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CT.REG,NO, 0621848 VISTA HOME IMPROVEMENT
MA REG.NO. 162058 2003 Riverdale Street
West Springfield, MA 01089 INSULATION
TOIL Free: 1-888-597-2323 * Local: 413-382-0249
FAX: 413-382-0241
Proposal Submitted To Homeowner Work To Be Performed At
p .
x,
Street
PP
Street t-- _ _- City; T _ State
City- = — State Date of Plans ---- --
x
Date _"_ --- __ Telephone
We hereby submit specifications and estimates for:
r
- - -----------------
Date work will start Date_ k will be completed
wcF p
All material is guaranteed to be as specified. All work to be completed in a vaorlortanliko manner according to standard t)ractices.Any alteration or deviation from the
above specifications must be made in writing on an And on/Mo dification of; oniwf,i form and may hermme an extra charge over and above th=amount stated herein_
this agreement is contingent upon delays beyonj our control.Owners to carry fiw I,)(n.l )and other ne';es.ary Inswance Our workers are fully Covered bit
Workmen's Compensation Insurance Homeowner agrees to pay for all wore aF-sral forth llolinw,if the l)orneowrier agr,cs to pay as cc.,s of co!-
iection,including reasonable attorneys fees,in addition to other darnaes murtred by f runiractor.Art 181/6 per month service charge will be assessed for all payments
riot made within 10 days of due date per the schedule below:
UP }Jf:OV05f hereby to furnish material and labor-complete in accordance with the above specifications,for the sum of:
= -- - --- -- -------- _._.
Said amount shall be paid as follows_
_-
Note:This proposal may be withdrawn by us it not accepted within day:,_
YOU,THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE
DAY OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FOR AN EXPLANATION OF THIS RIGHT.(SATURDAY
IS A LEGAL BUSINESS DAY IN CONNECTICUT.)THIS SALE IS SUBJECT TO THE PROVISIONS OF THE HOME SOLICITATION SALES
ACT AND THE HOME IMPROVEMENT ACT.THIS INSTRUMENT I.S NOT NEGOTIABLE.
Signature of Contractor or authorized representative: _- ^' - .., "
_
*(I/We)have read the terms stated herein,they have been explained to(melus),and(I/We)find them to be satisfactory"d hereby
accept them. l
Signature of Homeowner(s): X
X-;
The Commonwealth of Massachusetts
Department of Industrial Accidents
= I Congress Street, Suite 100
0
Boston, MA 02114-2017
M www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual):VISTA HOME IMPROVEMENT
Address:2003 RIVERDALE STREET
City/State/Zip:WEST SPRINGFIELD, MA 01089 Phone#:413-382-0249
Are you an employer?Check the appropriate box: Type of project(required):
1.Q✓ I am a employer with 9 employees(full and/or part-time).* 7. E]New construction
2.[—]1 am a sole proprietor or partnership and have no employees working forme in 8. [] Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]
10 E] Building addition
4.❑t am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole l I.[]Electrical repairs or additions
proprietors with no employees.
12.F1 Plumbing repairs or additions
5. 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet.
g 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.-
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#I must also 611 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 thepolicy and job site
information.
Insurance Company Name:SOUTHWICK INSURANCE ,
Policy#or Self-ins.Lic.#:�- -�� � _ — � Expiration Date: t
Job Site Address: City/State/Zip: i--IeV-e.1 c 4`�CAA CQ
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature• —, Date: 3 c /t
Phone 4: �_3- 232-2 q r1
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: (2 1.r —51) 'Mq `) 1
License Number
Address Expir ion Pate
Signat re Telephone
9.Registered H e Improvement Contractor: Not Applicable ❑
l Ly L b c A-
Company Name T' Registration Number
1 pc� I(2,z xal a � 2A � � El J dYl l (S'i CAS
Address ExpiratIbn Da
Telephone(413 3
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 '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 [[7] Decks [ Siding[O] Other[CI]
Brief Description of Proposed
Work: SUPPLYING AND INSTALLING 15 DOUBLE HUNG AND 3 BASEMENT WINDOW'S
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes x No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building: One Family V 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, EkeiSiine as Owner of the subject
property
hereby authorize Is}-wm.e L n^nrMIvv�tg c+ / ►^r.�n �,u cl a�
to act on my behalf, in all matters relative tow rk authorized by t is building permit application.
(cis ep�%,lrruA) 3/I Lt 15i
Sigg ature of Owner Date
A 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
1
�` Ce
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 tilled 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 cial Permit/Variance/Finding,ever been issued for/on the site?
NO Sp DONT KNOW Q YES C)
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW Q YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES Q
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 O 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
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 Q 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
i' Room 100 Water/Well Availability
rthampton, MA 01060 Two Sets of Structural Plans
DEPT OF f i ' 7',JNS
NOFl,HA. N ' -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
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
CHRISTINE LABEL 47 PINE ST.FLORENCE,MA 01062
Name(Print) Current Mailing Address: 413-320-1132
(s Telephone
Signature
2.2 Authorized Aaent:
►3 cu-% 12 ad 3
2c o` .fit, t�
Name(Print) Current Mailing Address:
pl;z—. 413-382-0249
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 9,150 (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) 9,150 Check Number a-
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
47 PINE ST BP-2015-0900
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A- 169 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:windows replaced BUILDING PERMIT
Permit# BP-2015-0900
Project# JS-2015-001736
Est. Cost: $9150.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: VISTA HOME IMPROVEMENT 099931
Lot Size(sq.ft.): 13198.68 Owner: LEBEL CHRISTINE Y&MARK O PAGE
Zoning:URB(100)/ Applicant. VISTA HOME IMPROVEMENT
AT. 47 PINE ST
Applicant Address: Phone: Insurance:
2003 RIVERDALE ST (413)382-0249 WC
WEST SPRINGFIELDMA01089 ISSUED ON:312512015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 15 DOUBLE HUNG REPLACEMENT
WINDOWS & 3 BASEMENT 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 Sienature:
FeeTvim Date Paid: Amount:
Building 3/25/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner