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25C-252 (7) 37 FAIR ST BP-2018-0106 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C-252 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# BP-2018-0106 Project# JS-2018-000178 Est. Cost: $27800.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STURDY HOME IMPROVEMENT 093603 Lot Size(sq. ft.): 21170.16 Owner: KARNEY STEPHEN Zoning: SC(100)/ Applicant: STURDY HOME IMPROVEMENT AT: 37 FAIR ST Applicant Address: Phone: Insurance: P O BOX 51033 (413) 543-5906 WC INDIAN ORCHARDMA01151 ISSUED ON:7/28/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF ON MAIN HOUSE - 15 SQ AND 7 SQ ON GARAGE - REPLACE ANY ROTTED WOOD 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 7/28/2017 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only 7 ' City of Northampton Static's of permit 'Po M ?�otp ��' Building Department CurbCuttrlyeway Pelniit 212 Main Street r/SepticAyat?iI , 4 Room 100 fete l 11 4vaila ilr r Northampton, MA 01060 Two is of tr u l Plans "� ' phone 413-587-1240 Fax 413-587-1272 Pte Plans , 4' Other,Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO q FAMILY DWELLING & SECTION 1 -SITE INFORMATION - !-R - la 0 1.1 Property Address: This section to be completedplby office Map ` ' Lot RCx/� Unit 3-1 (sr mer-+ (��� Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address_.„ 6I1 Telephone Signature 2.2 Authorized Agent: sAtk, ,) -io c'r r-E I la. a,,C_ t-1 so► Acton S.-i'cr 1- She i Ii- U Ptva ci3"j N. e(Print) Current Mailing Address: A '1,� . A L c -lt�) 43- `1(3 Signature Telephone SECTION 3-ESTIMATED :NSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (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) f al,%'00.00 Check Number 903 4190 10 This Section For Official Use Only Building Permit Number: Date Issued: Signature: c,,,. ----- , J ` C,. t -i f Z7/t 7 Building Commissioner/Inspector of Buildings Date a EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 1 r ,., Frontage ii IF Setbacks Front , Side L: ' R:a. J Lt.... R._ n ' i Rear I a .�_ Building Height Bldg. Square Footage , Open Space Footage % (Lot area minus bldg&paved i parking) #of Parking Spaces G Fill: (volume&Location) I - , A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO C0V-/ DONT KNOW CV YES 0 IF YES, date issued IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW 0.------ YES 0 IF YES: enter Book r I Page, i and/or Document #i B. Does the site contain a brook, body of water or wetlands? NO V DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , 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 lam+' IF YES, describe size, type and location: I E. Will the construction activity disturb(clearing, grading,exca ion,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. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing �R Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [El Siding [0] Other[0] Brief Description of Proposed Work:51-r-ip Pkv*rtokir�Il(k.�e &VA 644'3 . L,tQ '`a� ►15'fu�4 1 S 3 orN�Ictiv L u 4- '7J y�ati �a rcuct-�t�+4 Ci.�t J-�S (� iCk Litt ..✓. nk (fain lShI" 0-Use,ti'f.cil,G.C.k u14-k,sj e(qi'kl,a.v�.B ( r_: Alteration of existing bedroom Yes Adding new bedroom Yes 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 as Owner of the subject property hereby authorize to act on my behalf, in all matters elative to work authorized by this building permit application. Signature of Owner Date M vt( Y c . , as Owner/Authorized Agent hereby declare thatThe 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 ti i ature of Owner/Agent Da e SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Gt • Name of License Holder: a CS— 6 1- (e.O,3 License Number 2 o v ,,,,-4- thee -- Plrl MA- °,t l k. -,( 7 � Addreesss b �� Expiration Dat0-- Address •tcCk � ' 2\l 00?-� Signature Telephone 9. Registered Home Improvement Contractor Not Applicable ❑ SAu.rc � 1 Company Nai'ne Registration Number ' U ,Ctivq e - (4 3(e( t . . —A-dddr-ess t Expirat n Date 7 7I i ar u1U Uk C t l � Telephoned 3)S SC101c 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 buildin ermit. Signed Affidavit Attached Yes No ❑ City of Northampton S St �QY 441H1��' Massachusetts04,4 fel awf DEPARTMENT OF BUILDING INSPECTIONS S1.1% 212 Main Street • Municipal Building SO% b1 Northampton, MA 01060 4.fY ��OC 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("HIC"). 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. Type of Work: � �!� 'G2 � �E� Est. Cost: a� Address of Work: 3.1 T(tiiiy- .1\-)1.›A'VN;;i,brkiV\ ,1A )OLA U (.)LI 0 Date of Permit Application: � )-L{ I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): Job under$1,000.00 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 for a building permit as the agent of the owner: p1/441 ,-4- Dat Contliactor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: 1 �3O1- I 1 t Da e Owner Name and Signature City of Northampton cr g. Massachusettsw?4' crcyae. DEPARTMENT OF BUILDING INSPECTIONS rj212 Main Street •Municipal BuildingSJs h .Cb, 70,0' ' Northampton, MA 01060 s `' Debris 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. The debris from construction work being performed at: 31 Rtfr 0-k- (Please print house number and street name) Is to be disposed of at: MA Lcttok A- (Please print name and location+bf facilit Or will be disposed of in a dumpster onsite rented or leased fr . _ L00-6\-_ - 61/k°,ti • C lC� �'m !4.S. '_�-(30'N' a . (Company Name and Adds) ("T'iNALJ t r--- Signa ure of Permit Apant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. • a • HOME IMPROVEMENT fro '.9 t ,8-Mute fff re Octant?, WORCESTER SPRINGFIELD HARTFORD 459 MAIN STREET-P.O.BOX 51033-SPRINGFIELD,MA 01151 MA.REG#151711 CT.REG#601525 877-3STURDY FAX 413-543-3200 WWW.STURDYHOME.COM OWNER PERMIT AUTHORIZATION Name: �J RA' Address: i' t City/State/Zip: v� 1 "�M� � v 0 1 d 11, (owner), of the property located at: 3 7 Fc 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 Improvement,Inc to obtain a building permit for this project. I understand and accept responsibility to comply with all regulations and required inspections. 7/0 / 7 Signatur of Owner Date - - v Signature of Owner Date gii/ fn- fce o onsumer Affairs . d Business Regulation e r=2=II 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvem6ht Contractor Registration "_ Registration: 151711 ( - — ^ _ 1 Type: Supplement Card 11.. =n_.-_..__. / tjl 1.1.1 ':-.:f_7111\4- � '��-___�-�!:' Expiration: 6/26/2018 • STURDY HOME IMPROVEMENT, INC-= 1-.-;,•:-}- :-=4\ C DAVID DIAZ tyl i";l t__- :1` 1 __...-i 1- 459 MAIN STREET 'A.--\-;.'\ '--__' ...,J - INDIAN ORCHARD, MA 01151 I1 ' ' `<- 'r� -.:: :(,- =,•i' Update Address and return card.Mark reason for change. D Address ❑ Renewal Ei Employment ill Lost Card SCA 1 e 20M 05/11 J/ • GWO CF'Ommonwe((�%ClalciJQC/Ilio :Office of Consumer Affairs&Business Regulation License or registration valid for individual use only — �!7bME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Wig- Registration: .1'8.17:11, Type: 10 Park Plaza-Suite 5170 y Expiration 6/26/2.0_.18• Supplement Card !:a__-::_-' ,-..._. ,;, Boston,MA 02116 STURDY HOME IMPROVEMENT;:INC t _ DAVID DIAZ 459 MAIN STREET ._ Gx'�� INDIAN ORCHARD,MA 01151 Undersecretary Not valid without signat r • • • • • • • , Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-093603 Construction Supervisor DAVID DIAZ Y 270 TREMONT Si" SPRINGFIELD IVIA It„ [v - s. 1/4 , Expiration: Commissioner 08/07/2017 • r •g DATE(MM/DD/YYYY) ALCORE) 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 holder is an ADDITIONAL INSURED,the policy(les)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 CONTACT NAME: Orchard-Dowd Insurance Agency LLC PHONE Nadine West FAX 14 Hobala Road (A/O,No,Ext):413-437-1050 (A/C,No):413-437-1_a 50 Holyoke MA 01040 ADDRESS: nwest@dowd.Com PRODUCER CUSTOMER IDE:STURHOM-02 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA:AtlarltiC Casualty Insurance Company 42814 Sturdy Home Improvement, Inc. NSURERB: P.O_ Box 51033 Indian Orchard MA 01151 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:397345024 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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, INSR ADDL SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR wyD POLICY NUMBER (MM/DDIYYYY) (MMIDDIYYYY)__ A GENERAL LIABILITY M185000199 8/7/2016 8/7/2017 _EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED 50,000 COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 — PRO- POLICY JECT LOC COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS • PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS • UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- 0TH- AND EMPLOYERS'LIABILITY TORY LIMITS ER N $ ANY PROPRIETOR/PARTNER/EXECUTIVE Y N/A -E.L,EACH ACCIDENT OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL,DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) 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 BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE kVaN‘ ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009!09) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE I DATE(M24/201 YYY) T iR ICA 0R. THIS Jr) 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 holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement 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 485 MAIN STREET (NC,No,Ext): (NC,No): E-MAIL INDIAN ORCHARD,MA 01151-1241 ADDRESS: 28YCR INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA STURDY HOME IMPROVEMENT,INC INSURER B: INSURER C: INSURER D: PO BOX 51033 INSURER E: INDIAN ORCHARD,MA 01151 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE Ti OCCUR. PREMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ Ii POLICY I]PROJECT F-1 LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) — ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ _ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ — (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ — EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE RETENTION $ A WORKER'S COMPENSATION ANDX WC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-5B368505-17 07/21/2017 07/21/2018 LIMITS ANY PROPERITOR/PARTNER/EXECUTIVE nil N/A E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? �' E.L.DISEASE-EA EMPLOYEE $ 1,000,000 (Mandatory In NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. ss '� ' The Commonwealth of Massachusetts. AL, Department ofIndustrial Accidents 17POffice of Investigations 600 Washington Street Boston,Mass. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): S41.(,ii t�U ko rn e_` �ipro°ve r71P n Address: `I Sq Hain }'� fit° 1-3 1 City/State/Zip:__Lid Ian Orchtip.,i t M Act iSi Phone#: (14 I3) S'1 6 1, Are you an employer?Check the appropriate box: Type of project(required): 1.. I am an employer with ( 4. 0 I am a general contractor and I 6.0 New construction - employees(full and/or part time).* have hired the sub-contractors7.❑Remodeling 2.0 I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9 0 Building addition [No workers'comp.insurance comp.insurance.t required] 5.❑ 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. ❑Plumbing repairs or additions myself [No workers'comp. right of exemption perm MGI, insurance required]t e.152,§1(4),and we have no 12.0 Roof re airs employees.[no workers' 13.��� Other d-I/L � v iC .e : comp.insurance required.] lw *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. $Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have em lo ees,the must.rovide their workers'cornolio number. lain an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information. Insurance Company Name: ' ITA t/e ers . Policy#or Self-ins.Lie.#: it 6'5 3 ''.5Q I Expiration Date: ") I 1.1 Job Site Address: .&J-- City/State/Zip: ONE"4'4i ,hG•-vyt i MA- 6((.)i'C. 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 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 $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 covera:e verification. Ido herby ' under th ins and penalties of perjury that the information provided above is true and correct. Signature: l t,:{{e ' Date: -7 1-1-4..i t Print Name: . ( ;{.1.1. `y/t, Phone#• c{ 1 4.3 (k— 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 Heath 2. Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#: 459 Main Street Toll Free 378-8739 Indian Orchard, MA 01151 Worcester 797-6600 E-mail: HR@SturdyHome.com Springfield �4�-�9�� ����& �� ���������N� ���' www.SturdyHome.com (413) New Haven ���-���� `---^ HOME IMPROVEMENT, INC.Fax �4��� �4�~���� MAREG. #151711 CT #0601525 ' ' WINDOWS • SIDING • ROOFING • ADDITIONSREG. Name HomoPhoo»� ^ Business Phone �� _4 � ���� �~ �� ����� 3�� u���� ��6�� �47/� -~ ° - . -_.. _ ,` .�._ --� - Address ^ " Cell Roe Other � � ���� 1�� �-� ��m ��� u��/��� -" � � . . ` ~ . . °~.~� - - - . ' . . Representative Town/City ) Date\ ) Av»‘ +0�v v�yv (5 /4-7 4^°u_c_ z /Lon I/we the owner(s) of the premises described hereinafter, referred to as Owner, offer to contract with Sturdy Home Improvement, Inc. hereinafter 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: ut~ 1. Contractor to obtain required building permit(see attached permit authorization form) 1 23Family home. la" 2. Provide certificate of insurance for workers compensation, general liability. (see attached certificates). [le 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). ou-" 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). (Er [a 5. Keep job site in a clean and orderly manner. Rake work areas at end of job. Use magnetic sweep to pick up nails. 6. Provide OSHA approved staging to safoly perform work. tj 7. Work consecutive days excluding inclement weather. (rain,snow,high winds, high heat,thunder showers,etc). [i G. Staff p �h iM dmechmnicmoxpohoncmd|nrooidnnUeioopha|tmu�ng. �*� [� S. Strip existing 1 fr~ O3layers nfamph�tnznf ( roof plan, page 2). Number of squares 641""K �r . _ A. one layer cedar removal. Number of squares � �� � " = B. +~ one layer. 4ate removal. Number of squares AditeYn' el In) irl-c~w°— re 10.Inspect roof deck prior to re-roofing. Renail loose boards: 78 ��1��� ���^^~� r���� A. rottedcracked boards $ �,0�» per|ineorfooi '~ ' ' , ~ B. Replace orInstall new plywood at$ per sheet. y=-�x~ �Y�°� ~Weak 2f ‘„aa.4.,�__ C. Number of sheets of plywood ' into (seecost om~�[i11. Fumiohand inmb�| �� 1-.414_ "K.%14-Y- 1.444i h|ng|oo. Color a— 012. Furnish and install 8"aluminum drip edge around roof perimeter.White eMill Brown • E. '13. Install cedar drip edge at eaves under aluminum dripft [�~~ Li 14. Furnish and install ice/water shield at eaves 0 3' n' &» other. Three feet iU and around all roof penetrations. • Cj 15. Furnish and install undmdaymentbnanUn»nxof. Roohoroeiect ig"~ [Heffie*l-Beck Rae Cx*~2-4t3 - a"~-131G. Furniahandinuia||stadarnnumemhinQ|eu. nevom&mke. [� 17. Furnish and in�aUhip and ddgecap. 1 f�"" ��1U. Fumiohand inataUnew neoprene mufbnc�natooUpipes uptu4^|nd|omote� C)umnd{1y Size x (boots at electrical mast to be reused). c-J alb. Reuse stove pipe flashing kits. [� ��—� O. Reuse existing step flashing a1roof/wall intersections. Er 21. Furnish and install new A iA- aluminum 0 copec step flashing at roof/wall intersections. Linear feet. . If siding work is needed, a cost assessment will be made at that time. [� on12. Reuse existing wall flashing at roof/wall intersection. cr~023. Fumiahandinota4|nawa|uminumwalOnuh|ngcdnoohwa)| intorseohnnn. Uneorfmet . If siding work is needed,a cos assessment will be made at that time. O RN. Furniehand|notd! nevv 0 aluminum copper step flashing at base of chimney under existing lead counter flashing. LI 81S. Replace chimney lead counter flashing. 1flue 2flues 3flues other . [� a--. |notaUnevvmofhoodtovent bathroom(s)with insulated flexible tube. Remove roof deck to gain access into attic. Color: black only. � � [� ���/. GuUarHe|metohnberamuvedandreinsta||edbyothemo. [� Remove and dispose of gutters attached with spike and ferrule. • Wr29. Hamoveandre|nsto8|exiwdnQquttmm^wtnsppedbmmnf. |nobal}st,apwunderohing|o_-_-overuhing|ea ' [I . Remove and reinstall existing gutters with hidden hangers. Linear feet [� � R�uu�okyUghtOmahingW� Rep|mnamkyUghtOauhing�� Quantity 0/a|unmodels, �ockVn|vi. - [� . Remove and diupowe of the following:AntennaSow/|nm Wires Snow Guards/Ice belts Go|urpana|a_ _ [� A13. Remove Satellite Dish uphn24'|ndiameter. Alignment and installation by others. • 34. Page Two=ROOF PLAN. *� �� U°��T_��,^� ���~�� \L.� �� [�35. Page Three=VENT|L4J|(JN. ~ " '|~�t~e-� ,_-- ^`-~�~_ =,w, ' • I4E.Page Four=VENTILATION PLAN. Cir [337. Addendum (A)=OTHER WORK. • U�O. Addendum (B) =LOW%DPEROOFING. �]� aa.-}k' r�~ r�n� u°,m,^"",appnp � /"a/�/" �mav /" '"/" m.~ . , STURDY HOME IMPROVEMENT, INC. ACCEPTANCE PAGE MA REG. #151711 CT REG. #0601525 ANY WORK NOT STATED ON PREVIOUS PAGES IS EXCLUDED The following schedule will be adhered to unless circumstances beyond the contractor's control arise: Work scheduled to begin the week of__ /____/____. Expected completion date / / Weather permitting. The cash price for labor and material as described above is: 1st payment 2nd payment 3rd payment 4th payment Contract Total (upon signing) PA viTc•Kigik Go xrrf... Co•-vt,41. Roof S 27, 760 4 Ca.-A.4; Ve1vi:et4.,., rIkvcs___, c.,-t-Tai Ventilation $ "-- Other work $ "5-b0 --.. Roofing total $ —. $ ^ $ .... $ .'". $ Siding $ -- $ —. $ --- $ -. $ Windows $ ..- $ ....... $ _.- $ ••",* $ ow'. Special orders $ — $ —• $ --- $ .., S ..-- .—. .... Other $ -- $ '--- • $ S $ 01. Totals $ 2 7 OO --- $ 11.11rok el $ 'I,lid C.. $ I 1;gt 00 $ 1...5-0 o, ctl AP 1 i32_ Terms: Cash Finance Payment schedule: Any balance not paid in full within thirty days, will be charged 1.8%interest per month. In order to meet the completion schedule, the following material/equipment must be SPECIAL ORDERED 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 the 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 the completion schedule) O ei• $ to be paid for $ 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 be set forth in writing in this contract. Additional provisions arealed on reverse side and are part of this contract. In witness whereof Purchaser(s)has/have hereunto signed their names this -2 lAtt day of ..44--,141 20 (7 and acknowledge receipt of a true copy of this contract. UNLESS OTHERWISE SPECIFIED, IT IS UNDERSTOOD THAT THE OWNER IS READY FOR THE WORK TO BEGIN. THE PURCHASE PRICE QUOTED ABOVE WILL BE HONORED ONLY UNTIL 1 Pia 7 (Date). _ You the Purchaser(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 cancella- 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 142A: "The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided in MGL c 142A. Representative: 41-'214— l Owner: ?e, Keelefl,1- -7efk ' Italer C — Owner: NOTICE:The signatures of the parties above apply only to the agreement of the parties to altemate dispute resolution initiated by the contractor. The owner may initiate alternative dispute resolution even where this section is not signed separately by the parties" Do not sign this contract if there are any blank spaces Submitted Acce .- ,../ Q c Ar /14.<1 pted Purchaser Z) by: by: Representative PDate Accepted Accepted by: by: Representative Purchaser Date Addendum (A) OTHER WORK /(#vocX Z2bwi, 2 C gmiv% .eYc 74, ,e J- Ap tic.s_ 44 61/411c___ 7^d Pampa I no m w y 440S24:c. f ,©4fud` . 141- s"a '/c. lb, 5-0 4 t Us get P4, 1,t,004 f`o A?" 4L.R J17 k 1/2._ CAS yL, K, C313 41 kid 1` CA-4-A 1-74,;,.. /J PO/ q7ay„�,L ..'deo, iG Initials 04, Initials .44/'/ Initials C X X X C C 4.-• as — t. 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