23D-093 (5) DocuSign Envelope ID:EC34124F-62CA-4816-AC29-073670C9FD76 k-cnF
Department use only
City of Northampton --cr: Status of Permit:
.� Building Department / Curb Cut/Driveway Permit
212 Main Street4p Sewer/Septic Availability
( Room 100 WaterlWell Availability
V Northampton, MA 04060 ..01917 Two Sets of Structural Plans
phone 413-587-1240 Fax 44--587-1272 Plouste Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE 013 DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map_ — Lot Unit— —
26 Nutting Ave
Zone Overlay District
E::n S . CS District----
SECTION
istrict ,_SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Norman Spencer 26 Nutting Ave, Northampton MA 01060
Name(Print) Current Mailing Address:
DocuSigned by:
4)" Telephone 413-587-0801
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 $3,950.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Ccn-�tructicn fon 16'1
3, Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+ 3+4 + 5) $3,950.00 1 Check Number l
�� Date
This Section For Official Use Only
Building Permit Number:---6 �w /7 a Issued,
Signature:
Building Commissionerilnspector of Buildings Date
peakperformanceroofingllc na gmail.com
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
DocuSign Envelope ID:EC34124F-62CA-4816-AC29-073670C9FD76
DocuSign Envelope ID:EC34124F-62CA-4816-AC29-073670C9FD76
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition r7Replacement Windows Alteration(s) ❑ Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks (0 Siding[O] Other[01
Brief Description of Proposed Strip & re-shingle asphalt roof on detached garage
Work:
Alteration of existing bedroom Yes No Adding new bedroom-_Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -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 Bathroorrrs
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 .
1. 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
Norman Spencer
I 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.
Docusigoed by: 4/13/2020
Signature of Owner Date v
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
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 ypu an employer?Check the appropriate box: Type of project(required):
1.E2 I 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. ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P h'• 9. ❑ Building.addition
[No workers' comp. insurance comp. insurance.
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.VRoof 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.
Berkshire Hathaway Guard
Insurance Company Name:
Policy#or Self-ins.Lic.#: R,21WCO21353 Expiration Date: 4/27/2020
Job Site Address: aIvU�U MA AVAL, City/State/Zip: Or n
Y ��b
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.
Si ature: Date: Y S p2
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#:
Worker's Compensation and Employers Liability grimy
Berkshire Hathawa AmGUARD Insurance Company-A StOcktC.o.
y Insurance Policy Number R2WCO21353
GUARD Companies Nal� :;3;
Policy L dionnation Page(AR)
[1]Named Insured and Mailing Address Agency
PEAK PERFORMANCE ROOFING LLC WEBBER&GRINNELL INSURANCE AGENCY,INC.
LDVEFM D STREET 8 NORTH IQNG STREET
FAStw►MFTON,MA 01027 Northampton,MA 01060
Agency Code: MAMAIN15
Federal Employer's ID 00-1191951 Insured In Limited Liability Co. (LLC)
[2] Policy Period
From April 27, 2019 to April 27, 2020, 12:01 AM,standard time at the insured's mailing address.
[3] Coverage
A. Workers'Compensation Insurance-Part One of this policy applies to the Workers'Compensation
Law of the following states: Massachusetts
B. Employer's Liability Insurance- Part Two of this policy applies to work in each of the states listed
In item [3]A. The limits of our liability under Part-Two are:
Bodily Injury by Accident-each accident $100,000
Bodily Injury by Disease-each employee $100,000
Bodily Injury by Disease-policy limit $500,000
f1
C. Refer to Residual Market Limited Other States Insurance Endorsement-WC200306B
D. This policy includes these endorsements and schedules:
See Extension of Information Page-Schedule of Forms a
[4] Premium
The Premium Basis and,therefore,the premium will be determined by our Manual of Rules,
Clmsifications, Rates,and Rating Pians. All required:information is subject to verification and change by
audlL (Continued on another page)
Total Eodnm sad Polley Premium 31,202
Total Surduw9vs/Assessments $ $1,181.00
Total Estimated Cost S $32,39KLOO
IlOfR�w.use nor
MGA :R2WCD21353 Pegs- 1- Information Pepe
D4ft :04/01M19 WC 000001A
MANarE
zsaAq Office: P.O.sox A-i1,16 S.River Sbad,Wiraermne,PA 10703-0020•www.gu.rdA*1n
DocuSign Envelope ID:EC34124F-62CA-4816-AC29-073670C9FD76
Peak Performance Roofing LLC
1 Lovefield St. PEKRF
K
Easthampton,MA 01027
413-203-5888 P R CE
peakperformanceroofingllc@gmail.com • •
MA HIC#183698 MA CSL#103061
Contract
ADDRESS CONTRACT# 10067
Norman Spencer DATE 04/08/2020
26 Nutting Ave
Northampton, MA 01060
normspen@juno.com
413-587-0801
JOB LOCATION
26 Nutting Ave,Northampton
DESCRIPTION AMOUNT
-This contract is for the detached garage and excludes one of the newly shingles slopes. 3,950.00
Includes basement entry roof-
(L) Remove the existing roofing shingles
(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.) Cover entire roof with synthetic underlayment
(4.) Install new 8" aluminum drip edge on all eaves and rake edges
(5.)Install architectural shingles by Certainteed (Landmark)
http://www.certainteed.com/residenti al-roofing/products/landmark/
Color Choice: Moire Black
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=$3,950
A deposit of$1,975 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,
compounded monthly.
TOTAL $39950.00
Accepted By Dausaned by: Accepted Date 4/13/2020
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DocuSign Envelope ID:EC34124F-62CA-4816-AC29-07367OC9FD76
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
CS-103061
Name of License Holder -
License Number
James J. Flannery 09/21/2020
Address Expiratior Date
l lui��iar115 S+, Holyoke MA 01040
Signature Telephone
413-203-5888
9 Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Peak Performance Roofing, LLC 183698
Address Expiration Dato
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...... ❑
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DocuSign Envelope ID:EC34124F-62CA-4816-AC29-073670C9FD76
City of Northampton
F �s Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building
Northampton, MA 01060 rljy SON,
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:
26 Nutting Ave, Northampton
(Please print hc•use 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 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.