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J.Tinnereflo Waste
32 Ceniury Sneer
:Pwafln, MA 01001
Phone & E-mail A
(4 13)455-1672-Local
i ne t,ommonweatm of tnasaucnuseres
)Department of Indusbial Accidents
Office of.Investigations
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass govldia
Workers'Compensation Insurance Affidavit:Bndders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Busineworgmizatiowla&viduaD"Ic' o° �Aam e. -ZMD=1aM,, Ct TYIC'
Address: ?Sa.
City/State/Zip: o1o/nn Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
!Yt
1. l am a employer with IT .4. []I am a general contractor and I b- 0 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. 7- ❑Remodeling
ship and have no employees These sub-contractors have $. Demolition
working or me in act employees and have workers'
rking any capacity 4. Building addition.
[No workers' comp.msumee C°mP-insuranceJ
req�ired,1 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 1 LQ Plumbing repairs or additions
myself [No workers'camp right of exemption per MGL 12_ Roof repairs
insurance requhr&]t c. 152,§1(4),and we have no
employees. [No workers' 13.n Other
comp.insurance required.)
*Any apphcaatthat checks box#1 must also fill oar the section below showing their maAere compensationpolicy iufouam ion.
f Homeowners who submkthis affidavitiu&c adogthey are doing all work and then hire outside contactors mast submit anew affidavit indicating such.
#Contactors that check this box mast attached an additional shed showing thename of the sub-contactors and state whetheror not those endues)rave
employees. if the sab-o omhaveen4&yms,.theymustprovWethen'workers'comp•pohcymnnber.
I am an employer that is providing workers'compensation insurance far my employees Below is the policy and job site
information.
Insurance Company Name: h it-iA * 0 1,��nnnln Tr--
Policy#or Self-ins.Lie.#: S A(t(1 0 1?I' (A 13 Fxpiration Date 5�S��
Job Site Address: �-V �/ ST/�1 � 1�T 5 City/Statel ip: Q C "14 G IQ, 2
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 ofthe DIA for insurance coverage verification.
I do hereby ce=111-C and penalties ofperjury that the information provided above is true and correct
s tore: -----—~� Date: 141
Phone#: r`
use only. Do not write in this area,to be completed by city or town ojyk aL
City or Town: PermidUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3=M+ty/Town Clerk 4,Electrical Spector 5.Plumbing Inspector
6.der
C"t ct Person: Phone#•
u INaucr uratau LJ rtuur install
Soffit Covered es 0No Color Storm Door []Yes
Soffit Vented Tyes ❑ #No Type oloo
r Entry Door
Fascia Covered Aes ONO Color Entry Door DYeS folor o
Rakes Covered es 0No Color # _ Type
Contrasting Corners
Ty es 0No Color Shutters S -
Repair Rotted wood (not sheathing) es 0No #Pairs Raised anel
Location Porch Ceiling E]Yes N Color
tvC; Porch Inside Walls []Yes o Color
Windows Glass Screens Color GRIDS Fixtures
Qty. Bran S 2 Pane ane ption Half uii nside Exterior yout Style Style
Special/nstructions 1613 &00 l 1:0A/d'd-Zth'2 - AI .lh j F& 36 DAvS
f i 3 e e'`.d tc^ 19 Ks AD
DO Not DO 12 10 t.r We do not do any painting or staining
WORK SCHEDULE
Con r will not begin the work or order the materials before the third day following the signing of this Agreement,unless spec Pied rein, 9Mactor will begin the work on or abor
(date).Barring delay caused by circumstances beyond Contractor's control,the work will be completed by� zp;���it ate).The Owner hereby acknowledge
an agree that a scheduling dates are approximate and that such delays that are not avoidable by the Contractor including, ut n f rI ed to strikes,Acts of God,shortages c
materials,accidents,and all other delays beyond Its control,shall not be considered as violations of this Agreement. _
WARRANTY •/�' �L' ���.
The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship fo a period of ollowing completion and shall comp[
with the requirements of this Agreement.In the event any defect in workmanship or materials,or damage caused by the Contractor,its s tractors,employees or agents,is discoverer
after completion of any job,Including cleanup,the Contractor shall,at Its own expense,forthwith remedy,repair,correct,replace,or cause to be remedied,repaired or replace),sucl
damage or such defect in materials and workmanship.The foregoing warranties shall survive any inspection performed In connection with the agreed-upon work.
YHI agrees to perform the work,furnish the material and labor specified above for the total sum of:
(s upon signing contract; Name of Representative
Authorized Signature
($ I upon completion of
t
upon completion of
_Jkoj
Notice:No agreement for home improvement contracting work shall require a down payment(advance
f ° deposit)of more than one-third of the total contract price or the total amount of all deposits or payments
;°($ shall be made forthwith upon which the contractor must make,in advance,to order and/or otherwise obtain delivery of special order
completion of work under this Contract. materials and equipment,whichever amount is greater,
Acceptance of Proposal I have read both sides of this document and accept the prices,specifications and conditions stated.I understand that upon
signing,this proposal becomes a binding contract.You are authorized to do the work as specified.Payment will be made as outlined above.
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the Seller, which may be his main office or
branch thereof,provided you notify the Seller in writing at his main office or branch by ordinary mail posted,by telegram sent or by delivery,not later than
midnight of the third business day following the signing of this agreement. Please refer to the Notice of Cancellation below contents of which are referred
to above and incorporated herein by reference.
DO NOT SIGN'THIS CO TRACT IF THERE ARE ANY BLANK SPACES.
Signature ti ^Date
r gnature — — ✓ ??� �
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,
ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENT EXECUTED BY YOU WILL
BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE, AND ANY SECURITY INTEREST
ARISING OUT OF THE TRANSACTION WILL BE CANCELLED. TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS
CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO: YANKEE HOME IMPROVEMENT, INC., 82 INDUSTRIAL DR.,
NORTHAMF ,MA 01 NOT LATER THAN MIDNIGHT OF
$, '�✓j I HEREBY CANCEL THIS TRANSACTION
(Date.Sunda and hot' excluded) BUYERS SIGNATURE DATE
Buyer(s)acknowledge recei of two completely @led in copies of this notice on the date first above written hereof.
- � natures 'r- Buyer's Signature
Siding Agreement
Thousands of Satisfied Clients!
YANKEE 82 Industrial Drive MA Lic#160584 225 Cedar Hill St,Suite 200
Northampton, MA 01060 CT Lic#0673924 Marlborough,MA 01752
HOME IMPROVEMENT 413 341-5259 RI Lic#33382 877 88-YANKEE
The MOST Referred • • All home improvement contractors and subcontractors must be registered and any inquiries
England in New about a contractor or subcontractor relating to a registration should be directed to:
Office of Consumer Affairs and Business Regulation Ten Park Plaza,Suite 5170
WWW.YankeeHomelenc.com Boston,MA 02116 Phone:(617)973-8700
-: L /XA1 t All/Al Homeowner Information
Name Ste_Street Address A S-Zj�,�-S//71 City a e i tatod ip -02 ?-�
Home Phond� Work Phone Cell Phone E-Mail
Mailing Address (If different)
The Conhactora reel to do the fo/%win wor*for the Homeowner.
(DING Type—11,EL AW3 Color L1i - �C'J�4, Style G>p NU4 P
Removal of Existing Siding es ONO Yankee Ind.Sealant Yes o
Removal of Garage Siding es lo New Gutters ❑Yes o Color
Dumpster Yes ❑No :� New Downspouts ❑Yes No Color
Window Trim ❑ sided �4 Sided /�PV& Old Gutters Remove/Re-install Existing ❑ Dispose
Coil �VC ❑Flat Color-� Gutter protection ❑Yes 1)40
Gable Vents Wes ❑No Attic Energy Barrier ❑Yes yNo
J-Blocks Fwes ONO ❑ Rafter Install ❑ Floor Install
Soffit Covered es ONO Color Storm Door ❑Yes rolor Soffit Vented es []No No # Type Entry Door
Fascia Covered 'es ONO Color Entry Door ❑Yes No
Rakes Covered es []No Color # _ Type olor
Contrasting Corners
Ty
es ❑No Color I Shutters s AVo
Repair Rotted wood (not sheathing) CXes ❑No #Pairs Raised anel
Location AAtK keds7l2�4�L�'1�1 dle� grw-� Porch Ceiling []Yes N Color
Porch Inside Walls ❑Yes o Color
Windows Glass Screens Color GRIDS Fixtures
Qty. Bran S 2 Pane I J.Pane jOption Half 'Full Anside Exterior ,Layout Style Style
Special Instructions 16 ,6 hzw►'a ,4 -36:95 �% ° G 7 ��`"l ' LhAIA) 5141 i�' '�. �C 1�
} M �
j ,�
Do Not Do 'ZZ^" pjacr rc:l We do not do any painting or staining)
4C C OZ a 0
WORK SCHEDULE
Con r will not begin the work or order the materials before the third day following the signing of this Agreement,unless specified rei tractor will begin the work on or about
(date).Barring delay caused by circumstances beyond Contractor's control,the work will be completed by ate).The Owner hereby acknowledges
an agre that a scheduling dates are approximate and that such delays that are not avoidable by the Contractor including, n i ded to strikes,Acts of God, shortages of
materials,accidents,and all other delays beyond its control,shall not be considered as violations of this Agreement. / _
WARRANTY Ix G/
The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship lot a period of following completion and shall comply
with the requirements of this Agreement.In the event any defect in workmanship or materials,or damage caused by the Contractor,its subc%ractors,employees or agents,is discovered
after completion of any job,Including cleanup,the Contractor shall,at its own expense,forthwith remedy,repair,correct,replace,or cause to be remedied,repaired or replaced,such
damage or such defect in materials and workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work.
YHI agrees to perform the work,furnish the material and labor specified above for the total sum of: f ,
■■�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) es-o kgdu a 08 1� /c10l b
C-7 t-R AR Q QQ(V%I 1 v License Number Expiration Date
Name of CSL Holder
ea 141 L S,T n I L D n) vl� List CSL Type(see below)
M No.and Street 1/ IC IC Type Description
u UT M "T' A] U Unrestricted(Buildings u to 35,000 cu.f.)
V �
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
`x" 4—�41-SZ7 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
a YA ikEZ- 8096- IMPC 61AERE/l- diC HIC Registration N mber xpirat on Date
HIC Company mpany Name or HIC Registrant Name
�k -T&OLIETRYA�, '-�-
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6: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 .......... Rr No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize YAIJ K 9-�- HOME I R MOV 60WT WC.
to act on my behalf,in all matters relative to work authorized by this building permit application.
00 L0 7k'Ac---r
Print Owner's Name(Electronic Signature) Date
SECTION 71):OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information
contained in this applicati rue and accurate to the best of my knowledge and understanding.
Ll
Print Owner s'or A zed Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.inasL.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dam
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Iinclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
ah
J < The Commonwealth of Massachusetts
ev = Board of Building Regulations and Standards FOR
Li MUNICIPALITY
Massachusetts State Building Code,780 CMR
i CL USE
rj Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
r One-or Two-Family Dwelling
This Section For Official Use Only
ilding Permit Number: — Date Applied:
Building Official(Print Name) Signature Date
SECTION is SITE INFORMATION
1.1 _roper ddress: 1.2 Assessors Map&Parcel Numbers
, n
l.l a Is this an accepted street?yes no Map Number Parcel Number
I.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard � Side Yards Rear Yard
Required Prov=:ded _ Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 11.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zor,.e: Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 caner' f Rec rd:
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ 1 Existing Building CV1 Owner-Occupied `Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition 131 Accessory Bldg.❑
I Number of Units Other El Specify:
Brief Description of Proposed Work:':
I SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) y
1.Building $ 6 �� 1. Building Permit Fee:$ Indicate how fee is determined:
2_Electrical $ ❑Standard City/Town Application Fee
El Total Project Costa(Item 6)x multiplier x
3_Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ - Total All
Check NoV Check Amoun Cash Amount:
6_Total Project Cost: $ �� 0 paid in Full ❑Outstanding Balance Due:
50 HASTINGS HGTS BP-2014-1059
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-010 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Build'tng DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit# BP-2014-1059
Project# JS-2014-001819
Est.Cost: $16699.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: YANKEE HOME IMPROVEMENT INC 89442
Lot Size(sq. ft.): 13503.60 Owner: SKIBISKI JOHN F JR&ANN H
Zoning: RI(100)/URA(100)/WSP(100)/ Applicant: YANKEE HOME IMPROVEMENT INC
AT. 50 HASTINGS HGTS
Applicant Address: Phone: Insurance:
82 INDUSTRIAL DR UNIT 2 (413) 341-5259 O WC
NORTHAMPTONMAO1060 ISSUED ON:411512014 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE 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 4/15/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner