32C-180 (5) -'RC, POSAL---- --- -- --- --- .__ ----- -- _. . ----- --------__- - - ----- -- -
PIONEER VALLEY ROOFING ASSOCIATES PAA 6 Wd8 ALN0.
29 WOOD AVENUE
SOUTH HADLEY MA. 01075 SHEET No.
413-536-8616
DATE 12/27/06
PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT:
NAME ,JOHN BLEDSOE /PIP PRINTING ADDRESS 342 PLEASANT ST.
ADDRESS NEWTON 5T. NORTHAMPTON
SOUTH HADLEY MA. DATE OF PLANS
PHONE NO. ARCHITECT
We hereby propose to furnish the materials and perform the labor necessary for the completion of NEW R00F
APPLICATION OF TAMKO f GAF OR EQUAL 30 YEAR LAMINATE RQQF
WITH NEW RAKE & DRIP EDGE, SOIL PIPE FLASHING APPLIED OVER
EXISTING SINGLE ROOF. ^�
All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifi-
cations submitted for above work and completed in a substantial workmanlike manner for the sum of
TWENTY SEVEN HUNDRED AND FORTY `Dollars ($ $2740. 00 )
with payments to be made as follows. HALF UPON START BALANCE UPON COMPLETION
Respectfully submitted DWARD PIETRZYKO I
Any alteration or deviation from above specifications involving extra costs
will be executed only upon written order, and will become an extra charge Per
over and above the estimate. All agreements contingent upon strikes, ac-
cidents,or delays beyond our control, Note This pr oral may be withdrawn
b of accepted within days.
ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work
as specified. Payments will be made as outlined above.
Signature � a__
Date 1 t�� �'� Signature
r NC 3818-50 P AL
MADE IN USA
S
The Commonwealth of Massachusetts
Department of Industrial Accidents
0 Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information I Please Print LeeibIv
Name (Business/Organization/Individual): p Ae .,liz p PPS YT-e�
Address: (,t/oo Y I/e-
City/State/Zip: 10./g/ _ Phone.#: y/3 ��(o '—i419 le
Are you an employer?Check the appropri to box: Type of project(required):
I.[-`' 4. I am a general contractor and I
am a employer with 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers' 9. Building addition
[No workers' comp.insurance comp. insurance.$
required.] 5. Fj We are a corporation and its 101J 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 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.0 Other
employees. [No workers'
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.
xContractors 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.
lam an employer that is providing workers'compensation in urance for my employees: Below is the policy and job site
information.
Insurance Company Name: �.–S' P
Policy#or Self-ins.Lic.#: �p � Expiration Date: Z3-U-7
Job Site Address l�t��P 5'� City/State/Zip;
Attach a copy of the workers'compensation policy declaration page(showing the policy number an apiration 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 der P pain of perjury that the information provided ab ve is tr and correct
Signature: Date: 2 �? _
Phone#:
Z ,/
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/Liceuse#
Issuing Authority(circle one):
L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Versionl.7 Commercial Building Permit May 15,2000
J
SEGTION.1.0-S R IRAL PEERREVIcW(Z80 CMF1I014
Independent Structural Engineering Structural Peer Review Required Yes No Q
SEGTION-1't-OWNER-'AUTHORIZATION--TO-BE,COMPLETED`VIIFiEI!t
OWNERS AGENT.OR GONTRAGTORAPPLIES FOR BUILQTNG°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
1
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.
Si ned un r ins an altuI�o e"
Print Na e
J
12--Z '
Signa 6eFiAg eate '
-SECTION[12,, GORS.TRIlCTION S`ER�/[CES --- :-
10.1 Licensed Construction Su ervisor. Not Applicable ❑
Name of License Holder �Z° f
License Number
4/
Address 6cpiration Date
Si re Telephone
SECTION;13 WORKERS'COMPENSATION:INSURi4NGE A1=FIDA�IIT(Nf:G L.c, 52 §2SC }
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 0 No 0
r
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN.AND CONSTRUCTION SERVICES-FOR BUILDINGS AND-STRUCTURES 9613JECT TO
CONSTRUCTION CONTROL PURSUANT'T1 7801 CIUIR 1'16(CONTAIMNG MORE THAM,35,DOQ C:F..OF'ENCLOSED'SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
3
s
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
t j
Signature Telephone Expiration Date
i
Name Area of Responsibility
Address Registration Number
1 j 1 i
+ t It
Signature Telephone Expiration Date
! i I
z s
Name Area of Responsibility
k
Address Registration Number
3 �
Signature Telephone Expiration Date
9.3 General Contractor
j Not Applicable❑
Company Name:
s
Responsible In Charge of Construction
r
i
Address
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
8T�u'r»kMP�fQ1m2Q1�111�T r,.
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:! R:; L:I ," R:L _}
Rear I y
Bldg.Square Footage
F-1 % ;
Open Space Footage %
(Lot area minus bldg&paved
arldn )
#of Parking Spaces
Fill: ' } I
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q 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 Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained , 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 Q NO Q
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 i NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
1
SECTION 4-CONSTkUCTIQN SERVICES FOR PROTECTS LESS Tk�ANI 3000
CUBIC FEET OE=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 'Ent a f description here.
Of Proposed Work:
SECTION 5-USE GROUP AND ONSTRUCION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 16
A-4 ❑ A-5 ❑
B Business -- ❑ — 2A ❑
E Educational ❑ 2B ( ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 1 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:f
M Mixed Use Specify:
S Special Use Specify: !
f I
COMPLETE THIS.SECTION TF,EXISTING BUILDING UNDERGOING REN01/ATfONS,..Al1DITIONS.ANDIOR CHANGE-tN USE
Existing Use Group: s Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): '
SECTION 6=SUILDING.HEIGCiTANDxAREA:: „3
:^Q � N w
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION -
K nz.�e- {{
Floor Area per Floor(so
1st 1
u
2nd ,s�"'�
rd
3rd i 3
4th
4`h ' '
Total Area(so i Total Proposed New Construction(sf) �
V95 M
Total Height(ft) � ryry
Total Height ft z r
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone7 Outside Flood Zone[] Municipal ❑ On site disposal system❑
Version 1.7 Commercial Building Permit May 15,2000
�� 3*
City of Northampton
Building Department Ewa erg "
212 Main Street SewedTa �� x u
Room,100
Northampton, MA 01060
�phf nW413-587-1240 Fax 413-587-1272 P1o#ir ��lans
QflerYSpecl
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION _SITEINFORMATION
-°-__ T
-N-Poerty Addfess- his secton o be: rn ted b office_
Y
4/oZ -S',/ /Uo�,��a-•,��i+ f M P LOt µ Unit
i onei OverfaytDf stn66
3
"T rI W .e
u
ElcttSfrDsfr�cY CB Di tact
�SECTION2 PROPERTY O{NNERSrHIPlA17THORIZEDAGENT
� _ r
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
i
i W - /Z Ow
Name(Print) a- Current Mailing Address:
Signature Telephone
SECTION 3-ESTI TED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Officfal Use Only
co lted by ermit applicant
1. Building �7yo j '{a)`Buildiho Permit Fee i
2. Electrical Estimated Total`Cost of
! i °Coilstrudffori from ;6
3. Plumbing i Burliiirig PeiiriitiFee
4. Mechanical(HVAC) i
t,
5. Fire Protection 1
6. Total=(1+2+3+4+5) Check=Number
This Section Foc:Official Use Onl
_.
Build- Permtt lYurtitber`- Qafe;
-Issued
Signature:
Building Commissionedlnspecforof:Buildings Date
- R
d
BP-2007-0888
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: BUILDING PERMIT
Permit# BP-2007-0888
Project# JS-2007-001446
Est. Cost: $2740.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PIONEER VALLEY ROOFING ASSOC
Lot Size(sq.ft.): 5793.48 Owner: BLEDSOE CLARENCE T&IRENE A
Zoning: GB Applicant: PIONEER VALLEY ROOFING ASSOC
AT: 342 PLEASANT ST
Applicant Address: Phone: Insurance:
28 WOOD AVE (413) 536-8616 WC
SOUTH HADLEYMA01075 ISSUED ON:312312007 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 LAYER
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 3/23/2007 0:00:00 $50.002603
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo