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17C-046 (3) 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 Factory Use Only Tel: (508) 660-6665 Sales offices in Washington, Oregon, Hawaii, British Columbia, Ontario,Alberta, Saskatchewan and Alaska Name cC ►�� -L Q vt �a && a,-i S' (hereinafter the "Buyer") Date �~Z y nn Phon �3 Job Address �� 5,��w�.�.r✓'i- �i// d� ' � ��y^3 2-Z� City/Town o-e Zip l e�116 Z-- Buyer's Home Address Zip The Buyer is the registered owner of the land and premises described in the Job Address above, and hereby contracts with Interlock Industries, Inc. (hereinafter the "Contractor") and authorizes the Contractor to furnish all necessary materials and labor to install, construct and place the improvements according to the following specifications, terms and conditions (hereinafter the"Specifications")on the Job Address: Color:� SPECIFICATIONS � � S �� l�l/1 c�P��c✓��-cam� d-�Y P i-i V /�-=e Y'o o fT .T�,T�� e:� WAf7� l�- j-I ct%z �j LfyP� o4StPTO CfLx�J 1Q# �LT1;�I�t�11i�1�IIll - MASS achttsetts m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 ' WORKER'S COMPENSATION INSURANCE AFFIDAVIT (licensee/perm ttee) with a principal place of business/residence at: /PfIc ✓ ALK kle �r d i /1"14 (phone#) (strcet/city/stafeJap) do hereby certify, under the pains and penalties of perjury, that: 4-1 am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance Company) C=e'Nyanvy (Policy Number) (Expiration Date) ( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attarb additioml shoot ifnecessuy to include information pertaining to all ooa moron) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that whilo homeowners who anploy persons to do ,c one a rcpairwodc on a dwelling of not more than throe units is which the homeowner raids of on the grouodi appurtenarztthereto arc not gmaally o =Wood to be eznployem under the uvoticcr's ooaT=u4on Act(GL 152,ss 1(5)),application by a homeowner for a U=ise of permit may evidence the legal ctatua of an employer under the Worlida Compemat ion Ad. I undawAnd that a copy of this statemrnt may be farvard4d to the Dcpartmco2 of Industrial A=daa&O!$oe of Innwance for the oovertge verification and that failure to soeu a cover ap under section 25A of MOIL 152 can toad to the imposition of--roil penalties ooasistiag of a fine of up to S1,500-00 anNor n¢prisonmcai of up to one year and civil pmaltia is the form of a Stop Work order and a fmo of 3100.00 a day against tne. For depvt="i use oedy ✓ �/ Permit Number Lot# Signahlre of Li Gam' ermittee -.ire�RSSC` SECTION S-CONSTRUCTION SERVICES 81 icensed Construction Su ervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone i.1 In Offiallmil Malliffi A MO Not Applicable ❑ Company Name Registration Number Address Expiration Mte 1 ✓� . Telephone SECTION 10-WO1RKERS'COMPENSATION INSURANCE ,FF1DAVIT(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 Sri.CTIQN RE$_CRJP11QN PF P R all applicakDe New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 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 AGENTPRICONTRACTOR APPLIES3FOR BUILDING 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 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 Date ignature of Owner/Agent 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 ize 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 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 DON'T KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO ✓ DON'T 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: City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION:1-SITE.INFORMATION 1.1 Property Address: � ''� i r s 5t tt SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: .ep. Name(Print) Current Mai in Address:. Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing dress: l�q� Signature Tele hone P SECTION I:-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Ofificial 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: Date Issued. Signature: Building Commissioner/Inspector of Buildings Date I f 53 STRAWBERRY HILL BP-2001-0310 GIs#: COMMONWEALTH OF MASSACHUSETTS MW:Block: 17C-046 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:roofm BUILDING PERMIT Permit# BP-2001-0310 Proiect# JS-2001-0505 Est.Cost: $23000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: INTERLOCK INDUSTRIES, INC 129369 Lot Size(sq.ft.): 63162.00 Owner: NORRIS RICHARD&LAURA Zoning.URA Applicant. INTERLOCK INDUSTRIES, INC AT: 53 STRAWBERRY HILL Applicant Address: Phone: Insurance: UNIT 7 25 WALPOLE PARK SOUTH (888) 921-9994 Workers Compensation WALPOLEMA02081 ISSUED ON.9121100 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. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: 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: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 9/21/00 0:00:00 105 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo