24D-218 (2) 4n1 . `' t
U.S. METAL ] o0 FING
f „r
740 High Street•Suite 2 • Holyoke,MA 01040
1-800-232-0399. 1-413-536-5474•Fax 1-413-533-8166 DATE PROPOSED TO BE DONE ON
wwwusmetalroofing.net r -rte"
SUBMITTED TO PHONE NUMBERS
STREET JOB LOCATION
CITY,STATE AND ZIP CODE
DIRECTIONS
We will furnish and install new Englert standing seam metal snaf lock system,24 gauge as listed below.
Work is guaranteed for five years and the manufacturer warranties the finish on the metal for 35 years.
COLOR:C'}��ir�`�'C' e HOUSE: z-'k SPECIAL INSTRUCTIONS/COMMENTS
/(2\ � !
ROOF: 1 PORCH: p
i
f' fit, t.? cr y
SOFFIT: ADDITION:
FASCIA: GARAGE:- 4/C
PLYWOOD:,4p .�, f--- GUTTERS:
RIP/REMOVE: L"t'1 � 4 �DOWNSPOUTS: fG,r P
OTHER: REPAIR:
1 �
Contractor will begin work on or about ti k,r (date).Barring delay caused by circumstances beyond Contractor's control,the
work will be completed by I L e (date).
All roofing panels are custom fabricated on-site with state-of-the-art roliforming equipment.
'As with any rollform steel panels,a certain amount of waviness or oil canning may become evident at certain times of the day when
sunlight hits them.This is standard in the industry and does not affect the integrity of the metal.This shall not be construed as a product
defect and shall not be cause for rejection.
Contractor does not perform or assume any responsibility for any painting,staining or wood or wall finishing on interior or exterior.
The contractor does further agree with the owner that(a)he will begin work within a reasonable time after the execution thereof,and will
prosecute it diligently and with due care,and in a good and workmanlike manner;(b)in doing the work,he will comply with all statutes,
rules,regulations and ordinances applicable thereto:
Contractor to procure all permits required by law.Contractor shall provide public liability insurances.
Owner warrants that he is the owner of the property on which the work is to be performed or that he is otherwise authorized on behalf of the
owners to enter into this agreement.
We Propose hereby to furnish material and labor-complete in accordance with above specifications for the sum 0:
Aj r1 ^? ��� �,%�> � �l F/°t <"L-6),4;. f V dollars($ ! )
Payment to be made as follows:
Name of Contractor/Designated Registrant
INC.
U.S.METAL ROOFING DISTRIBUTORS,
%($J1! )upon signing Contract; Street Address
r) 740 High Street,Suite 2,Holyoke,MA 01040
-`' % u< )upon start of job; Phone
t 1-800-232-0399
(!r y^%($ )upon 1/2 iob completion; Registration No.
MA#134740 CT#602546
i %(S fI )shall be made forthwith upon completion Na pemyelesman
work under this contract A> /
Notice:No agreement for home improvement contracting work shall require a down payment Authoriz Si lure
(advance deposit)of more than one-third of the total contract price Or the total amount of all �,;� ,. ___-�.------'"
deposits or payments which the contractor must make,in advance,to order and/or otherwise To be approved by office
obtain delivery of special order materials and equipment,whichever amount is Mater.
Acceptance Of Proposal I have read both sides of this document and accept the prices,specifications and conditions stated.
I understand that upon signing,this proposal becomes a binding contract.You are authorized to do the work as specified.Payment will be
made as outlined above.
You,the Buyer,may cancel this transaction at any time prior to midnight of the third business day after the date of
this transaction.Cancellation must be done in writing.See accompanying cancellation.
O NOT SIGN THIS COPTR�CT IF THERE ARE ANY BLANK SPACES
1 jZ H,Z / vi Date -�I t& S Signature Date
Signature
IMPORTANT INFORMATION ON BACK 0
J
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: Axe-
The debris will be transported by: ,Xf ,'blj/ot,5 _tA)C,-.
The debris will be received by: Q a , r or�h�'a,
Building permit number:
Name of Permit Applicant/,/-
Date Signature of ermit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
= W Office of Investigations
I Congress Street, Suite 100
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): > r G 1 k" L" d Y ��
Address: U-r�,.A / r. - ` Lc �!. /G
City/State/Zip: Phone #:
you an employer?Check the appropriate box: Type of project(required):
1 I am a employer with & ❑ I am a general contractor and 1 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. ❑ We are a corporation and its 0.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I [] 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: —
Policy#or Self-ins. Lic. #: Ol. '� ,�� �,'�� Expiration Date:j– - -1K
Job Site Address:— � �%7 j ✓� City/State/Zip: 2hh -yr.l 0
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 c ify u der the pains enalties ofperjury that the information provided above is true and correct.
i
Si atu Date: S
Phone#:
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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable)❑ /
6 Name of License Holder �� �%�'i�t`'^il --,J `� ( �z?
License Number
{ d c 1-i
AddreAs Expiration Date
1 V,-.e---
07
Signatur telephone
9. Registered Home ImDrovement Contractor: Not Applicable /❑
l / �L V
�dYS. � � 1
Co oanv Name Registration Number
- Cry v,C D
d e s Expiration Date
-tp_.., Telephoned -5t
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 oft a building permit.
Signed Affidavit Attached Yes....... No...... ❑
11. - Home Owner Exemption
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 Windows Alteration(s) ❑ Roofing
Or Doors 171
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[O] Other[a
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes o
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following: 14
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?
In. 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 as Owner of the subject
property
hereby authorize - �l �l f C �(/Y S C-J
to act on my behalf, in all matters relative to work authorized b s building permit application/.
F Q I?J 4145
gnature of Owner Date
as Owner/Authorized
Agen hereby declare that the state ents an inf rrration on the foregoing applib6tion are true and accurate,to the best of my knowledge
and b lief.
Signed under the pains an nalties of perjury.
�Zzt--p 2
Print Name
Sig re of O er/Agent 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
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 0 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the,,Registry of Deeds?
NO Q 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 Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading\exgavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
t 212 Main Street Sewer/Septic Availability
►� Room 100 Water/Well Availability
o sUno,"�,�,�PF.�� rthampton, MA 01060 Two Sets of Structural Plans o'.
oro�J Ado" ne 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
/--� Map Lot Unit
Zone Overlay District
/7 y Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
C' ,- <'e i 7Y Telep ones
ignature
2.2 Authorized Anent:
a (Pri t) Current Mailing Address:
Signature Telep noh e
SECTI N 3-ESTIMATED CON TRUCTION COSTS
Item Pco:m�leted ated Cost(Dollars)to be Official Use Only
b permit a licant
1. Building C (a) Building Permit Fee
2. Electrical / (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) �I /
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
13 PERKINS AVE BP-2015-0950
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D-218 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: ROOF BUILDING PERMIT
Permit# BP-2015-0950
Project# JS-2015-001837
Est.Cost: $19276.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: U S METAL ROOFING DISTRIBUTORS, INC 031003
Lot Size(sa. ft.): 3571.92 Owner: CAMPBELL JOANNE
Zoning: URC(100)/ Applicant: U S METAL ROOFING DISTRIBUTORS, INC
AT: 13 PERKINS AVE
Applicant Address: Phone: Insurance:
740 HIGH ST SUITE 2 (413) 536-5474 WC
HOLYOKEMA01040 ISSUED ON:41912015 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 4/9/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner