29-083 y .
\Epp--SAFE r 1� Window World of Western Massachusetts HIC#165641
1' i,j J�e WI 1029 North Rd.-Hampton Ponds Plaza CSL#57011
y J I,„ &V CO14 10, Westfield,MA 0108'5
cFkriF Fo 1,` Phone(413)485-7335•Fax(413)485-7055 S ✓ GOOD''.
"Simply the Beef for Leas" T NOUSBASSPlNG
www.windowworldofspringfield.com I BBB •n ... f a lode Chiklreas
NAT-41779-1 "----''" Leh llosplw
. Name: bah d t.1 q✓\/ 0//1.(�f�St'//a(,(/- Phone(H): S,3-41�6pl�1
Install Addr: -7,( CV?L'Db ft pr, Phone(W):
Bill Addr: /J✓PiLICP ) /1h O/c26,2/ E-Mail: `/
WINDOW WORLD 111\9_1l11gy*uy•L!:r:hrI'h:h:h. dalx.9cPS.l.F
i
Series 2000 Mech.Frame Welded Sash $189 i 17 MA.Energy Reg w/SolarZone+Argon 5
/1/ Series 4000 Double Hung - $205 2_5r1 O Energy Star Upgrade $24
Series 6000 Double Hung $239 I Foam Insulation on Jambs $16
_Picture Window $329 Remove Window From Property $16
2 Lite Slider $329 Lifetime Glass/Seal Failure Warranty $16
3 Lite Slider('/4,'/2,'/4)('I3,'/3,'I3) $520 Transferable Lifetime Warranty $10
Awning $285 In Home Service $15
_Casement LH RH $285 Double Strength Glass $16
_Twin Casement(Requime2 value,)(0973)(0979) $570 Total Options: $158
Three Lite Casement(Requires 3 Value) $885 09 SALE PRICE(Save 50%) $79 17'J
Basement Sliders<55 UI ,$3g j Heat Buster Package Upgrade $20
S Hopper(In existing wood)(Vent 044$126). '0109 S 5 S —4 PRE 1978 BUILT HOMES(Federal Lead Containment Law) I—
Specialty Window EPA LEAD SAFE(Perwindow) $60
B• ay/Bow 0...kw.em,Inn.c..ing&en.cap) $2875 EPA LEAD SAFE(Patio Dr/hay/Bow/Garden) $100
Garden(Int.casing A out capping/ $1875
odde/Eceowtrim.vgoag.wcaor.eakelat.d:rwwUpgrades MY HOME WAS BUILT IN THE YEAR ?.d90 Initial:
R• emove Existing Bay&Reframe $295 I decline third party verification(Initial):
Roof for Bay/Bow Window $450 (Initial)I have received a copy of the Lead hazard information pamphlet
S• econd Floor Installation i$500 informing me of the potential Ask of the lead hazard exposure from renovation activity to be
Window Color w fnv/� $ performed in my dwelling unit The EPA"Renovate Right"brochure.
Inside outside _(initial)I have received a copy of the lead test result(s).
' I WINDOW WORLD UPGRADES I
Full Screen $25 Sign: Date:
BEIGE Color charge $35 Name(s)(Print):
Ext.Color(A As)(DC)IH t(TO)(ER)(CG) $165 _ ) MISCELLANEOUS LABOR
Woodgrain Interior(col(Doi(cw(F)g(AosISM) $95 1L/ /W
Full Exterior WhiteTrimrap(SMOOTH)r(PVC) $75 /0
Contoured/Flat Grids crop)(FUw(ENDS) $40 t Color Other Than White $10
—Prairie Grids(smgleu(DOUheq-(Fletv(contourl $69 - Specialty Custom Exterior Trim/Wrap $
D• iamond/Brass Grids(TOP)(FUw $69 Quick Trim(Int)(Ext) $30
Oriel/Cottage Style(40/60)(60/40) $30 Metal/Vinyl Out $100
O• bscure Glass Per Sash(eo,)(FULL) $35 Mull Removal $30
Tempered Glass Per Sash(eoruFuw $65"- Mull to Form Multi-unit $30.
.28 Glass(scoosuiteso0)» $129 Install Interior Stops MITEVINyq $45
Catalog Options $ Install Exterior Stops(wino VINYL) $45
VINYL PATIO DOORS-LH or RH(Outside Looking In) Customer Provided Stopslfrim.T. $20
Includes:White Interior Casing and Exterior Trim. I Install Interior Casing $60
5 Ft.Sliding Patio Door(u4)(RH) $1250 Repair/Replace Sill or Jamb $75
__6 Ft.Sliding Patio Door(Ltt)(RH) $1300 Mobile Home Conversion $200
__8 Ft.Sliding Patio Door(LH)(RH) $1500 Remove/Re-Install A/C or Awning $100
__Patio Door Beige Color $125 Site Setup: $250.00
Patio Door Low-E/Argon $125 - EPA Lead site setup&disposal fee: swing
__Heat Buster Package Upgrade ,. $215 EPA Lead,third party verification: $47�&88-
Patio Door Grids(Regular)(ywodgra�n) $1Q0 Extra labor(Box on left f�desccription)$
Woodgrain/Brown(LO)000)(CH)(Fl) $2,p5, Total Amount Due$) S� (3 9 407
Exterior Colors 5(395 lr
Patio Door Triple Pane Upgrade $'150 50%Deposit Amount:$
Keyed Lock $36 Foot Lock $51 [ ]Cash ,✓
Storm Door $ [1,}4inance-(+4;e'lls Fargo ( )Other
NO EXTRA WORK IF NOT IN WRITING/INSTALLER NOTES [ ]Check fade ttndow World of WM# ,
f2 t y -t 1 l„� i I'y)On� Exp.Date:_ L(_/S V-code: riiICEXP-
. -/ l u/ Final Payment Amount:$
\ To be paid to the Installer upon installation.Thank you.
I WINDOW WORLD CARES I
Sales Rep Recommended: [1 Interior Stops[]Exterior Capping:
Customer Declined: [I Interior Stops[]Exterior Capping: St.Jude Children's Research Hospital
F
WW of w.Massachusetts anticipates starting live work on-' a and be11i subshantikket,plerad _Uan:Se�ritY In ereStlha e .Any depose required in advance of the start at Me wok
SHALL NOT exceed 331/3%af the total contract price or the actual cost of any material or equipment of a specie orderer custom made nature,which must be ordered in advance of the start of work to assure the project
will proceed on schedule.No final payment shah be demanded until the contract is completed to the satisfaction on all parties.Ml home improvement contractors and subcontractors shall be registered and that any inquiries
about a contractor subcontractor relating to a regabation should be directed to:Office of Consumer Affairs and Business Regulation,Ten Part Ran,Suite 5170 Boston,MA 02110 Phone:(617)973-9700.No work
shag begin prior to the signing of the contract and transmittal to the eweer of a copy of such contract.WW of W.Massachusetts under provision of Chapter)42A of the general laws is required to appy for and obtain
all required construchar-related permits.WW of W.Massachusetts shall not be deemed responsible for delays in the work described in this agreement caused by regulatory,permit granting agencies,authorities or indhhdu-
.als Notice:If the PURCHASE/1(S)obtains his own construction related permits for the work deacdhed under this agreement or deals with unregistered contractors,the PURCHASER(S)is INrnbg advised Mat in
• the event of a dispute,judgement and nonpayment,the PORCNASER(s)will not be entitled to make a claim or collection from the guaranty fund established by Chapter 142A,KAI.
You the buyer may cancel.thls transaction at any time prior to nddedgbt of the third business day alter the date of the transaetlnn. -
Notice of cancelaton mum be in writing or posbnarked notate,than midnight of the following third business day.v S IS A CUSTOM-RPER NOT FOR RESALE!
• G i s" c /7-/n
•
/ I 1wn--r Date
c 9'1, fL - /77_ .
Sales Rep...: Date Own Date
,' 3. White Copy-Original Tallow Copy-Fll.ti, Pink copy-Customer Roe 07)1
The Commonwealth of Massachusetts
--- Department of Industrial Accidents
Ili=MNM 9�wl Office of Investigations
_��
�.r _;� 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): W 1 N DNA) h1 DR lb PF wESTRI) MkSSAC(4I SETTS
Address: 1 d 2a ja1 V a'i14 9:1)
City/State/Zip: WESTlr1.-tj MA- c'tCSS Phone #: 4i 3 'I SS — 7 335
Are you an employer?Check the appropriate box: Type of project(required):
1.I I am a employer with 2. 4. [II 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. ❑Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' q 0 Building addition
[No workers'comp. insurance comp. insurance.:
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 1 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 12.0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no 13.M Other R�QI.ACEMIT
employees. [No workers' W I R X05
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: LI BEtav MUTUAL l/1/4151441ANCE —
Policy#or Self-ins.Lic.#: W C,2.— 3 1 S- 3/-71147 -01 t2 Expiration Date: 6-7-ZD t
Job Site Address: Z r A Ilk l_hrt' k Dr. City/State/Zip:He%'`0l f 414 0/Oct:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify u ,er the pains and penalties of perjury that the information provided above is true and correct.
Si ature: Are'r firhh 44 Date: `71.22-y 3
Phone#: 14 13 gi 5 - '7335
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑■
Name of License Holder: nU �7 E. 5 3 i1.1 jr
License Number
117 rictiZrre 1-1 /4.a
.3701/
Address ' Expiration Date,
ji,P1,►1cs //►/(s f_ i O/b3o 6/1137/3
Signature Telephone
At,
, .---A Not Applicable ❑
9.Registered Home Improvement Contractor: pP i 1,
gl,„,/- Lz Y .0 ` 1
Company Name �� / jr.�� Registration Number
N dc,:/, Cori) ti
� bikci 01 Alf Ckgr iP(.. 3// //y
Address [� / / /'�A Expiration Date
110 Z-"t /Vc'i111 l W/114tT Ii/ A Telephone L/3—i i3'+335
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 y 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 n Addition ❑ Replacement Windows Alteration(s) i J Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [❑ Siding[El] Other[CI]
Brief Description of Proposed j
Work: ( I re p(
ciz 1A : &,,.)(.v1CG`"4/..S
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
, 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.
C~ a4 Date
Signature of Owner
I, Kehl L5U-51C-e l , as Owner/Authorized
Agent hereby declare that the statementsnd 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.
'chill 81, 'Ury�J
Print Name l
CS �s .7 A
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 C YES C
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T 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 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
, Date Issued:
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 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 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
R _
Department use only
APRCi r of Northampton Status of Permit:
APR ,2 5 20/3 B ilding Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
DEPT.oF T-- — Room 100 WaterMlellAvailability
I NCI-37 NAMP _-_
r�'� t�ti 0-71 IONS No hampton, MA 01060 Two Sets of Structural Plans
phone 4 -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
This section to be completed by office
1.1 Property Address:
2 1 1 A 4_tDv 1;�- 'De-, Map Lot Unit
Zone Overlay District
1—(e,P-C/4 L.L / M A V L O t, Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
3o + `ri Dt ee& (-f 2) A'-it i t a Di.
Name(Print) Current Mailin Address: 55
C,3 Q (,u'YI, aC+ Telephone
Signature
2.2 Authorized A
7
ent: ( ��
'&441 C�. 614S`e /67- AJ4 /? / IA.4s/I /J` A 6/t
Name(Print) f/ Current Mailing Address:
4113-1/ 5 -7335
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 55/5. (.3z3 (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) 5l 57 , 0V Check Number /0? •7 9 # 3.-
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
A.
21 ACREBROOK DR BP-2013-0999
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-083 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit# BP-2013-0999
Project# JS-2013-001670
Est.Cost: $5515.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ROBERT E BUSHEY JR 57011
Lot Size(sq.ft.): 14984.64 Owner: DUSSEAULT ROBERT EDWARD&MARY P DUSSEAULT
Zoning: Applicant: ROBERT E BUSHEY JR
AT: 21 ACREBROOK DR
Applicant Address: Phone: Insurance:
1029 NORTH RD (413) 485-7335 0 WC
WESTFIELDMA01085 ISSUED ON:4/26/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 17 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 4/26/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner