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23D-029 THIS AGREEMENT SHALL BECOME BINDING ONLY UPON THE SELLER'S ACCEPTANCE HEREOF OR UPON THE SELLER'S COMMENCING PERFORMANCE. UPON ACCEPTANCE THIS SHALL CONSTITUTE THE ENTIRE AGREEMENT AND BE BINDING UPON THE PARTIES HERETO,THERE BEING NO COVENANTS, REPRESENTATIONS,WARRANTIES GUARANTEES,PROMISES OR AGREEMENTS, WRITTEN OR ORAL,EXCEPT AS HEREIN SET FORTH. YOU MAY CANCEL THIS AGREEMENT IF IT HAS BEEN CONSUMMATED BY A PARTY THERETO AT A PLACE OTHER THAN AN ADDRESS OF THE SELLER,WHICH MAY BE HIS MAIN OFFICE OR BRANCH THEREOF,PROVIDED YOU NOTIFY THE SELLER IN WRITING AT HIS MAIN OFFICE OR BRANCH BY ORDINARY MAIL POSTED,BY TELEGRAM SENT OR BY DELIVERY,NOT LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS AGREEMENT. OWNER HEREBY ACKNOWLEDGES THAT HE HAS READ ALL THE TERMS AND CONDITIONS SET FORTH ABOVE. WE HAVE EACH READ THIS CONTRACT BEFORE SIGNING THE SAME. BOTH PARTIES HAVE PLACED THEIR SIGNUATURE ON THIS PAGE,AND HAVE PLACED THEIR INITIALS ON EACH OF THE-PR-EVIOUSPAGES,AND ALL SUBSIQUENT.PAGES. "DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES" DATE OF ACCEPTANCE: 0/6 SIGNATURE: SIGNATURE: (REMAINDER OF PAGE IS BLANK) Owners Initials PAGE 5 OF 5. Contractor Initials"l INFORMATION AND SERVICES REQUIRED OF OWNER: EXTERIOR ROOFING: REMOVE 2 LAYER EQUALLING 10 SQUARES OF EXISTING ROOFING SHINGLES AND ROLL ROOFING FROM THE SHED DOORMER. ALL ROOFING DEBRE TO BE DISPOSED OF TO A LANDFILL. INSPECT THE ROOF SURFACE FOR ANY DELAMINATION,WATER DAMAGE,OR INFESTATION OF INSECTS TO PLYWOOD SURFACE. PREPARE ROOF DECKING FOR TARPAPER. INSTALL TARPAPER,WHITE 8"DRIP EDGE,AND INSTALL WEATHER WATCH OVER THE ENTIRE SHED DOORMER SURFACE. INSTALL 5 SQUARES OF TAMKO 30 YEAR ARCHITECUAL SHINGLES. REMAINDER OF PAGE IS BLANIg Owners Initial - PAGE 2 OF 5. Contractor Initials� WILSON CONSTRUCTION GENERAL CONTRACTOR 155 Buffam Rd. Pelham,Ma 01002 lie. CS-102973 lic. 115172 Telephone(413)253-5105 Fax(413) 253-5105 SEPTEMBER 3,2015 REBECCA LEOPOLD 460 ELM STREET NORTHAMPTON,MA. 01060 413-658-5875 THE FOLLOWING IS THE SCOPE OF WORK TO BE PERFORMED TO A TWO STORY HOUSE CONTRACTED BY REBECCA LEOPOLD. WILSON CONTRUCTION(CONTRACTOR)WILL REMOVE TWO LAYERS OF THE EXISTING ROOF MATERIAL. OUTER LAYER SHINGLES AND UNDERNEATH ROLL ROOFING. THE WORK IS LIMITED TO THE SHED DOORMER SECTION OF THE HOUSE ROOF ONLY. THE SHED DOORMER AREA WITH TWO LAYERS EQUALS 10 SQUARES OF ROOFING MATERIAL. PREPARE AND INSTALL 5 SQUARES OF TAMKO 30 YEAR ARCHITECUAL SHINGLES(OWNER TO CHOOSE COLOR.) THE OWNER AND CONTRACTOR AGREE AS SET FORTH BELOW. THE CONTRACTOR SHALL SUPPLY ALL LABOR,EQUIPMENT,AND MATERIALS TO EXECUTE AND COMPLETE THE WORK DESCRIBED HEREIN. EACH PHASE OF THE ENTIRE PROJECT IS OUTLINED BELOW. SOME ITEMS MAY COVER MULTIPLE APPLICATIONS EXCEPT WHERE SPECIFIED. THE WORK SHALL BE IN COMPLIANCE WITH THE MASSACHUSETTS STATE BUILDING CODE. GENERAL CONDITIONS: SUPERVISION&COORDINATION REMOVAL OF CONSTRUCTION DEBRE MAINTAIN JOB SITE. BUILDING PERMIT ISSUED BY THE TOWN OF NORTHAMPTON (REMAINDER OF PAGE IS BLANK) Owners Initials PAGE 1 OF 5. Contractor Initials-h 0• r City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: 7 0 The debris will be transported by: The debris will be received by: 14 ,41111--`Q�n ld Building permit number: � r Name of Permit Applicant /�D G • % �4� Kira � Date Signature of Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl i Name (Business/Organization/Individual): Address: &—C�—_ ShArlv� & City/State/Zip: Phone#: �,3 Are you an empl er? Check Ae appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. New construction employees (full and/or part-time).* have hired the sub-contractors 2.9 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.[:1 Electrical repairs or additions 3.[:11 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.❑ Roof 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. I 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: /f Policy#or Self-ins. Lic. #:A/ 'yDa"70,M,74 J e? , Expiration Date: 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. I do hereby ce Yf nder t p ins and penalties of perjury that the information provided above is true and correct. Si afore: / 0A) Date: Phone 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#: SECTION 8•CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: �� Not SApplicable ( ❑ Name of License Holder:��/ r/ 4 ��/ -'�� �c� — /[J p��73 Licen Numb pr �'/yI oGl al Q, �0 a� �a d ess Ex Oration Qkite ignature Telephone 9.Bepisig;14 Home Im ouement Contract' r: Not Applicable ❑ �a Company Name Regis793 tion N;mber A ress — Expir6tion D to Telephone 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....... No...... ❑ 11. - Home..Owner Exempti©n 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 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 ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[0] Brief Description of Proposed ,� e Work: �00 A • Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet ea.ff Now house and or addition to existing housing, complete the'followina: 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 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 U �i Id//JQ/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. Sign 1d under the pains and penal ie�o perjury. -'o so/I Pri me 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) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW Ncy YES IF YES, date issued:'. IF YES: Was the permit recorded at the Registry of Deeds? NO Q 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 0 YES Q 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 Q 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. i •�.r�.�.�4��� i�spattrrfehttise- tiy . y of Northampton Status of Perrot B ilding Department Curb cut/I i y Perrntt 9 212 Main Street Ser do Availability Room 100 WatertWall Avallab ity' dew o; nrN N hampton, MA 01060 TWO SetsaStructuralPIan's� NOR 7}AM PToN MAp 41 -587-1240 Fax 413-587-1272 PIot/S �r► 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 -z e-1 Map Lot Unit A/D/�/QlVll4AI/ 11A 64/d, Zone Overlay District_ _ /V // //` Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: L-Ap-e(4-0- Z-6 0 /Zln .�kl I Name(Print) Current Mailing Address: / �VU 7 75' Telephone f� o (J Signature 2.2 Authorized A ent: / i Al ame(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 2� �D (a)Building Permit Fee 2. Electrical J (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) Ob Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 460 I:LM ST BP-2016-0774 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23D-029 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) C�ite.;on: ROOF BUILDING PERMIT Permit# BP-2016-0774 Project# JS-2016-001308 Est. Cost: $3200.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HAROLD E WILSON 102973 Lot Size(sq. ft.): 12588.84 Owner: LEOPOLD REBECCA A zoning: URB(100)/ Applicant. HAROLD E WILSON AT. 460 ELM ST Applicant Address: Phone: Insurance: 155 BUFFAM RD (413) 253-5105 WC AMHERSTMA01002 ISSUED ON:121912015 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE PARTIAL 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: T I I I S 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 12/9/2015 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner