Untitled 47 REVEL1,AVE BP-2017-0715
(1S#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:38D-059 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-2017-0715
Project# JS-2017-001179
F„st.Cost:$5808.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WINDOW WORLD/ROBERT E BUSHEY JR 57011
Lot Size(sa.it.): 7318.08 Owner: LUCAS CHRIS
Zoning URB(IOQ/ Applicant: WINDOW WORLD/ROBERT E BUSHEY JR
AT: 47 REVELL AVE
Applicant Address: Phone: Insurance:
1029 NORTH RD (413)485-7335 p WC
WESTFIELDMA01085 ISSUED ON:II/22/20I6 0:00:00
TO PERFORM THE FOLLOWING WORK INSTALL 13 REPLACEMENT WINDOWS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring B.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: O_ 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 11122/2016 0:00:00 $40.00
212 Main Street.Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
;'1\
Department use only
ity of Northampton Status of Permit
/ :y Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Avaitadility,_,_,,.
Northampton, MA 01060 Two Sets of Structural Plans
pct phone 413-587-1240 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
69- /7 - -7S
1.1 Property Address: This section to be completed by office
1�1 (1Q V�,r nv Map^ Lot Unit
• 4 t !C I ti Zone Overlay District
Ocktarn m mfn OIDipO
Elm St.DistilctCB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 1 p
C 1 jA (.�.LL.. L.n{'Up11 2
Name(Print) Current Mailing Address:
(see (ai-raol COO 302 2-
e�eph�ne
Signature
2.2 Authorized Agent: -�
_ 6 At _ W2 q Noctil Ot.,.,
Name(Print) - Current Mailing Address:
t c z _ qi3 wt 7335-
Signature Telephone
SECTION 3•ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 5p-Og (>v (a)Building Permit Fee
2. Electrical -�- Ort.��OO (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) - �w
5. Fire Protection � /�7
6. Total=(1 +2+3+4+5) 5br�� "O Check Number J;S h7U
This Section For Official Use Only
Building Permit Number, Issued:
A Date
�//� O_f
Signature 4 ��vim` a//
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING ( Ad Information Must Be Completed.Permit Can Be Denied Due To Incomplete information
F 'sting 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 °u
Open Space Footage
(Lot areaminus Meg Sr paved
parking) _______
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Specfat Permit/Variance/Finding ever br-n issued forfon the site?
NO O DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit teLorded at the r- -stry of Deeds?
NO O DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document i<
B. Does the site contain a brook, early of water or wetlands? NO 0 DONT KNOW Ca YES O
IF YES, has a permit been + need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on e 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 Q
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over I acre or is it part of a common plan
that will disturb over I acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
1 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House El Addition ED Replacemen inflows Alteration(s) El Roofing El
Or Doors �^
Accessory Bldg. ❑ Demolition D New Signs [p) Decks [Cf Siding ICI] Other[C]
Brief Desai p n of Proposed
Work! Mit-A t()t3 I rkplgtomprvt Ainathids Non-stru 01 YOLQ
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Se.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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT. OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, Kock- * tiyles LiA('r s ,as Owner of the subject
property n
L.hereby authorize i L. r L
R _
to act on my behalf,in all matters relative to work authorized , , is building permit application.
Ott Y • lin
ure of Owner Date
111111.1.11.1.1.1.11.11.1111111110.
1, Robert P 'u. i .as Owner/Authorized
Agent hereby declare that the statements and i •rmation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
ROheck ? &USWW
Pent Neme 1 , / 40
Signature of OwnerfAgent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
r
Name of License Molder: � � �� G �, 51011
License Number
2 7 r rlaCleA.?dl /A—VL Fee(4Ing +fl115 Mil 04030 tQ !nit 7
Ad• Expiration Date
r S r 413 ti 't 351
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
Company Name Registration Number
Address (i) R3 v eivfiticl mfl o Q 51151is ._
2 >^� Expiration Date
�ry/ Telephone`/13 9s 7& r
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.t.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 by{tiding permit. _
Signed Affidavit Attached Yes SI No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(i) 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 Hemeownee: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 WI 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 Sable 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 C&kC krf c>) �_
The Commonwealth of Massachusetts
r74
Department ofIndustrial Accidents
Office of Investigations
1 Congress Street, Suite 100
- - 4 Boston,MA 02114-2017•tom/ www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Midn ) d Vn VA/MSS
Address:_ (01 Q(? It R{}
City/State/Zip: \AIP 2td (11�}, J2t_a _ Phone#: '1,3 L6-7S.--- 73 3 5"
Are you an employer? Check the appropriate box:
i Type of project(required):
L I am a employer with_E.0 4. ❑ am a general contractor and i
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 S. 0 Demolition
workingfor me in anycapacity. employees and have workers'
P nJ 9. 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 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] .1 c. 152, §1(4),and we have no ( jet.,
employees. [No workers' 13.W Other^ �„r1i
comp. insurance required.] yganti ONS
`My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing atl work and then hire outside contractors must submit a new affidavit indicating such.
tCounactors 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. lithe sub-contractors have employees,they must provide their workers'camp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name:- U, '}('t-E"�{__..( [,�,'tlAi i -7 ski mitt
Policy#or Self-ins. Lie. #: wag - 31S -, , [ 1 I-t ( - [ ( p Expiration Date: 51
Job Site Address:_ L r- t I etv-e IU £-' City/State/Zip: r S 4IU. 10 I t
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). i(,fib'O
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.
(do hereby cert/fy u dirr the pains d penalties of perjury that the information provided above is true and correct.
Sieuature:�1 LISTS—
"`�-7337-
Official
1 1�r--' Date: WI
Phone#: T 1 3 '7 U � i ,7 3 J _...._.. _
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):
L Board of Health 2.Building Department 3,City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
CERTIFICATE OF LIABILITY INSURANCE pen
" m
04/01/2016
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 OP 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 en ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, sublem to
ths tams and conditions of the policy, Certain poINbs may rpuhe en endorsement. A sMemem on this certificate does not confer rights to the
Certlllcet holder In lieu of such sodof.ement(M).
4R9nUCER x4ME,DT Laurence R. Forrest
Forrest Insurance Agency W"O"E 413 858 2680 x 413 858 2685
Jew s
603 North Main Street Y `gym w --
ADDRESS.
Bast Longmeadow, Mass. 01028
INSYflER191 AFFORDING CDVERADa I UNC•
___
muses*:Arhella Protection Insurance Company
�._..�__.... _ _.... __ ---
MUM INSURER a.
Window World Of Western Massachusetts, Inc. wwnERC ""'-
1029 North Road Massa to
Westfield, Ma. 01085 INSURER e:
INSURER
COVERAGES CERTIFICATE NUMBER: REVISIONNUMBER:
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.
ATH 1 TYPE M mSO4ANCE WAN SUV POLICY NUMBERPOLICYXi(MINNDYXYi lMI DrvEWCY P Ln
A GENERA&.LIABILITY SAC«otalnReNCE ''A 1,000,000
II.B DCMMERCUL GENERAL imacirV 7520025998 104/09/16104/09/1] PRrmses ua.�. ml Is 100,000
ICLAWS-MACE x OCCUR MED ESM‘Any nne mum) S 10,000...
PEfl5oNA1 s+Dv m.vRY 19 1,000,000
OENERAL AGGAEGAYE $ 2,000,000
GENT GGREGATE TONT APPLIES PENPPOOUCYS�@uwOP 4_ 'IS 1,000,000
TOCDT n TA �LDC 1 5
AUTOMOSRELIABNrta
Y 1020010702 05/12/15105/12/151 caMeno'ut,LN LIMIT E 1,000,000
Ln NA AUTO I SOODY PUSSY(Pe,poser) '.S
u.oxweo u�sc«eduLEo SONDE IN:URYdarane�c $
AUT6 AON.O ` NP DFXTY DAMAGE
R .NSW AUTOS J'AUTOS ki.IPonaaennI
$
A IB IMURELLA NAB A OCCUR 4600045451 :04/09/16 04/09/17 EACH OCeoRRENCE s 1,000,000
B ' ExCE55 Lth CNIMSMADE AGGREGATE
f 050 1 DETENTION 9 e
I WORKERS COMPENSATION Certificate Of wt srxru- DrH
TORY own E 1 __ _
I ANT EOM o ry EXEC VE =1" Insurance To Follow EL.EACH ACCDENTT IIs
'U t BP C. I .ELtRATE•EA EMPLOYEE I5
OES.Wynne Ander
CRIP'TION OF OPEPATFNS MFn s L..OISSASE'POLCY curt ,5
1
DES DFOPEREWONSJLGCNT sfVEaCLEe(Arises ACOROT,.AOenpro:nsons RNTITANanenwrtS n,pea/TO
CERTIFICATE HOLDER CANCELLATION
City Of Northampton
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 4E CANCELLED BEFORE
212 Main Street
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Northampton, Ma 01060 ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: Building Dept.
nr, 0 TNEAwDEPRESENTATreE
�J
duwu4, ,2I, � r
I019884010 ACORO CORPORATION, All rights reserved.
ACORD 25(2010!05) The ACORD name and lege are registered mare.of ACORD
ACORne CERTIFICATE OF LIABILITY INSURANCE DATE IMMgin YI
16
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: N the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
it SUBROGATION IS WAIVED,subject to the tens and condhfons 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 endorsements),
PPaettCEE FORREST INSURANCE AGENCYJpiNNTTACT
603 NORTH MAIN STREET PHONE PAX
E LONGMEADOW, MA 01028 -E-MAIL tA10'N[I
ADDRESS: ( _
INSURER(SI AFFORDING COVERAGE NAICH
INSURER A. Liberty Mutual Fire Ins 33600
INSURED INSURER a:
WINDOW WORLD OF WESTERN MASSACHUSETTS INC
1029 NORTH ROAD INSURER C
WESTFIELD MA 01085 INSURER o:
INSURER E:
INSURERF:
COVERAGES CERTIFICATE NUMBER: 29470857 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 NTH 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
ND¢n . fiF
/RSR TYPE OP INSURANCE IPOLICY NUMBER IMM/De YYYT'1 IMPW DyIYVvel LIMITS
ttt1 COMMERCIAL GENERAL UABILITY EACH OCCURRENCE
CLAIMS-MADE I OCCUR PREMISES(LaO'. ]
1 i MED EXP(Any one FaPcip
PERSONAL&ACV LNJURY
0EN1AGGREATE LIMIT APPLIES PER GENERAL AGGREGATE
IPOLICY II AECT LOC I PRODUCTS.COMPOP A(G '
OTHER
AUTOMOBILE URaNTY COM6MED$WGLE LtMIf
IEa arpdentl._.,
ANYAUTO BODILY INJURY(Pe mum))
OWNED CHEDULED BODILY INJURY IPM acdtlerel
AUTOSUTOSONLY AUTOS
HIRED NOH-UWNLY (Pe ,rycRdeflIL E
AUTOS ONLY . AUTOS ONLY (Per ayGCeDII.
UMBRELLA Luta __ OCCUR EACH OCCURRENCE
EXCESS1AB CLAIMSMADE AGGREGATE.
OED I RETENTIONS
A WORERSCOMPENSAION WC231SS77947-016 6/7/2016 5/7/2017 / Ig4RTUTe I -°d"
AND EMPLOYERS'LIA8ILRY
ROPRIETORIPAnTNEWEXECUTIVE Y N - EL EACHACCIOENT 1000000
OFRCEWMEMREREXCLUDE02 N NIA
(MXndaNIVIn XNI I EL DISEASE EA EMPLOYEE 1000003
i ee niter mar
OESCR1PTtONOFOPERATi0NSMae El.DISEASE-POLICY LIMIT 1000000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101.AGtlNonM RemaMs S[Neeulp May M needled if more space M rMulretll
WORKERS COMPENSATION INSURANC 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
CITY OF NORTHAMPTON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
BUILDING DEPT. THE
WITH THE POLICY PROVISIONS.
WILL BE DELIVERED IN
212 MAIN ST.
NORTHAMPTON MA 01060 AUTNORIEED REPRESENTAWIE
{liebt-1 C
Liberty Mutual Fire Insurance
1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
29410851 11.377947 116-17 WC I ahaMae.9adalealiber[ym tuaLCo 14/15/".tl16 12::9:18 AN IP09 I Page 1 of 1
feessachusers-Department of Public Safety
Board of Building Regulations end Standerds
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Cmm.tlssIcner 0812672047
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Mee ofConsumer Affairs&Business Regulation
Te0gMtrMbPoRnO. VEM65E6NaTt CONTRACTOR
i Type:e
or
ExPiratiPnr 3/15.12018 Private Corporation
WINDOW WORLD OF WESTERN MASS INC
ROBERT BUSHEY
1029 NORTH RD
WESTFIELD,MA 01065
Undersecretary