31B-284 4
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EXTERIOR HOME 1MPROVEMEPETS, ■mac -
ilge i �.��d c r, < 3 ,, t, y: 171 413/45463 --6354
Roofing & Seamless Gutter Pros
Eric c uk {:T
21- center st We propose to furnish all material and perform all the
Northampton ma labor necessary to complete the following:
1.) Remove and dispose of the existing membrane roofing materials, insulations,
flashing and facial metal, ect down to original built up roof
2.) Provide and install new 2" perimeter wood nailer
3.) Provide and install new 2" A.C. foam high density polyisocyanurate insulation set
over existing built up roof
4.) Provide and install mulehyde / carlisle tpo mechanically attached membrane
roofing system per manufactures specifications
5.) Provide and install all wall, curb, pipes ect. Flashings per manufacturers specs
6.) Provide and install new brown aluminum metal c 6 drip edge
7.) Provide owner with a 10 yr mulehyde /carlisle labor warranty
We propose to furnish the material and labor to complete in accordanance with the above
spec for the sum of:
Total: $ 17,500.00
Down: $ 7500.00
Bal upon completion: $10,000.00
"‘' The Commonwealth of Massachusetts
D epartment of Industrial Accidents
.µ,�.,. -- ` -'' Office of Investigations
600 Washington Street
fi/;, Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): Q f ■ t7f ,y
Address: ' 7 i rk 1 j P C Y"
City /State /Zip: ��-f.., L 1 i 6'1 . Phone #: c , 3 l 3 c
Are you an employer? Check the ap?iropriate box: Type of project (required):
1.am a employer with 4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
listed on the attached sheet. 7. ❑ Remodeling
2. ❑ I am a sole proprietor or partner-
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. ❑ 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' 13.0 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: 4u r i t `21/4. ( � '" C ` 1
Policy # or Self -ins. Lic. #: (2 12— 4 gJ 0 3 c l ' 7N3 f ( / 0 Expiration Date: / / ..-- > 0 ✓1/
Job Site Address: 0 C el' <kii" 5 T City/State /Zip: /J ✓ vi _p r7' ii / i
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.
do hereby certify un r
,// 7 ab
t ains and penalties of perjury that the information provided above is true and correct.
Signature:
Sis nature:
Date: p - d 2 (6)
Phone #: (.0 G. ) S C I
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 #:
R +
Version1.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCT RAL PEER REVIEW (780 CMR 110.11)
Independent Structural : ngineering Structural Peer Review Required Yes 0 No 0
SECTION 11 - OWNER • UTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR • ONTRACTOR APPLIES FOR BUILDING PERMIT
I *.. Ai. A 4 'k 4,r � . : �� r . . ► ._.._.e ' _._. l�t ', as Owner of the subject property
hereby authorize �K/ p ✓ C— to
act on my behalf, in all n atters relative to work authorized by this building permit application
/ -A --- _,,,,,. ...
Signature of Owner Date
I kr L.-- 1: e:_� _. __ .._ ,_1.",.,,.._ - ._ ._.,._... _._ _.._,._ ._ ._____ _ _ ..__ as Owner /Authorized
Agent hereby declare th.:t the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains nd penalties of perjury,
Print Name /
2 '/
(/ Sig ature of Owner /Agent Date
SECTION 12 - CONSTR CTION SERVICES (. L ! J , r -, i .,1
.1 Licensed Constru . tion Supervisor: Not Applicable 0
{\
N ame of License Holder : ,.,t". ti. �'�� - ... � __.. � . � v ... ■ C � .�_ _ . ,_.._,. e..
License Number
Address Expiration Dat
��- c�3 ? S al
Sig ture Telephone
SECTION 13 WORKE ' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation nsurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issua ce of the building permit.
Signed Affidavit Attache' Yes a ®' No 0
Version1.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility _.
Address Re_.__.
gistration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
N' 6 Q �e = U •.w f `� C-- Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
•S 3s-r
Si Lure Telephone
Version1.7 Commercial Building Permit May 15, 2000
8. NORT MPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks 'ront
`ide L: R:
ear
Building Hei :ht
Bldg. Square Footage
Open Space iootage
(Lot area minus .1dg & paved ---
parking)
# of Parking .paces
Fill:
(volume & Loca ion)
A. Has Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YE 0
IF YES, datz issued:
IF YES: Was the permit recorded at the Registry of Deeds?
Ns 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 0 DONT KNOW YES 0
IF YE has a permit been or need to be obtained from the Conservation Commission?
Need. to be obtained
0 Obtained
0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YE', describe size, type and location:
D. Are the e any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YE', describe size, type and location:
E. Will the fonstruction 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 YE', then a Northampton Storm Water Management Permit from the DPW is required.
•
Version1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing Change of Use ❑ Other ❑
Brief Description Enter a brief description here.
Of Proposed Work: Q
dues ut, 0 t .._.... Q, ., r _M K ._Li_. A:,....5.141,11 _So_ kl( . ' v_
SECTION 5 - USE GROUP AND CONSTRUCTIO( TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑
A-4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B - f ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group: _ ___ __ Proposed Use Group '.....,._,. .,.
Existing Hazard Index 780 CMR 34):. .__ __.„_. Proposed Hazard Index 780 CMR 34)
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1 s r
1 st
2nd 2 nd
3 rd 3r
__
LID' in . _. 4 m
_.,
Total Area (sf) Total Proposed New Construction jsf)
Total Height (ft)
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private 0 Zone Outside Flood Zone❑ Municipal ❑ On site disposal system El
,
Version1.7 Commercial Building Permit May 15, 2000
City of Northampton Status f� t t t x
Building Department Cur uttrs� y P
uaer� ��
212 Main Street S ewr/Se D p#1 A atia ltt
���° Room 100 u{�ateritelf aria- 4
AlG 2 , Northampton, MA 01060 Two Sets otStructurai`Plan E
h��
phone 413- 587 -1240 Fax 413 - 587 -1272 Plot/Srte Plans» x .
Other eC r
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
/ 1.1 Property Address:
This section to be completed by office
-e--/ � ,(,/ S - Map Lot Unit
Zone Overlay District
_ w m _ _,...._.. _..ope - Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
/Signature ,��' Telephone
2.2 Authorized Agent:
N RAI Q..� )-(/ ,_ 0,E! ,5 _ ...� ter y__.� .
ame (Print) Marling Address
Signature %L Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
/ Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
_M
V 1. Building (a) Building Permit Fee
.
/ _ _ S. cal. _ �_ . _._
2. Electrical -. —. -' -m _.- ..._ ___m -' (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 3 v 3 (03( / i 7 .ilad
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
BP- 2011 -0179
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 284 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP-2011-0179
Project # JS- 2011- 000297
Est. Cost: $17500.00
Fee: $1 02.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License: \..
Use Group: NRB EXTERIORS INC 99565
Lot Size(sq. ft.): 3179.88 Owner: ES 21 CENTER STREET LLC
Zoning: CB(100)/ Applicant: NRB EXTERIORS INC
AT: 21 CENTER ST
Applicant Address: Phone: Insurance:
7 PHILIP CIRCLE (413) 563 -6354 WC
GRANBYMA01033 ISSUED ON:8/30/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REMOVE & INSTALL NEW MEMBRANE 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 8/30/2010 0:00:00 $102.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner