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31A-168 The Commonwealth of Massachusetts l D'e 1 r :Tent of Industrial Accidents 1" = = , Office of In estigations =: '� 600 Washington Street .*S. -1= , , r Boston, MA 02111 . www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Y) 540, 1( 0 (A) OlVerrV Address: J --q Cc . r Y'Y� - ' -_--e c� City /State /Zip: y) - "� 9k (x') t Phone #: t-1(�j , 5 (. - -C' / Are ou an employer? Check the appropriate box: Type of project (required): 1.1I am a employer with 4. [] I am a general contractor and I ((((((��� employees (full and/or part- time).* have Nixed the sub - contractors 6. ❑ New construction 2.0 I art a solo proprietor or partner listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub - contractors have 8. 0 Demolition for me in any capacity. employees and have workers' working Y p ty. 9. 0 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof rep ' s insurance required.] t c. 152, §1(4), and we have no „ employees. [No workers' 13. [Other X'. 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 the policy and job site information. Insurance Company Name: ■ \ \\ o.x' r\ A V :1 ._.1 l Y I__ so _ - C Policy # or Self -ins. Lic. #: CUE 315 - , 37,-; ' 3V -() i ■ _ Expiration Date: : , / / Job Site Address: '7 L ��Q� v v - C City /State /Zip: i..I�. 'D s AA yi 4 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. CI Signature: , iy' ( _ Date: '7/ /// Phone #: L it :' — t :' . _t 9 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: , 100079 00 *0 ROBERT POWERS JR 159 BRAINARD RD NO 12 ENFIELD, CT 06082 C f :97 •-■ 3/8/2012 100079 Reetricted to: 00 Oa - Unrestricted 1G - 1 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Refer to: WWW.Mass.Gov/DPS . CERTIFICATE OF LIABILITY INSURANCE opos (IMMOINYYYY) 05/05/2011 THIS CERTIFICATE I8 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSWNO IN$URER(8), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: W the Cereficate hoWer Is en ADDITIONAL INSURED; the poticy(fei) must be endorsed. if SUBROURCION 15 WAIVED, subject to the terms slit conditions of the penny, certain pollutes may require an endorsement. A statement on this certificate doss not confer rights to the certificate holder In lieu of such endotssment(s). . PRODUCEFI CURTRCT- wrrzaA t MIS WILLIAM J MIS INSURANCE AGENCY puma 413 -568- 6111Ne�413 -572 -9191 156 ELM ST ADORsa, BILLSBILLMISINSrRAt4Cs.CCM WEBTFIELD, MA 01085 PRODUCER CUSTOMER VP IN3URERIS) AFFORDING COVERAGE NAIL • - INSURED anima aAP9ELLA PROTECTION SAMBPICO LLC D13A INSURER a LIBERTY MUTUAL _ • VISTA HCME IMPR0 RHENT essURaRC _.— - - - -- — — x - -- 244 IttM ST INSURER O: ^ WEST SPRINGFIELD MA 01089 Daum a: . . INSURER F. _ _ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LI$TE11 SLOW HAVE BEEN ft51l8D tO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 8E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO All THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR mane OF INSURANCE PAR Weir PDUCY NUMBER 1 I ! II (YYY) LASTS GENERAL LIABILITY ! EACH OCCURRENCE $2,000,000 A X COMMERCIAL GENERAL LIABILITY ` PR Mumma BfiiItU7 BIITY 310, 000 0 r � 8500041702 12 /12/201012 /iZ /2011 PREa+�sEatr�«ra,RaRra> CLAIMS -MADE I i OCCUR j I f "! MED EXP (Any one person) 55,000 -_--------.-_._-- PERSONAL IS ADV INJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GENT. AGGREGATE USW APPLIES PER: • PRODUCTS- COMPIOPAGG $ 2,000,000 — 1 POLICY i 1 sr-, L ----- LOG ! $ AUTOMOBILE UAOaJTY f COMBINED sane uurr — _ 1 (E a seelean8 $ -� ANY AUTO � BODILY INJURY Mot parson) a AU. OWNED AUTOS BODILY INJUIY! (Paraeldsnt) 1 SCHEDULED AUTOS HItEDAUJI08 PROPERTY DAMAOE etl a (Per adu0) NON -OWNED AUTOS $ UMCRELU Le./3 OCCUR 1 EACH OCCURRENCE 1 $ EXCESS LIAR i -- AGGREGATE is DEDUCTIBLE ! 1 a RETENTION $ a ..,• . . • AND EMPLOYERS' LM8RITY Y 1 N ! ! x 1_ TO UNIT MP ER B ANY FROPRIETORPAR CUTAIE WC1- 315- 372839 -011 105/051201105/05 /2012 E.L. EACH ACCIDENT $ 100,000 oFFICER/MEMBER N (Mandatary In NN) 1 E.L DISEASE- EwEMPLOYEE a 100 I yes. dose** under 1 DESCRIPTION OF OPERATIONS Wow j EL meASE- POLICY LIMIT $ 500 , 000 DESCRPTWN OF OPERATIONS f LOCATIONS I VEHICLES (Attach AGGRO 101, AddltIonal Remarks aoh.duIs, R mom space M meshed) CERTIFICATE HOLDER CANCELLATION SAMBRICO LLC DBA VISTA HOME IMPROVEMENT SHOULD ANY OF E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO. TE THEREOF, NOTICE IMLL BE DELIVERED (N 244 ELM ST ACCORDANCE WITt T • ' PROVISIONS. WEST SPRINGFIELD MA 01089 AtimornoN 1 t ' 1 tC 198$ -200, ACORD CORPORATION. All rights reserved. ACORD 28 (2019109) The ACORD nsnme end logo srs registered me A .. - • . ,..,/ f2e �,,d , "4 , 4 ' i 4 Office of Consumer Affairs and us Regulation _ 0 .. 10 Park Plaza - Suite 5170 ` Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 162058 Type: LLC Expiration: 1/12/2013 Tr# 208705 SAMBRICO LLC dba VISTA HOME IMPROV BRAIN RUDD 244 ELM STREET RIGHT SIDE WEST SPRINGFIELD, MA 01089 Update Address and return card. Mark reason for change. Address Renewal , Employment i Lost Card DPS-CA1 C, 501x- 04/04- G��1//01216 f // / ;,.. ' ( (V� !(.7JW/4 4ma Office or Consumer Affairs & Business Regulation License or registration valid for individul use only ,Ti`s , ; HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: I LI - - Registration: 162058 Type: Office of Consumer Affairs and Business Regulation , ; Expiration: 1/12/2013 LLC 10 Park Plaza -Suite 5170 " Boston, MA 02116 SAMBRICO LLC dba VISTA HOME IMPROVEMENT BRAIN RUDD 244 ELM STREET RIGHT SIDE .r' .r r { WEST SPRINGFIELD, MA 01089 Undersecretary o valid without signature t, t` -`\L�d ^�a t « ts: t L t ., `t t ` L 5 7 1 1 -i . 1 4 t t 5 I hat to 1i. : f I :4 .51,r r ' } 44 1 :;*.:14:' , ✓y�� 4 [[�� v '� m &+ + r i �, P t>: n t .?! :1:1 ' 44 , 6 f r 5, r , y i' , i f: l i ' 1 r r kt'K ..e r 1 { t ;', !J'Jt 4, 0 :',44 � r tp..4 1t , ¢ '%- x",1 6 n . '/ { .t , , j gF 1 , G A 1 -v„:„., „ . ? i� f F I C 31 ', " 14k h,Q J 'k.. J i t i g i" , , t____ _"____ " __ '!� Lr _ _ : '__ 1S—Ai _k seta*: _"1: 1 S...*' ! ___”! I�_"i' rte __ '— _ - y STATE OF CONNECTICUT + DEPARTMENT OF CONSUMER PROTECTION _y a t ' Be it known that f SAMBRICO LLC fti o ;,} 1346 ELM ST NI . r W SPRINGFIELD, A e1089 -2709 ' - is certified by the Department of Consumer Protection as a registered i > ; f HOME IMPROVEMENT CONTRACTOR 1 A '3::',41 l Registar'at"9 s # IC.O621848 ' a 1 k r , 7. VISTA HOME IMPROVEMENT _r 1... *:1 Effective: 12 /01/2010 , , - ;,--= K , Expiration:11 /30/2011 ` `� I f,. Jetty Farrell, Jc , Commiusioner tt : � ;ice,. , *..,,f4.:1, .. . ,., > -` I l/ ice � +i f+r r� � :, • ♦ V { t ;} f r i S' N ' f b 3; Y „f 41 i wy;,i „ a it, °: , r n ,.. -,'.-4;,.,,,,,,,: f ?f ' 1'. ., d i .. ..1 Mfr .' � . 5 }, t \ . iy ; t t t` ,y� , l',, {, \0. } Y`' k, ' �, t ' . : . ,..' .q:. L . ? , 14, i f/ Rt• ',41.54 t ,7t >v , VS' 'i n ' .P' tr' .1. d * '1ti ; I . k:::'4:`,`4 . s . ' t 5' , ,, f , ' . , :4 4:, .: 3 t I .< 4 : I 'iv tt �"v+' s ' 1 1 ' ° . 1 ' 4 t ,�i.` �h. i: i. } a .1 CA) ai „ddio--r Page No. of Pages Propo5at airlw CT. REG. NO. 062184 WIDTH c VISTA HOME IMPROVEMENT ) MA REG, NO. 162058 1346 Elm Street West Springfield, MA 01089 INSU , TION Toll Free: 1-888-597-2323 • Local: 413-382-0249 : FAX: 413-382-0241 Proposal Submitted To Homeowner Work To Be Performed At Name 4 ' 4, `-4, .7 Y4, if. Street Street. `q. City State City State ' Date of Plans it Date '- /L Telephone Wallereby submit specifications and estimates fpr: • • ' , v ' P , • . 4 ^. % 'J41 r , • Date work will start ' Date work will be completed All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from the above specifications must be made in writing on an Add-on/Modification of Contract form and may become an extra charge over and above the amount stated herein. This agreement is contingent upon delays beyond our control. Owners to carry fire, tornado and other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance. Homeowner agrees to pay for all work as set forth below. If the homeowner defaults, homeowner agrees to pay all costs of col- lection, including reasonable attorneys fees, in addition to other damages incurred by contractor. An 18% per month service charge assessed for all payments not made within 10 days of due date per the schedule below: C propo4c hereby to furnish'rnaterial and labor - complete in accordance with the above specifications, f o r t nesum of: Said amount shall be paid as follows: Note: This proposal may be withdrawn by us if not accepted within days. YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DAY OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FOR AN EXPLANATION OF THIS RIGHT. (SATURDAY IS A LEGAL BUSINESS DAY IN CONNECTICUT.) THIS SALE IS SUBJECT TO THE PROVISIONS OF THE HOME SOLICITATION SALES ACT AND THE HOME IMPROVEMENT ACT, THIS INSTRUMENT INOT NEGOTIABLE. Signature of Contractor or authorized representative: z' *(INVe) have read the terms stated herein, they have been explained to (me/us), and (I/We) find them to be satisfactory and hereby accept them. Signature of Ilomeowner(s): , X SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : ( . '} ( -r oan- 9 License Number E mi ' - ` - l c r n o 1o& 9 • dress Expiration Date ig ature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ VI v4 gy m€ � rrv-e at e n +- J (Q 0 5 Company Name 1 Registration Number 1 394 PI' - L! 5f( l 11- 0 \O 1 ' ( � a) 3 Address ° Exp ration Date 713 h Tele "I 13 — � ( pone 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 Exemption 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 C„1�'�� C.,. " Cy` ° SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Rol Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [0] Other [0] Brief Description of Proposed )v � - 6:A..`a( L ���� �� C'C)O kv. cveb,-' i �'� 5(-) p '3 Work: A— \rl '> \ \\' ‘ - ,CE' ° 4-- 0. ' C . )0 c d - ,h \ \es 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 1, Q,\C?t ,a '(L) C\ 7 , as Owner of the subject property hereby authorize `f \ G `(1 ■ X t — VI ` � \ i ? ro ift 1e n * to act on my behalf, in all matters relative to work authorized by this building permit application. iY)/ I I Signature of Owner Date I, 8110.Y - 1 LAE! - 1l1A'F' 0 T , as Owner /Authorized Agent hereby declare that the statements and information on the fordgoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and �� penalties of perjury. Print Name -Z61e( C- 1/ _-tY r i 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 DON'T KNOW 0 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 ode 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 Obtained , Date Issued: C. Do any signs exist on the property? YES Q NO ► ±$ IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NOS. 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 Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. . ^ . ©x \ .. 7 i lict { < .!:)ri q \ { , \ .2 , .,_: . ,. ...........,,..... R RECEI VED' Department use only GCE V G ity of Northampton Status of Permit: uilding Department Curb Cut/Driveway Permit SEP 2 9 2011 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability DEPL OF®UILDINGiNsPE � C p tioNs N hampton, MA 01060 Two Sets of Structural Plans N 11 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans, 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 1 Lt o3Lx -- Map Lot Unit f C5 roc -V Cl '01 A G'WU° Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Q- vard `CU r � S CAL- '7 ki ccj Ca 0( ro r) Name (Print) Current Mailing Addr Li 3- c o -Go- j u 1t) Telephone Signature 2.2 Authorized Agent: ' Rr 04V\ u — V 5A rn 7.1Arnprove1401 1 31 F1( 34 Ck1 VF M Name (Print) Current Mailing Address: o L13- 3g -()-(4 5 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Rem Estimated Cost (Dollars) to be Official Use Only completed 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) (0 (QC) Check Number /4/5 "33 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date 74 MAYNARD RD BP- 2012 -0314 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 168 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- 2012 -0314 Project # JS- 2012 - 000510 Est. Cost: $6605.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VISTA HOME IMPROVEMENT 100079 Lot Size(sq. ft.): 7492.32 Owner: BRUNSWICK RICHARD P & ELIZABETH BETKE Zoning: URB(100)/ Applicant: VISTA HOME IMPROVEMENT AT: 74 MAYNARD RD Applicant Address: Phone: Insurance: 1346 ELM ST (413) 382 - 0249 WC WEST SPRINGFIELDMA01089 ISSUED ON:9/29/2011 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 Signature: FeeType: Date Paid: Amount: Building 9/29/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner