Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
13-023 (3)
aacolion* 1 � Mrr WEE p.4. Ntk ©A079 -tF14 f satw �u Weis �qRuis►�°' Buwoo ,... l �� (• Y t RIGHTS TO CANCEL The Owner may Oencel this agreement if it has been signed byAe Owner at a,plane other than an ad8rtss of the.Contractor which may be his main office or a branch thereof,_ provided,that the Owner notifies the contractor in writing at his rnalm,offtwe or branch by Ordinary trail posted;'by telegram sent or by detivcry;not later than midnight of the`third business day folio Wing the signing of this agreernerit. See attached Notice of 4 Cancellation; { Lt A HOMEOWNER- DO NOT SIGN THIS CONTRACT IPTHERZ ARE ANY BLANK SPACES. Owtiar'a Signature Date Signed E Contractor 3 Due Signod i I f XIII.WARRANTIES The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of one year following completion and shall 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 or agents, is discovered within three years after completion of any job,including cleanup,the Contractor shall,at its own expense,forthwith remedy, repair,correct,replace,or cause to be remedied, repaired, or replaced, such damage or such defect in materials or workmanship based on Commercial Construction Performance Guidelines for Professional Builders and Remodelers.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. All warranties for equipment supplied by the Contractor under this Agreement shall be those given by the manufacturers of such equipment, which shall be and are hereby passed through directly to the Owner. Under such manufacturers' warranties,the Owner may be required to register or mail in a warranty card or other evidence of ownership and use of such equipment in order to activate such warranties. The Owner's failure to mail in or register such documentation,which failure voids the manufacturer's warranty,shall not create any responsibility for the Contractor to warranty such equipment. This warranty gives the Owner specific legal rights, and Owner may also have other rights, which vary from state to state. Under Massachusetts law,sales of goods carry an implied warranty of merchantability and fitness for a particular purpose. XIV. COMPLETENESS OF AGREEMENT FOR EXECUTION The Owner is hereby advised that the Owner should not sign this Agreement unless and until all blank sections have been filled in or marked as void, deleted or not applicable,and until all exhibits and related or referenced documents that are incorporated herein are attached hereto. XV.COPY OF AGREEMENT TO BE GIVEN TO OWNER This Agreement is governed by the laws of Massachusetts. It must be executed in duplicate,and an original signed copy hereof given to the Owner at the time of execution. No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to the Owner of a copy thereof. This Agreement,including the Exhibits attached hereto,constitutes the entire agreement of the parties with respect to the subject matter hereof. The Contractor•under provisions of Chapter 142A of the General Laws is required to apply for and obtain all construction-related Permits- The Contractor shall not be seemed responsible for delays In the work described in this Agreement caused by regulatory, permit granting or inspectional.agencies,authorities or individuals._ IX.MODIFICATION This Agreement,including the provisions relating to price(Section II)and payment schedule(Section III)cannot be changed except I by a written .statement signed by both Contractor and Owner. However, canceilation by Owner Is allowed in accordance with the Notice of Cancellation(annexed). C X. CHANGE ORDER Change orders are:additional items contracted subsequent to the signing of this Agreement,the cost of which is not included in the original design and specifications stated on the original scope of work(see Exhibit I). Upon agreement of a change Tn scope to the original scope of work,a change`order forth(see Exhibit III)shall be signed.by both parties. Any additional charge established by the change order shall be due upon signing of thechange order form., Each change order'shiill be treated as a separate doritract and coiripletion of those iterris specifiedn;any change order shall not be grounds for withholding any other payments speci.ad in this Agreement. All change orders are subject to an administrative fee of$15.00 per change order. XL,COLLECTION FEES AND FILINGS Interest of 1.5% per month will be charged on past due accounts over 30 days. Should collection proceedings be instituted for Payment,Owher agrees to•pay reasonable attorney's fees,court costs,and other costs incurred. There will be a W.60 charge for.any returned checks. While no security interest is created by this Agreement,the Contractor shall have the right to file a notice of contract and a statement of account in order to create such a security interest to ensure that payment is made as required hereunder. XII.SETTLEMENT OF DISPUTES Any controversy:or claim arising out of or relating to this Agreement,or the breach thereof,shall be.settled by arbitration before one arbitrator administered.by the American Arbitration Association (AAA) under its Construction Industry Arbitration Rules and judgment on the award rendered by the arbitrator may be.entered in any court having jurisdiction thereof. 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 Session of the Trial Court of Massachusetts. Such an agreement must be put in writing and signed by both parties. If either party does not agree to submit the action to Smatl Claims,the arbitrafion clause contained herein shall be In.full force and effect, Owner'. Signature: r signature XIII.WARRANTIES The Contractor warrants that the work fbrnished hereunder shall be free from defects in materials and workmanship for a period of one year following completion and shall 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 or agents, is discovered within three years after. completion of any job,including cleanup,the Contractor shall,at its own expense;forthwith, remedy,repair,correct,replace,or cause to be remedied, repaired, or replaced,such damage or such defect in materials or workmanship based ori Commercial.Construction Performance Guitelines;for Prflfessipna),iaailders and Rem_odelers. The foregoing warranties shalisurvive any inspection performed in connection with the agreed-upon work. DETAILED DESCRIPTION OF MATERIALS TO BE USED Materials to be used in performing the above-described work consist of the following: A more detailed description of the materials to be used in performing the work is contained in the Scope of Work attached hereto as Exhibit 1. B. PRICE Contractor agrees to do all work described in Section I for the amount agreed upon with MAPFRE; with supplemental items to be determined at a later date. III. PAYMENT Payment will be made as follows: Payment I: Deductible to be collected prior to work beginning Payment 2: Remainder of balance to be paid by MAPFRE to ARS directly once Certificate of Satisfaction(COS)is signed by insured. Contractor reserves the right to bill each Iine item in the contract that has a price associated with it independently from all other line items. Payment for each line item,which has been satisfactorily completed, is due upon receipt of invoice from Contractor. More specifically,Owner agrees to not withhold payment on any item, which has been satisfactorily completed due to his/her complaint(s) with any other item(s). W.COMMENCEMENT AND COMPLETION OF WORK Contractor will not begin the work or order the materials before the third day following the signing of this Agreement,unless specified here in writing. Contractor will begin the work on or about two weeks after receipt of contract and selections,barring delay caused by circumstances beyond Contractor's control.The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. V. NO ACCELERATION OF PAYMENTS BUT ESCROWING ALLOWED The Contractor may not require payments to be made in advance of the times specified in Section III(Payment)above for the reason that Contractor deems itself or the payments to be insecure. If, however, Contractor deems itself to be insecure, Contractor may require,as a prerequisite to continuing the work described herein,that the balance of the payments under this contract that are in the control of the Owner, shall be placed in a joint escrow account that requires the signature of both the Contractor and the Owner for withdrawal. V1.INSURANCE Contractor will be responsible to Owner or any third party for any property damage or bodily injury caused by Contractor, its employees or its subcontractors in the performance of,or as a result of,the work under this Agreement. Contractor agrees to cavy insurance to cover such damage or injury. 60? �w Fire. Flood, Smoke. Mold. Reconstruction � ! 4 7 1 4 1 i I 1 1 • sPECIALisrs WORK AlJTHORIZ�A TIONICONTRACT,*DXRECTION OF PAYMENT The t►iadersigned,ns the.owner/representative of the PROPERTY,hereby authorizes and instructs ARS Services,Ine.to perform work and services due to doss submitted owSeptembier 26,2018. ;TOB NUMBER: S18-3908 CUSTOMER NAME: Susan Kan EDFPT _ STREET NAME: I9 Stonewall Drive ' "�� SO CITY; Northhampton :STATE: MA ZIP CODE: 01060 7:2018 INSURANCE COMPANY: Iv1APFRE Insurance INSURANCE_ADDUS.TER; CUSTOMER CLAIM#: PWXX91 u��_n+Nc,INSPECTIONSDATE 4F I:C)SS: September 28,2018 AMI rTON,MA o�oso W 1.) 'I hereby authorized ARS,Services,loc.to perform the,necessary work at the above property and I give the above Insurance Carrier permission to directly pay ARS Services,Inc.,for any.&all work required to restore the structure within the premises to as near pre-loss condition. L) I.n the event,that any part or whole of the authorized work is not covered by my'property insurance,I accept full responsibility for payment.I understand that 1.5°!o interest per mouth will be charged on past due accounts over 30 days. Should-collection proceedings be instituted for payment,customer agrees to pay reasonable attorney fees,court costs,and other costs incurred. There will.be a$26.00 charge for returned checks: 3.) The undersigned agrees to pay AAS Services,Inc.the deductible amount of the policy before the work'begins unless it has been deferred to other areas of the policy for said claim by'the insurance adjuster. Name(Print) Authorized MguaturP Date I ARS. Always Ready to Serve Throughout New England 2V/365 Emergency Service 1-877-1461.1111 www.arsserve.com I C C)top CERTIFICATE OF LIABILITY INSURANCE DA-Mo F 11/01/2018 THIS CERTIFICATE IS ISSUED AS A MAT FER OF INFORMATION ONLY AND CONFERS NO ROM UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRIIIIATIVELY OR NEGATIVELY ANDO MEW OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CouSmurE A CONTRACT BETWEEN THE ISSUMG INSURERM AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: Ifthe certificate holder isanADOFFN)NALINStNtEDthe poNcy(mmI)mustbeemkirsed. ffSUBROGATION ISWAIVED,subject fjo the terms and n n -Me s of the policy,aNteitt Policies may require an endarsartwoL A statement an this certificale does not cmdiw rights to the �e hokler in Neu of such a da an a rKr'E H Unt =A" Paula WYAO GAUDETTE INSURANCE AGENCY INC PHONE M fig 0* (SM)2344MM PAx 15-010411. ADDRESS; pwybia@ -corn ONE PUJMMERS CORNER AFF01MMISCOVERNE "AICS WHITINSVILLE MIA 01588 nsummA: LMIIS CORP 33600 INSURED INSURER 8: ANTHONY ROBITAILLE Ir MINEItc: DBA LOCAL BUILDING&REMODELING INSURER 0: PO BOX 892 INSURER E: I THORNDIKE MA 01079 sesuRotF: COVERAGES CER IFICATE NUNSM- 3326M REVISION NUMBER: THIS IS To CERTIFY THAT THE POLICIES OF RCMANCE LISTED BELOW HAVE BEEN ISSUED TO THE BRED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOrNITHSTANOM 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 St.IBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAW NMI POLICTEW FOLICYEXP LTR IYPEOFOOSURAMM J=WWD POUCYNUNM owcowym Lima COMMERCIALGENERALLUUMLITY EACHOCCURRENCE $ CLAIMS-MADE n OCCUR PREMISES(Ea IED EXP(Ay ane poem) $ WA PERSONAL&ADV NJURY $ GEWL AGGREGAT&LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY El M F-1 LOC PRODUCTS-COMPIOP AGG $ I OTHER- AUTOMOBILE LIABILITY COMBKVED SINGLELIMFT ANY AUTO BODILY KKIRY(Per PK=) ALL OWNED SCHEDULED AUTOS AUTOS WA BODILY KKIRY(Per acddw4 NON-OWNED PROPS"Y DAMAGE HIRED AUTOS AU70S $ UBM3RBJALL4kS OCCUR EACH OC $ 7— LIARCLAIMS-MADE NIA AGGREGATE $ 0T I wrwnokz $ COMPENSATION Tw ANDENEtArIEWLL48PJff YIN x R ANYPROPRIETOROPARTNEWEXECUITWE MIA WA E.1-EAMACCIDENT $ 1,000,000 A OFFICERAIIEMBEREXCLUDED? W=1S374786MB 10111=18 10fil/2019 in 11" 1w E.L.DISEASE-EA EMPLOYE $ 1,000,000 I W=UO OPERATIONS' A, I I E.G.DISEASE-POLICY LIMIT $ 1,000,000 I I NIA DES'FUFnDNOPOPBtATIONSILOCit WwkeW Compensation beneft VA be Paid to OFTNIA"M 0* PUF5uwft to BVIomormot WC 20 03 06 B,no authorization is given to pay dwm for benefits to employees in states odw than Massachusetts If the wmxed twes,or has hired those employees outside of Massachusetts. This,certifixate of instnance shows the policy in force an the daft that this eerNThcate was issued(uniess the topkadan data on the above policy precedes the mAje date of this certificiale of wxwranoe)_ The Stan of this coverage can be iriorikoW daily by acoessing the Prod of Coverage-Coverage VerAcallon Search W at %WVWW we :' il V*r4esfig8tk%w- Sais proprietor has not elected coverage. HOLDER CANCELLATION SNOtX.0 ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL HE DELIVERED IN Jim Taylor ACCORDiANCE VKM 7HE POLICY PROVISIONS. 2.%Main Street AtInIORIZEDINWAMMATM - New London NH 032U 3, DwM4 Cray,CPCL1.Vice President—Red*M Varitet—WCRIBMA ®198&2014 ACORD CORPORATION. An rights reserved. ACORD 25(201401) The ACORD nmw and logo are registered marks of ACORD ARS Services,Inc. ARS Services,Inc. 38 Crafts Street Newton,MA 02458 (413)272-0101 (413)788-0418 fax Tax ID#042980173 CONTINUED-Labor Minimums Applied DESCRIPTION QTY 32. Finish carpentry labor minimum 1.00 EA 33. Fireplace repair labor minimum 1.00 EA NOTES: Grand Total Areas: 384.00 SF Walls 144.00 SF Ceiling 528.00 SF Walls and Ceiling 144.00 SF Floor 16.00 SY Flooring 48.00 LF Floor Perimeter 0.00 SF Long Wall 0.00 SF Short Wall 48.00 LF Ceil.Perimeter 144.00 Floor Area 160.44 Total Area 384.00 Interior Wall Area 506.24 Exterior Wall Area 50.67 Exterior Perimeter of Walls 1,078.34 Surface Area 10.78 Number of Squares 124.23 Total Perimeter Length 62.92 Total Ridge Length 0.00 Total Hip Length SUSAN—KAN 10/31/2018 Page:5 ARS Services,Inc. ARS Services Inc. R E czOuis" 38 Crafts Street Newton,MA 02458 (413)272-0101 (413)788-0418 fax Tax ID#042980173 CONTINUED-Roof2 DESCRIP'T'ION QTY 26. R&R Valley metal 12.00 LF 27. R&R Ridge cap-composition shingles 8.00 LF NOTES: -12'8" Exterior Height:8' 384.00 SF Walls 144.00 SF Ceiling 528.00 SF Walls&Ceiling 144.00 SF Floor 16.00 SY Flooring 48.00 LF Floor Perimeter 48.00 LF Ceil.Perimeter DESCRIPTION QTY 28. Plane and refit door 1.00 EA NOTES: Labor Minimums Applied DESCRIPTION QTY 29. Gutter labor minimum 1.00 EA 30. Painting labor minimum 1.00 EA 31. Framing labor minimum 1.00 EA SUSAN_KAN 10/31/2018 Page:4 ARS Services,Inc. ARS Services,Inc. SVPMFCMLAN" 38 Crafts Street Newton,MA 02458 (413)272-0101 (413)788-0418 fax Tax ID#042980173 CONTINUED-Roofl DESCRIPTION QTY 13. R&R Sheathing-plywood- 1/2"CDX 32.00 SF 14. R&R Trim board- 1"x 4"-installed(pine) 5.00 LF 15. Seal&paint trim-two coats 10.00 LF 16. R&R Chimney flashing-average(32"x 36") 1.00 EA 17. R&R Continuous ridge vent-shingle-over style 38.00 LF 18. R&R Ridge cap-composition shingles 38.00 LF 19. Masonry-Labor Minimum 1.00 EA Labor to repair damaged chimney 20. R&R Flue cap-oversized 1.00 EA NOTES: RooU 150.74 Surface Area 1.51 Number of Squares 30A8 Total Perimeter Length 14.92 Total Ridge Length R 'o 61' 6 4* DESCRIPTION QTY 21. Remove 3 tab-25 yr.-comp.shingle roofing-w/out felt 1.50 SQ 22. 3 tab-25 yr.-comp.shingle roofing-w/but felt 1.67 SQ 23. Ice&water barrier 48.00 SF 24. Roofing felt- 15 lb. 1.03 SQ 25. R&R Drip edge 18.00 LF SUSAN—KAN 10/31/2018 Page: 3 ARS Services,Inc. ARS Services,Inc. .N,ur'rri 38 Crafts Street Newton,MA 02458 (413)272-0101 (413)788-0418 fax Tax ID#042980173 SUSAN_KAN General Conditions DESCRIPTION QTY 1. Dumpster load-Approx.20 yards,4 tons of debris 1.00 EA 2. 1.00 EA Permit fee as incurred. NOTES: Main Level Roofl -------------- 927.60 Surface Area 9.28 Number of Squares _ 124.23 Total Perimeter Length 48.00 Total Ridge Length a t •.151 Y,.:S Q DESCRIPTION QTY 3. R&R Gutter/downspout-aluminum-6" 36.00 LF 4. R&R Fascia- 1"x 4"-#1 pine 4.00 LF 5. Prime&paint exterior fascia-wool,4"-6"wide 36.00 LF 6. Prime&paint exterior soffit-wood 36.00 SF 7. Prime&paint gutter/downspout 36.00 LF 8. Remove 3 tab-25 yr.-comp.shingle roofing-w/out felt 3.75 SQ 9. 3 tab-25 yr.-comp.shingle roofing-w/out felt 4.00 SQ 10. Ice&water barrier 216.00 SF 11. Roofing felt- 15 lb. 1.44 SQ 12. R&R Drip edge 46.00 LF SUSAN KAN 10/31/2018 Page:2 ARS Services,Inc. ARS Services,Inc. arr IZALAW" 38 Crafts Street Newton,MA 02458 (413)272-0101 (413)788-0418 fax Tax ID#042980173 Insured: SUSAN KAN Home: (413)348-6635 Property: 19 STONEWALL DRIVE NORTHAMPTON,MA 01060 Horne: 19 STONEWALL DRIVE NORTHAMPTON,MA 01060 Claim Rep.: Elena Bourassa E-mail: ebourassa@mapfreusa.com Company: MAPFRE Estimator: Ernie Gomez Business: (508)459-7097 Company: ARS Services E-mail: egomez@arsserv.com Business: 480 St.James Ave. Springfield,MA 01109 Contractor: Business: (781)227-4668 Company: ARS Services Business: 480 St.James Avenue Springfield,MA 01109 Claim Number: PWXX91 Policy Number: BDXZSL Type of Loss: Other Date of Loss: 9/2612018 Date Received: 9/28/2018 Date Inspected: Date Entered: 10123/2018 10:01 AM Price List: MASP8X_SEP18 Restoration/Service/Remodel Estimate: SUSAN_KAN Estimate is for repairs only to restore property back to pre-loss conditions. � ( � � 3 0 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." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-NlASSAFE Fax#617-727-7749 www.mass.gov/dia Form Revised 02-23-15 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 ajoint 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." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leaibly Name (Business/Organization/Individual): L ocl�l / q A'106�17,U 6 Address: fG �q �9 City/State/Zip: Phone#: 413 (2 C 5 2 g C Are you an employer?Check the appropriate box: 'Type of project(required): 1.W I am a employer with employees(full and/or part-time).* 7. []New construction 2.M I am a sole proprietor or partnership and have no employees working for me in 8. F1 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.E]I am a homeowner doing all work myself.[No workers"comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work an my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole l l.F_1 Electrical repairs or additions proprietors with no employees. 12.F1 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.WlRoof repairs These sub-contractors have employees and have workers'comp.insurance) 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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'camp.policy number. I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Name: CT ft Py 1061Yp,� Policy#or Self-ins.Lie.#: S � �" 71(7 D D GZ ' Expiration Date: {0 Job Site Address: Ttf /l City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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: � G�J �' r �� 'G Date: /7- - j �5 Phone#: Ll( T 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#: City of Northampton Massachusetts - DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street •Municipal Building 1� Northampton, MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: I q ST0N r-c'qc t op, (Please print house number and street name) Is to be disposed of at: N WA$71 ACAW 104 (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Sigriatuire-'af Per it Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. Y.. ., City of Northampton st Massachusetts �. DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building ', a' Northampton, MA 01060 } Massachusetts Residential Building Code Section 110.R5.1.2 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 accesspry 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. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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. City of Northampton Massachusetts T DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building ?3� �'4 `y Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation,repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: Est. Cost: Address of Work: Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: (vtyal X11111.-Lt t- 16 ggi7 Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:m w6ki �?fi�rfih ,r,�y C� 2-- y5 3 License Number Po &V p2 f{l02 qry r 100 010-79 3y 16-- 19 Address Expiration Date Itg& 413 6z6 52-q(Signure Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ t u c A 0&Jt df11 + RE WAI alG 16 qq5 7 Company Name Registration Number v,or 'k-72_1Q Address Expiration Date Telephone 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...... ❑ SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [M Siding[❑] Other[❑] Brief De cr ti n of Proposed Work: T � 7HUPoWf Qf 1tft Nook- OfAVEIW110- W lhkU--t- IBJ S4&3 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 axistina 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 1, , 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 1, LAul 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. ,gOMOLY P013-7MI Print Name L /2- 5- /s Signature o 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 ..._Fronta e 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 DON'T KNOW 0 YES 0 IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T 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 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO 0 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 ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. -7 Deparftwmt use onhr r City of NorthamptonStatus of Peril* Building Department C4rbCrriy Piit 212 Main Street Sewer/SeOCA:,Vaitablity Room 100 Water/Well Aveftility Northampton, MA 01060 Two'Setso Structurat,Plans phone 413-587-1240 Plan EIVE �r5 cifY APPLICATION TO CONSTRUCT,ALT R, R PAIR, RENOVATE OR D MOLI H A ONE OR TWO FAMILY DWELLING DEC 6 2018 Z N - dP•�_G t SECTION 1 -SITE INFORMATION 1.1 Property Address: �FPT of cUll_D1NG iNSP�CTIONS Th section to be completed by office Iq 570iX WA It OR NORTHAMPTON,MA 01060 �_ p----- Lot OA -)2 Unit Zone. Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 5(/5AIV KflN Name(Print) CurrentMailidd s: �I13 3 w 3 S Telephone elephone 2.2 Authorized Agent: ,f I41169y P0134-tl/Ill f pv goa $ R2 f f/aR/zO.,�KL /�rA 01079 Name(Print) Current Mailing Address: CZ L(13 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building r -000 (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) d(/ G Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 19 STONEWALL DR BP-2019-0694 GIs#: COMMONWEALTH OF MASSACHUSETTS Man:Block: 13 -023 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-2019-0694 Proiect# JS-2019-001130 Est.Cost: $6000.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Ude Group: ANTHONY ROBITAILLE 102453 Lot Size(sg. ft.): 12806.64 Owner., KAN SUSAN Zoning: Applicant. ANTHONY ROBITAILLE AT: 19 STONEWALL DR Applicant Address: Phone: Insurance: P O BOX 892 (413) 626-5296 WC ThorndikeMA01079 ISSUED ON:12/7/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE FRONT OF HOUSE ROOF 14 SQRS 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 Sianature: FeeTYpe: Date Paid: Amount: Building 12/7/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner