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23B-044 (16) • 1 - - • . • . ' : . es „ • • . •• • • . . . . . .... .. . • ' ' ' .' ' . _. . • . , . • • . ... . . . . . ' ' . . .• . . . . . • • . • . . ....... . . . . . .. .. ., • ' ' . ' . • • • .... • . . . . . . . , . .. • • 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 .definecl. by MGL • • - ' . e Ili, S 150A- . , . . . ' .. . • . . . . . . . • . • . . • • • ' ' . . . . ... ... •.. . , . .. • .• I certify that twill notify the Building Official by : • . . (Two months maximum) of the location of the solid waste disposal facility where., the debris •resulting from ' f . .. . the said construction activity shalt be disposed of and I shall submit the .apploPriate fonpl far attachment ' • : to the Building Permit. ''• • • .. • , • ...... .. . - • • . . • . • ..• • . A • . ,,,, . .. . . . . . • . ,.. ,,, . • . . . . • . • . • • . .. • . . ... ., • ..."'': • .."'" ..0 ‘.. ' /....„*.'.• . .... ... . • . • ....,,,, ,.. ,,, .. . *. ,..,......- - • , .• ■.,, ..., • ... . . • . • . • • . . . . . . • . . • • Date — CT • r-- • / / Signature of Permit Applicant . . . .. . • • . . . . . . . . . • . . ' . ' •• . • • . . . . . . • • ... • ...... . . • • • ' (Print or type the following information) • ' . • • ... -, • . ' . . . . , . .. .. . • . . • . • ': . . • ' . • • • , • • ' • . . '. . . . .. 1 C 146 j7C- • • . .. • . . .. . i .• • . . • Name of Permit Applicant • . . . • • . . . • • . . . . 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The Commonwealth of Massachusetts ' • Department of Industrial Accidents It - , .fit..:. ; t Office of Investigations =�•�1= —Aso— * 600 Washington Street a i� ' "' ��— G Boston, MA 02111 wivw.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers Applicant In formation Please Print Legibly Name ( Business /Organization /Individual): f'1 1 f V a / Address: . 0. g (5 City /State /Zip: C ,-� , `ct_ H l Phone #: e2 / 7 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. 0 1 am a general contractor and 1 6. ❑ Ncw construction employees (full and/or part - time).* • have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I 7• 0 Remodel ng 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 10.0 Electrical repairs or additions required.] officers have exercised their 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, .§ and we have no 12.0 Roof repairs insurance required.] t employees. (No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box If l 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. tContractors 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. 1l Insurance Company Name: E'. G �^ , �' � jS _J---Y S ►'1 Policy # or Self -ins. Lie. #: �- C. �J-9 (/ Expiration Date: 5 3 Pk 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature . . Date: Phone Official use only. Do not write in this area, to be completed by city or town official City or Town: Pcrmit/Liccnsc # 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 #: • PROPOSAL 49 The Jubb Co., Inc. d.b.a. LARRY JUBB'S MA Registration 100001 MA Cons. Sup. Lic. 055333 Page 2 of 2 IMPROVE- A- HOMETM 7 Devens Street P.O. Box 51 P.O. Box 429 Hatfield, MA 01038 Greenfield, MA 01302 -0429 Northampton, MA (413) 772-6217 (413) 584 3716 PHONE DATE TO: Sikorski,David & Joannie 413 - 247 - 0016 7/7/2011 171 Main St. JOB NAME / LOCATION Hatfield, Ma 01038 41 Locust Street Florence, Ma 01062 JOB NUMBER JOB PHONE We hereby submit specifications and estimates for: - Supply & install 02 pair of white cathedral louvered shutters from Girardin. (01 Pair to the upper right side rear window where missing and 01 pair to the left lower side window where missing). Service Fee: $250.00 cost of permit and disposal of job related refuse to be added to final price. We Propose hereby to furnish material and labor — complete in accordance with the above specifications, for the sum of: Four Thousand Three Hundred Eighty Five and 00 /100 Dollars dollars($ 4,385.00 ). Payment to be made as follows: $500.00 DEPOSIT upon acceptance. Balance in full upon completion. An interest charge of 2% per month(24% per annum) on past due balances,plus call costs, including reasonable attorney's fees,inrurred in rollerting any stems owed. All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from above specifics- Authorized tions involving extra costs will be executed only upon written orders, and will become an Signature extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado, and other necessary insurance. Note: This proposal may be Our workers are fully covered by Worker's Compensation insurance. withdraw • • if not ac d within /30 days. Acceptance of Proposal — The above prices, specifications and „ conditions are satisfactory and are hereby accepted. You are authorized to do the work Signature 4 � / as specified. Payment will be made as outlined above. / ? i 6 1 / Signature Date of Acceptance: f � I U l • . PROPOSAL 49 The Jubb Co., Inc. d.b.a. LARRY JUBB'S MA Registration 100001 MA Cons. Sup. Lic. 055333 Page 1 of 2 IMPROVE- A- HOMETM 7 Devens Street P.O. Box 51 P.O. Box 429 Hatfield, MA 01038 Greenfield, MA 01302 -0429 Northampton, MA (413) 772 -6217 (413) 584-3716 PHONE DATE TO: Sikorski,David & Joannie 413- 247 -0016 7/7/2011 JOB NAME / LOCATION 171 Main St. Hatfield, Ma 01038 41 Locust Street Florence, Ma 01062 JOB NUMBER JOB PHONE We hereby submit specifications and estimates for Description: ,,t1 3 , ( :� - 7�zi !/ -To install a custom white vinyl sunburst with 1/2 round white vent to the front facing gable over the fro t entry roof of the left building. -Cover approximately 387' of painted (not presently covered with siding) soffits with white vented vinyl soffit material. -Cover approximately 387' of painted (not presently covered with siding) fascias with custom white baked enamel aluminum. - Cover approximately 20' of fascia to the upper right front section where missing with custom white baked enamel aluminum. -Cover approximately 47' of freeze board to the left front corner and to the left side wall with white baked enamel custom aluminum. To install horizontal battens prior to covering with aluminum so as to provide a stabilizing effect for the aluminum due to the overall width. (less wrinkling of aluminum) - Cover (replace) approximately 22' of white custom aluminum at the front carport area ceiling where presently damaged. - Take 01 existing single shutter from the right side upper rear and install it to the front right window where 01 shutter is missing. We Propose hereby to furnish material and labor — complete in accordance with the above specifications, for the sum of: Cont ' d dollars ($ Cont ' d )• Payment to be made as follows: $500.00 DEPOSIT upon acceptance. Balance in full upon completion. An interest charge of 2% per month(24% per annum) on past due balances,plus call costs, including reasonable attnrnPy's fePS,inriirred in collPrting any slims owed. All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from above specifica- Authorized tions involving extra costs will be executed only upon written orders, and will become an Signature extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado, and other necessary insurance. Note: This proposal may be Our workers are fully covered by Worker's Compensation insurance. withdrawn . if not acce .-within 3 0 days. ' Acceptance of Proposal — The above prices, specifications and / , conditions are satisfactory and are hereby accepted. You are authorized to do the work Signature / as specified. Payment will be made as outlined above. I g , a0 1 / Signature Date of Acceptance: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: /j (� Not Applicable 0 Name of License Holder : / ; f /, 77(k. /U �(,�j J � es License Number u 16 c /2 f 6- ,4111? Address Expiration Date ._..e.12-1'1Z-C-Z-69Ci, Signature Telephone 9. Registered Home I • ro eme Ctintractor. Not Applicable 0 v � ), loo / Company Name Registration Number pc; 136 ci2c? ( )71 , -- Address ,, Expiration Datte 1 •( Telephone - 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors i] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [(] Slding Other [0] Brief Description of Proposed,,__ --- -" Work: - -. � (15� - out. ,c;L V 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 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 1, , 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. Pri Name - Sig rt e - et/Agent Date 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) ft of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO O DONT KNOW 0 YES IF YES, date issued:! IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O 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 O NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • • RECC� v • Department use only City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit AUG -- 2 2011 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability OEM OF eutnpro Ecmo,li No rthampton, MA 01060 Two Sets of Structural Plans NORTHAMPTON. MA 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 J // J` 3J L / Map Lot Unit -,c . a „ d% cii e Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 er of Record: r r l,itr/ ) JO ,7 �I c.,,,, J ) ti Jli r< . Name (Print) Current Mailing Ad Signatur A `.— Telephone 2.2 Authorized Ascent: Jc ,% i) C J(1- 1' L47 :, WY Name (Print) Current Mailing Address: .. 7l Si ture / , Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS l 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) Z/,. `Yc 6U _ Check Number / 4 4:5- / This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissionedlnspectorof Buildings Date 41 LOCUST ST BP- 2012 -0157 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23B - 044 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: vinyl siding BUILDING PERMIT Permit # BP- 2012 -0157 Project # JS- 2012- 000227 Est. Cost: $4385.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THE JUBB CO INC 055333 Lot Size(sq. ft.): 23435.28 Owner: SIKORSKI DAVID & JOANNE Zoning: NB(100)/ Applicant: THE JUBB CO INC AT: 41 LOCUST ST Applicant Address: Phone: Insurance: P 0 Box 429 (413) 772 -6217 Workers Compensation GREENFIELDMA01302 ISSUED ON:8/9/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: I NSTALL SIDING 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 8/9/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner