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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 2 ,G vl,asc� , .� �1,a I S° �, ,cl�•u1� D!ft tSW.+�L o o G�rf �i✓�� c7c> I;yi 1L L°'r�.s?" t�e�l�" vlt d /0 '!: Tr Al �p i Aj7L�i 1^ L a o YSM�` aL9 b 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