36-259 (4) LQ C UQ CCU Q QQ QQ 0 0 cc nc�
&0 w til
0 0 0 r- Pd �od
o iz k
0, UQ 0 0
4
a CD 0
CD IR
to
CJ. 0 1 ,t
co
QrN,
Vzk
21— c>
O
..............
.. . ...... ION
Coll
SA +1
1 0 �
%6 A -Loo-)
17
96
It
ilk
TA
2.b
2d WH8Z:20 200E ST 'unf 'ON XU-4
,
— Agreement Between
® INTERLOCK INDUSTRIES, INC.
Unit 7,25 Walpole Park South
Walpole, MA 02081
Registered as a Massachusetts Home Improvement Contractor
Registration#129369
Toll Free: 1-888-321-9994
Tel: (508)660-6665 Factory Use Only
Nil? 12110
Name n) 'ANC (the"Buyer") pate U0
Job Address (' j _00APCQ1 Phone l3 -SEUSP-2
City/Town �VKPn�G _ YY1i4 Zipf o�2
Buyer's Home Address s Zip 119-
The Buyer is the registered owner of the land and premises described in the job address above (the"Premises")and�hereby contracts with
Interlock Industries, Inc.(the"Contractor")and authorizes the Contractor to furnish alt necessary materials and labor to install,construct and
place the improvements according to the following specifications,terms and conditions(the"Specifications")at the Premises.
SPECIFICATIONS
YES NO ROOFING MATERIAL YES NO OWNER WILL
_�/_ Shingle -Color _L-11 - Supply adequate electrical power.
_6Z_ LQcaation for hipment 5 ? �R� ,d_ ✓ , Be responsible for all rot damage and other necessary
roof repairs. (le)I Roof decking, fascia boards, etc.
_ Flash` kyligh#s - Nu er ✓ Roof repair work may be undertaken by Interlock at a
t/ Flash Vents i0ne JeA`f P(pe M cost to be mutually agreed in advance between the
Interlock Underlayment parties. ^)v �w
Snow Guards J=�g2 IA&x pcs.
ROOF REMOVAL Start date:
Strip existing roof_ Zpy layers. --
Haul away roof debris and pay re se fees. -
„ Note location for bin
Supply'/Z' plywood. ,J5t;;E-
^g= _ Ila
i
pq
J`� n
c
SPECIAL INSTRUCTIONS.
,
Sales Price $ /A 990
Financing Requested Yes f/�No Sales Tax $ '
Pre-Approved Interest Rate 10,9% to 14.9% Sub-Total $ 1 I
Payment not to exceed $ Down payment $ �-- --
�57-omsz �'R I iq k Total Balance•orr Completion
MAKE ALL CHECKS PAYABLE TO, INTERLOCK INDUSTRIES, INC.
Do not sign this contract if there are any blank spaces.
IN WITNESS WHEREOF, the Buyer and Contractor have hereunto signed their names this �� day of_ft& 20-"
The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute
concerning this Contract, the Contractor may submit such dispute to a private arbitration service which has been approved by
the Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as
provided in Ni 2A. _
Signed
Per. e
INTERLOCK INDUSTRIES, INC. Signed
�fogw ct� A� fJRo -e ( '4 (_-Buyer
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
Form 046-06103
t7d Wd87-:20 2002 ST 'unf 'ON XU.J -
W0a d
' L \" E EBROARY2.2O(S! COR !— RtIfi�ATEE ; " ` _IT II -.
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
MARSH CANADA LIMITED AND CONFERS NO FLIGHTS UPON THE CERTIFICATE HOLDER. THIS
$00 - 550 BurrtrdSC. CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE
Vancouver, S.C. CANADA V6C 2K1 AFFORDED BY THE POLICIES BELOW,
CERTIFICATE No. DBE'-04-010 � COMPANIES AFFORDING COVERAGE
INSURED COMPANY A Amerfcan Home Ps urance Company
Interlock Indwstries Ine. COMPANY
#7-25 Walpole Park South —
Walpole, MA. 02081 COMPANY G
COMPANY ❑
COVERAGES
THIS IS TQ CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW AVE BEEN ISSUED TO THE INSURED ARMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY
R20UIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED
AY THE POI-ICIES DESCRIBED HEREIN IS SUBJECT YO ALL THE,TERMS,EXCLUSIONS AND CONDITIONS OF 5UCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO POLICY EFFttvVE POLICY EXRIRA710N -
LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DDPM DATE(MWDDM) L1AkTS
R
GENERAI,LIABILITY - _, GENERAL_AGQREQATE 1,QDQ,OOO.DOUS
RMGLA 2507�1I Feb.01,2004 Feb.01,-2005.
COMMBRCIALG2NERALLIABILrrY _ FROCUCTS-COMP/OPAGG- $ �.,000,QQO-QOIIS
_'— CLAIMS MADE. I )( IOCCUR PERSONAL S ADV INJURY Y,000�QOO.QOIJS
OWNER'S S CONTRACTOR•9 PROY. - EACH OCCURRENCE 1,000,000:DDUS
FIRE DAMAGE(ANY ONE FIRE) . 1,000,QOD.00U$
• - _ - - -- MED EXP(ANY ONE PERSON) 10,000.DOUS
AUTOMOBILE LIABILITY $-
COhIB)NED SINGLE[IMIT
ANY AUTO
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS $
HIRED ALTfOE - LIMIT OF L,.IAQILITY
NQN-OWNED ALTTQS(S`PF NS}
PROPERTY DAMAGE
$-
EXCESS--LiABJUT-Y - EACH OCCURRENCE
UMBRELLA FORM AGGREGATE - $ -
OTHER THAN UMBRELLA FORM - -
WC STATU- bTH- �.^a J �• 9+sre_ I.._-.
WORKQR$COMPF,WSATIQN AND
EMPLOYER$'LIABILITY �-
TORY LIMITS ER 5.1
-- EL EACH ACCIDENT ,
THE PROPRIETOR/ INCL. EL DISEASE-POLICY LIMIT
. PARTNFRS/EXECUTIVE' - - -
OFF.ICERSARE: EXCL. EL DIS[ASG—EA GMPLAYEE $ -
-DESI IFUPTION OF OPERATIONS/LOCATIONSVEHICLES)SPECIAL ITEMS-
Re: Evidence of Insurance
: ..-
- . .... -
�FR7f�"lCAT�_�3Dt'.P��.:�•.:_,-.- .- . - - -_ , -
. .. ,t'•sANOE Cry :";"'.�
_ .SHOULD ANY OF 7HE ABOVE DESCRIBED PC)LICIE$BE CANCELED BEFORE 7HE
TO Whom It May Concern ExPiRATION DATE THEREOF.THE ISSuNO COMPANY WILL
( ENDEAVOR TO MAIL n/a DAYS WRITTEN NOTICE TO THE CERTIFICAT5
NOLDf'a NAMrn YO YKF LKf'Y,ru.IY FAIT LIRE YO null SUCH NOT CE.SHALL IMPOSE No
OBLIGATION OR LIABILITY OF ANY KIND UPON THE(-OMPANY,ITS AQENTS-OR-
REPRE$ENTATIVEB.
MARSH CANADA 1-MUTEFI)
be
- bAG(142D:C0#pokAT1001588'
1411 'IN
0.�ttAtr�r —
�O �cr3%a O� —
3 of Tort IJUIIIP toll
A J E JR1a5asthntsrtla"
w o DEPARTNIE14T OP DUILDDNG INSPECr10t:S
212 Alain Street ' Municipal Building
?Northampton, Mars. 01050
WORKER'S CO)'IPENSAT70N GNSURA-NCF A FDM` IT
�•�--- --
(li ccusx/permi t ICC)
vlith a principal plat: of buSlneSsJrcSldencc at.
h,� Qt d�L
_ U �Q_ �c1A oc C� �Q�Q(l�er^I�(Ph0nc
`T (sv�t/city/starc�z�p)
do hereby certify, under the pa_trl_s and penalties of perjury, :hat
( ) I man employer providing the foUowim-, WOrkcrs comnens-ndon cove age for Inv
etuplovecs wot-�Jing on ulis job:
C�aracz c1C1' L;m. OB P re
(Isar-`n= Coona>;y) (PcLic: Nu_-acrr) (G.piraon 2fc}
( ) I am a sole proprietor, general contractor or homeowner (Ci tie one) and hzve- hired
the coasactors listed below who have the fok.Vitlg worker's compensation pcklcs:
(N e of Cootramor) (lsuurance Comoaavi%p c; Nunerr) (iiou Lion Date)
(Name of CoarraCior) (Lnsuranc; Compan)"/Polio- Nu-mb:r) (Expir- aoo Date)
(Namc of Contractor) (LaSU=c--- Compatry/Pobcy Numbs) (L-xpu-avon Date)
(ndiG�ad�i�ocil r'_xci if ncctian to a>GU�iarory-ua oa pertniaias to.L nom--.-CO:�)
( ) I am a sole proprietor and have no one wort ng for me
( ) I am.a home owner performing all the work myself.
NOTE:plmsc be aw i=tb�w't.Jc 6eaxouvcn�tbo czmploy p,z to do r,a:,�c'=-:cam,K)C rcpav..Orx of.d.•clL^�of
ant moca tlL.n Lb-c_L-Ifj is wbieb the bwc wvcr rcudd=oc oo the U� jz'd�zppartcn_n tbcen��ox m be
employe-3 I, Lhe A,=(GL152-,.1(S)l zpplia6cro by n bomeowvcr fcr c bc:::r-'-.a permn r-y c�ldcocc he
Icgil ataAU of a.n ex?loyec uador din Woc4c.olr Coaipamii Act.
I uadcrrLx d tha a copy of thi.a-t wcm may be fog- dj d to Lbo popartmczss of In�:.uiJ Accidcuti Uffioo of lru+r,no.for LE-
cov=-x• vcnfi=oo and diet L d=c to torus t:oventb-O under 34e -a 25A of MOL 151 tin Iad to the L- i -of enmia�l Pea+l -
eoa is u of a fmc of up to S 100.00-r-woe impCisoam�o(up to oat year f-Dd o"il Pau)-o io ct c room or-Slop Wort Order aad a
fim or 5100.00 a day apinst me
FFo-,6�unm^'•-�t u. orjly
-MjI lU LX-'r
Lot
> J Si�-ttun of Liccnscclpccmitt� -_ - mwm� maw
OQ.'CHAMpTO
Gl i#g of Xart4aniptan L r
9 � �i tassacgtcsrtte
S" DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Ncudhampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction sups: , sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants any person(s) who seek to
use the home owner exemption, to act as their own construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and regulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings(before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9: Regiistered Home Improieriieri#Cotiactor Not Applicable ❑
Company Name Registration Number
7 2 ob � r K- Cufk � MI g 6 �
Address / � � Expiration Dat&-
Telephone(5L-)
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 Alterations) ❑ [Roofing ❑
Windows Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ J Decks [ ] Siding [ ] Other( ]
Brief Description of Proposed
Work: 1 Lt-61M O V Qt' t 'UQ (.0tic)
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative C Renovating unfinished basement Yes No
Plans Attached Roll C-Sheet C
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. Mascheck 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 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Of C �•Q� 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, 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.
Print Name
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parkin Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES_
No
IF YES, describe size, type and location:
4 4.
City of NorthamptonK
Building Department � .. ,
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-12721
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Proaerty Address: This section#o,be completed by office
Map Lot Unit
Zone Overlay District
Elm ft District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
re 01(
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized A ent:
Name(Print) Current Mailing Address:
Signature Telephone l
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (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
This Section For Official Use Only
Building Permit Number: / gcaos--old Date Issued:
Signature:
Building Corn i ioneryInspector of Buildings Date
131 MAPLE RIflGE`RD BP-2005-0124
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map 3G'-259 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-2005-0124
Project# JS-2005-0131
Est.Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groo: IINTERLOCK INDUSTRIES INC
Lot Size(sg.ft): 44431.20 Owner: MCGRATH JOHN E&NANCY T
Zoning: SR Applicant. MCGRATH JOHN E & NANCY T
AT. 131 MAPLE RIDGE RD
Applicant Address: Phone: Insurance:
131 MAPLE RIDGE RD
FLORENCEMA01062 ISSUED ON.7130104 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL SHINGLES OVER ONE 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 Sienature:
FeeType: Receipt No: Date Paid: _ Check No: Amount:
Building 7/30/04 0:00:00 937 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo