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23C-065 (7) BP-2008-1095 GIS#: COMMONWEALTH OF MASSACHUSETTS INW CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2008-1095 Project# JS-2008-001619 Est. Cost: $1280.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THE JUBB CO INC 100001 Lot Size(sq. ft.): 111949.20 Owner: COHEN JEFFREY R&DARLENE S Zoning:URA Applicant: THE JUBB CO INC AT: 113 BLISS ST Applicant Address: Phone: Insurance: P O Box 429 (413) 772-6217 Workers Compensation GREENFIELDMA01302 ISSUED ON:6/6/2008 0:00:00 TO PERFORM THE FOLLOWING WORK:REROOF PORCH 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 6/6/2008 0:00:00 $25.0010705 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo r• , t Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot Unit { O�_ �_f Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: e_ 13 431 t S S . Name(Print) Current Mailing A d 43 - � 5 — 31 Telephone Signature 2.2 Authorized Agent: , 4. J l J -. Pr �S • Pc vx '1 29 etcl MA Name(Print) ‘—:•ti‘fddg Current Mailing Address: / 0 I.30 Z 717 -6,9.0 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION 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) S I/ o. f�0 Check Number /V 77) This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date •. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House n Addition ❑ Replacement Windows Alteration(s) I I Roofing Or Doors l] Accessory Bldg. El Demolition ❑ New Signs [O] Decks [C] Siding[O] Other[O] BWorf rie Description of Proposed fk: 2.rZ--Ir+90- / Alteration of existing bedroom _ Yes ✓ No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes ✓No Plans Attached Roll -Sheet sa.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 relative to work authorized by this building permit application. 5 e� o s iv Signature of Owner Date I, rP44.-C.e— A. -,l tA-1, 'f r. P-ec- ,as Owner/Authorized Agent hereby declare that the statements and�informa>ion on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. L.-11-4A) ,-e iit.e-e- A . J wio b ...hr./ Pir-�s . Print Name cf‘i/o V Signature of Owner/Agert I SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: p Not Applicable 0 Name of License Holder: ~ �►� -CZ, A• J 1.1.10 b� . ►� - £ 3 3 3 License Number f?� Q oX ` `1 L . M A 0 i 3v L. 5/ J P-0 I 0 Address / Expiration Date ,w,..011a:4144/04.4.4Cr' -7-7 - 1 Signature Telephone 9Regi„stered Home Improvement Contractor. Not Applicable 0 Company Name Registration Number P© 80x +2_9 e,P-r'tin e cL AA A O i j c�2 ��� aZo l O Address " Expira on Da Telephone "—4 u 7 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 building permit. Signed Affidavit Attached Yes No 0 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) 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 shall 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 PROPOSAL The Jubb Co., Inc. d.b.a. MA Registration 100001 LARRY JUBB S MA Cons. Sup. Lic. 055333 IMPROVE-A-HOMETM 7 Devens Street 18 North Hatfield Road P.O.Box 429 Hatfield,MA 01038 Greenfield.MA 01302-0429 (413)772-6217 Northampton,MA (413)584-3716 TO: Cohen, Darlene PHONE413-695-5731 DATE_/21/08 113 Bliss Street JOB NAME UO11.3 CAfl N Florence, Ma. 01062 iss Street Florence, Ma. JOB NUMBER JOB PHONE 'Wa hereby< �tiCAt)an8=,and eatintatofl tot: J g(8 -TO ROOF REAR PORCH- f1 (� uJ 0 1) . to remove and dispose of existing roof layers. (up to two layers) 2) . clean and pre-pare roof deck for installation of Mule Hide self adhere roof. 3) . color light grey (will not match existing main house roof color exactly) . SERVICE FEE: S275.00 (includes permit & disposal of all job related refuse) (service fee amount not included in total below and will be included in job completion invoice.) 0 Votrogi hiff8y;lawdriglattillytcyabayid-Tupiftiontc.tstrIwn with the above specifications,for the sum of: 1,280.00 dollars($ nttEbefttrrOMEME`T ION. An interest charge of 2% per month (24% per annum) on past due balances, plus all costs, including reasonable attorney's fees incurred in collecting any sums owed. All material is guaranteed to be as specified.All work to be completed In a professional manner according to standard practices.My alteration or deviation front above specifica- Authorized tons Involving extra Coats will be executed only upon written orders,and will became an Signature extra charge over and above the estimate.All agreements contingent upon strikes.accktents or delays beyond our control.Owner to carry tire.tornado,and other necessary Insurantm. N . is proposal may Our workers are fully covered by Worker's Gcxttpensairon insurance withdrawn by us if not accepted within days. ,.// Acceptance of Proposal- The above prices.specifications and / conditions are satisfactory and are hereby accepted,You are authorized to do the wink Signatur as specified.Payment will be made as outlined above. Sgnatur Date of Acceptance: - f j— • • ,y • • • � t The C'o»ttnonweallh of Massachusetts Department of Industrirt!Accidents 1 -. Office of Investigations- 1?. 600 Washington Street 1�e=) Boston, MA 02111 %�`t Iv1vIv.ttiaS.s'.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information —7-- r Please Print Legibly Name (Businessiorganizatiowilndividual): --1 l.A—✓3b �o . .-�'L., . Address: 4/- 0. ao K 4)—_9 City/State/Zip: ve- mil� MA Ot3o�, Phone f: '17%L —6� Are u an employer?Check the appropriate box: Type of project(required): 1. I gut a employer with —.5 4. n 1 am a general contractor and 1 6. 0 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 0 Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. 0 Building addition [No workers' comp. insurance 5. n We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.]1 employees. [No workers' 13.[] Other comp. insurance required.] •Any applicant that checks box I l must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �-�...-t--Ii_l 04 &_1 Policy#or Self-ins.Lic.If: C-- j 039 1-}-4-9._g Expiration Date: / 3 /° 9 Job Site Address: i l 3 +2)1( S S• City/State/Zip:-1-1 C)r AA A 0 l 0(7 2-- Attach a copy of the workers' compensation policy declaration page(showing the policy number and.expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under he pains d pe hies of perjury that the information provided above is true and correct. Signature: '�� Date: P( V 0 8 Phone if: 1"-12- —(v21`j Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License II Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone II: 37L eo/nvirto4uvea&A, ,.,2 sac/ � Board of Building Regulations and Standards t. ����== g 3�1)!l-= One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Construction Supervisor License License CS: 55333 Restriction: 00 Expiration: 5/21/2010 Tr# 25298 LAWRENCE A JUBB JR _ _—_- PO BOX 429 GREENFIELD, MA 01302 - — Update Address and return card. Mark reason for change. OPS-CAI 0 50M-07/07-PC8490 1-1 Address rl Renewal I Lost Card • toil -� /(.4 ==eft Boar o nil m e u_` -= g g la ons an tandar s ��' One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 100001 Type: Private Corporation Expiration: 6/8/2010 Tr# 267161 The Jubb Company, Inc. Larry Jubb P. O. Box 429 --- — - - -— Greenfield, MA 01302 Update Address and return card. Mark reason for change. DPS-CAI 0 50M-07/07-PC8490 L-] Address Li Renewal ❑ Employment Lost Card