31B-154 (2) The Commonwealth of Massachusetts
a Department of Industrial Accidents
1 1 4 -
=;? Office of Investigations
1;1! 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual); VI 54 - C't }'n(V 3 f j g
Address: v1', ���'. �-
City /State /Zip: 1 • iJ 4 " hone #: _ 0 `f
Are you an employer? Check the appropriate box: Type of project (required):
1. I am a employer with' 4. fl I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction
2. ❑ I am a sole proprietor or partner listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub - contractors have 8. 0 Demolition
for me in any capacity. employees and have workers'
working Y P ty 9. 0 Building addition
No workers' comp. insurance comp. insurance.*
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers'
13.(71 Other PL } rG�C
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
f 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 state whether or not those entities have
employees. lithe sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ` ` C' c T ,rye . 3..e r)C i
Policy # or Self -ins. Lic. #: _LA 1 ( . - ( 2 )) 3 & 9 d R Expiration Date: `sl <-4(7)1
Job Site Address: 1 ��l? ' ' E' h - e - f' 4- City /State /Zip;NQyCkhwy\F - t Yl y )
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 certi t under the pains and penalties of perjury that the information provided above is true and correct
Sit ature: . .ate. .41 Date: C
Phone #: ! I J — 0
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 #:
CERTIFICATE OF LIABILITY INSURANCE DATE(MMDDIYYYY)
05/05/2011
THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMP RTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(tea) must be endorsed. If SUBROGATION i3 WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in Lieu of such endorsement(s).
PRODUCER LONTAcT WILLIAM MIS
WILLIAM J MIS INSURANCE AGENCY PHONE 413 -568 -6111 FAX 413- 572 -9191
156 ELM ST INC, eMl: (Alt, Nn):
ADDRESS: BILL @BILLMI3INSURAPTCE , COM
WESTFIELD, MA 01085 PRODUCER
CUSTOMER IDS:
INSURERS) AFFORDING COVERAGE NAIC 0
INSURED saunaa *ARBELLA PROTECTION
SAMBRICO LLC DBA
INSURER BLIBERTY MUTUAL
VISTA ROME IMPROVEMENT INSURER C :
- --
244 ELM ST --- - - -- - - - - -_ __ _- --- - - - - - --- .,_._- -- —
INSURER D : _ —
WEST SPRINGFIELD MA 01089 INSURERE.1
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR i ADDL SUER I 1 POLICY EFF POLICY EXP ' -- _ —..-- —
LTR TYPE OF INSURANCE I pdSR WVD i POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) LIMITS
GENERAL LABILITY EACH OCCURRENCE $2,000,000
DAMALse 1O Hell i eD
A X _COMMERCIAL GENERAL UABIUTY 8500041702 '12/12/ 201012 /12/2011 PREMISES (Eaacalarenee) $100,000
CLAIMS-MADE ( 1 OCCUR MED EXP (Any one person) $ 5,000
I I i PERSONALS ADV INJURY $2,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE. LIMIT APPLIES PER: PRODUCTS • COMP/OP AGG $ 2 , 000 , 000
—1 POLICY 1 JE I LOC $
AUTOMOBILE UABILTTY COMBINED SINGLE LIMIT $
._._.._ (Ea accident)
ANY AUTO
-- BODILY INJURY (Per person) 0
ALL OWNED AUTOS
BODILY INJURY (Per accident) 0
SCHEDULED AUTOS
PROPERTY DAMAGE $
HIRED AUTOS (Per accident)
NON-OWNED AUTOS $
$
UMBRELLA UAB OCCUR ` EACH OCCURRENCE I $
EXCESSLIAB CLAIMS -MADE - AGGREGATE $
DEDUCTIBLE i $
RETENTION $ f $
WORKERS COMPENSATION X I T WC S TA
AND EMPLOYERS' URBRJTY Y / N —_`- T ----- L ER
B ANY PROPRIETOR/PARTNER/EXECUTIVE ^11 WC1 -31S- 372839 -011 ' 05/05/2011 05/05 /2012 Et. EACH ACCtDENT $ 100,000
OPFICERJMEMBER EXCLUDED? N / A
(Mandatory In NH) E.l_ DISEASE - EA EMPLOYEE $ 100,000
HYea descA6e render t — ._—. -----
DESCRIPTION OF OPERATIONS below 1 E.L. DISEASE - POLICY LIMIT $ 500 , 000
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, I more space is required)
CERTIFICATE HOLDER CANCELLATION
SAMBRICO LLC
SHOULD ANY OF E ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
DBA VISTA HOME IMPROVEMENT THE EXPIRATIO, . ATE THEREOF, NOTICE WILL BE DELIVERED IN
244 ELM ST ACCORDANCE WITH TH POU PROVISIONS.
WEST SPRINGFIELD MA 01089 AUTHORIZEOREPRES ' ,
4
1
@11988 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered ma s . A ''RD
fi Page No. of Pages
Vropo5ar
COLOR WIDTH
CT. REG. NO. 0621848 VISTA HOME IMPROVEMENT
MA REG. NO. 162058 1346 Elm Street
West Springfield, MA 01089 INSULATION
Toll Free: 1-888-597-2323 • Local: 413- 382 -0249
FAX: 413 -382 -0241
Proposal Submitted To Homeowner Work To Be Performed At
Name *s
Street _
r f
Street - » r —__ City . . State --- _-____
City State Date of Plans
Date Telephone
r t . r
We hereby submit specifications and estimates for: ° I.
t ,
= x
s w
. t 7 to
'
T v
" _ ` x � � v\
,
Date work will start Date work will be completed
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from the
above specifications must be made in writing on an Add -on /Modification of Contract form and may become an extra charge over and above the amount stated herein.
This agreement is contingent upon delays beyond our control. Owners to carry fire, tornado and other necessary insurance. Our workers are fully covered by
Workmen's Compensation Insurance. Homeowner agrees to pay for all work as set forth below. If the homeowner defaults, homeowner agrees to pay all costs of col-
lection, including reasonable attorneys fees, in addition to other damages incurred by contractor. An 18% per month service charge will be assessed for all payments
not made within 10 days of due date per the schedule below:
f propo5C hereby to furnish material and labor_- complete in accordance with the above specifications, for the sum of:
Said amount shall be pfiS °'ptlow
Note: This proposal may be withdrawn by us if not accepted within _ ., .) days.
YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE
DAY OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FOR AN EXPLANATION OF THIS RIGHT. (SATURDAY
IS A LEGAL BUSINESS DAY IN CONNECTICUT.) THIS SALE IS SUBJECT TO THE PROVISIONS OF THE HOME SOLICITATION SALES
ACT AND THE HOME IMPROVEMENT ACT. THIS INSTRUMENT IS NOT NEGOTIABLE.
Sign tore of Contractor or authorized representative :". 4 `""
*(1/We) have read the terms stated ierein, they have been explained to (me /us), and (I/We) find them to be satisfactory and hereby
accept them. a,'
- r
Signature of Homeowner(s): l "° X
NOTICE OF CANCELLATION Date of Transaction
YOU MAY CANCEL THIS TRANSACTION, WITHOUT ANY PENALTY OR OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE ABOVE
DATE, IF YOU CANCEL, ANDY PROPERTY TRADED IN, ANDY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE, AND ANY
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : CA F %�;� ` c� • (L b V)00 - TS
License Number
L l2 C � v -•* 't t, ∎e 1 )
. ess Expiration Date
/ ._..
.1. . re Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name I Registration Number
Address // Ex ratio Date
Telephone `113 "5Oc?GGll `c)tr1
—
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 ❑
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 %'_r 'c��C'Q--
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding L. ,r] Other [0]
Brief Description of Proposed y e ,�' bect
Work: ( - �� L�� s 5h r� wA)11 5 1 fl �Q 11 c� Y i p �c e , Ice A- (mac...{ - er ,
flew 3An (n I B PS
Alteration of existing bedroom Yes I No Adding new bedroom Yes No •
Attached Narrative Renovating unfinished basement Yes 4_No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family iC 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,`CNC\. G4 j Y') , as Owner of the subject
property
hereby authorize l S f' �`�l� - 8 CY1 �� /✓v �_> ��
to act on my behalf, in all matters relative to work authorized by this buildinl permit application.
0.-C) --- //a-ci/a-01/
Signature of Owner Date
Q U c r1 e V -e Vt ( Its Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application ale true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
JP, , 1 (
ature of Owner /A.ent 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)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page, and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO o DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
G Department use only
Q► �� City of Northampton Status of Permit:
'�` • Q�" ' uilding Department Curb Cut/Driveway Permit
AV" i 212 Main Street Sewer /Septic Availability
�.� c,.0 � c'� Room 100 Water/Well Availability
dFw' 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
! '3 T'L) rrNOVE 54Y -r-e Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) j Cur nt Mailin Address:
Telephone
Signature
2.2 Authorized Agent: (�
'i^ Cs eUc\\ - t f 14) Ilerme to-fpc (A) ?ri
Name (Print) Current Mailing Address:
`//3 - .��
nature 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 ID
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection c
6. Total = (1 + 2 + 3 + 4 + 5) Co 9 � Q Check Number /5,>25— c. 357 �
;
This Section For Official Use Only
Building Permit Number: I s
g Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
13 TRUMBULL RD BP- 2012 -0140
GIS #: COIF` "4WEALTH OF MASSACHUSETTS
Map:Block: 31B - 154 CITY OF NORTHAMPTON
Lot: -001 PERSONS CO Q: :NG WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACC - O THE GUARANTY FUND (MGL c.142A)
Category: ROOF UILDING PERMIT
Permit # BP- 2012 -0140
Project # JS- 2012 - 000205
Est. Cost: $6950.00
Fee: $35.00 PERMISS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VISTA HOME VEMENT 100079
Lot Size(sq. ft.): 12719.52 Owner: sTITP L & BARRY S GOLDS
Zoning: URC(100)/ Applicant: V. ME IMPROVEMENT
AT: 13 TRU ,D
Applicant Address: Phone: Insurance:
1346 ELM ST 1) 382 -0249 WC
WEST SPRINGFIELDMA01089 ISSUED ON :8/4/2011 0 :00 :00
TO PERFORM THE FOLLOWING 1 ' RIP &SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FRO "BEET
Inspector of Plumbing Inspector of Wiring Building Inspector
Underground: Service:
Footings:
Rough: Rough: Foundation:
=ival:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY TII OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy .ature:
FeeType: Date Paid: Ar
Building 8/4/2011 0:00:00 $3
212 Main Street, Phor -1240, Fax: (413) 587 -1272
Louis Hash! ling Commissioner