17C-107 (4) s UYes UNo hing
Rear Porch Roof Yes a FlasLocation , 0 4r" [ii Z
Drip Edge e o Color r
GUTTERS Color Downspouts Color
s t
Ali hn d Five's
t. 1 ltrro
n '. I It''r�'Mtt�ctlon
Downspout u ❑ Residential ❑ Commercial Type
Garage ❑Yes ❑No Location
Porch ❑Yes ❑ Color _
ATTIC ENERG ARRIER BLOWN-IN IWSULATION
CI Ratter Instal L1 Floor Install U Open Attic Blow Walls ❑Yes []No
Kneewall _ ❑Yes ❑No 11 Net Blow
Area to be cleared by homeowner []Yes ❑ Kneewall []Yes ❑N Type of exterior Cladd' _-_
Special Instructions
WORK SCHEDULE
C n�actorAli not begin the work or order the materials before the third day following the signing of this Agreement unless will begin the work on or about
R!.'. ,;.7i_a, :,Use o .rr 64,,01C.64kin e t cyond we k ,.l'A., iii flRt
matenals.accidents,and all other delays beyond its control, hall not t rnsic�MlW's as vi ations of this A reement '} r-r�� �� �:g r d ,n L�
WARRANTY {} 7 tJtl �[
The Contractor warrants that the work furnishe ereun r shalt be free from it}materials and workmanship for a period of--A—following completion and shall comply
with the requirements of this Agreement.In the event any defect in workmanship or materials,or damage caused by the Contractor,its subWntractors,employees or agents,is discovered
after completion of any job,including cleanup,the Contractor shall,at its own expense,forthwith remedy,repair,correct,replace,or cause to be remedied, repaired or replaced,such
damage or such detect in materials and workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed upon work.
_ rurftish bite mater�tal and labor specified above for the tcstc:a stsrrt od
W . _•�r'�>e;� to�r3y fur=E i �?i�x=�f?� } __
upon signing contract 1!3 maximum); Name of Representative
Authorized Signature
----�( __._................._.. —)upon completion of
utnnr,completion of
_ ._.`i6.L°'.....__.__..)shall be made forthwith upon which the contractor must make,in advance,to order and/or otherwise obtain delivery of special order
completion of work under this contract. materials and equipment,tttevar attnxant is grgawr.
Acceptance of Proposal I have read both sides of this document and accept the prices,specifications and conditions stated. i understand that upon
signing,this proposal becomes a binding contract.You are authorized to do the work as specified.Payment will be made as outlined above.
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the Seller,which may be his main office or
t r rchl thereof,r)rovidpd yeti notify the Seller in writing at his main office or branch by ordinary mail posted.by tPIPoram Sent or by de&vPry not later that,
'lip 11"al 4si i::it5a>>„ i.++.r '3 n?irirt"I tftic C:lon'z.raft,,to t Pi'eh .ni f;_trxr�aitatinn r�ar_.x r nt, ,t<of;a sir rs
to above and incorporated herein by reference.
DO NOT SiGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Signature_ ^~- f 1° ' Date + c Signature Date
_ .}.__..
DATE OF TRANSACTION
YOU MAY CANCEL THIS TRANSACTION,WITHOUT ANY PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE.iF YOU CANCEL,
ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENT EXECUTED BY YOU WILL
BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST
ARISING OUT OF THE TRANSACTION WILL BE CANCELLED, TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS
CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO: YANKEE HOME IMPROVEMENT, INC., 62 INDUSTRIAL DR..
__
t'dllti±tt r:u ::.i$$t'i,fi':�e iii�t7t)- t ..-xTE� I F'!.�t4 f<4It_.ti�flfis'r4 5.�.' -
I HEREBY CANCEL THIS TRANSACTION r —
(Date.Sundays and holidays excluded) BUY t URE DA rE
Buyer(s)acknowledge receipt of two completely filled in copies of this notice on the dat�'fir above written hereof.
` � J "
Buyer's __ .. t-__Btrber°c 4tj!nainre aattre
Roofina Gutters/Attic Barrier Agreement
Thousands of Satisfied Clients!
82 Industrial Drive 1224 Mill Street,Big B 224
EE k 01060 MA Llc#160584
YANKEE Northamoton. M.il! r.T Lit-*nA7';Q*?d East Berlin,CT 06023
F77 88-YANKEE
The MOST Referred Contractor i
All home improvement contractors and subcontractors must be registered and any inquiries
i n New England about a contractor or subcontractor relating to a registration should be directed to:
office of Consumer Affairs and Business Regulation Ten Park Plaza,Suite 5170
www.YankeeHomelnc.com Boston,1L102116 Phone:(617)973-8700
mate_ - Homeowner Information
Name 0 klA�J Street Address Stat
city--ti e lj�kl i3i(LLe��
L
Home Pill �f I Work Phone —Cell Phone
Mailing Address (if different), —E-Mail I
The Cbn#actor agrees to do the
" =fqr the Homeowner
ROOFING Type Color Style
Removal of Existing Roofing lKyes FIND FL A I C06F ice and Water Barrier X Full n Partial
Removal of Garage Roofing *o Ridge Vents [.-]Yes Mo tPl
71
Price per sheet as needed
Main House Roof []Yes []No j"
Garage Roof [] s
Yes NOO J
Rolled/Low Slope e q o X.ic is 16'Fle
Front Porch Roof es LEI No Location
Fleshings f DYes E]No
Rear Porch Roof Yes XNo Location ,e7,,vv Cii,!1LA4 "r —S
nrin FrinA
GUTTERS Color Downspouts Color
Layout Attached ElYes E]No Gutter Protection []Yes EINo
D Residential Sin Commercial bin Type ................. ...........
Downspout ❑ Residential Commercial X0 CC 0.r.,1 MM
ATTIC ENERG ARRIER BLOWN-IN P6ULATI4N
ED Rafter Instal v"', Cl Floor Install ;l Open Attic Blow Walls 5Yes F-IN
F1 Net Blow 0
Kneewall
.!Yes ONO
nor
Cz
DE C!Oarc"a Oy hrecTov�
Special Instructions
WORK SCHEDULE
begin the work or order the materials before the third day following tPe signing of this Agreement, I d Intact ill begin the work on or about
te)oBarfing delay caused by circumstances beyond Contractor's control,the work will i a Owner hereby acknowledges
delays that are not avoidable by the Contractor including,Q t e Z"�m at )
17 ,The 171. 1ley' f r; d to strikes,Acts of God, shortages of
n'
XtC
h
Od agri es at he scheduling dates are approximate and that such
matenals,accidents,and all other delays beyond its control,phall not wnsider%as v
Oations of this Aq reemenL
WARRANTY
The Contractor warrants that the work furnished hereunder shall be Iree from's eiecfs int materials and workmanship for a period of A toitowino completion and shall comoiv
%;
0 cvf�a;""
dify jub,if.Oudiltg cteanult'1!I. i"O QWI� 'XPv work.
damage or such defect in materials and workmanship.The foregoing warranties shall survive any inspection performed in connection with thLagneel-upon
YHI agrees to perform the work,furnish the material and labor specified above for the total sum of:
Name of I Representative
• �J%e�ii�r?
Fast & Reliably Waste Removal Services
CAI
(413) 455-1672
{
'3;'dfa--nd 30 yard dumpsters
+ s .
30 YEARS EX EMENC
. CD.^•arC*V.-L X+73 Nw&: s
Local Weather
r.
Our Address
j.Ti.-me.-*U*4Va5re
''hone .fix`. E-Mlfl r MA
City of Northampton 212 Main Street, Northampton, MA 01 060
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:
The debris will be transported by:
The debris will be received by: f2 _ os?o �l _4-?41
Building permit number: ------
-----------------------
Name of Permit Applicant - ai� �7oi1Z� 441
------------------------------------------
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
A a I Congress Street, Suite 100
,= Boston, MA 02114-2017
~ '°y www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): jan�_Rf m r oy2rYl�n� _
Address: g2 I ndus�-riC� r I t�� f'11 Z-
City/State/Zip: N0V4QL#VfVn MR 010(go Phone#: 1,3-515-2-82-6 3- -5259
Are you an employer? Check the appropriate box: Type of project(required):
1.VI am a employer with 7 4. ❑ I am a general contractor and I
employees (full and/or part-time).
have hired the sub-contractors 6. ❑New construction
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 for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance. y• E]Building addition
required.] 5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself ' per MGL
m se No workers comp. right of exemption p
Y [ P 12. oof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13T] Other
comp. insurance required.]
'Any applicant that checks box#I 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:
Policy#or Self-ins. Lic. #: /N U� - IjQ I�(I`�-(9' I`� Expiration Date: 5/25/2-015-
Job Site Address: 0—/ f C—t City/State/Zip: D( C)6 Z_
Attach a copy of the workers' col4pensation 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.
1 do hereby certify under the ns andpenalties ofperjury that the information provided above is true and correct.
Signature: L_- -- "—� 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 Construction Supervisor: Not Applicable ❑ /
Name of License Holder: ,��7/'�i�`;�'/ �)h �— oe /C�W_,-///
c
License Number
o � 6 . ter/ 01 J / 9/
Add ess / Expiration Date
Signature Telephone
9.;Re istered Home`Improvement Contractor: Not Applicable ❑
l< aam /"d0<J'�L
Company Name Registration Number
Acl ress ' — Expiration Date
Telephone
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 buildi g 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 pen-nit.
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 It
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E] Siding [O] Other[a
Brief Description of Proposed
Work: C1f F-p
t, 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
I, as Owner of the subject
property
hereby authorize Q�I �D/ / ✓y(�'�
to act on my,�b'eehalf, in all matters relative to work authorize by this building permit application.
�n—�'�Y!-f i/'ril&It
Signature of Owner Date
1
as Owner/Authorized
Agent hereby declare that the statements and ' ormation 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
Signature of Owner/Agent 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
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 DON'T KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry 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 l Obtained 0 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 l NO I@
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 MN
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
QCity of Northampton Status of Permit:.
Building Department Curb Cut/Ddveway Permit
SEP 2 5 2014 t 212 Main Street Sewer/teptid Availability,
Room 100 Water/Well Availability
p,Plumbing&i3 a9 Northampton, MA 01060 Two Sets of Structural Plan's
Northam on,MAO 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
�* F10✓�17(ft Zone
Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: '��/�
Name(Print) Curre t M iling dre
Oaf zn 6t Telephone
Signature
2.2 Authorized Agent:
l-11M /�ryvo rr� i d',a? /� 1��� 7,�r *6 iP7t80 L�E
Name(Print) f Current Mailing Address:
Signature Telephone
SECTI '-ESTIMATED CONSTRUCTION COSTS
' Item Estimated Cost(Dollars)to be Official Use Only
:t
complete 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) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
;:ti
81 HIGH ST BP-2015-0353
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 107 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-2015-0353
Project# JS-2015-000659
Est. Cost: $7278.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: YANKEE HOME IMPROVEMENT INC 89442
Lot Size(sq. ft.): 10497.96 Owner: LAK JUDITH
Zoning URB(100)/ Applicant. YANKEE HOME IMPROVEMENT INC
AT. 81 HIGH ST
Applicant Address: Phone: Insurance:
82 INDUSTRIAL DR UNIT 2 (413) 341-5259 O
NORTHAMPTONMAO1060 ISSUED ON.912912014 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 9/29/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner