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36-259 (9) 131 MAPLE RIDGE RD BP-2019-0743 GIs#: COMMONWEALTH OF MASSACHUSETTS MM:Block: 36-259 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2019-0743 Project# JS-2019-001224 Est.Cost: $25500.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor., License: Use Group: EAST COAST METAL ROOFING 101285 Lot Size(sa. ft.): 44431.20 Owner: MCGRATH JOHN E&NANCY T Zoning: Applicant. EAST COAST METAL ROOFING AT. 131 MAPLE RIDGE RD Applicant Address: Phone: Insurance: 701 TREASURE ISLAND (508) 341-8339 O Liability WEBSTERMA01570 ISSUED ON.1212612018 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 12/26/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner > City of Northampton € Building Department 212 Main Street Room 100 \ Northampton, MA 01060 T r phone 413-587-1240 Fax 413-587-1272 Pi APPLICATION TO CONSTRUCT,ALTER,F EPAI H A 4NE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION DEC 2 6 201 o'"do 1.1 Property Address: / f Th sect n to be completed by office in( / er u k"Clyt l ✓l DEPT OF ORTHA NAPG FAA 2=i Lot Unit Flo- P-A u 1 ,4.4 010(0' 7- Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: � i .�04r, 3 /1/cehc.y �( -t"ti fC /�j .9itGn[t tWg W Flo-ehu . IU4 Name(Print) Current Mailind Address: tt� n /` f 4//49 .S Z�— �.1{l ✓T �G C U 64 Telephone Signature 2.2 Authorized Anent: PCICJ LPC�,r'4�� �4.1f Cvclf /NtA ( T—ee,.( —c- Zjl&ca Pa lue4./j!L�l N (Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building a (a)Building Permit Fee s "vv 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) If-0 5. Fire Protection 6. Total=(1 +2+3+4+5) a 0 Check Number This Section For Official Use Only Building Permit Num er: Date Issued: Signature: /2-21,46 Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 i Bldg. Square Footage ; ___ _, Open Space Footage (Lot area minus bldg&paved parkinR) x t #of Parking Spaces �- Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® DONT KNOW 0 YES Q IF YES, date issued:z 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 Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ObtainedQ , Date Issued C. Do any signs exist on the property? YES Q 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, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[O] Other[a Brief Desc'n' tiop of P oposed Work %_1`(-�-ep /Curm,4 , -r.--7J/cell aca /A.GIt-, .([.�iC�G�. rAJi-C/1 104*, 4luc1( /2uL. Alteration of existing bedroom Yes '-�No Adding new bedroom Yes `._111 No Attached Narrative Renovating unfinished basement Yes •--'-No Plans Attached Roll -Sheet 69.1 Now house and or a+ddMon to existina houshri a 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 I, O�ti 3 n C c V�� 4 as Owner of the subject property 1 hereby authorize /����f- t_G t J h 1,/�-e i,t t /C n c- t, "l')� ( to act on my behalf,in all matters relative to work authorized by this building pe it application. Signature of Owner Date I, L / c h 5 r i!e74>-f C"GCJ I Vic I A, D /7 + I as Gruner/Authorized Agent hereby declare that the statements and information on the foregoing application are true afnd accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. GfLI &eco, I"Cf P' tName Signature of Owner/Agent Date SECTIONS-CONSTRUCTION SERVICES 8.1 Licensed Construction SuDervisor: Not Applicable ❑ a Name of License Holder: T /n 1678 S License Number Address Expiration Date /1--__-_ /_ !- 9 3. 3 2 3 Signature Telephone 9.Registered Home Imaroverrtent Contactor: Not Applicable ❑ �--40 t CCzj f AI-e)1-. (, Af, ► A8 l q 7z. Company Name / Registration Number Address G'+f S7 U Sv _3 E(� Expiration Date Telephone ce s 3ci SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(B)) 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....... V' No...... ❑ City of Northampton Massachusetts I y .� DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building �uF Ca Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration,renovation,repair, modernization, conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note.If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work:_Ty U fiEst.Cost: U 0 Address of Work: /.04h(,� �'� tju,ehcy6 d 1 d 6 Z— Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied _Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A. SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: /8 Pbi,, L e Cout A&it, l 1/412L Date Contractor Nam HIC Registrari No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts F: :G DEPAR7WRT OF BUILDING INSPECTIONS �? 212 Main Street • Municipal Building4D Northampton, MA 01060 rs6j� 1^0Q Massachusetts Residential Building Code Section 110.R5.1.2 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. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work,then such homeowner shall act as supervisor. 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. City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building lding vG ti .�a Northampton, MA 01060 Debris 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. The debris from construction work being performed at: Z,? l ./lit 124 C.e R (`r, a /W (Please print housb number and Oeet name) Is to be disposed of at: Ohl-4{(� 1t4&4-e,4 I'C. 1 I IU 4(a c r-e h-i,c 11 :j 231A S z-v C L � (Please print name and location of facilV 114;116 /44 51 d -� Or will be disposed of in a dumpster onsite rented or leased from: Z4(/C17s (Company Name and Addres Signature of Permit Apflicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. 4w 1�6-mmoxweald olgAwadvae& Office of Consumer Affairs and Business Regulation One Ashburton,Place-Suite 1301 Boston, Massachusetts 02108 Home Improvemen�Cdhtractor Registration I. 109 YDS Corporation �—� =iJ Registration: 181472 EAST COAST METAL ROOFWG,LLC ; `�= 701 TREASURE ISLAND RD - 0^ 01/19/2020 WEBSTER,MA 01570 � 3'- Upda3s Address and Return Card. SCA1 0 2ou4snr �i{r�fowrwvonitw�o�/��.::��icuutl�iax/4 Office of Con$~MWM&awskws RquUtlon HOME NPROVEMENT CONTRACTOR Repislradon valid for Mdivkfusl us*only TYPE:Conwradcn beton the expbadon dMe. N found rslurn to: 811511111111111M subw Mm of Conmew Affairs and Duan"Repulatlon 161172 01/19/2020 10 Peek Ph=-Sulte 5170 EAST COAST METAL"ROOFM.LLC aoston�MA 02116 PAULLECHWaA . 701 TREASURE ISLAND FID" C WEBSTER.MA 01570 ndwwcmtwy Not valid 610009 tlQiwur• sr ' Li r;4i A CERTIFICATE OF LIABILITY INSURANCE °"T 04/022/2°01/18n THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Kevin Pires Platinum Insurance Agency,Inc. P NEExill 401 272-5900 &AX N 401 272-5901 1990 Pawtucket Avenue EA DRESS-MAIL kpires@platinumins.com Fast Providence,M 02914 INSURER(S)AFFORDING COVERAGE MAIC M Phone (401)272-5900 Fax (401)272-5901 INSURERA; Western World Insurance Company INSURED INSURER B: RGSW,LLC. INSURER C: 41 Edgewood Avenue INSURER D: Beacon Mutual Insurance Company INSURER E: Cranston RI 02905 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INR TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LIMITS LTRPOLICY NUMBER MMIDD/YYYY MM/DDNYYY © COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 1,000,000 ❑ CLAIMS-MADE 0 OCCUR PRA M SES EaEoccur�nce $ 50,000 ❑ MED EXP(Any oneperson) $ 5,000 A ❑ NPP8410827 04/05/2018 04/05/2019 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 ❑ POLICY El PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 ❑ OTHER $ AUTOMOBILE LIABILITY CO eBcci QentSINGLE LIMIT $ ❑ ANY AUTO BODILY INJURY(Per person) $ OWNED ❑❑ AUTOS ULED AUTOS ONLY BODILY INJURY(Per accident) $ ❑ HIRED ❑ PeaccRiYy DAMAGE AUTOS ONLY AUOSONY r d $ ❑ ❑ $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION ©PER ❑OTH- ANDEMPLOYERS'LWBILITY YIN ATUTE ER__ ANY PROPRIETOR/PARTNER/EXECUTIV�l y r E.L.EACH ACCIDENT $ 100,000 D OFFICERIMEMBER EXCLUDED? N i A 0000076113 03/16/2018 03/16/2019 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 100,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Marlborough THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 140 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Marlborough,MA 01752 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103)CIF The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts 19 Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 0211¢2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORI'T'Y. Annlicant Information Please Print Legibiv Name(Business/Organization/Individual):East Coast Metal Roofing, LLC Address:701 Treasure Island Rd City/State/Zip:Webster, MA 01570 Phone#:508-333-0106 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. New construction 2.n I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.[]l am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.12]Roof repairs These sub-contractors have employees and have workers'comp.insurance? 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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. tContractors 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: p� jt 1,&� Z st Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: /3 AAI;n 11 A.(4z hu City/State/Zip: f-/ r- 0Io&Z Attach a copy of the worke s'compebsation policy declaration page(showing the policy number and ex iration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cet�fy under the pains and penalties of perjury that the information provided above is true and correct. Signature: 7 "G6t,. Date: f - 3 U -/P Phone#:508-333-0106 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Depagment's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia AAEASTCOAST fast toast Metal Roofing,LLC. METAL R 0 0 f I N� � 701 Treasure Island Rd,Webster,MA 01570 Tel:844611-3267' eastcoastrn=Iroofina.com REQUIRED PERMITS Registered Home Improvement Contractor MA#184472 Registered Home Improvement Contractor CT#HIC.0644642 Rhode Island Registration #40663 Homeowner Information Name: -Ta�JtJ t NANCY M r. GRAD Address: r 31 /Lu ak /fit City: Fl o r emfe MA Zip: 010(0), Phone: 913 -5'$y- SI-73 1 Required Permits: The following building permits are required and will be secured by the contractor as the homeowner's agent and I/We as Owners of the subject property, hereby authorize East Coast Metal Roofing, LLC.to act on my/our behalf, in all matters relative to work authorized by the building permit application: 11 -8- {S qner's Signature Date Owner's Signature Date Owners who secure their own permits will be excluded from the Guaranty Fund provision of the MGL Chapter 142A This permit notice forms a part of the Purchase and Installation Contract of the same date.