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23D-153 (2) 9TWADMF Toll Free(877)3-STURDY All home improvement contractors and subcontractors Springfield(413)543-1681 engaged in home improvement contracting,unless spetaff- ' Worcester(508)797-6600 cally exempt from registration by Provisions of Chapter 142A TOTAL HOME Stu d New yHome.com RENOVATION Haven(20 3)848-2118 of the general laws, must be registered with the 459 Main St.•Indian Orchard,MA 01151 Fax(413)543-3200 Commonwealth of Massachusetts.Inquiries about regislra- P.O.Box 51033•Indian orchard,MA 01151 tion and status should be made to the Director, Home MA REG.#151711 Member Better Business Bureau Improvement Contract Registration, CT REG.#601525 Fully Licensed Insured One Ashburton Place,Room 1301,Boston,MA 02108 Submittedtto: Lov it c�D 2k71�t�y`'`e ?,to 0-1 p �? (617)727-8598 41- AL .-,,RG. �Y A WORK* We hereby submit specifications and estimates for Work to be performed and materials to be used: zr WORK SCHEDULE Contractor will not begin the work or order the materials before the third day following the signing of this Agreement,unless specified herein.Contractor will begin the work on or about (date).Barring delay caused by circumstances beyond Contractors control,the work will be completed by (date).The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor including,but not limited to strikes,Acts of God,shortages of materi- als,accidents,and all other delays beyond its control,shall not be considered as violations of this Agreement. WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of fallowing 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 subcontractors,employees or agents,is discovered after completion of any job,including cleanup,the Contractor shaft,at its own expense,forthwith remedy,repair,correct,replace,or cause to be remedied,repaired or replaced,such dam- age or such defect in materials and workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. We Propose hereby to,fuu_rnish material and fab r-compleette�i •actor ante with above specifications,for the sum of: r� `�GvG ,--/A'�� t. 1!/ I'r dollars($_2 Payment to be made as follows: eft. } LC 3 ($ 2—J �/ pan n n c�ac� STURDY HOME IMPROVEMENT,INC. Name of Con tractodDesignated Registrant )upon start of work; P.O.BOx 51033 Street Address ($ y tJ0' 1 upon eempletivn of Y7 Indian Orchard MA 01151 413-543-1681 City/State ,,,,p®/gyp,/ Phone shall be made forthwith upon �Salesman �6n r-- completion of work under this contract. Name of Authorized Signature Acceptance Of Proposal I have read both sides of this document and accept the prices,specifications and conditions stated.t 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 Setter,which may be his main office or branch thereof,provided you notify the Seller in writing at his main office or branch by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement.Please refer to the Notice of Cancellation that accompanies this contract;con- tents of which are referred to above and incorporated herein by reference. � nn DO NOT�SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Date The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 k1ri Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLibly Name (Business/Organization/Individual): Address: 14S9 m ou n City/State/Zip: n1151- Phone #: '6[ Are employer? Check the appropriate box: Type of project(required): 1. a employer with Z 4. ❑ I am a general contractor and I employees (full and/or part-time). * have hired the sub-contractors 6. New construction 2.El 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.$ 9. F-] Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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: R L.(Z°Q nQ_V_ Policy#or Self-ins. Lic. #: ()j 0 5)()D - �J 2- ' 161 Z. Expiration Date: -7 /Z- Job Site Address: IA42 ffin City/State/Zip: P ltj r 1( . M_4 010(D2 Attach a copy of the workers' compensation olicy 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 paizand penalties ofperjury that the information provided above is true and correct. Si nature: Date: fty1_1 S— Phone #: 1136q3l 6� 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: Iq 3 wo� License Number lq -}, IO r ?3/I/!s" A e s Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ SyLk�w ft IM n2�v2n'�P�k (SI 7 l l Company Name Registration Number 4A69 Main &. Ioof.toun Creharaf 10A C(tL4 h/z(o//(,g Address Expiration Date Telephone A3 6q3 l(D$1 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(l) 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 W' doves Alterations) Roofing ❑ Or Doors ff Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks Siding[❑] Other[❑] Brief Description of Proposed Work: 0,001 106)PAIS NA-1) 'VP�l kK e VV4-4C-Q1 St:" Lie . 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 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 to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date MEN- I, 1 'ok 1 `Z 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. Prin l 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:`' .. _ a 1 Rear Building Height Bldg. Square Footage % _ i l Open Space Footage % (Lot area minus bldg&paved parking) 3 . #of Parking Spaces ---° i— Fill: (volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q YES 0 IF YES: enter Book ` ? Page, and/or Document#i B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 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 0 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 Q 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 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. �� De~partment use only t_ City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit IF 212 Main Street Sewer/Septic Avallabitit�r Room 100 WaterANeil,Availabitity Northampton, MA 01060 Two Sa77,77 ets of,Structural'Plans of c, _-.L ©n6 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 dress: This section to be completed by office oAddd--,, c+ Sir-cam Map Lot Unit (J Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Cntt Mailin lAOddress. 4 Telephone Signature 2.2 Authorized Agent: N Print) Current Mailing Address: X13 2t� -'1G 2 a u Telephone _F SECTION 3-ESTIMATED l66NSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 21 5u-0 (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=0 +2+3+4+5) -2 5—CM Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 142 HINCKLEY ST BP-2015-0993 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23D- 153 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: window replaced BUILDING PERMIT Permit# BP-2015-0993 Project# JS-2015-001913 Est. Cost: $2500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STURDY HOME IMPROVEMENT 093603 Lot Size(sq. 1): 30448.44 Owner: WILSON SUZANNE T&GROCCIA LOU Zoning URB(100)/ Applicant: STURDY HOME IMPROVEMENT AT: 142 HINCKLEY ST Applicant Address: Phone: Insurance: P O BOX 51033 (413) 543-5906 WC INDIAN ORCHARDMA01151 ISSUED ON.•412112015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL SKYLITE 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 4/21/2015 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner