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29-065 (6) PATRICK KUBALA HOME IMPROVEMENTS All home improvement contractors and subcontractors engaged in home improvement contracting,unless specifically exempt from registration by Provisions of Chapter 142A MA HIC#150118 of the general laws, must be registered with the Commonwealth of Massachusetts. 5 Pell Street Ludlow, MA 01056 Inquiries about registration and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 413-589-1010 02108(617)727-8598 Submitted, � 12 � G. , i Jr�A ,,Job Name: /�,� .r�Sd` [.d,[� d[a✓ e, A, ©i0 Q­ Job location: ��- Phone r S D_ —,J,©� Date `�-y Estimator: r-lc_r `��� W reby submit specifications and/estimates for work to be performed and materials to be used: c i a- � y 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 being the work on or about (date). Baring delay caused by circumstances beyond the contractor's control. The work will be completed by (date). The owner hereby acknowledges and agrees that 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 materials,accidents,and all other delays beyond the 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 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 subcontractors,employees or agents,is discovered after completion of any job,including clean up,the Contractor shall at its own expense, forthwith remedy,repair,correct,replace or cause to be remedied, repaired or replaced,such damage 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 furnish material and labor-complete in accordance with above specifications,for the sum of: �- dollars($ /a97— ��P t to bees fpllo�s;5: /1 7 C12-�T� (tom %(_ [� )upon signing contract; P"" PATRICK KUBALA HOME IMPPOVEMENTS %(_ )upon completion of 5 PELL STREET % J ^)upon completion of Z t LUDLOW, MA 01056 413-589-1010 %( 576 7 )shall be made forthwith upon MA HIC 150118 completion of work under this contract. Notice:No agreement for home improvement contracting work shall require a down payment Salesperson: ,� (advance deposit)of more than one-third the total contract price or the total amount of all deposits or payments which the contractor must make,in advance,to order and/or otherwise Authorized Signature: obtain delivery of special order materials and equipment,which ever amount is greater 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 the buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See notice of cancellation form for an explanation of this right. Please refer to the Notice of Cancellation that accompanies this contract;contents of which are referred to above and incorporated herein by reference. DO N I THIS CONTRACT IF THERE ARE ANY BLANK SPACES Si natur _ - Date �` Signature Date g ---- - -- - - --_.-- --- -- Signature --- - -- — -- PATRICK KUBALA HOME IMPROVEMENTS All home improvement contractors and subcontractors engaged in home improvement -_ contracting,unless specifically exempt from registration by Provisions of Chapter 142A MA HIC#150118 of the general laws, must be registered with the Commonwealth of Massachusetts. 5 Pell Street Ludlow, MA 01056 Inquiries about registration and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 413-589-1010 02108(617)727-8598 Submitted t To: Job Name: i t IF. sC l 9t� P7!et..� rr 106 Z� Job location: Phone Date t) l Y�`•Z1- Cy Estimator:, i7�rc_ W eby submit pspecifications and estimates for work to be performed and materials to be used: y} / i �G�,s /G cam^ � s� !•G � f 6ii G ee sue! 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 being the work on or about (date). Baring delay caused by circumstances beyond the contractor's control. The work will be completed by (date). The owner hereby acknowledges and agrees that 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 materials,accidents,and all other delays beyond the 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 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 subcontractors,employees or agents,is discovered after completion of any job,including clean up,the Contractor shall at its own expense,forthwith remedy,repair,correct,replace or cause to be remedied, repaired or replaced,such damage or such defect in materials and workmanship. The foregoing warranties shall survive any inspection performed in connection with the a;reed- upon work. We Propose hereby to furnish material and labor-complete in accordance with above •specifications,for the sum of ( dollars($ pze�q ). Payment to be tpa e s: �3 % C � )upon signing contract; ATRICK KUBALA HOME IMRPOVEMENTS upon completion of ��7` 5 PELL STREET %( �r�f d�-� )upon completion of l ��Y LUDLOW, MA 01056 413-589-1010 %( o% )shall be made forthwith upon MA HIC 1501 completion of work under this contract. Notice:No agreement for home improvement contracting work shall require a down payment Salesperson: f C (advance deposit)of more than one-third the total contract price or the total amount of all deposits or payments which the contractor must make,in advance,to order and/or otherwise Authorized Signature: obtain delivery of special order materials and equipment,which ever amount is greater 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 the buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. See notice of cancellation form for an explanation of this right. Please refer to the Notice of Cancellation that accompanies this contract;contents of which are referred t above and incorporated herein by reference. DON S N THIS CONTRACT IF THERE ARE ANY BLANK SPACES Signature ,G' Date T'L7P-1 / Signature_____ — - _ .__----- --------,Date The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Patrick Kubala Home Improvements Address:5 Pell Street City/State/Zip:Ludlow, MA 01056 Phone#:413-589-1010 Are you an employer?Check the appropriate box: Type of project(required): 1.FE-1 I am a employer with 3 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. Q 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 tY• 9. E) 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' 13.❑Other comp.insurance required.] *My applicant that checks box#1 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:Utica National Policy#or Self-ins. Lic.#:4697961 Expiration Date: 10/27/2015 Job Site Addressi� %t tv-� .l 1 ' -t 0� k�. _ City/State/Zip:n i t��;7 y�r.e.t✓� �'f` t? ����`�? 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 an�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 or insurance coverage verification. I do hereby certify un r the pains and penalties ofperjury that the information provided above is true and correct Sianature: L '. Date: Phone#• 14 Offccialluse 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 Issuing Contact Person: Phone#: ^ ` SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder !00 i License Nu ber Address Expiration Date Signal6re Telephone 9.Realstered Home Improvement Contractor: Not Applicable Company Name Registration Number J Lx, Address Expiration Date Telephon SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152, 26C(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. The current exemption for~bomoowne,s"was extended minclude one(1) or twm(DfamUieo and m allow such homeowner m engage un individual for hire who does not possess ulicense, 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/o,farm structures. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official, responsible for all such work performed under the buildinz permit. As acting Construction Supervisor your presence ou the job site will hv required from time to time,during and upon completion of the work for which this permit ixissued. Also be advised that with reference to Chapter l5Z(YVorkca`Compcuoo1ion) and Chapter |53(Liability o[Employers to Employees for injuries not resulting in Death)ofthe Massachusetts General Laws Annotated,you may be liable K/,pcmo*o) you hire|o perform work for you under this permit. The undersigned`1bomconmcr`ucrtifico and assumes responsibility for compliance with the State Building Code,City nf 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 WIXdows Alteration(s) ❑ Roofing ❑ Or Doors E' Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [[] Siding[ Other[❑] Brief Description of Proposed Work:i20x)l �1i2���%��C11��r 'U�VA V'�IViCUwS Alteration of existing bedroom Yes��No Adding new bedroom Yes ✓ No Attached Narrative Renovating unfinished basement Yes r 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 to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 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 V S ature of Owner/Agent Date i 1 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:'111111 .... . Rear Building Height Bldg.Square Footage Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location) A. Hasa 9pecial Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW 0 YES IF YES, date issued:'. IF YES Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES enter Book Page, and/or Document #' B. Does t he si t e cont ai n a brook, body of wat er or wet I ands? NO 0 DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 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 I 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 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. GJepartment us e on City of Northamptoni '' Building Department Orb: ufiOrivy�tr' tlt APR 2 9 Nis ��,�� 212 Main Street Room 100 it�taterllt�tlAlalll '' Electric,Plumbing&Gas Inspection orthampton, MA 01060 �; Plan i Northampton, MA o 3-587-1240 Fax 413-587-12721 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 CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ,C'V'-1( 1�'.r k' Name(Print) Current Mailing rest: Telephone Signature 2.2 Authori d A ent: Y41 ,iG' Name(Print)/y Current Mailing Address: Si nature Telephone 4^SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building —f ' co (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) ` �3 3_ /L Check Number r This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/inspector of Buildings Date 23 GILRAIN TER BP-2015-1037 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-065 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) Category: replacement windows/siding BUILDING PERMIT Permit# BP-2015-1037 Project# JS-2015-001971 Est. Cost: $29278.00 Fee: $70.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PATRICK KUBALA Lot Size(sq. ft.): 18513.00 Owner: KOWALSKI PAUL E&BARBARA K zonine: Applicant. PATRICK KUBALA AT. 23 GILRAIN TER Applicant Address: Phone: Insurance: 5 PELL ST (413) 589-1010 WC LUDLOWMA01056 ISSUED ON:412912015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOWS & SIDING 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 4/29/2015 0:00:00 $70.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner