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29-173 Renewal - #;;- byAnder �en� > WINDOW REPLACEMENT an AnckraenComparty To whom it may concern: Enclosed is a permit application package for a project we have been contracted to do in your town. Thank you in advance for receiving this package by mail. As we work in every town in the state, it greatly helps us in our process. We have also enclosed a self addressed and postage paid envelope and would request that when the permit application has been processed, that you would mail it back to us. Enclosed for you review in this package is: o Permit Application o Home Improvement Contractor License o Construction Supervisor License o Proof of Insurance o Proof of Energy Efficiency Rating o Signed Contract from Customer o Permit Fee (if accepted at time of applying) If you have any questions regarding this application please call me at: 508-351-2200 X55285 Regards Kelley Donahue Permit Coordinator 104 Otis Street Northborough,MA,01532 Phone(508)351-2200 Fax(651)-351-4807 Website:www.renewalbyandersen.com • f'1rr.CO n:d fnr rry rn0!4_[.�E. QJn hS;ih Sl`rt:rlr 1_. 1n•'•5 . Canada qJ : :T { __ ..rr m Weser w tiaaresedimma4aaayare 'N. newal EWE by derseri. AM•awA**1 an* rr A.erimGrpv» AND-N-37 Nottgattreittlirattn Vtnywlood Composite Material Dual Argon Low-E4 SrnartSun Product Type: Picture ENERGY PERFORMANCE RATINGS U-Factor Solar Heat Gain Coefficient 0.27 1 . 53 0. 22 (U.SJI-P) (Me311c1S1) ADDITIONAL PERFORMANCE RATINGS Visible Transmittanr 0 . 51 ;dr.ralaself~ma ma WAN!Ares emaarrn molars*!FM preowares for aslenrolnlnue.i.polka' Paaomonad WSW mew arc aancaa for alms•aaa en.1.1 rara..rur w s*WM*Praars�. •FRC saws mar•ooramaao ap'paling amt Iwo**+.***1111**mall.+Haws MaF.aYOr stf mama um con.; amass■craw F'aarCP•laalraaaws aaanansea war n1111as '' ‘.1 �.4r.• [ Ii (I !; Andersen • •- —011: a VVIndow • MMYNnquref • corsa ranaiaa7)11 Surd Rating tome NI...aN Oi4eICS11 itts„auI...n-ra OP psi F-050 • • Gan Sears �aMre, s ,64 a.wr•.r=Was'maws ewes ("smog mbar Ay. naarrr mr aaala and tkrirtse rn�l eauarwor 100-00591OO6-001 halal W aledeom Cr-G:>1 IX1`.0.AW W1a701.*/awerserom word"Humane cafmld0aafl PlgOlar�. • • • • ir��+ car ,rail 3 • • • m 1 F. •••• . " c• Ls . I . .• �, �, _ 1: . < C _ c E'• •_(` iT IY� • . - • -GC ...vim.+... ,n ', • • . ®<c�..ar • . • 1 .+c . aii -t - bi i., <- • • 1i1-- , .,,,. • • • • A 1D-1 34 WoadffirrYl Cnpc #F •-77_7-- - _ •- Dual P`rodUat Ty,GUder . • ' ENERGY PEfoEMANCE Val:NM — _ • U-F r • 'Sa r Neat( 1 1eri 029 J L i • d c � . V)s Transmdfrrce - '• • . '0 r43 • .. -- ... . • . . • . • . • . _ ... ,.„......•11,1012leieWMINOMEMMOIVIIIIIMaireidak Few& . - Ra.eYaarrrrsamre..wmeskar-MIIMMIcMBuelik . 1114Cesqleglimialf zarranm+rmsnan!allailcdmw' '► 1'TdtMk • . -1' 1\' --• . • ' • _ ri; i-`-:vi'ca'r` • • • Ivlderleh _'Rb'1�, !Vihnclov • M ,r7�ratwtm�rh gdRO • • • , 5tar�d' • .-F�sa1 •A� LL 3 • • ,•• ' stupor _ yecaloc.moe - • • •1E04E5114c 12•' - 1 w Y a" ',mew.URPMCEM[MT IAMivaGis, vseisror,.. �C N full Argon tow E4 q Oath i 100404736111-010 1 . (KERRY PERFORMANCE RATINGS t1-Factor(U.S)fl-P lar Haat Gain Coefficient II 0 .29 • 0 . 19 I . ADDITIONAL PERFORMANCE RATINGS Visible Transmittance . • i 0 4 2• . .. w++.l.+. Myr galweaselrotsapplbak MC piregme•Ilar----mt,irww/NNW podmvors. v..ar rnY--renitard_roU•r••ta4•ef¢/carer•ia IOW ilessaal' a.w..or�w•wifetwwtwrbserser ram Os h.:�ge•pe.e■. a • q.r.rtpmtrMw etlkIt e i 1 DESIGN PRESSURE('SF) ' > 1.�• j -L 5 - ►D8lnpedSiLl. 011 IR fat rams*114.CfA,$E.O.C.iYMMY.•phorreMalwrkatwla AYM•a 1 • ��.rw..Y•. .�.r..r�-�r�� ..• • • .- �• ' T �• I ' 1 • c_Jlie of adoac%it6el ffice of Consumer Affairs&Business Regulation `c".°' •ME IMPROVEMENT CONTRACTOR dr= egistration: 170810 Type: Expiration: 12/23/2013 Supplement( RENEWAL BY ANDERSON CORPORATION JOSEPH REZZA 104 OTIS STREET � —�8�-- NORTHBOROUGH,MA 01532 Undersecretary • 9 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen isor License: CS-065272 4), ms's w aY JOSEPH P REZZ/,` 168 KELLEY BLVD k N ATTLEBORO MA f 92.••••• ,� �" Expiration Commissioner 04/25/2014 CERTIFICATE OF LIABILITY INSURANCE J DATE 5/2""'°0112'"'' 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 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: H the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 1-612-333-3323 CONTACT Jonelle Hargrove or Eric Johnson Hays Castpanies PHONE mac�AM FAX 612-333-3323 ph* 612-373-7270 80 South 8th Street ADDRESS: Suite 700 PRODUCER Minneapolis, MN 55402 CUSTOMER IDS: INSURER(S)AFFORDING COVERAGE NAIL INSURED INSURERA: OLD REPUBLIC INS CO 24147 Renewal By Andersen Corporation INSURERS: NATIONAL UNION FIRE INS CO OP PITTS 19445 104 Otis Street INSURER C: INSURER D: Northhorough, MA 01532 INSURER E: _INSURER F: • COVERAGES CERTIFICATE NUMBER: 29229436 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION 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 HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. • POUCY E POLICY EXP 1L RR TYPE OF INSURANCE INSR_WVD_ POLICY NUMBER .iMyIDWYYYYL ARWDp/YYYY1 LETS A GENERAL LIABIUTY MWZY 59828 10/01/11 10/01/13 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY ES(Ea occurrence) $ 500.000 {CLAIMS-MADE X OCCUR MED EXP(My one person) $ 10,000 PERSONAL i ADV INJURY $1,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 3,000,000 I I POLICY JfEOT 1 1 Loc A AUTOMOBILE LJABILJTY MRTB 21700 10/O1/1: 10/01/13 COMBINEDSINGLE LIMIT $3,000,000 (Ea accident) X ANY AUTO BODILY INJURY (Per person) f ALL OWNED AUTOS BODILY INJURY(Per sodden!) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS accident) X NON-OWNED AUTOS $ $ B X UMBRELLAUAB X OczUR 13273355 10/0l/l: 10/01/13 EACHOCCURRENCE $25,000,000 EXCESS IJAB CLAIMS-MADE AGGREGATE :25,000,000 _ DEDUCTIBLE _ X RETENTION $ 25,000 $ A WORIRRSCOMPENSATION MC 117948 00 l0/0l/1: 10/01/13 I To Yt1titR AND EMPLOYERS'UABSJTY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE © NIA EL EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.LDISEASE-EAEMPLOYEE $ 1,000,000 — DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY UNIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES (Math ACORD 101,Additional Ressrks Schedule,N more space Is required) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE eric j ®1988.2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD • The Commonwealth ofMassachusetts �R :� Department of Industrial Accidents y W Office of Investigations ;; 600 Washington Street. i Boston,MA 02111 , , www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Elect ricians/Plumbers Applicant Information Please Print Leeibly Name(Business✓Organization/Individuao: K e r e o ci,\ 10 t o ,d - Address: k b -\ ,M, s S't . City/State/Zip: No r,--\- \\061`3 . ` 0 15 33 Phone#: 5- - ,3 S 1 —c9c 0 p . Are you an employer?Check the appropriate box: Type of project(required): i.0I am a employer with 3 p 4. Q I am a general contractor and I . employees(full and/or pact time).• have hired the sub-contractors 6 ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [ Remodeling ship and have no employees These sub-contractors have $. Q Demolition working for me in any capacity. employees and have workers' q Q Building addition [No workers' camp.insurance comp.insurance? required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing all work 11.0 Phunbitig 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 13.0 Other employees,[No workers' comp.insurance required.] *Any applicant that checks box g1 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 actors 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's providing,workers'compensation insurance for my employees. Below is the policy and job site information. . ` nn • ii Insurance Company Name: 0`c+r K��1_)`D\k c -n S . C.3 . Policy#or Self-ins.Lic.#: t A C- � I �- q'[ Y0(� Expiration Date: i 0 (- i 3 Job Site Address: )(D Uect t O1 . City/State/Zip: - \.,,, , D I O b 2 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify;i; - ; the pains and penalties ofperjury that the information provided abolt s and correct yl /3 Signature: . WO Date: r • Phone#: .3-0$ ' 3,s 1- 6O [Oiiiclal 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 . • 1 Contact Person: Phone#: - • • Renewal . , inewa1 by Andersen COrporati.. __ MA Home Improvement Contractor tAndersen. F 11/4 **,-- 104 Otis St.,Northborough,MA 01532 License#170810(Expires 12/23/2013) WINDOW REPLACEMENT an Andersen Company (508)351-2200•Fax:(651)351-4810 Federal Tax ID#41-1918413 WINDOW SPECIFICATION SHEET Buyer(s)Name Date of Agreement f l('z.r.6c/% _ X-€C 1, J--17- f 3 The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT, of which this Specification Sheet is a part. WINDOW DETAILS 1. Contractor will Install a total of ? windows in Owner's home,using the following individual quantities: Double Hung(DB) TEqual sash Cottage sash(1/3 top,2/3 bottom) Oriel sash(2/3 top.1/3 bottom) Flat sill aware of class oss) Square Check Rail_Curve Check Rail Casement(CS) Hinge right_Hinge left(as viewed from exterior) Double Casement(CD) 2 Lite Gliding Window(GW) Casement/Picture/Casement(CT) 1:1:1 or 1:2:1 I Glider/Picture/Glider(GPW) 1:1:1 or✓1:2:1 Picture Window Bay or Bow Awning Window #Lights Soffit/Roof Shingle/Copper Specialty Window Patio Doors(see separate door spec sheet) Seat to be Primed/Oak/Pine 2. 6 Qty of Windows to be Custom Fit Replacement: 3. 1 Qty of Windows to be Custom Fit FuII frame(INCLUDES NEW INTERIOR&EXTERIOR CASINGS) Exterior casings:_Pine ✓Maintenance-free material Factory applied 908 Fibrex brickmold 4.Glazing to be:_HP Low-E-4 TM Tempered Other If other,please specify:5.'s44-f 5.r •-, 5.Exterior color to be: by-White Sand_Canvas Terratone Cocoa Bean Dark Bronze_Forest Green Black 6.Interior color to be: /White Canvas Pine Maple_Oak_Same as Exterior Note:Wood interiors need to finished by Owner. 7.Hardware:White Stone Canvas Estate Hardware: Style: 8. ✓ Install Lifts with Double Hung Windows � 9. Screens:windows to have: Half or Full screens Screens to be: Fiberglass Aluminum ✓TruScene GRILLE DETAILS 10. Windows have grilles: Grille Between Glass(GBG)_Removable Interior Wood(INTW) Full Divided Light(FDL) ( )Owner approved(initials) Draw grille patterns below 'Use additional sheet if needed Qty: Qty: Qty: Qty: Qty: Qty: Qty: ADDITIONAL WORK DETAILS 11. c Qty of_Sills_Sill noses to be replaced by Contractor 12. - Contractor will remove metal frames of windows. ,r 13. ss Contractor will install new paint-ready or stain-ready_Interior Exterior casings in Pine Maintenance-free material 14. Contractor will install new paint-ready or stain-ready_Interior_Exterior stops in_Pine Maintenance-free material 15.( �C ) )Intls-Owner is aware,contractor does not do any painting or removal/installation of alarm system/hardware. It is the responsibility of the homeowner to have the alarm system/hardware removed prior to installation. 16. G Contractor will wrap exterior casings with coil stock of 1-4,% color. Note:Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing. 17.Contractor will insulate,caulk and seal windows with 3-Point system to prevent water and air infiltration. Removal and disposal of all job related debris,win- dows,storm windows and vacuum nightly included. Upon completion of the job and payment in full,a limited warranty shall be issued. 18.[►)'Yes❑No Building Permit—Contractor will secure any and all necessary permits.The fee for the permit(s)is not �� included in the Contract Price and a separate check is required at the time of sale for this fee. Ck# r(5 4 $ 35- 19. +11 res❑No All discounts have been applied to this agreement price. 20.Additional job details: 21.1J 4s❑No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment/finance form(s). It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,constitutes the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terms.This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both the Buyer(s)and Contractor.Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet. Re71,Anderse Corporation Buyer(s) Buyer(s) c Signature of Product Manager re Signature AkZe(7 r ELt be a back) Print Name of Product Manager Print Name Print Name Renewal ,:+0--!../„ .-,i, MA Home Improvement Contractor I _ License#170810(Expires 12/23/2013) bYAnderSen. Renewal by Andersen Corporation Federal Tax ID#41-1918413 WINDOW REPLACEMENT an Andersen Company 104 Otis St.,Northborough,MA 01532 (508)351-2200•Fax:(651)351-4810 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s)Nome Date of Agreement cf r.7 ,6e,tI, 5- 1 'u<< 6, 3 - 1-?- i3 Buyer(s)Street Address,City,State,and Zip Code / J �f/,�/ �+�, L 1 0 . -'c';,,----!%r e�< 2.�. n%)/7,41; ,' 7�c..-j /Y 1,i- li i L7 6 Z iY v� E-Mail Address Home Telephone Number Work-Telephone Number Cc-tf1 / ,-t Z S be-,--4 6 c o"..C-&>/ et `---/13-5-S-6--cf 2%f f l l 3- v /C? - 6 /07 Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of Renewal by Andersen Corporation ("Contractor"),in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheet(s) (collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreement. e. Estimated Starting Date: Method of Payment: Total Job Amount: /I 75 ( Amount Financed Ss-- t s" e it s ❑Check Cosh Deposit Received(33%): 0 5 E5--. C'c'r.5-C OVisa/MC ODiscover 0 ranted OAMEX Balance at Start of Job(33%): D Estimated Completion Date: If credit card is selected,please Balance on Substantial .-- - -�. I - 2 c.- . f see Credit Card Payment Form. Completion of Job(33%): ° 2 �' 1. S Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation from this Agreement will be valid without the signed,written consent of both Buyer(s) and Contractor. Buyer(s) hereby acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a completed,signed,and dated copy of this Agreement,including the two attached Notices of Cancellation,on the date first written above and 2)was orally informed of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Renewal by An rse. orporation Buyer(s) Buyer(s) By i . � ' Signature of Product Manager • Signature Signature ,4 // El 1 2 ob e:T4 Both Print Name of Product Manager Print Name Print Name YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. NOTICE OF CANCELLATION X NOTICE OF CANCELLATION Date of Transaction 3-i 7-/7 You may cancel Date of Transaction t- /7'/ You may cancel this transaction,without any penalty or obligation,within I this transaction,without any penalty or obligation,within three business days from the above date.If you cancel,any three business days from the above date.If you cancel,any property traded in,any payments made by you under the I property traded in,any payments made by you under the Contract of Sale,and any negotiable instrument executed Contract of Sale,and any negotiable instrument executed by you will be returned within 10 days following receipt I by you will be returned within 10 days following receipt by the Contractor ("Seller") of your cancellation notice, I by the Contractor ("Seller") of your cancellation notice, and any security interest arising out of the transaction will I and any security interest arising out of the transaction will be canceled.If you cancel,you must make available to the I be canceled.If you cancel,you must make available to the Seller at your residence,in substantially as good condition Seller at your residence,in substantially as good condition as when received, any goods delivered to you under I as when received,any goods delivered to you under this this Contract or Sale; or you may, if you wish, comply I Contract or Sale;or you may,if you wish,comply with the with the instructions of the Seller regarding the return instructions of the Seller regarding the return shipment of shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk.If you do make If you do make the goods available to the Seller and the I the goods available to the Seller and the Seller does not Seller does not pick them up within 20 days of the date I pick them up within 20 days of the date of your Notice of your Notice of Cancellation,you may retain or dispose I of Cancellation,you may retain or dispose of the goods of the goods without any further obl' tion.If you fail to without any further obligation. If you fail to make the make the goods available to the Seller, or if you agree I goods available to the Seller,or if you agree to return the to return the goods to the Seller and fail to do so,then I goods to the Seller and fail to do so,then you remain liable you remain liable for performance of all obligations under I for performance of all obligations under the Contract. the Contract.To cancel this transaction, mail deliver a I To cancel this transaction, mail or deliver a signed and signed and dated copy of this cancellation notice or any I dated copy of this cancellation notice or any other written other written notice,or send a telegram to Contractor: I notice,or send a telegram to Contractor: Renewal by Andersen Corporation, 104 Otis � Renewal by Andersen Corporation, 104 Otis Street, Street, Northborough, MA 01532, BY NOT LATER THAN Northborough,MA 01532,BY NOT LATER THAN MIDNIGHT MIDNIGHT OF 3 z-- /7 .(Date) OF 7--. -0 /; (Date) I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION. Buyer's Signature Print Name Date I Buyer's Signature Print Name Date RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink ©JBUP2009.RBA-Ph.MANH 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 I 1 F ) I Frontage I I Setbacks Front .. = I ' Side L: R:I I L:_...1 R:= I =1 Rear I I I Building Height Bldg.Square Footage Open Space Footage (Lot area minus bldg&paved I 1 I i = = 1 I parking) #of Parking Spaces 1 I = !ml Fill: 1, _ _. _ — I (volume&Location) 1 1, A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Paget 1 and/or Document#1 1 B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 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 0 NO IF YES, describe size, type and location: 4 D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO IF YES, describe size, type and location: µ 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 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 8-CONSTRUCTION SERVICES , 8.1 Licensed Construction Supervisor: �i Not Applicable ❑ Name of License Holder: J f.7,)t'p ,-\ t,e Z 2-Gk to_S?9.c License Numb r )61' \41 btuS 0 ■kAle. ,30,0,0 AA.,N 0;19-6 a /4 ,, ,c-ii 3 - Addres. r Expiration Date _5"b7- 3s- 1 - Qaco X )75-d t Signature ! Telephone 9 eriBred l-Iaiiiimprove.en.fCotttracoK I ES.ELM NR P A EL NotA PP Applicable ❑ rv\ctJ� . A An t seA j 4-b310 Company Name Registration Number • c \rt - r--\-\h\bto VV() 533 ) (9- -„93- (3 Address Expiration Date• Telephone...9-)i 3S t 0c)( _ Nt II SECTIO 0 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 j No ❑ .onie�.O ner t emithon, The curren$exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow'ch homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMt 780, Sixth Edition Section 108.3.5.1. Definition of Home .er: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 on • two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constr■ , s more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the : ilding Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed I . a er the building permit. As acting Construction Supervisor your presen - on the job site will be required from time to time,during and upon completion of the work for which this permit is issues. Also be advised that with reference to Chapter 152(Work- 'Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachu z is 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 : pliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massa setts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement�1 endows Alteration(s) E] Roofing n Or Doors DU . Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [I=] Siding [0] Other[0] Brief Descriptippp of Proposed Work: 1Zt,P cu-e- L) G`oti:� AD ,c't-r•0 Jrc 1 C,,L_&A1 Alteration of existing bedroom Yes 7-No Adding new bedroom Yes Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll -Sheet a if 1 e iv o ise anti or a Ic ition#o exilst�n�riousinp; complete:t'he 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, E\( v6_(,[` , as Owner of the subject property hereby authorize J O 0\1\ e to act on my behalf, in all matters retative to work authorized by this building permit application. Signature of Owner Date I, J O 5- 1`) ,as Owner/Authorized Agent hereby declare tl at the statements and information on the foregoing application are true and accurate,to the best of my k noZedge and belief. Signed under the pains and penalties of perjury. Print Name I I y)w C 3 Signature of Owned,gent \ Date . ��1 � ��'" Qep.;=pert � sPonl� �,�'��1z��� t��', fRECE1' ° City of Northampton t e , I s ,$ - 3 3 %Y , �sa Building Department s a 04. " :_ k i ni3 212 Main Street m d lay , 2 2 Room 100 " l O:`tli t ,� oly; INSPECTIONS orthampton, MA 01060 t �,& S��` � tiO F BUILDING.INSPEC " r pEPT.O PTON,MA° 3-587-1240 Fax 413-587-1272 P�t� � , 4140 �� RTHFM r r NO € acv ; i}2a Q , ar f. APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Pro er Addres sF -- - This section to be completed by office ID eel' <- \ Ur' ap Lot w "`Unit ,,� >�z - F kO e A c e , (ik d Zone 0 Overlay District ,w f x Y 3, Eirr� t District " ' ., CB District '� SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: -1\ ACA A,L n b ctL,L \kD 6cec r v U O., - ,„f.,. t,^,c. Oko6a ss: Name(Print) Current Mailing Addre k-- _- s2(G - a GL� Telephone Signature 2.2 Authorized A ent: • \ oSe. VCx-2-0, ,t— c - s -, k„)br�I. n ,I`ve Name(Print) Current Mailing Address: 06-3 fi s - s\- ajov x o-(;-,) 8S Signature '1' ` Telephone SECTiO' 3 STIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Budding Permit Fee ■1i3q-c--' 2. Electrical c-�( (b)Estimated;Total Cost ofi y� Construction from'(6) 3. Plumbing Building Permit Fee' 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) IA fi t , - .31. `3� Check Number !')7 — „ This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Com missioner/Inspector of Buildings Date 110 DEERFIELD DR BP-2013-0952 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29- 173 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 PE1RIVIIT Permit# BP-2013-0952 Project# JS-2013-001598 Est.Cost: Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: RENEWAL BY ANDERSEN 065272 Lot Size(sq.ft.): 16509.24 Owner: BACH LOUIS T&ELIZABETH J Zoning: Applicant: RENEWAL BY ANDERSEN AT: 110 DEERFIELD DR Applicant Address: Phone: Insurance: 104 OTIS ST (508) 919-0900 WC NORTHBOROMA01532 ISSUED ON:4/11/2013 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 4/11/2013 0:00:00 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner