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18C-127 (8) 86 BLACKBERRY LN BP-2020-0741 GIS#: COMMONWEALTH OF MASSACHUSETTS May:Block: 18C- 127 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Siding BUILDING PERMIT Permit# BP-2020-0741 Proiect# JS-2020-001278 Est.Cost: $19500.00 Fee:$60.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: WINDOW WORLD/ROBERT E BUSHEY JR 57011 Lot Size(sg. ft.): 19384.20 Owner: SULLIVAN NEIL Zoning: URB(100Applicant: WINDOW WORLD/ROBERT E BUSHEY JR AT. 86 BLACKBERRY LN Applicant Address: Phone: Insurance: 1029 NORTH RD (413) 485-7335 O WC WESTFIELDMA01085 ISSUED ON.1212012019 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE SIDING 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 12/20/2019 0:00:00 $60.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner CS OWG_ Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit Lw 212 Main Street ` ,; + Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans th r.'SRecify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR iO- LISH A ONE OR TWO F ILY DWELLING SECTION 1 -SITE INFORMATION J DEC 1 7 2019 1.1 P oi)erty Address: This section to be comp) ted 4y office r/I I�l� IoCtnc P'ui }+ rl I",1, S"e: b((J l Map N�tf,<r,�+Lbt Unit �QY1'►IU/'}�11�TU� 000 Zone Overlay District Elm St.District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: n y Name(Print) Cu t ailin ddr ss: see onxa( Telephone Signature 2.2 Authorized Agent: C�2.G MA U i(AcS Name'Pn t) / n Current Mailing Address: I l Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only —completed by permit applicant 1. Building r � \ _ (a) Building Permit Fee 2. Electrical 1 (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) O 5. Fire Protection Do 6. Total = 0 +2+3 +4+5) Check Number n This Section For Official Use Only Building Permit Number: d6P'a Date Issued: Signature: i Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding Other[a Brief Description of Proposed Work: Llldd-,�)jdiq Alteration of existing bedroom Yes_�No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction��� i. Is construction within 100-fC of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will buil ' 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,�Ve-j I &t[-1)(a4') as Owner of the subject property ','ll ( ' 1 herebyauthorize W/116� ) I, IKIJ f f JPS 1'y� to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, _ Q Oxy 1- 13Osy ' as Owner/Authorized Agent hereby declare that the statementd 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. Print N me' Signature of Owner,, gent , Date SECTION 8-CONSTRUCTION SERVICES I 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: Ro ct B-q�VICA License Number Al2- DcAlk�l Ln o (�)l-1 Address Expiration Date 5 Sign :Telephone 9. Registered Home Improvement Contractor: Not Applicable 0 _?Ob-rt Company Name Registration Number -W i n6ow No V-id ok, 11,nion—ft'ss Anc, '31 �+ /2-0 Address Expiration Date J U11 'N WAY) k6 V\J-0,SVal � a tIR 010 'FSlephone_443-4-ts-15,35 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....... ..I No...... D R Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellinl!s of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the buildint!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 The Commonwealth of Massachusetts W Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Window World of Western MA Address:1029 North Road City/State/Zip:Westfield, MA 01085 Phone#:413-485-7335 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ i am a employer with 20 employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E] Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doingall work myself. t 9. ❑Demolition y [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E] Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.F]Roof repairs 6.[_1 We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑✓ Other Replacement WincloW 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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:Liberty Mutual Insurance Policy#or Self-ins.Lic.#:WC2-31 S-377947-020 Expiration Date:05/07/20 Job Site Address:_nS W 6 Lc ry- .j `1MV City/State/Zip:f�14 ay)C✓{�j✓� �� U1�0 Attach a copy of the workers' compensatji n policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb rtify under,-the pains and penalties ofperjury that the information provided above is true and correct i Si natut e: ' Dat , Phone#:413-485-7335 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACCO a® CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE H 04/02/19 OLDER.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 have ADDITIONAL INSURED provisions or 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: Forrest Insurance Agency PHONE 413-858-2680 603 North Main St A/C No Ext): FAC No): 413-858-2685 E-M IL East Longmeadow, MA 01028 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: ARBELLA PROTECTION INSURANCE CO. INSURED INSURER B: LIBERTY MUTUAL FIRE INSURANCE CO. WINDOW WORLD OF WESTERN INSURER C: MASSACHUSETTS INC 1029 NORTH RD INSURER D WESTFIELD, MA 01085 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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 CONTRACTOR 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, IN R LTR TYPE OF INSURANCE P FF P p INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 100,000 MED EXP An one person $ 10,000 A 7520025998 04/09/19 04/09/20 PERSONAL BADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY❑ PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A O OSDONLY X AUTODULED 1020063881 04/09/19 04/09/20 BODILY INJURY(Per accident) $ X HIRED X NON OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident) $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE 4600055451 04/09/19 04/09/20 AGGREGATE $ UED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/A Certificate To Follow E .EACH ACCIDENT $ (Mandatory in NH) If yes,describe under E .DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Of Northampton ACCORDANCE WITH THE POLICY PROVISIONS. 212 Main Street Northampton,Ma.01 060 AUTHORIZED REPRESENTATIVE Attention: Building Department, 0_. )?,ecIi/(V_ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Ac�� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYVYY) CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 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 have ADDITIONAL INSURED provisions or 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 603 NORTH MAIN STREET -NAME: T PHONE ---_ —---- E LONGMEADOW, MA 01028 _(AtC,.No ExtJ: FAX -- E-MAIL --------- (_A(C,N�------- INSURERS)AFFORDING COVERAGE NAIC# INSURED – -.------INSURER A: Liberty Mutual Fire insurance 23035 _ WINDOW WORLD OF WESTERN MASSACHUSETTS INC INSURER B 1029 NORTH ROAD --------- -- WESTFIELD MA 01085 INSURER -- D INSURER E: COVERAGES INSURER F: CERTIFICATE NUMBER: 48525637 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDESION-NAMED IABOVEB OR.THE POLICY PERIOD NU 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. INSR ADDL LTR TYPE OF INSURANCE BR POLICY EFF POLICY EXP COMMERCIAL GENERAL LIABILITY POLICY NUMBER MMIDD/YYYY MM/DDIYYYY LIMITS CLAIMS-MADE OCCUR EACH OCCURRENCE $ A E TED PREMISES(Ea occurrence $_ MED EXP(Any one person) $ GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY $ POLICY D PRO- GENERAL AGGREGATE JECT D LOC $ OTHER: PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY $ -- COMBINED SINGLE LIMIT ANY AUTO Ea accident $ OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY AUTOS HIRED NON-OWNED BODILY INJURY(Per accident) $ .--. AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ Per accident UMBRELLA LIAR $ OCCUR EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE $ - DED — AGGREGATE $ RETENTION$ _ A WORKERS EMPLOY RS'LI COMPENSATION WC2-31 S-377947-019 5/7/2019 5/7/2020 PER OTH- $ AND EMPLOYERS'LIABILITY ✓ STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N OFFICER/MEMBEREXCLUDED? N/A E.L.EACH ACCIDENT $1000000 (Mandatory In NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ QQ�000 _ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1000000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it 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 TOWN OF NORTHAMPTON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 212 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. NORTHAMPTON MA 01060 AUTHORIZED REPRESENTATIVE Jon Smith ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 98525637 1 1-3'/7947 1 19-20 WC 1 ❑0270258 1 5/5/2019 7:59:95 PM (PDT) I Page 1 of 1 City of Northampton *7 iTYF� Massachusetts t, ;. DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street *Municipal Building Northampton, MA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. The debris from construction work being performed at: (Please print house n tuber and street name) Is to be disposed of at: (Pleasb print nam and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name And Address) Ili ignature of rmit Ap licant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. u� Window World Of Western MA 1029 North Road 413-485-7335 */0 western mass@windowworld.com Neil Sullivan nsullivan67@gmaii.com Estimate:Whole house Bill Address: Install Address: Estimate#E1573594175207 86 Blackberry Ln, 86 blackberry In, Northampton,MA Northampton,Me Date of Estimate: 11/12/2019 101060 01060 Valid Until:12/12/2019 DESCRIPTION • • Siding Soffit and Fascia 16 1,200.00 19,200.00 DISPOSAL/DUMPSTER FEE Siding no strip 1 300.00 300.00 TOTAL AMOUNT $19,500.00 CUSTOMER PAYMENT DETAIL Finance Amount Financed TOTAL PAID $0.00 CUSTOMER DUE $19,500.00 "No extra work if not in writing 'Customer Comments: 'Installer Notes:D4 alpine white corners...18 month promo 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 PURCHASERS)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. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Customer Signature Sales Rep Signature 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®Franchisees independently owned-and operated by Window World of Western Massachusetts,Inc.under license from Window World,Inc.