17D-005 WlewEnglandsbestl roof.corn
4r-'Agreement Between
/ INTERLOCK INDUSTRIES, IN
Unit 7, 25 Walpole Park South 1 1 6 7 4
Walpole, MA 02081
registered as a Massachusetts Home Improvement Contractor Registration#139640
Registered as a Rhode Island Residential Contractor# 18345
p� Customer Service: 866.588.ROOF (7663)
U04 �l
Name ("Buyer") Date 14?_ �t 31
Job Address S _0 1 A , 13&
City/Town G us^CdUC p ,,, y�Q Zip Code 6106"G2.,
Buyer's Home
Address Zip Code
Work Phone {6M W--6477 Home Phone yy4 `770,. Cell Phone
The Buyer is the registered owner of the land and premises described in the job address above(the"Premises")and hereby contracts with
Interlock Industries, Inc. (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.
(Circle One): SHINGLE SLATE.....
SPECIFICATIONS
YES NO ROOFING MATERIAL S O OWNER WILL
OMd ✓ Supply adequate electrical power.
Shingle -Color:
IB Low Slope Roofing— olor: ✓ Be responsible for all rot damage and other necessary
Flash Skylights - Number roof repairs. (ie) Roof decking,fascia boards, etc.
_ Flash Vents Roof repair work will be undertaken by Interlock
Underlayment Industries, Inc. at a cost to be mutually agreed upon in
Snow Guards _ PCs. advance between the parties.
/ ROOF REMOVAL LOCATION OF SHIPMENT:
Strip existing roof t layers. --tV h or I>Al l6Wf
Haul away roof debris and pay refuse fees. ) START DATE: WGWKS
_ Note location for bin Mwpi ?_x>T" W ft/QL,�56{ i oAb COMPLETION DATE: / W6CrkbPP'rf1,V17.W1r'
y/ Supply M." plyvyood. Start and completion dates are subiect to change
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THIS CONTR CT INCLUDES:
LIFETIME LIMITED WARRANTY,TRANSFERABLE,NON-PRORATED FOR MATERIALS MANUFACTURED BY INTERLOCK ROOF
PLUS 10-YEAR LIMITED LABOR WARRANTY PROVIDED BY INTERLOCK INDUSTRIES,INC. y�►
LIFETIME LIMITED MATERIAL WARRANTY FOR IB ROOFING,PROVIDED BY IB ROOFING SYSTEMS Ir
Financing Requested Yes d No Sales Price $ /J 7�
Sales Tax $ .Ab a>
Interest Rate: 11.9%to 14.9% Sub-Total $ '7 `S"o
Down Payment $
Payment not to exceed $ Total Balance on Completion $ C-
O.A.C.(on approved credit)
MAKE ALL CHECKS PAYABLE TO: INTERLOCK INDUSTRIES, INC.
IN WITNESS WHEREOF, the Buyer and Contractor have hereunto signed their names this_ day of din) 20_a,9
The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute
concerning this Contract, the Contractor may submit such dispute to a private arbitration service which has been approved by
the Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as
provided in MGL c 142A. DO NOT SIGN THIS CON3:mBuyrer ANK SPACES
INTERLOCK INDU RIES, I
Signe
Per:
(Print name) "' S (S Signed
c/o Unit 7, 25 Walpole P&T<'Southl Buyer
Walpole, MA 02081 Witness
HIC. # 139640 Print Name
Relationship to homeowner
This Agreement is a binding agreement and contract between the parties. This is not a credit transaction and will not be financed by the Contractor. If
financing is required,the Buyer hereby authorizes the Contractor to obtain credit information and the Buyer hereby agrees to provide and sign all necessary
documents required by any third party financial institution to complete the financing, immediately on request. The Buyer hereby acknowledges receipt of this
Agreement. See reverse of Agreement for additional terms and conditions.
All surplus material is the property of the Contractor.
MASC CR0707
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. 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 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),
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
e� h
The Commonwealth of Massachusetts
Deparrntern,of Inriusrrial Accidents
Ofjsce of Pitvestigations
600 ff ashington Street
Boston, MA 02111
N'wn Inass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians,'PIumbers
Applicant Information � Please Print LeaibIv
Name (Business./Organization/Individual):' C,V_ /�Y1�S xw(o _
Address: —a�L,d�P,p� K
City/State/Zip: VIA Qap V Phone #: TZ,6—.Sgg'`7L 6 3
Are you plover? Check the appropriate box: Type of project(required):
1. I am a employer withl`o5ZV 4• ❑ I am a general contractor and I 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
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
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 10.7 Electrical repairs or additions
3.❑ I am a homeowner doing all work
officers have exercised their 11.7 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.7 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.
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 thepolicy and job site
information.
Insurance Company Name: 49,56 2n-MA L-72)
Policy#or Self-ins. Lic.#: by C./— 9"71—07,R,3,—?/— 0 3-9- Expiration Date: 02,/1�0
Job Site Address: .S Q ,?(7 J5,e ko( City/State,/Zip: Fi_nr= ,/Wt OIOLoZ
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 certi 7 under thhee�pains andpenalties ofperjury that the information provided above is true and correct.
Signature: /� Date:
Phone#: 9 �lG
Official use onlp. Do not write in this area, to be completed by city or town officiaL
Citv or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town CIerk 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
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Cdntracto'1711 Not Applicable ❑
-Ti r t o 'Iti dus ^�cs �rw l 3q li �/O
Company Name Registration Number
7-,2S-Uf
im Qcc sa 7---;Lr-O
Address I Expiration Date
WA�./Yw p1 o nl Telephone gig/,
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 E`t ti6n
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-vear 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 Iiable 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
l Q
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House F7 Addition ❑ Replacement Windows Alteration(s)
Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [[] Siding[❑] Other[[3]
Brief Description of ProposedL
Work: S ;L r
Altertibn of exisf g 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 existl'nq ho asinq.'comofete the fo[[owing:
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
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
as Owner/Authorized
Agent hereby declare that the Vateffients and information on the forego ng application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Nam
Signature of Owner/Agent Date
Section 4. ZONING AU information Must Be Compteted. Permit Can Be Den-led Due To Incomplete information
Existin- Proposed Required by Zoning
This column to be filled in by
Building Department
Frontage
Setbacks Front
Rear
Bui ding Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variance/Flnding ever been issued for/on the site?
�� ��
NO �_�� YY \_�� DONTKNO YES v��
IF YES, date issuedr /
IF YES: Was the permit recorded at the Registry ofDeeds?
�� YY
NO �� DONTKNO YES
�
IF YES: enter Book / Page and/or Document#! )
D. Does the site contain a brook, body of water orwetlands? NO 0 DONT KNOW YES
IF YES, has permit been or need tube obtained from the Conservation Commission?
Needs to t~+^benbta obtained »�� Obtained »-� Date Issued:
�
^ ' v_� '
C. Do any signs exist on the pnopert ��y7 YES �~/ NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size' type and location:
E. Will the construction activity disturb(clearing,gradingexcavation, or filling)over 1 acre orish part ofa common plan
that will disturb over 1acre? YES C ) NO K ~�
��
|F YES,then a Northampton GG��lXkalfff K�nagemehtPennit from the DPW iarequired.
( Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Dryeway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water./Well Availability.
Northampton, MA 01060 Two Sets of structural Plans'
phone 413-587-1240 Fax 413-587-1272 P
Otir pe
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMMISH A ONE OR TWO FAMILY< WELLING
APR µ
SECTION 1 -SITE INFORMATION
This to be d0liit0l4t y office
1.1 Property Address:
5-5--0 l3r) R.d Map Lot Unit
Flo re 11 CPS f A4+ Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
AL4rry Ti+KKI SSA l3ri43,e Pool
Name(Print) Current Mailing Address:
Y/3-.5-Ir 5-IT70 3
Telephone
Signature
2.2 Authorized Agent:1 L n
(?male 475-f' t ef- 7-J S-Gc a Q Q P,,L(C _S�af-�/�•Q.ti'Y�
Name(Print) Current Mailing Address: 010
/2�• jl -7 7r-
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by permit 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) /3 7,5 O Check Number
This Section For Official Use.Onl
Date-
Building Permit Number. Issued:
Signature:
Building,.Commissioner/Inspecto 'd ui ings - Date
File#BP-2008-0924
APPLICANT/CONTACT PERSON INTERLOCK INDUSTRIES,INC
ADDRESS/PHONE UNIT 7 25 WALPOLE PARK SOUTH WALPOLE (508) 660-6665 Q
PROPERTY LOCATION 550 BRIDGE RD
MAP 17D PARCEL 005 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
F e Paid
uil in Permit Filled out
e Paid 2.Z,6
Tyneof Construction: Roofing
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 129369
3 sets of Plans/Plot Plan
THE�O i3OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO _ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Azlo
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
4
' 1 �„ BP-2008-0924
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate-Z' BUILDING PERMIT
Permit# BP-2008-0924
Project# JS-2008-001383
Est. Cost: $13750.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: INTERLOCK INDUSTRIES, INC 129369
Lot Size(sq. ft.): 35065.80 Owner: TAKKI LAWRENCE
Zoning: RR Applicant: INTERLOCK INDUSTRIES, INC
AT. 550 BRIDGE RD
Applicant Address: Phone: Insurance:
UNIT 7 25 WALPOLE PARK SOUTH (508) 660-6665 0
Workers Compensation
WALPOLEMA02081 ISSUED ON:412212008 0:00:00
TO PERFORM THE FOLLOWING WORK.-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:
BUiiding 4/22/2008 0:00:00 $25.002267
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo