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Product Type: Casement
ENERGY PERFOFMANCE RATINGS
U-Factor Solar,Heat Gain Coefficient
0.29 1 .65 0 28
U.SA MerdQ
ADOMONAL PFAFOSMMCE RATINGS
Visible Transmittance
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Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Super-dwr
License:CS-MI25
JABS
36 GARDINM ST-
LYNN MA 0190 ' x y=;7li:
i
jil Expiration
Commissioner 101OW2016
t�I�e �pon�onu�a�o�C'�aaoaa�tiJetli
ffice of Consaaur Affairs&Easiness Regulation
E IMPROVEMENT CONTRACTOR
Registration: 170810 Type.
Explrab0n: 12123/2015 Supplement e
RENEWAL BY ANDERSON CORPORATION
JAIME MORIN
104 OT)S STREET
NORTHBOROUGH,MA 01532
Undersecretary Y
ANDECOR-01 YADAVYO
CERTIFICATE OF LIABILITY INSURANCE 101112014 Y)
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 polk:y(les)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 endorsemeht(s).
PRODUCER NAME CT cortificates@wlills.com
Willis of Minnesota,Inc. PHONE S77 945-7378 FAX
do 26 Century Blvd No Eat:( ) Arc No):(888)467-2378
P.O.Box 305191 ADDRESS:
Nashville,TN 37230-5191 - -— - —--
INSURER(S)AFFORDING COVERAGE NAIC 0
INSURER A:Old Republic Insurance Company 24147
INSURED INSURER 0:
Renewal by Andersen Corporation INSURER C:
30 Forbes Road INSURER 0:
Northborough,MA 01532 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.
INTiR TYPE OF INSURANCE ADD P
POLICY NUMBER POLICY EFF MME LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
CLAIMS-MADE a OCCUR MWZY302940 10/0112014 10101/2015 PREMISES[Ea Ea occurrence $ 500,00
MED EXP(Any one person) $ 10,00
PERSONAL&ADV INJURY $ 1,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,00
X POLICY❑EC - OMPlPAGG $JT � 4,000,00
OTHER: $
AUTOMOBLE UABIL}TY COMEa aBcciINED SINGLE LIMIT derrt $ 5,000,00
A X ANY AUTO MWT8302575 10/0112014 10/0112015 BODILY INJURY(Per parson) S
ALL OWNED !SCHEDULED
AUTOS ..AUTOS BODILY INJURY(Paraccdent) S
HIREDAUTOS q� SQED Perwd en)DAMAGE S
$
UMBRELLA LIAB HOCCUR EACH OCCURRENCE $
EXCESS LIAS CLAIMS-MADE AGGREGATE $
DED RETENTION$ S
WORKERS COMPENSATION X PER O H-
AND EMPLOYERS'LIABILITY STATUTE I ER
A ANY PROPRIETOR/PARTNER/EXECUTIVE Y!N MWC30293800 1010112014 10/01/2015 E.L.EACH ACCIDENT S 1,000,00
OFFICERIMEMBER EXCLUDED? N❑ NIA
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,00
If yas,tlescribe under
DESCRIPTION OF OPERAI IONS below E.L.DISEASE-POLICY LIMIT S 1,000,00
DESCRIPTION F OPERATIONS I LOCATIONS I VEHICLES ACORD 101 Additional Remarks Schadula may be attached It more space t•required)
IP ON 0 0 ( y spa
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPREESE-NTTAATTIME
Evidence Of Insurance
Q 1988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department oflndustrialAccidents
O.;Q`ice of In vestigations
9 I Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electiricians/Plumbers
ABIRlicant Information Please Print Le 'bl
Name (Business/Organization/individual): RENEWAL BY ANDERSEN
Address:30 FORBES ROAD
City/State/Zip:NORTH BORO, MA 01532 Phone#:508-351-2200
Are you an employer?Check the appropriate box: Type of project(required):
1.n I am a employer with 30 4. ❑ I am a general contractor and T
employees(full and/or part-time).
have hired the sub-contractors 6. New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g, E] Demolition
working for me in any capacity. employees and have workers' g Building addition
[No workers' comp. insurance comp.insurance.#
required.] 5. E] 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 l l.[]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
employees. [No workers' 13.0 Other
comp.insurance required.]
'Any applicant that checks box#]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 anew affidavit indicating such.
tContractors 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:OLD REPUBLIC INS. CO.
Policy#or Self-ins. Lic. #:MWC 30293800 Expiration Date: 10/01/15
Job Site Address: 44 Westhamptom Rd City/State/Zip: Florence, MAO 1062
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 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 her y erti u der the pains and penalties of perjury that the information provided above is true pd correct
Signature: Date. '"C r
Phone#: 508-351-2200
Oflcial 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#•
RenLnVQj.jM Renewal by Andersen Corporation
-10 Foibe-�,Road*Niorthbaeuah, NljssaehuwLL8 fj 153-1 NA MmL
.%i-,t L,c r
bArx1emn Mme(50S 1 351,.41110-F as 4 SUS 1 9h6-70 72 12"'::1,2 i 1
WINDOW ■EPLACIENICUT Fe—teral'UxlPit 41,I9!S41-i
QWMACT AKM&MT
Tlu S Mlw-t Idjue.-it('.Al!iondflu.1 it-)Is L 0 t 1W t.1 IS TOM"YV1.NLV%V AM K RIMOEMING AV,KUNW-W f'.,V Mv rMt I t-)tly and
bQtWLCn X-twwjl EMI ArtIcmn CorpLxALLOCL 111d rUXtt1M 1111L:i Contr.rt:'Lr unt SUVCr(S)t'Wx►b ;k,-rcc tuMifv 1h,
Lvkw. #.'4kwr than ALS+JV Afic:jjl�, irt,V-JLA !Vlk-,-V.Aj 41,; t1w Agmvrum!will remain 2 ti full
t�)N,:-tad.L!-.fcL:t- rjiLi Airte,ulmeto is subj%�A,L!Utz Qnu,and 01IAi'.kVV101 tfIL VIVeIIW1I!. Tito JkAdjous
to the Swoeris)onl,-f-rod&w beirig tuadi!-
Amendment to contract there were noies copied over from a different contract OxtLog that we are dcAng header work to the"Indow
that Is not the cut with this project we w111 remove this.This has no effect on the price.
AS a rc.&Ult of thc`.w Ckwi see. 11W tolk-witt-, tc-rtn-i ,4 thL! -,\-.ovL:nwnt .irc A-w, L11AA1SLtl.4 411 ib,:rL LS 11-1 L01 12011 Will LN.- lCif b Wil LT
riLirkcd as`Y,e'.tnL1x4fi;iv,,th;d no%Akng�:
NEW TA-.j1 L+Ammuul: $5JAt)1.00 Pa-mk-ni Nielhad:
N,6:w Pqx-tiit R"vivW.S I Chcek
N,w RAin,-c at Start of j,*,:$1,96,3-67 (,.hevk",Cu4tiE Cud
\,',%v SjUm,-c -I ('h,.,vk,('tcdjE('.ird
S ub-zalit Ld CVMj-3,tx-n of jC b:S 1.`t4 64--
ft is alp wd and wxheetiaad by and bdween dia partin that"AmaWmtut and the ajgd&d Agowwzf wwdtiav 6%cn =unduAandirg bey
tureen ft pKta.ad ft=am no VMW=M&r*mftvp d=Mg or lwdWM=V of am terlms of thb Arnmdme�, PW hmvty wbwwi-
edSatho vua has r=d this An=Wumd and Ins raptiv sowTct4so4jmddoodoMcfidsArmnxbnadonhwirwrfflmb4ow
Rcriowd -
by Md==Carpmfim 09yaw
[E-Siqned : DEV21,213 0 M:15 W CST
Barbara D Jones
St.
Flat,:
S." 511,20 15
Print Narw 4 rn',,tuet Nbtttt,%:r
Renewal Renewal by Andersen Corporation MA(tome improvement Contractor
byAndetsen.1m 30 Forbes rd Northborough,MA 01532 License#170810 (Expires 1 2/23120 1 5)
WINDOW REPLACEMENT (508)351-2'.200 Fax:(508)'986.7072 Federal ID#41-1918413
Window Specification Sheet
Buversl Nano Date of Agrectnent
BARBARA JONES MARTIN KONOWITCH T SAT, AUG 1, 2015
The lxnt.t•s?listed above he_rehy jointl a
y and cera(k agree to purchase the gtxxis and/or services listed beltm.in acaxdance with the prices and ternvc described
on the STw6fwation Sheet and the fmnt and the metre of the accompanying CUSTOM WINDONC ALND DOOR REMODELING AGREEMENT of\,hick
the Specification Sheet is part.
WINDOW&DOOR DETAILS
app. Mv. aptu ExterlorAritenor Color Hard Ware Hard.— L—E4 r Cxilla Grate Glass
Room # .lain . uL Wutdow/Door Style Detail Castrxs Ext-Int Color Style Screens Srrvrt" Grilles Sash s,3 Sash 2 U is Options
Livino 100 116 57 173 CT 1:21 full frame Int/Ext MF 908 WWPN Stone Standard FFG 3martsur jmw pralr prair No No
Tonal 1 RAY,BOW&BUILD OUT DETAILS
rox
Style Detail t w dW Approx. Number Frame Window End Center LOWS/ Roof/ Hard Ware
Room Count Style Rankers w tasrngs Angle Lites Interior ExtMt Color Ght1as sashes sashes Screens smWtsun Soffit Color
SPECIALTY WINDOW DETAILS
Fun t Approx. Lowe/ specialty BAY BOW ADDITIONAL WORK NOTES
Roam Count style [risen U.L 3rnartS m Grilles Grille Style Exvint Color c—,kch.wufi tncnxn.k.....drr 72 innc�
nun c,ill tx•.ierufin.ea.gL,-M,.-_
ADDITIONAL WORK DETAILS:
Uving room 100: roiden opening and nndude header or new window
I No Contractor will wrap exterior casings with coil stock color of
Owner is aware that Contractor does not do any pairWrig/staining or removatlinstatiation of alarm system or window treatments/hardware.It is the responsibility of
L49 homeowner to have the alarm system and window treatments/hardware removed prior to installation. VNe make no guarantee as to whether alarms of window
2 treatments/hawWai a will fit after replacement. Customer is also aware in some cases there will be glass loss. H there is the amount will be dependent on the type
of existing windows,type of installation and window style.We make no guarantee as to the amount of glass loss.Customer is aware and understands any and at/
unseen rot is not included in this contract.Should any rot be frond there will be an additional charge for time and malenafs unless so stated in this contract
3 yes Contractor will insulate,caulk and seal windows with 31potnt system to prevent water and air infiltration.Removal and disposal of all job related debris,
windows,doors,stone windows and vacuum nightly included. Upon completion of the job and payment in full,a limited warranty shall be issued.
1 Yes Building Permit--Contractor will secure any and all necessary permits. The fee for the permit(s)is included in the total contract price.
5 yes All discounts have been applied to this agreement.
6 ✓ lea Nn Owner agrees to be present on the final day of installation for Tonal Inspection and to deliver final payment/finance form(s).
It k aSrrxvt and mxk r u xl by alxf Ixucren thr t>to ,dot dris Slxti i(u atuan S}irrt..drntL m tla dn•Cl"ti l'o\l tCI\l)04\":>CD DOOR RF\IOI)F.IJNG AGREF\SF_1T,crun iit wu•c the cntin
.un<kntandinK Ix•twa•rn tlu.fxutics,aril then•an•no verbal urxkTStandiuLn tdlarrsgilr>Z rx nuxiif,iva{:ury.d Uw term.-"f hi,Stu•r:dx:dinu tihrrt matt nrx Ix•rlr:m>tn,d or its h•rrn,rna) c•xf or<�aried in
sane.cap unkss vu•h elnul�>x an'ut trritity;sod+as;ucd tn•lerih t!x'Buyvri+i and(wut[ex'tor, t3rnrrsi hertlr:rr krun.k•.d s+that Ef rvef s ha,raid dii.Slxxifimlion Sheol.
Renewal by Andersen Corporation ;91__// Ae/rcf/t _
Signature of Consultant Signature
lv
at e
GERALD PERRON BARBARA JONES MARTI ITCH
Print Name of Consultant Print Name Print Name
01N.'enewal MA Home Improvement Contractor
License#170810(Expires 12/2=015)1
byMidersen. Renewal by Andersen Corporation 11 I
WINOOW *10LACtatt.T Federal Tax ID#41- 9184113
30 Forbes Rd. Norlhborough,MA 01532
(508)351.2200 Fax(508)-986-7072
CUSTOMER WINDOW AND DOOR REMODELING AGREEMENT
Buyer(s)Name Date:
BARBARA JONES - MARTIN KoNOWITCH AUGUST 1, 2015
Buyer(s)Street Address city State Zip Code
44 WESTHAMPTOM RD FLORENCE MA 01062
Email Address Home Telephone Number Work/Cell Telephone Number i
IDJONES5500MAIL.COM (413) 537-0160 (413) 575-6709
Buyer(s)hereby jointly and severally agrees to purchase the goods 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.
Total Job Amount $ 5,891 timoon:Financed S 0- Est.Stall We Methgo gi eillylpepl
Deposit Received(33%)S 1,963.67 o9perit at sig"S 0.00 Check/Cash
B-10 weeks
Balance Start of Job(33%)$ 1,963.67 chock#
Balance on Substantial est.Install-The
At Subs1w" ve Credit Card
Completion of Job(33%)$ 1,963.67 Completion S 0.00
1-2 days If cmdlt cafd is selected,please
No hnai parventstwii w gemandea unit an partes are satsted see Credit Card Payment form
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 ft signed,written consent
of both Buyer(*)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 Buyees right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Renewal by Anderson Corporation ,.Buyer(s) Buyer(
By: Cie--w 0-rA
Signature of Consultant Signal 6txT- Soalure
X GERALD PERRON BARBARA JONES MARTIN KONOWITCH
PrInled Name of Consultant Pontod Name Printed Name
YOU,THE BUYER($),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 NOTICE OF CANCELLATION
Date of lem—action vl/C, You may cancel Ohl. I Due.of Tranmaction 10/111 You may cancel this
tram"don,without any penalty or obligation,within three huwin".do).from the transaction,without any penalty at obligation,within three business day. &tun the
above date.If you cancel,any property traded In,any payments made by you under I above date.If you camel,any property traded in,any payments made by you under
the Contract of Salt'and any negotiable Instrument executed by you will he I the Contract ofSalle,and any negotiable instrument executed by you wMbo
returned within 10 da)%following receipt by the Contractor of your I returned within 10 days following receipt by the Contractor("Seller")of your
cancellation notime,and any security Interest"Ishmis out of the transaction wUl be I cancellation notice,and say security interest arising out of the transaction will be
canceled. It you cancel,you most make avallable to the Setler at your residence,in I canceled. If you cancel,you must make available to the Seller as your residence,In
b%taittlaily 0.SO"emodidou ON when"ceive4,any goods delivered to you under I aubstandafty as good condition as when received,any goads delivered to you under
dds Contract or Salt;or you may,If you wish,comply with the Instructions of the I this Contract or Sale;or you may,if you wish,comply with the instruedom of the
Seller regarding the return shipment of the goods at the Seller's expense and ci.k. I Sell.,regarding the return shipment of the goods at the Seller'.expense,and risk.
if you do make the goods avalliahle to the Seller and the Setter does not pick them up I If you do—11P the goods available to the Seller and the SeBer does not pick them up
within 20 days of the date of your Notice of Cancellation,you may retain or dispose t within 20 days of the date of your Notice of Cancettatlost,you may retain or dispose
or the goods without any 1wtherabligation. If you fall to onke the good.—liable I of the goods without any further ahligation. If you fail to make the goods available
to the Seller,or if you age"to return the goods to the Seller and 110 to do ma,then t to the Seller,or if you agree to return the goods to the Seller and f*U to do an,then
you remain liable far pWarmance of all obligations under the Contract.To cancel you remain Liable for performance of all obligadomm under the Contract.To cancel
this tramstacdom,mall or deUwr a signed and dated copy of thIm cancellation under I this transaction,mail or deliver a signed and dated copy or this cancellation,notice
or any other written notice,or send a telegram to Contractor:Renewal lOyAndittwen,1 or any other written notice,or send a telegram to Contractor. Renewal by Andersen.
,30fbrbealtd. NordLborougl4MA01532. 1 30 Forbes Rd.Northborough,NtA 0I532
I HEREBY CANCEL IMS TRANSACTION. I I HEIUMV CANCEL THIS TRANSACTION.
Ww'.sqw— P,1.N— Dtt I 0.0,b 8.t,— P'.1 N— Do.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Jaime Morin 90125
License Number
86 Gardiner St nn MA 01905 10-6-16
Address Expiration Date
508-351-2214
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Renewal by Andersen 170810
Company Name Registration Number
30 Forbes Rd orthb rou h MA 01532 12-23-15
Address Expiration Date
Telephone 508-351-2214
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....... 1$ No...... ❑
11. - Home Owner Exemption
The current exe ion for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such ho owner to engage an individual for hire who does not possess a license,provided that the owner acts
as su ervisor.CMR 78 ixth Edition Section 108.3.5.1.
Definition of Homeowner:P on(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 tw roily dwelling,attached or detached structures accessory to such use and/or farm
structures.A who constructs m e than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the BAN Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed and the buildin2 permit.
As acting Construction Supervisor your presence 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(Worke ' Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachu 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 mpliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massa usetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Vyindows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding[O] Other[L7]
Brief Description of Proposed
Work: Replacing J windowi, no structural change
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 3— 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
1, Barbara Jones as Owner of the subject
property
hereby authorize Jaime Morin
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, Jaime Morin 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 penaIt'es of perjury.
Jaime Morin
Print Name
Signature of Owner gent 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 () DON'T KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the eof Deeds?
NO 0 DON'T KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW LQ—YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES Q NO kt:7-
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavatO ,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
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`CuVDdveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/WellAvailability
Northampton, MA 01060 Two Sets of Structural.Plans
Fax 413-587-1272 PloVSite Ptens
NU' a.: r.�,, ,::� ,r ..,
--- Other Specify_,_,_
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
44 Westhamptom Rd Florence, MA 01062 Map 43 Lot 108 Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Barbara Jones 44 Westhamptom Rd Florence, MA 01062
Name(Print) Current Mailing Address:
413-537-0160
Telephone
Signature
2.2 Authorized Accent:
Jaime Morin 30 Forbes Rd Northborough, MA 01532
Name(Print) Current Mailing Address:
508-351-2214
Signature Telephone
SECTION V-."ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building f",97C,00 (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)
Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
44 WESTHAMPTON RD BP-2016-0351
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:43- 108 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-2016-0351
Project# JS-2016-000561
Est.Cost: $5896.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RENEWAL BY ANDERSEN 090125
Lot Size(sq. ft.): 52707.60 Owner: KONOWITCH MARTIN&BARBARA DICKEY JONES
Zoning: Applicant: RENEWAL BY ANDERSEN
AT: 44 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
30 FORBES RD (508) 919-0900 WC
NORTH BOROMA01532 ISSUED ON:911512015 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOW
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 9/15/2015 0:00:00 $35.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner