36-318 (2) A & J Home improvements, Inc.
60 Washington Avenue • South Hadley, MA 01075
Certified Office / Fax: (413) 467-1500 - Cell: (413) 575-1290
AJHomelmprovements @yahoo.com
HIC Lic# 135399 - GAF-ELK ID # CE17267 • CT Lic# 600705 / CS, SL, RF, WS # 101017
Proposal Submitted To: Jell; Phone#'s:
Home: Cell:
Street:
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�i5��tf� 1'�i �- rte � � � tS
/
City, State, Zip Code: lrt G`, Esc' f��/�t° l s-
House ❑'Garage ❑ Other
Proposal to furnis7Tear-off nd install the following:
❑ Re-Roof ❑ Gutter
7 Co plete Roof Preparation
H me exterior to be protected by tarps and plywood
rubs, landscaping, trees to be protected
ofers buggy shall be used where accessible with permission from owner
Entire existing roofing material to be removed to existing decking, including flashing, etc.
Yite to be cleaned everyday with roll magnet debris removed at project completion (included in price)
et . rated existing decking replaced at $45.00 per sheet plywood (only if needed)
YO:ew itep rown 8 inch metal drip edge installed at eaves and rakes ❑ White/Brown 5 inch for re-roof only
flashing will be installed where necessary / install lead to chimney
II stall new pipe boot flashing
Vvv
Le shall acquire all appropriate permits etc. for all roofing work
Co plete Roof System ❑ 3
We propose hereby to furnish materials and labor - complete in accordance with above specifications for
the sum of:
Total Sale Price $ S� +Ti Down Payment $ �T_�60 Upon Completion $ �d
l
ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory and
are hereby accepted. You are authorized to do work as specified. Payment will be 1/3 down upon
signing, and balance due upon completion. Unpaid balances shall accrue with interest at 18% per
annum. Purchaser(s) will pay f¢r:a11' st ,.,e1penses and reasonable attorney's fees incurred by
A& J Home Improvements, Inc. tP9 c, r any sums due under this contract.
Date: Signature: ` -. 0 :�° Phone #
Z
Dater Estimator's Signature - � --
ATTENTION HOMEOWNERS: Please cover all personal belongings in the attic, garage or storage
areas due to the possibility of roofing debris or dust coming through cracks of the wood. A& J
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,M4 02111
www,mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): t g)pn e m n�y-oyl-Klt
Address: L0 WxA-)t.-u iu)
City/State/Zip: «y � (i Phone #: i,--'- `�4 7
Are you an employer?Check the aft6ropriate box: Type of project(required):
1.9 I am a employer with ?, 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have aired the sub-contractors 6. ❑New construction
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. E] Building addition
[No workers' comp. insurance comp. insurance.1
rp
required.]
5. We are a corporation and its 10.❑ 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. Roof repairs
insurance required.]' c. 152, §1(4),and we have no
employees. [No workers' 131-1 Other
comp. insurance required.]
*Any applicant that checks box#I 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: C 1_)L d%`7 —
Policy#or Self-ins. Lic. #: l��- V ��4 Expiration Date:
Job Site Address: �� �n��1110A Wit", City/State/Zip: �o� � t�11 t
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 tip 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 cer ' nd77--t ins and penalties of perjury that the information provided above is true and correct.
Si nature: Da e:
Phone# ` B t "� qu) i ' OC)
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 ❑
Name of License Holder:. y _ 100 J,7
License Number
Address Expiration Date
ot7
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
A-f,T C ,p ,,�,�fs 1,3,53 'P9
Company Name Registration Number
Address(.tJc35l/1 Jn N r 3C� Expiration Date
Telephone ` - rS Gv
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....... I;?" 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 tinder 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) F—I Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding[CI] Other[EQ
Brief Description of P sed
Work: �s70
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes _No
Plans Attached Roil -Sheet
6a.If New house and or addition to existing housing, complete the following:
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?
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
bo PQ I as Owner of the subject
property _ {—,�,�
hereby authorize A -1 -� M 4Q ),,%
to act a in all matters relative to work authorized by this building permit application.
5
Signature of Owner Date
� )J JA)m e I VY) P l,'0 `+j S 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
Signature of Owner/Agent Date
Section 4. ZONING Alt 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 DONTT KNOW 0 YES 0
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 0 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 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
cy Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
J Room 100 Water/Well Availability
< ' Northampton, MA 01060 Two Sets of Structural Plans
•�' phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Q
o Other Specify
P (CATION 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
��3 CQ��N w{� Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
G(LIFin Co.rv, 'e d ei I I (�Irz wyl wv�(
Name(P Current Mailing Address:-7
Telephone 1 , 53 a 3 s(�Y 5-
Signature i 3
2.2 Authorized Agent:
t�►S t' dr. _r vc u>t� O (A 05�042r\ Xt lt1.�
Name(Pant) Current Mailing Address.
1167 Is o
Signature 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) ,E'� �✓'
5. Fire Protection �f
6. Total=0 +2+3+4+5) b S-00 Check Number 6(�
This Section For Official Use Only
Building Permit Number: V Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
223 CARDINAL WAY BP-2016-0022
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-318 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2016-0022
Project# JS-2016-000035
Est. Cost: $20500.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: A & J HOME IMPROVEMENT INC 101017
Lot Size(sq. ft.): 60025.68 Owner: CAMPADELLI BRIAN J&REBECCA THOMAS
zoning: Applicant: A & J HOME IMPROVEMENT INC
AT. 223 CARDINAL WAY
Applicant Address: Phone: Insurance:
60 WASHINGTON AVE (413) 467-1500 O WC
SOUTH HADLEYMA01075 ISSUED ON.71812015 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 7/8/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner