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17D-006 (6) 558 BRIDGE RD BP-2017-1423 GIS n: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-006 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 it BP-2017-1423 Project JS-2017-002356 Est.Cost: $19500.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: STURDY HOME IMPROVEMENT 093603 Lot Size(s0.ft.): 189921.60 Owner: KAISER WILLIAM F Zoning: R1000)/RR(I00)/ Applicant: STURDY HOME IMPROVEMENT AT: 558 BRIDGE RD Applicant Address: Phone: Insurance: P O BOX 51033 (413) 543-5906 WC INDIAN ORCHARDMA01151 ISSUED ON: 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: FeeTvpe: Date Paid: Amount: • Building 4 IQ I i1 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner em City of Northampton SYatus of Pettnh Building Department Curb Z'tryClrive&ay Permft _ 'UN 212 Main Street Sewer/Septic Availabdrty '\ Room 100 Water/Well Availability \ Northampton, MA 01060 Two Sets ofStmotuml Plans 1 \, phone 413-587-1240 Fax 413-587-1272 PbUSfte Plano Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATEqOR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION U I' I7_ /��� 1.1 Property Address: This section to be comp! by office l Map I� Lot Unit a�-�I e"1 O t O Zone Overlay District vv2nCC a Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 1.011ti.am F. Kamer S ? or�cp Rc a4 Name(Print) Cu ent Mai ing res d.1 3° t.-al Telep one Signature 2.2 Authorized Agent: C �� JT t.t1'Gt1 - gS9 tcoA t4- S' -e 41lJ-0. NVt O,(� Name(Print) Current Mailing Address: Signa SureLu eco.<�;t �It3� Su3Sgbe Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building n ISS. o (a)Building Permit Fee 2. Electrical 'I - (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) ri1 \c1 SbO. cp Check Number y� VV � ff �/ `� This Section For Official Use Only / Building Permit Number Date J Issued: Building m/ Signature: om sinner/Inspector of Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning N 1 \ /A- This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: _._ R Rear Building Height - — -j Bldg. Square Footage .. "_. . °o • Open Space Footage / (Lot area minus bldg&paved parking) - -. k of Parking Spaces - . -- Fill: _ (v'ohmic&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW O YES O 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 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 O 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 O NO • IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House 0 Addition E] ReplacementrI'-4Sws Alteration(s) ❑ Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [CJ Siding[CO Other[C] Brief e� tion of Pr.++ ed n t t at t»$ t=1EF c r,•rhe t n-li(r.thVtczt Work:-I ILf, A ll: Np. 1 A. ,, i. I , ie. .. J .L •IL 6 F i6.1 (�'DkiteannfY' 1 • 'C (U±Q1eCI Cuw.n Alteration of existing bedroom Yes o Adding new bedroom Yes I ae- Attached Narrative Renovating unfinished basement Yes t...----<;; Plans Attached Roll -Sheet Ga,If New house and or addition Jo existing housing, complete the following: a. Use of building :One Family, __ Two FamilyOther 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 a 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, Vt )] I(,4.o4 ( Ct 16-12-C ,as Owner of the subject property p hereby authorize S rak`-1 -OW10t, q-l-r'cA C'IYtO-.t.d'-"GWLC • to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner f L,,,,,r, �p —�^, Date I, �4ru4(,r1 cj ''f/'wr Xq - 24tc • as Owner/Authorized Agent hereby deciar that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. 1Sed under the pains and penalties of perjury. D P1tMariaame R / - Signature of Owner/Agent L 1 rr I ] Si g /Agent ........... Date SECTION 8-CONSTRUCTION SERVICES + ` ¢.1 Licensed ConstructonSupervisor: Not tAApplicable e�❑ v\ Name of license Holer/1-000./i ^, )hcC� t �' (\R, V? License Number 01101 I - . iJ ! AO-01 I V1 ., Expiration ate it` 4l - I 1)is Signature • ' ' Mori- / hom/ S.Registered Home Improvement Contractor: Not Applicable ❑ S-4uo dsk-t 9vrv4 CL 'yliea re/vALA" d:ttC . l 51 `! ) Company Name 4 Registration Number t" � Ltrlotoi1`i . Address Explatio Date /X°U/�'[•CSti�N Pr rp Cilt a l -..._Telephogi3)9I3'Ma,„ SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(HMI_c.152,§25C(S)) Workers in Signed rCompensation the issuance Affidavitpion Insurance affidavit st be completed and submitted with this application.Failure to provide this affidavit will result denial of the buirdin ermit. gAttached Yes No ❑ 11. - Home Owner Exemption The current exemption for"homeowners”was extended to include{honer-occupied Dwellings of one(I) 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 shalt 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 City of Northampton 212 Main Street, Northampton, MA 01060 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: 5`51.-Zi. &ric . 4j The debris will be transported by: � 1� Lk5A (n)a$A e F 4 rl`6 l The debris will be received by: SA Wit c. L V - iyt✓vA Rc& - i F. concisn.4 Building permit number: 1� Name of Permit Applicant W, �� U^M 16‘-‘Xe c Date Signature of Permit Applicant City of Northampton is Massachusetts uz { ti ''} . DEPARTMENT OF WILDING INSPECTIONS 212 Main Street • Municipal Building ' � C? Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor CHIC"), M.G.L.Chapter 142A requires that the"reconstruction,alteration,renovation,repair,modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units...or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered OL' Type of Work: i2otc,C. V'PPta,CcV,W4 A �" Est.Cost: ('JC.IG , Address of Work: 6 CX hLIG' APC. T""Lc 'tv1C .I" • Date of Permit Application: (.¢ \ 14" I hereby certify that Registration is not required for the following reason{s): _Work excluded by law(explain): Job under$1,00000 Owner obtaining own permit(explain): Building not owner-occupied .._Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply forma building permit as the agent of the owner: {r1) 1 sk1ttiUtz � i'Overy rte L-51 -*- 1 l Da(e Contractor Name I HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual, partnership, association, corporation or other legal entity,or any two or more of the fbregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152,§25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es)and phone number(s)along with their certificate(s)oP insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to cavy workers' compensation insurance. If an LI.,C or LLP does have employees, a policy is required. Be advised that this affidavit may he submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents, Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pennitilicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address" the applicant should write"all locations in__(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Revised 7-2013 Fax # 617-727-7749 wwwmass.govldia City of Northampton i� Massachusetts a+yrs s. JO'y jG tv!1 irt DEPARTMENT • nA pn MunicipalBBuilding 212 Main .e2;;, Nort INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HQMAOWNE&L P .K.1Q1Y. _ 2_, The State of Massachusetts allows the homeowner the tight under 78OCMR 108.34 to act as histher construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervisor,to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill), sonotube hss(before pour). a rough building inspection (More work is concealed) insulation inspection lif repuiCe�and a Final building_gsgection The building department requires these inspections before the work is concealed,failure to secure these inspections can result.' .i .. _• .', '-rate of occ pal t it r.- . _.. inspected if the homeowner hires other trades to perform work(electrical, plumbing &gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date (01 I\ rar— ? Address of work location 5 4L ~ a ik? ba e 1_ "No Substitute far tuatity>' WORCESTER SPRINGFIELD HARTFORD 959 MARL STTREET-P.O BOX 51013--SPR/NGFR'LIL IAA 01151 ML4.RIIO#151711 CI.REG#601525 877-3SIIJRDY FAX 413543-3200 WWW.STURDYIIOME.COM OWNER PERMIT AUTHORIZATION Name: Weill Jetear_ g gar /se Address: 5'✓Fg HhndpG. R'4, city/Statelzip: F%4',z*c 444 106-X. T Wt i//Q ax. 1.'(4 P.'. r- (owner), of the property located at: ''• 6. r- authorize Sturdy Home Improvement, Inc. 'To act as my agent for the construction project taking place at the above address.I also, authorize Sturdy Home finprovement,7nc to obtain a building permit for this project.I understand and accept responsibility to comply with all regulations and required inspections. ' . 0- 1G7 Signature of Owner Date Signature of Owner Date C.72_, 0142 C-) t t rn � eaU6 ,; fceoonsumerAffais dBfineot 10 Pare PIaza - Suite 5170 Boston, Massachusetts 02116 Home Improvemgirtsclontractor Registration H r Registration: 151711 I , _� 1 Type: Supplement Card ' � tt - Expiration: Ci/28/2018 STURDY HOME IMPROVEMENT lir1� 1Y�� t� '-�1�� DAVID DIAZ n, f t f 1 1 ti 459 MAIN STREET ' ., 1 , 9110•11.--„110 ! ' ...._ _._ INDIAN ORCHARD, MA 01151 � �J _. — — w Update Address and return card.Mark for change. xxi n 2094)S/11 - - [1 Address D Renewal El Employment L-1LostCard Cf%fo ¢ommonaca(N 9"017m.sterde uetb Office of Consumer Affairs&Business Regula tion License or registration valid for individual use only Lg�JME lfi1AROVEMENI CONTRACTOR before the exphaUondaft If found return to: { istTatinn Office of Consum r Affairs and BusinessRegulation 7o1ZiiTypB: 10 Park Plaza-Suite5170 Expnah n ec6aoi Su lement Card Y _¢„ PPBoston,MA 02116 STURDY HOME IMP1404,10ifeiHde navlo n:az - 459 MAIN STREET lEsr-.._... GAJ NDIAN ORCHARDMA 01751 Budsecretary Not valid without aignat .� . Massachusetts Department of Public Safety % Board of Building Regulations and Standards License: CS-083603 Construction Supervisor a,rnIf . DAVID DIAZ c 270 TREMONTS7,r, SPRINGFIELD Mp. g Expiration: Commissioner os/07/2017 A��® DATE(MMIODIYYY✓I CERTIFICATE OF LIABILITY INSURANCE 8/8/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTiTUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate hewer is an ADDITIONAL INSURED,the policy(los)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CA T. - Orchard-Dowd Insurance Agency LLC PHONE Nad $e WERE FAX 14 Hebeia Road - „(NC.xol'413-a'iT-last Holyoke MA 01040 AOOAAIL$$`nw_5CR3dOlg.COD,PRO ussTioOMFRR ID L G'PURHO f-02 INSURERISI AFFORDING COVERAGE NAICA INSURED LSURER A:Atl antra.Casualty Insuranc(a Company 42214 Sturdy Home Improvement, Inc. IrvsuRERa: P.O. Box 51033 Indian Orchard MA 01151 wwRERC1 INSORER": INW RE0.E: ....... MSURERF: COVERAGES CERTIFICATE NUMBER:397345024 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED NOTWi IRSTANOING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WIN RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR .. POLICYEO' Poser ETR LT; _ TYPE OP INSORAACE INSR %We POLICYNUMBER i{ oou/YJY% IMM2)DtYYYI LIMO A GENERAL LIPOID? M285000299 41/7/2014 0/7/2017 EACH OCCURRENCE $1,000,000 11. DNUOG 10 REN1PD COMMERCIAL GEIFPAL LABILITY PREMISFt colaypal $5P,OPP 1CIAIMSM40E OCCUR MED EXP(My one person) $5,000 I PERSONAL&ADV INJURY $1,033,044 II GENERALAGGPEGAiE P.000,000 GENLAWREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $2,000,000 FOUCY,PRfrO- •LOC _ S AUTOMOBILE LIABILITE COMBINED SINGLE LIMIT $ ANY ALTO ;Ea scatlma AUOWNED AUTOS 20GLYent) Pe:pnoI S SCIIEDULEDA DES III BODILY INJURY(Per OWdeni) $ PROPERTY DAMAGE S 11. P:f,YDAUTOS (Persmtlene III NONOWMED AUTOS E g LAMELLA WAS .OCCUR EACH OCCURRENCE S • llEXCESS UAB CLAIME.MADE AGGREGATE S alDEDUCIBLE ..... 1 III PETERSON $ $ WORKERSCOMEENSATION WC STATE. DTH- ANDEMNOYERs''LIASIUTYYIN ;RV,{DOTS ER ANY PROIRIETORMARTNERJFXECUIVEEL EACH ACCIDENT $ MEEMBER EXCLUDED) J N/A ( antlaW er in NH) E:.L DISEASE-EA EMPLOYEE$ ayes,dram uCer DESCRI(MONOFOPERATIONQ below 6L DISEME-POLICY LIMIT S II DESCRIPOON OF OPERATIONS I LOCATONS I VEHICLES(Attach ACORD I01,Additional Remarks Schedule,if more spate Is requirod) Workers' Compensation Certificate of Insurance to follow separately from the carrier. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL EE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHO$i2ED REPRESENTATIVE 21'4 vM4. ©1988-2009 ACORD CORPORATION. AU rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD ar nT CERTIFICATE OF LIABILITY INSURANCE IDA E(MM1tl016 OR.TJPOte CERTI KALE ATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS OERRFECATE DOES NOTAFFIRMATIVELY CONSTITUTE' EXTEND ORALTERTHETHE COVERAGE AFFORDED HYTHE POLICIES BELOW. TH19 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTES A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED •EPRFSEN ATIVPO• PRO.UCE- • !T CE T{FGTE:DTI R. IMPORTANT;If the certificate holder Is on ADDITIONAL INSURED,the policy(les)must he endorsed. If SUBROGATION 15 WAIVED,subjeot to the Terms and coodfltons of She policy,certain policies may require and endorsement. Astatement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: ORCHARD INS AGCY INC PHONE FAX as MAIN STREET (NC,ND,Est (AIC,NO): E-MAIL =IAN ORCHARD,MA 01151-1241 ADDRESS: 28YCR - INSURER(S)AFFORDING COVERAGE NAIL INSURED INSURER A: TRAVELERSRJDIT9NNY COMPANYOPAMEWWCA STURDYHOME IMPROVEMENT,INC INSURER P3 INSURER C. PO BOX$1033 INSURER D: INSURER E: INDIAN ORCHARD,MA 01151 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 1 Tt11S is ITS CERTIFY-DDT THEPC41CIES Or INSURANCE LISTED DELGtY?'AVE 6EH4I56VEO TOME INSURES NAMFDADOVE FOR THE POLWY KINOD INDICATED. NOTVAINSTANDING ANY REQUIREMENT,TERM OR CON01IION OFANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO MICR THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOM TMETER:AyEXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LENS SHOWN MAY HAVESEND REDUCEDSYPAID CLAIM& INSR ADD SU51 MOLDY VAT RASE POLICY ells DALE LIR TYPEOF INSURANCE 4 R POLICY NUMBER (MMIDDIWYm (MMIODIYYYY) LIMOS GENERALLIARILITY EACH OCCURRENCE COMMERCIAL GENERAL LLIABILITY DAMAGE TO RENTED CLAWS MACE (ALI OCCUR. PREMISES(Ea ncanence) MED SW(Anyone MKT) $ PERSONAL&ADVINJURY $ GEN'TAGGREGATELIMIT APPLIES PER: GENERAL AGGREGATE $ —1 POLICY n PROJECT nLOC PRODUCTS-COMPIOPAGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO _ LIMIT(Ea accident) ALLOWNEDAUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Po accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR �- EACH OCCURRENCE— $ EXCESS LIAR CLAIMS-MADE AGGREGATE va DEDUCTIBLE RETENTION$ $ A WORKER'S COMPENSATION ANDWCSTAMORY I OTHER! EMPLOYER'S LIABILITY YM US-55368505-16 0121)2016 07121120l7 `A LIMITS AOFECERPE MBER EXCLUDED/7 XCLUDEw 11TIVE iwl t)A EL EACH ACCIDENT $ 1000,000 ANY PRCPERNFRFYMTNEPDt 1' (Msnd Tory in NH) E.L.DISEASE-LA EMPLOYEE $ 1.000,000 Ityes,cIstroWWeer DESCRIPTION OFOPERATIONSbelew E.L,DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONSAOCATIONSNEHroIEStRESTRiCTIONStSPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CER1IPICA'TEHOLDER AFFECTING WORKERS COMP COVERAGE CERTIFICATE HOLDER _CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATETHEREOP,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT E I AGGRO 26(2010105) The AGGRO name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. The Commonwealth of Massachusetts Department.of Industrial Accidents Office of Strt 600 Washington Street Boston,Mass.02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Ausiness/Organizadov/Ivdivldval)_ lf"p •• - iA COV L 4- ,ail • Address: 4Sci kd{t0 t.th e k _i_ t3 -.. City/State/Zip:-l_tr.4(Gtxt )triawri bids tcttci Phone: (1.3' S4g'2,-Srt6l, ..._ Alcu an employer?Check the appropriate box: Type of project(required): 1.. I am an employer with (0 4.❑ I am a general contractor and I 6.❑New construction - employees(foil and/or part time).* have hired the sub-contractors 7,0 Remodeling 2.0 I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contactors have 8.U Demolition working for me in any capacity. employees end have workers' 9.0 Building addition INo workers'comp.insurance camp.insurance.$ required] 5.0 We are a corporation and its 10.0 Electrical repairs or additions 3. 0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself[No workers'comp. right of exemption perinMOL insurance required]t c.152,§1(4),andwe have no 12.0 Roof repairs pp I� employees.(no workers' 73!y� ther ' i J(�T c '�' comp.insurance required.) I YS °Any applicant that tbacks box#i must also fill out the section below shoving their workers'compensation policy information. taomeowners who submit this affidavit indicating they are doing allwork and then hireoutside contractors must submit a new affidavit indicating such, 4Contactors thatcheek thisbosmust attach an additional chestshmving the name ntthesub-contractors-and state whether or not those entities have employeesi if the stilt-contractors haveem•Is ees the must rovrde their workers'com•,ioik number. I am an employer that is providing workers'compensation Insurance for my employees.Below is the policy andjob site information. Insurance Company Name: _ 1 2/y)7_.1 V'!' w?-Y$ •--Fti1C Policy#or Selfins.Lic.#: (1e51213 LLYioc'i c. �JE1xpirationDate:�) Ilett ,in Job Site Address:`J ' eJ City(StatdZip: C_,y(I+/Pft(•c 1`� d fir: i 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 MGT,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 hi the form of a STOP WORK ORDER and a fine of $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. Ida herby cert fy under thepainsand penalties of perjury that the information provided above is true and correct Signature: (�� Date: 11111 19" P,ntMame:' i t� i.�1k,Z. Phon L13 -STD(i+ • 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): I•Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6,Other Contact person: ' Phone it: 459 Main Street Toll Free (877)378-8738 Indian Orchard,MA 01 Worcestergfiel (508)797-6600 E-mail:HR urdyHeyHom Springfield (413)543-5906 www.SturdyHome.cc New Haven(203)848-2118 Fax (413)543-3200 HOME IMPROVEMENT, INC, MA REG.#751711 CT REG.#06 // WINDOWSi • SIDING • ROOFING • ADDMONS Name 141.- ' 4 I ESM IC, I SCi.iSt-r - HomoPhone 21/ I er s Phone AddressS-S-A findie rq Cell Phone Other ee Town/CIA yam-! 1/ �'( Representative d L(uI<PGx-G� {YLV RepresentativeHLd� Date ,e. 67h✓ S- 460 I/we the owner(s)of the premises described hereinafter,referred to as Owner,offer to contract with Sturdy Home Improvement,inc.herei referred to as Contractor,to furnish,deliver and arrange for installation of all materials to improve the premises as described below. Yes No ROOFING SCOPE OF WORK: Q 1. Contractor to obtain required building permit(see attached permit authorization form) 1 2_0 3<) Family home. C%' Q 2. Provide certificate of Insurance for workers compensation,general liability.(see attached certificates). • Q 3. Provide Job site dumpster, set on planks, to remove job related debris only. Please Note:dumpster for contractor's use only. (see dumpster clause). l� Q 4. Prior to stripping roof,tarp sides of house beneath work area,from roof edge to bottom of wall. (see additional protection clause on back). [� Q 5. Keep job site in a clean and orderly manner. Rake work areas at end of job. Use magnetic sweep to pick up nails. i0 6. Provide OSHA approved staging to safely perform work. at' Q 7. Work consecutive days excluding inclement weather.(rain,snow,high winds,high heat,thunder showers,etc). rQ" ❑ 8. Staff project with qualified mechanics experienced in residential asphalt roofing. 3 1$' ❑ 9. Strip existing 1 C 2 3�layers of asphalt roofing(see roof plan, page 2), Number of squares A. 0 one layer cedar removal. Number of squares__1 . B. D one layer slate removal. Number of squares col tr❑10.Inspect roof deck prior to re-roofing.Renail loose boards: A. Replace rotted or cracked boards at$"7 .�W per linear foot. p �9 B. Install new plywood at$ -70,120 per sheet. 1rt G b . act vr+x ' £ep at C.Number of sheets of plywood included into this estimate:Quantity (see unit cost above for additional sheets). Car Q 11. Furnish and install C'c2u1u.atarif In 4.lr rsw.s..P, shingles. Color Il:'r f91-1-- c iibiL..- I - Q 12. Furnish and install 8"aluminum drip edge around roof perimeter,White ✓ Mill Brown . ❑ ern.Install cedar drip edge at eaves under aluminum drip edge.Liar ft f]' 14. Furnish and install ice/water shield at eaves 3'_Lt',._other. Three feet in valleys and around all roof penetrations. 7Q' Q 15.Furnish and install underlayment to entire roof.__Roofer select�'`Di'ki'.'v'd-Brk Rao:,r tr016.Furnish and install starter course shingles,eaves&rake. [yr' tJ 17, Furnish and Install hip and ridge cap. 3_ 1W Q 18. Furnish and install new neoprene roof boots at sail pipes up to 4'in diameter. Quantity 2 Size z-t (boots at electrical mast to be reused). F$''Q 19. Reuse stove pipe flashing kits. ❑ ij�2O.Reuse existing step flashing at roof/wail Intersections. ❑ Fh}21. Furnish and install new_...-._aluminum copper step flashing at roof/wall intersections. Linear feet . II sir work is needed, a cost assessment will be made at that time. ❑ F'22.Reuse existing wall flashing at roofhvall intersection. ❑ v3. Furnish and install new aluminum wall flashing at roof/wall Intersections. Linear feet . If siding work is needed,a cost assessment wilt be made at that time. a(e- 024. Furnish and install new 2-, aluminum eI sapper step flashing at base of chimney under existing lead counter flast p^--Q 25. Replace chimney lead counter flashing. 1 flue Y 2 flues 3 flues__other a- C lip., „ ❑ ❑26. Install__now roof hood to vent bathroom(s)with insulated flexible tube. Remove roof deck to gain access into attic.Color:in only. ❑ 0427.Gutter Helmets to be removed and reinstalled by others. (kin ❑28. Remove and dispose of gutters attached with spike and ferrule. ❑ 5 2g. Remove and reinstall existing gutters strapped to roof. Install straps under shingle over shingles . ❑ 930. Remove and reinstall existing gutters with hidden hangers. Linear feet [9^' Q 31. Deristarektelight flashing kits 2- „Replace skyllghties_2 Quantity,„,,,?L.(Velux models,stook only). ..../ca a, ix @•" Q 32. Remove and dispose of the following:Antenna__Snow/Ice Wires Snow Guards/Ice belts Soler panels�m 0 ❑ a33. Remove Satellite Dish up to 24'in diameter. Alignment and installation by others. 2r 034 Page Two= ROOF PLAN. VCh,' a' Q 35. Page Three=VENTILATION. Q at-36.Page Four=VENTILATION PLAN. • ❑37. Addendum (A)=OTHER WORK. 'Z-. S eY .Igki.. cir ❑38. Addendum(B)=LOW SLOPE ROOFING, Stec Oh-NV"^-1. not ri..� nn •_,,,,,,,,,,,,,,,D+..,. Initiate f { inaiatsr" STURDY HOME IMPROVEMENT INC. MA REG.n151711 Leaend• CT REG. #0601525 PAGE 4 - VENTILATION PLAN y l<4uc. Gait.. 1 24) Ridge vent ev---`94H11 Elf •7.40.."1-Y"›71 Z .� /6\= 8 x 16 r.- 1---- 1-.--."'!'"vs 6.1E1‘4" i. 111L----r- _ .. 6 = 6 x 16 —*44^7t -,7J v 1 mn (1). 4 tVent a \ I 1 I4 3 2� Soffit Vent - L$? V Proper Vents • r .. ...� _ - CII - Vented soffit f \ Panel +Alum Thavv72;ri 7 if Facia Wrap L-tfr. 4.(.4t._ i li, _._ .. . .. 4W rte- S.o p� M Vented soffit f, - ,,t'G, x"frvv- 6s ( only tiff 6 J l.UVger, C F.O. C Fascia only C .r , I. nnrJ ( _ t k Gutters LEI - Roof Hood f- .2-c > I £ Kitchn Hood STURDY HOME IMPROVEMENT, INC, ACCEPTANCE PAGE NIA REG. h CT REG. #OE \NY WORK NOT STATED ON PREVIOUS PAGES IS EXCLUDED Nie following schedule will be adhered to unless circumstances beyond the contractor's control arise: Nork scheduled to begin the weak of / /_; Expected completion date_ _I__../_...._Weather pert ting. the cash price for labor and material as described above is: . 4 r fan leir L 1 1st payment 2nd payment 3rd payment 4th paym Contract Total (uyonf� signing) reit:" (�,'4rc�- et'KOle. Roof $_......—.... SGI _t2eiiimi -ziYks,.G-. C C--S3 1--(.fixity Ventilation $_,,,,,. Other work $_, =__ Roofing total $ $ _ $ :,. $ $_" Siding $ $_, — $_ _ $ -.. $ Windows $ — $ -_ $�...- $_ .--, _ $ — Special orders $ $ J $_ — $ " $ `— other $ 66 $� $ $ Totals $ I Z, j S $_ - $y70` $77.1 $i--e) ck3k Slit Terms: ...- Cash _.,Finance 4/„ lira Payment schedule: Any batance not paid in full within thirty days, wilt be charge%1.8%interest per month. In order to meet the completion schedule, the following materiel/equipment must be,SPECIAL 090ERED before the contracted work begins. (Law requires that any deposit or down-payment required by the contractor before work begins,may not exceed the greater of(a.)one-third of tit total contract price or(b.)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet ft completion schedule) /2 $ C✓ to be paid for 0 0__ $ © to be paid for Any additional work orders are to be paid for once accepted and approved by purchaser. Verbal understandings and agreements with representatives shall not be binding. All understandings and agreements must he set forth in writing in tit. contract, Additional provisions are stated on reverse side and�-are part of this contract. In witness whereof Purchaser(s)has(have hereunto signed their cern .2 r this . 2_day of__Alley fx 20 / and acknowledge receipt of a true copy of this contract. UNLESS OTHERWISE SPECIFIED,IT IS ONDERSTOOD THAT Frit OWNER IS READY FOP THE WORK TO BEGIN. THE PURCHASE PRICE MOTEL ABOVE WILL BE HONORED ONLY UNTIL 7 P4 1 _(Date). You the Purcnaser(s) may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction,See notice of oddest tion form for an explanation of this right, Signature affixed below also acts as receipt that Purchaser(s)received separate cancellation forms. The following is a requirement by Massachusetts General Law, Home Improvement Contractor Law MGL c 142k "The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute Concerning this contract, the contra( may submit such dispute to a private arbitration service which has been approved by the office of Consumer Affairs and Business Regulation and the tonna- shag onsunshag be required to submit to such arbitrator:as provided in AML c 142A. Representative: PJ_ /per .— Owner: r _ — Owner: NOTICE The signatures of the parties above entity only to the agreement of the parties to alternate dispute resolution initiated by the contractor The owner may initiate alternative dispute resolution even where this section is not signed separately by the parties" ,( Dg no si n this contract if there are any blank space% SubmittedS /4, /l. — Accepted ea EI or. 93/I Represeennt++taatitivvee�t-d'""ttUi��W?�_= Purchaser Date l Accepted Accepted by _ ._.._ ____ by: _..._.-- ._....___ Purchaser Date