38A-009 (4) , \ The Commonwealth of Massachusetts
� Department of Industrial Accidents
= 'r� Office of Investigations
_l.
- t__
c 4 :_, 600 Washington Street
1 Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 'f) i () • se., - U i
Address: 1 3 L\'Q E rn S--\--�( _��--
City/State/Zip: 0 - 13
V) Phone #: ' I ----Ma-_ O 3-y 9
Are you an employer?Checbthe appropriate box: Type of project(required):
1.4t I am a employer with 4. E I am a general contractor and I
. emplo_y_ees_(full and/or part-time).* have hired the sub contractors 6. 0 New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have
8. 0 Demolition
working for me in any capacity. employees and have workers'
comp. insurance.t 9. 0 Building addition
[No workers' comp. insurance P
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13. Other t 1 1i C1l Ca1'3"I C41.)
employees. [No workers'
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 state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. ,/
Insurance Company Name: RO W \ C C_ SO Ca nC `e___
Policy#or Self-ins.Lic.#: -,lit Q 5-80?0? Expiration Date: '6//c ) / -/
Job Site Address: ( R 2r\ 1n e'E 3 1 City/State/Zip:l( ( Yri 4
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: U\ ` Aiodid- D ate: `"7 rr `` 1
j q/ 13
Phone#: `"f I�j_''3 -Ua1-19
Official use only. Do not write in this area,to be completed by city or town official
City or Town: 'flCx \ i N.Y.\-0 1n Permit/License#
Issuing Authority: Building Department
Contact Person: Phone#: (413)499-9440
Page No. of Pages
•
COLOR WIDTH
CT.REG.NO. 0621848
VISTA HOME IMPROVEMENT ,,f
MA REG.No. 162058 1346 Elm Street /l . �C 4 ii
West Springfield, MA 01089 INSULATION
Toll Free: 1-888-597-2323 • Local: 413-382-0249 A 6
FAX: 413-382-0241 ---y..Y--
Proposal Submitted To Homeowner Work To Be Performed At
Name "�, '�' ; 1;,, Streeter r,
Street �._:+i � v I- '/ City A..,`� 7-1- ":�:.-frp.,-,1 tt-.. State f
City , State 7)74 Date of Plans ✓T j'1 a
Date � � Telephone f . . f i ,
1 �i
We hereby submit specifications and estimates for:12.
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'a t ,....[,.�r S,2 1 -..1 '4( ,-!•Tt.JIC.-3- iA-;�' 3,., l ),�,i-e.,.. do l:-ie a..:.,,.1 7"--+( 11 r a..1.7C,,^ ,,,..+-
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,v,f%'"l`s�u '��
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Date work will start 715,1L3 Date work will be completed :t:7.2,/,7
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from the
above specifications must be made In writing on an Add-on/Modification of Contract form and may become an extra charge over and above the amount stated herein.
This agreement is contingent upon delays beyond our control.Owners to carry'fire,tornado and other necessary insurance.Our workers are fully covered by
Workmen's Compensation Insurance.Homeowner agrees to pay for all work as set forth below.If the homeowner defaults,homeowner agrees to pay all costs of col-
lection,including reasonable attorneys fees,In addition to other damages incurred by contractor.An 18%per month service charge will be assessed for all payments
not made within 10 days of due date per the schedule below:
1' C N F ! t r� with the above specifications for the sum of:
e propose hereby to furnish material Land labor-complete in accordance with
•,,�i� ,I , }�V�x r.f.!rl r-t 1 Pit. r f +C. �." .,� j �.Ir-.i .,.�..vs. ,�/i 7^^-] VY
Said amount shall be paid as follows �, + `1,4'"x` '��! 4, • ),,�. -c r Jt` )/(, 7,r !
---,, .,,.,. .,1! h _.. ./� :' i,, i� i a ..F z' k C;°y11a° c :
Note:This proposal may be withdrawn by us if not acre ted w n ._- days. /
YOU,THE BUYER,MAY CANCEL THIS TRANSACTION AT ANY I''T ME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE
DAY OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FOR AN EXPLANATION OF THIS RIGHT.(SATURDAY
IS A LEGAL BUSINESS DAY IN CONNECTICUT.)THIS SALE IS SUBJECT TO THE PROVISIONS OF THE HOME SOLICITATION SALES
ACT AND THE HOME IMPROVEMENT ACT.THIS INSTRUMENT IS NOT NEGOTIABLE.
i
Signature of Contractor or authorized representative; , 1 ;.
*(1/11Ve)have read the terms stated herein,they have been explained to(me/us),and(I/We)find them to be satisfactory and hereby
accept them.
Signature of Homeowner(s): X \rC ^-- -" X
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑/,
Name of License Holder: c' �a\(\ ���I)C E ` \C)(0 t Slit
License Number
‘3u FA om-- w . c-( d 414 vv ) its ls'
Address ` Expiratio Date\-k ■3 ----s Pc)--- ---1 q
Signature r Tele one
(I
9.Registered Home Improvement tractor: Not Applicable ❑
\J t 5 ) _ \ ' rent- . ( q-en y-- 1 IQ,9 0 S8'
Company Name J Registration Number
13 4 P l r - - \ Q--\-- 11 i a � S'
Address ,, ( ,/� E� Expi ation Date
I
U), - 5 YJ�-I OA 9T ( to ' Telephone �l.(i 3"3 -O q9
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$( 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) n Roofing r l
Or Doors E
Accessory Bldg. ❑ Demolition ❑ New Signs [ID] Decks [❑ Siding[ ] Other[0]
Brief Description of Proposed r iPAN't vl 9 `n j .5 <c=rf2', n ).1r=t-‘X -3r4 V 141
Work:,(`(\ \\ C'X 2E ' 2f - VC)5 \\ 4E.1
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
ox-Nr\Y' , as Owner of the subject
property
hereby authorize \C`;``(1 C\A �\nc-y r(Pe m�P
to act on my behalf, in all matters relative to work authorized by this building permit application.
�_ Ce-A-4 ,C; - 7/ 9/ 13
Signature of Owner Date
I. "--7)r\ et �v C,\— \ JC )i ` 1� ,v�1� v �-'r r` as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are tale and accurate, to the best of my knowledge
and belief.
Signed under the pains and pen- 'es of perjury.
sCX
Print Name
Sig at - of Owner/Agee' Date
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Ope Spacr 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 ® DONT KNOW ® YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO etV DONT 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 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, gradin., ex avation,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.
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit
f-C? ---V`r\Y\ Zone Overlay District
Elm St.District CB District
SEC(r4.-. :'�?' fRTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
U3c c \n-e, C 55 ion+c u e �.� � �r� }4
game(Print)
• Curent Mailing Addressa at
c C 4c-
Telephone
Signature
2.2 Authorized Agent:
t: `�7 r l ,rte n+ I 34(e 5-I-few'+ W 5 -'i d rn l
Jame Print) J Current Mailing Address:
iig re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
tern Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
'. Building (a) Building Permit Fee
!. Electrical (b)Estimated Total Cost of
Construction from(6)
Plumbing Building Permit Fee
Mechanical(HVAC)
Fire Protection
. Total=(1 +2+3+4+5) f) lg 5-0D Check Number 11 3 b ✓
This Section For Official Use Only
uilding Permit Number: Date
Issued:
ignature: ":"/
Building Commissioner/Inspector of Buildings Date
68 PRINCE ST BP-2014-0024
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38A-009 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit# BP-2014-0024
Project# JS-2014-000082
Est.Cost: $6500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: VISTA HOME IMPROVEMENT 106156
Lot Size(sq.ft.): 16552.80 Owner: WARNER STEWART
Zoning:URB(130)/RR(1)/ Applicant: VISTA HOME IMPROVEMENT
AT: 68 PRINCE ST
Applicant Address: Phone: Insurance:
1346 ELM ST (413) 382-0249 WC
WEST SPRINGFIELDMA01089 ISSUED ON:7/16/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE SIDING
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 7/16/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner