17C-249 teptatcment Wilinboth Propolat Page No. t of Pages
Main Office: p t
7 Devens Street • P.O. Box 429 THE JUBB CO., INC. d.b.a. Northampton, MA:
i i Greenfield, MA 01302 (413) 584 -3716
(413) 772 -6217 LARRY JUBB'S Brattleboro, VT & Keene, NH
1 -888- 639 -JUBB
Hatfield, MA 01038 �MPROVE�A�HOMETM Email: JubbCompanyinc @aol.com
PROPOSAL SUBMITTED TO PHONE DATE
/AND y C/iu rf/ 4 1/3 - 5'? - 8/g/6
STREET JOB NAME
/ g spat Sf .. 6 l A va�7, ' ,A-/w tv7
CITY, STATE At ZIP JOB LOCATION
F( o RF._.NC Al II-SS r G ( 6itP'vC MARegistration 100001 MAWS
TENTATIVE JOB SCHEDULE (Weather Permitting)
Approximately weeks from date of signed proposal received by Jubb Co., Inc. MA Cons. Sup. Lic. 055333
We hereby submit specifications and estimates for: �`�
Supply & Install Mastic Vinyl Re em
PP Y a� ax`e aid lac ent Windows Y P
• 1/2 Screens (double hung only). • Interlock meeting rail. 041 • Locking Screens (double hung only). • Welded sash & frame.
• Tilt -in Sashes (double hung only). • Five degree sloped sill.
• Non - conductive intercept glass system. • Seven - eights thermo glass. CPA • Continuous Balances (double hung only). • Insulated padded frame.
• Sun Shield Vinyl Compound (Mastic exclusive). • Energy Star approved. 10/7
• Twin locks on double hung units 32" or wider. • Virgin vinyl.
• Twenty year manufacture guarantee on glass seal failure. ° RR. " GAS (A)INOXA'S ML>
' • Lifetime transferable manufacture guarantee on vinyl window frame. FedetAl S - ! «
• Labor guarantee as required by CT,, NH, VT contractor regulations. '(.'
Color: Linen White ❑ Almond* ( *extra charges apply for this colors)
TOTAL UNITS REPLACED: a r►tr4- E(0D 12_ FrbiA, W IN DOW-S Ta k. Double Cw
5 4_Grids 9 ! y (F+ (Note: Grids are beveled)
Low "E" Glass y $rtArgonyES $ Insulation (into weight pockets) al< Storm Window Removal 2/
❑ Aluminum Clad Exterior Castings (❑ Full ❑ Partial) N b
OTHER / NOTE: 7 /n red C' �s �k
o � a m �t -lam' �o s -��v,� d o e "v
F l aaa_
L_esje,\ o Ni t rc,I* •
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/titQ0EG # $` 3 O -- / V Stec-4 C o2DF� rJ /z€ ?S X i<'s
Whk. e h -d J - Si N) (e V eUf ow, ID s'` Isz. i1
IQ oTe *, tJF.cA1 Fit° Oo«hle k a Se inoua-fed t N C.PNTe2 of �,e/ sr/ /06 apes wA)p
N cw P t Ne wo��o Sd�PS do be e f1 D O E D o a �� E�D,e � tN >�eR
owrver NeSpoivS i 3 t..L f3,96;4* . cW-Stx 'iv
SERVICE FE . ', .9. ' - - . - - -- - - - - - - .. - - I job related refuse.)
[service fee not included in total amount below, and will be billed separably.] �•14`!et-14j3E1:3) 4—QT _ __.
• 6
•
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The Commonwealth of Massachusetts
t* _ Department of Industrial Accidents
_1 = Office of Investigations
= v 600 Washington Street
Slle Boston, MA 02111
• Y `''' +,'.1�' www mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): I h `J U I I I v C�► v\
-
Address: 0. g U a c1
City /State /Zip: C v H Phone #: -7 7 c / /
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ 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. ❑ Building addition
[No workers' comp. insurance 5. ❑ We arc a corporation and its
required.] officers have exercised their 10.111 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.] t employees. No workers' 13.0 Other
comp. insurance required.]
Any applicant that checks box 01 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 their workers' comp. policy inlbnnation.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Pe- C C j �l ' 5 )(C rl (
Policy # or Self -ins. Lic. #: C U -/ Expiration Date: 5 / 3 / )
Job Site Address: City /State /Zip:
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 the pains and penalties of perjury that the information provided above is true and correct.
Signature: yq' —. Date:
Phone #:
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 #:
AFFIDAVIT • . • . .
• . As a result of the provisions of MGL c 40, S54, I acknowledge that as a condition of Building Permit
' • . Number 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 -
cI11,S150A_ -
I certify that I will notify the Building Official by
• . (Two months maximum) of the location of the solid waste disposal facility where the debris resulting from ,
. the said construction activity shall be disposed of, and I shall submit the appropriate form.for attachment
to the Building Permit.
•
(
. Date Signature of Permit Applicant
•
. (Print or type the following information) •
1 ,---0(_.( JreoCe (-:4 . . •
• Name of Permit Applicant
•
•
Firm Name, if any •
• ' ' C) • -367\ (.../3_, :... •.(- • . , ..,,..----...,.... •
• . • Address .
• • ••Tits :::debris -v ill...be • se of': ` .. ....
L..„./1 V . I�1� J' IC- Co.iC-b ,-)/
(Location of Facility)
•
105/ 15: 52 41:.3E.3 1: F 8 AHP'1ST PAGE 01/01
ACORD` 7:A ;N�Lr,0
1i'rrYY;
CERTIFICATE OF LIABILITY INSURANCE 05/07/2010
PRODUCER rhona 413 BG3.1370 Pas 613 EB3 - SG50 THIS CERTIFICATE IS 18SUED AS A MATTER OF INFORMATION
A.H. RIST INSURANCE AGENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
159 AVENUE A HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. BOX 391 ALTER THE COVERAGE AFFORDED BY THE M F. __CV
TURNERS FALLS MA 01376
INSURERS AFFORDING COVERAGE IIM
INSURED INSURER A: PEERLESS INSURANCE COMPANY
THE JUBB COMPANY, INC. INSURER 3'
P.O. BOX 429 INSURER C:
GREENFIELD MA 01302 INSURER D. __ ii=
INSURER E•
COVERAGES
_ _
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PO;JCYPERIOD kl) :C,ATED, NOT;HITI13TAND'T,G
ANY REDIJIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 'r ;II" N' RESPECT TO WHICI I THIS CERTIFICATE MAY DE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED f3Y TI'IE POLICIES CESCP,IAEO HEREIN IS SUO.ECT TC ALL T!•!E TPPMS, F.Y,OLUSIONS AND CONDIT ;]NS 'OP SG_' -,
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED I3Y PAD CL.Ar'v15
!NEP PDD'I. POLICY EFFECTIVE POLICY EXPIR AT1oM
! rF. 'N3R[ TYPE OP INSURANCE POLICY NUMBER LIMITS
DATE Itd`ArDDM9 A7C tWG1;L+bIr1
GENERAL LIABILITY CBP 8661749 05/03/10 05/02/11 EACH CCC!jRP.ENCE E 1,000,000
X COMMERCIAL GENERAL LIABILITY ':41aAr3E TO RENTED 100,000
^ryEMIgG3 (En oco'.ven:,n
— CLAIMS MADE OCCUR MED. EXP (Any ono DDI'eSn1 'a 15,000
A � PEPSC':AI. A. ADV INJURY - 1,000,000
GENERAL AGGRE_CIATE 2.000.000
GENT. AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP) OP ACC 1. 2,000.000
— 1 POLICY I I If -CT I-OC
AUTOMOBILE LIABILITY CA 8669247 05/03/10 05/03/11 coMOINFD SINOIA LIMIT 1,000,000`
ANY AUTO (SE RCCICIent)
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Par pc-r.0,1 "
A X HIRED AUTOS I -
P..OD!I_Y INJURY
X NON..OWNED AUTOS • (Per aoeidam) .
—
PROPERTY ;PERTY DAMAGE
- aceldEnti
• GARAGE LIABILITY N/A AUTO OPII.Y - EA ACCIDENT
ANY AUTO OTI.IF t THAN EA ACC
AUTO ONLY AGO
i _ . 1 . . ,+,..�,....
EXCESS / UMBRELLA LIABILITY N/A CROP/ OCCURRENCE
— I OCCUR n CLAIMS MADE AGGREGATE
DEDUCTIBLE
RETENTION $ _ _ _
WORKERS COMPENSATION AND WC 8664947 05/03/10 05/03/11 X I '4:.7 IJWITE L cT "
EMPLOYERS' LIABILITY Y; N / E,I.. EACH ACCIDENT .$ 100,000
A ANY PROPRIETORiPARTNriRIf; CECUTIVE
OFFICER /MEMBER EXCLUDED? r_ L. DISEASr. r-MPI 500,000
(Mnndntnry In NISI
I,ly ria:anec under RI . DISEASE-POLICY LIMIT S 100, 000
C PI-.ovimME belw+ _
OTHER JI N/A
DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL. PROVISIONS
CLASSIFICATION: CARPENTRY /SIDING INSTALLATION
WORKERS COMP POLICY INCLUDES COVERAGE FOR CORPORATE OFFICERS
CERTIFICATE HOLDER CANCELLATION
THE JUBS COMPANY, INC. SHOUAD ANY OF THE ABOVE, DESCRIBED POLICIES f1_ CANCEL-ED S,_GOPF -Ii-
P.U. BOX 429 EXPIRATION DATE TI-IPRF'5F, THE IS`_U'I' INBURER 'NIL ENOL,M /ONTO MAIL 1.^. :=/:VS
WRITTEN NOTICE TO FHH CERTIFICATE HOOTER NAMED Tf2 TI i.10-'b, BI! ; "A'LJ G TO
GREENFIELD MA 01302 DC SO SHALT. IMPOSE NC CPLICATION CR LIAHIMTY OF ANY RIND UPON hip- INSURER 'T S
AGENT OR REPRESENTATIVES
AUTHORIZED REPRESENTATIVE' �J
on: r cep rgik Ie'�
Attention: -
� ` T"a L1k rJlc. "---
ACORD 25 (2009/01) Certificate if 22985 C 1988 -2009 ACORD CORPORATION. All rights reserved.
The ACORD name anO logo are reqstered marks of ACORD
e
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SECTION 8 - CONSTRUCTION SERVICES l
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : L)f e C , - 3
License Numb
pr a- �-- ��, � �� ,` - 5 I
Address Expiration Date
Sign ure Telephone
9. Realstered Home Improvement Contractor. Not Applicable ❑
Company Name Registration umber
PC) f �� �f � �/ O--,
Address M Q Expiration Date
'-e �'r1 � T: I a 1 ' A 3) C1 Telephone - 7
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(0))
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 ❑
11. - Home Owner Exemption,
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (I) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
ps 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" shell 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 buildin8 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
'
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement ndows Alteratlon(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [D] Other [D]
Brief Description of P pposed
Work: (''Z'sl I I { 10 �(' t /''1
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
1, , 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, ,, C �' � S J , as Owner /A rized
A en hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my kno edge
and belief.
Signed under the pains a d penalties of perjury.
R f
PrinttName !�
Signature of Owner /Agent Date
fi
-
./ , ..
Department use only
City of Northampton Status of Permit
Building \Department Curb Cut/Driveway Permit
•�4; 212 Main Street Sewer /Septic Availability
• \\,\C° i adm 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 DWELUNG
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
(o I no. Q 1 r Map Lot Unit
10( e c)c e I e Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
C�
O c I 1 1 ( t J p s r, Name (Print) Current Mailing Addr
Telephone
Signature
,2,2 Authorized Anent:
l x )� e e fq c) L P 9 1d Ni*
Name (Print) Current Mailing Address:
Siinatare 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 /0 6. Total =(1 +2 +3 +4 +5) 1 a(. 0 • �' Check Number '0 3
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
1
1 WORTH MAIN ST BP-2011-0144
GIS #: COMMONWEALTH OF MASSACHUSETTS
Mai : 17C - 249 ` 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-2011-0144
Project # JS- 2011- 000239
Est. Cost: $1260.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THE JUBB CO INC 055333
Lot Size(sq. ft.): 21780.00 Owner: CHURCH ANDREW
Zoning: URB(100)/ Applicant: THE JUBB CO INC
AT: 61 NORTH MAIN ST
Applicant Address: Phone: Insurance:
P O Box 429 (413) 772 -6217 Workers
Compensation
GREENFIELDMA01302 ISSUED ON:8/20/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS /DOOR
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 8/20/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner