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36-117 1 Loomis Way, P.O. Box 778 413-527-6355 Easthampton, MA 01027 -v e V 1-800-767-6355 ti q REMODELING This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A).Any person planning home improvements should first obtain a copy of"A Consumer Guide to the Home Improvement Contractor Law"before agreeing to any work on your residence.The guide will inform you of your rights and respon- sibilities as well as provide you with important information about what to do if a dispute arises.You may obtain a free copy by calling the Executive Office of Consumer Affairs'Consumer Information Hotline at 617-727-7780 Homeowner Information Contractor Information Company Name f1Q Z'EAtjo 71>4icAT Five Star Remodeling Street Address(do ngt use a Post Office Box address) Contractor/Salesperson/Owner Name .Q{ Kevin Perrier City/Town State Zip Code Business Address(must include a street address) MOREMZ F lA• OIO6 1 Loomis Way,P.O.Box 778 Daytime Phone Evening Phone City/Town State Zip Code -S - 3 1 - - Easthampton Mass. 01027 Mailing Address(if different from above) Business Phone Federal Employer ID or S.S.Number fE IQ po2RrYt 1-413-527-6355 75-3034389 HPTtO Mu&XaL 0PJ A6t-✓_ Law requires mar aR tnme Home Improvement Contractor Reg.Number Expiration Date o�r{O M p11J , ., V" M • o► �P ovement conVa moor. naM vaad registration 134511 12-3-05 The Contractor agrees to do the following work for the Homeowner: FleQ, prrAc44(3p ltyv.. 3' 1cED t!-$-oS (Describe in detail the work to be completed,specifying the type.brand,and grade of materials to be used_) trM%p UXWZ jftF IWACUE AODa1200V OF-4X1U"TAaIjWi4 solo zz-#^AM s AID PiPty)(,. Fpm aaa'siryutyr•900 e&*&Loo M'Pwu kits-'SC'Ir E&wee Chetz. At 9WaRr./(/NLEYS cW_t1*u.,i ihlajE CWTIMA tAdmct.TM MeD r (jf} AfiJDt" a"r0 _ GtA•1lint, JWLAACE V86t ZW S- 1%WAU.'5'4P1rA 0113110T- DWO-DU:ALl�';� Vr►i[S^Kfatto Sr.L�►9oR Iu1tWt�ED A FQXP- 1CM LW WC A MJ ST�iAt►'RS tP-Z le To 94 OZHa�t. rtt3 -- F1CAT1oriJ So�E0- Check this box if additional pages are used for this section 313 PEA, OOit'THANPTOA) CcUUULOA)A&X8M 6FMj F 1CAT101; Id-2S-0 A"00 Required Permits-The following permits are required and will be secured by the contractor as Proposed Start and Completion Schedule-The following schedule will be adhered to unless circumstances beyond the homeowner's agent.Owners who secure their own permits will be excluded from the the contractor's control arise.These dates are approximate start and finish dates. Guaranty Fund provisions of MGL chapter 142A r�y.� t�1C dF 11-71-650 -Date when contractor will begin contracted work t�0u7T1�A��• ' � T � 06 -Date when contracted work will be substantially completed 141�tC-OF I��- Total Contract Price and Payment Schedule The contractor agrees to perform the work,furnished the material and labor specified above for the total sum'of:$ 80M.f90 Payments will be made according to the following schedule: $ 80a•Oil upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items,whichever is greater).7AQP ALMi $ by_J_J or upon completion of $ by / / or upon completion of $ '7,2 • upon completion of the contract.(Law forbids demanding final payment until contract is completed to both party's satisfaction). The following material/equipment must be special $ O to be paid for ordered before the contracted work begins in order to meet the completion schedule: $_ to be paid for Homeowner is responsible for all collection and reasonable attorney fees 9 payment is not received at time of completion. Express Warranty-Is an express warranty being provided by the contractor? O No axes (all terms of the warranty must be attached to the contract) Sub Contractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor.The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. Contract Acceptance-Upon signing,this document becomes a binding contract under law.Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence.Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract.Take time to read and fully understand it.Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration.The law requires all home improvement contractors and sub contractors to be registered with the Director of Home Improvement Contractor Registration.You may inquire about contractor registration by writing to the director at One Ashburton Place,Room 1301,Boston, MA 02108 or by calling 617-727-8598 or 617-727-3200. • Does the contractor have Insurance?While it is not required by law,it is a good idea and an additional protection. • Know your rights and responsibilities.Read the important information on the reverse side of this form and get a copy of the Consumer Guide You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business,provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement.See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! Two identical copies of he contract must be signed.The white copy goes to the homeowner.The yellow copy should be kept by the contractor. Homeowner's Signature Date Contractor's Signature ' O Date PART 1 OF 2 ------ The Commonwealth ofMassachusetts Dep&rtment of Industrial Accidents 600 Washington Street BostonY Mass. 02111 'davit:Buildi Workers' Compensation Insurance AM n PEY/m/m, work site location(M address): I am a homeowner performing all work myse If Project Type: D New Construction EIRemodel �fn a so!1 gr rietor and have no one world inany cgagty. El Building Addition am an employer providing workers'compef sation for my employees working on this job. insurance co. Roliev F-1 I am a sole proprietor, general contractor, oi homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices- company name: ` insurance co. Rolicx H company name: insurance co. Mlicy# Failure to secure coverage as required under Section MAW 1GL 152 can lead to the imposition of criminal penalties ora fine up to$1,500.00 glad/or one years'imprisonment as well as civil P&BIties in the form i I a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement y be forv:�o the Office of Invei tigations of the DIA for coverage verifleation. ,.:rwar 6to I do hereby certify u It: andpenalties ofpe�ruty that the inforination provided above is true and correct. Signature Date Print name Phone 9 official use only do not write in this area to be complet ed by city or town official Ir ]LIcensing B�ogr�d check if immediate response is required [J& OSelectmen's Office .F13 -u 0 t e t N []Health Department contact person: phone#; OZ r ElOther L(r-ev-ist.�d�Sep7210�3) SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: �g Not Applicable ❑ Name of License Holder: License umber i b�/ 2 Address Expira ion to Sign r \-'Teleplione 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name Regstr6tion Number /, i%� Address Expiration Date Telephor 4 j - 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....... ❑ 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 O Accessory Bldg. ❑ Demolition ❑ New Signs [O) Decks [M Siding[0] Other[d] Brief Description of Proposed Work: ^� '`� 1-C Z!;z 'r6�6 j ns // ii eav Zee&- yPyc� Alteration of existing bedroom Yes J 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 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 I as Owner/Authorized Agent her by declare tha 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. IV* puv Print Nam Signature of er/ ent Dale 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 Sppcial Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW 0 YES Q IF YES, dat issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW ® YES 0 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 ® YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES ® NO (' i 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 ® 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/Driveway Permit 212 Main Street Sewer/Septic Availability j Room 100 Water/Well Availability 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 Proaertv Address: This section to be completed by office m Moot uv� Map Lot Unit ww Zone Overlay District N� t V Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: I k1 1 Name(Print) C n Mailin Ad ss: Te ephone Signature 2.2 Authorized Agent: bq i Name(Punt) Cu ent Mailing Addre Signature Te phone SECTION 3-ESTIMATED CONSTRUCTION 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) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 224 BROOKSIDE CIR BP-2006-0741 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:36- 117 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2006-0741 Protect# JS-2006-1139 Est. Cost: $8000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: FIVE STAR REMODELING 134511 Lot Size(sq. ft.): 20473.20 Owner: DWIGHT JEANNE Zoning: Applicant. FIVE STAR REMODELING AT: 224 BROOKSIDE CIR Applicant Address: Phone: Insurance: P O BOX 778 (413) 527-6355 () WC EASTHAMPTONMA01027 ISSUED ON:112412006 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 1/24/2006 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo