32A-131 ` T
gr
93603
DAVID DIAZ
270 TREMONT ST .
SPRINGFIELD, MA 01104
�_ 8/7/2013
20303
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Office of Consumer Affair and Business Regulation
' e- 3 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 151711
Type: Supplement Card
STURDY HOME IMPROVEMENT, INC Expiration: 6/26/2012
DAVID DIAZ
459 MAIN STREET SUITE 13
INDIAN ORCHARD, MA 01151
Update Address and return card. Mark reason for change.
Address ! Renewal I Employment Lost Card
.4' f�'nixiirairr.k'u /r /i cf li�,J(teiiei_;,
— = - Office of Consumer Affairs & Business Regulation License or registration valid for individul use only
4 HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to
_ - Office of Consumer Affairs and Business Regulation
_._ Registration: 151711 Type: 10 Park Plaza - Suite 5170
Expiration: 6/26/2012 Supplement Card Boston, MA 02116
STURDY HOME IMPROVEMENT, INC
DAVID DIAZ / y(J/
PO BOX 51033 -.i�- ,. ./.4!" • ��y'
INDIAN ORCHARD, MA 01151 `
Undersecretary Not valid without sign re
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HOME I M P R O V E M E N T
"No Substitute for Quality"
WORCESTER SPRINGFIELD HARTFORD
459 MAIN til la1':1 I'.O. 13()X 51033 - SPRIN(;FII1,I). MA 01 1 51
MA. RI- 1 5171 1 (' 1 . R1-(14 601 525
X77-3 1I I;RI)' 1 AN 413-541_320o
\\ U \\ 5 I t RUV "II( )y11
OWNER PERMIT AUTHORIZATION
Name: � ' ` "t Y `�'`
Address: 7-= L k 4 .0
City /State /Zip: 1:; j ��� ! b t �:� < _ �� -
I (owner), of the property
located at: ' �' , , � _ ��:< �� _A,'' i' - tf.rg iU',/ iuthorize 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 for this project. I understand and accept
responsibility to comply' with all regulations and required inspections.
• . ' " � ,� 1 •
Signature of Owner Date
Signature of Owner Date
. The Commonwealth of Massachusetts
Department of Industrial Accidents
l�
G s4� 1..:_ Office of Investigations
r _,f ar± ?
€� _l; f _ 600 Washington Street
• r - liv tl 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`'/Cji k J t'K Trit2►-ll. 'M'i It.c
Address. L I S kt ,Y\ 5)--- • S i- 1
City/State/Zip: - . C) . MA- b t t C I Phone „: (1 % L( 3- 'j U i. •
Are yo n employer? Check the appropriate box: Type of project (required):
1. I am a employer with 4. ❑ I am a general contractor and I
6. CD New construction
employees (full and/or part - time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7 . El Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its -
officers have exercised their 10.❑ Electrical repairs or additions
required.]
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.) t employees. [No workers' l34❑ O 1N .-v e_6,4---
comp. insurance required.)
'Any applicant that checks box #1 must also fill out the section below showing their workers compensation policy information.
I 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 infornu+tion.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: (u--a. -A -Z 'e r`S
Policy # or Self -ins. Lic. #: L3 C - co)- U . - -k4 r - 1 ( Expiration Date: - 1, ( 7 l (2_
Job Site Address: tS Rift ► i ` e--t 40 6 • (' 1441, l_f ity /State/Zip: 01 O2.0
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 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 d is a nd penalties of perjury that the information provid de ed ab ve is and correct.
gn Si ature: t Date: ..z 7,/, (
Phone #: V/
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 #: .
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable D
Name of License Holder : ( A b( ?_ q � 3
License Number
• ?p64.( 1 0 t C9 7- I 2_c 3
Address Expiration Date
Signature Telephone
9. Reaistered Home Improvement Contractor: Not Applicable 9
Company Name (Q� Registration Number
1 r 0- ti
Q • 241 7.tl 0
\ -
Address �} ./� QQ 1 /� Expiration D to
"lI `�r�/�S�- St 2 13 ). Telephone C 3J593S90 .
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SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit mus a completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin rmit.
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 buildine 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 Ic
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks EN Siding [0] Other [0]
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Brief Description of Proposed C �
Work: �J uv t }" S'1 L !.i-0- ( O C-
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 l L (,L Vr e °L V (k , as Owner of the subject
proper Imo,
hereby authorize 5 h - , zi t V i UIY_ ^ IP J TA C .
to act on my behalf, in all matters re active to work authorized .y this building permit application.
Signature of Owner Date
I 5 r VtQ. 6141 � 4- ,y�t� as Owner /Authorized
Agent ereby declare at the statements and ihformation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
9 / f /
Signat`jo Owner /Agent Date
P
k;
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 DON'T KNOW 0 YES
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained (3 , Date Issued:
C. Do any signs exist on the property? YES Q 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 Q
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 Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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Department use only
%sa - Ci of Northampton Status of Permit:
Bu ding Department Curb Cut/Drlveway Permit
p 'L ?. " 2 Main Street Sewer /Septic Availability
Room 100 Water/Vl Availability
Is • pton, MA 01060 Two Sets of Structural. Plans
.° - 13 587 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
M ce- 4- n "6 Map Lot Unit
N ✓���I o r � �- 6 Lc) .0 Zane Overlay District
Elm St. District, CS District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
orS tc I CV��
NarrW(Print) Current Mailing Address:
Teleph c2 Signature 2
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
( j3) 6
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated C os t (Dollars) to be Official Use Only
completed by permit 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= (1 +2 +3 +4 +5) fr/4/ / >(-)f.) � Check Number
This Section For Off Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
15 MERRICK LN BP- 2012 -0304
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 131 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- 2012 -0304
Project # JS- 2012- 000493
Est. Cost: $16800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STURDY HOME IMPROVEMENT 093603
Lot Size(sq. ft.): 2352.24 Owner: FREEDGOOD JULIA
Zoning: CB(100)/ Applicant: STURDY HOME IMPROVEMENT
AT: 15 MERRICK LN
Applicant Address: Phone: Insurance:
P O BOX 51033 (413) 543 -5906 WC
INDIAN ORCHARDMA01151 ISSUED ON:9/27/2011 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 9/27/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner