42-145 (4) DocuSign Envelope ID:4573B093-F39D-4CBA-837D-5294B992CDDB �
Department use only
City of Northampton Status of Per
,. Building Department - ,7Curb Cut/Driveway Permit
212 Main Street '�9 Sewer/Septic Availability
: Room 100 �,�, c��,�� WattarlWell Availability
4 Northampton, MA 01060 Two Sets of Structural Plans _
phone 413-587-1240 Fax 413-587-127,,, Plot/Site Plans
?so% Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVAT9 OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address.
923 Westhampton Rd Florence Map — Lot f _ Unit
—
923 .
Zone Overlay District
Eim 5t.Disirict CD District----
SECTION
istrict __SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Timothy Sossa 923 Westhampton Rd, Florence MA 01062
Name(Print) Current Mailing Address: 914-774-6331
DocuS�i/gned by:
I itti,htli CAStq Telephone
Signature - -
2.2 Authorized Agent:
James J. Flannery 1 Lovefield St., Easthampton MA 01027
Name(Print) Current Mailing Address:
413-203-5888
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $11,950.00 (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
i rnnstr,icti�n from (6)
3. Plumbing Building Permit Fee �[
4. Mechanical HVAC
5. Fire Protection
6. Total=0 +2+3+4 + 5) $11,950.00 Check Number
This Section For Official Use Only
Building Permit Number: k—� Date
t ed;
Signature:
Building Commissioner/Inspector of Buildings Date
peakperformanceroofingllc CCD gmail.com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
',y _ _ �� �+ ��a{}/. �r ''."`l� �j5,"y�,.�L���9" Y4�'* �AcdY+R�N iv�S ����� �+'.
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DocuSign Envelope ID:4573B093-F39D-4CBA-837D-5294B992CDDB
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors I]
Accessory Bldg. ❑ Demolition ❑ New Signs [tom] Decks [C7 Siding [E3] Other[Ell
I
Brief Description of Proposed Strip & re-shingle asphalt roof
Work;
Alteration of existing bedroom Yes No Adding new bedroom _Yes No
Attached Narrative Renovating unfinished basement Yes _No
Plans Attached Roll -Sheet
sa. 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
1. Timothy Sossa as Owner of the subject
property
hereby authorize
James J. Flannery / Peak Performance Roofing, LLC
to act on my behalf, in all matters relative to work authorized by this building permit application.
Doc Signed by: 4/I6/2020
Signature of Owner RK01 OWL Date
James J. Flannery
1, , 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.
James J. Flannery
Print Name
Signature of Owner/Agent Date
DocuSign Envelope ID:4573B093-F39D-4CBA-837D-5294B992CDDB
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
CS-103061
License Number
James J. Flannery 09/21/2020
Address Holyoke, MA 01040 Expiratior Date
Signature Telephone
413-203-5888
9.Registered Home Improvement Contractor: Not Applicable ❑
------ _ — ---u ..
Compan�Name Registration Nmb—er
Peak Performance Roofing, LLC 183698
-- — ..._..___ __ --- ---
Address Expiration Date
1 Lovefield St., Easthampton MA 01027 _Telephone 413-203-5888 11/03/2021
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....... 9/ No...... ❑
Aa « -
y�. t� ''
j�
DocuSign Envelope ID:4573B093-F39D-4CBA-837D-5294B992CDDB
_ City of Northampton
sus .r�C
- Massachusetts �y�
y c
ce
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building
+4 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:
923 Westhampton Rd, Florence
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
Aaron's Roll-Off, 1 Loomis Way, Easthampton MA 01027
(Company Name and Address)
Signature of Permit Applicant or Owner bate
If, for any reason, the debris vvill 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Peak Performance Roofing, LLC
Address: 1 Lovefield St.
City/State/Zip: Easthampton, MA 01027 Phone #: 413-203-5888
Are you an employer? Check the appropriate box:
Type of project(required):
1.VI am a employer with 4 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. E] 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. 0 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 10.E] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.VRoof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 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.
lContractors 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.
Berkshire Hathaway Guard
Insurance Company Name:
Policy#or Self-ins. Lic.#: R2W/C-0213533 Expiration Date: 4/27/2020
Job Site Address: 1 d'3 ��S�l7Q.i'I1�ToIU City/State/Zip: 961ribla Mg b It&2
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 under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: 111dtozo
Phone#: 413-203-5888
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#:
DocuSign Envelope ID:4573B093-F39D-4CBA-837D-5294B992CDDB
Peak Performance Roofing LLC
1 Lovefield St. PE K
Easthampton,MA 01027
413-203-5888 P E R F O R CE
peakperformanceroofmgllc@gmail.com • •
MA HIC#183698 MA CSL#103061
Contract
ADDRESS CONTRACT# 10073
Timothy Sossa DATE 04/15/2020
923 Westhampton Rd.
Florence,MA 01062
sossatimothy@gmail.com
914-774-6331
DESCRTPTTON AMOUNT
1. Remove the existing roofing shingles 11,950.00
2. Inspect the plywood for any rot or deterioration.We will provide up to 64 square feet of
plywood at no cost.Any additional plywood will be$75 per sheet installed
3. Install six feet of ice and water shield on eaves and three feet in valleys/around pipes and
chimney
4. Cover remaining roof with synthetic underlayment
5.Install new 8" aluminum drip edge on all eaves and rake edges
6.Install architectural shingles by Certainteed(Landmark)
http://www.certainteed.com/residential-roofing/products/landmark/
Color Choice:
7. Install ridge vent on peaks of roof
8. Complete all necessary flashings including new pipe boots
Remove all debris from premises, and throughout the job, continue cleanup and keep the
premises undamaged. WE ARE NOT RESPONSIBLE FOR DEBRIS THAT MAY FALL
INTO ATTIC. Please use caution during the process; do not walk/drive under active work or
on areas of potential roofing debris. Contractor will obtain building permit. Installations are
weather permitting. Long periods of inclement weather will cause scheduling delays.
Total: Landmark shingles=$11,950
A deposit of$5,975 is due at contract signing. The balance shall be due upon completion.
Accounts outstanding over 10 days past final invoice date subject to 2%finance charge.
TOTAL $119950.00
Accepted By Doc"S`9ned by: Accepted Date 4/16/2020
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