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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 /,y ,•�`
WORKER'S COMPENSATION INSURANCE A>iFMAVFr
(licenste./permiuee)
with a principal place of business/residence at:
(phone#)_
-- (street city/stalrJap)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
Ot-4,additioaal shed ifnoocniry to include infncmarioa pertaining to all 00a4ndois)
O I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plcasa be aware that v6lo homcowsxn who employ per;=to do Oa or rcp=`7u��s�d�g of
not more than ihroo units in which the homoowacr resides or on the grounds appuutenarrt tb d'.arc oot g�sily
employ=under the wocica's a mpc=4oa Act(01,152,ss 1(5)),application by a homoow ner far a liccase or pamad may e%dc the
legal stahsa of art employer undertho Wodcoes Compamatioa Ad.
I understand that a oopy of this statement may ba foewwd d to the Dq rt o o2 of Indautrid Ard4m •Offioo of tmur—foe tlm
coverage vcr ficdioa aid that&U um to&care coverages under section 25A of MGL 152 an lead to tba imposition of aiminw penalties
ooauit wg of a fine-of up to S1,500.00 and/oe i npr6oamart of up to one year and civil pem hies in the form of a Slop Watic Order aid a
fm of 3100.00 a day against tae..
For 6V=U—W use only
permit Number
Lot#
SignaWre of LiccnseeRetmittee Date
��
SECTION 8,, O—RUCTION SERVICES ftl
8.1 Licensed Construction) Supervisor: - Not Applicable ❑
Name of License Holder: F = Q CU.( r1 C `�l�' 1�— �
License Number
�o s s 3
Address Expiration Date
Signature felephone 1 /w
R r re om in r. vemen r: _� Not Applicable.❑
T ��e� t C) 4 oG
Company Name Registrati n Number
PC) c):$ qa9 (,Address 1 Expiration Date
Telephone
SECTION 10 -WORKERS' COMPENSATION>INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(6))
Workers Compensation Insurance affidavit mu e completed and submitted with this application. Failure to provide this affid,
will result in the denial of the issuance of Wilding permit.
Signed Affidavit Attached Yes....... No...... ❑
1a O i r W I 4' In
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)famili
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner act:
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(
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
R ,sq? ty�>#`ru .'�^5. ''"a� t�om,„„s d w•,.i., ,' t,v
SECTION `�D�ESCRIPTf10NOFPROPOSEDINORK(ch�all aaulicable)
5�?+1b"3rP4Nv x.:f! AAf A'CYcx::GY +i,C«+ A#t4*:-!n�ke+nn+.qM'":ia,- j uV m. <dAintttM'i:dvTxk0.'?YNftCh:%.'F '4 +�A �i`,7 .,,i -
New House ❑ Addition ❑ - Replacerne;ntW ndows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ j Decks [ ] Siding[ ] Other [ )
Brief Description of Proposed Work: I ►'is 4q 1 ( t Z r T)QC i I'1 J Oi��J
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll o• Sheet D
6a Ifi" New h-ouse.and o- ddition t rexi"s in housin cornW"°IbTe.the�fota:owi"n
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. Mascheck 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
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„x TO BE COM'0i&ED 1NHEN
OYVNERS AGENT OR'CON7RACTOR"APPLIES 10RBUILDING PERMIT:
as Owner of the subject prope
hereby authorize to ac
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
Qas Owner/Authorized Agent
hereby eclare that the statements and inf mation o b foregoing app ica ion are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
LAn
Signature of Owner/Agent Date
I
I
I
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
7
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 DON'T KNOW c/ YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registr of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 —
No
IF YES, describe size, type and location:
S
City of Northampton a
Building Department
212 Main Street S
Room 100 ef.- =
Northampton, MA 01060 Q e#s a _;
phone 413-587-1240 Fax 413.587-1272 ite,
O er peo r
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: r"w This sectio #o`he comp'eted by office
Map a Lothllnrt
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QP
ZU2 � v �,;b�Verly DI5t t ����
t1
4
(G(" Elm StDistnct� � .�. CB Drstrrct
SECTION 2 - PROPERTY'OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: (- (r
(2 Dry,r � ��qo � �/?r�S I en1P'r � ��m� Cya �boL�-
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
GI U
k 41-3
si r h
gnature -�;������
SECTION 3 -'ESTIMATED CONSTRUCTION.COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted 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 =(1 + 2 +3 +4+ 5) G Check Number
This Section For Official Use Only
Building-':Per mi#Number: Date Issued:
Signafor-e
Building Commissioner/Insoector,of B�Idings Date,,,
2t is f BP-2003-0298
GIs#: COMMONWEALTH OF MASSACHUSETTS
P�3'
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003.0298
Project# JS-2003-0510
Est.Cost: $3768.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Coast.Class: Contractor: License:
Use Group: THE JUBB CO INC 100001
Lot Size(sq.ft.): 7187.40 Owner: SHULMAN NAMOMI A&
Zoning:URB Applicant: THE J U B B CO INC
AT: 212 BRIDGE ST
Applicant Address: Phone: Insurance:
P O Box 429 (413) 772-6217 Workers
Compensation
GREENFIELDMA01302 ISSUED ON.9123102 0:00:00
TOPERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/23/02 0:00:00 5838 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
;Reptarement WinboW Propool IJ
Page No. of Pages
Main Office:
7 Devens Street• P.O. Box 429 THE JUBB CO., INC. d.b.a. Northampton, MA:
/�(41f3)1d72--6217 02 LARRY J U B B�S Brattleboro)VT& Keene, NH
18 North Hatfield Road IMPROVE-A-HOME 1-888-639-JUBB
Hatfield, MA 01038 Email: JubbCompanyinc @aol.com
PROPOSAL SUBMITTED TO J, PHONE DATE
�l I'll A ti SAP.- 0-7) '-7 9/
STREET JOB NAME
CITY,STATE AND ZIP JOB LOCATION
TENTATIVE JOB SCHEDULE(Weather Permittin ) MA Registration 100001
Approximately .�— weeks from date of signed proposal received by Jubb Co., Inc. MA Cons. Sup. Lic. 055333
We hereby submit specifications and estimates for:
Supply & Install Mastic TRULOK2 Vinyl Replacement Windows
• 1/2 Screens (double hung only). • Interlock meeting rail.
• Locking Screens (double hung only). • Welded sash & frame.
• Tilt-in Sashes (double hung only). • Five degree sloped sill.
• Non-conductive intercept glass system. • Seven-eights thermo glass.
• Block & Tackle Balances (double hung only). Insulated padded frame.
• Sun Shield Vinyl Compound (Mastic exclusive). Energy Star approved. `mod
• Twin locks on double hung units 32" or wider. Virgin vinyl. q/f /o
• Lifetime transferable manufacture guarantee on vinyl window frame.
• Twenty year manufacture guarantee on glass seal failure. ( � 4
��• Labor guarantee as required by CT, MA NH, VT contractor regulations.
Color: 2"Linen White ❑ Almond` ❑ Brown* (*extra charges apply for these colors) # �-7 C
TOTAL UNITS REPLACED: UT'-Storm Window Removal !mss
❑ Grids !VO (Note: Grids are beveled)
@--Low "E" Glass ��'{S ❑ Argon: /V J
❑'Insulation I-�-s (into weight pockets)
❑ Aluminum Clad Exterior Castings: / ( ❑ Full ❑ Partial )
OTHER/ NOTE: 710 /U�/
'
G 1 V V , /�. V Y
2
SERVICE FEE: $125.00 (includes permit and disposal of all job related refuse.)
(service fee not included in total amount below,and will be billed separately.]
CONTRACT SERVICE CHARGE:An interest charge of 2%per month(24%per annum)will be added to outstanding balances over 30 days,
plus all costs,including reasonable attorney's fees,incurred in collecting any sums owed.
Ut propos;t hereby to furnish material and labor-complete in accordance with above specifications, for the sum of:
�`'�✓ n
/`//1.u.- u,�l�ry ✓-t?,�/ vt,¢•�/te� ,};�("r-1/�-Z i y�1;�J--�f�ollars($ -7 !a[P
Payment to be made as follows:
1/3 DOWN PAYMENT UPON ACCEPTANCE Make checks payable to: The Jubb Co., Inc. (Our installers will collect final
balance upon completion).
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 above specifica- Authorized
tions Involving extra costs will be executed only upon written orders,and will bocome an extra Sign U
charge over and above the estimate.All agreements contingent upon strikes,accidents or
delays beyond our control.Owner to carry fire,tornado and other necessary insurance.Our Note:This proposal may be
r kers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within THIRTY days.
cceptance of propoga[-The above prices,specifications and
nditions are satisfactory and are hereby accepted.You are authorized to do Signature work as specified.Paymentt will be made as outlined above.
te of Acceptance: ! Signature
WHITE-Remittance Copy YELLOW-Customer Copy PINK-Office Copy
.A