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30C-036 vo --PATRICK KUBALA HOME IMPROVEMENTS All home improvement contractors and subcontractors engaged in home improvem, contracting,unless specifically exempt from registration by Provisions of Chapter 14: MA HIC#150118 of the general laws, must be registered with the Commonwealth of Massachusel 5 Pell Street Ludlow, MA 01056 Inquiries about registration and status should be made to the Director, Ho Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, N 413-589-1010 02108(617)727-8598 Submitted ] / _ 1. ,.ti,?{b..�a 5,33:-.0 5,I . ,� 5,,� '� f /�J Job Name: l�//?C(/+'� b� 'X' ,-- re,t:,� fl'' 010i; .. Job location: +�' /' . P(i/3 -,3/o - 67© -� Date 03 Estimator: C?` K44 Wp eby submit specifications and estimates for work to be performed and materials to be used:_ , �-- 7 n /'• ., erb1s 1 i'/'4 ",f747 . ./ -11:::5-fj- I4-vet f �.i/ A,LAE. fr). E4iC%Jr 1. 10%54c G//����4cr- re•Ct lilt" !. . fo SA fi "' Lt.i a/ Ir...r. n1-14 Y'! bro2.c/1 _Yillr/ tee' r` tic iC't ti I trte,' /r?m-aY E' y�7 <'°-i ''-1 r•7�Ct'[ �l r 1 Giok 5. k�ii c vr+_eels 1- 01 /ett-itt .77. . c'-1c.,— / 4':,A--1j,.c k re, RtAiiu. +r �. f'C(.l Pr 4o,4-1 p/ I�'C*TZlI1�( /' 4 ` ' `-- I ih�-Z+4�, �'`t'�i 4/I Chrrnn 2 , . e �l;r,' 71-1 -sill __ ( C�;v� G`e -r.. 1 0-44 . ce':. . �+1.€ ' ., ., <., 6, I - ��nt C.C� A •/ �/ .r c"1 14- �' •.4�+,, e C y'GA ),i:k tspca a II •1-�th r..! r IC.t i^CA-7A e:// 44 Cars_ Ircx`Y ,,..es fc-+4 , -b tcd04:4--e 4rcrer"4ii., 010: 40 1547 tvec;-t/)1,.) bvao 4 WORK SCHEDULE Con _ ll ne work or order the materials before the third day following the signing of this agreement,unless specified herein. Contractor will being the work on about date. Baring delay caused by circumstances beyond the contractor's control. The work will be completed b Gt,j.J(date). The owner here acknowledges and agrees that scheduling dates are approximate and that such delays that are not avoidable by the Contractor including but not limited to strikes,Acts of 0 shortages of materials,accidents,and all other delays beyond the its control,shall not be considered as violations of this Agreement. WARRANTY The contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of irelrf following completion and sh comply with the requirements of this Agreement. In the event any defect in workmanship or materials,or damage caused by the Contractor,its subcontractors,employees agents,is discovered after completion of any job,including clean up,the Contractor shall at its own expense,forthwith remedy,repair,correct,replace or cause to be remedil repaired or replaced,such damage or such defect in materials and workmanship. The foregoing warranties shall survive any inspection performed in connection with the agree upon work. We Propose hereby to furnish maerial and labor complete in accordance with above specifications,for the sum of: '�✓S�> 144'‘....'- #4I / "C;(?).,. 1 o dollars($ / .2/ 35'4— Payment to be made as follows:" . ,?ef tg $li rte-' 1/,fie/f fftt��, nsigningcontract; PATRICK KUBALA HOME IMRPOVEMENTS �° ��,( +� )upon completion of —11 4 5 PELL STREET JJ �Jt ( )upon completion of �r - f LUDLOW, MA 01056 413-589-1010 /? %( 3y5 )shall be made forthwith upon MA HIC 150 completion of work under this contract. �j / Notice:No agreement for home improvement contracting work shall require a down payment Salesperson: / !�Gr� �� G'/fir (advance deposit)of more than one-third the total contract price or the total amount of all , deposits or payments which the contractor must make,in advance,to order and/or otherwise Authorized Signature: L l obtain delivery of special order materials and equipment,which ever amount is greater Or Acceptance of Proposal: I have read both sides of this document and accept the prices, specifications and conditions stat-'. I understand tl upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be 'lade as outlin above. You the buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of tl transaction. See notice of cancellation form for an explanation of this right. Please refer to the Notice of Cancellation that accompan this contract;contents of which are referred to above and incorporated herein by reference. DO NOT SIGN THIS CONTRACT IF THER • RE AN : • NK SPACES ; /• Signature Date _ a Dyt�e ', �� [� The Commonwealth of Massachusetts Department of Industrial Accidents '`. 4 ?N Office of Investigations 600 Washington Street ,"- Boston,MA 02111 F s www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): f'a.it l C K 4 bale- _( 1( roYexn.,2.a 1 Address: S k4 I St City/State/Zip: c tC;1 IOW itY1 A t7 i CS1 Phone#: (1 i'3)531- 10i G Are you an employer?Check the appropriate box: 4. I am a general contractor and I �of project(required): 1. 4 I am a employer with 3 ❑ g employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [g6Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.$ 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.0 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 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. 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:U'tiC N ok- 16Y1Cd ,_ Policy#or Self-ins.Lic.#: 43 .Q1-592_ Expiration Date:JO 1 / Job Site Address:S12- fxY etl tom. City/State/Zip f CQ, (- Oibtt'�-.. 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 fy n the pains and penalties of perjury that the information provideeaadcab ve is true and correct. Signatur Date: lJ 6 jOP,b/ Phone#: ( 13) S `L 9- 10 i 0 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 Pak-VC, �/, '+ J�/� Not Applicable :2.2. Name of License Holder: Pa �i�l -'�v tl�x'1� I o Q t t �"I License•Num er t,'d ' _, . • Icy 1 a (OCIp 91q 1, Add - Expirati n Da e `° SgCf '1(�(0 v in � cue. rL¢,rt.¢,taas?, rum lep e cat -}o vcx1f U . 9.Reg Improvement Home I rovement Contractor: Not Applicable 0 Company Name Registr tion Number Address ��((yyj \ Expirat n Date Telephone0—)0 1�I V 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 build" permit. Signed Affidavit Attached Yes....... No.,.... E 11. --Home Owner Exemption The current exemption for"homeowners"was extended to include Own er-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,von 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 El Addition ❑ Replacement Windows Alteration(s) El Roofing pr Or Doors El Accessory Bldg. El Demolition ❑ New Signs [0] Decks [C7 Siding[0) Other[0] Brief Dfription of Propose Work: 7—E',Ut(,Q[i.. 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 I, s ,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 I. `�� ` , as Owner/Authorized Agent -reby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Si•ned under the pains and penalties of perjury. � Pant J�� aC1,141 5 iir Sig . ure of OwnenAgent Date Section 4. ZONING All Information AAa Be Completed Permit Can Be Defied 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 °io Open Space Footage °o (Lot area minus bldg&paved pulsing) of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DCNT KNOW 0 YES 0 IF YES, date issued:, IF YES Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 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 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 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 NO IF YES4 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. Department use only -7 1` City of Northampton Status of Permit: IF i Building Department Curb Cut/Drivewray Permit ;13 212 Main Street Sewer Septic Availability Room 100 Water1Well Availability trio,Pig Gas Inspections Northampton, MA 01060 T4iro Sets of Structural Mans North: MAOioso one 413-587-1240 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 rI 1? LL pi— -�{• Map Lot Unit �c•� Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 1.3 Ck f 1')vVY1 14 C I �i:..g...f0� :w ' • A i. ' it 4 0(0(17i Name(Print) I Curren Mailing i.ddress ele+ .ne &kgnature 2.2 Authorized Agent: Vu-Aaa — 6 edi i Luctlav, ?AA oiclto Na Current Mailing Address: '' a e elephone �_ t•N3- Ti , I • . •, ti_ 1•N • 1 Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building i,L)r J�?c=)y 4) (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical(IiVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) 1 O) 3 X07. Check Number �$6'? 3 This Section For Official Use Only Y Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 512 BURTS PIT RD BP-2014-0322 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 30C-036 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-2014-0322 Project# JS-2014-000555 Est. Cost: $10352.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PATRICK KUBALA 100114 Lot Size(sq. ft.): 34586.64 Owner: MOORE WAINWRIGHT JEANE E&ROBERT D WAINWRIGHT Zoning: SR(100)/ Applicant: PATRICK KUBALA AT: 512 BURTS PIT RD Applicant Address: Phone: Insurance: 5 PELL ST (413) 589-1010 WC LUDLOWMA01056 ISSUED ON:9/17/2013 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 9/17/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Louis Hasbrouck—Building Commissioner