23B-044 (16) • 1 -
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.. • • AFFIDAVIT • '
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.• . 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
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• .• 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
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the said construction activity shalt be disposed of and I shall submit the .apploPriate fonpl far attachment
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. . • • Date — CT • r-- • / /
Signature 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
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Contact Person: Phone #:
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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
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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.
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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