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32C-112 ✓e-62amweonevealtA ol�/ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 139640 Expiration:: 7/28/2009 Type: Supplement Card INTERLOCK INDUSTRIES INC KEITH O'DONOGHUE #7-25 WALPOLE PARK SOUTH WALPOLE,MA 02081 Administrator ry R s' ,i -- ' � ••._ �.... • CERTBICLTE NUMER C' ti � i Y C.d L " 032 '17,- .-Z.-- :y'.....,`�..__. . .� PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON • MARSH CANADA LIMITED THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED BY THIS POLICY.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES DESCRIBED HEREIN. 70 UNIVERSITY AVENUE,SUITE 800 TORONTO ON M5J 2M4 - COMPANIES AFFORDING COVERAGE •- MUM COMPANY LIBERTY MUTUAL INSURANCE COMPANY • A INTERLOCK INDUSTRIES, INC., COMPANY A MASSACHUSETTS CORPORATION UNIT#7,25 WALPOLE PARK SOUTH COMPANY WALPOLE,MA 02081 C. COMPANY 0 • .. ._u..��...�,.,r.. ._ Y z:L.3-r_%,: TMS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED HEREIN HAVE SEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE PERIOD OF INSURANCE INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TD WHICH THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES LISTED HEREIN IS SUBJECT TO ALL THE TERMS.CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.LIMBS SHOWN MAY HAVE BEEN REDUCED BY PALO CLAIMS. tER DATE TYPE INSURANCE POLICY HOMER fBWfDD1Y11} MAVDDVYY) warn SENNHNLL LIABI.ITY GENERAL AGGREGATE $ ■ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMPIOP AGE $ CLANS tome n OCCUR PERSONAL&ADV INJURY $ ■ OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ i RILE DAMAGE UAm,oR.SEW IVIED EXP CAN,one person/ $ AUTOMOBILE LIABILITY COMBINED SINGLE LINT 5 • ■ ANY AUTO ■ AU.OWNED AUTOS BODILY INJURY 5 III SCHEDULED AUTOS IPA aweel HIRED AUTOS BODR.Y INJURY — 5 war sodden*} • ■ NoNOWNED AUTOS ■ PROPERTY DAMAGE GARAGE WMLITY AUTO ONLY-EA ACCIDENT 5 ■ ANY AUTO OTHER THAN AUTO ONLY: y "- a EACH ACCIDENT 5 AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ ■ UMBIEU.A FORM AGGREGATE • $ OTHER THAN UMBRELLA FORM A WORKERS-COMPENSATION AND WC STATU- xi OTHER OIM'OYEIIS LUMEN TORY LIMITS EL EACH ACCIDENT $ 1,000.000 ��7 • WC1-B71.072231-057 2/1/2007 2/1/2008 5 1.10,E THE PRDPIUET'OW t X{ RICL EL DISEASE-POLICY LIMIT FARNON EXECUTIVE OFFICERS ARE EXCL EL DISEASE EACH EMPLOYEE $ 1,000,000.' OTHER DESC(INIDM OF OPERATIONSASCATIONSMENCLESSPECIAL HEMS PROOF OF COVERAGE. � 9 SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE 7LE EXPIRAT1ON SATE TO WHOM IT MAY CONCERN: THEREOF.THE INSURERS)AFFORDING COVERAGE WILL ENDEAVOUR TO MAR 39 DAYS NNUfTHN NOTICE TO THE CERTIFICATE HOLDER NAMED NEREF4 BUT FAILURE TO MAIL SUCH NOTICE SNAIL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND NON THE INSURERS}AFFORDING COVERAGE.THEIR AGENTS OR REPHESENTATNES.OR TTNE ISSUER OF THIS[HRIRCA7E./'ry MARSH CANADA LIMRED pia) V „ Ofi 211/2007 .. _—d,c_.-.. �rr.:wu,rda..e�:.:.rc•�e�K. m.,.,...wr .... r+,.ws.?n'�'.-�<$55-..M-'�..,..,...��cl-v'.«.5 ..a,. 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(the"Contractor) and authorizes the Contractor to furnish all necessary materials and labor to install, construct and place the improvements according to the following specifications,terms and conditions(the"Specifications")at the Premises. SPECIFICATIONS YESJ1O ROOFING MATERI• YES NO OWNER WILL ✓✓,, (Circle Ole): SHINGL: SLATE N( Supply adequate electrical power. -• Shingle -Color: ',"'" -�"--"• - ` IB Low Slope Roofing-Color: Be responsible for all rot damage and other necessary _ • Flash Skylights - Num er roof repairs. (le) Roof decking,fascia boards, etc. �.�`— Flash Vents Roof repair work will be undertaken by Interlock Lr Underlayment Industries, Inc. at a cost to be mutually agreed upon in Snow Guards 5? pcs. ?dvanccee betw n.by parti s. ROOF REMOVAL LO TION F SHIPM P /.7s-2f-fy-,,, — �. Strip existing roof I layers. aa • - W __ Haul away roof debris and pay refuse fees. -S r,D`z __ Note location for bin START T�;�L'•' -,y, ✓ Supply'/2 pl � ,`__�..n t f1i t mac. r_�4 _ G�t../ '"t •'t 1FCT'T)t if I . rob S S �,�'� _ pi J Pfr 4=2-4 V14-A4-44901 :W ►ShVii 1 S n 1� - - , S -a. do 14.' • • _..,,d 0 L� 4 /1U?t — sda t_ .� A is ' . __,..ji -' c — a.�, = �:ll6cu- G�/•.+1�v MCP /'a- '�6 THIS CONTRACT INCLUDES: � Al TRANSF' RABLE, NO P-ORA'FED FOR MATERIALS w "PROVID�R OCK ROOFING LTD. GUARDIAN LIFETIME LIMITED ARRANTY, :0 Y �� PLUS 10-YEAR LIMITED LABOR WARRANTY PROVIDED BY INTERLOCK INDUSTRIES, INC. LIFETIME LIMITED MATERIAL WARRANTY FOR IB ROOFING,PROVIDED BY IB ROOFING SYSTEMS Sales Price $ 'ZLF! 5q s---- __ Financing Requested_ Yes No -Sales Tax $ /1/44'--' Interest Rate: 11.9%to 14.9% Sub-Total $ 2.1f 9Lf 5------- Payment not to exceed $ Down Payment $ /5 t S• ^ O.A.C. on approval of credit) Total Balance on Completion $ / 2.3i dry MAKE ALL CHECKS PAYABLE TO: INTERLOCK INDUSTRIES, INC. - . .. . .. t4-- . x-7-1 t .,n ., ; \ scit1AMp7 v � i',.; _ ��� � (rfi t f cirf1 &ntpfutt it I a 5 d uSttt9 I_=Lt ��1+1► '111. DEPARTMENT OF BUILDING INSPECTIONS -- INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 ow e" HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sup,_: ..:sor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings(before backfill)t sonotube holes (before pour), a rough building inspection (before work is concealed). insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work(electrical, plumbing&gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location • The Commonwealth of Massachusetts Department of Industrial Accidents II _; Office of Investigations �� d 600 Washington Street • _;„. Boston,MA 02111 `'” sr " ° www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name(Business/Organization/Individual): jr.. /7.-/c--1/0 C. ti C < Address: `a (,)i !7,2/c & 4 S D /Jc, -f- 7 City/State/Zip: pct (t ii� c /( Phone#: (le 3/ 7-6)/ Are yo an employer? Check the appropriate box: Type of project(required): 1.�'J I am a employer with / 4. I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. U Demolition working for me in any capacity. employees and have workers' 9. U Building addition [No workers' comp.insurance comp. insurance.t required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Pl bing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] - - -`1kny applicant that checks box#1 must also till 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. / Insurance Company Name: /9/d 6 u Ca �u e/ L— G(�c ;-1(c_, _ Policy#or Self-ins. Lic. #: et,c/C I —l- ?/—O.7 a J 3/- U S 7 Expiration Date: (29- 4 A) Job Site Address: City/State/Zip: 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. e I do hereby certify unde the pains and penalties perju that the information provided above i true nd correct. Signature: ,__;Ze.,'—,G7t '�� Q Date: C Phone#: C ' ,./ T -o Y 7 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#: • � 1 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date I I I Signature Telephone �� �..� .._ . �.,.� _� --� ,-.- r -, Not Applicable ❑ 9:R&iT tered-iome_lmbtaiemenl Con"traofor - = Company Name Registration Number ,72-5' C �� � � s� . u,t 4 7 / 3 q/ 6 v o Address &sic,(774) (L( oG} 0 0S- ( '/ -‘)-57 Expiration Date Telephone ,gl! - 3/7 SECTION 10 WORKERS'COMPENSATION INSURANCEAFFIDAVIT(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 g/ No ❑ 1171:;"4Altilite:Oith—eit-ZElafttinit 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.Aperson who constructs more than one home in a two-year period shall not 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 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. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature • SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ri Replacement Windows Alteration(s) n Roofing Er— Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [E] Siding[D] Other[DJ i = — Brief Description of Proposed > Work: /7 pGit /��7 �, oom Yes No Adding new bedroom Altera*.io^,of existing t?e�� -- - Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet saAffre''vr 61-1- 4aZ addition.#o=exisii hoaSillti complete fihe oClovr nq: 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 Wood stoves 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. fluudplain 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-.OWNERAUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i, ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 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. / 1 '7C'\ 0 L c.t of Print Name Signature of Owner/tAIIPF Date 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 Bldg. Square Footage Open Space Footage % (Lot area minus bldg&paved parking) - #of Parking Spaces Fill: (volume&Location) —_- A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW Q YES 0 — IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page and/or Document#'� B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW G) YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Date Issued: C. Do any signs exist on the property? YES 0 NO 0 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 O 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. Department:t use only City of Northampton Status otpermt Building Department Curb CutlDnveway Permit R 212 Main Street ewer/ epti 7-:27-abrlity 1'- Room 100 Wafer/Wet!AvadabtLty Northampton, MA 01060 TwaSetsofStrucktrrar`Rlans k" -,-:.phone 413-587-1240 Fax 413-587-1272 Plof/SitePtans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -'SITE INFORMATION — — I This section to be-completed by office 1.1 Property Address: b- c /'e-�. Map Lot Unit t Cane- Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: cg78 S �i-�c. frr-c �.^�, II �%GLjZ �%?t' f Gtbv+``',, (J i s vu .4 C f o�o 0 Name(Print) Current Mailing Addrbss: yf3- 5 ''-1 - 5& 3S Telephone Signature 2.2 Authprized Agent: ,./-5- L✓�'c f��le Pc� L 5 ti U�t ; 7 Name(Print) / Current Mailing Address: _ (` _ rS'� Signatur Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit on'fro Fee m(6) 2. Electrical (b),EstimaConstructedtiTotal Cost_of _ 3. Plumbing Building Permit fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) a yl S y Check Number ���2 s S " This Section For Official°Use"Only Building Permit Number. Issued: 1 i i...,‘, -_-1 1 Signature: , AUG 3 2007 -' i Building Commissioner/inspector of Buildings + Date 1 s i n i$ n i� o ._....�J i BP-2008-0124 GIS#: COMMONWEALTH OF MASSACHUSETTS Mir: � a s - ` CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2008-0124 Project# JS-2008-000192 Est. Cost: $24945.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: INTERLOCK INDUSTRIES, INC 129369 Lot Size(sq. ft.): 6751.80 Owner: WEBER WILLIAM R Zoning: SI Applicant: INTERLOCK INDUSTRIES, INC AT: 68 CONZ ST Applicant Address: Phone: Insurance: UNIT 7 25 WALPOLE PARK SOUTH (888) 921-9994 Workers Compensation WALPOLEMA02081 ISSUED ON:8/6/2007 0:00:00 TO PERFORM THE FOLLOWING WORK:ROOF OVER 1 LAYER 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 8/6/2007 0:00:00 $25.002102 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo