13-089 information. U
z Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new
4 affidavit indicating such.'Contractors that check this box must attached an additional sheet showing the name of the sub-
b contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide
their workers'comp.policy number.
Wy SV v
I am an employer that is providing workers'compensation insurance for my employees. Below is
the policy and job site information.
Insurance Company Name: Afm ru,L _
Policy#or Self-ins. Lic.#: WM Z 9ookoo 6 49J201/3A All#I* / Expiration Date: 11-24-1 N
Job Site Address: rG/c�w f��e l►hT! Rune( City/State/Zip: Vprlhwn Of/', .*A,.G/ub V
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 andpenalties ofperjury that the information provided above is true and correct
Signature: Ae�A_ Date:
Phone#:1C/11 27 —U7 u l
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
Inc %-Unintanwcunn of lvlu��uutu�ctta
Department of Industrial Accidents
Office of Investigations
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): ARS Sr'-wt>J
Address: R Craf-f ST
City/State/Zip: 4/6,/'oK /)7A 0 0.1L15 6 Phone #: IV C/7 -147- Mel
Are you an employer?Check the appropi Type of project(required):
box:
1.ffI am a employer with } 6. New construction
employees(full and/or part-time).* 2.F] I
am a sole proprietor or partner- ship
and have no employees working for 7. Remodeling
me in any capacity.
[No workers' comp. insurance
8. Demolition
required.]
3. Q I am a homeowner doing all work4. I am a general contractor and
myself. [No workers' comp. I have hired the sub-contractors 9. Building addition
insurance required.] t listed on the attached sheet.
These sub-contractors have 10. Electrical repairs or additions
employees and have workers'
comp.insurance.$
5. We are a corporation and its 11. Plumbing repairs or additions
officers have exercised their
right of exemption per MGL
c. 152, §1(4),and we have no 12. Roof repairs
employees. [No workers'
comp. insurance required.] 13 Other 13{pg),,-.r
May. 1. 2014 11 ; 31RM No. 4013 P. 2
rii,c , Flood , Smoke, Sold, Reconstructfoti
- 4 C
v l f 7 /
� 4 5 1 1 1 1 1 a r>,° tt w a 1' t' .f v k, C. o ilr
PROPOSAL
Phone.')917)359-2113 tart. Data:21612OA4
To. IVAN ORANSKY
116 Rockland Heights Road
Northampton,MA 01060'
JOB Ill. S14-1047
Job NamnAocaUan;
116 Rockland Height*Road
Northampton,MA 01060
E HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR: REPAIR RECONSTRUCTION:
Purchase and installation of materials as specified in the attached scope of work.Please note we do not schedule a Job untliwe have received a copy of the signed proposal,V wrl(
authorization,selection sheet,and deposit(If applicable).
aymeht terms as follows:,
$1,000......................... ......:Due upon signature
$12,181.23............................Due upon completion of work
e propose hereby to furnish material and labor-complete In actordance with the above spedRcations,for the sum of;Twelve Thousand One Hundred and eighty one Dollars and TwaAly Three Cents
Payment to be made as follows: SEE TERMS ABOVE.1.5%Interest per month will be charged on past due accounts over 30 days,should collection proceedings be Instituted for paymen
customer agrees to pay reasonable attorney's fees,court costs,and other costs Incurred.There will be a 5250 charge for any returned checks,All changer orders are subject to an
administrative fee of$75.00 perchange order,
Any controversy or claim arising out of or relating to this contract,or the breach thereof,shall be settled by arbitration before one arbitrator administered by the American Arbipfadon
Association(AAA)under Its Construction Industry Arbitration Rules,and Judgment on the award rendered by the arbitrator may he entered in any court havingJurlsdiction thereof,If the
arbitration process results in a monetary reward to the contractor,the customer will pay the AAA's administrative fees,In all other cases,the fees will be split evenly by both parties,As
an alternative to arbitration,both parties may voluntarily agree to have the matter settled in the appropriate Small Claims Sesslon or otherTrial Court of Massachusetts,as appropriate,
Such an agreement must be put In writing and signed by bath parties. If either party does not agree to submit the action to Small claims,the arbitration clause contained herein shall bell
full force and effect.
Contractor warrants for a period of one year from the dace of the suhstentlal completion of work that It is free from defects which would make It not fit for the use for whkh It is
normally intended
Authorized A.RS.Services Signature Amy Meo This Contract is valid for -5,0 days,
Date of Acceptance; Acceptance of proposal-The above Slgnature
prices,spedfieadons and conditions aresatrsfactory and are hereby accepted.
You are authorized to do the work as specifled, Payment will boa made as outlined
above. Slgnature
white copy i7 to berelurned Yeauweoprisloryaurrecor67
,ARS, Always Ready to Serve Throughout New England
2417/365 Emergency Service 1.877.461-11x1 www.argservexom
Signature of Owner Date
I. �krv,c+l l eh'u as Owner ized
Agen 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.
Arf sfr'yrC-,1 Chrll
Print Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder: l/rom (�:S FA - /VL o 7 2
License Number
61 Tr It Crerrl Garo/n•r' INA 0 J yI-/v l 21 iT/2071.
Address Expiration Date
272 0/0/
Signature Telephone
9. Registered Home improvement Contractor:
i
Not Applicable
.S ,Str c+J
Company Name
3? Crd1zT''J Sfi n.r nn,
,# Registration Number
Address
Telephone'f-//7 -172 0101 Expiration Date
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...... o,
May. 1. 2014 11 : 37AM No, 4013 P, 3
Signature of Owner bate
C
as owner&Xwrizad
AAeni/hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
anMellef.
Signed under the palns and penalties of perjury.
A/'I Srrva�l l !��• 1l�'//yb.a.n
Print Name
4gnalure or owner/Agent Date
SECTION 8-.CONSTRUCTION SERVICES
8.1.LI can sed.Construction 5uperylsor: .. .. Not Applicable
Name of Lfaens�Holder', .�.i'pl� ��ka�� - _ • - 1176 E3 7z
Llcenae Number
l ExpirtionDafa NA
Address
'-//? 27;?-0 /
Signature Telephone
:RRe leered:.ometilm ro�i'erlle C;Cbh"t C�OI�'�f�6��'$:��J':I��t'�k�Ul:.•ra,':(•Y'�...,:°'�.b..,�`F,?(���'.:�.H�',I.rt�� i���l
nn Not Applicable �
/�l).S .StrUrz+J
Company Name /b fe�-j I r
- Registration Number
Y Cry,fir'.► g erx,.,rte. /h�
Address 71,r9 T bro I y
Telephone G/17 010i Expiration Date
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIbAVIT(M.G.L.c.152,§25C(6)) j
Workors Compensation.lnsurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result. .
' in the denial of the lssuence of the building permit.
8i ned Aflidavlt Attached Yes....... oO' No...... 0
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. Demolition New Decks Signs g [ ] [ ] Siding[ ] Other[ ]
Brief Description of Proposed
Work: rg f�rit�oc% a.it 14'rtall. \rU"f '07/vur
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, lVa e as Owner of the subject
property
hereby authorize Afls srrvr1rJZCh,d Hdltb.-..,4 to
act on my behalf, in all matters relative to work authorized by this building permit application.
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
ON'T KN YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO N'T KNO YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES V0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, excavation, or fillin )over 1 acre or is it part of a common
plan that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
DCity of Northampton Sttu " Permlt
MIS' BUilding Department Curb Cut/3 vewa ' e rt
-7 r 212 Main Street Sevier/Sept c y a ab '
Room 100 �fiVaMrietl rlat �� °
�'' a a.�
i rthampton, MA 01060 Teo ets�#St
Electric Plur4
mbrngl Q a 41 -587-1240 Fax 413-587-1272 Pigt/S e ans
N��th ,nto nspectio
A 07060 ns OherS eCl sr
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
II G gockl4../f Hr,o1'`s R Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: // ' I/
--VI(oM n r o!n.r k -J Io 0 W . 1y 3,./4 sr
Name(Print) Current Mailing Address:
212-d-116r-Cl 1i0
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
i SUU•U v Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total = 0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-1139
APPLICANT/CONTACT PERSON A R S SERVICES
ADDRESS/PHONE 38 CRAFTS AVE NEWTON (413)272-0101
PROPERTY LOCATION 116 ROCKLAND HEIGHTS RD
MAP 13 PARCEL 089 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building,Permit Filled out A o4
Fee Paid
Typeof Construction: REPAIR SHEETROCK&INSTALL WOOD FLOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included• -
Owner/Statement or License 106072
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
elay /
Si re o B ilding ffi ial 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.
116 ROCKLAND HEIGHTS RD BP-2014-1139
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 13 -089 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2014-1139
Project# JS-2014-001915
Est.Cost: $20000.00
Fee: $120.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: A R S SERVICES 106072
Lot Size(sg. ft.): 350222.40 Owner: ORANSKY IVAN&CATHERINE E VOJDIK
Zoning: Applicant: A R S SERVICES
AT. 116 ROCKLAND HEIGHTS RD
Applicant Address: Phone: Insurance:
38 CRAFTS AVE (413) 272-0101 WC
NEWTONMA02456 ISSUED ON.51512014 0:00:00
TO PERFORM THE FOLLOWING WORK.REPAIR SHEETROCK& INSTALL WOOD FLOOR
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 5/5/2014 0:00:00 $120.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner