30C-035 (2) 4 x. :>,=s — .5`.44.. t +.,.: i- .E,.;,:. =}: -,- �'. :U - :::a,. , _ ..a -. t+e:huia '+F-.. — - : ;:: se- - sr- - _
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AFFIDAVIT rl
!31
A In accordance with the provisions of MGL c 40, §54, I acknowledge, as a
i :i
condition of the Building permit, all debris resulting from construction activity
,, governed by this Building Permit shall be disposed of at il
OM iC- Al an & Q [1t f L I .- -a n of f
:, (NAME OF FACILITY)
{
i a properly licensed solid waste facility as defined by MGL C 111, §150A.
8104/ -
Date Signature of Permit Applicant
1
P.
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I
PRINT OR TYPE THE FOLLOWING INFORMATION:
a
1
Takil CAL° 4 V 1 rgry'Ventif
(NAME OF PERMIT APPLICANT) -
i
RO C P t
(TYPE OF MATE AL TO BE DI SED OF)
4-6 Lf 3 1- 4ty . R� (AA
I
(PROPERTY ADDRESS)
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PATRICK KUBALA HOME IMPROVEMENTS All home improvement contractors and subcontractors engaged in home improvement
contracting, unless specifically exempt from registration by Provisions of Chapter 142A
• MA HIC #150 118 of the general laws, must be registered with the Commonwealth of Massachusetts.
5 PeII Street Ludlow, MA 01056 Inquiries about registration and status should be made to the Director, Home
Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA
413 -589 -1010 02108 (617) 727 -8598
Submitted S ► fa
I K
To: P. 1
O c t re"oP Q c Job Name: f A/, ,W05/ r',► -. �'a/ r5 imce _ m o . Q t O 6Z_, Job location: . P..4- e-
Ph o.ie i Date r ?a/pc s ?_ =° �O C i Z_ Estimator: A 9/3- 335 757 5
We hereby subJpaitt specincauons and - tes for work to be performed and materials to be used:
j
- , el ,e_ b 15 ' erv-�t t- e t , c a �
�� c
_ _ �JG f • fie, , ... _ ti -
.cricia,,A.- - 4 / CAP it verNfi 4" teuy
� Ss __, _ - - - _ Q _.- , Klrlb , l c�jr f41� t.en 4n-4.k Gy 0-4 n(Gg►'!t.i..�.^
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• __.. n11 _tic,,) . .s°-!... - c,. i1- 6 S A ► z.- 3 ' _•__.. A. Ai. s Ali i
1 e .
- ( e r .ar ` :: �� -i f";;;- ��/ / "ft-47 4 -4 ?r 10/pagcI-
t" %. ref 'I -46 0 Fra 1502 — o?so ts
WO ,CIIEDUL r ' � it .. ^ , a ■ t s far 4 s - yCc. 7v (:...•'% et 4.% , 7 —
Con r / ' will nc' b;gi' *the •.-. - ` ..r the :r. ?Aerials be . e tth . da ollowing the signing of this agreement, unless specific he i ontra r will being the work on or
abou 6' t�te). Bari- dela caused '...)y circumstr ..-s, ; a'j' . th s. ■ tor's control. The work will be completed by �A: aate). The owner hereby
acknowledges and i.g e s twat s it:, tuar g dries are approximate and . at t, li 4 a at are not avoidable by the Contractor including but not limited to strikes, Acts of God,
shortages of mate :i:.!s, c :.: :,::, :.s, w....' ;al Miler ck..ays beyond the its centre., shall not be considered as violations of this Agreement.
WARRANTY
The contractor warrants 'hat he ...ar Punished her-under shall be free from defects in materials and workmanship for a period of i rrS following completion and shall
comply wita the reyt.,-�_,,, :;a; :,1 , .Ag.;een,e r_: in the event any defect in workmanship or materials, or damage caused by the Contractor, its subcontractors, employees or
agents, is discovered after compiet on of any jo:, including clean up, the Contractor shall at its own expense, forthwith remedy, repair, correct, replace or cause to be remedied,
repaired or replaced, such damage o- such defect in =materials and workma.iship. The foregoing warranties shall survive any inspection performed in connection with the agreed -
upon work.
We Pv oPose i,r,c „. w , •. n sh ,rtaa
‘ •al and lab.- - cor.i irte in accordance with above specifications, for the sum of:
,I'� . h
,,� . b 9 �1. I , „ 0 - , 7. -: ; ,' e �.q 7 • /�'�/ M 4_• ; •c '` Y ! /4 dollars ($ 7 7 ).
P ent to b dr . 'toa. � � : ���� ,
, J rt � __ • ATRICK KUBALA HOME IMRPOVEMENTS
/o ( t om i e.: + cpon signing corruact;
..••••"'” % (_ ' - - - _ _) t' on completion of �� 5 PELL STREET
Ga.5 7 ; 'pon coriple on of 1 -II f LUDLOW, MA 01 ' • 413- 589 -1010
J
1/3 °,b ,,v25 e ) hall be mad+; fo +thwith upon MA HIC 1501 • .
- ornnletion of 7.c•r under this contract
Notice: T' agreement for home ir, jrovement co,�tr4cting work shall require a down payment Salesperson: ‘,/ C.. / ..w :.J
(advance de:pc sit c: f,i . the e icta..,t . tract prier or the total amount of all
deposits or ^ yrr ... ,,... ,, .
. 1 : a ci ,..,. :l :e. in adver -e, to cre::..nd/or otherwise Authorized Signature ,/
obtain delivery of sr e. i7.! e• * a'.. -his and eon , anent, whir ever am.;.., - is greater /
Acceptance et PIT , :4 / .1' i ' e read bath sides of this ' ocument and accept the prices, speci ations and conditions stated. understand that
upon signing, this r ^rirr;• -•I aco r:es a binding contract. You are authorized to do the work as specified. Payment will be made as outlined
above. You use wuyes to xr cancel this transaction at any time prior to midnight of the third business day after the date of this
transaction. Sr., r• tin.'' of "prcellatir-n form fu. an explanation of this right. Please refer to the Notice of Cancellation that accompanies
this contract; ccrt :•r., GI „i..ch are referred to abo.'e and incorporated herein by reference.
1X NO 1 SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Signa � . e i,4. _,.: - J .. .;.�u_` -._ Date 1 / // a.. Signature Date
v
The Commonwealth of Massachusetts I Print Form
Department of Industrial Accidents
, 1...
?
.1; t - Office of Investigations
1,_ 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 Legibly
Name ( Business /Organization /Individual):
Patrick Kubala Home Improvements
—
Address:5 Pell Street
City /State /Zip:Ludlow, MA 01056 Phone #:(413) 589 - 1010
Are you an employer? Check the appropriate box: Type of project (required):
1. 0 I am a employer with 4 4. ❑ I am a general contractor and I
employees (full and /or part- time).* have hired the sub - contractors 6. ❑ New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in acit employees and have workers'
g any capacity. y . 9. ['Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. ❑ We are a corporation and its l0.0 Electrical repairs or additions
officers have exercised their 11. Plumbing re
3. ❑ I am a homeowner doing all work g airs or additions P
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' 13.0 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: Utica National
Policy # or Self -ins. Lic. #:4364592 �'` Expiration Date:
Job Site Address: /�a- City /State /Zip:F enC 61 -'
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Aldo hereby cer, un ' the pains and penalties of perjury that the information provided above is true and correct.
,Signature: , . / Date: Q$ .0.0 -1—
Phone #: (' 13) 589 -1010
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 - tl' ' ' 'RTrI Ir LOON SERVICES
8.1 Licensed Co' :trc _t o',, Supervisor , . ',,, Not Applicable ❑
Name of License !icicle; : POD. ( `-'r �[ �( " ' AAJe 0n L IC 0 t
Licen e Nu ber
e fie.( . s-t- �.� �1 t or 9 13
Addr s Expir tion ate
(44-( C$"`
si uE Telep
9. e inter A angst C .ntractor: Not Applicable ❑
�1V l (0■ 1)t(VC
Company 1'`at:- Registr tion umber
Address Expirati n Da e
C44r�) Telephone v
SECTION 10- '.' l<FRS COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
_ _ __ a +.`:_ : ,t must e compla.ad and submitted with this application. Failure to provide this affidavit will result
in the denial of t4, :05 of tie bu,id ing permit.
Signe .4ffi :. °,,_ ,e Yes P No ❑
1 .. M rc Owner Exemption maim
The ;tion for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
'n.eoww°er to engasre an indi''dual for hire who does not possess a license, provided that the owner acts
° "' Q ±h Edi aon Sec* >n 108.3.5.1.
D21. I, _ r neE. Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or nte: ,o : to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
-s ',.' _`a"' 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
respo lsible f i all such work performed under the building permit.
As actiitg Con;, ruction Supervisor your presence on the job site will be required from time to time, during and upon
c�E »k for which this permit is issued.
iii,,, , ..:,;;,ence t:, Chapter i (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 ° _ w ork fni• you unde this per
..,.. z.uci, :`' certif;_:; and ass .roes responsibility for compliance with the State Building Code, City of
and 1_- . al Zor_i Laws and State of Massachusetts General Laws Annotated.
nom •,`Wi .•k• gz °llifCt re
SECTION 5- DESCRIF A OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing d
Or Doors El
Accessory Bldg ! Demolition ❑ New Signs [Dl Decks [p Siding [p] Other [CO
Brief De rption rnr�r
Work: Q�((J
Alteration of exis.i Yes ✓No Adding new bedroom Yes ‘/No /
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached • �t
ea. If New hot a ci addition to existing housing, complete the following:
a. Use of building : C;n= = amily�J Two Fami'y Other
b. Number of -Dom: ^ oar.h family unit: Number of Bathrooms
c. Is there a gars AiF: , tt, -bed?
d. Proposed S,;,;a e ;c,, qe of new construction. Dimensions
e. Number of stories
f. Method of n._ °iS! ' Fireplaces or Woodstoves Number of each
g. Errorgu r.,;.. : • :a ,,, ,,,,i: �r,c Masscheck Energy Compliance form attached?
h. Type of cor t tt .ict; : _ -
i. is construction , of wotands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of !pas_ , -Aar floor below finished grade
k. Will buiid,no cr n:orm the Building and Zoning regulations? Yes No .
I. Septic Tan! , City Sewer Private Pell City water Supply
SECTION 7a - OW' NEP A UTHORIZATION - TO BE COMPLETED WHEN
OWNERS l-m.W•\ t° ' r ^•r,L'1 L' ti. APPLIES i=OR BU,' DING PERMIT
, as Owner of the subject
property
hereby auth :n
to act on my beha`f, in all matters relative to work authorized by this building permit application.
Signa_we of 0 r Date
r °--7"
I ✓P , as Owner /Authorized
- - - -- - - - - -- lam" —
Agent hereby declsre the" he statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the Dains arid penalties of perjury.
Print Warn:
0 c' CP - 0 I I
S�'r 2y l e of 11.11L1 , P,, Dare
Sectio, 4. Z'AING 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 Si
Frontage
Setbacks Fr
Side L: R:
Building Height
Bldg. Square Footage
Open Space Footage
(Lot minus bldg & paved
lark Ina)
# of Parking Spaces
Fill:
(volianc Lo,,citk,a)
A. Has a Special PE rmit/Variance/Finding ever been issued for/on the site?
! DON'T KNOW ( YES 0
IF VS, date issued:
II- 1ES: vas the permit recorded at the Registry of Deeds?
DON'T KNOW 0 YES 0
i'ES encer Book Page and/or Document #
13, riCeS 'ilte contain a brook, body of water or wetlands? NO CY DON'T KNOW 0 YES 0
IF v., ias a percri;z been or need to t)e obtained from the Conservation Commission?
Nee0s be obtained 0 Obtained
0 , Date Issued:
C. ary; : exist Cr the property? YES 0 NO er
it YE.; describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
II- YES, YES, describe size, type and location:
E. Vvil. tne c activity disturb (clearing, grading, excav ation, or filling) over 1 acre or is it part of a common plan
th,t . u5 o'er ' ?ore? YES 0 NO
II- YES. men a Northampton Storm Water Management Permit from the DPW is required.
' a
I � � R0,40
` City of Northampton
uilding Department 0 '"
212 Main Street « ° u
adds 9
' p Z Room 100 _ ab
�� � hampton, MA 01060 Try . - «, r � i� �a�r
� -}
� 87 -1240 Fax 413- 587 -1272 `
t
iC
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Prope c ity , Address: This section to be completed by office
4G) Fl O t • i CL 0,C( Map Lot Unit
Ft 0 Y4XICQ , MA Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
d :w I n d 1 � - ' - i-1�;► tiAE. t
Name (Print) Current yili ds O 0 c a
Telephone
Signature
2.2 Authorized Accent:
cK a(a S (k.,u o law, C
Name Pri ) Current Mailing Address:
(I-4t3)c '9 - ro1b
S' ature Telephone
ECTION 3 - ESTIMATE!" CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building — 7 - 1 S--• (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 # R 3 r 4 3 � . Check Number 3 6
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: _
B iil•Jirg Commissioner /Inspector of Buildings Date
464 FLORENCE RD BP- 2013 -0192
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30C - 035 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-2013-0192
Project # JS- 2013- 000310
Est. Cost: $7778.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PATRICK KUBALA 100114
Lot Size(sq. ft.): 71438.40 Owner: HOLIK JOSEPH L
Zoning: SR(100)/ Applicant: PATRICK KUBALA
AT: 464 FLORENCE RD
Applicant Address: Phone: Insurance:
5 PELL ST (413) 589 -1010 WC
LUDLOWMA01056 ISSUED ON:8/21/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE PORTION OF 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 8/21/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner