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12-022 (2) 10/10/2011 08:21 8604665079 PAGE 01/02 RECEIVED 89/39/207.1 17:19 4137363962 MA.30P HOC IMPR5 e 03 99/30/2811 17 tea 8604665079 •'- ..rig HO 11111111111111111 h., .„...;.,, s,„1.4' ' ..• LIM 61 ,"-''''' 4„ "-Leo', "1111111111111111111111111 7 ; 7 "i ' hi t III ;.:. ::;_ d Nil , F;;;; .-p., i "i111111111111 111111111 .+" VA ii,iii,IlIIII1II • iI t 1 1 ,lzkli a r "x :.}'2 5 •'7 440104002 :, gli11111111111111111111111 6 '1411 Z 9 ' lil 441014ril . • 811 li 1 9 g Cee x. .. yi P CI ��Fhu � � � o 1111111111111111111 Z0 /t0 99t)d S21dW1 3 OH ilrt/W Z9669£LEtb 90 :90 tt6Z /6t /01 Received on 10/10/2011 8:37:18 AM I , 1111 11 I lii1 III Job Number - Z 9 NOTICE TO BUYER 1. DO NOT SIGN THE AGREEMENT IF ANY OF THE SPACES INTENDED FOR THE AGREED TERMS TO THE EXTENT OF THE AVAILABLE INFORMATION ARE LEFT BLANK. 2. YOU ARE ENTITLED TO A COPY OF THIS AGREEMENT AT THE TIME YOU SIGN IT. KEEP IT TO PROTECT YOUR LEGAL RIGHTS. 3. YOU MAY PAY OFF THE FULL UNPAID BALANCE DUE UNDER THE AGREEMENT AT ANY TIME, AND IN SO DOING YOU SHALL BE ENTITLED TO A FULL REBATE OF THE UNEARNED FINANCE AND INSURANCE CHARGES. 4. YOU MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY [FIFTH BUSINESS DAY IN ALASKA, FIFTEENTH BUSINESS DAY IN NORTH DAKOTA IF YOU ARE AGE 65 OR OLDER] AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. FAILURE TO EXERCISE THIS OPTION, HOWEVER, WILL NOT INTERFERE WITH ANY OTHER REMEDIES AGAINST THE RETAIL SELLER YOU MAY POSSESS. IF YOU WISH, YOU MAY USE THIS PAGE AS NOTIFICATION BY WRITING' I HEREBY RESCIND' AND ADDING YOUR NAME AND ADDRESS. A DUPLICATE OF THIS RECEIPT IS PROVIDED BY THE SELLER FOR YOUR RECORDS. 5. IT SHALL NOT BE LEGAL FOR THE SELLER TO ENTER YOUR PREMISES UNLAWFULLY OR COMMIT ANY BREACH OF THE PEACE TO REPOSSESS GOODS PURCHASED UNDER THIS AGREEMENT. NOTICE TO MASSACHUSETTS RESIDENTS ONLY In addition to the Notice to Buyer shown above, Massachusetts law requires that contracts for home improvement work state that all home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration P.O. Box 871 Taunton, MA 02780-0871 Telephone: (508) 821 -9375 Please note that owners who secure their own construction - related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund. Notwithstanding any other language in the contract or associated documents, Sears will not remove, replace, or install any heating or air conditioning system, or any portion thereof, if asbestos or asbestos-containing material is known or likely to be present in that heating or air conditioning system, or any portion thereof. If it is determined or reasonably suspected that asbestos is present, either before commencement or during performance of the work, it shall be the customers responsibility to select, retain and pay all costs of a Division of Occupational Safety ( "DOS ") licensed Asbestos Contractor to remove all asbestos or verify that none is present in the components involved in the job. If the determination or reasonable suspicion of the presence of asbestos arises after Sears has started the work, Sears will immediately cease performing the work until a DOS licensed Asbestos Contractor, hired by the customer, removes all asbestos from the components scheduled for repair or replacement in accordance with 310 C.M.R. 7.00 and 453 C.M.R. 6.00 or verifies that none is present. By signing the contract the customer agrees that it understands the above. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES / 09/23/2011 09/23/2011 Customer's signature Date Customer's signature Date Niegfidcift-eg Accepted by Sears Home Improvement Products, Inc. ("Sears ") on 09/23/2011 b Date Management Representative SW1 -MA (Dig) Rev 05, 2' 11 Page 3 of 3 A • s. . 1111111111111111 Job Number -29 APPROX MATE START DATE and APPROXIMATE COMPLETION DATE The work will start approximately 1 -2 WEEKS (Approximate Start Date) It will be substantially completed by approximately 3 -4 WEEKS (Approximate Completion Date) These dates are subject to change at the time the contract is accepted by Sears Home Improvement Products, Inc. ( "Sears ") or at any other time by mutual written agreement. Customer understands that the Approximate Start Date is only an estimated date and the Customer will be contacted prior to this date to schedule the actual start date. The TOTAL PRICE induding all labor, material, taxes and any applicable discount is $ 5 ,146.63 Contract Price $ 5,146.63 Initial Payment (not to exceed 30% of Total Price unless Special Order) $ 1,543.99 State Sales Tax ( 0.00 %) $ o. 00 Final Payment (balance payable upon completion of job) $ 3,602.64 Local Sales Tax ( o. oo %) $ o. 00 The Initial Payment is due prior to Sears ordering products. Total Amount Duel$ 5,146.63 The form and method by which the Customers) will pay is described in a separate Cash/Credit customers) jar,. . Card Payment Addendum made a part of and incorporated into this contract by reference. NOTICE TO BUYER: YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY (FIFTH BUSINESS DAY IN ALASKA, FIFTEENTH BUSINESS DAY IN NORTH DAKOTA IF YOU ARE AGE 65 OR OLDER) AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. ADDITIONAL PROVISIONS Proposal and Approval. Sears offers to furnish the materials and arrange for their delivery and installation as specified on the first page and/or the attached sketches and specification sheets for the TOTAL PRICE shown. This offer must be approved by the Installation Department. If this is a credit sale or a payment on completion sale, it must be approved by the Credit Sales Department. If this proposal is not approved or the installation cannot be made in accordance with the law, this offer will be withdrawn and any payments you have made will be refunded to you. Any materials left over after the installation has been completed are Sears property and will be removed by Sears. Installation. I understand that Sears will not install the materials but will arrange for the installation. Sears is not responsible for materials or installation NOT furnished or arranged by Sears. Sears' installation contractor(s) will obtain all building permits required by local law. For homes located in historic or landmark zoning districts, Customer will be responsible for obtaining required approvals and related permits prior to the commencement of work on this contract. Authorization. I authorize Sears to: (1) arrange for a contractor (licensed where required by law) to make the installation of materials; (2) issue a work order for this installation to a contractor; (3) inspect the installation; and (4) pay the contractor when the installation is complete if I have signed a certificate that the installation has been completed to my satisfaction. Delays in hstallation. I agree that Sears is not responsible for delays in delivery or installation due to weather, fire, strikes, war, government regulations or any causes beyond Sears' control. Oral Agreements and Changes in Contract. I understand that there are no oral agreements between Sears and me. Everything I expect Sears to do has been included in writing in this contract. Nothing can be changed in this contract unless it is in writing on a separate form accepted by me and Sears. Responsibility of Buyer. I agree that any information or measurements that I give to Sears are correct and complete. I am responsible for any special work described in this contract. Electrical & Plumbing Service. I will provide adequate electrical and/or plumbing service(s) to run any newly installed appliances or other furnishings. If the electrical and /or plumbing service(s) do not meet the standards of the utility company or electrical and/or plumbing codes, I will make the necessary changes at my expense unless Sears has agreed in this contract to make the changes. Payment. I will pay Sears the cash price that covers the price of material and installation as shown on the first page. Warranty Information. Appropriate product warranty documents will be given to me by Sears. Sears' Warranty on Installation is: SEARS' LIMITED WARRANTY ON INSTALLATION In addition to any manufacturer warranty extended to you on the product(s) used (which warranty becomes effective the date the merchandise is installed), if the workmanship (or application) of any Sears' arranged installation proves faulty within (i) one year for Weatherbeater Value Line, (ii) two years for Weatherbeater Plus, or (iii) three years for Weatherbeater Max, and Weatherbeater Stormbeater, then upon notice from you Sears will cause such faults to be corrected by repair at no additional cost to you. If Sears determines that repair is not commercially practicable or cannot be timely made, then, at Sears' sole discretion, Sears may elect to provide replacement or refund. Service under this Limited Warranty is available by calling Sears Home Improvement Products at 1-800-222-5030, Option 4. This warranty gives you specific legal rights, and you may also have other rights that vary from State to State. WI-MA (Dig) Rey 05 2' 11 Page 2 of 3 S 1IAIII11III III X \ Office Location: HARTFORD ProposalDaie 09/23/2011 Job it -29 Sears Home Improvement Products, Inc. Customer Name P.O. Box 522290 ROBERT CHABOT 1024 Florida Central Parkway Customer s Home Phone Customer s Work Phone Longwood, FL 32750-7579 (413) 584 -3494 (413) 733 -4032 Home Improvement Products Phone(800)469-4663 Street Address ESTIMATE AND PROPOSAL Contractor License /Registration Number 31 COUNTRY WAY MA (148607) City State Zip Code Windows All plumbing and electrical services performed FLORENCE 0 MA 01062 Is installation within city limits? by licensed subcontractors tnstallaton Address County HAMPSHIRE (Yes/No): YES FEIN 25- 1698591 Billing Address (if ditferentfrom above) City State Zip Code Project Consultant Name & License No Of applicable) MATTHEW GELINAS Description of the Project and Description of the Significant Materials to be Used and Equipment to be installed 1. Remove existing units to be replaced. (PLEASE NOTE: The removed units are likely to be damaged.) 2. Prepare openings as necessary to receive replacement units. (No finish work other than normal installation is to be done unless otherwise noted below.) 3. Installation includes the clean-up of all job-related debris upon completion of the job. 4. Install Sears Weatherbeater MAX Windows in the openings described below according to the following specifications: COLOR: (WhitefTan/Clay/Whi@e/Light Woodgrain Interior/Wtite/Dark Woodgrain Interior): WHITE TYPE 0 DH Qty 5 ❑ PW Qty ❑ Casement Qty Type ❑ SH Qty ❑ PD Qty ❑ Casement Qty Type ❑ 1 -LR Qty ❑ Garden Door Qty ❑ Bay ❑ Bow (3 lite/4 litef5 lite): ❑ 2 -LR Qty ❑ Garden Window ❑ 3 -LR Qty ❑ Other Qty GLASS: ❑ Tempered' Qty ❑ OBS Half Qty SCREENS: Check if other than FIBERGLASS * PLEASE NOTE: Tempered glass will be installed to ❑ OBS Full Qty (on sashes only) ❑ Aluminum meet building codes. ❑ Laminated Qty GRIDS: Type _ Color Placement -- Existing units NOT to be replaced: ❑ Yes ❑ Col Flat ❑ White ❑ Woodgrain ❑ Top 0 No ❑ Col Sculp/Contour ❑ Tan ❑ Full ❑ Other (Specify): ❑ Brass ❑ Bottom ❑ Clay ❑ Rankers Only 5. (If applicable) After the completion of the project, the customer will be responsible for the application and removal (storage) of shutter panels. In the event that the project requires the installation of storm shutters or egress windows, Sears Home Improvement Products, Inc. ( Sears ") will not re- install any affected security bars. 6. (If applicable) In the event Sears is unable for whatever reason to obtain the proper permits prior to the commencement of any work, Sears will refund any previous payment and this contract will be automatically cancelled. Additional work to be done: WOOD ROT ON LAUNDRY ROOM WINDOW Work NOT to be done: SPECIAL INSTRUCT1ONS: All of the above check boxes, Work NOT to be done," "Additional work to be done," and "Special Instr ucons" sections have been reviewed and explained to me. Customer(s) initials C.---- 1 R In C A ; fi r �' 0 (..,\ ` w / /; =.-.-4 , i , y-s+ ( - ) ,. y 1'I c k- a \ V r SW1 MA (Dig) �J ) Rev 05 2. 11 ! " Page 1 of 3 A °® CERTIFICATE OF LIABILITY INSURANCE DA o ' /2011 ' 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 m the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the w certificate holder in lieu of such endorsement(s). c PRODUCER CONTACT .0 NAME Aon Risk Services Central, Inc. PHONE (866) 283 7122 FAX I8g7) 953 -5390 m Chicago IL Office (- I' I0'' E><t IAA Nag 'O 200 East Randolph E-MAIL ss Chicago IL 60601 USA INSURER(S) AFFORDING COVERAGE NAIC # INSURED NSURERA Indemnity Insurance Co of North America 43575 Sears Holdings Corporation sisURERa ACE American Insurance Company 22667 dba Sears, Roebuck and Co. Attn: Risk Management E3 -219A INSURER Q 3333 Beverly Road Hoffman Estates IL 60179 USA wsURERD: INSURER E: INSU rtER F: COVERAGES CERTIFICATE NUMBER 570043294986 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES 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_ Limits shown are as requested WTR TYPE OF INSURANCE I POLJC.Y RIMER LIARS EFF ( POLICY EXP LIARS B GENERALUABIITy HGOG25530962 8/01/201 8/06 1 0 2 EACH OCCURRENCE 55,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S5,000,000 _ PREASSES (Ea ocmarena) CLAIMS-MADE © OCCUR MED EXP (Any one person) Excl PERSONAL & ADV INJURY 55 ,000,000 m GENERAL AGGREGATE SS,000,000 GEENL AGGREGATE LW APPLIES PER PRODUCTS- COMP/OP AGE S5,000,000 0 X 1 n PRG. n LOC — 0 y PoLEY B AUTOS QTY IsAH08696637 08/01 /2011 08/01/2011 CCMtsNED SINGLE LaJT 55 ,000, 000 B _ ISAH08690649 08/01/2011 08/01 /2012 � ) .. ANY AUTO BODILY INJURY ( Per person) 0 z X ' ALL OWNED — SCHEDULED BODILY INJURY (Per accident) _ AUTOS AUTOS 11 X HIRED AUTOS X PROPERTY DAMAGE v _ — AUTOS (Per accident) ,r., X m UMBRELLA LAB OCCUR EACH OCCURRENCE L1 EXCESS LIAR CLARAS -MADE AGGREGATE DED I !RETENTION A WORKERS COMPENSATION AND WLRC46482815 08/01/2011 08/01/2012 X I Tony I loR B EMPLOYERS'LIABLITY YIN WLRC46482803 08/01/2011 08/01/2012 A O IEXcL li CUTIHE + N NIA SCFC46482827 08/01/201108/01 /2012 E.L EACH ACCIDENT 52,000,000 (Mandatory in NH) EL DISEASE -EA EMPLOYEE S2,000,000 IA yyes, descr under ESCRIPTION OF OPERATIONS bebw EL DISEASE-POLICY LSAT S2,000,000 NM DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, AddIfional Remarks Scheduled/ more space is requited) igii 6 CERTIFICATE HOLDER CANCELLATION .p.+ SHOULD ANY Of THE ABOVE DES( RED POLICES BE CANCELLED BEFORE THE EXPI2ATION DATE THEREOF, NOTICE WILL BE DELNEfED IN ACCOF1DA NCE WITH THE POLICY PROVISIONS. Sears Home Improvement Products, Inc. AU174ORIZED REPRESENTATIVE IA 1024 Florida Central Parkway � Longwood FL 32750 USA E MEI MO ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010 /05) The ACORD name and logo are registered marks of ACORD • • 1024 Florida C nfral Parkway, Longwood, FL 32750 Phi: 407 - 551 - 6000 June 2011 LEI TER OF AUTHORIZA1ION I, Alfred W. Nyman, Jr., Assistant Secretary and Connecticut State Qualifier for Seals Home Improvement Products, Inc., grant permissionto l li ole Easley to submit p� and lionises, pick up permits and licenses, make changes to permits, licenses and plans and initial changes made by the building department on behalf of Sears Home Improvement Products, Inc. I also grant permissam to Nicole Easley to purchase permits and/or licenses with a company check, personal check, personal credit card or cask I certifiy that the above xnfonnation is true and correct. r - _ Alfred W. Nyman, Jr; Assistant Secretary and CoimeclkutState Qualifier (HIC.0607669, HTG.0400133 -S ) Sears Home Improvement Products, Inc STATE of Florida COUNTY of Seminole SWORN TO AND SUBSCRIBED BEF ME TFl.S 1(th day of June 2011, by Alfred W. Nyman, Jr., Assistant Secretary for Sears Home Improvement Products, Inc. and who is X personally know to me or has produced a valid Drivers License. Seal: -- � 1 I )1/ . 1*IJATITIVMSIMOF ► .+ : Print Name: Deborah P. c � Deborah F hi, Notary Pahl, State of Florida - AUG. Canmilasks Espinst 13, nit Commission l: DD689052 niggauaMCsaeame MY COMMISSION Aug 13, 2011 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : V I l I L' l ti-- k -- ' IQ-( 4 1, 4 ' l"' / 0 :3 as '`t License Number � ( p s +- k, S p r1r,-lL(c) ni, 1 2- 4 1/0- Address Expiration Date S iLL I I 1- 1 I a (c3 tr -- .5 31 Signature a �r S Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ a a-✓s "„z rzv(z.,„a-.. /yY u --7 Company Name Registration Number S i e- l rxnco5�_.) e loct (q I 0? / t /l3 Address ) ' vC, GG, - 7 Expiration Date Telephone ) . U L ug -(3636 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 JJ— No ❑ 11. - Home Owner Exemption AI 14- 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 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 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 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 e • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Wind Alteration(s) n Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [El Siding [D] Other [0] Brief Description of Proposed Work: Pr two 01A- (2_. (}) (n d c2.aS Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes -- 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 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, " f ) 3 - � Q- /7 / , as Owner of the subject prope hereby authorize N L, ( L - " iu I S m to act on my behalf, in all matters relative to*4vork'authorized by this building permit application. Signature of Owner Date /6 / p / / I, / rkc /2. / , as Owner /Authorized Agent hereby declare that th6 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. (( l k _ c _ j I/ Print Name Signature of Owner/ ent 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 eve been issued for /on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW 0--YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained (.) Obtained ® , Date Issued: C. Do any signs exist on the property? YES O NO 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, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 4- • +;_L - 7 o 4y Department use only CENE1D City of Northampton Status of Permit: R► E Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability n o g ZQ,k Room 100 WaterNVell Availability prthampton, MA 01060 Two Sets of Structural Plans of gunnu ]>: 4 • • - 587 -1240 Fax 413 -587 -1272 Plot/Site Plans �a� 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 31 CO 4i 1ic j Map Lot Unit f / Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 1 041d_, b 6 4- 3 i Name (Print) Current Mailing Address: SQ-L C t I l3 �i ' ' i ' ,31- 9 J-1 Telephone Signature 2.2 Authorized Agent: J' 1 ku EaS /Q) lb ti ' Name (Print) Current Mailing ddress: Signature C Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (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 = (1 + 2 + 3 + 4 + 5) 5 Check Number � d f 7 3 This Section For Official Use Only f Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 31 COUNTRY WAY BP- 2012 -0399 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12 - 022 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- 2012 -0399 Project # JS- 2012- 000639 Est. Cost: $5146.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEARS HOME IMPROVEMENT PRODUCT 103054 Lot Size(sq. ft.): 19994.04 Owner: CHABOT ROBERT & FRANCES HACK Zoning: RR/SR(100) //WSP Applicant: SEARS HOME IMPROVEMENT PRODUCT AT: 31 COUNTRY WAY Applicant Address: Phone: Insurance: 51 BELAMOSE AVE (860) 620 -9036 () WC ROCKY HI LLCT06067 ISSUED ON:10/19/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 10/19/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner