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24C-168 (4) PELLA PRODUCTS INC 155 MAIN STREET GREENFIELD, MA 01301 M et, e rtfc . • 1/ • e Subject: Disposal of Debris The purpose of this letter is to certify that all the debris resulting from any project undertaken by Pella Products Inc. in your Town will be transported to a dumpster at our main facility at 155 Main Street, Greenfield, MA. Pella Products Inc.is under contract with Waste Management of Massachusetts for the disposal of the contents of this dumpster. Very Truly Yours, PELLA PRODUCTS INC. John P. Benjamin Accounting Manager The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations S 600 Washington Street Boston, MA 02111 r .,g4 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): / C 4 /�z' / i' e ! 5 5 / 'i f: _ Address: i -',.) M r`-ii 0 , t" - (i( City /State /Zip: (, vile'? --ii- lri ? /V/ 65/ 26/ Phone #: ' '// 7j7 6)/53 Are you an employer? Check the appropriate box: Type of project (required): 1. r3 I am a employer with 4/ 4. 0 I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. (11 New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. _J Remodeling sub-contractors have ship and have no employees These su 8. 1 I Demolition working for me in any capacity. employees and have workers' �� [No workers' comp. insurance comp. insurance ± Buildin addition required.] 5. H 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. Roof rep ' s insurance required.] t c. 152, § 1(4), and we have no , employees. [No workers' 13. Other) ( �.,4`c'e i i tai detk.. •_. > comp. insurance required.] {?' Cl I) c..)0' *My 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. ) ` �. f I Insurance Company Name: 7 Cl/ V 0 5 u F r-1 vi C E r (l k' < p''1 Policy # or Self -ins. Lic. #: a ( ( LJ Q3 / V - Expiration Date: (,1 '" (',) 7 , e:)/,--;?' Job Site Address: 6� i -ii 1; l ih Sire P. City /State /Zip: ei' ' ' .� / /I' M /Q 6 e Attach a copy of the workers' compensation policy declaration page (showing the policy number and ex t ration 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. aims and penalties of perjury that the information provided above is true and correct. Signature: r4 Date: ' 7 ,7 Phone #: q 13 1 77 T 1 C, 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 #: To Whom It May Concern: I, s , o k. e n n k. , as property owner, give permission to our contractor, Pella Products, Inc., to obtain a building permit for the installation of windows or doors in my home, located at = - AttiLl 6A , 6/ t _ 4-. . Please accept this letter in lace t; signature on the P P Y g permit application. Thank you, l 1 1 e..1 Please Print Name eowner's Signature Date Future Sample Pre-Renovation Form This Sample Turin may be used by renovation firms to document compliance with the edam! pre•enovatien education and renovation, repair, and painting regulations. Occupant Confirmation Pamphlet Receipt Ziel have received a eop of the leaci hazard information pamphlet informing lite of the potential risk or the lead hazard exposure from renovation activity to be peiforrned in ray (Mt:Mktg unit. I ii:Ice.ivecl this pamphlet before the work began. ytv lex- occupant Opt-out Acknowledgment i . AI conrirm that I own and live in this property, that no child under the age of resides hele, that no pregnant woman resides here, and that this property is not a child -occupied facility. Note: A (Mild H. in the prirnary residence of his on her custodial parents, gi ate lint is tester parents, or informal caretaker it the child lives and sleeps most of the tulle, at the caretaker's residence. . Note: j\ child-OCCUI.Ned I iutil I ;A pre-ig78 euilding visitecl regularly by the 8arne Child, under years of age, on at least two difterefit clays within any week, for at least 3 hours each day, provided that the visits total at least 60 hours annually. Ii Box A a checked. cheCk etther Box B Or Box C, but not both. • I leetiest that the renovation firm use the lead-sate work practices required • by EPAs rtanoyation, Repair, and Painting Rule; or I understand i.hat the firm parlor ming the renovation will riot be required to use the leaci-saie work practices required dv EPAs Renovation, Repair, and Painting Rule. i ants t Qvvr ; s tAgrAtt ire of Owrievoccupant Signature Date, Roc ivator's Self Certification Option (tor tenant-occupied dwellings only) iilstructions to Renovator: If the lead hazard information pamphlet was delivered her a ionant signatt ire was rtot obtainable, you may check the appropriate box be.;low. Declined certify that I have made a good faith effort to deliver the lead ha7..atd inloanation pamphlet to the rental dwelling unit listed below at the slate and time tidicateri and that the occupant declined to sign the conlirmation of receipt. I further certify that I nave left a copy of the pamphlet at The unit with the occupara. U Unavailable for signature -- I certify that I have made a good faith effort to deliver the lead haIard information pan iphlet to the rental dwelling unit listed below and that the occupant was unavailable to sign the confirmation of receipt. I further certify that have left a copy of the pamphlet at the unit by sliding it under the door or by (NI in how pamphlet vvas lett). • Printed Name , :stt Person Certifying Delivery Attempted Delivery Date • t',ignarero of Person Certifying Lead Pamphlet Delivery • , Unit Address Note Regarding Mailing Option ---- As an alternative to delivery in person, you n lay mail the lead ha:,::.ard information pamphlet to the owner and/or tenant. Pamphlet irittat be mailed at least '.,;even days before renovation. Mailing must be documented by a certificate of mailing 1,0m rne post olfice. Note: This form is not effective until April 2010. • Customer: Marge Bruchac Project Name: Bruchac Marge Order Number: 739 Quote Number: 2748492 within the wall system. Neither Pella Corporation nor Pella Products Inc will be bound by any other warranty unless specifically set out in this contract. However, Pella Corporation will not be liable for branch warranties which create obligations in addition to or obligations which are inconsistent with Pella written warranties. Clear opening (egress) information does not take into consideration the addition of a Rolscreen [or any other accessory] to the product. You should consult your local building code to ensure your Pella products meet local egress requirements. Per the manufacturer's limited warranty, unfinished mahogany exterior windows and doors must be finished upon receipt prior to installing and refinished annually, thereafter. Variations in wood grain, color, texture or natural characteristics are not covered under the limited warranty. Refer to Pella Corporate Warranty This form constitutes a contract between Buyer and Seller. Prices are subject to change anytime after 30 days following date of estimate and does not guarantee availability of any product listed. Pella Products Inc. management has final authority on acceptance of this order. Your signature confirms the accuracy of the product(s) chosen. Pella Products assumes no responsibility for accuracy of take offs from drawings or blueprints or that the products listed will be sufficient to complete customer's intended project. The Buyer agrees that the product(s) listed herein are correct, final and cannot be changed, returned or canceled. Deposits are partial payment of the contract and are not refundable. The Buyer agrees that if paying by credit card that authorization is granted to the seller to debit the Buyers credit card by signing this contract. The Buyer agrees that payment discounts do not apply when paying with a credit card. A 1 -1/2% SERVICE CHARGE per month (18% PER ANNUM) will be added to all outstanding balance past our stated terms, plus lawyer and account fees for collecting outstanding accounts. The Buyer agrees that the customer delivery date is a realistic estimate of when the product is to be delivered. Items remaining in our warehouse for more than 30 days beyond the agreed to delivery time will be subject to a storage and handling fee of 1% of the net amount of the order ($25.00 minimum charge). The Buyer agrees that the product can be delivered without the Buyer present and agrees to accept the shipping documents as proof of delivery. The Buyer agrees not to hold the Seller responsible for any damage to driveways, sidewalks, trees and overhead wires caused by the Seller's delivery vehicles. The Buyer agrees to examine the product(s) upon delivery and within 7 DAYS OF DELIVERY provide the Seller notice of any discrepancy between the product(s) ordered and the products(s) delivered, including hardware. If the Buyer does not provide notice within 7 days the Buyer accepts the product(s) as is. Project Checklist has been reviewed Order Totals Taxable Subtotal $1,716.18 Credit Card Approval Signature Sales Tax © 6.25% $107.26 Non- taxable Subtotal $839.00 F. / IA cr, .AA iA % Total $2,662.44 Customer Name (Please print) Pella Sales Rep Name (Please print) ,¢� Deposit Received $0.00 4 r;,,,,�, 4 Amount Due $2,662.44 ustomer Signature Pella Sales Rep Signature r✓r� °�' .7)// Date Date For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com Drir,+eAr! .,r, cui /71141 rsnrs +turd+ fly, +o1i ,i D.,n., c .,f a Customer: Marge Bruchac Quote Description: 739 Architect Series Phase 4 413 - 584 -2195 Order Number: 739K3GL01 I Order Pricing Totals Total List Price $2,555.18 Discountable Amount $3,193.18 Discount @ 0.000% $0.00 Non - Discountable Amount ($638.00) Net Before Payment Discount $2,555.18 Payment Discount Amount $0.00 Net After Payment Discount $2,555.18 Taxable Subtotal $1,716.18 Sales Tax @ 6.25% $107.26 Non - taxable Subtotal $839.00 Total (Total Net + Taxes) $2,662.44 Deposit Received $2,662.44 Amount Due $0.00 Printed on 6/3/2011 Office Order Copy Page 8 of 8 Customer: Marge Bruchac Project Name: Bruchac Marge Order Number: 739 Quote Number: 2748492 Remove interior or exterior stops, install new window in existing sash opening, re -use existing or replace window stops (interior r exterior). Glass loss will occur. Lead Paint Discloser: 1. ,( Home was built prior to 1978, Pre Renovation Form signed and "Protecting Your Family From Lead in Your Home" brochure has been given to the Home Owner. 2. Are there children under the age of 6 or women who are pregnant? Pella Will Owner Will Authorize install of Yard Sign on 1st day of installation and remove 7 days afterward S- Finish (paint or stain) product purchased: Trim will be painted by customer _X_ Ensure someone over age 18 is present at all times while Pella Employees are in the home _X_ Cut -back or tie trees, bushes, shrubs from exterior wall _X_ Arrange to have alarm system disconnected and reconnected - Pella Products can re -route alarm wires but can not reconnect contacts _X_ Arrange to have any plumbing or electrical repairs or changes by appropriate licensed contractor - $500 charge for site unprepared on 1 day job _X_ Remove and reinstall existing window treatments, wall hangings and air conditioning units - 4 -5 feet in front ! 1 foot to side with clear path _X_ Remove and reposition furniture in work area _X_ Secure pets in a safe manner X Remove valuable / breakable items from work area _X_ Remove snow from area of worksite if necessary _X_ Deliver and unload products _X_ Place drop cloths in work areas _X_ Remove and reinstall interior and exterior trim if applicable _X_ Remove and reinstall existing shutters and awnings by contract _X_ Remove existing product and adjust or modify opening as needed _X_ Provide all equipment necessary to install products X Cut all wood and other materials outside of home _X_ Install all products purchased _X_ Insulate and caulk around products _X_ Remove stickers and perform initial cleaning of all glass surfaces • _X_ Demonstrate proper operation of products _X_ Confirm that all products are in working order X_ Remove drop cloths, vacuum and remove all old products from premises Signature: gl,t4 , 22 Thank You For Purchasing Pella® Products PELLA WARRANTY: Pella products are covered by Pella's limited warranties in effect at the time of sale. All applicable product warranties are incorporated into and become a part of this contract. Please see the warranties for complete details, taking special note of the two important notice sections regarding installation of Pella products and proper management of moisture For more information regarding the finishing, m aintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com o,-; , +„,-1 n C/4 J7ni 1 f•.,., +r no+oli,,,A D,,.,.. ,,+ a Customer: Marge Bruchac Project Name: Bruchac Marge Order Number: 739 Quote Number: 2748492 may be declared due and payable because the holder deems himself to be insecure. However, where the contractor deems himself to be insecure he may require as a prerequisite to continuing said work that the balance funds due under the contract, which are in possession of the owner, shall be placed in a joint escrow account requiring the signatures of the home improvement contractor and the owner for withdrawal. 13. No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. 14. Arbitration: If the contractor determines that in the event of a dispute, the contractor wishes the dispute to be settled by arbitration, this fact must be signified on the contract and both the contractor and owner shall sign this clause separately. The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided in MGL c 142A Owner: \ J� °1..., Contractor: Notice: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor, The owner may initiate alternative dispute resolution even where this section is not signed separately by the parties. Site Responsibilities 1. 50% Deposit required at time of order. 2. Final payment is to be made to installation team on the morning of the last day of installation. 3. If the customer will not be present at time of install, payment is to be made prior. 4. Checks returned NSF will be assessed a fee of $50.00 to cover fees incurred by Pella. Failure to pay your final bill will result in finance charges of 1 -1/2% per month (18% Annual) and legal fees associated in the collection of owed monies. 5. Due to inclement weather or site conditions, it may be necessary to reschedule. 6. We cannot and will not guarantee specific dates or days of the week for installation. 7. Time given to complete a job is an estimate, extension of time is possible. 8. An install appointment will be confirmed at Verification. A courtesy reminder cal will be placed 1 week prior. 9. Unforeseen rot repair will be quoted on site as additional work via a Change Order. 10. Substantial completion is achieved when all available products have been installed and are operational. Items such as missing or broken parts and service adjustments are covered by Warranty and do not affect the status of a project from being Substantially Complete. 11. In the even that any products are unable to be installed, the final payment will be recalculated. The cost of the products not installed will be subtracted from the balance due. A subsequent and final payment equal to the cost of products not installed as scheduled will be due upon final completion. 12. Order is not binding until approved by Pella Products management. 13. Pella will secure all necessary Building Permits. Type of Installation: New Construction: (tear out installation - existing frame is disposed of) Remove interior and exterior Trim, remove existing window frame, install new window in rough opening, trim both interior and exterior of window / door. Pocket Install: i (sash replacement, existing frame remains) For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com ci4 inns A c Customer: Marge Bruchac Project Name: Bruchac Marge Order Number: 739 Quote Number: 2748492 Line # Location: Attributes 45 Site Responsibilities Qty 1 Customer Notes: HOMEOWNER - FOR YOUR INFORMATION LEGAL CONTRACT REQUIREMENTS FOR HOME IMPROVEMENT CONTRACTORS IS DETAILED BELOW THIS SITE RESPONSIBILITIES FORM IS PART OF YOUR CONTRACT WITH PELLA PRODUCTS INC. 155 MAIN STREET, GREENFIELD, MA 01301 HOME IMPROVEMENT CONTRACTOR REGISTRATION # 142279 EXP. 3 -24 -12 FEDERAL TAX ID #: 04- 2303271 The law requires the following fourteen items to be included in any contract between the homeowner and a registered home improvement contractor in all contracts for home improvement work subject to MGL c 142A 1. The complete agreement between the owner and a clear description of any other documents which are part of the agreement. 2. The full names, federal ID, addresses (not PO box #'s) of the parties, the contractor's registration number, the names(s) of the sales person(s)) involved, if any and the date the contract was executed by the parties 3. The date on which the work is scheduled to begin and the date the work is scheduled to be substantially complete. 4. A detailed description of the work to be done and the materials to be used. 5. The total amount agreed to be paid for the work to be performed under the contract. 6. A time schedule of payments to be made under the contract and the amount of each payment stated in dollars, including all finance charges, if any. Any deposit required to be paid in advance of the start of the work shall not exceed one -third of the total contract price or the actual cost of 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 of all parties. 7. All parties must sign the contract. 8. There shall be a clear and conspicuous notice stating; a. That all Home Improvement Contractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to; Registration Division, Program Coordinator One Ashburton Place - Room 1301 Boston, MA 02108 617 - 727 -3200 x 25239 b. The contractor's registration number must be on the first page of the contract. c. The homeowners three day cancellation rights under MGL c93s48; NGK c 140D s 10or MGL c255D s 14 as may be applicable. d. All warranties on the owners rights under the provisions of 780 CMRR6 and MGL c 142A e. In ten point bold type or larger, directly above the space provided for the signature, the following statement; DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES f. Whether any lien or security interest is on the residence as a consequence of the contract 9. An enumeration of such other matters upon which the owner and contractor may lawfully agree. 10. Any other provisions otherwise required by the applicable laws of the Commonwealth 11. Permit Notice: Every contract shall contain a clause informing the owner of the following; a. and all necessary construction related permits b. that it shall be the obligation of the contractor to obtain such permits as the owner's agent c. that the owner's who secure their own construction related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund. 12. Acceleration of payment: No contract shall contain an acceleration clause under which any part or all of the balance not yet due For more information regarding the finishing, maintenance, service and warranty of all Pella® products, visit the Pella® website at www.pella.com n.,._ C/4 / 4 4 r i. a n i ,i a n o c Customer: Marge Bruchac Quote Description: 739 Architect Series Phase 4 413 - 584 -2195 Order Number: 739K3GL011 Line # Quote Qty PO Qty Description Item Price Ext'd Price 25 1 0 INSTALLATION - INSTALLATION List Price: $320.00 Location: None Assigned Rough Opening: Discount %: 0.00 % Frame Size: Discount $: $0.00 $0.00 Final Wall Depth: Frame Perimeter (inches): Assembly Type: Branch Catalog Net Price: $320.00 $320.00 Last Revision Date: Customer Notes: Permit Fee * * * LP -2 - Lead safe practices this opening over 150 UI Qty 1 • Printed on 6/3/2011 Office Order Copy Page 4 of 8 Customer: Marge Bruchac Quote Description: 739 Architect Series Phase 4 413 - 584 -2195 Order Number: 739K3GL011 Outside View Line # Quote Qty PO Qty Description Item Price Ext'd Price 10 2 2 Architect, Precision Hung Double Hung, 31.5 X 61, White List Price: $1,436.59 111 Location: Dining Room Rough Opening: 32" X 61.5" 1: Non - Standard Size Double Hung, Equal Split Discount %: 0.00 ++� Frame Size: 31 1/2 X 61 Frame Size: 31.5" X 61" General Information: Style Edition, Clad Discount $: $0.00 $0.00 Final Wall Depth: Exterior Color / Finish: Standard EnduraClad, White Interior Color J Finish: Early American Stain Interior Frame Perimeter (inches): 185 Glass: Insulated Low E Advanced Argon Gas Assembly Type: Branch Finished Hardware Options: Spoon Lock, Brown, Order Sash Lift Net Price: $1,436.59 $2,873.18 Last Revision Date: Screen: Full Screen, InView Grille: ILT, No, 7/8 ", Traditional (2W1H / 2W1H) Wrapping Information: Perimeter Length = 185 ", Glazing Pressure = 85. * * * EAC -1 - Exterior Aluminum Capping (Coil Stock) up Qty 1 to 110 UI * * * PF-1 - Interior Pocket Installation for Precision Fit Qty 1 * * * LP -3 - Lead safe opening within an adjacent Qty 1 containment * * * ITS -EX - Re -use existing stops (replace if broken) Qty 1 Line # Quote Qty PO Qty Description Item Price Ext'd Price 15 1 0 Summer Promotion: 20% off Installation List Price: ($209.00) Location: Rough Opening: 0" X 0" Discount %: Frame Size: Discount $: $0.00 $0.00 Final Wall Depth: Frame Perimeter (inches): Assembly Type: Manual Line Net Price: ($209.00) ($209.00) Last Revision Date: Line # Quote Qty PO Qty Description Item Price Ext'd Price 20 1 0 Summer Promotion: 20% off Product List Price: ($429.00) Location: Rough Opening: 0" X 0" Discount %: Frame Size: Discount $: $0.00 $0.00 • Final Wall Depth: Frame Perimeter (inches): Assembly Type: Manual Line Net Price: ($429.00) ($429.00) Last Revision Date: Printed on 6/3/2011 Office Order Copy Page 3 of 8 Sufficient on -site parking? YES Distance to work site from parking: . 25' Do any openings need to be altered? NO Extra Man Required to Lift: NO Scaffolding required? None # of Sections for Pipe Stagging Material of existing units: Wood Existing Exterior Trim Style: Wood Subsill (medium) Type and Color of Drip Cap: Existing Interior Trim: Color of Existing Trim: STAINED Will paint lines be missed: NO Exterior painting required: NO Counter weight windows w /pockets? : YES Chair Rail: NO Floor Coverings: Hardwood Cut back flooring ?: NO Tile cutter needed ?: NO Siding Type 1: Clap: Siding Exposure: 7" Siding Type 2: Brick: Paneling: Brake Metal: YES Brickmould: NO Drywall: NO Wallpaper: NO Plaster: YES Other: • Approximate height from the ground to the highest opening: 12' Landscaping concerns: Describe: Notes to Installer: Customer: Marge Bruchac Quote Description: 739 Architect Series Phase 4 413 - 584 -2195 Order Number: 739K3GL011 Printed on 6/3/2011 Office Order Copy Page 2 of 8 ec6•T Office Order Copy Branch Number: 73900 Order Number: 739K3GL01I C±-11 ' Pe c Window Store Name:Pella Window and Door Quote Number: 2770431 Showroom of Greenfield Quote Description: 739 Architect Series Phase 4 413 - 584 -2195 Project Name: Bruchac Marge 63 Franklin Street Northampton MA Customer Information Deliver To Address Order Information Marge Bruchac f � V . r - c Lot # Sales Rep Name: Lukomski, Adam Cust Delivery Date: 7/25/2011 63 Franklin Street Address: Business Segment: Retail Quoted Date: 6/3/2011 63 Franklin Street Market Segment: Single Family Replacement Contract Date: 6/3/2011 Order Type: Installed Sales Booked Date: NORTHAMPTON, MA 01060 Effective Discount: 0.000% Earliest LRD: Contact Name: NORTHAMPTON, MA 01060 Commission Split: Lukomski, Adam - 100% Day Phone: (413) 584 -2195 County: HAMPSHIRE Tax Code: MASS Mobile Phone: Owner Name: Tax Exempt #: Fax Number: Marge Bruchac Payment Terms: C.O.D. Customer PO #: E -Mail: Order Verifier Name: Adam Lukomski Order Verification Date: 6/3/2011 Great Plains #: 52H5842195 Owner Phone: (413) 584 -2195 Customer Number: 2458071 Delivery Instructions: GPS, WHITE COLONIAL HOME WITH #63 MARKED CLEARLY AT THE END OF THE DRIVEWAY Installation Notes: GPS, WHITE COLONIAL HOME WITH #63 MARKED CLEARLY AT THE END OF THE DRIVEWAY Order Verification Notes: Project Name: Marge Bruchac Street: 63 Franklin Street Town, State, Zip Code: Northamptom, MA 01060 Phone: 413 - 584 -2195 Directions /Landmarks : Sales Rep: Adam L. MEN : 2 FOR DAYS: 1 OV SHED: TOTAL MAN -DAYS REQUESTED: 2 Installation Date : 7/25/2011 DATE TIME OV AGENT Days of Week : Monday Thru Tuesday Sales Notes to PM: • Job Desription: 2 ARCHITECT PRECISION FIT Flights of Stairs to Climb: 1 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : a. I (k. C. C: y i T1Q (' License Number / fl i SCe- Ce tii k1;A 01 I 7 01 Address Expiration Date 0 c a Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number /SIC 1 6 Fti C Oc i SrP , � ( Address Expiration Date Cb C Telephone - 7 / •3 — 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 , SECT4ON 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacemen indows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks (Q Siding [0] Other [0] Brief Description of P sed I I Work: �n..� A kt1+. C 2 , t(LFC4'Yt:(✓►ti iAk✓ , 143. _- , 0 ,c ;'11 e t< S :1 y en1 7 ‘ Q id "Le \.r'1ri, Alteration of existin bedroo Yes No Addin new bedroor Yes No C�t;�% existing bedroom.... � Adding � 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, V i :i 541'n k `-4'1 ✓4 i Gk_ n/i~at,a�� ,.2 Erlyuke , as Owner of the subject property hereby authorize I g f _I . Z to act on my behalf, in all matters relative to work authorized by this building permit application. �1 w► r- -e `L Si ure of Owner Date - I, ,)AAA.GI LJi +e_ , 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 and penalties of perjury. '--- q ll i A 0,- Print Name ( a;t4Q C CSIh i< /7 // 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 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 C IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES C IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW 0 YES Q 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 ® 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 © NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. a r I Department use only �� City of Northampton Status of Permit: c( G °\1 Building Department Curb Cut/Driveway Permit 2011 212 Main Street Sewer /Septic Availability 0 , Room 100 Water/Well Availability • , • rthampton, MA 01060 Two Sets of Structural Plans 0.00 1 '' vim' 3 587 -1240 Fax 413 -587 -1272 Plot/Site Plans , :::a ___ Other Specify I 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 C 3 -1- ;2 n kl0 c Map Lot Unit ILI Cy-4k0,06:\ 1 iA r� A 0 i 0 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: -(---c / Ss- �Z' r .i.i„ J7y',c (� G re � ' I A L Name (Prin Cp l U., ` Current Mailing Addre s: 0 130 I r C a 6 1 � `77? s 7 1� Telephone ` Signature 2.2 Authorized Agent: _ -TO 54 k p.vi u1 CI (A/ 4. ire T r t/cL. . 6 , (• �/� Name (Print) Current Mailing Address: Si. _ - ure Telephone - CTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 00 0 1 �� (a) Building Permi Fee 2. Electrical (b) Estimated Total Cost of 0 Construction from (6) �/ (to,: 00 3. Plumbing a Building Permit Fee a 4. Mechanical (HVAC) , , , 00 5. Fire Protection ( J 6. Total = (1 + 2 + 3 + 4 + 5) _ / (o,1 , O( Check Number ()(1-11 - L/ This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date S � 63 FRANKLIN ST BP- 2011 -1082 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24C - 168 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit# BP- 2011 -1082 Project # JS- 2011- 001746 Est. Cost: $3000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 091496 Lot Size(sq. ft.): 6882.48 Owner: KENNICK JUSTIN H & MARGARET M BRUCHAC Zoning: URB(100)/ Applicant: PELLA PRODUCTS, INC AT: 63 FRANKLIN ST Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772 -0153 WC GREENFIELDMA01301 ISSUED ON:6/22/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL 2 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 6/22/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner