29-409 PREPARING FOR YOUR NEW WINDOWS A`JD ,bOCRS
Congratulations on your decision to increase the comfort level, value and appearance of your home. To maximize your
investment and enable the installation to take place as smoothly as possible, we have created this handout to acquaint
you with what to expect when our installers arrive.
1. Expected Delivery Time. All of our windows are custom made at one of our manufacturing plants located around the country and shipped
to any of our over 200 Window World locations. The time between when your order is placed and when the windows are ready to be installed,
though not guaranteed is typically 6 to 8 weeks. At that point we will call you to set an installation date. If for some reason you need to delay
your installation for more than a couple of weeks after notification that we are ready to install your order we will be happy to work with you. We
will need to collect the remaining balance before installation if the delay you request is more than three weeks.
2. Access to the Windows and Doors. We will need approximately 2 feet in front of each window, inside your home, so we can place our
drop cloths and tools necessary to perform our work. When the old windows are removed, gusts of wind typically flow through your home. It
is advisable to gather together important papers, and other small items that can be disturbed by the wind and relocate them. Computers and
other electronic equipment should be covered or relocated temporarily. Please move aside any furnishings that are in the way of our work. If
any furniture items are too heavy to move easily, we will gladly assist you.
3. Window Coverings. To gain access to the interior of the windows, we need all mini blinds, vertical blinds, roll -up shades, shutters, drapes
and any other window covering removed prior to our installation. We are not responsible for removing or reinstallation of these items
and are not responsible for damage resulting in the removal and reinstallation. We also are not responsible for any window covering
alterations that may be required to reinstall them.
4. Plants and Bushes. Occasionally we need to work in planters and other landscaped areas of your home that are adjacent to the windows
and doors. Please survey your yard prior to us arriving and look for potential problems. Some trees and vigorous bushes need to be pruned
back to give us access to your windows. Delicate plants and shrubs in areas right below a window should be temporarily relocated if
they cannot survive being stepped on and you want to preserve them. We strive to be careful when working around vegetation, but our
priorities are to focus on our work, your windows and our safety while working on your property. We are not responsible for any damage to
plants, shrubs or landscaped areas.
5. Arrival and Departure Times. We will advise you of the expected arrival time for our crew at the time we set up the installation date with
you. We generally stay till the job is done, unless it will be a 2 or 3 -day job, in which case we may work as long as there is daylight. It is our
policy that our installers get a sign -off form and collect the outstanding balance at the completion of the job. We ask that you be
available to approve the job and make final payment at the time of completion. If this is not convenient for you, we need to know
before we start the job. Inclement weather and other unforeseen hindrances are a fact of life and as such we ask that you understand
if the weather, traffic, etc. cause a delay or cancellation of an installation appointment. We typically do not schedule more than a day
or two in advance to try to avoid such issues.
6. Our Worksite. We like to set up our worksite as close to your windows and doors as possible and generally your driveway is the best spot.
If using the driveway will block a garaged car, please be ready to pull it out upon arrival.
7. Alarm Systems. For those of you who have alarm systems, the alarm company should be notified and advised of our job. They will be
responsible for the disconnection and reconnection of your alarm system.
8. Where do we start? Upon arrival, the crew leader will survey the job and determine where to begin. If you have a preference, feel free
to advise us and we will accommodate to the best of our ability. Because we work in stages (i.e., removal of old windows, setting the new
window, wrapping of exterior, etc.), we don't complete the job one window at a time. The job moves along in a rolling progression where each
operation is done on all windows at the same time. This produces a quality job.
9. If the job takes more than a day, will there be any openings in my house? Of course not. We only remove that which can be reinstalled in
the same day. Although there may not be a complete window, it will be weather -tight and secure for overnight. (Please no critiquing at this time).
10. Pets. We love furry, four - legged creatures; however, we need your help in supervising them. We are not always able to close a gate or door
behind us when carrying a window, so please keep them in a safe place. Our job description does not include scampering down the street
after Fido with new found freedom. Many people say, don't worry, he doesn't bite, but many installers have been bitten. So please secure dogs
that have an aggressive bark towards strangers.
11. Expect some dust, noise and general disruption of your living space. Construction work can sometimes be messy depending upon
the scope of your job. It's an unfortunate reality of remodeling, but we do our best to keep things under control. We appreciate your patience
and understanding during the job and until everything is finished. Even after we have cleaned up, it is advisable to survey the areas for
something we may have overlooked (i.e., kids rooms, baby's room).
12. *Damage to walls and old trim stops. For those of you who have old aluminum and steel windows and are replacing them due to
sweating and damaging of the walls be advised that all water damage plaster will most likely fall out. In addition, all the patch work you have
done over the years will fall out also. This is normal; however, we are not plaster experts, so the repair to those walls would best be left to the
experts. In some cases due to out of square openings, new trim is required to make the window look good. *Unless noted on the contract
new trim will not be provided or installed by us. You can expect to do some touch up painting on the trim after the installation of your new
windows. This is not always necessary and is usually minor if it occurs. If your trim stops around your sashes are very old, dry, and brittle, they
may snap and crack upon removal. If this happens, we can leave them off if you please, or for a small up charge, replace them with newer
ones. Many of the old style stops are no longer available so we would replace the entire window with newer style stops. Should we discover
any hidden damage to the frame or wall area we will advise you before we proceed. Should you decide to replace or repair anything, the price
will be added to your balance.
13. Relax and enjoy the show. After we've been introduced to your home, feel free to run errands, take a walk, or just relax. If a question
should arise; by all means ask the crew leader for clarification. We enjoy people who are interested in what we do, and most customers are
intrigued with the process. We do get nervous, however, when a customer constantly hovers over our shoulder. Like any professional, we're
always happy to answer questions, but we appreciate being able to concentrate on our work without interruptions and distractions. This
ensures a safe and quality installation.
14. Past Due Balances are subject to a service charge of 1.5% per month. In the event that this amount is placed in the hands of an
attorney for collection, the purchaser agrees to pay all costs of collection, including a reasonable attorney fee. Return check fee is $50 (fifty
dollars).
Salesperson Home Owner
P.S. Now would be a good time to review contract with the salesman to be sure of your order options and work to be done.
Only the items and services on the contract will be done. If you have any questions whatsoever, now is the time to ask.
National WC 3 -10
TM ' j Window World of Western Massachusetts MA HIC Reg. #
il i - 351 Walnut Street Extension • Agawam, MA 01001 165641
�I�u° t \ 4$ f ; fi d o.1 : 4
l� Phone (413) 786 -9900 • Fax (815) 366 -8039 Construction Supervisors
www .windowworldofspringfield.com ------- License # 57011
"Simply the Best for Less "®
Customer: . _d ! , ? ,'` Phone (h) '/1 ,), ' ,fir t
Install Address: 1 i" ts..,j '% im`t s .. ' R YA F :. , ' i a , f ... r; , yr / ., , l A s ! 1 i Phone (w)
Bill Address: E -mail - -f' '
WINDOW WORLD GLASS OPTIONS
1000 Series DH Mech $180 '7 Stimulus Energy Package* $79 /1/ __
2000 Series DH Mech - Weld $189 Includes Solarzone ETC Package
4000 Series DH All -Weld $200,/,';:,,I) Solarzone Glass $45
6000 Series DH All -Weld $235 Argon Gas $15
2 Lite 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, 1/3, 1/3) (1/4,1/2,1/4) $520 ( *Series 4000 & 6000 Only - Qualifies for Federal Tax Credit)
3 Lite Slider Swing & Clean (1/3,1/3,1/3) (1/4,1/2,1/4) (* *Series 6000 Only - Qualifies for Federal Tax Credit)
Picture / Fixed Lite $329 WINDOW OPTIONS
/ Awning $255 ''' i, . `-' _ 1/2 Screens INCLUDED
Casement $285 r Foam Insulation on Jambs and Head INCLUDED
2 Lite Casement $570 l� Double Strength Glass (4000 & 6000 Only) INCLUDED
3 Lite Casement (1/3, 1/3, 1/3) (1/4,1/2,1/4) $855 P,''' 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 Sas (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 9r60/40) $30
Brown Exterior (Series 6000 Only) $95 - Foam Enhanced Frame (Series 6000 Only) $25
Window Color £'r V,../ ( / j, ' , PRE 1978 BUILT HOMES (Federal Lead Containment Law)
Inside Outside 9 With Custom Premium Exterior Trim $50 `,r`._ ._. --
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 --
Includes Exterior Vinyl Trim Custom Exterior Trim/ $60 �+�'t') - -
Y Facing Color ,, r h ,, ,
Facing Color Specialty Window Exterior Trim $
Specialty Door Facing Color
Grids Patio Door $100 Mull to Form Multi Unit $30
Solarzone Glass for Patio Door $125 9 Install Interior Stops $45 r; , s -
Solarzone Elite Glass for Patio Door* $168 Install Interior Casing $45
( *Qualifies for Federal Tax Credit) Repair Sill or Jamb $50
$ Mullion Removal $30
$ Remove Storm Window $15
Storm Door $ Remove and Install A/C $100
Door Color / WINDOW WORLD CARES
Inside Outside St. Judes Children's Research Hospital $ 2 , .
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:
Extra Labor(' $
Site Set -Up Fee $ $2 , r, C.:.).
Total Amount $ 122 /. 1
Custom Order Deposit 50% $ "°Ck#
Balance Paid to Installer upon Completion $ c 2c)573" "
Amount Financed $
WW of W. Massachusetts anticipates starting this work on 't; ti f and being substantially completed in / days. Security Interest: Yes No'`-
Any deposit required in advance of the start of the work SHALL NOT exceed 33 1/3% 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 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` houldbe
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 the following third business day.
THIS IS A CUSTOM ORDER NOT FOR RESALE!
' �r �`P g Owner Date
(4 / a '''''I -ef r - ! ' e- `.+ ' 4 7 r , % ,, %° es ' / % x .
Salesman / Date` Owner Date
Agawam we 3 -10 White Copy - Original Yellow Copy - File Pink Copy - Customer
•
•
glee look onantusalfi£ (1✓ileaQaci/uueali
0.,,.. Office of Consumer Affairs & Business Regulation
\2" .1. ', • . HOME IMPijQVEMENT CONTRACTOR .
r. '# Registration. .4165841 .
_,,. Expirat # !, �S 912 Tr# 294888 .
L ^
Typed Y '�, r ' 4 � 'o �S'atlon
WINDOW WOR ° '. MASS INC
ROBERT BUSH ;t � + i
351 WALNUT ST .•E r T' : ,. 1
AGAWAM, MA 01001Vq - . ,2 ' - Undersecretary I
Massachusetts - Department of Public Safety \
fi Board or Building Regulations and Standards
k - . Construction Supervisor License .
License: CS 57011 '
—Rash ictwctio: 00
ROBERT E BUSHEY JR "
127 ROOSEVELT AVE '
FEEDING HILLS, MA 01030
4 - —go.....--,..e.. Expiration: 6/28/2011
C'ummissioncr Tr#: 1339 '
CERTIFICATE OF LIABILITY INSURANCE DATE LI'BTIWYWY)
. 05/20/2010
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.. THIS CERTIRCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND TIE CERTWICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poIcyties) must be endorss. if TION 15 WAIVED, subject to
the terms and conditions - of the policy, certain Policies may require an endorsement A statement on this certificate does not curter rights to the
certificate holder in lieu of such endorsernent(s).
PRODUCER Noma Laurence R. Forrest
Forrest insurance Agency PHONE 413 858 2680 1 I13 858 2685
-
603 North Main Street - .
ADDRESEt
East Longmeadow, Mass. 01028 PRODUCER -
aESram sa
INSURERS) AFPOlOSeiCOVERAGE ?LAIC*
INSURE!) ee*Arbella Protection Insurance Company
Window World Of Western Massachusetts, Inc.
evamataLiberty Mutual Insurance Company
351 Walnut Street Extension
Agawam, Mass. 01001 INSTetE(D:
INSURERS:
INSURER F: 1
COVERAGES CERTIFICATE NUMBER: REVISION NUMBEtt
THIS Is TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITSTANDMG ANY REQUIREMENT. TERM OR CONDRION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED ICI IS SUBJECT TO ALL THE TUNAS.
EXCLUSIONS AND CONDfONS OF SUCH POLEGIES- LAIRS SHOWN MAY HAVE BEN REDUCE? BY PAID CLAIMS.
INSR - MALL meet POLICY EPF ' POLICY EXP --
L7R TYPE OF INSURANCE BUR PhD POUCYMARM PRWOF IPYYY) meow YYY) MRS
A cENetaLUA�JTY 7500046889 04/09/201004/09 /2021 EACHO 51,000,000
UANAt.,E TO MU
X I COMMERCIAL GENERAL UABLITY PREMISES ( „ s- 100,000
I CAeR3WDE I jOCCUR NEDoP (Any mepavan) s 5,000
PERSONAL & 51,000, 000
1 - cep AOGYEGAI 5 2,000, 000
GENT. AGGREGATE t APPIESPEG PRODUCTS- COPA)'PAGG 52,000,000
POUCY- } n 5
AUTOAOee.E LJANUTY - _. . - COMBINED SINGLE UNIT - .
- -
acellerN
__ ANY AUTO - 0004Y NUDITY (Memnon) $
_- ALL OWNED AUTOS
'HOOe.Y eNJUftY(Aeraoddeiq S
SCHEDULED AUTOS PROPERTY DAMAGE
5
(Perao9dei)
HIRED AUTOS _
NON WNED AUTOS - 5
S
UT6REUAUAS OCCUR EACH OCCURROICE S
_.
EXCESSUAS (LAaI iKOE AGGREGATE S
DEDUCTIBLE _ 5
RETENTION 5 - - s
is " WORKERS COMPENSATION . WC3372193 105/07/2010105/07 /2021 WcsrA7u - rift
AROBWWYHtsLM JT7 1 `` TORYLIfdiTS
ANY PROPWErORIPARTNEROCE ITTN m
E 1 N/A
- I EL EACH - $ 100,000
� EXCUAED7
(Mandatory in NH) Ei. DISEASE -EA EMPLOYEE $ 100,000
It yes. describe seer
DESCRIPTION OF OPERATIONS b ELmiseese- POUCYLaeT s 500,000
•
r e a m e IDN OF OPERATIONS/ LOCATIONS r V B s Q . E S A ac ACORD 101..Addelonst F t ados Schedule Ireee vowels !squired)
CERTIFICATE HOLDER CANCELLATION
Window World Of Western ( asachusetts, Inc.. -
S'HOULD ANY OF THE ABOVE DEANUBED POLICES 98 CANCELLER BEFORE
351 Walnut Street•Eirteasion THE exemomotr DATE THEREOF. NOTICE MIN.L HE DEJVERED - - IN
Agawam, Mess. 0100177 . ACCORDANCE WITH THE POJCYPROVISIONS.
_ . . _. AUTHORIZED REPRESENTATIVE .. -
4 itukuut_.6_, 94A00.0( - •- - - - - - -
09988 -2009 ACORD CORPORATION. All Tights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marts of ACORD
- The Commonwealth of Massachusetts
� --- Department of Industrial Accidents of
Office of Investigations
_y 600 Washington Street
=� , Boston, MA 02111
;L, www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): 1 ,.1 1 II ci/tho li‘6c,(1 iW UUe Y' MASSAal IA Sett) I h C
Address: ? T) \4 ! Vbv�T $ -f- p y -- -
City /State /Zip: A i ,G .i u it 1.. 001 Phone #: t - 2 ' I
Are you an employer? f • ck -the appropriate box:
I am a contractor and I Type of project (required):
4.
1. ❑ I am a employer with ❑ 6. ❑ New construction
employees (full and/or part- time).* have hired the sub- contractors -
2. ❑ 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. (3 Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insurance comp. insurance.:
required] 5. ❑ 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 12. goof repairs
insurance required.] t c. 152, §1(4), and we have no - -emp ogees: - o- workers' -- - - 4 3,V_4ther_ 12.0 _ 1 - kf k
_-- --
comp. insurance required] UJ tVsZ
'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 - contactors 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�c , the p ,, r' ndpenal • fperjury? h
a the information provided above is true and correct
LA Signature: ''° D ate: (
Phone #: 1 4 I? ? °` 1 4) 6'0 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 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) [D Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks ID Siding [Q] Other [0]
/ Brief Description of Proposed p
Work: 1 /-- eplacen -1- 1 I r►.1.0,4 ‹ --1-Y ,M
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 .
1. 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
, 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 , id , 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.
�r
P nt f p!
Signature of Own Agent / f Date
SECTION 8 - CONSTRUCTION SERVICES
��8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder : (2.-0 T' E 3i -k
1 License Number
1 2"j (2_ooseue t- , tj-e a 7 0 1 I
Address Expiration Date
Fc8-i t I . k / Al t o f`) 1 o 3 9
Signature L a„...tie d____ Telephone 7 7 , t ZS ^ i A j �U 1
i9 Registered Home improvement Contractor: Not Applicable ❑
tJ Qo b-r f B i- :Y" 1 5 . 4 1
Company Name Registration Number
tA) t n anq GOV Let- 4- 1.0 4e-rn AAA S / A r.. 3 /is ) / 2
Address ( C Expiration Date
3.7 1 W A t Yl t , C t ' S+ G)L'- Telephone 4137 t tag eta)
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 0.- 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 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 O DONT KNOW O YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO a DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O ,Date Issued:
C. Do any signs exist on the property? YES O 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 O NO O
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 O
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 Pernrnit
• 212 Main Street Sewer /Septic Availability
ti
• Room 100 Water/Well Availability
- -' Flo pton, MA 01060 Two Sets of Structural Plans
pho -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 Property Address:
This section to be completed by office
q.-7 C,.. µ �' Q Map Lot Unit
f � - rn � M ft o F 4 o to 2- Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
i
I f , e,2r E &it i.Flva 35i VIA inIA- St 6+ A a 3.
V Na e - ri ) / - Current Mailing Address:
s It " i n 3 — 1 ifo . q q Cav
Sig nature P. � ` ��/ Telephone
SECTION 3 - ESTIMATED CONSTRUCTION CO ;
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant ,
j i. 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) Check Number /ova.. ,36--
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
97 AND' HILL RD BP-2011-0252
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map :Block: 29- 409 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- 2011 -0252
Project # JS- 2011- 000422
Est. Cost: $4111.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT E BUSHEY JR 57011
Lot Size(sq. ft.): 1 5071 .76 Owner: BRICK JUDITH R
Zoning: URA(100) / /WSP Applicant: ROBERT E BUSHEY JR
AT: 97 SANDY HILL RD
Applicant Address: Phone: Insurance:
351 WALNUT ST EXT (413) 786 -9906 WC
AGAWAMMA01001 ISSUED ON:9/21/2010 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 9/21/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner