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35-153 PREPARING FOR YOUR NEW WINDOWS AND DOORS 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 t$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. Window World of Western Massachusetts may not require an acceleration of payments as specified in the payment section (front) for the reason that he deems himself or the payments 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 of 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. Arbitration: Window World of Western Massachusetts and the PURCHASER(S) hereby mutually agree in advance that in the event Window World of Western Massachusetts has a dispute concerning the contract, Window World of Western Massachusetts may submit such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulations and the consumer shall be required to submit to such arbitration in M.G.L.c 142A. Window World Owner Date Date 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 dispute resolution even "where this section is not signed separately by the parties." This Window World`A Franchise is independently owned and operated by Window World of Western Massachusetts,Inc.under license from Window World,Inc. WM WC 05-14 Window World of Western MassachusettsGOOO - ; 1029 North Road-Hampton Ponds Plaza, • Westfield MA 01001 HOUSE*EEPINGI Phone (413) 786-9900 • Fax (815) 366-8039 NAT-41779-1 BBB "Simply the Best for Less"- www.WindowWorldofSpringfield.com HIC# 165641 St.Jude Cbildrens CSL#57011 Research Hospital Customer:. . Phone (h) Install Address: t . /•. t4if4, 4 1 Phone (w) d� Bill Address: f' r;";311 u' L>, E-mail WINDOW WORLD YAL S 4000 + 6000 SERIES PACKAGES 2000 Series Mech. Frame Welded Sash $189 n rgy St Plus U-Value_SHGC_ $79 4000 Series DH $205 oa lation Wrap $26 6000 Series DH $239 Lifetime Glass/Seal Failure Warranty $32 NZ Picture Window $329 Transferable Lifetime Warranty $15 2 Lite Slider $329 TDouble Strength Glass $26 N/C 3 Lite Slider (1/4,1/2,1/4) t1/3,1/3,1/3> $520 Total Options: $178 Awning $285 �`- PACKAGE PRICE Casement LH RH $285 Triple Pane U-Value SHGC $50 " Twin Casement(Requires 2 Value+) (0973) (0979) $570 Three Lite Casement(Requires 3 Value+) $885 PRE 1978 BUILT HOMES (FEDERAL LEAD ONTAINMENT LAW) Basement Sliders <55 UI $239 MY HOME WAS BUILT IN THE YEAR i ttr , IITIAL;—C ►°1 Hopper(In existing wood) (Vent add$150) $185/$250 EPA LEAD SAFE (Per Window) $60 Specialty Window $ EPA LEAD SAFE(Patio Dr/Bay/Bow/Garden) $100 Bay/Bow(Insulated seat,Int,Casing&Ext.Cap) $2875 Garden Window,(Insulated seat,Int.Casing&Ext.Cap) $1875 EPA Lead site setup &disposal fee: $100.00 Grids/Ext.Color/Int.Woodgrain/Colors calculated in WW Upgrades <-- ., EPA Lead,third party verification: $475.00 Remove Existing Bay/Bow $250 '�`�`-J 1 decline third party verification ❑ (INITIAL): Reframe&Retrim(stain/paint not included) $250 (Initial)I have received a copy of the Lead hazard information pamphlet Roof for Bay/Bow Window $450 informing me of the potential risk of the lead hazard exposure from renovation activity to be Second Floor Installation $500 performed in my dwelling unit,the EPA"Renovate Right'brochure. Window Color t/U f` / p (initial)I have receiveda copy of the lead test result(s), Inside WINDOW WORLD UPGRADES Sign: Date: Full Screens $25 Name(s)(Print) BEIGE Color charge $35 MISCELLANEOUS LABOR --' Ext.Color(AT) (AB) (DC) (HK) (FG) (ER) (CG) $165 Full Exterior White Trim/Wrap (SMOOTH) (PVC) $79 f' Woodgrain Interior(LO) (DO) (CH) (FX) (RM) (SM) $95 Color Other Than White $10 Contoured/Flat Grids (TOP) (FULL) (ENDS) $45 Specialty Custom Exterior Trim/Wrap $ Prairie Grids(Single)/(Double)-(Flat)/(Contour) $69 Quick Trim (Int) (Ext) $30 Diamond/Brass Grids (TOP) (FULL) $69 Oriel/Cottage Style(40/60) (60/40) $30 __,_Z�luminum/Vinyl or Steel Out $50/$125 Obscure Glass Per Sash (BOT) (FULL) $35 Mull Removal $30 Tempered Glass Per Sash (BOT) (FULL) $65 ul�ull to Form Multi-unit $30 Catalog Options $ 61nstall Interior Stops (WHITE VINYL) $45_ n Install Exterior Stops (WHITE VINYL) $45 VINYL PATIO DOORS - LH or RH (Outside Looking In) Customer Provided Stops/Trim $20 (Includes: White Interior Casing and Exterior Trim.) Install Interior Casing $60 5 Ft. Sliding Patio Door (LH) (RH) $1250 Repair/Replace Sill or Jamb $75 6 Ft.Sliding Patio Door(LH) (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 Patio Door Low-E/Argon $125 Site Setup, Removal, In Home Service, etc.: $250.00 Heat Buster Package Upgrade $215 Extra labor (Box on left for c-script' n)$ Patio Door Grids (Regular) (Woodgrain) $100 Total Amount Due$ `Sj ' SS ((�� Woodgrain/Brown (LO) (DO) (CH) (FX) $225 50%Deposit Amount: $ Exterior Colors $395 Patio Door Triple Pane Upgrade $250 Keyed Lock$36 Foot Lock$51 [] Cash Storm Door Model $ (fiance- O Wells Fargo ( )Other NO EXTRA WORK IF NOT IN WRITING! [] Check made to Window World of WM# CC# Exp. Date: V-code > ' Wo Final Payment Amount$ To be paid to the installer upon installation.Thank You. Sales Rep Recommended: [] Interior Stops [] Exterior Capping: WINDOW WORLD CARES Customer Declined: [] Interior Stop [] Exterior Capping: St.Jude Children's Research Hospital $ WW of W.Nhassachu5etts artlCipates starting this wont on "�' grid beirig� ob tantially`oompfe`ted in days Security Interest:Yes No Any deposit required in advance of the start of the work SHA L 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 of all parties. All home improvement contractors and subcontractors shall be registered and that any inquires about a contract or subcontractor relating to a registration should be directed to:Office of Consumer Affairs and Business Regulation,Ten Park Plaza,Suite 5170 Boston,,MA 02116.Phone: (617)973-8700 No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. WW of W. Massachusetts under provision of Chapter 142A of the general laws is required to apply for and obtain all construction-related permits.WW of W. Massa- f 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! Owner Date "ALI / Sale an k Date Owner Date This ftndow CrW Franchise is independently owned and operated by Window World of Western Massachusetts,Inc.under license from Window World,Inc. WM WC 0e-14 White Copy-Original Yellow Copy-File Pink Copy-Customer + -1 ® YY r DATE(MMIDDNY) ACOMI CERTIFICATE OF LIABILITY INSURANCE 4!512014 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: If 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 FORREST INSURANCE AGENCY rug E: T 603 NORTH MAIN STREET PHONE FAx E LONGMEADOW, MA 01028 EAWL A/C N°' ADDRESS: INSURERS AFFORDING COVERAGE NAIC# NSURERA: Liberty Mutual Fire Ins 33600 INSURED INSURER B: WINDOW WORLD OF WESTERN MASSACHUSETTS INC IN URERC: 1029 NORTH ROAD INSURER D: WESTFIELD MA 01085 NSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 19759433 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.POLICY EXP INSR TYPE OF INSURANCE INSD WVD POLICY NUMBER LTR MMIDDY EFF (MMIDD/YYYYi LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ A CLAIMS-MADE I OCCUR PREMISES $ MED EXP(Any one person) $ PERSONALSADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY PRO ❑LOC PRODUCTS-COMP/OPAGG $ JECT OTHER $COMBINED SINGLE AUTOMOBILE LIABILITY Ea accident $ ANY AUTO BODILY INJURY(Par person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ A WORKERS COMPENSATION WC2-31 S-377947-014 5/7/2014 5!7/2015 / STATUTE ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 1000000 OFFICER/MEMBER EXCLUDED9 ❑Y NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1 000000 If yes,describe under DESCRIPTION OF OPERATICNS below E.L.DISEASE-POLICY LIMIT $ 1000000 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF NORTHAMPTON THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN: BUILDING DEPT ACCORDANCE WITH THE POLICY PROVISIONS. 212 MAIN STREET NORTHAMPTON MA 01060 AUTHORIZED REPRESENTATIVE lea Liberty Mutual Fire Insurance ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD CERT NO.: 19759433 CLIENT CODE: 1481715 Anne ChandLes 4/5/2014 4:39:16 PM Page 1 of 1 -- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 105/23/2014 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: If 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 NAME: Laurence R. Forrest Forrest Insurance Agency PHONE 413 858 2680 FAx 413 858 2685 (A/C,No,Ert): (,C,No): 603 North Main Street E-MAIL ADDRESS: East Longmeadow, Mass. 01028 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Insurance Company INSURED INSURER B: Window World Of Western Massachusetts, Inc. INSURER C: 1029 North Road INSURER D: Westfield, Ma. 01085 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. POLICY EFF POLICY EXP ILTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DDlYYYY) (MM/DD/YYYY) - LIMITS A GENERAL LIABILITY X EACH OCCURRENCE E 1,000,000 x COMMERCIAL GENERAL LIABILITY 7520025998 04/09/14 04/09/15 pREMISES(Eaoccurrence) E 100,000 CLAIMS-MADE [il OCCUR MED EXP(Any one person) E 10,000 PERSONAL&ADV INJURY E 1,000,000 GENERAL AGGREGATE E 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG E 1,000,000 POLICY JE° X LOC E-enr9m SINGLE LIMIT AUTOMOBILE LIABILITY 1020018702 05/12/2014 05/12/2015 (Ea accident) E 1,000,000 BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) E AUTOS x AUTOS I PROPER TY DAMAGE NON-OWNED E X HIRED AUTOS X AUTOS (Per accident) E A X UMBRELLA LAB X OCCUR 4600055451 05/17/14 05/17/15 EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE E $ DED RETENTION $ H- WORKERSCOMPENSATION Certificate To Follow TORY LIMITS ER AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? IN/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE E If yes,describe under E.L.DISEASE•POLICY LIMIT E DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if moos space is required) CERTIFICATE HOLDER CANCELLATION City Of Northampton SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 212 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Northampton, Ma. 01060 Attention: Building Department AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Massachusetts - Department of Public Safety Board of Building Regulations and Standards CumtructOn Supenicur License: CS-057011 ROBERT E BUSHXY, 127 ROOSEVEL);AV1 <: 7;� Feeding Hills MA--0103'� A Expiration Commissioner 06/28/2015 ouin.u.rincvr M.......1uj(Wj 4��__Office of Consumer Affairs&Business Regulation IMPROVEMENT CONTRACTOR Registration: 165641 Type: ; zpiration: 3/15/2016 Private Corporatio WINDOW WORLD OF WESTERN MASS INC ROBERT BUSHEY 1029 NORTH RD WESTFIELD, MA 01085 Undersecretary The Commonwealth of Massachuseft Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 www mass govMa Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): W I lV JMW tUDR LD DE WV-ST r= Mq SSACN%l5aFTT3 Address: 1 02a NVR-FR City/State/Zip: W PSTF 1 F L.> M Or 17 t 0 SS Phone#: 413 't 4 S — 7 Yb S Are you an employer?Check the appropriate box: Type of project(required): 1.(9 I am a employer with Z 4. ❑ I am a general contractor and I employees(full and/or part-time)." have hired the sub-contractors 6 C]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 g, [] Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers'comp. insurance comp.insutance.t 10. Electrical rs or additions required.) 5. [� We are a corporation and its ❑ ' 3.❑.I am a homeowner doing all work officers have exercised their 11.❑Plumbingg,repairs or additions myself.[No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.) c. 152,§1(4),and we have no 13.(�Other RLACsFlr►E�IT employees. [No workers' comp.insurance required) *Any applicant that checks box#I must also fill out the'section below showing their workers'compensation policy information. f 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: 1_1 BE-0-TV MkTUAL 1A1S1.LR,Wa Polic-#or Self-ins.Lie.#: 111/(!,2-- 3 1 S- 377 Q�7 '01 g► Expiration Date: •20_� Job Site Address: 725 e\ AN KD City/State/Zip:RWENCA IW, 6 (6 6 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 S 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 5250.00 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 wider the pains penytties of perjury that the information provided above is true and correct e. TA Phone#• 13 4Q 5 • 7335 Offw--W use only. Do not write in this area,to be completed by city or town ofj`reial 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 1 licensed Construction Supervisor. Not Applicable ❑ Name of License Holder: ���RT E dL($14 ky License Number 12'7 R005EvEL-71 AVE 57011 Address Expiration Date FEEDiM WLI-S MA (7)S)30 41 £'A Signature Telephone l 2 � J f� .Registered Home Improvement Contractor. Not Applicable ❑ Rv 6EP.r 1;RSV+f_V 55fZ 1 5 LP 4 1 Company Name Registration Number W I A 'DU-A) W DYL1.D 4€ W�STEP-0 M ASS 1.0 G � 1 151 ) (,o Address Expiration Date 107A NOM {Z-b W%STE1tLtd AAA 011D$5 Telephone yt3L 733! 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.......V 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 1083.5.1. 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 Officials that he/she shall be responsible for all such work performed under the buRdine 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 i SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) i New House Addition EJ ReplacementVAndows Alteration(s) � Roofing Or Doors Accessory Bldg. 0 Demolition 0 New Signs [Q] Decks [Q Siding[Q] Other[d] Brief Description of Proposed C' Work: ) �C�MT V�tNti11j d' 'I Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No I Plans Attached Roil -Sheet sa. 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 L 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 1. 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. ( sic "rc,Cf) -- Signature of Owner Date 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. (Z 0B T OVS 4E Py nt Name =' 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 O DONT KNOW O YES O 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 O 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 O 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 0 IF YES, describe size, type and location: E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 4 acre or is it part of a common plan that will disturb over 1 acre? YES O NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Dew use oniy of Northampton y Iding Department . 4 , JUL 3 0 2014 !! 12 Main Street r. 1�u{� Room 100 as V��� a /z Insp mgton, MA 01060 Electric,Plumbing& zf Northamptorp anwW 3- -1240 Fax 413-587-1272 �' u S 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: 7 jZI) map> Lot Unit F Ul 2 EN C E I N\-A p( d W_ zom overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: TCi"tJ N\6N()Y­fi 7`6 RNAN D b t02 Name(Print) w Current Mailing A ddress: j Telephone Signature 2.2 Authorized Agent: R�q o&P_T >F 8 u 5 N E 102C1 N O M W E STf 1 eLD AAA ©I 0 f5S Name(Pri Current Mailing Address: 1 1 2 4d�_A, -- 413 4g5 33 S Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by rmit applicant 1. Bui.Jing (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=0 +2+3+4+5) i-3 0 v . Check Number This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date 788 RYAN RD BP-2015-0132 GIS#: COMMONWEALTH OF MASSACHUSETTS MW:Block: 35- 153 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-2015-0132 Project# JS-2015-000237 Est. Cost: $3050.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ROBERT BUSHEY JR 057011 Lot Size(sq. ft.): 15333.12 Owner: MONSKA JOHN M&JEAN M Zoning: Applicant: ROBERT BUSHEY JR AT. 788 RYAN RD Applicant Address: Phone: Insurance: 1029 NORTH RD (413) 485-7335 O WC WESTFIELDMA01085 ISSUED ON.81112014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 5 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 8/1/2014 0:00:00 $35.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner