31A-008 (2) - woofing Propo al -
CT.AEG.No.0621848 • Page No. of Pages
MA REG.No. 162058 Vista,
HOME IMPROVEMENT
2003 RIVERDALE STREET
WEST SPRINGFIELD,MA 01089
Toll Free:1-888-597-2323-Local:413-382-0249
FAX:413-382-0241 '>
Proposal Submitted To Homeowner Work To Be Performed At
Named ' Name _
Streetl� St-reeet `
City h t? IA r k yt T I-` State�Zip .'"rCity `- -' State—Zip
Date `t Telephone �— Date Telephone
Vista Home Improvement agrees to do the following:
Acquire all permits for roofing work ❑Material Location _
❑Shingle Over Tear Off Omi.House ❑Garage ❑Shed ❑Supply Dumpster-Location
❑Inspect Decking for damage t❑Replace Decking @ per sheet
Install all New Decking-Type//.,,.,, C C� oer sheet
Roofing MFG�f!kl �,Of..ColorAV#fri Style 9?5— 64-/Brown drip edge dF-8 F-5
.�Deck Underlayment Ll#15 Felt ❑Rhino Liner ❑ 61 L`1-`: N!!3t
LI Ice and water Barrier LJ 3' U 6' ❑Full ❑Flash all valleys,penetrations,eaves and chimneys
Supply and install pipe boot flashing ❑Supply and install ridge vent ❑Generic I]Cobra Exhaust
U Supply and Install vent kit ❑Supply and install soffit vents- Oty. . R&R Gutters 'Id/Total Job Clean-Up
Supply and install 12 in.lead on chimney e a, �'
r'frV/-A nom,"°
WARRANTY
❑Standard ❑System Pius ❑Golden Pledge a
a
Attention Homeowners:Please cover all personal belongings in the attic,garage,or storage areas due to the possibility of roofing
debris or dust coming throught the cracks of the wood.Vista Home improvement will not be responsible for debris or dust In the areas
mentioned.Also Vista is not responsible for gaps from siding on home and root line due to multi layer strips.
A T Rolled/Rubber Roofing Type /li✓L 4 A/Oi- Color �vAfr''T s'- Location—
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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 collection,including reasonable attorneys fees,in addition to other
damages Incurred by contractor.An 18%per month service charge will be assessed for all payments not made within 10 days of due date per the
schedule below:
We propose hereby to furnish material and labor-complete in accordance with the above specifications,for the sum of:
Said amount shall be paid as follows:
Note:This proposal may be wNhdrwm 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 IS N T NEGO
Signature of Contractor or authorized representative:
'(M)have read the terms stated hsttp,they h e ensxplalned to(me/us,and(1/We)11nd them to be satisfactory and hereby accept them.
Signature of Homeowner($): X -?e X__
f The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
k9 600 Washington Street
Boston,Mass 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/organization/Individual):VISTA HOME IMPROVEMENT/ BRIAN RUDD
Address:2003 RIVERDALE ST.
City/State/Zip:WEST SPRINGFIELD, MA 01089 phone4.413-382-0249
Are you an employer?Check the appropriate box: Type of project(required):
1.OI am an employer with 9 4.O I am a general contractor and 1 6.0 New construction
employees(full and/or part time).* have hired the sub-contractors 7.0 Remodeling
2.0 I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8.0 Demolition
working for me in any capacity. employees and have workers' 9.0 Building addition
[No workers' comp.insurance comp. insurance.$
required] 5.0We 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 perm MGL
insurance required] t c. 152, § 1(4),and we have no 12.0 Roof repairs
employees. [no workers' 13.1Other
comp. insurance required.]
*Any applicant that checks box#1 must also 611 out the section below showing their workers'compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contactors that check this box must attach 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. SOUTHWICK INSURANCE
Insurance Company Name:
Policy#or Self-ins.Lice.#:JUB2E072183 Expiration Date:03/12/2015
Job Site Address: i 04 S� City/State/Zip: t/ 1✓y� rv_�_.GL�� ,�(�/1 �l��c 0
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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
/� ,,�-�� ,
Si nature: �z-.�-.-
Date:
Print Name: BRIAN RUDD Phone#: 413-382-0249
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 Heath 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 Supervisor: Not Applicable ❑
Name of License Holder: r Ca i7 C 1 60A -k +jjle IS
License Number
L6D. '1��� ANA C)i CGS"L0 l i t 11 1 1 5
Address Expirati n Dale
11 i-01
Signature V Telephone
l"
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration-lumber
Or'?`- vzlr. SV� tom E1 el nnA 01C-13"`I
Address –� Expira on Dat
Telephone1
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 buildin g 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)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [M Siding[[7] Other[Ci]
Brief Description of Proposed
Work: T � ►�rdc =
Alteration of existing bedroom Yes No Adding new bedroom Yes t," No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the followina:
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
as Owner of the subject
property
hereby authorize V i s _i-k- oe,prt5yLeY�i? 4- VN' ^
to act on my behalf, in all matters relative to work authorized by his building permit application.
lee C >>yl Y'ZLC-A- l
Signature of Owner Date
as Owner/Authorized
Agenl hereby declare that the Atatements and intbrmation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
P-' it L�
Print Name
Signs ure 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 0 DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO � DONT KNOW O YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO l'*' DON'T KNOW o 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 a NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O 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 I
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
L Department use only
City of Northampton Status of Permit:
2014 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Gas inspections Room 100 Water/Well Availability
MA 01060 rthampton, MA 01060 Two Sets of Structural Plans
phone 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
Z5 q F—I rh 51+ Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
DELIA MARTINEZ 289 ELM ST.NORTHAMPTON,MA 01060
Name(Print) Current Mailing Address: 413-387-5765
c5tr C s t/�' � '� 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 14,705 (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=0 +2+3+4+5)
14,705 Check Number S
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
289 ELM ST BP-2015-0246
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 A-008 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-2015-0246
Project# JS-2015-000464
Est. Cost: $14705.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VISTA HOME IMPROVEMENT 106156
Lot Size(sc. ft.): 35327.16 Owner: MARTINEZ DELIA
Zoning. URB(100)/ Applicant: VISTA HOME IMPROVEMENT
AT. 289 ELM ST
Applicant Address: Phone: Insurance:
2003 RIVERDALE ST (413) 382-0249 WC
WEST SPRINGFIELDMA01089 ISSUED ON.•91312 01 4 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 Siznature:
FeeType: Date Paid: Amount:
Building 9/3/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner