17A-048 (5) sTUR0,Y
HOME IMPROVEMENT
WORCESTER SPRINGFIELD HARTFORD
459 MAIN STREET-P.O.BOX 51033-SPRINGFIELD,MA 01151
MA.REG#151711 CT.REG#601525
1-877-3-STURDY 508-797-6600 413-543-5906 FAX 413-543-3200
OWNER PERMIT AUTHORIZATION
Name: a ,
Address: �'-
v
City/ State /Zip: (o z
I 1 (Owner), of the property located at:
hob PwAA.-e d2d . Fjoj b pN« authorize Sturdy Home Improvement
Inc. to act as my agent for the construction project taking place at the above
address. I also authorize Sturdy Home Improvement Inc. to obtain a building
permit. I understand and accept responsibility to comply with all regulations and
required inspections.
Signature of Owner:_ Date:
Page 1 of 1
���®� Toll Free(877)3-STURDY All home improvement contractors and subcontractors
Springfield(413)543-1681 engaged in home improvement contracting,unless specifi-
Worcester(508)797-6600 rally exempt from registration by Provisions of Chapter 142A
'TOTAL HOME e.com RENOVATION New Haven(203)848-2118 of the general taws, must be registered w'i$i the
www.SturdyHome.com
159 Main St.•Indian Orchard,MA 01151 Fax(413)543-3200 Commonwealth of Massachusetts.Inquiries about mg'LSh'a.
0.Box 51033•Indian Orchard,MA 01151 lion and status Should be made to the Director, Home
IA REG.#151711 Member Better Business Bureau Improvement Contract Registration,
T REG.#601525 Fully Licensed&Insured One Ashburton Place,Room 1301,Boston,MA 02108
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ubmitted to: +�; 7 of '' L rn L� / (617)727-8598
rt !'Ct_� (n��i1 PHONE �G D %
1 WORK
Ve hereby submit specifications and estimates for work to be performed and materials to be used:
To
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WORK SCHEDULE
Contractor will not begin the work or order the materials before the third day following the signing of this Agreement,unless specified herein.Contractor will begin the work on or about
(date).Barring delay caused by circumstances beyond Contractor's control,the work will be completed by (data).The Owner hereby acknowledges
and agrees that the scheduling dates are approximate and that such delays that are not avoldable by the Contractor including,but not limited to strikes,Acts of God,shortages of materi-
als,accidents,and all other delays beyond its control,shall not be considered as violations of this Agreement.
WARRANTY
The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for 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 subcontractors,employees or agents,is discovered
after completion of any job,including cleanup,the Contractor shall,at its awn expense,forthwith remedy,repair,correct,replace,or cause to be remedied,repaired or replaced,such dam-
age or such defect in materials and workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work.
We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of'. (�
// ff // / Cs',
Laic TYL'✓_ X'A dollars($ I•
Paymentto be made as follows: —,Ili—/ n
G^ upon sig In con J�'
(S STURDY HOME IMPROVEMENT,INC.
C; + ct;
Name of Contractor/Designated Registrant
on a 51n33
_A($ � -2-C C' 1 upon start of work; Street Address '
_*/6(s 3
2�--1.. 1 uponcowWotiat+of �l„�-. Indian Orchard MA 01151 413-543-1681
' City/State Phone
(S T_ + - 1 shall be made forthwith upon /
completion of work under this contract. _Z3
G �✓�(�
Name of Salesman
Authorized Signature
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 it 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 that accompanies this contract;con-
tents of which are referred to above and incorporated herein by reference.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Signature s,�-IL' r /' r L! Date J > Signature Date
City of Northampton 212 Main Street,Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit 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 defined by MGL c 111 , S 150A.
Address of the work:
The debris will be transported by:
The debris will be received by: �i Yl Y1 C
3 2 �,-�+c.l�� S1—v-�•2-r-,rtg a-�Czrn , Ita�,o�ao
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
kvi Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: C�I i5 Phone #: j
Aran employer? Check the appropriate box: Type of project(required):
1. m a emp loyer with R 4. ❑ 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. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers'
9. E] Building addition
[No workers' comp. insurance comp, insurance.$
required.] 5. ❑ 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.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §l(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 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.
$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. If the 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:
Policy#or Self-ins. Lie. #: 3619 5YCK-- I D Expiration Date:
Job Site Address: �,� 1�1(�f ! Ci City/State/Zip: - _ rerra k7r, C 6x)
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Si nature: Date:
Phone
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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction SSu/p�ervisor: Not Applicable ❑
Name of License Holder: ,JWk% I d
License Number
Lf
Add r Expiration ate
r 413
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
ear_ '�,� -�� 1 ►��r�s��e �� s ���-7 1 i
Companv Name. Registration Number
L��r ri S-4 S ►to an ox-c Ka . ►� - � ) 'Z�i i
Address ,, ii Expiratio Date
Telephone O )3L�/73"�
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....... n 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Ef
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[ ] Other[a
Brief De ription of Proposed
Work: trnG:: i � :r n tr�c� l'om me b a c K zi t&m sc Reps
Sid � oe or►-►-,
Alteration of exis' g bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.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, C*1(NA S4at/] (Yl ' as Owner of the subject
property
I'
hereby authorize ➢
to act on my behalf, in all matters relative tojmork authorized by this buil ing permit application.
Signature of Owner Date
I, m-ord Q k'M C_ imp l JV J` Dl(,,(J 1 1. '/ 1J ^(.Ae—" ,as Owner/Authorized
Agent hereby declareAhat the statements and inf rmation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signe n the pains and p na It.es ury.
/ r �
/ CJ
Pri
Signature of Owner/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 _I
Side Ll R: _ L: . R:i. . _
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/Findin ever been issued for/on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Re istry of Deeds?
NO 0 DON'T KNOW YES 0
IF YES: enter Book Page= and/or Document#`
B. Does the site contain a brook, body of water or wetlands? NO 0 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 0 Obtained ® , Date Issued:
C. Do any signs exist on the property? YES Q 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 Q 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 0 NO C)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
�r7 Department use only
U City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
OCT 6 is 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
C,Plumbing&Gas In
Northampton,,AAI1 01
s ne 3-587-1240 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
ocao Map Lot Unit
J" Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
C! i+r)y1Akn[rn�Sleu
Name(Print) Current /a" g Addres
Telephone ``l
Signature
2.2 Authorized Agent:
Name p Current Mailing Address:
403--543
Sig Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit 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) CO Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
160 BRIDGE RD BP-2016-0465
GIs#: COMMONWEALTH OF MASSACHUSETTS
Man.Block: 17A-048 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2016-0465
Project# JS-2016-000767
Est. Cost: $8000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STURDY HOME IMPROVEMENT 093603
Lot Size(sq.ft.): 11107.80 Owner: WALMSLEY CATHERINE A
Zoning: RI(100)/uRA(100) Applicant. STURDY HOME IMPROVEMENT
AT. 160 BRIDGE RD
Applicant Address: Phone: Insurance:
P O BOX 51033 (413) 543-5906 WC
INDIAN ORCHARDMA01151 ISSUED ON:10 1612015 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 8 SQ ROOFING & REPLACE
SIDING ON DORMERS
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 10/6/2015 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner