15B-046 U (Z. (.v
A 0 �. 1.
The C'unurtuurvcul!lt of Massachusetts (� l .'1 � � I � % I ' �
_ Department r of Industrial Accidents
it ft Office of Investigations
_�Tr:= 600 Washington Street •
• t C Boston, Mil 02111
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Lctlibl'
Name ( Business /Organizatiun/individual): 1 ..) r A _L. to Co ., _!--t,,.c_ , •
Address: t' • D . nJ..ox ±-)_._9
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City /Stale /Zip: ��- v -4e4 d MA- 01 3 0 2_111w ic II: - 7 2- -6 2.1 — 1
Are ou an employer? Check the appropriate box: Type of project (required):
1. 1 am a employer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction
employees (full and/or part - tithe).* have hired the sub - contractors
2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. i 7. ❑ Rernodcling
ship and have no employees 'These sub - contractors have 8. ❑ Demolition
working for nno in any capacity. workers' comp. insurance. 9• ❑ Building addition
[No workers' comp. insurance 5. 0 We arc a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3. ❑ 1 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 Ksof repairs
insurance required.] t employees. [No workers' 13. Otltcr
comp. insurance required.]
*Any applicant that chucks box 111 must also fill out the section below showing their workers' compensation policy information.
t 1 lomcowncrs 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 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: �--.. - Ait ( t..-4U • /
Policy li or Self -ins. Lic. #: e-vJC. 0 A 9 44 i Expiration Date: Jl?5/ 0
Job Site Address: 62 ( � - t -- • City /State/Zip: 1- -ee-�5 M A d I OS 3
Attach a copy of the workers' conrpensatl 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 itnprisonnnnent, as well as civil penalties in the forth 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 pair nd Wallies of perjury that the information provided above is true and correct.
r.
Signature: it — iz ' T Date: ? /2-41
Phone ? 7 2 a 2-1
r
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit /Liccosc ll
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 11:
PROPOSAL
The Jubb Co., Inc. d.b.a.
LARRY JUBB'S MA Registration 100001
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
PHONE DATE
TO: O'Brien, -Lee#e I-es (e j- 584 -2565 06/12/07
610 Spring Street JOB NAME / LOCATION
Leeds, Ma. 01053 610 Spring Street
Leeds, Ma. 01053
JOB NUMBER JOB PHONE
J� 17 5o0
We hereby submit specifications and estimates for:
- SUPPLY & INSTALL NATIONAL VINYL PRODUCTS "DESTINY SERIES" VINYL REPLACEMENT WINDOWS-
- welded sashes & frame. -heavy duty block & tackle balance system.
-7/8" thermo glass with super spacer. -tilt - in sahses for easy cleaning. n I ,
-full screens (double hung only) -true sloped sill for water run off. f -Gd •
- interlocking meeting rail. -dual night latches. - 772_4/ 0
-twin cam locks on windows @ 28" or wider. - energy star rated low -e- glass.
-20 year manufacture guarantee on glass seal. - Health Smart Glass system. 4 / . rt.)
- lifetime manufactures guarantee on vinyl window frame & parts. -labor guarantee as required by MA. BBRS.
COLOR: white interior windows with unfinished head, seat & Jambs. 30
NUMBER OF UNITS REPLACED AND STYLE: 01 @ 30 degree angle bay with 22" wide double hung flankers.
GRID CONFIGURATION: grids to all glass lites
LOW - E - GLASS: yes ARGON GLASS: no
STORM WINDOW REMOVAL: n /a. ALUMINUM CLAD EXTERIOR CASING: yes. white customized baked enamel
OTHER /NOTE: we will install new interior trim that is wider than the existing trim. new trim will be same style, which is clam shell.
width to be 3-1/2" instead of 2 -1/2 ". The head, seat and jamb are to be stained and properly preserved with urethane, minimum 4
cotes. this is the owners responsibility. all exterior finish work to be done by Jubb. there will not be a roof. we will install window
under present soffit overhang.
SERVICE FEE: $125.00 (includes permit & disposal of all job related refuse)
[service fee amount not included in total below and will be added to final invoice.]
We Propose hereby to furnish material and labor — complete in accordance with the above specifications, for the sum of:
Two Thousand Nine Hundred Sixty Four and 00/100 Dollars dollars ($ 2,964.00 ).
Payment to be made as follows:
1/3 DEPOSIT UPON ACCEPTANCE. ALL INVOICES ARE DUE UPON RECEIPT. An interest charge of 2% per month (24% per
annum) on past due invoives, 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. Any alteration or deviation from above specifiea- Authorized
lions 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, tomado, and other necessary insurance. Note: This • "posal m be
Our workers are fully covered by Worker's Compensation insurance. withdrawn by us if not accepted 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 fix' 01 (
as specified. Payment will be made as outlined above.
Signature
Date of Acceptance: 1( t 0 (n'I
PRODUCT ism FOLD AT(,) TO FIT COMPANION 771 DU -U -VUE ENVELOPE. NFRR To Reorder: 1-800-225-6380 or www.nehT nom PRINTED INU.8.A B
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y! AILI r�'1l",. 411 1; iu('i �I I I
S EGTIONIB•r •• � C r 0 � NS bf R � UCTI0 SERVICES -\s'
8.1 Licensed Construction Supervisor: A Not Applicable ❑
Name of License Holder : is i �'�1n C 2� H • J `J� °G5 3
/ / License Number
PO A 4 — � � C� �,- ��,►� - � ,ei AA of 3O s �j OL o /0
Address Expiratio Date
7 —Co 2—C
• Signature Telephone
„,,,, M T ,— •.: i• , ct 77 1 0 ��i'� g a Not Applicable
�' '' �""i" ' . ' � I � � i e 1 i • • v � m e n ;. i r r . • Y .h� ^i�� ;'�; j .G° + '.�' . �tio:a.:ILi�a� u1 r� o
1 - J L t 100001
Company Name / Registration " Number
,
'Address Expiration Date
GY024'v e,(4 AA- Ps
0 l30`2 Telephone --(o2-t.
ISET�Otu�r . „1 R. ORKE,RSIOMN,ENSATION I (M.G.L. c: 152, § 25C(6))
�a. ;n � sta „11 ,.
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affid:
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes No ❑
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i n4. 'U o m a @wrier” . 'e m:p ioli
The current exemption for "homeowners” was extended to include Owner occupied Dwellings of one (1) or two(2) famili
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner act:
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(
• 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
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SECTION S= (DESCRIPTION OF�PROPOSEDIWORK ((check +a 'f,r�j
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f.W4N49avj , 414(. I.. jGpli",' u4h�fn , "iP ?',Br'ry+tAlY'YINCI4 ?Ki I'/.4.. AS r4t'1: •d. .M ^ +h "r1+ +pin ^["r?4:YP:r• 1,"t•VT'.S'1•V7. .. • , • ._
New House ❑ Addition ❑ Replacen ent Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: 17 (t LA_ t LA JO ti3
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll o - Sheet 0
p- ot f UWiliouse?and�o'r aiidifion "t`o'�ezis'firigfliou'si rig; °corTiplet - 6U Fi o11biAi g:
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?
1. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck 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
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
A6 t rk; t a , .;'r i 4.1 � -:+: r rf l •, 1 'c
E }S ECTt1,0 * N POO PI .Y .0 ,Ip sGO,MPLETED' •WHEN •
Q G 4 E(JT9O I R1CO . �N 10,, PLI
1, , as Owner of the subject prope
hereby authorize to ac
my behalf, in all matters relative to work authorized by this building permit application.
(/U c - C t.�.,'iv
Signature of Owner Date
•
1. A • ' 7 - 0 - 6 " Piet. • , as Owner /Authorized Agent
hereby declare that the statements and informartion on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
A- . - -TuJoL ...J J
Print Name
7b -4-- O 7
Signature of Owner /Agent Date
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PtibrI 4P-587-1240 Fax 413-587-1272 .4 '''• e r.,- _
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• APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
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SECTIPN`12 •
2.1 Owner of Record:
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Name (Print) Current Mailin Addr4
• Telephone
Signature .
2.2 Authorized Agent: •
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L.,..-lob
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Name (Print)..„ . . . r Current Mailing Address: . / c i 302_
Signature • Telephone
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Item Estimated Cost (Dollars) to be :,,.... ...: .,,:.;::, • ..., .,.;;;;ii,i),D ;;
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1. Building , (a)'Building . !Permitifee,...,!. • . !i ;.. .:.,., .,. :,,'• :,•1• ,
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2. Electrical . (b) Estimated Total; • .,:,•• .:, , i. .: 1. . ,,,1 •
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3. Plumbing 'Building PermitTee.!.','•'::
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6. Total = (1 + 2 + 3 +4 + 5) Zt; a l q (...: 4 c C) Check Number . .. ..,.. . :'
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BP- 2008 -0097
GIS #: COMMONWEALTH OF MASSACHUSETTS
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 -0097
Project # JS- 2008 - 000150
Est. Cost: $2964.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THE JUBB CO INC 100001
Lot Size(sq. ft.): 29664.36 Owner: O'BRIEN LESLEY J
Zoning: URA Applicant: THE JUBB CO INC
AT: 610 SPRING ST
Applicant Address: Phone: Insurance:
P O Box 429 (413) 772 -6217 Workers
Compensation
GREENFIELDMA01 ISSUED ON:7/27/2007 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOW
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 7/27/2007 0:00:00 $25.0010045
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo