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17C-042 (5) MASS.REG.#106353 R.I.REG.#6634 ortheast CONN.REG.#005339919 NHOME & ENERGY 21 N.MAIN STREET(RT.140) • NO.GRAFTON,MA 01536 (508)839-7001 • 1-800-828-7001 Uwe,the Owner of the premises mentioned below,hereby contract with and authorize you as Contractor,to furnish all necessary materials,labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and conditions,on premises below described with reference to which we wan-ant we fare the record holders of title. nt OWNER'S NAME:T&:4' 1 .rlf.( J/tu-ili ([/�s t/ TEL.: e2 JOB ADDRESS: - SO «iLLU,�r�jl� CITY. �,i-e.17i:4 STATE: /M ZIP: 0106-2 EMAIL ADDRESS: CELL: Y SPECIFICATIONS 1 f t' q Nuv �r�.;��r an�Ccl ��r�'�r uscucd r�i,:r,.zw "I- 4, PhyGS 7 �'a S faCGr�?Cii7 /-,7 Iuear� a >Li�7�� ar u/ T SfsJ C/r?S / �ec•S LUaYY�t�7Yt1 /Sa7li u r /J1�ei�u( .cull✓IZsfi?ra—iaTIEC� Required Permits-The following building permits are required and Proposed Start and Completion Schedule-The following schedule will be secured by the contractor as the homeowner's agent,(Owners will be adhered to unless circumstances beyond the contractor's control who secure their own permits will be excluded from the Guaranty arise. Fund provisions of MGL chapter 142A.) ,tQ.-.gZ' Date when contractor will begin contracted work. 4$7147)p Date when contracted work will be substantially completed. Total Contract Price and Payment Schedule 7 L.� Q The Contractor agrees to perform the work,furnish the material and labor specified above for the total sum of- Payments ` (*) Payments will be made according to the following schedule: $ upon signing contract(not to exceed 1/3 of the total contract price gr the cost of special order items,whichever is greater) $ by_/_/_or upon completion of $ by_/_/_or upon completion of $ 7,Y-5 0 upon completion of the contract.(Law forbids demanding full payment until contract is completed to both party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order to meet the completion schedule.(**) $ to be paid for NOTES:(*)Including all finance charges(**)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Express Warranty-Is an express warranty being provided by the contractor? No Yes (all terms of the warranty must be attached to the contract) Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor uti- lized 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 most home improvement contractors and subcontractors 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)727-3200 or 1(800)223-0933. • Does the contractor have insurance?Check to see that your contractor is properly insured. • Know your rights and responsibilities.Get a copy of the Consumer Guide to the Home Improvement Contractor Law. 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 pasted,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 the con ct must be comp)oed and signed.One copy s old go to the homeowner.The other copy should be kept by the ccontrwtor. Homeowner's Signature Date (f //34 Contractor's Signature �'� Date 6 IJ 1, NORTHEAST J City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: `S�— cZ--- The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant � �Ig// Date Signature of Permit Applicant City of Northampton Massachusetts iy T• DEPARTMENT OF BUILDING INSPECTIONS Wi=t 212 Main Street • Municipal Building w• Northampton, MA 01060 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street 4r Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): �4 e � t►tisZ� _K C)Address: + Oft-' N S � City/State/Zip: ° �/1 w Phone #: S i� 7 6 Are you an employer? Check the ap ropriate box: Type of project(required): 1.2I am a employer with L/ 4. ❑ I am a general contractor and I 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 g_ ❑ Demolition working or me in an capacity. employees and have workers' g Y p �' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.T required.] 5. ❑ We area corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHo meowners 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: /I aj V\.-(i`f Policy#or Self-ins. Lic. #: (, 'l Z S� 1 I l Expiration Date: c7& J Job Site Address: City/State/Zip: 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 he eby cer ' under he pains and lties of perjury that the information provided above is true and correct. Si atur . Date: Phone#: 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 Construc ' Su ervi r: Not Applicable £ Name of License Holder License Nurn er ( � 12-1-/ 20 ddre Expir on Date Signaiare Telephone 9.R istered Hp Im'rovement Contractor:';; Not Applicable £ Non-4 �� Company Name Registration Number N . M �� ►� -�' z- Address r �,( 2 C� Expir ion Date �1 Telephone"- �A J ,7, 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 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 "aal Zoning Laaw�sand State of Massachus tts General Laws Annotated. Homeowner Signature. -S SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors E Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [O] Other[[31 Brief Description of Proposed L Work: ✓`�ll� Q11� reroo6 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'fouse'and or'addition to-existing housmg, 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 1 , 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 n I � � CJN (2A � t(`(.�ty ( �� , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed unde he pains and penalties of perjury. ov& Pr' t n A a W` Signature o wner/Agent ate , . 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 Setbacks Front Rear J Building Height Bldg.Square Footage Open Space Footage % #of Parking Spaces (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW 0 YES 0 |F YES, date iouedd � IF YES: Was the permit recorded at the Registry ofDeeds? NO � J DONTKNO YES �� YY IF YES: enter Book Page and/or Document# �� �� B. Dues the site contain a brook, body ofvvaternrwetlands? NO �~��� DONT KNOW «�� YES �_� IF YES, has a permit been ur need tnbe obtained from the Conservation Commission? Needstobeobtained v— \ Dbtained »�� Date �~� �_� ' . C. Do any signs exist on the pmperty �� ��� YES �^� NO v�� 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 typeand \ocatinn� } ) ' ' __-_------ _-_____-__-__-� E.' Will the construction activity disturb(clearing,grading vaUon.or�UinQ)over Iomnor�dpo�ofa common plan that will disturb over 1acre? YES NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ^ '^ I L Departmeht use orly i City of Northampton Status ofPertntt j' 1 ` M_ Building Department CtrrEa Cut/Dnveway Perrrttt r Y F r I 212 Main Street Sewer(SeptlGAvaira6tlity ^i Room 100 INaterll/UeilAva�lability J.V' JUN 1 9 2014 % Northampton, MA 01060 Twa Sets of StFUCtuTal P6arfs jH_ph ne 13-587-1240 Fax 413-587-1272 Plof/Site Plans r I ectric. Plumbing&Gas inspections Other Specify or amp on, FOOT— AP STRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address This section to be completed byoffice Q < <""� Map Lot Uar /a Zone Overlay D�strtct f Elm St District CB Distract . SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Pant) L9 Current Mailing Address: 1 3 —` __ 1 Telephone Signature 2.2 Authorized A e Na �aA< Current Mailing Address:4j S 0c)b 70 C / Signature Telephone 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 T' Construction from 6 3. Plumbing r Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number: Date Signature: Building Commissioner/Inspector'of Buildings Date 50 STRAW AVE BP-2014-1363 GIS#: COMMONWEALTH OF MASSACHUSETTS Map.Block: 17D-042 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) catego!y: ROOF BUILDING PERMIT Permit# BP-2014-1363 Project# JS-2014-002295 Est. Cost: $7450.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RICHARD PRUNIER 099195 Lot Size(sq. ft.): 7579.44 Owner: PUCHALSKY RICHARD J& SHERRI Zoning. URB(100)/ Applicant: RICHARD PRUNIER AT. 50 STRAW AVE Applicant Address: Phone: Insurance: 115 SYCAMORE DR (508) 839-7001 WC HOLDENMA01520 ISSUED ON.611912014 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 6/19/2014 0:00:00 $35.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner