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43-089 STURDY HOME IMPROVEMENT, INC. ACCEPTAiVCE PAGE MA REG. #151711 CT REG. #0601525 ANY WORK NOT STATED ON PREVIOUS PAGES IS EXCLUDED The following schedule will be adhered to unless circumstances beyond the contractor's control arise: Work scheduled to begin the week of----/..../ . Expected completion date-----/ /----Weather permitting. The cash price for labor and material as described above is: 1st payment 2nd payment 3rd payment 4th payment Contract Total (upon signing) Roof $ °i i j $ ,/ L. Ventilation $ Other work $ r 5 Roofing total $ $ $ Siding $ $__ $ $ $ Windows $ $ $ $ $ Special orders $ $ $ _ $ $ Other $ $ moo $ $ $ Totals $ ` t ;t%t. $ , �..� $ s $ $ + Terms: X1 Cash _Finance `+ Credit Card:#— — — — " —=4' —=.. 1, } ► ' , €,, — Ex p.date---- / ----Code— — — - - - — Payment schedule: Any balance not paid in full within thirty days, will be charged 1.8%interest per month. In order to meet the completion schedule, the following material/equipment must be SPECIAL ORDERED before the contracted work begins. (Law requires that any deposit or down-payment required by the contractor before work begins,may not exceed the greater of(a.)one-third of the total contract price or(b.)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule) $ to be paid for $ to be paid for Any additional work orders are to be paid for once accepted and approved by purchaser. Verbal understandings and agreements with representatives shall not be binding. All understandings and agreements must be set forth in writing in this contrast. Additional provisions are stated on reverse side and are part of this contract. In witness whereof Purchaser(s)has/have hereunto signed their names this '. day of 20, — and acknowledge receipt of a true copy of this contract. UNLESS OTHERWISE SPECIFIED, IT IS UNDERSTOOD THAT THE OWNER IS READY FOR THE WORK TO BEGIN. THE PURCHASE PRICE QUOTED ABOVE WILL BE HONORED ONLY UNTIL (Date). r... x You the Purchaser(s)may cancel this transaction at any time prior to midnight of the third busirleas day after th`¢data pf his transaction.See notice of cancella- L... tion form for an explanation of this right. Signature affixed below also acts as receipt that Pur,L�tiaser(S)re6Ae�separate cancellation forms. The following is a requirement by Massachusetts General Law,Home Improvement Contractor Law MGL c 142A: 'The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided in MGL c 142A. Representative: rr„W ` ' {} Owner: Owner: NOTICE.-The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor. The owner may initiate alternative dispute resolution even where this section is not signed separately by the parties” Do not sign this contract if there are any blank spaces Submitted'/ Accepted bv- Representative Purchaser 'Dafe' Accepted Accepted by: by: — -- Representative Purchaser Date 459 Main Street Toll Free (877)378-8739 Indian Orchard, MA 01151 Worcester (508)797-6600 E-mail: HR®SturdyHome.com Springfield (413) 543-5906 S www.SturdyHome.com New Haven (203) 848-2118 Fax (413)543-3200 HOME IMPROVEMENT, INC. MA REG. #151711 CT REG. #0601525 WINDOWS • SIDING • ROOFING • ADDITIONS Name Home Phone Business Phone �f Address Cell Phone Other Town/City Representative Date I/we the owner(s)of the premises described hereinafter, referred to as Owner,offer to contract with Sturdy Home Improvement, Inc. hereinafter referred to as Contractor, to furnish, deliver and arrange for installation of all materials to improve the premises as described below. Yes No ROOFING SCOPE OF WORK: ❑ 1. Contractor to obtain required building permit(see attached permit authorization form) 1 . 2_ 3_ Family home. d ❑ 2. Provide certificate of insurance for workers compensation, general liability. (see attachedcertificates). f] ❑ 3. Provide job site dumpster, set on planks,to remove job related debris only. Please Note: dumpster for contractor's use only. (see dumpster clause). 00 ❑ 4. Prior to stripping roof,tarp sides of house beneath work area, from roof edge to bottom of wall. (see additional protection clause on back). d ❑ 5. Keep job site in a clean and orderly manner. Rake work areas at end of job. Use magnetic sweep to pick up nails: IEII ❑ 6. Provide OSHA approved staging to safely perform work. a ❑ 7. Work consecutive days excluding inclement weather. (rain, snow,high winds, high heat, thunder showers, etc). ❑ ❑ 8. Staff project with qualified mechanics experienced in residential asphalt roofing. ❑ ❑ 9. Strip existing 1_ 2,V; 3_layers of asphalt roofing (see roof plan, page 2). Number of squares A. one layer cedar removal. Number of squares B. - one layer slate removal. Number of squares U ❑ 10. Inspect roof deck prior to re-roofing. Renail loose boards: A. Replace rotted or cracked boards at$ ` per linear foot. B. Install new plywood at$ I F I per sheet. C. Number of sheets of plywood Included into this estimate: Quantity (see unit cost above,for.additional sheets). ❑ L)11. Furnish and install ( j I �k`" !I s i '` ►:,t t •A shingles. Color ❑ ❑12. Furnish and install 8"aluminum drip edge around roof perimeter.White :: Mill Brown ❑ L, 13. Install cedar drip edge at eaves under aluminum drip edge. Linear ft d ❑14. Furnish and install ice/water shield at eaves 3' �6' other. Three feet in valleys and around all roof penetrations. �] ❑15. Furnish and install underlayment to entire roof. Roofer select K Diamond Deck ❑16.Furnish and install starter course shingles, eaves&rake. ❑ 17. Furnish and install hip and ridge cap. ,d ❑18. Furnish and install new neoprene roof boots at soil pipes up to 4"in diameter. Quantity Size i (boots at electrical mast to be reused). ❑ t]19. Reuse stove pipe flashing kits. I] ❑20. Reuse existing step flashing at roof/wall intersections. ❑ ❑21. Furnish and install new " aluminum copper step flashing at roof/wall intersections. Linear feet . If siding work is needed, a cost assessment will be made at that time. ] ❑22. Reuse existing wall flashing at roof/wall intersection. ❑ d 23. Furnish and install new aluminum wall flashing at roof/wall intersections. Linear feet . If siding work is needed, a cost assessment will be made a+!hat time. j Sp d L)24. Furnish and install new , aluminum s copper step flashing at base of chimney under existing lead counter flashing. ,I] ❑25. Replace chimney lead counter flashing. 1 flue LL. 2 flues 3 flues other ❑ ❑26. Install I new roof hood to vent bathroom(s)with insulated flexible tube. Remove roof deck to gain access into attic. Color: black only. ❑ ]27. Gutter Helmets to be removed and reinstalled by others. ❑ ❑28. Remove and dispose of gutters attached with spike and ferrule. ❑ ❑29. Remove and reinstall existing gutters strapped to roof. Install straps under shingle over shingles 'Cl ❑30. Remove and reinstall existing gutters with hidden hangers. Linear feet ❑ E)31. Reuse skylight flashing kits Replace skylight flashing kits Quantity (Velux models, stock only). ❑ ,❑32. Remove and dispose of the following:Antenna Snow/Ice Wires Snow Guards/Ice belts Solar panels ❑ I]33, Remove Satellite Dish up to 24'in diameter. Alignment and installation by others. • ❑34. Page Two= ROOF PLAN. • ❑35. Page Three=VENTILATION. ❑ ❑36. Page Four=VENTILATION PLAN. ❑ a 37. Addendum (A) =OTHER WORK. ❑ 38. Addendum (B) =LOW SLOPE ROOFING. ❑ ❑39. Acceptance Page Initials Initials Initials HOME I MPROVEM ENT sTURDY WORCESTER SPRINGFIELD HARTFORD 459 MAIN STREET-P.O.BOX 51033-SPRINGFIELD,MA 01151 MA.REG#151711 CT.REG#601525 1-877-3-STURDY 508-797-6600 413-543-5906 FAX 413-543-3200 OWNER PERMIT AUTHORIZATION Name:. IAddress: City/ State /Zip: VA (Owner), of the property located at: U = authorize Sturdy Home Improvement Inc. to act as my agent for the construction project taking place at the above address. I also authorize Sturdy Home Improvement Inc. to obtain a building permit. I understand and accept responsibility to comply with all regulations and required inspections. Signature of Owner: ,[ G na4-9-- Date: 1 Page 1 of 1 The Commonwealth of Massachusetts Lh Department of Industrial Accidents MW IR Office of Investigations 600 Washington Street U1W Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): S Address: O` H ma( If 1 :±a-e+ City/State/Zip:-._ n I Q ii (I ft rl M)}, n( f5I Phone #: l --SLl Are y6u an employer? Check the appropriate box: Type of project(required): 1. I am a employer with Y 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.F] I am a sole proprietor or partner- listed on the attached sheet. F-1 Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.[:1 Otherj Ql comp. insurance required.] *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. f 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 their workers'comp. policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _ }��II _ Insurance Company Name: I w-ue1� —�-- �r��c Policy#or Self-ins. Lie. #: �{� �� — Expiration Date: J Job Site Address: ��1 tj±ie�� r � City/State/Zip: ( n�P� �,66,2 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 and penalties of perjury that the information provided above is true and correct Signature: Date 3 I ' Phone# 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 S. Plumbing Inspector 6. Other Contact Person: Phone#: t, Office of Consumer Affair s / � T Vatxon 0 fax Plaza Suite 5 170 Boston, M,4ssachusctcs 02116 " Home Zmpro-vei g ontxactox Registration Registration: 15171'1 Type: Supplement Card Ex iration: 6/26/2016 «..t�n-°Y�� P' STURDY HOME IMPROVEMENT, j" '-, DAVID DIAZ UN 459 MAIN STREET '��-Y= INDIAN ORCHARD MA 01151 'v �� :�,,ti ' Update Address and return card,Mark reason for change. E]Address ❑ RenewaI E] Employment E] Lost Card Vl1C L/'n771?Jt091CO000If/L P��i�[Cl11CCC✓1CCICffS ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation egisiration; 1",x.711 Type: 10-Park Plaza-Suite 5170 Expiration:,=g.. &�6, Supplement Card Boston,MA,02116 STURDY HOME INIPRQ EMEffl-NG e Jr DAVID DIAZ o 459 MAIN STREET �� �� 0- _-- �° INDIAN ORCHARD,MA 01151 Undersecretary Not valid without sign .e Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-093603 Construction Supervisor DAVID DIAZ 270 TREMONT ST i SPRINGFIELD MA 0� t�=/{►^^� �/�— Expiration: Commissioner 08/07/2017 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) TNLS.GERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: ORCHARD INS AGCY INC PHONE FAX PO BOX 51088 (AIC,No,Ext): (A/C,No): E-MAIL INDIAN ORCHARD,MA 01151 ADDRESS: 28YCR INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA STURDY HOME IMPROVEMENT,INC INSURER B: INSURER C: INSURER D: PO BOX 51033 INSURER E: INDIAN ORCHARD,MA 01151 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTH POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDMYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ ff::CLAIMS MADE [:]OCCUR. PREMISES(Ea occurrence) MED EXP(Anyone person) $ GEN'LAGGREGATE LIMIT APPLIES PER: $ PERSONAL&ADV INJURY GENERAL AGGREGATE $ POLICY PROJECT❑LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB 8 OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND X =WCSTATUTORY OTHER EMPLOYER'S LIABILITY YIN UB-5B368505-15 07/21/2015 07/21/2016 ANY PROPERITOR/PXCLUDEDXECUTIVE � NIA E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONSI LOCATIONS NEHICLESIRESTRICTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION.A All rights reserved. '4 ® CERTIFICATE OF LIABILITY INSURANCE 1R° DATE(MMIDDIYYYY) 8/10/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NTACT NAME: Nadine West Orchard-Dowd Insurance Agency LLC PHONE FAX 14 Bobala Road A/C No Ext: -437-1050 A/C No: - - E-MAIL Holyoke MA 01040 ADDRESS: nwest @dowd.com PRODUCER CUSTOMER ID#:STURHOM-02 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:Atlantic Casualty Insurance Company 42814 Sturdy Home Improvement, Inc. INSURER B P.O. Box 51033 Indian Orchard MA 01151 INSURERC: _ INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1576065919 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR - POLICY NUMBER MMIDDY/YYYY MM/DDYIYYYY LIMITS A GENERAL LIABILITY TBD 8/7/2015 8/7/2016 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED 50,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE I—]OCCUR ME EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $1,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ER ANY PROPRIETOR/PARTNER/EXECUTIVE� N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers' Compensation Certificate of Insurance to follow separately from the carrier. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Sturdy Home Imrovement, Inc. P.O. Box 51033 Indian Orchard MA 01151 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: \ /� N�1ot Applicable 0 Name of License Holder:. �U d � il12„ l � �.✓`1 License Number am kml 1 t- r lie Is .1111►are bdCr (Q A <91 -711'-f Address �r (J' ` Expira on D to Signature Telephone 9. Registered Home Im rovement'Contractor: Not Applicable ❑ Y h I �r 1 j�f 71 CompanV Nam I Registration Number Mal a St zrd t`(i a d � t fC( ,A R- G t5 I k 12-6 1� t- Address Expiration Date Telephone X113-S43--1 Y 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) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other[�] Brief D sgnption of Proposed /r Work: l+ '; K i Q era r existn � t room 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, L` as Owner of the subject property hereby authorize to act on my behalf, in all matters rela ve to work authorized by thi building permit application. Signature of Owner Date I, ofJU , lrnorcuea�f-'�� , as Owner/Authorized Agent hereby declare at the statements and inforniation on the foregoing applitalion are true and accurate,to the best of my knowledge and belief. Signed under the pains and p ties of perjury. Print N L Signature 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 s 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 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 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 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 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb:Cut/DrivewayPermit 212 Main Street Sewer/Septic Availability ` Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of structural Plans .'.� phont? 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify `TPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING CTION 1 -SITE INFORMATION 1.1 Pro`peaty Address: This section to be completed by office W uq h r'rl i e Map Lot Unit —,��e��e Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: R61 &LL)an SL4 yjhlfher Name(Print) Current Mailing Address: Telephone Signature ) 2.2 Authorized Accent: Nam t) Current Mailing Address: e / q)3— SLa b�f I I D14 Signature Telephone SECTION 3-ESTIMATED CO TRUCTION 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 Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total = 0 +2+3+4+5) LI '2Q0 Check Number VLIL This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 84 WHITTIER ST BP-2016-0332 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 43-089 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2016-0332 Project# JS-2016-000538 Est. Cost: $14200.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STURDY HOME IMPROVEMENT 093603 Lot Size(sq. ft.): 54014.40 Owner: ROWAN KATHLEEN N Zoning-: Applicant: STURDY HOME IMPROVEMENT AT. 84 WHITTIER ST Applicant Address: Phone: Insurance: P O BOX 51033 (413) 543-5906 WC INDIAN ORCHARDMA01151 ISSUED ON.•911412015 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 9/14/2015 0:00:00 $40.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner