ADV INJURY $ 2,000,000 `- GENERAL AGGREGATE $ 5,000,000 'GEE J Nt AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 J POLICY JET l PP 1 LOG $ AUTOMOBILE LIABILITY ( COMBINED Es SINGLE LIMB $ XXXXXXX MY AUTO NOT APPLICABLE BODILY INJURY (Per person) $ XXXXXXX _ A A U O AUT SCHWULED BODILY INJURY (Pereccident $ XXXXXXX - HIREOODSSAUTOS NQ,tl PROPERTY e(cade $ XXXXXXX _ nu $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ XXXXXXX EXCESS LIAB CLAIMS -MADE NOT APPLICABLE AGGREGATE $ XXXXXXX DED ! J RETENTION $ — WORKERS COMPENSATION WC STATTU�-. OTH� AND EMPLOYERS' LIABILITY Y NOT APPLICABLE (TORY LMITS I FR ANY PROPRIETOR/PARTNER/EXECUIIVE EL. EACH ACCIDENT OFFICER/MEMBER EXCLUDED, N 1 A $ X . (Mandatory In NH) E L DISEASE EA EMPLOYEE $ XXXXXXX I OESORPTION Or OPERATIONS below _ EL, DISEASE - POLICY LIMIT $ XXXXXXX DESCRIPTION OF OPERATIONS !LOCATIONS !VEHICLES /(Attach ACORD 101, Additional Remarks Schedule, if more spots le required) CERTIFICATE HOLDER CANCELLATION 11146434 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TO WHOM IT MAY CONCERN AUTHDRIZEDREPRESENTATIVE ACORD 25 (2010/05) ® 9 8 -2010 AC ORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD t NCO ® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIOO YYY) 02/01/2011 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 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 NAME: Connie Hanson BFL CANADA Insurance Services Inc. Mx. PHON ,g■u: 604 678 -5461 -FAX _�_ (Arc, No): 604 683 -9316 1177 West Hastings Street, Suite 200 ADDRESS. chansBF ANADA a Vancouver, BC V6E 2K3 INSURER(S) AFFORDING COVERAGE NAIC INSURER A : Libel Mutual Insurance Company 23043 INSURED INSURER B Interlock Industries, Inc. - Unit 7 - 25 Walpole Park South INSURER C Walpole, MA 02081 INSURER D INSURER E : INSURER F : M COVERAGES CERTIFICATE NUMBER: WC -32 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, INTRR TYPE OF INSURANCE N°SR S WV D POLICY NUMBER ( POLICY MIOD(YYVY) (POLICY ✓1 WY) LIMITS GENERAL LIABILITY EACH OCCURRENCE LIABILITY DAMAGE TO RENTED COMMERCIAL GENERAL PREMISES (Ea occurrence{ $ CLAIMS -MADE r 1 OCCUR MED EXP (Any one person) $ _ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ ^ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS_- COMP /OP AGG $ POLICY r1 JER0. LOC $ A [ 1 COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) -- --- - - ---- ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) 5 AUTOS AUTOS NON -OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (per accident) UMBRELLA LIAB - OCCUR { [ EACH OCCURRENCE 5 _ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ _ _ s _ WORKERS COMPENSATION w X WC STATU- OTH- T ORY LIMITS ER AND EMPLOYERS' LIABILITY Y l N ANY f rtOr'RIFTORlPARTFIFRlFXFCUTIVF '-- F FA 1. CH ACCIDENT $. 1 000 000 A a r�r a „�rrr FXi:,�.17FL • 'Lr�rr, : V 1-871 - 01-02 Orin 7/1 01 - (Mandatory in NH) �J 1 El. DISEASE - EA EMPLOYEE $ 1,000,000 If yes. describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (Attach ACORD 101. Additional Remarks Schedule, If more space is required) Proof of Coverage CERTIFICATE HOLDER CANCELLATION To Whom It May Concern SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORliED REPRESENTATIVE l `, © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and Togo are registered marks of ACORD f:loar All The Commonwealth of Massachusetts `�= - =' Department of Industrial Accidents c ' ~ '` " Office of Investigations 7 600 Washington Street yr, - Boston, MA 02111 (:`' = ='' www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/individual): - r'' _, --1; — _. ,, � .x Address: 9 $ kV Part, si il!/I 7 City/State/Zip:14 )(.Mlle, 1404 C0)08'1 Phone #: 50 6 0 -- & &4„s' Are C] u an employer? Check the appropriate box: em p 1. I am a employer with t 4 • I am a general contractor and I Type of project (required): employees (full and/or part-time).* have hired the sub- contractors 6. ID 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 P bing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 oor repairs insurance required.] f c. 152, § 1(4), and we have no employees. [No workers' 13. ❑ Other comp. insurance required.] Any applicant that checks box #1 must also 611 out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then but 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 subcontractors 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: Lek f in cm 4/Z / C -1'4-4' - 1 ((-v,2,5‘'L.5 e Policy P or Self -ins i.ic. ti:LO !^. � 1 _ 6� J 3 1 05c°: E xpir ation Datc:_ j) 1 - 4 Job Site Address: -O L- e 62 C 1-62 ` / 1 City/State/Zip: /Jo / ?Ed /Y/m i /O / / t //4 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 cove a verification. I do hereby certify un�dre- the . dpenalties of perjury that the information provided above is true and correct it ..2__. Signature: 6-- Date: ,� `%� // Phone #: .5 t 2 S r'6 7 t l(' 5 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 ,. L 8.1 Licensed Construction Supervisor: r Not Applicable ❑ f r Name of License Holder : /�.r�! / / ' r'� � �` ����f � 10/ License Number Address Expiration Date � 3 660 b'4' S S Sign Telephone 9�Ri3gisterea. ImprovembittCri#iractort.,�;..; MILigalt Not Applicable ❑ / 2 la e� -77v 12 e 6 0 Company Name Registration Number a 7 iii/ / j /�f� / ) ' �, o2 / t Td�-� �li,(,�! / >� �- e Address , Expiration Date ti/ ss 9i O< / C /11/J MCC? / Telephone 6 5P � — 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 Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks ([] Siding (0] Other [01 Brief Description .$- o 2 fProPosed �J 7 Q ? Work: �s /2( 0/� ► " ' / lt r'I� Z — �'l � � , �'(/ Alteration of existing bedroom Yes No Adding new bedroom Yes v /'c C C '/ Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa [fNewhous i .Q c i ��Eo' C� t toi�stnp: ai ip�e a itr Il a: a. Use of building : One Family Two Family Other Y y r to 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 Ta OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT X24' t? 047 53 fit_ A .5 as Owner of the subject property hereby authorize l-.4 /2 /U L to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 1 c L e ic j , z-4,,LD , 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, kit e /'1 re h f r V Print Name Signat r= . • r /Agent Date 1w J Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information • -,, Existing Proposed ' Required by Zonin This column to be rilinSyS 1111 Building Department ._ _._. _. .._..... i ............... 1 s 1 Y ew Lot Size � �— '....�,,,� m � �� .� > Frontage i' Setbacks Front i 1 f Side L ` R:1 --' L:' R:' I , Rear i 1 1 1 } Building Height 1 � , Bldg. Square Footage f----1 % j---- I Open Space Footage , t % (Lot area minus bldg & paved € _._.1 i F = � , parking) # of Parking Spaces _._ Fill: i 1 (volume & Location) i 1 A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 i 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 ' 1 Pagel and /or Document #'. B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 ,Date Issued: C. Do any signs exist on the property? YES 0 NO Q IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q IF YES, describe size, type and location: F 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. s City of Northampton t� ' ��r t : uil ing Department { -1". - . 2 Main Street '° k y .s` ilk 2 ���� �oom 100 �� No ha pton, MA 01060 m _ - . 87 1240 Fax 413- 587 -1272 f, 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: 04 C... , ?Pe Q (t/ Map Lot Un 0 Zone Overlay District kia 2 Al / #2)141 l � ' �h-(9 Elm St. District _ CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: /C -.71.7 7/ ,t i e(f T/c� l Y 2 1 �/ � i�1f � i2/� S f i�.�dl "i ' / Name (Print) Current Mailing Address: a � L - '��� Telephone Signature SECTION 3 - ESTIMATED CONSTRUCTION COSTS' Item Estimated Cost (Dollars) to be Officia Use Only completed by permit applicant 1. Building je 9 r� S � — (a) Building Permit Fee 7 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 0 �D ,3s This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 204 CRESCENT ST BP- 2011 -0757 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24C - 183 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofing BUILDING PERMIT Permit # BP- 2011 -0757 Project # JS- 2011- 001250 Est. Cost: $29650.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: INTERLOCK INDUSTRIES, INC 101285 Lot Size(sq. ft.): 7013.16 Owner: DOUGLAS THOMAS JR & SHOSHANNAH WINEBERG Zoning: URB(100)/ Applicant: INTERLOCK INDUSTRIES, INC AT: 204 CRESCENT ST Applicant Address: Phone: Insurance: UNIT 7 25 WALPOLE PARK SOUTH (508) 660 -6665 0 Workers Compensation WALPOLEMA02081 ISSUED ON:3/24/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP SLATE ROOF & INSTALL INTERLOCK ROOF SYS 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 3/24/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner