23A-082 t:4133820241--2013.10.0910:43:41--FAX ID;CO01E901755-ROC_N-Unknown--Unknown--Unknown
10/09/2013 10:51 14133820241 VISTA HOME IMPROVE PAGE 02/02
i►:_. �?,414.‹- i� � Pees No. of Peres }
CT.R G,NO. 062184$ VISTA HOME IMPROVEMENT mop WIDTH
MA RPC,NO. 162058 2003 Riverdale Street • . ,
West Springfield,MA 01089 INSULATION
Toll Free: 1480-507-232S a Local:41 3482-D249
FAX: 413.382-0241
propowtl Submitted To Horneownet Work To Vie Performed At
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wO needy submit^--- ,-,eons and mime -for; _
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Data work wilt start.. A—A , ::+L'. . Date work bo cot ': {• 1101.... arr-+�
At medal is guaranteed to be as specified. All work io be eornpkNed in it workmardke metier aocading to standard graces Any alteration or-- :on from the
above specfba cons must be made in wilting on an Add-ommodkicetIDn of Connect term and may'totem an extra Outgo over and s Dore the amount witted herein.
This agreement is contingent upon delays beyond ow oo.WG1.Owners to carry kre,tornado and ether necessary tnsvraone.Our workmate fully covered by ,
WoMman'a Otwnevneation Ina, ,wa.Homeowner agrees to pay kw as work as sat loOOh Wow-H Ma hwmopwner tloratats,homeowner amrea6 to pay 811 rnosts of Wt.
+salon,Including reasonable anorrwye few,In addition to other damages incurred by contractor,An 10%per month aeltvlea charge will be assessed fur ea payments
run made within 10 diya of due date Or Me schedule DOW
Its propose helot)),to kunleh material and labor-complete accordance with the above ep9C11.-,• s,tor'the sum , y��y�,
!RLf, �A At a W it. - �,.��) -,.. :I- Y / II/�M f.N"'
Said amount shatl be paid as follows; ,
Nate,This proposal may be withdrawn by us it not accepted within days_
YOU THE BUYER,MAT CANCEL.THIS TRANa1A+ert'tw l AT ANY TIME Mori TO aMONpONIT or THE TRIAD DUeINBO9 DIY AMR T148
DAY OF THIS TRANSACTION.SEE THE ATTACHED NOVICE OF CANCELLATION FOR AN EXPLANATION OF THIS RIGHT:(SATURDAY
E$A LEGAL BUSINESS DAY IN CONNECTICUT.)THIS BALL IS SUBJECT TO THE PROVISIONS OF THE HOME SOLICITATION SALES
ACT AND THE HOME IMPROVEMENT Aar THIS INSVN ISISS NN;, . - E.
Signature of Contreolor Ar authorized representative' �•�f '' ..-------
w+ar.
'VW")here mud the tam's abated herein, have been aaplalned to(tne/w).and W>W$find thorn so be NelielatiV and y
aotx><rt awn. L Ai f SW$ 6►�r-- !tsttAL- i-- !Y1a
Signature of Horruowner(s)IN .o-= .. y....._ pit : M _
NOTICE OF CANCELLATION Date of Transaction ~
YOU MAY CANCEL TRIO TRANSACTION,WITHOUT ANY PENALTY 014 OBLIGATION,WITHIN THREE BUSINESS DAYS FR M THE ABOVE
DATE,IF WV c`"AHCEL,ANDY PROPERTY TRADED IN,ANDY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY
HI/CO 39 'd1 JLS3H3O 3O 3e!VOINI'lO E899E03OO81 ZO:TT ETOZ/60/01
The Commonwealth of Massachusetts
„r„.....,
Department of Industrial Accidents
Office of Investigations
• 7? 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
,..._,
Name (Business/Organizationllndividual): Wifj-- ..._. _VV_ysjae,______ ---i--
---
e"A
_
City/State/Zip: , • 5 ip •\ m_____A- Phone #:
I Are you an employer?Chec the appropriate box:
Type of project(required): 1
1. I am a employer with q____
El am a sole proprietor or listed on the attached sheet
and/or part-time) *
!I ?,El I rartner- 4. El I am a general contractor and I
employees(full
have hired the sub-contractors
. 6. 0 New construction
7 0 Remodeling
1 ship and have no employees These sub-contractors have i 8. El Demolition
employees and have workers' I —
working for me in any capacity,
i 9. [_.] Building addition
1 No workers' comp. insurance comp. insurance.1" .
I required.] 5 7 We are a corporation and its 10.1-1 Electrical repairs or additions
1
1 3.0 1 am a homeowner doing all work officers have exercised their 1 I I.0 Plumbing repairs or additions
my sel f. [No workers' comp.
- + right of exemption per MGL
.C.1
c. 152, §1(4),anti-we have no 12 Roof repairs
insurance required.]
employees. [No workers' ! 1 3. 1.-Other f-e."--- V—C-D(Er_____
I comp. insurance required.) _j
Any applicant that checks box Al must also fill out the section below showing their workers'compensation policy information.
t I 10111COVvIleiS W110 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 ot the sub-contractors and state whether or not those entities have
employees. lithe sub-contractors have employees,they must NIA ide their workers'Lorop.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:
Policy#or Self-ins. Lie,#:L.V._.(22 tps Expiration Date: 3/ 1,9-1/1-
Job Site Address: I 'Or\C`i,\.`C\ t)*- i.:.ity/State/Lip:_
C kOICC,fle ..... ill 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 [MA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
I
...
Signature: • A.,. .. - MA #\ 'ilf-Ak. Date: (0 I qi (3
Phone#:
Official use only. Do not write in this area,to be completed by city or town official 1
1 City or Town: Permit/License# II
Issuing Authority: Building Department
Phone# (4131. 499-9440
- , ,
ll
I
11
li
1 . i
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: \ Not Applicable ❑
Name of License Holder: Q--(7)\a(i Z_ 1 1�`l l l ' I Cj (. 1
License Number
9- r_i141 � .L C , � `� 1� . S \\
yo. Expiration Dae
S. At:Ai / it - 1
Signature Te-phone
9. Registered Home Improvement Contractor: Not Applicable 0
J `7 vc \-e3 (`f\t' \(`n I 0 X S O
Company Name Registration Number
(c4 ale ∎ it �
Address Expiration ate
? /� pry
-- ,f.,d1iti1
Telephone \ 3 —
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) MD/6
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing fp
Or Doors CD
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[0] Other[0]
Brief Dggscription of Proposed^ F� P d'`S'sposQ c's- die` fi`h3 'JY1``n9 S 'z 6"-r'-15 5 F�
W rk:"�- \ \S \\ vEw y' f' f (Ce '� 1��C� '� (��'1►Yl t`, 5Lj s`]-e rn , (rev)?' p\
`("cot'S. Cobra_ `\�� rI e 'er -V\ 1< one \Alt) 5ho1nq`c t
Alteration o1 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 V 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? V 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'PCt) SC.V\Ck C , as Owner of the subject
property '
hereby authorize ' `C\ v1 Q j 6 c \ J(Th(\c—
to act on my behalf, in all matters relative to work authorized by this building permit application.
S—J2-12 C Y1A-' CAC A— `01 q I 3
Signature of Owner Date
I, \J r CO() RU — v\5& f 71(`(\� ,(Yl YaVLf'ilit vley' , as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
rte. �� � �Y a
Print Name
o/ 413
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 DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW ® 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 O NO (X
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, grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO (r‘)?
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
w , Department use only
, ,-----, - -7-7 : ,,i \-1`\ 1' ity of Northampton Status of Permit
C
1
�1 ,.,I.uilding Department Curb Cut/Driveway Permit
' 212 Main Street Sewer/Septic Availability
0''' 1 1 2
Room 100 Water/Well Availability
Plumbing Gm.as Inspec 1 ns
oio,600 ampton, MA 01060 Two Sets of Structural Plans
ElectrlNorthampton, e , 13-587-1240 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
11 'MCA\Yl c)'\-- Map Lot Unit
F\O-ce r\Ce G. Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
\ �€-Wn S Can cue {• j 9-8-0 6ck. 5∎./ . X51 Vc� v4)c -F .r
Name(Print) Ct r t ailin dress,
_ Telephone
Signature
2.2 Authorized Agent:
V' 5A o ` \o n u e X A Q?%1 1$' 3 ( Ave r cable _ L) . - -P l
Name(Print) Current Mailing Address:
A LE t3 —0aqCI
ture Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 6999 (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) 99' ? Check Number 0251/ $'3J"
I This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
17 MAIN ST BP-2014-0448
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A-082 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-2014-0448,
Project# JS-2014-000771
Est.Cost: $5999.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VISTA HOME IMPROVEMENT 106156
Lot Size(sq. ft.): 10323.72 Owner: SCHAEFER JEAN
Zoning: GB(100)/ Applicant: VISTA HOME IMPROVEMENT
AT: 17 MAIN ST
Applicant Address: Phone: Insurance:
1346 ELM ST (413) 382-0249 WC
WEST SPRINGFIELDMA01089 ISSUED ON:10/11/2013 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 10/11/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner