12C-029 A&J
Home Improvement Inc
MA Reg# 135399 60 Washington Ave
Conn Reg# 600705 South Hadley, MA 01075
Phone: (413)467-1500
Customer Address
Jay O'Sullivan
296 North Maple Street
Northampton, MA
Description of Duties: Roof Replacement
1. Remove existing layers of shingles from entire home
2. Protect home and landscaping with tarps and plywood
3. Any Bad decking will be replaced at $50 per sheet of plywood (if needed)
4. Install 3' of Ice and water barrier at all eves as well as in all valleys and
around penetrations
5. Install synthetic over rest of roofing deck
6. Install new 8" drip edge (white) on all eves and rakes
7. Install new GAF starter shingles at eves
8. Install new GAF Timberline HD (lifetime) asphalt shingles to roof(color of
choice)
9. Install new roll style Ridge vent
10. Install new GAF Cap shingles
11. Clean up all debris (removal fee included)
12. Pull permit for all work
Agreement bonded to furnish materials and labor according to the description above.
Roof Replacement $ 7,400.00
This quote guaranteed for 60 days.
Signature Andrew Deren Date_11-22-2013
Accepted: I hereby authorize A&J Home Improvement to perform work to the above
specifications. Payment is agreed for 1/3 down deposit and balance to be due upon
completion. Please sign and re one copy and return to the above address.
Thank You.
Date 4-1-7-Pl Signature Phone
W_ The Commonwealth of Massachusetts
Department of Industrial Accidents
!4
Office of Investigations
r 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/Ind ividual): 1 )m
Address: t�U � tt:Yrnrc.vi�r
City/State/Zip: Phone 4: Ll 1:3 LI4 7
Are you an employer?Check the aoOopriate box: Type of project(required):
1. I am a employer with 4. D I am a general contractor and I
employees(full and/or part-time).* have fiired the sub-contractors ' 6 D 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. DemoIition
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.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑ Plumbing repairs or additions
myself. o workers' con tight of exemption per MGL
Y � P� 12.EP400frepairs
insurance required.] } c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#r must also fill out the section below showing their workers'compensation policy information.
'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 subcontractors 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: ,,, c� t
Policy#or Self-ins.�Lic. #: (,i*- fl�,j�C> f�41 Expiration Date: ' tih °- 1 " d,I
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 tip 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 certi�ztttd er the Gains and penalties of perjury that the information provided above is true and correct.
Si nature: Date:
Phone#: Vl!,j yG
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):
I.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction
��Supervisor: Not Applicable ❑
Name of License Holder: �f)4tsj into 17
License Number
uS ;v c;z i I — 1(�, —
Address Expiration Date
LAO
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
4iT J716mF Innp 13534 �
Company Name Registration Number
_(to C1 - ( -010) (
Address J Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(ti))
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....... No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied DweIIings of one(I) 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 fann
structures. A person 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 fornt 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
ammINEENEENM
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors C]
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks Siding[O] Other[pJ
Brief Description of Proposed
Work: Sfif_'P+ �y v
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 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, Lauo'l- feC Ak' as Owner of the subject
property (
hereby authorize Pi-tj
to act on my behalf, in all matters relative to work authorized by this building permit application.
Z��_
Signature of Owner Date
asOwne Authorized
e hereby declare that the sta ements and information on the foregoing application are true and accurate,to the best o edge^
an belief.
Signed under the pains and penalties of perjury.
A"Lu 1—
Print Name
�s/
Signature of Owner/Agent 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)
#ofParking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT 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 Q DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , 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 0
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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
35
Department use only
D ity of Northampton Status of Permit:
uilding Department Curb Cut/Driveway Permit
5 Z�l� 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
N rthampton, MA 01060 Two Sets of Structural Plans
EMctrio,Plumbing 8, P -587-1240 Fax 413-587-1272 Plot/Site Plans
Northampton,MA n,A.&A
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
r (qj voli� i n Map Lot Unit
"Itc I y +C Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner wt ner of Record:
` ,�,{
A J2 ��ccn�C� ��� N / Cep Fja ,.tc-f
Name(Print) Current Mailing Address:
oC." `tl .. _ Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Addres .
L-169 S-06
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total =(1 +2+3+4+5) 7'Yoo. c, Check Number 0
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspectorof Buildings Date
296 NORTH MAPLE ST BP-2014-1057
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C-029 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2014-1057
Project# JS-2014-001815
Est.Cost: $7400.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group. A & J HOME IMPROVEMENT INC 101017
Lot Size(sq.ft.): 24393.60 Owner: FRANKL LAURIE A
Zoning: RI(100)/URA(100)/WSP(100)/ Applicant: A & J HOME IMPROVEMENT INC
AT. 296 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
60 WASHINGTON AVE (413) 467-1500 () WC
SOUTH HADLEYMA01075 ISSUED ON:411512014 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 SiEnature:
FeeType: Date Paid: Amount:
Building 4/15/2014 0:00:00 $35.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner