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30B-037 229 RIVERSIDE DR BP-2014-0692 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30B-037 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-2014-0692 Project# JS-2014-001180 Est. Cost: $41422.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: INTERLOCK INDUSTRIES, INC 101285 Lot Size(sq. ft.): 1 1979.00 Owner: DECOWSKI PIOTR&HERMINE G.M.TER-MEULEN-DECOWSKI Zoning:URB(100)/ Applicant: INTERLOCK INDUSTRIES, INC AT: 229 RIVERSIDE DR Applicant Address: Phone: Insurance: UNIT 7 25 WALPOLE PARK SOUTH (508) 660-6665 0 Workers Compensation WALPOLEMA02081 ISSUED ON:12/5/2013 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 12/5/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner _• �._ ��;. xlµ 1�j n i GSs`etit rs alr ti e G tr4 a/SuI Ugr lJ r DQ,4tfif t�3 c v ef4�u 4;vt,�asa9u 0�i rlt t}�1 yaA z.r 01 z r 4lu e.4:�st0 il,u x,se1�f=4�o nt3y 101% 1'�. J 1 34t_1�p 1b e stx r 4,yr l rfiJ x J E tIx,,t sE k x^ ii ,f Permtt k � a rala� , xOU N City of Northampton iLatusito M M , ,rw iHa„, `PM r3`Mt4 4, -y•+ 4vi TT Building Department o t y s O y 2y i r EW � 1, 212 Main Street s tr�ir_at�-l'`�1 4 x Oih�,.t t t; C�?li,l � �Ny't•O — Room 100 IWat gliiRalb tr ek as . N n I i%ji mx s a R I h m ` o` { J' I Northampton, MA 01060 ' Ph F la -,�" r 1 1R I 1 4 y ,;al le phone 413-587-1240 Fax 413-587-1272 U 11 ♦�" p r s5 k} �� �� 414 2 `£ I r C* IN''� ( �w a �' •''� �� ION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION • his s ctwrr to be completed by office 1 1.1 Property Address: .g t 00(2 5 � l�l Ma Lot M1� Unit p i , t i.4 }t 1 J i 1 i i i 1 � } -b h J Zone { r Overlay Distrrct + i I i y x EIm St District CB Distnct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT. 2.1 Owner of Record: t?t��IZ ����w s� Pi.Ve 9rae Oil /0 o, -/h olv M�- Name(Print) Current Mailing Addres Telephone Signature 2.2 Authorized Agent: /C>l) Name(Print) Current Mailing Address: Si. re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS. . Item Estimated Cost(Dollars)to be Official Use Only /// completed by permit applicant - 1. Building 4,it G(0262 (a)Building Permit Fee 2. Electrical `7 (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 c.,?f :435 This Section For Official Use Only Date Building Permit Number: Issued: • • Signature: • Building Commissioner/Inspector of Buildings 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 gg Building Department Lot Size i h __ I 1 FrontageL___.________I. _-._._-_-____-._J -_-.-_...______._.______I Setbacks Front E-1 1? r I ....�.. ...� c: Side Li _ R:J L: R: ED Rear 1.___.1 = 1--••-•-- Building Height L I I i Bldg.Square Footage ---"1 % i`-j -~- L Open Space Footage (Lot area minus bldg&paved L..-,_,I 1._.....] L_____L_____...1 I [ parking) #of Parking Spaces = i I ETI Fill: .....,.,,��..._......_�........_........,,,_._._....�.._� ; .._...�,_,-�....,-:._...._..�._...�..._..._...._ (volume&Location) 1` A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW Q YES Q IF YES, date issued:; 1 IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES Q IF YES: enter Book _ I Page and/or Document#,Y B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: i C. Do any signs exist on the property? YES Q NO 0 IF YES, describe size, type and location: I 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: I 1 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. I SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition El Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [C] Siding [0] Other[0] Brief Description of Proposed$ C f� 5I& Work: I?C PXr 1I( A3� 1,� �� ��P22 ! /� �i( eL Alteration of existing bedroom Yes No Adding new bedroom. Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa.,if Newhouse andeor addlt�on.f `existlnq:h'ousinq, c"o'mplete fFie<followlna: 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 Pc.2ti'6()CC2 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 r-- I' , 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 I, X1" e i� C)r4 )7(./i v ,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 penaltie of perjury. Print Name Signature of 0 :"Agent /' Date / • SECTION 8-CONSTRUCTION SERVICES • 8.1 Licensed Construction Supervisor:f 421---71•(1 Not Applicable�£jn Name of License Holder: k / ( `L ��/2 /0( Q`" 5 License Number r,� d /� V d2- /(-(L! Address / j a7.- Expiration Date C2 I../ / 0.? Signature �� Telephone s 2 rev ..Registered ome'ImprovemeritContractoi , . .;' „___r ';._. Not Applicable £ 77,' (210(tc ALL) /3' 64' Company Name Registration Number 2 41,//2 v / /ni2lf .� �c J �.� 77 ;2'e Address )` Expiration Date / t 512/p-2/ �l) ja 2 ( Telephone �C48(406G 60 • 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 £ 1!1. . Home Owner Egemptilon 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. The Commonwealth of Massachusetts ® �� „„ Department of Industrial Accidents .119E611 ,1118■1119.1119 Office of Investigations =eitif 1 Congress Street, Suite 100 4311 �$ �� Boston, MA 02114-2017 ``'? + '' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Interlock Industries,Inc. — Address: 25 Walpole Park South, Unit 7 City/State/Zip: Walpole, MA 02081 Phone #: 508-660-6665 Are you an employer? Check the appropriate box: Type of project(required): 1. Si I am a employer with 9 4. I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. n New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. El Remodeling ship and have no employees These sub-contractors have P 8. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance. required.] 5. r] We are a corporation and its 10.n Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 PI ing 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.© 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: BFL Canada Insurance Agency-Liberty Mutual Insurance Company Policy#or Self-ins.Lic. #: WC1-B71-072231-053 Expiration Date: 02/01/2014 Job Site Address: .2 Z 9 hct`/,pF u'e ,� /? City/State/Zip: /vl(9f7LI ”)Y Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).04762 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 covera tcation. I do hereby certi y under the lain %-• allies o 'er'ur that the in ormation provided above is true and correct. Signature: _ ' Phone#: 7 2 ? 66 l9 ‘6 6 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#: ACC)R°a CERTIFICATE OF LIABILITY INSURANCE 2/1/2014 DATE( MIDDI Y`Y) 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(les)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 RAM N,EXt)' FAX No): KANSAS CITY MO 64112-1906 E-MAIL (816)960-9000 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: National Union Fire Ins Co Pittsburgh PA 19445 INSURED INTERLOCK INDUSTRIES INC. INSURER B: 1333138 A MASSACHUSETTS CORPORATION INSURER C: UNIT 7,25 WALPOLE PARK SOUTH WALPOLE MA 02081 INSURER D: INSURER E: INSURER F: COVERAGES INTIN18 CERTIFICATE NUMBER: 11152803 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. INSR ADDL SUBR POLICY EFF POLICY EXP I TR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDD/YWYUMI ooreYYYI, LIMITS A GENERAL LIABILITY N N GL5836199 2/1/2013 2/1/2014 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 500,000 ICLAIMS-MADE X I OCCUR MED EXP(Any one person) ,$ 50,000 PERSONAL B AEA/INJURY $ 2,000,000 GENERAL AGGREGATE $ 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY I-I JECOT n LOC _ AUTOMOBILE LIABILITY CCOMBINED SINGLE LIMIT (Ea acc dent) $ XXXXXXX ANY AUTO NOT APPLICABLE BODILY INJURY(Per person) $ XXXXXXX AUTOS NED _SCHEDULED BODILY INJURY(Per accident/$ XXXXXXX HIRED AUTOS NON-OWNED PROPERTY cadent) AGE $ XXXXXXX _ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE _$ XXXXXXX EXCESS LIAB CLAIMS-MADE NOT APPLICABLE AGGREGATE $ XXXXXXX DED I I RETENTION$ $ WORKERS COMPENSATION (WC STATU- 0TH- AND EMPLOYERS'LIABILITY Y/N (TORY LIMITS I ER ANY PROPRIETOR/PARTNER/EXECUTIVE NOT APPLICABLE OFFICER/MEMBER EXCLUDED? I N/A E.L.EACH ACCIDENT $ XXXXXXX (Mandatory in NH) X =OVAdescdbe under E.L.DISEASE-EA EMPLOYEE $ XXXXXXX DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT XXXXXXX DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES((Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 11152803 AUTHORIZED REPRESENTATIVE TO WHOM IT MAY CONCERN I ACORD 25(2010/05) © 988-2010 AC D ORPORATION.All rights reserved The ACORD name and logo are registered marks of ACORD A CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDfYYYY) I 01/28/2013 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. (A/cC.No,Bet):604 678-5461 FAX Noj:6114_0_1-R316 1177 West Hastings Street,Suite 200 EMAIL ADDRESS: s.s .,iL e • :e_.ca Vancouver,BC V6E 2K3 INSURER(S)AFFORDING COVERAGE NAM# INSURER A: Liberty 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: 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. INSR ADDLSUER POLICY LTR TYPE..OF INSURANCE INSR WVO POLICY NUMBER YY POLICY EXP EMMIDO/YY) {MMIOD/YYYY)I LIMITS GENERAL.LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY 1-"'I-- PREMISES(Ea occurrence) $ CLAIMS-MADE 1 OCCUR # MED EXP(Any one person) $ ___ ....._.-.__—_ PERSONAL&:ADVINJURY $ _—. _.--.__ GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ -I POLICY^ JECT 7 LOC S AUTOMOBILE LIABILITY [1 - (CEOMaBINNEeDl,SINGLE LIMIT –$ ___ ANY AUTO � BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ___ AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION X WC STATU- 0TH- AND EMPLOYERS'LIABILITY Y/N /-I TORY LIMITS I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE A OFFICE/MEMBER EXCLUDED? N N/A WC1-B71-072231-053 2/1/2013 2/1/2014 E.L.EACH ACCIDENT $1,000,000. (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 II yes,describe.under DESCRIPTION OF OPFRATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 F r DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,IF more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN To Whom It May Concern ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR,IZZD REPRESENTATIVE- ,/� ---e1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I (`.1 or-Ali`<1 , - dia mac, 54- . � ���v�� l y L3 5 -7- la 1-1C_ i'! 'L F io-� tb OCT 3 ® 2013 h iue - lam t-(, -�. r�: YU,-700000000000,70000000 NewEngiandsbestroof.corn IH INTERLOCK INDUSTRIES.INC. Lifetime Roofing SystemsQ6 Unit 7,25 Walpole Park South,Walpole,MA 02081 Massachusetts Home Improvement Contractor Registration#139640 FEIN 43479096 Customer Service:;1-866-588-ROOF(7663) Name pi eA r 6-er-g-atk+ -E - -a.c1.4-a -1 M 1 bec0 -t ("Buyer) Date to�% Job Address gal 0.21,0.--,,-,44?...... Dr.. ("Premises") City/Town {Uo o.w‘0fY1 I Mk Zip Code 0106 a.Mailing , ae Address E-Mail eco+avLu Q"t . Work Phone ( ) Home Phone (Lill ) 5Qt—4(411 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 all necessary materials and labor to install, construct and place the improvements according to the following specifications,terms and conditions(the"Specifications")on or at the Premises: SPECIFICATIONS LOCATION OF SHIPMENT:k*" d Color.o SHINGI�EC E ��'`�''� Color: f�noru �.� 1 G,.,�,a YES NO ROOFING MATERIAL 6 YES NO OWNER WILL _ ✓' Flash Skylights# ✓ Supply adequate electrical power. er _....__ Flash Vents ti/ Be responsible for all rot damage and other necessary roof Underlayment repairs ie:roof decking,fascia boards,etc.at a cost mutually _ Snow Guards# 40' _ agreed upon in advance. _ Ridge Vent PROPOSED START AND COMPLETION SCHEDULE: ROOF REMOVAL. o `er Start Date: ,,i GtaltsSubstentiai Completion Date:1,'a. Strip existing roof(crnreone): y 2 3 layers —ter "" Supply'/2"plywood REQUIRED PERMITS:The following permits are required and 1 Haul away roof debris and pay refuse fees. will be secured by Pill Contractor as the homeowner's agent. t LOCATION FOR BIN: i Mx 4* 'D tQ-tt t ers who secure th ' permits will be excluded from the t ` Guaranty Fund provision MGL chapter 142A. ,,o 0..T T„,4,,-<" ,4 - .-+.. s-1/441,- "wive..., '� u._ ix e,5.z -bo otrA 4r,ruj 1re1n t h 5x43-) 'e.sl4t,. �t .tot�`uod— bt"�4:13t Q rIt V-c a `�n . + A - r `' 0.301 . ( • IC 4>n hs M.L or, . 4. 4,c›. 'S(�c d 4o •• M dr> u1/4-9-1, • M h -6 Nk , or,o. b c- 0‹.)42,L4..,c� oCC-MI UM, .!1 44 `C. ► :® ,it ° Lai %L to" 0 V f-T THIS CONTRACT INCLUDES: LIFETIME LIMITED WARRANTY,TRANSFERABLE,NON-PRORATED FOR MATERIALS MANUFACTURED BY INTERLOCK ROOFING LTD. PLUS 10-YEAR LIMITED LABOR WARRANTY PROVIDED BY INTERLOCK INDUSTRIES,INC. SEE THE WEBSITE FOR WARRANTY TERMS. LIFETIME LIMITED MATERIAL WARRANT FOR IB ROOFING,PROVIDED BY lB ROOFING SYSTEMS. Financing Requested Yes 0,- No Sales Price $ L t.)Lt Sales Tax $ interest Rate: 11.9%to 14.9% Total Contract Price $ `t lt't Down Payment(not to exceed 1/3 of total contract(rice} $ SLD t7 0 Payment not to exceed$ Total Balance on Completion $ 3bt Loa) O.A.G.(on approved credit) MAKE ALL CHECKS PAYABLE TO:INTERLOCK INDUSTRIES,INC. You may cancel this agreement if it 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 delivery,not later than midnight of the third business day following the signing of this agreement.See the attached notice of cancellation form for an explanation of this right. IN WITNESS WHEREOF,the Buyer and Contractor have hereunto signed their names this iY\, day of"°'�3 -20 l3 . Do Not Sign This Contract if There 'e Any Blank Spaces INTERLOCK INDU RiES,INC. LQ Signed `1 Per: Buyer (Print name tr i Signed did,4 d�!► Unit 7,25 Walpole Park South - Buyer Walpole,MA 02081 HIC#'139640 This Agreement is a binding agreement and contract between the parties. This is not a credit transaction and will not be financed 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 financial institution to complete the financing,immediately on request. The Buyer hereby acknowledges receipt of this Agreement. See reverse of Agreement for additional terms and conditions. All surplus material Is the property of the Contractor.CRSCMA0813 - 1:1, ISK17.0\\ ti IS, ,,,,,I1 1) ,1-1,,,k,f.koll .rii, Iii icii *3 ..4 ti .15.7 ,Is (2: zz, _to , ‘-,,,.... (,,, ,w,,,,,, 7 — t...: \ ,r,;7 .61. 6_,(1' 6',5"/,_ ..6 12-01_.\ t:r.i.,..3 *..,,,.... ri,..,_.,:i 1.,.:(0... -•`",;, op,..0. 2.c,„ ..e, e, Ci 17 4 • a; Allir. tri co