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25C-191 Office of the Building nspector CONSTRUCTION DEBRIS AFFIDAVIT (Required for all Demolition and Renovation Work) In accordance with the provisions of MGL Chapter 40 § 54, a condition of demolition/renovation permit is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL Chapter 111 §150A. The debris will be disposed of in: a Sr( .�✓dn i/K c C " - , g 6574 Ai 040 (,J. L6 V ged r) (If the debris wi of be disposed as indicated, the holder of the permit shalt noti the Location of Facility building official in writing , as to the location where the debris will be disposed.) The debris ill be transported by: q S , TA L v 6 t / 1: - D (5 7&e,i 1 1 Name of Hauler/ al z.IA P C ht-----e-L--) XAP/ i Signature 7.e f permit applicant Date US. METAL ROOFING D I S T R I B U T O R S , I N C. 740 High Street • Suite 2 • Holyoke, MA 01040 1 -800- 232 -0399. 1- 413 - 536 -5474 • Fax 1- 413 -533 -8166 DA D TO BE DONE ON www.usmetalrooring.net SUBMITTED TO PHONE NUMBERS / _ — o n c llt ,`�.. °' ,S' ?C/ STREET 025 i Ind ilveipi.e, JOB LOCATION CITY, STATE AND ZI x DE / DIRECTIONS We will furnish and install new - tanding seam metal snap lock system - _•. -_.e as listed below. Work is guar tee for five yea and the manufacturer warranties the finish on the etal for 35 yea ,., - - COLOR: �.: HousE: _ SPECIAL INSTRUCTIONS / COMMENTS ROOF: 1'6 PORCH: yam+ SOFFIT: ADDITION: f - i,N4 / FASCIA: GARAGE: ! 'CZ l/l1P . te. y 1' tee et LL.' s. , - J PLYWOOD: _� GUTTERS: € /` d Or c 1r84--{ 3c° rn /ne-- 1.04 -C -c ∎ -J�✓ ` � J RIP /REMOVE: _ 3 teJ DOWNSPOUTS: 4 n � ( � it ► t k r '�� 1. ‹e,ervs�e. Mvm►. OTHER: REPAIR: U�r dx3 ,h I 5` Contractor will begin work on or about (date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed by (date). All roofing panels are custom fabricated on -site with state -of- the -art rollforming equipment. *As with any rollform steel panels, a certain amount of waviness or oil canning may become evident at certain times of the day when sunlight hits them. This is standard in the industry and does not affect the integrity of the metal. This shall not be construed as a product defect and shall not be cause for rejection. Contractor does not perform or assume any responsibility for any painting, staining or wood or wall finishing on interior or exterior. The contractor does further agree with the owner that (a) he will begin work within a reasonable time after the execution thereof, and will prosecute it diligently and with due care, and in a good and workmanlike manner; (b) in doing the work, he will comply with all statutes, rules, regulations and ordinances applicable thereto: . Contractor to procure air permits required by law: Contractor shall provide public iiabiiityinsurances. - Owner warrants that he is the owner of the property on which the work is to be performed or that he is otherwise authorized on behalf of the owners to enter into this agreement. We Propose hereby to furnish material and labor - complete in accordance with bove specifications for the sum of: E �4 T o ' /t'AKA, 4`► 171 .-t-iy 'f'"'e.— r dollars ($ (FC 7. "`_"----'-- )• Payment to be made as follows: '(� , �°l, tr 1p j '' i / 0 o Name of ContractodDesignated Registrant 0?D % ($ l , 7S ) upon signing Contract; )5.o V U.S. METAL ROOFING DISTRIBUTORS, INC. �E 1. � / Street Addrese 30 %($ 2�� ) upon start of job; c) J 740 High Street, Su 2, Holyoke, MA 01040 __-----► --- Phone 0 % ($ 5 ) upon 1/2 job completion; 1-800-232-0399 Registration No. / E} # 740 CT# 602546 % ($ � e ® ) shall be made forthwith upon completio Name Salesm work under this contract \ i ' I L Notice: No agreement for home improvement contracting work shall require a down payment Aath t at (advance deposit) of more than one -third of the total contract price or the total amount of all deposits or payments which the contractor must make, in advance, to order and/or otherwise obtain delivery of special order materials and equipment, whichever amount is greater. To be approved by office Nla.,acbu.ctt. - Ucpartntcnt nt Public'afct� ` B(, :r(! of Bur!(li1J2 Re2ulati,r rn(I'tan(tar(. �` .. License: CS 31003 Restricted to 00 GARY C REHBEIN 16 JONATHAN JUDD CIR SOUTHAMPTON, MA 01073 Expiration: 5/19/2010 ( nuni �i ntr+' Tr= 28292 fB oar. o • uildln e ulat4ons an. tan. are s g g One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Registration: 134740 Type: Private Corporation Expiration: 1/11/2010 Tr# 262024 U.S. METAL ROOFING DISTRIBUTION , IN GARY REHBEIN 740 HIGH ST. SUITE 2 HOLYOKE, MA 01040 Update Address and return card. Mark reason for change. El Address LI Renewal El Employment [l Lost Card DPS -CA1 ea 50M- 07/07- PC8490 u ff.14 =) i1 4-1 SXMTOZio• ut. i= AAbt =y = = D ■Q )EpHu WO 10= 1 114 1 SGTIVCQ 4a *XQ 4 DVXDp6 4, AH)Q 4 a44X•61)DVVW, 3 9ADQ@AW1i414 ) u01§Ab HW) Q XZ, 4 HXOIQd u ACORD CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DD/YYYY) 12/1/2008 PRODUCER (781) 273 -3200 FAX:' (78-1-) 2.73 -0600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Bonacorso Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 83 Cambridge Street ,_.:___ ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 1502 Burlington MA 01803 t G' L r INSURERS AFFORDING COVERAGE NAIC # INSURED t INSURER Al Aspen Specialty Ins. US Metal Roofing Distributors, Inc. INSURERB:Associated International 740 High Street INSURERC: State Ins. INSURER D: • Holyoke MA 01040 INSURER E: COVERAGES 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. AGGRE1 TE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD POUCY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM/DDIYY) DATE (MMIDDM') UMITS GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 _ X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 50 , 000 PREMISES (Ea occurrence) $ A X CLAIMS MADE X J OCCUR TBD 11/7/2008 11/7/2009 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE 1_ AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 X I POLICY pi JER& I ( I LOC AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABIUTY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LABILITY EACH OCCURRENCE $ 3,000,000 X OCCUR 1 CLAIMS MADE AGGREGATE $ 3,000,000 $ B X DEDUCTIBLE 955739089 11/7/2008 11/7/2009 $ RETENTION $ $ C WORKERS COMPENSATION AND X TORY LAMITS NY - EMPLOYERS' LIABIUTY ANY PROPRIETOR/PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ 500,000 OFFICER/MEMBEREXCLUDED? WC3798224 12/2/2008 12/2/2009 E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POUCY UMIT $ 500, 000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE Specimen EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR UABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Michael Bonacorso ACORD 25 (2001/08) © ACORD CORPORATION 1988 INICfl' R in +no, no,. Pane I of The Commonwealth of Massachusetts ,; Department of Industrial Accidents 1 Office of Investigations i [[ 600 Washington Street i r Boston, MA 02111 • SJ ' Workers' Compensation Insurance Affidavit Name Location City Phone ❑ I am a homeowner doing the work myself. ❑ I am a sole proprietor and have no one working in any capacity. I am a employer providing workers compensation for my employees working on this job. ❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices. Company Name: [ , (, 5, /T1 7g 'To 6 / kit r D / J7(< 9 / 3a 7.0S /de . Address: . /i — 5a de City : :JIG, <) kF 'AA . O/" /Q s Insurance Co: G kii7� '51.67E ,�41. theanln : Policy # t e ; Company Name: Address: . City: Insurance Co: Policy # . Fadure to secure coverage as required under Section 25A of 1vIGL can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 3 I do hereby , und: • 'lar rs and penal!' ofperjury hat the information provided above is true and corn: t. Signat If - . - / I .__..Y._ Date i u ' Print Name ,, Phone — S ? Official use only Do not write in this area. To be completed by city or town official City or Town: Permit/ License # - ❑ Building Department ❑ Licensing Board ❑ Check if immediate response is required. ❑ Selectboard Office • ❑ Health Department C ontact person: Phone SECTION 8 • CONSTRUCTION SERVICES I 8.1 Ltceased Construction l ip pervisor: 1 Q r Not Applicable ❑ ' Name of License polder : ( t . t-t J"JC�/ IL,+ Oi) License Number • Idcrls J J /17 4 0 l I 6.� , r c 1 1 9 K - 01(741.4 �� :� 5 , , �/ / I / 4 Expiration ate ALA ✓. /`.e / i 5 4 - _ Signatu 1 Telephone • 211:414 ; r3 : i s - r- :til Cto3 ' .: " Not Applicable ❑ S . . F74L vri 1 ; D /i7R'gzC7x.i r 7AJ C_ '3 7 j C. 0,4 . , n . r R is'tratfon Number LA) . 1i<. ) 57447S d , 11 dL <//�� . O1O`7 llrrl /v •ress I 1 Expiration mate 1 9 t SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insuran affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of th wilding permit. Signed Affidavit Attached Yes No ❑ 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 c,�talljiot 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 un • er 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. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature A dsE :1 o t70 t7 i das SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [l Addition ❑ Replacement Windows Alterations) n Roofing , or Doors D Accessory Bldg. El Demolition ❑ New Signs [D] Decks [Q Siding [D] Other [D] Brief Description of Pr s y o 7.T¢ f r� j Work: J7 ti zeA )J71 .1C ' �l j J .I K d i SQ 27 . y�1CS7 dY , P t' , W/411 J ' S(4'77 ( J ,J -'� S74fC- La 11117 tin e 2s 0v<�is�lou7J � U Alter of exis bedroom u Yes No Adding new bedroom Yes 4 No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet ea trN 0. hotite?'l adaitib bagel ;h`d r e latifi ;i: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit:_ Number of Bathrooms 7 \t 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 la - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , as Owner of the subject property S. j hereby authorize • �J . 4 `....- 1 / ' ( I '1 d • 1 1^' v to act on my behalf, in all matters relative to work , ut oriie• by • ilding permit application. 1(, Signature of Owner Date 1 1 / _ 4 1 C .. , as Owned' uthorized • ge hereby declare that th • statements and infor ation on e foregoing a. plication are true nd accu :te, to the best of •• , • • edge an. belief. Signed u ;` r the pains and pea o •erjury. a me t g�.--i ! ' - ____ n - Q . * -- P.r,- , , of owner? Date E •d dec.' Trl Ln LT ,1,-. f , City of Northampton t _ 0' JUL 1 3 n Building Department "'` t , • , /l . 2v 242 Main Street i ,, t i ,, * _,� At- - . .a Ijoom 100 .i, t ,, 4 � , lf ,. , t L ., ° • Ntorthampton, MA 01060 f s , » . ' phone 413 - 587 - 1240 Fax 413-587-1272 . ��: _ } ,, "? -L APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION Map Property Address: / �r Tat sectioW o be cgfnPJeted by office 4 / ��„ N 116.., . .. Lot Unit :S7se Qtferlayisirict N 0R - T AAin lux A/ EImr5t;District .. _ CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 7..1 Owner of Record: 1 Current pl ddrIs � 7 `ame (Print) '/ 3 O� Telepho e Signature' a) .. . ,, ,/,, f_. , . c1 ..04. 0 ild,Oloi 'riot C rrent Mailing • •4" ss: i e �,��o� -�� , - ,3 — . -3Z, -s7 Signature Tel SECTI • 3 - ESTIMATED CONS RUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building /PP 7j (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (61_ 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) . 5. Fire Protection 6. Total = (1 + 2 + 3.+ 4 + 5) ) f j 7 5 Check Number This Section For Official Use Only Building Permit Number. Issu Signature. Building Commissionerllnspector of Buildings Date . t•d dbe:in bn bi daS r 2...;:.. BP- 2010 -0041 GIS #: COMMONWEALTH OF MASSACHUSETTS k: 25C - 191 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofing BUILDING PERMIT Permit # BP- 2010 -0041 Project # JS- 2010- 000055 Est. Cost: $8875.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: U.S. METAL ROOFING DISTRIBUTORS Lot Size(sq. ft.): 5706.36 Owner: ALBARELLI DEAN & SARA LONDON Zoning: URC(100)/ Applicant: GARY C REHBEIN AT: 29 HIGHLAND AVE Applicant Address: Phone: Insurance: 16 Jonathan Judd Circle SOUTHAMPTONMA01040 ISSUED ON: 7/14/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP ROOF AND INSTALL STEEL ROOFING 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 7/14/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo