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31A-150 (3) DocuSign Envelope ID:172725D1-9D02-4FF4-8310-6FBB7876086B Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit �A 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural"Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER')t0AIRi RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION AP 7 7 This section to be completed by office 1.1 Property Address: f U A1 Lot Map Unit „ "•- 25 Maynard Rd - - Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: 25 Maynard Rd, Northampton, MA 01060 Emily Kieval Name(Print) Current Mailing Address: ZiT by: Telephone (617) 721-4786 Signature —�— �..1„11,o= 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 17,400.00 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from "6 3. Plumbing Building Permit Fee t4O 4. Mechanical(HVAC) 5.Fire Protection 6. Total=0 +2+3+4+5) 17,400.00 Check Number This Section For Official Use Only Q�- I Date Building Permit Number: V(J' //, Issued: Signature: Building Commissioner/Inspector of Buildings Date peakperformanceroofingllc Cd gmail.com EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) N'41 7 .. :. _ .. .. 1 jr. y ,} , r rig�sr+ P ;4w ��{• � tip Sit DocuSign Envelope ID:172725D1-9D02-4FF4-8310-6FBB7876086B SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [O] Other[p] Brief Description of Proposed strip & replace asphalt roof "fork: Alteration of existing bedroom Yes -No Adding new bedroom_ _Yes No Attached Narrative Renovating unfinished basement Yes _No Plans Attached Rall -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 I Emily Kieval as owner of the subject property James J. Flannery / Peak Performance Roofing, LLC hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. DocuSigned by: 4/15/2020 Signature of Owner Date rY� James J. Flannery 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. James J. Flannery Print Name Signature of Owner/Agent Date DocuSign Envelope ID: 172725D1-9D02-4FF4-8310-6FBB7876086B SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable O CS-103061 Name of License Holder License Number James J. Flannery 09/21/2020 Address Expiratior Date W,%t1A(L^ St Holyoke MA 01040 Signature Telephone r " 413-203-5888 9 Registered Home Improvement Contractor: Not Applicable 0 Company Name Registration Number 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...... O _____— DocuSign Envelope ID:172725D1-9D02-4FF4-8310-6FBB7876086B City of Northampton Massachusetts WK 'A # DEPARTMENT OF BUILDING INSPECTIONS e 212 Main Street •Municipal Building 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. 25 Maynard Rd (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) I�—�" /I q 15- Signature SSignature of Permit Applicant 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. 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/Organi�ationrindividual): Peak Performance Roofing, LLC Address: 1 Lovefield St. City/State/Zip: Easthampton, MA 01027 Phone#: 413-203-5888 Are u an employer?Check the appropriate box: Type of project(required): 1. Are 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, ❑ 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 11.E] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.gRoof 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#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. Berkshire Hathaway Guard Insurance Company Name: Policy#or Self-ins.Lic.#: R2WCO21353 Expiration Date: 4/27/2020 Job Site Address: J5 Mdl na- Rd, City/State/Zip: 1A10#r& ��7I1(Od 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: ks 12,6 W 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:172725D1-9D02-4FF4-8310-6FBB7876086B Peak Performance Roofing LLC 1 Lovefield St. Easthampton,MA 01027 PE K 413-203-5888 PIL CE peakperformanceroofingllc@gmail.com MA HIC#183698 MA CS0103061 Contract ADDRESS CONTRACT# 906 Emily Kieval DATE 04/15/2020 25 Maynard Rd. Northampton,MA 01060 617-7214786 emily.kieval@gmail.com DESCRIPTION AMOUNT *We will provide up to 64 square feet of CDX plywood if necessary at no cost. Any 17,400.00 additional plywood will be$65 per sheet installed.* 1. Remove the existing roof shingles. Inspect the sheathing. 2.Install six feet of ice and water shield at eaves and three feet in all valleys, around pipes, chimneys,skylights, and low slope roofs 3. Cover remaining roof with Certainteed "Roof Runner" synthetic underlayment 4. Install new 8" aluminum drip edge on all eaves and rake edges 5. Install architectural shingles by Certainteed (Landmark 30yr) http://www.certainteed.com/residential-roofing/products/landmark/ Color Choice: 6. Install new Certainteed ridge vent on peaks of roof 7. Complete all necessary flashings including new lifetime heavy duty pipe boots and new base flashing around chimney 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. Landmark shingles: $15,900+Porch roof in back: $1,500 =$17,400 Total A deposit of$8700 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, compounded monthly. .. ..................... ......... TOTAL $179400.00 Accepted By DocuSigned by, Accepted Date 4/15/2020 C� 523B9DD386E9404... t „' a- �� ... .. � .. - ., .. ,. A " i''� d ;e 1 �ryR �,A'a{yfy°!st��' •t++''#b� ��y4r u f.� , .�`�,"fir r b.