32A-078 (4) Massachusetts - ]eon tmeit of P:,o Safa y
Board o?Buiidwg Regu atior,s and
ce—se CSSL-101017
ANDREW J DER"` At
60 'VASIIINGTON AVE,
South Hadley NIA--01075 ,
.�rr,� �ssior�er 11/1612015
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 0211.6
Home Improvement Contractor Registration
Registration: 135399
Type: DBA
Expiration: 4/1/2016 Trk 248655
A & J HOME IMPROVEMENT ----
ANDREW DEREN
60 WASHINGTON AVE.
SO. HADLEY, MA 01075
Update Address and return card.Mark reason for change.
-` Address -- Renewal — Employment Lost Card
,$CA'- 20M-05+11
. 1 License or registration valid for individul use only
Office of Consumer Affairs&Business Regulation
-��OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 135399 Type: Office of Consumer Affairs and Business Regulation
xpiration: 411!2016 DBA IO Park Plaza-Suite 5170
Mir
:,., Boston,MA 02116
mss;.:
A&J HOME IMPROVEMENT
ANDREW DEREN
60 WASHINGTON AVE.
SO.HADLEY,MA 01075 Undersecretary Not valid without signature
A&J
Dome Improvement Inc.
MA Reg# 135399 60 Washington Ave
Conn Reg# 600705 So. Hadley, Mass
Phone: (413) 467-1500
Cell: (413) 575-1290
Customer Address
Hampshire Property Management CZ
Attn: Jeanne Harlow
8 — 22 Graves Street
Northampton, MA
Description of Duties:
1. Protect building and landscaping with tarps and plywood
2. Remove existing layers of roofing down to wood deck.
3. Any damaged or rotted decking will be repaired at $55 per sheet '/2" plywood
4. Install your choice of GAF Timberline HD (lifetime) asphalt shingles:
5. histall aluminum 8"drip edge on all eves and rake edges.
6. Install ice and water barrier 6 feet along bottom of the roof. 3 feet in all valleys
and around all roof penetrations.
7. Install Synthetic underlayment on all other areas of the roof.
8. Install new pipe flanges to roof
9. Install new lead counterflashing to chimneys
10. Replace any step flashing as needed
11. Ground is to be cleaned at the end of every workday. (Removal fee Included.)
12. We will pull all permits
Labor Guaranteed for Ten Years
Agreement bonded to furnish materials and labor according to the description above.
Main Roof Replacement S 34,500.00
This quote guaranteed for 60 days.
Signature Andre-vv Deren Date_4-02-2014
Accepted: 1 hereby authorize A&J Home Improvement to perform work to the above
specifications. Payment is agreed for 1/3 down deposit and balance to be due upon
completion. Please sign and return one copy and return to the above address.
Thank You.
Date 'f ��'' Signature ✓'�' r %;. Phone,-'
ell,
`y The Commonwealth of Massachusetts
:i
Department of Industrial Accidents
Office of Investigations
600 Washington Street
r Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): A V fpm r1��R€� VYlic1 f1 c;
Address: LO �c�l�u IDI)
City/State/Zip: S1'_A &A11 11,401QL, Phone #: Ll 1• L/tO
Are you an employer?Check the a ropriate box: Type of project(required):
1.9 I am a employer with_�_ 4. F] I am a general contractor and I
employees(full and/or part-time).* have Aired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, 0 Demolition
working or me in an capacity, employees and have workers'
g Y p Ty• .� 9. ❑ Building addition
[No workers' comp.insurance comp. insurance.1
required.] 5. E] We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.[�Roof repairs
insurance required.]t' c. 152, §I(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:
Policy#or Self-ins. Lic.#: �+�. C7 ��4 7 Expiration Date:
Job Site Address: 1:�>66-J City/State/Zip: U•4,
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 certify e' ,I 'ns and penalties of perjury that the information provided above is true and correct.
Signature. l� 1, Date:
Phone#. L-i? 1, ` U 7 - /'500
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#:
Versionl.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
°Lt., "`` �`"t �"�A M.,04,"d as Owner of the subject property
hereby authorize T >0 LA-r--. t to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, � } � �(r'� �✓Y'�1��t7+s. _"'� ,as Owner/A prized
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.
Al
Print Name l y
_ 3 () —
L I
Signature of er/Agent Date
SECTION 12 -CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: NotApplicablle El
Name of License Holder: F'tYl V,��'�� 10101 -7
License Number
Addressss/� Expiration Date
Signature Telephone
SECTION 13 -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 0
Versionl.7 Commercial Building Pemiit 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 o esponsibility
Address (y y Registration Number
ignatu 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
} T Not Applicable ❑
Company IN'ame:
9'1► cw
Responsible In Charge of Construction
�0 WrASig("�q S i 4., /1h 61,01 s
Address
-7
Si ature Telephone
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
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 Parking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO C) DONT KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 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 Q DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 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 O NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.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[�KChange of Use❑ Other❑
Brief Description Enter a brief description here.
Of Proposed Work: Px�51
rh p r al U�inlec3' F I✓\St�lX�l y1�W /*S �c (` ��S �1
J
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ is ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ( ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H Hi In Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 38 ❑
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)
1St 1st
2nd 2nd
3`d 3 rd
4
4 t tn
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 ❑ On site disposal system❑
Version].7 Commercial Building Permit May 15,2000
Department use only
i i M City of Northampton Status of Permit:
MAY 2 8 2014 'J Building Department Curb Cut/Driveway Permit -
j 212 Main Street Sewer/Septic Availability
Electric. Fumib nc 'r G:�s Sn_sp_e_cltions Room 100 WaterlWell Availability
Nc "`''' '` MA 01 0,60 qorthampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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
-a,a Gl ass ,S >r-ekA Map 90 / Lot "G ol 7-- Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
��am?'Sk"-c 'PA--Vvt� S/ / &+. cF M14- 010 r
Name(Print) lie-CIA-1e 14wd oeU Current Mailing Address:
/'� �a�
Signature ,S-e�e l Canfiiln I Telephone v
2.2 Authorized Agent:
A+J7
Name(Print) Current Mailing Address:
Signature ���'1� Telephone
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=0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-1263
APPLICANT/CONTACT PERSON A&J HOME IMPROVEMENT INC
ADDRESS/PHONE 60 WASHINGTON AVE SOUTH HADLEY (413)467-1500 Q
PROPERTY LOCATION 8-22 GRAVES AVE
MAP 32A PARCEL 078 000 ZONE URC(,100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
BuildinjZ Permit Filled out
Fee Paid
Typeof Construction: STRIP&SHINGLE ROOF
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 101017
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
Demolition Delay
Si re of Buil ng Official 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.
8-22 GRAVES AVE BP-2014-1263
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV Block: 32A-078 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ROOF BUILDING PERMIT
Permit# BP-2014-1263
Proiect# JS-2014-002126
Est.Cost: $34500.00
Fee: $207.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: A & J HOME IMPROVEMENT INC 101017
Lot Size(sq. ft.): Owner: HAMPSHIRE PROPERTY MANAGEMENT
Zoning: URC(100)// Applicant. A & J HOME IMPROVEMENT INC
AT. 8-22 GRAVES AVE
Applicant Address: Phone: Insurance:
60 WASHINGTON AVE (413) 467-1500 O WC
SOUTH HADLEYMA01075 ISSUED ON:513012014 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 5/30/2014 0:00:00 $207.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner