12C-037 (5)DIVISION OF PROFESSIONAL LICENSURE6-5-1OFFICE OF INVESTIGATIONS ��
Application for Complaint
617-727-7406
www. mass.gov/dpl
Date Received (stamp):
Entered into the Database (Date): / / Docket #: - -
Acknowledgement letter sent (Date): / / Signature:
Please complete this form as fully as possible. (PLEASE DO NOT WRITE ABOVE LINE.) Please type or print legibly in ink.
SUBMITTED BY:
Name:��
Last Name First Name M.I.
Address: \-\0\ `S -,z-- 0 C,-- Q . t-� \�� -- --IS
Number Street Daytime Phone
City State Zip Code Evening Phone
Best way to reach you: vening Phone N?aytime Phone -mail:
LICENSEE SEEKING COMPLAINT AGAINST (use separate form for each licensed individualibusiness):
Name: L V C \C*-,.�
Last Name First Name M.I.
Address:
Number Street
City
Business Name
Business Address
Daytime Phone
State Zip Code License Number/Type Class
Daytime Phone
City State Zip Code Business License # / Type Class
Please check the trade or profession that this application for complaint pertains to
Accountant
Aesthetician
Architect
Athletic Trainer
Audiologist/Speech Language
Pathologist
Barber
Barber Shop
Barber Schools
Chiropractor
Cosmetology School
Dietitian/Nutritionist
Dispensing Optician
Drinking Water Operator
Electrician
Electrologist
Engineer
Fire / Burglar Alarm Installer
Funeral Director
Gas Fitter
Hair Salon
Hair Stylist
Health Officer
Hearing Aid/Instrument
Specialist
Home Inspector
Land Surveyor
Landscape Architect
Manicure Salon
Manicurist
Marriage & Family Therapist
Massage Therapist
Mental Health Counselor
Occupational School
Page 1 of 2
Occupational School Sales
Representative
Occupational Therapist
Optometrist
Physical Therapist
Plumber
Podiatrist
Psychologist
Real Estate Agent/
Broker/Salesperson
Real Estate Appraiser
Rehab Counselor
Sanitarian
Sheet Metal Worker
Social Worker
Veterinarian
Description of the incident(s):
Briefly describe the incident(s) that led to your application for complaint and note the times and dates that
events occurred. List the names of all individuals involved. Please attach additional pages if needed.
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(Please use a separate sheet if necessary. Do not write in the margins.))
Additional information or materials attached Q'es lao
To speed up the application for complaint process, submit legible copies (not the originals) of all relative documents
supporting your application (e.g. contracts, medical records, cancelled checks, etc.). You will receive an
acknowledgement letter notifying you if a complaint is issued based on your application. If a complaint is not issued,
you will receive information on additional resources that may be available to you.
AUTHORIZATION FOR RELEASE OF RECORDS AND FORM REFERRAL
My signature to this form, or a photocopy thereof, authorizes the Division of Professional Licensure to:
(1) receive copies of all medical, dental and mental health records relating to my application for complaint, and (2) to
refer my application for complaint to other appropriate law enforcement authorities to investigate and/or prosecute.
Please note that all applications for complaints are examined to determine their factual basis. The act of filing an
application for complaint does not assure or imply that disciplinary action will be taken against the licensee.
I attest that the information provided is true, correct and complete to the best of my knowledge.
Signature Date
Mail this form to:
Division of Professional Licensure, Office of Investigations
1000 Washington Street, Suite 710
Boston, MA 02118
Page 2 of 2
COST ESTIMATE
AddiI 49SHRUNGSTW)MMIPTONI
Location: 1- General Requirements
Datir. 7/22/201,7
SM HEART
aj church
('Rill) S48I
Page 1 of 3
Quantity
Unit
unit Price
Total Price
OWWEJrS FOIISH SELECT11ONS
7x. O*,*WsWSVj9&*aQ*' =km swes & 4ves of MWMM1S*M a SOI
options pertaining to spec* The contractor & property owner shall submit to
the Rehabilitation Spedalist, a copy of the agreed upon colors, styles and
types of materials prior to job start.
MANUFACTURER'S SPECS AND MA CODE PREVAIL
All materials shall be installed in full accordance with the manufacture's
speciftabons, for *Mkirg conditicII surface prepara6m, meoxxft,4
protection and III All work performed WE be equal to or gloater than MA
state building code requirements.
rORt4MANSHIP STANDARDS
I
H work shall be performed by mechanics both licensed and skilled in their
articular trade as well as the tasks assigned to them. Workers shall protect all
urfaces as long as required to eliminate damage and will be held responsible for
damage dam,
I IN
NAL CLEAN
]Remove from site all construction materials, tools and debris. Sweep dean all
1--*erior work areas. Vacuum and mop all interior work areas, removing all visible
i�
ust, stains, labels and tags. Final payment will not be released until property is
s s
and
leaned and passes visual and dust wipes clearance. On rehab jobs a tetter of
leaned
reeds to be issued. On Lead jobs a kWw at Full DE loading
reeds to be isswed.
Page 1 of 3
Address: 49 STERLING STREET, NORTHAMPTON, MA
Location: 2 — BATHROOM RENOVATION
Page 2 of 3
QxarAw
Una
Unit Pace
Tatal Price
BATHROOM RENOVATION -TOILET, SINK,
KOHLER MEMOIRS CLASSIC 2 -PIECE 1.28 TOILET
1
EA
$475.00
$475.00
KOHLER MEMOIRS STATELY CERAMIC PEDESTAL BATHROOM
SINK
1
EA
$475.00
$475.00
VICTORIAN 4 IN. GENTERSIET 24I IANDLE BATHROOM FAUCET IN
SATIN NICKEL
1
175.00
$175.00 .
GLACIER BAY RECESSED MEDICINE CABINET IN WHITE
1
EA
$60.00
$60.00
LLANTE 3 -LIGHT SATIN NICKEL BATH LIGHT
1
125.00
$125.00
UTER KERDI SHOWER SYSTEM
32 IN- X Sit W -CENTER Sf*7V#ER Ki i 4V AS TH
LESS STEEL DRAIN GRATE
t
15W.t11�1
15W.00
SIC 601N X 701N SEMI-FRAMELES SLIDING SHOWER DOOR
DELTA IN21TION 4 -SPRAY HAND SHOWER AND SHOWER HEAD
1
EA
$75.00
$75.00 ,
JELN-WEN "ANEL PRIMED COMPOSITE MOLDED BORED INTERIOR
1
EA
$75.00
$75.00DOOR ,,..
ACCENT SATIN -NICKEL BED AND BATH LEVER
1
EA
$60.00
$60.00
SATIN NICKEL DOOR HINGES
3
EA
$75.00
$75.00
ISPER CEILING 110 CFM EXHAUST FAN
1
EA
$175.00
$175.00
Page 2 of 3
Address: 49 STERLING STREET, NORTHAMPTON, MA
Location: 2 — FLOOR REPLACEMENT
All work performed shall be to MA State Building Code.
TOTAL BID FOR PROJECT:
$11,395.00
HOMEOWNER'S ACCEPTANCE:
Homeowner's Signature: Tara Heart
Homeowner's Signature: Lindsay Heart q40151i.
Page 3 of 3
Quan ty
Unit
Unit -Price
Total Price-
riceBATHROOM
BATHROOMFLOOR REPLACEMENT
FLOOR REPLACEMET-Remove all layers of current flooring, prep surface
for tile. Customer must decide on pattern
40
SF
$2000.00
$2000.00
BATHROOM WALLS
TILE BATHROOM WALLS 0K of j; prep wal, vnsW tiles
1
-SF
$ .oa
$nw- 00
PLUMBING
PLUMBING
Center drain, replacement hardware Toilet, sink and shower
$1500.00
$1500.00
ELECTRICAL
MISC. C W4GING LOCATION OF OUTLET AND LWN- ' FIYTI E
$51W.00
$500.00
MISC. CHARGES
Dump fees, hardware, equipment, misc. materials, subs etc....
$500.00
$500.00
All work performed shall be to MA State Building Code.
TOTAL BID FOR PROJECT:
$11,395.00
HOMEOWNER'S ACCEPTANCE:
Homeowner's Signature: Tara Heart
Homeowner's Signature: Lindsay Heart q40151i.
Page 3 of 3