31B-079 (2) Proposal
INDEPENDENT ROOFING CO., INC.
294 Union Street (Zip 01085)
P.O. Box 1446
WESTFIELD, MA 01086
(413) 568 -9405
FAX (413) 562 -5906
PROPOSAL SUBMITTED TO PHONE CELL DATE
PAUL - OWNER DUNKIN DONUT FRANCHISE , (413) 587 -0161 413- 246 -9476 10.18.2012
STREET JOB NAME
132 KING STREET RE -ROOF PROPOSAL:
DUNKIN DONUT'S FRANCHISE
NORTHAMPTON, MASSACHUSETTS 01060 132 KING STREET - NORTHAMPTON, MA. 01060
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
SCOPE OF WORK TO BE PERFORMED:
PROPOSAL TO: MECHANICALLY FASTEN 1 LAYER OF 2" ISO INSULATION
- - - OVER EXISTING—ROOF—
------------- - - - -._ - - -- __._______ TO: - INSTAtL:060 -- MECHANICAL FA ST - T. R.O. ROOF - ___ -
---- .--- .------ _ - -_ —_
SYSTEM OVE
TO: FLASH WALLS & PENETRATIONS PER MANUFACTURER'S
SPECIFICATIONS
------ - - - - -- TD— MANUF- ACTURE -&- INSTALL- .040 -- ALUMINUM -FL- ASHING - - -- -
--- __--- - - - -_- -- -- - - AND T ON PERtNIETER ROOFS
fi11 BUILDIN - OWFE R KTWENTY1201Y
WARRANTY ON ROOF SYSTEM
TO: REMOVE ALL RUBBISH AND DEBRIS FROM JOB SITE UPON
- - - -- - -- CCOO,MPL- E-- TION- OFP -- ROJEC - -- -
-__ PLEA - S - KNOW: -- MA S T TAX CLUDED BID PROPOSA-L
TOTAL COST: MATERIAL/LABOR $14,999.00
We Propose hereby to fumish material and labor — complete in accordance with above specifications, for the sum of:
FOURTEEN THOUSAND NINE HUNDRED NINETY -NINE AND NO /100 - - -- DOLLARS 14,999.00
1/3 ACCEPTED AS DEPOSIT - BALANCE REQUESTED UPON JOB COMPLETION Payment to be made as follows:
Terms: 1Y:% Interest Charged After 30 Days THANK YOU
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above Authorized
specifications involving extra costs will be executed only upon written orders, and will Signature Peter A. Ruszala — President 10.18.2012
become an extra charge over and above the estimate. All agreements contingent upon
strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other
necessary insurance. Our workers are fully covered by Workman's Compensation Note: This proposal may be withdrawn
Insurance. by us if not accepted within days.
Any/all legal expenses incurred due to non - payment of this proposal will be at building owners expense.
Acceptance of Proposal - The above prices,
specifications and conditions are satisfactory and are herby accepted. You are
M,lTnnlnrn TPY fin min WnFI( RV snrriflrn 1' ilWrIrl1T Will nr 197 Rn RV nnninP.n nnnir
/a/r5 /
The Commonwealth of Massachusetts
"' Department of Industrial Accidents
1.1 Office oflnvestigations
600 Washington Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information • Please Print Legibly
Name ( Business / Organization /Individual): 0 EP /oe po i,it/6 CG .1-k'C
Address: O' 9 LIiiid.r/ S 7 ?, 0 131 x' t sox
City /State /Zip: •j fl , i 7 eL 11/A D /oP hone #: 1 3 .�,� �/ ` . 0�
Are you an employer? Check the appropriate box: I f Type of project (required):
1.,12 I am a employer with / Z 4. (l I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. El New construction
listed on the attached sheet. 7. 1:1 Remodeling
2.0 I am a sole proprietor or partner-
ship and have no employees These sub contractors have g. ❑ Demolition
capacity. employees and have workers'
working for me in any P ty. 9. fl Building addition
No workers' comp. insurance comp. insurance.
required.] . 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
3. C] I am a homeowner doing all work ❑
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. ❑ 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 contactors 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 cert' • under the pains and penalties of perjuty that the information provided above is true and correct.
Si • nature:
l
. € [I _ �i► �� Date: i t — 2 4 -/ Z
Phone #: // 3 .5 L
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 #:
Version1.7 Commercial Building Permit May 15, 2000
SECTION 10— STRUCTURAL PEER REVIEW (780 CMR 110.11)
-
Independent Structural Engineering Structural Peer Review Required ' Yes 0 No 0
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,V r4vcr, > ...4 0,01..... 6 . _ , as Owner of the subject property
hereby authorize _ _ . ' .. ...., _ _ __ _.m .4 __... to
act on m ehalf, in all m- ers relativ- p work authorize y this building permit application __.. _ __
Sign ure of Owner Date
I, __.._.._ __.___...__._._......... _ ...._.r..,....._ , 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 perjury. . q _ __ _ __„ k _ ,_ . ...w.
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction ervisor: Not Applicable ❑
Name of License Holder...... ..... .. (.,..✓ / . 7 ..
License Number
1
3r -� __ . ___ ,___ _ _ _ _ r a t. . 0 . � _. 9__„ X/3 -
Addre t Expira on Date
Signature Telephone
SECTION 13 - WORKERS'' COMPENSATION INSURANCE AFFIDAVIT (MG.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 build' permit.
Signed Affidavit Attached Yes 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 ENOLOSED 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 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
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
��
9.3 General Contractor
./- �--/ /. _..." .._ Not Applicable ❑
ompan a 44
Res ponsible In Charge of Construction -
Addres
G , 1 , /.� 3 f t 5 -(�.. ,q q4
Si - / Telephone
Version1.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON. ZONING
Existing Proposed ` Required by Zoning •
This column to tie filled in by
Building Department
Lot Size
Frontage •
Setbacks Front
Side L. __...__ R. ._.....
Rear __ ._. - _. - -__ _-
Building Height
Bldg. Square Footage '
Open Space Footage % __
(Lot area minus bldg & paved _.,. - .... w _ _
parking)
# of Parking Spaces r____,
Fill:
(volume & Location)
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:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page ._. 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 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 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 (0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
I
Version1.7 Commercial Building Permit May 15, 2000 0
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 CI Other ❑ '. o
Brief Description Enter a brief description here.
Of Proposed Work: , / / ,
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly El A -1 ❑ A -2 ❑ A -3 0 1A I ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B - I ❑
F Factory ❑ F -1 ❑ F -2 0 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1 -1 0 1 -2 ❑ 1 -3 0 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B I ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify: ,o...-. , , . .W� . w._ n, ,. �.
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): „_ w_ _,_._._.,__.__w 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 st
1 st
2nd ... 2 nd "
... ._.. _._ . rd ,....,.._._.,.,.... �.,._,_„_
3rd 3 4th 4
Total Area (sf) Total Proposed New Construction (sf)„
,
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 ❑ Zone ___,,,_ _ Outside Flood Zone❑ Municipal 0 On site disposal system
Version 1.7 Commercial Building Permit May 15, 2000
Department use,only
City of Northampton status o Perrrirf �
e� uilding Department Curb C tfl]nrteway Perrntt m t "
r� "" - - "� l 212 Main Street SewerlSa ttcAuatfabrll # y �
Room 100 Water/Well Avai ablfity
E____01 6 � �Z No hampton, MA 01060 Two s of tructraf Plans -13- 87 -1240 Fax 413 - 587 -1272 Pl �ttler SfpeClfy ot/Ste Plan 06 N 1 01 060
T ON
TO �PTO CONSTRUCT, MA REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
D Nn - j -, ..r/t./ 00uv7
Map Lot Unit
/37- $T- Zone Overlay District
CSA 7f�i'� ni�°T 1 'v ,
, - :,.. ._.. .._._..._ Elm. St. District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address
Signature _t,f 'der t Telephone
2.2 Authorized Ag t:
Name (Print) Current Mailing Address:
Signature f � � A f ' Telephone
SECTION 3- 'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) D (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 9/9y I'1
This Section For Official Use Only 111"'���
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0585
APPLICANT /CONTACT PERSON INDEPENDENT ROOFING CO INC
ADDRESS/PHONE P 0 BOX 1446 WESTFIELD (413) 568 -9405
PROPERTY LOCATION 132 KING ST
MAP 31B PARCEL 079 001 ZONE GB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /___
Fee Paid T Z
Typeof Construction: REROOF
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 017759
3 sets of Plans / Plot Plan
THE FOLL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
/�
f/
Si o f Building Of icial ' Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
132 KING ST BP- 2013 -0585
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 079 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- 2013 -0585
Project # JS- 2013- 000946
Est. Cost: $14999.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: INDEPENDENT ROOFING CO INC 017759
Lot Size(sq. ft.): 8537.76 Owner: SARDINHA JOAD JOSE
Zoning: GB(100)/ Applicant: INDEPENDENT ROOFING CO INC
AT: 132 KING ST
Applicant Address: Phone: Insurance:
P O BOX 1446 (413) 568 -9405 WC
W ESTF I ELDMA01086 ISSUED ON:11/28/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REROOF
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 11/28/2012 0:00:00 $90.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner