15B-012 (5) ill �
INSULATION OCT 10
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SIDING CO., INC. IM3 .
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EASTHAMPTON OFFICE 413-527-0044 CSL License #CS SL 99739 1 1
53 jF1AKIKLIN STREET • EASTHAMPTON, MASSACHUSETTS 01027 FAN: 4.13-527-1222
Proposal Submitted to Phone Date
,-y Sam Adams "Purchaser"413-584-5249 (H) October 1, 2014
Street Job Name
582 Spring Street
City.State and Zip Code Job Location Job Phone
Leeds, MA 01053
Contractor hereby submits to Purchaser specifications and estimates for INSTALLATION OF SKYLIGHTS, STEEL DOOR, AND PATIO
- GLIDER
S 'L IGHTS
1 We will install (2) V _I_ u�--x non-operating skylights on rear of main house.
2. We will install fiberglass insulation around units installed.
3 We will install flashing kit on exteriQr. Approximate size will be 24"X 36".
cULLL QOOR
1 We will frame in new door opening on front porch.
? We will install (1) Therma-Tru Steel Prime Door nit with Adjustable Threshold on front porch.
3 We will install fiberglass insulation around door units installed and seal with Silicone Caulking on interior and
exterior.
4. We will reinstall existing wood door casing around interior of door unit installed.
5. Homeowner will he responsible for any ap inting or staining.
6- We will mnstall bright bras IQck set-
t
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): All Star Insulation & Siding Co., Inc.
Address: 56 Franklin Street
City/State/Zip: Easthampton, MA 01027 Phone #: 413-527-0044
Are you an employer?Check the appropriate box: Type of project(required):
1.E3 I am a employer with 10 4. ❑ I am a general contractor and 1 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 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a 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' 131-1 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: Star Insurance
Policy#or Self-ins. Lic.#: WC0681114 Expiration Date: 8/13/15
Job Site Address: 582 Spring Street City/State/Zip:Leeds, MA 01053
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 andpenalties of perjury that the information provided above is true and correct.
Signature 'no,C( Xy-Y Date: /Q/t W N
Phone#: 413-527-0044
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: Ed LOsacano CSSL 099739
License Number
128 Glendale Road, Southampton, Ma 01073 2-14-16
Address Expiration Date
413-527-0044
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
All Star Insulation & Siding Co. Inc.
Company Name Registration Number
56 Franklin Street, Easthampton, MA 01027 101858
Address Expiration Date
Telephone 413-527-0044 6-29-16
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....... ly, 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 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
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[O]
Brief Description of Proposed
Work: (2)Velus Skylights(1)thernaa-trn steel door and(1)Patio glider
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
Sam Adams as Owner of the subject
property
hereby authorize
All Star Insulation &Siding CO, INC Ed Losacano, Owner
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date 10-17-14
Ed Losacano, All Star Insulation &Siding Co, INC 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 under the'pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date 10-17-14
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 e DON'T KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 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 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 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 e
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 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
CR of Northampton Status of Permit:
Bul Ing Department Curb Cut/Driveway Permit
2 2 Main Street Sewer/Septic Availability
&GaS wsVP uor oom 100 Water/Well Availability
�tectt� ohaRpton,MP plc rthampton, 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 Prooerty Address: This section to be completed by office
582 Spring Street Map Lot Unit
Leeds, MA 01053
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Sam Adams 582 Spring Street Leeds,MA 01053
Name(Print) Current Mailing Address:
413-584-5249
Telephone
Signature
2.2 Authorized Anent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building $5,832.00 (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) $5,832.00 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
582 SPRING ST BP-2015-0494
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 15B-012 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2015-0494
Project# JS-2015-000926
Est. Cost: $5832.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ALL STAR INSULATION & SIDING CO INC 069281
Lot Size(sq. ft.): 21780.00 Owner: ADAMS SAMUEL&DANIEL J ADAMS
Zoning.URA(100)/WP(74) Applicant: ALL STAR INSULATION & SIDING CO INC
AT. 582 SPRING ST
Applicant Address: Phone: Insurance:
56 Franklin Street (413) 527-0044 Workers Compensation
EASTHAMPTONMA01027 ISSUED ON.1012812014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT PATIO DOOR,ENTRY
DOOR & SKYLIGHTS
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 10/28/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner