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25C-110 MA REG. 127893 ENERGY SAVERS OF AMERICA INC. CT REG. 567734 3339 Boston Road Palmer: 413 - 283 -6695 Wilbraham, MA 01095 Toll Free Springfield: 413- 734 -4777 888 - 882 -4288 Greenfield : 413 - 774 -7777 Fax: 413 - 283 -9335 CA This agreement made the 3I day of Or) 20 1 2 between S - t.) Mar- Lr�e a L4,3- 231-1422 Q'r�{^ Ho meowners) (Ho e Phone) /� (Business Phone) Of (3 v' Address} 1 ( n Sta j 01 v � 0 (Zip Code) Hereinafter called the owner and ENERGY SAVERS OF AMERICA INC. of the Town of Bondsville, Massachusetts here- inafter called the contractor, witnessed: The said Contractor hereby agrees that it will for the consideration hereinafter mentioned, furnished all labor and mate- rial necessary to install the following described work at premises located at: (Job Address) Total Quantity No. of Additional Work Total Total Windows Purchased Panes Cash Price /8201. Regular Double Hung Sliding Doors Down Payment (6% "" Picture Windows Siding Upon Start E, 3 Lite Sliding Windows Roofing YeS Upon Completion 9? , 4 2 Lite Sliding Windows Bay Window Casement Windows Bow Window OTHER - DESCRIBE 54 ,eft z-4, , S .4 a..sC, re..AeLie C,In � . ....r-11—X6 1 Ot,3Pr.S Cara b , r ic. ,�n1 �.g iJ -- . C Ace Sier'r 4, c . 4revir\e) rewfieleto d.er 2.x...‘.2.1A A $ t _t,.e t - k c , e' 14 5Pek 2a-A rep s t-t- 4- - 7r L t 1.e.. -z til P , "lkali ON "fra-d 47.4l I The Commonwealth of Massachusetts *■ :_ Department of Industrial Accidents Office of Investigations 600 Washington Street =` Boston, MA 02111 www mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information __ Please Print Legibly ri"r Name (Business/Organization/Individual): i G 1 t )) . ! — S Cs y�j t [;C, - 11C i Address: 2, 1s Iu r .t` City /State /Zip: {r 1.,1 6 0141 iLrri / 1 l !(�l c ; Phone #: / 1 f ; 1., Are you an employer? Check the appropriate box: Type of project (required): 1. ©` I am a employer with 1 4. ❑ I am a general contractor and l 6. ❑ 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. + 7 • ❑ 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 10.0 Electrical repairs or additions required.] officers have exercised their 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. ❑ Roof repairs insurance required.] t employees. [No workers' 13. Other `- 0 comp. insurance required.] *My 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 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. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: (1'U )'/ /h/ L City /State/Zip:! )l ' 1C-01 0 d (") I) 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 untie _ he . Ins and penalties of perjury that the information provided above is true and correct. _ .� Date: 6 - _ Phone #: 4i,"3 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 #: AMP SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ / Name of License Holder : I) t/ Soj T t � 0J Am i f'7 6 A ic 8 7/ / 9 ' License Number 2 7 t l? ` f") O I (/i 5 - • ess Expiration Date C\ ( 0 ,-5 /2 --- i • nature 11 Telephone 9. Registered Home Improvement Contractor: 1 Not Applicable ❑ • Company NaMe Registration Number .< , .i<C\ (LEll zJ CLni TIM 6109s / ,?5 - /3 Address Expiration Date t . Telephone !o - S / 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 1;2 No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner- occupied Dwellin!s 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 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 Q DON'T KNOW Q YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 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 Q NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Ei Or Doors I] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [0] Brief Description of Proposed Work: _ I . � 1, L . i ., / / 1 4( Ira Alteration of existing bedroom Yes No A. ng ne I. edroom Y s o Attached Narrative Renovating u • nished 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, S (A :Z-601/15<_ 0/04 ' J 1'3 - /- , as Owner of the subject property hereby authorize rik1( to act on my behalf, in alKiinkters relative to work authorized by this building permit application. I - ) dr (k 630 ( -- r -- Signature of Owner Date 1, -61 g ;SG2L 01- ilryltri CDC. 3c , as Owner /Authorized Agent her eclare 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, Print Name ��► _ _ �d 6 ` 5' i Si• . ure o • • r /Agen Date Department use only G City of Northampton Status of Permit: uilding Department Curb Cut/Driveway Permit 2 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability v cF eu E �T6 0 oN': No hampton, MA 01060 Two Sets of Structural Plans 1 NpRTHAMF 87 - 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 Yg & cul J Map Lot Unit NC't t haunp i a /+ , /'l') /-) O I0 t10 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ak c nr--. I k- r1 /)L2 _ f)(kr) - o *, . N,1 N4)W7 ? krt 01A- Name (Print) Current Mailing Address: L/ /3 f -3/— )O3f 11 Er s', i ' Ll ktr k- - or c -k6 Telephone Signature 2.2 Authorized Agent: Q 1 L 4 c , raw. rS C: " / ! ITN // (' C:� 6�1 ZC. _ � 39 7C~ ` z `k/1 � J . ti) I 87. CL1)CQ.rr /�� 6/6,5 P ) Current Mailing Address: c 4/3- ,383 - (q'S :ignat .'11111111 ur R `+ _ Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Budding (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 3 o 6. Total = (1 + 2 + 3 + 4 + 5) Check Number "' 0 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 38 GRANT AVE BP- 2012 -1089 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C - 110 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 -1089 Project # JS- 2012- 001873 Est. Cost: $18289.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ENERGY SAVERS OF AMERICA_ Lot Size(sq. ft.): 10585.08 Owner: MARTINEZ - DANTONET SUZANNE & SEAN R MARTINEZ- DANTONET Zoning: URB(100)/ Applicant: ENERGY SAVERS OF AMERICA AT: 38 GRANT AVE Applicant Address: Phone: Insurance: 3339 BOSTON RD (413) 283 -6695 Workers Compensation WI LB RAHAM MA01095 ISSUED ON: 6/7/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP,PLY & 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 6/7/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner