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22D-102 Or ' . , Window World of Western Massachusetts MA HIC Reg. # Aw__/ his , I' 351 Walnut Street Extension • Agawam Phone (413) 786 -9900 • Fax , ax (815) 366 -8039 MA 01001 165641 WIP7 G _ / Air \ Construction Supervisors i/I�ICG www.windowworidofspringfield.com License # 57011 "Simply the Best for Less "' f) j SO ?i - t' i,t 7 ai jj Customer: `; C ✓ G - � r' " , ci Ph one (h) i y / j / ) 5 7 £. (/ ( 6; 1 r Install Address: /of / ti L j � . r /i)v v rr _ / LLi f , ( 7, i . L - Phone (w) Bill Address: --, 'J 7i i 7 E -mail WINDOW WORLD rt GLASS OPTIONS 1000 Series DH Mech $180 /Y Stimulus Energy Package* $79 7 j C 2000 Series DH Mech -weld $189 Includes Solarzone ETC Package 1 G' 4000 Series DH All -Weld $200a 0 D[) Solarzone Glass $45 6000 Series DH All -Weld $235 - Argon Gas $15 2 Late Slider $329 Triple Glazed TG2 ** (Argon Filled) $155 2 Lite Slider Swing & Clean $389 Triple Glazed TK2 ** (Krypton Filled) $196 3 Lite Slider (1/3, 113,1/3) (1/4, 112. $520 ( *Series 4000 & 6000 Only - Qualifies for Federal Tax Credit) 3 Lite Slider Swing & Clean (113, 1/3.113) (1 /4,1/2,1/4) $595 (* *Series 6000 Only - Qualifies for Federal Tax Credit) Picture / Fixed Lite $329 WINDOW OPTIONS Awning $255 t a 1/2 Screens INCLUDED Casement $285 - , r ` Foam Insulation on Jambs and Head INCLUDED 2 Lite Casement $57o Double Strength Glass (4000 & 6000 Only) INCLUDED 3 Lite Casement (113, 1/3,1/3) (114, 112,1/4) $855 Double Locks (> 26 ") INCLUDED Basement Hopper $ 200 Full Screens $22 Bay Window $ Colonial Grids (Contoured /Flat) $38 Bow Window $ Prairie Grids $44 Garden Window $ _ Diamond Grids $69 Specialty Window $ Simulated Divided Lite $182 Beige $35 Tempered DH Sash (BSO) (TSO) $65 Wood Grain Interior (Series 4000 / 6000 only) $95 Obscure Glass (BSO) (TSO) $35 (Light Oak / Dark Oak/ Cherry/ White / Fox Wood) Oriel Style (40/60 or 60/40) $30 Brown Exterior (Series 6000 Only) , , $95 Foam Enhanced Frame (Series 6000 Only) $25 Window Color ),,L,. E 1 , - / I. :, 1 , r— _ - PRE 1978 BUILT HOMES (Federal Lead Containment Law) Inside Outside With Custom Premium Exterior Trim $50 DOORS Without Custom Premium Exterior Trim $70 Vinyl Rolling Patio Door Eft. $895 MY HOME WAS BUILT IN THE YEAR Initial Vinyl Rolling Patio Door 8ft. $995 MISCELLANEOUS Vinyl Rolling Patio Door 9ft. $1095 V Custom Exterior Trim $60 .; (^ Includes Exterior Vinyl Trim Facing Color j...- ,-e �t t � e -, Facing Color Specialty Window Exterior Trim AL Specialty Door Facing Color Grids Patio Door $ ,_. Mull to Form Multi Unit $30 / e,- Solarzone Glass for Patio Door $125 -- install Interior Stops $45 1-' Z2 Solarzone Elite Glass for Patio Door* $168 Install Interior Casing $45 ( *Qualifies for Federal Tax Credit) Repair Sill or Jamb $50 $ ,2_, _ Mullion Removal $30 (- $ Remove Storm Window $15 Storm Door $ Remove and Install A/C $100 Door Color / i WINDOW WORLD CARES • Inside Outside St. Judes Children's Research Hospital $ :i • DISCLAIMER: The information herein related to the Federal Stimulus Package is for informational purposes ONLY. This information is not intended to be legal or tax advice. You should contact your accountant or other tax professional for advice related to specific tax benefits of purchasing energy efficient windows. NO EXTRA WORK IF NOT IN WRITING! Customer agrees to the terms of payment as follows: l ,-) 1 Extra Labor $ \ , ,1, 1;,k ; )1 L ' 1 , t - f C Li._ ; `*C . /)/) Site Set -Up Fee $ $209:00 / CY', C e° Total Amount $ t'I- ct Custom Order Deposit 50% $ ,Ck# 71 PC : . ( ,: Y rt. T r .1' Balance Paid to Installer upon Completion $ ,- ,� t t V\-% e,>r ti 1,:' Amount Financed $ WW of W. Massachusetts anticipates Starting this work on ,41„ 1 ' / and being substantially completed in,15 days. Security Interest: Yes No --.-- Any deposit required in advance 01 the start onhe work SHALL NOT exceed 33 the total contract price or thr actu any material or equipment of a special order or custom made nature, which must be ordered in advance of the start of the work to assure that the project will proceed on schedule. No final payment shall be demanded until the contract is completed to the satisfaction on all parties. All home improvement contractors and subcontractors shall be registered and that any inquires about a contract or subcontractor relating to a registration should be directed to: Office of Consumer Affairs and Business Regulation, Ten Park Plaza, Suite 5170 Boston, MA 02116. Phone: (617) 973 -8700 No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. WW of W. Massachusetts under provision of Chapter 142A of the general laws is required to apply for and obtain all construction- related permits. WW of W. Massa- chusetts shall not be deemed responsible for delays in the work described in this agreement caused by regulatory, permit granting agencies, authorities or individuals. Notice: If the PURCHASER(S) obtains his own construction related permits for the work described under this agreement or deals with unregistered contractors, the PURCHASER(S) is hereby advised that in the event of a dispute, judgement and nonpayment, the PURCHASER(S) will not be entitled to make a claim or collection from the guaranty fund established by chapter 142A, M.G.L. You the buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. Notice of cancellation must be in writing postmarked no later than midnight of tht 1ii1Iowing third business day. / THIS IS A CUSTOM ORDER NO7 FOR RESA 1 c't ! )- - - , , ' , - -- - _ ./.: .,. 7„/ I \ Owner Date 1 , i f f ) ) �t n t A ��, �, �ti �? �.'�l � � � \ � - '_ ((- - )L-, ii ; i " ` Salesrrian ate t Owner Date Agawam WC 3 -10 White Copy - Original Yellow Copy - File Pink Copy - Customer Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the - members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees policy -is- required. Be advised that this affidavit-may-be subnaitted to the- Department of - Industrial -- Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self - insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant • that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111. Tel. # 617 - 727 -4900 ext 406 or 1-877-MASSAFE Revised 4 -24 -07 Fax # 617 -727 -7749 www.mass.govidia • The Commonwealth of Massachusetts Department of Industrial Accidents _ .= w Office of Investigations ° 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): ((/� vt GQ Cv 0,44 1(k 6 d " l Address: 3 c l w 0.d ut 1 City /State /Zip: a w-� , A/2..c 4 Phone #: g�� 12 O Are you an employ Check the appropriate box: Type of project (required): 1.0 I am a employer with 4. 0 I am a general contractor and I 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors 2.0 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 working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance.t required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 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 1 �.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no -- - — - -employees. {Noworkers'— 3.0 Other comp. insurance required] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. tHo meowners 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. Lic. #: Expiration Date: 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. I do hereby ce ' - un , r 1 pans nd penal ' f perjury that the information provided abov is true d correct ' ,� i . / ) Signature: � Date: � d n 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 #: CERTIFICATE OF LIABILITY INS" NSURANCE OMENSIMONTT" 05/20/20.0 TMS CERTIFICATE IS ISSUED AS A riArnot OF ME0RN&110N ONLY AND comma NO moon UPON THE CEITORCATE HOMER TINS CERTIFICATE 00ES NOT AFFIRMATIVELY OR NEGATIVELY AHEM EXTEND OR ALTER TIE COVERAGE AFFORDED BY TIE POLICES BELOW. "-THIS CERTIFICATE OF RISURANiE DOES NOT CONSTITUTE A CONTRACT EETWEHI TIE SIG , AUTHORIZED REPRESENTATWEORPRODUCE; AND7EE CERTFR ATE HOLDER. IMPORTANT: If the ontificate bottler Is no NDDU'fOVAL INSURED, the pelt:3004 met be endorsed 8 SIEIROGATION IS WAIVED. subject to the terms and conditions "of the poky, certain policies n y a an endorsement. A stabreent on Ws caracole does not confer rights to the certificate holder in lieu of slldr endanramengs4. PRODUCER Name Laurence R. Forrest Forrest Insurance Agency PRONE 413 858 2680 1 858 2685 mew 603 North !fain Street + East Loagiwadw., Mass- 01028 INIONUrE - CINTONNUDt aINe19NNAFAeRONCOVERAGE wit MEM meteDulBstelLa Protect: on Insurance Caopaww Window World Of Western - iniumeardherty Mutual Insurance COepeuy 351 Walnut Street Extrroaiou mousesc_ Agawam, Sass. 01001 RANNER D_ e SUREREc elirarRF: 1 COVERAGES CERTIFICATE NUDISM REVISION NCR THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTE0 BELOW HAVE BEEN ISSUED 10 THE INSURED IUIEED ABOVE FOR THE POLICY PERIOD INDICATES NOTWITHSTANDING AMY REQUIREMENT. TEAM OR COMMON OF ANY CONTRACT OR OTHER DOCUMENT VATHI RESPECT 10 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES SCRIBED HEREIN IS 311B,ECT TO ALL THE Tt3RM3. EXCLUSIONS NDOOED ITIONSOFSUCHPt1ECES.LaUVs SHOWN MAY W►VE BEET R®UC @BrPNDCLAIMS. e RR TTPEOFSInRrnCE SSR IMO POUL71a�9t �drrrt) INNOI tails A GENERAL UA55JTY 7500046889 04/09/ VO4/0 nj s'CHOOrcn $1,000,000 X COeae9ecVL GENERAL UNe/rtt PRENNES ty GONMER4 $- 100,000 CLAilsarADE © OCr7JR +ie IVIP(Aaja s 5,000 PERSONAL &NW INJ Y 51,000,000 OMBMENAMEMUE 2, 000, 000 GEM AGGREGATE LSIT.PPPUBSPet PROMOS - COrF/OP *2,000,000 7 - nom FILM AOTO saeLELee* UY - - - - • - eL(aELAIR $- - . - - NNY AQIO e00e.YOULOWI Yrponeel S ALLOeNEDAUTOS 'a00a_Yeraetrrous d.* $ SCIED LEDALMS I+ROl Y MAIN E i HIREOAUTOS (Peroxides NON- MMAUTOS $ USIOR9.twtno OCCUR SPCH OCCURRENCE MONOTONE s — RETENTION $ - - - n g WORKERS ODupasuLTION _ WC3372193 05/07/201005/07 /2011 t- aBCSrATU- 7 Ic AND NPLOYSaWUNISlY_ TOAYLaIi$ 1 et Nn a - scri - s 100,000 (Rsadatay MISS t,0 t1oE0/ ELU - EAMPLO EE $ 100,000 f Hs. dewite oe3cRFNON cc OPERATIONSTaba esomENE- FoucriAm s 500,000 DESCRIPTION OFOPERATg16 /LOGTIOr6/V91CtIS I ACDOD/p4A iDosiinrAs'JdMiL`eemes aoeiswpiq CERTTRCATE HOLDER CANC LLATION Window World Of Western lfsseachosette, Inc. SNOIRD AMY OF THE ABOVE DINCRDED POLICES BE CAIIC91 BEFORE 351 Walnut Street •Rktension TEE EXPIRATION" tMTE' DERECIF, NOME NELL BE DE3MYERS) -- II Agawam, Maas. 01001 - ACcONDANCENIMT EPOUCVPROAMONS - AMMIDISBDOEFFIESEMSODE 94,auJ - - CI vauktoO0 AC0RD CORPORATION. Ali rights resolved. ACORD 25 (200915$ The ACORD name and logo are registered nudes otACORD / Mee loaseteoeuevailii a/ellimie +r , "r = Office of Consumer Affairs & Business Regulation . , 4 5 , HOME IMPRSaVEMENT CONTRACTOR . 1 Reeistrstio,. x.,185841 ,.' Expirat 12 TO 294585 Typeb)Y P : f?s1lon WINDOW WOR �:!o1` MASS INC ROBERT BUSH , 41 ; • ; 4 1 t � ' , ' ' 'i r + 361 WALNUT ST T < • . ^ s AGAWAM, MA 01001' t . '. '' Undersecretary Massachusetts - Department of Public Safet■ \ Board of Building Regulations and Standards Construction Supervisor License License: CS 57011 • Reaiti l..ta.J to: 00 ROBERT E BUSHEY JR 5 127 ROOSEVELT AVE FEEDING HILLS, MA 01030 — --¢� Expiration: 6/28/2011 ('ommiriloner Tr#: 1339 SECTION 8 - CONSTRUCTION SERVICES v /3.1 Licensed Construction Su i r: n (---.1 Not Applicab - ■ Name of License Holder : 0 -Q. (7 tJ f r V ✓I ?Q 1 License N � • • - Y Address Expiration Date Signature Telephone 9. Renist Home Improvement Fontractor: Not Ap likable - © -- tiO O tkA { ) Ok ()- tiie5left4 i Comoanv Name Registration -- ,.,u, 'i . o _ Address Expirati Date Telephone 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [J Addition El Replacement Windows Alteration(s) ❑ Roofing 1 1 Or Doors El Accessory Bldg. D Demolition ID New Signs [O] Decks [EJ Siding [D] Other [0] nef Description of Pro�Qs Work: Cam, > i -p V,`,1i f i t lRc 6)• t1 �5, ND lk�S / ✓itc . cl Alteration of existing 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, , 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 I, , 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 a • penalties of perjury. Prin le 'e / 2 0 /U gnature of a -r /Age' ' 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 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO Q 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 Q 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 Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only - City of Northampton Status of Permit: -"`- __._ ' Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability 3 ", A A 3 .010 , Room 100 Water/Well Availability m 58 Ianpton, MA 01060 Two Sets of Structural Plans phone r1240 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 V 1.1 Property ddress: This section to be completed by office l t� q Map Lot Unit F/041A-C-e r Uq t 0 106-1_ Zone Overlay District 4 Elm St District CB District SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: Telephone Signature fl uthorizr A ent: ;I/ t,t) qi vt uti 59. g-Y4, 6104.4 1/14 a - •' nn Y� C ( f&) nt Mailing Address: Of 0 ignature hone SECTION 3 - ESTI TED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1 1. Building /) 4 C (a) Building Permit Fee 2. Electrical �( J (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) Check Number 1 035 — This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date Am- BP- 2010 -1168 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 22D- 102 a 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- 2010 -1168 Project # JS- 2010- 001704 Est. Cost: $4450.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT E BUSHEY JR 57011 Lot Size(sq. ft.): 36329.04 Owner: SUPRENANT RICHARD D JR & GLORI Zoning: URA(100) //WSP Applicant: ROBERT E BUSHEY JR AT: 149 RYAN RD Applicant Address: Phone: Insurance: 351 WALNUT ST EXT (413) 786 -9906 WC AGAWAMMA01001 ISSUED ON:6/21/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS 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 6/21/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo AFFORDABLE C O N S T R U C T I O N ; j l X port roafing, ROOFING & SIDING Inc. North Main greet 444 A North Main Street Fast st Longmeadow MA 01020 East Longmeadow, MA 01028 Phone: 413.474.6999 Factory Trained & Fully Insured & Licensed Fax: 413.474.6354 Certified Installers MA. LIC.139915 Proposal Submitted To: Date Phone #'s H: W Street Starting Date City, State, Zip Code Job Location Proposal to furnish and install the following E1 RE -ROOF ® TEAR -OFF ❑ PLYWOOD ❑ REPAIR ❑ GUTTER ❑ OTHER Complete Roof Preparation ❑ Home exterior to be protected by tarps and plywood 0 Shrubs, landscaping, trees to be protected from damage ❑ Entire existing roofing material to be removed to existing decking, including flashing, etc. ❑ Site to be cleaned every day with roll magnet debris removed at project completion ❑ Deteriorate existing decking replaced at per ❑ Sq. ft. ❑ Liner foot Metal drip edge installed at eaves ❑ Metal drip edge installed at rake edges ❑ New metal step flashing will be installed where necessary Q New plumbing vent flashing will be installed and flashed in 2" ❑ 3" ❑ 4" ❑ other ❑ Shingle valleys will be installed ❑ New metal flashing will be installed around all chimneys 0 We shall acquire all appropriate permits etc. for all roofing & siding work Complete Roof Preparation 0 Leak Barrier installed in at all eaves to protect from ice dams (and meet codes in New England) ❑Leak Barrier installed in all valleys, around skylights and chimneys to protect critical areas ❑ Shingle -Mate reinforced underlayment installed over entire decking (the best underlayment available) 0 Other underlayment will be used Ridge vent will be installed ❑ Cap Shingle Shingles: Shingle's name color -- 30 40 50 lifetime factory warranty Hip and ridge that matches shingles warranty and color will be installed GRAND TOTAL 1/3 deposit due at signing of contract. Balance due job completion and final inspection. Customer Approval Signature ' - j ? / e fl l / ` / Authorized Signature l f a • HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) - who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached 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 home owner." The building department for the City of.Northampton wants persons) who seek to use the horse owner exemption;-to° act as their owsconstruction - supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that.the.building department be called to inspect work at various stages, which include foundation /footings (before backfill), . sonotube holes (beforepour), a rough building- inspection (before work is concealed). insulation inspection (if required) - and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in' failure 'to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will . be responsible to make sure that the trades hired secure their proper jermits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made . • I, understand the above. .(Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to Date Address of work location • The Commonwealth of Massachusetts Department of Industrial Accidents =IV =t Office of Investigations ' _ Te ~ 600 Washington Street w • Boston, MA 02111 www.mass.go -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual) : x e{/ re ryfi • • Address: /Or z / r t - /Z' e " S City /State/Zip: > C,a rvc,e i f Phone. #: 2 t< if Are o .an employer? .Cll�ek the appropriate 'box: t Y - Type ofpioject (required): 4 .. I am a ontractor and I 1. I am a employer with p ❑ g 1 eneral c , 6_Q_New_ nstiuc employees (full and/or part tip: * - - -- - have -huedthe- sttb-confraetors 2._0 I am a sole proprietor or partner- listed on the attached sheet 7. delrng These sub-contractorshave- � and b no :employees -- ._- . 8. ❑ Demolition working r me in an employees and have workers' 13 Y �aP� # . 9. 0 Building addition [No workers' comp. msttiance - comp. insurance. re ` 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers haveixercised 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 13.0 Other comp. insurance required} *Any applicant that checks box #I must also fill out the section below showing their wor±czrs' 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 *Contactors 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, . r Insurance Company Name: e C''7 h . L. (.? • . Policy # o r S e l f - i n s . Lic. #: 9 el 4 / `i s Expiration Date: 7,10 /1 Job Site Address: ( '� /7V/ C-t C( G City/State/Zip:" /� �P v �' 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 51,500.00 and/or one -y .' �. risonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against .lator. Be advised that a copy of this statement maybe forwarded to the Of be of Investieations of the DIA , ti.. . . ce coverage verification I do. hereby certify n % pains and penalties of perjury that the information provided above is true and correct :tire: -- / . . = Date: r �.t�; • Pho.e #: e t ' 1 '7 !�. : Official use only. Do not write in this area tb be completed by city or town offidal City or Town: • Permit/Licensee# Issuing Authority (circle one): . 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical ,Inspector 5. Plumbing Inspector 6.Other 1 Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: ` Not Applicabl2 ❑ ' dame of License Holder : v c S7e . �� �7 m Q l a — � (/ License Number Ad're Expiration Date . - Telephone r `; ��� €tea >��= ,� "�"�� � .. �: � , .: Not Applicable ❑ Com. ame Registration Number Address o f ' expiration Date .J Telephone <i "71'6 — SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (IVI 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 0 No ❑ 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 buildine 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 WORKJcheck all applicable) New House ❑ Addition 0 Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. 0 Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [0] Brief Descriptio f, used 1-e ` work: - i o l l u c a 0 "I Alteration of existing bedroom Yes VNo Adding new bedroom Yes No 9 9 Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet ,� r .:' •* ti ; s a s ®6 ' •?4® ; , s .. • , ®.4 Y 1 A .. . a e x 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. Wifbuilding 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, � re f),� 21 rl�P' P WS (C ( , as Owner /Authorized Agent hereby declare that the statements and it f rmati on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed u er the pains an• penalties of perjury. Print Name OK. 30 0 O/( Sign e o • - Age ' Date A -, Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Inf at 91 ' R Existing Proposed Required by Zo ng , - This column to illed ' b y illt Building Depa ent 1 ,,t Lot Size 1 1 1 �. Frontage 1 1 l Setbacks Front 9 f I = } a Side L: - R:= L:L__.d R:{ 1 = Rear 1 1 Building Height 1 1 1 1 Bldg. Square Footage 1 1 1 1% 1 1 r1 _Open_ Space- Footage - % .. -- 1 I (Lot area minus bldg & paved = 1 a , parking) # of Parking Spaces = I 1 , Fill: - (volume & Location) a A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:? IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT 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 0 DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES a 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: I —i 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. r City of Northampto ' 9 '+� • Building Department � °` }' .- " ' �� 212 M ain S Rm 1 Street . , s K �11 � I'" -� oo tr 55 F RS , °4� (� 't h'v . 7 u a , .raw 4 f � . ampton, MA 01060 '' 'f, 1 1 ; - , �r 13-587 -1240 Fax 413 -587 -1272 � - ' ' ,,, }'� � +,r : 'h °tee' I `' ATION 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 /%;- ,, n,, , lterla�rstr ct✓ (' l b V e ►'` s 14:i I8 t rr ct CB Distri SECTION 2 - PROPERTY OWNERSHIP!Al1THORIZED AGENT . 2.1 Owner of Record: 0 r-e 'r rc� C' 2 4 /eC -0S Lt( /rvi el 1 Name (Prin. / Current Mailing Address: tt// it'A .x^43 -e000 Telephone Signature 2.2 Authorized Agent / Name P ' Current Mailing Address /- ( ) ' � e- , s'' / k c.�•t o ‘-k.) Signature hone (3 L('7 P7 SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant ilding `7 v 0 ° (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) Check Number ' , This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspeotoi•of Buildings: Date 41 AVIS CIR • BP- 2011 -1116 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 22D - 110 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofing BUILDING PERMIT Permit # BP- 2011 -1116 Project # JS- 2011- 001795 Est. Cost: $7200.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: X -PERT ROOFING INC 100312 Lot Size(sq. ft.): 22738.32 Owner: ZAKRZEWSKI GREGORY & SYLVIA Zoning: URA(100) //WSP Applicant: X -PERT ROOFING INC AT: 41 AVIS CIR Applicant Address: Phone: Insurance: 444A NORTH MAIN ST (413) 474 -6999 WC EAST LONGMEADOWMA01028 ISSUED ON:6/30/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: STRI P & SHINGLE ROOF 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 6/30/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner