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29-599 (6) 42 STONE RIDGE DR BP-2019-0812 GIs#: COMMONWEALTH OF MASSACHUSETTS Map.-Block:29-599 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-2019-0812 Project# JS-2019-001342 Est. Cost: $26890.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: NORTHEAST SPECIALTY CORP 110285 Lot Size(sa. ft.): 81021.60 Owner. DIBRINDISI ERIC P&SUSAN M zoning: Applicant: NORTH EAST SPECIALTY CORP AT: 42 STONE RIDGE DR Applicant Address: Phone: Insurance: 148 DOTY CIRCLE (413) 739-4333 WC WEST SPRINGFIELDMA01089 ISSUED ON.111512019 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE AND REPLACE EXISTING ROOF WITH NEW STONE-COATED STEEL 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 1/15/2019 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Department use only City of Northampton Status of Permit: Building Department Curb Cut/DrivewayPermit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, '" e jn�!dural Plans phone 413-587-1240 x 4 - - V ite Othe Sp APPLICATION TO CONSTRUCT,ALTER REP IR,i4A bV14fE 8916EM LISH Ok ONE OR TWO FAMILY DWELLING - SECTION 1 -SITE INFORMATION DFPT OF r)UILDING INSPFCTIONS ba l q 91 Z 1.1 Progertv Address: ction to be complete by office q� Com,-���'�`�n �v� Map q Lot 6 Unit I r��v 'e �-A C'T O,Ckp a Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT ee 2.1 Owner of Record: q a Ot' Ct 5G _Dr 1=_r(C Sl I"�a n 1n I �to re_f-c P N,lc� oio(.P a Name(Print) Current Mailing Address: _ /' La OJUCA(Ct C Telephone Signature 2.2 Authorized Agent: N9 Nime rint) Current Mailing Address: Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building s� r / p�I, (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) , CA u Check Number This Section For Official Use Only Building Permit Number: Date sued: Signature: u' miss' /Inspector o Buildings Date rYlOr�o@ 88B r� Sco�� Com 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 Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Findin ever been issued for/on the site? NO © DON'T KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO V) DONT KNOW © YES 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 IF YES, describe size, type and Location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO IF YES, describe size, type and Location: E. Will the construction activity disturb(clearing,gradingex vation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO 9 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 Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[O] Other[�] Brief Desc tion of Proposed Work: MR �vk. OLOA I e1 k- _U S6nn fM� JOVIAL rye W staCe -CC a-te(1 5-tee-) 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 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, �r C �� n I>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 I, V/b+v� -;� \) ` ) 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. rint ame 11 ig uorj" wner/Agen Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: V-)bA-�N 7bu l IO2�S License Number d ss Expiration Date Slg'ftkire Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ W(A-h�t r�oPC LCA.,\� Cb c o Company Name I Registration Number iug CON Ids m f� flys G 7 I I ?: 1 2C;20 Address \' Expiration Date Telephoney�3— SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buil 'ng permit. Signed Affidavit Attached Yes....... No...... ❑ City of Northampton S�5"•�-SSC Massachusetts `G -� DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building yJti.. 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("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 hha(s�contracted with a corporation or LLC,that entity must be registered. Type of Work: Est. Cost: 2(o �a Address of Work: `'a, S�Or1 e, 1��C�G e l o r r`C� R t��� Qk0(0 Z Date of Permit Application: I G 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 buildingspe ermit as the agent of the owner: 1 _ C NaAV\s_czs�- baM-i-J car(=-/ 15 f � Llf',' n r 103 13 Date Contractor Name 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 City of Northampton Massachusetts G DEPARTMENT OF BUILDING INSPECTIONS a. z 212 Main Street • Municipal Building yeti•,, c�� Northampton, MA 01060 Massachusetts Residential Building Code Section 110.R5.1.2 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. Section 110.R5.1.3.1 Any homeowner performing work for which a building permit is required shall be exempt from the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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. City of Northampton Massachusetts t, c -.A H 3 R. DEPARTMENT OF BUILDING INSPECTIONS a' 212 Main Street •Municipal Building • Northampton, MA 01060 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: A 5)t-me 1��010►e, I�r�ye. (Please print house number and str66t name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Ad ss) ignature of Per pplicant 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. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 y www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Kko`k:�WM Address: �, City/State/Zip: `J\ � J \"�� �1 Phone#: Are you an employer?Check the appropriate box: Type of project(required): l.Q�I am a employer with L�q Zemployees(full and/or part-time).* 7. E]New Construction 2.F1 I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.[31 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.FJI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.n 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: p 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[:]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#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. ,/� �` e Insurance Company Name: \ , \ • A .. y� Policy#or Self-ins. �Lic.#: V ��x ��� n 1 r� "' (�J`_J Expiration Date: I Q I tq Job Site Address:" ()� City/State/Zip:�1cw)& ,MkP 00.� Attach a copy of the workers'compensation polic declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage veri, ation. I do hererti fy under thepa' s and p allies of perjury that the information provided above is true and correct. Si nature: ',fir Date: I ✓ Phone#: " �L� �)?R_ q W3 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#: 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 foregoing 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)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be 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 permit/license 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 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 foregoing 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 your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be 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 permit/license 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). 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 www.mass.gov/dia Form Revised 02-23-15 I Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation NORTH EAST SPECIALTY CORPORATION Registration: 103713 148 DOTY CIRCLE Expiration: 07/13/2020 WEST SPRINGFIELD,MA 01089 Update Address and Return Card. SCA 1 v 2OM-05117 C"%`/fie�Pomneoozuiccr,�l�o�Q��aatar�eusclla Office of Consumer Affairs&Business Regulation R HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 103713 07/13/2020 One Ashburton Place-Suite 1301 NORTH EAST SPECIALTY CORPORATION Boston,MA 02108 SHARON M.TARIFF 148 DOTY CIRCLE WEST SPRINGFIELD,MA 01089 Undersecretary Not valid without signat e DEBRIS DISPOSAL AFFIDAVIT In accordance with the provisions of M.G.L. c. 40, s. 54, Building Permit # was issued with the condition that all debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L c. 111, s. 150A. The debris will be disposed of in: J Name of Waste Fa ' ty Address of Waste Facility 111.5 Debris: As a condition of issuing a permit for the demolition, renovation, rehabilitation or other alteration of a building or structure, M.G.L.c.40 s. 54 requires that the debris resulting therefrom shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L.c.111 s. 150 A.Signature of the permit applicant, date and number of the building permit to be issued shall be indicated on a form provided by the Building Department and attached to the office copy of the building permit retained by the Building Department.If the debris will not be disposed of as indicated, the holder of the permit shall notify the building official,in writing,as to the location where the debris will be disposed. 780 CMR—6th Edition Signature /—Pplicant Date Lepartment of IndustrialAc5idents Office of Investlgation� y 600 Washington Street` Boston, MA 02111 www,mass,gov/dia j Workers' Compensation Insurance Affidavit: Builders/contractor so ecti icia siPlumbers Applicant Information Pl ase rint Le ibl Name (Business/Organization/Individual): �a 6r — I Address: ; City/State/Zip: �'S Phone t Are you an employer? Check the appropriate box; Type of p of eet required): / nd I 1, am a employer with —2—b4. I am a general contractor' 6, [ New cons ction employees(full and/or part-time),* have hired the sub-contractors 2,❑ I am a sole proprietor or partner- lasted on the attached sheet. 7, [ i Reniodelirg ship and have no employees These sub-contractors ha�e [ 8. Der iolitio working for me in any capacity. employees and have wor lers' [No workers' comp, insurance comp. insurance. 9. [ Bui ding a dition required,] 5, 0 We are.a corporation and fits 10.[ Ele trical epairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.[ Plu I bing epairs or additions myself, o workers' com , right of exemption per MGL L Y [N p 12.[ Ro f repai s insurance required,] t o. 152, §1(4), and we haveno - employees, [No workers' 13.[ Oth r_. comp, insurance required:] _ Any applicant that checks box#1 must also fill out the section below showing their workers'corppensation policy inf rmatio r Homeowners who submit this affidavit indicating they are doing all work and then hire outside iontractors must subm,it ane affida it indicating such, Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state w I ether r not th se entities have ;mployees. If the sub-contractors have employees,they must provide their workers'comp,policy number, F am an employer that is providing workers'compensation Insurance for myi employees. Bel w Is hepo icy and fob site ?nformatlon, Insurance Company Name; 7y--N Policy#or Self-ins,Lic,#; y WCT�' _c"�G���1III, I Expiration Dale; Ct fob Site Address;�' ��� L X �� �� City/State/Zip; (DI C(, Attach a copy of the workers' compensation policy declaration page(sho*ing the policy ni mb r and.expiration date). Failure to secure coverage as required under Section 25A of MGL c, 152 can ad to the impos'tion f criminal penalties of a Fine up to$1,500,00 and/or one-yeiar imprisonment, as well as civil penalties i the form of a S OP ORI<ORDER and a fine )f up to$250,00 a day against the violator, Be advised that a copy of this stat ment may be formward d to the Office of (nvestigations of the DIA for insurance coverage verification, f do hereby certify undert e pains erta ies_gf er pry that the information provided ab ve is rue and correct, 3ignature;�""`�L/ I Date, Phone#; �3-739-!ki _ ! Official use only. Do not write In this area, to be completed by city or ton n official, City or Town; Permit/Licens a# Issuing Authority(circle one): 1. Board of Health 2,Building Department 3. I"ity/Town Clerk 4,El ctrical Inspecto 5, lumbing Inspector 6. Other Contact Person: Phoriie#: _ 10/8/2018 Details f Ise :Aicial web,Pi O of the'E.xecailive Oft i( of put)lic safi ty acrd Sf;c,u�ity(C:::C)PSS) Ma;ja,,G,ov Homo Stato Agc;nci;s ensee Details emographic Information Full Name: KEITH W DEVIN Owner Name: 01 1 icenseAaaress inTormation City: WEST SUFFIELD State: CT ipcode: 06093 o nt : Unitedktates icense inTormation License No: CS-110285 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: Issue Date: Expiration Date: /9/2020 License Status: Active Today's Date: 0/8/2018 Secondary License Type: Doing Business As: atus Chan e Reason: License ls§LLance rerequisi a inTormation No Prerequisite Information Close Window ©2011 Commonwealth of Massachusetts Site Policies Contact Us http://eIicense.chs.state,ma.us/Verification/DetaiIs.aspx?agency_id=1&Iicense_id=847296& 1/1 CERTIFICATE OF LIABILITY INSURANCE DATE(MM)DDtYYYY) �....--�' I 1 07/10/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPO. THE CERTIFICATE.HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVER GE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE SSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If'the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. It S.:UBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may requ're an endorsement, A statement on this certificate does not confer rights to the certificate holderInlieuof such endorsement(s). PRODUCER 413.737-5359 1cT J aymond LUSsier Ins gcy Inc J Raymond lussier Ins Agcy Inc p 413-737-5359 F 413-732-2027 181 Park Avenue,Suite 8 t�"lc�r o Ext): �C No PO Box 499 n a uss ec nsurance, om West Springfield MA 01090.0498 J Raymond Lussler Ins Agcy Inc INSURER(S)AFFORDfNG COVERAGE NAIC N INSURERA:COLONY INSURANCE CO INSURED Northeast speclaity Corp INSURERs:A.I.M. Mutual lns,Co, Nescor Safet insurance Com an 39454 148 Doty Circle INSURER C: Y y West Springfield,MA 01069 INSURER D: INSURER E INSURER F COVERAGES 'r ICA E U BES: RE46ION THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED B"ELOW.HAVE BEEN ISSUED TO THE INSURED N MED 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 ADL Foam POLICY EXP TYPE OF INSURANCE POLICY NUMBER ! LIMITS A X COMMERCIAL GENERAL LIABILITY EAC6 OCCURRENCE $ 1,000,0( CLAIMS-MADE ®OCCUR 101PKGO09417'9.00 03/1812018 03/1812019 DAM'GET[SESORENTED PR IE' Curreq 100,0( M xP n n 5,0( PER NAL&ADV INJ'RY $ __1,000,0( GEN'L AGriR :GATE LIMIT APPLIES PER; GENg RAL AGGREGATg $ 2,000,0( X POLICY L_..�I J19& ID L,CC PR- U S-COMP/0R.AGI, $ 2,000,0( OTHER I C AUTOMOBILE LIABILITY0 81NED S)NGLE LIMIT $ 1, 6,01 ANY AUTO' 2433925 03/14/2018 03/11/2018 BODILY INJURY Por r on OWNED SCHEDULED AUTOS ONLY AUTOS Eta BRODILY INJURY Per accident X MUSS ONLY X Ata 69 NNLY Pepe R nl AMAGE 3 UMBRELLA LIAS OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE �v DEO RETENTIONS B �p/pp{� R8 Cp��MPENSgqTIppN X PER 0TH: ANDL�PLOYERS'IIABILIIY 06003962-2017 07/09/2018 07/0912019 '100 Ot ANY PR�OOPREII�EITggO�ERR�IPARTU� ECUTIVE Yf Ar I N t A E.L.EACH ACCIDENT (Mandatorylo NH) l'=1 E,l.DISEASE-EA EMPLOYEE 100,0( Ites;describevnder 500 Dt R I N OF OPER TION below E: .DISEASE-P LICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached It more space Is required) ENFIETO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, N07ICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE + • f ACORD 25(201.6103) O 1988.2015 ACORD CORPORATION, All rights reserved The ACORD name and logo are registered marks of ACORD Page 1 of 9 NESCOR THE LEVEL BEST IN NOME RENAMING 148 Doty Circle West Springfield , MA 01089 1-888-Nescor-1 1-888-637-2671 1-413-739-4333 CT LIC#0545323 MA LIC#103713 RI LIC#42249 Customer Information Eric & Susan Dibrindisi essr42@comcast.net Date: 01/09/2019 42 Stone Ridge Drive 4135864315 Rep: Geraldo Luciano Florence, MA 01062 All-in Package All-in Roof Package Yes Locations INCLUDED in scope of work to be performed Single family home Locations EXCLUDED in scope of work to be performed Detached shed in back yard Job Specifications Existing Shingles Asphalt Metal Color barclay Install Underlayment Synthetic Install Drip Edge F 4.5" Install Ice &Water Shield on Gutter Eaves and Valleys Included Install Ice&Water Shield Around All Penetrations&Along All Flashings Included Install Ridge Vent attic ventilation system on all required areas (Length) 0 Number of Skylight(s) being installed 3 Skylight Size(s) being installed 0 Skylight type(s) being installed Vented Platinum Warranty Included Additional Details Cleanup job site and haul away debris. Protect bushes on front and side of home. Protect deck on rear of home Unforeseen costs that could occur. Additional cost could arise due to damaged wood not recognized at time of estimate.Any wood replacement will be charged upon the homeowners approval an additional cost of$40 per 4'x8'sheet of CDX plywood and $50 per 4'x8' sheet of FRT plywood. Homeowner understands that damaged plywood can only be evaluated after the existing layer(s) of shingle(s) have been removed. Homeowner has completely read, and fully understands that any and all plywood replacement will be charged in addition to the total amount of this contract. I understand the additional charges that could occur at time of installation. (Customer Initials) Page 4 of 9 NORTHEAST SPECIALTY MA License#103713 1-888-NESCOR-1 CORPORATION d/b/a NESCOR 148 Doty Circle. WEST SPRINGFIELD, 1-888-637-2671 MA 01089 nescornow.com All home improvement contractors and subcontractors engaged in home improvement contracting, unless specifically exempt from registration by Provisions of Chapter 142A of the general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director of Consumer Affairs and Business Regulation, Ten Park Plaza, Suite 5170 Boston, MA 02116 - Phone (617) 973-8700 Eric & Susan Dibrindisi essr42@comcast.net Date: 01/09/2019 42 Stone Ridge Drive 4135864315 Rep: Geraldo Luciano Florence, MA 01062 JOB NAME essr42@comcast.net Date: 01/09/2019 JOB LOCATION 4135864315 Rep: Geraldo Luciano ESTIMATOR We hereby submit specifications and estimates for work to be preformed and materials to be used: Specifications and estimates for work to be preformed and materials to be used >> Please See previous product specification pages. Please see reference contract/ proposal with itemized units 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. Estimated Starting Date 01/15/2019 Baring delays cause by circumstances beyond Contractor's control, the work will be completed by Estimated Completion Date 01/30/2019 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 or materials, 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 of materials of workmanship for a period of days. DAYS OF WARRANTY COVERED lifetime +50 WARRANTY CONTINUED 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, it's subcontractors, employees or agents, is discovered after completion of any job, including cleanup, the Contractor shall survive any inspection preformed in connection with the agreed-upon work. Total Contract Amount $261890.00 to hereby to furnish material and labor - complete in accordance with above specifications, for the sum of Total Contract Amount $26,890.00 Payment to be made as follows Page 5of9 $ Due at signing $3,000.00 Measure amount Measure $10,445.00 Enter $ Due for "Start" $10,445.00 Enter $ Due for "1/2 Completion" $0.00 Enter $ Due for "Completion" $3,000.00 Name of Contractor/Designated Registrant NORTHEAST SPECIALTY CORPORATION d/b/a NESCOR Street Address 148 DOTY CIRCLE City/State WEST SPRINGFIELD, MA 01089 413-739-4333 Registration No. 103713 Name of Salesmen Geraldo Luciano Authorized Signature Totals Total Amount $26,890.00 Deposit Paid $3,000.00 Remaining Balance $23,890.00 Remaining Balance Form of Payment Cash Form of Deposit Payment Check Check# 4690 Check Date 01/09/2019 Ownership of Property:The undersigned warrants that he/she is Owner of the property on which the work is to be performed or that he/she is otherwise authorized an behalf of Owner(s)to enter into this Contract. Notice of Scheduling Changes: Contractor agrees to provide Owner with notice when delays become known to the Contractor. Concealed Conditions: Should concealed conditions encountered in the performance of the contract be at.variance with the conditions indicated by the contract and/or Owner or should unknown conditions of an unusual nature, differ from those ordinarily encountered and generally recognized as inherent in the work of the character provided for In this con-tract be encountered,the contract shall be equitably increased. Furthermore, if unknown and/or concealed conditions prevent Contractor from completing the contract,the contract shall be equitably increased or decreased,as the case may be. Delays in Completion Due to Concealed Conditions: Owner hereby acknowledges that in certain remodeling work,the demolition of portion Of the pre-existing structure may reveal additional defects,conditions or the need for additional work, which must be repaired, altered or carried out in order to complete the wort described under the contract.In such case(s), Owner agrees that the duration of the work and the scheduled date of completion may differ from the date stated on the front,and that such variation shall not be considered to be a violation of this contract. Page 7 of 9 Choice of law: The laws of the Commonwealth of Massachusetts shall apply to all disputes and claims arising out of or relating to this Agreement, including any breach hereof. Jurisdiction: Any action relating to a breach of this Agreement or any disputes and/or claims arising out of or relating to this Agreement, shall be brought in the Courts of the Commonwealth of Massachusetts, Hampden County division. Subcontracting: Contractor has the right to subcontract any part, or all of the work agreed herein to be performed. All permits, license requirements, workmen's compensation and/or other job requirements shall be the sole responsibility of the subcontractor. Contractor agrees that notwithstanding any agreement for materials and/or labor between Contractor and a third party, Contractor is responsible to Owner for completion of all work described in a timely and workmanlike manner. No Acceleration of Payments but Escrowing Allowed: The Contractor may, not require payments to be made in advance of the times specified in Payment Section (front), pro vided, however, if it deems itself to be insecure, it may require, as a prerequisite to continuing the work described herein, that the balance of the payments under this contract that are in control of Owner, shall be placed in a joint escrow account that requires the signature of both Contractor and Owner for withdrawal. Insurance: Contractor will be responsible to Owner or any third party for any property damage or bodily injury caused by itself, its employees'or its subcontractors in the perfor-mance of or as a result of the work under this Agreement. Contractor agrees to carry insurance to cover such damage or injury. Page 8 of 9 Construction Related Permit Acquisition: Contractor, under provisions of Chapter 142A of the Massachusetts General Laws, is required to apply for and obtain all construction related permits. Contractor shall not be deemed responsible for delays in the work described in this agreement caused by regulator, permit granting or inspectional agencies, author-ities or individuals. NOTICE: If Owner obtains his/her own construction related- permits for the work described under this Agreement, Owner is hereby advised that in the event of a dispute, judgment and'nonpayment of Contractor, Owner will not be entitled to make claim to or collection from the guaranty fund established in M.G.L. c. 142A. Modification: This Agreement, except as to concealed conditions or delays occasioned thereby or by restarts, cannot be changed except by a written statement signed by both Contractor and Owner. However, cancellation by Owner is allowed in accordance with the Notice of Cancellation. Owner hereby grants Contractor a limited Power of Attorney to complete incomplete documents on Owners behalf. Completeness of Contract for Execution: Owner is hereby advised not sign this Agreement unless and until all blank sections have been filled in not applicable, and until all exhibits and related or referenced documents that are incorporated herein are attached hereto. Attorney's Fees/Costs Owner agrees to pay all costs of collection, including reasonable attorneys fees, cost and expenses. Furthermore, interest shall be charged at the highest lawful rate of interest on any and all overdue payments. Copy of Agreement to be given to Owner: This Agreement is governed by the laws of the. Commonwealth of Massachusetts. It must be executed in duplicate, and an original, signed copy hereof given to the Owner at the time of execution. No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to Owner of a copy therefore. Disclaimer: Contractor, its affiliates, employees, agents and assigns are not tax advisors. Owner acknowledges and Contractor confirms that no certification has been made or provided by Contractor to Owner as to whether the purchase or other criteria required for qualification of any such tax incentive has been met by Owner. Owner is responsible for consulting with a tax professional or accountant to determine certification and qualification under the IRC for any tax credit or incentive requested. Contractor is not responsible or liable for Owner's ability or inability to receive tax credits or incentives. * Any dispute between the parties hereto shall remain confidential. Customer shall not make or encourage others to make any public statement that is intended to or reasonable could be foreseen to, embarrass or criticize the company or its employees, without obtaining prior written approval from the company" or marked as void, deleted or encourage others to make any public statement that is intended to, or reasonable could be foreseen to, embarrass or criticize the company or it's employees, without obtaining prior written approval from the company. - L Geraldo Luciano Eric&Susan Dibrindisi MA Lic. # 103713 / CT Lic. # 0545323 01/09/2019 State License Date 01/09/2019 Date Page 9 of 9 NOTICE OF CANCELLATION NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION, WITHOUT ANY PENALTY OR OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE DATE STATED BELOW. IF YOU CANCEL, ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE, AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. IF YOU CANCEL, YOU MUST MAKE AVAILABLE TO THE SELLER AT YOUR RESIDENCE, IN SUBSTANTIALLY AS GOOD CONDITION AS WHEN RECEIVED, ANY GOODS DELIVERED TO YOU UNDER THIS CONTRACT OR SALE; OR YOU MAY, IF YOU WISH, COMPLY WITH THE INSTRUCTIONS OF THE SELLER REGARDING THE RETURN SHIPMENT OF THE GOODS AT THE . SELLER'S EXPENSE AND RISK. IF YOU DO MAKE THE GOODS AVAILABLE TO THE SELLER AND THE SELLER DOES NOT PICK THEM UP WITHIN TWENTY DAYS OF THE DATE OF CANCELLATION, YOU MAY RETAIN OR DISPOSE OF THE GOODS WITHOUT ANY FURTHER OBLIGATION. IF YOU FAIL TO MAKE THE GOODS AVAILABLE TO THE SELLER, ORIF YOU AGREE TO RETURN THE GOODS TO THE SELLER AND FAIL TO DO SO, THEN YOU REMAIN LIABLE FOR PERFORMANCE OF ALL OBLIGATIONS UNDER THE CON- TRACT. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO: NESCOR 148 Doty Circle W. SPRINGFIELD, MA 01089 1-888-NESCOR-1 ** 1-888-637.2671 NO LATER THEN MIDNIGHT 01/12/2019 1 HEREBY CANCEL THIS TRANSACTION (Date) (Buyer's Signature) BUYER(S) ACKNOWLEDGE RECEIPT OF TWO COMPLETELY FILLED COPIES OF THIS NOTICE ON THE DATE FIRST ABOVE WRITTEN HEREOF. ��k_j Eric&Susan Dibrindisi 01/09/2019 Date