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23B-103 (2) 01/22/2010 09:44 8604665079 PAGE 03 II III 1II ADD)TIONAL PROVISIONS Promise! _a pinpreentl, Sears offers to furnish the materials and arrange for their delivery" and installatioh as specified • ,4n, on-the first page and /or the attached skrphes and specification sheets for the TOTAL PRICE shown. This offer must be approved by the installation Department-II this is a Credit sale or a payment on completion sale. it must be approved by the Credit Sales Department. 11thls propdsal is not appiolTed'or the Installation cannot be made in accordance with the law, this offer will be withdrawn and any payments you have made will be refunded to you.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. • • talstlon. 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 agrees to procure all permits required by local law. - authorization. I authorize Sears to: (1) arrange for a contractor (licensed where required by taw) 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 cornDlete If I have signed a certificate that the installation has been completed to my satisfaction. !Ways in_IILII.lattalio4. •I apre9 Sears, is not responsible for delays in delivery or installation due to weather, fire, strikes. war, government regulations or any causes beyond Sears' control. Q[Al. AOreemegiK awl Chanties fn Comet. 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. Uesnonsibility al foyer. 1 agree that any Irrtormation or measurements that I glve to Sears are correct and complete. I am responsible for any special work described in this contract. Electacal A Plumbing Sarvlea. 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, 1 will make the necessary changes et my expense unless Sears has agreed in this contract to make the changes. i',nyment. I will pay Sears the cash price that covers the price of material and installation as shown on the first page. Warmly llt1Q![Fnallon. 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 productts) used (which warranty becomes effective the date the merchandise is installed), If the workmanship (or application) of any Sears' arranged Installation proves faulty within one year after products are installed (two years for Series 2000 doors; three years for Series 3000 doors). 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 cannbt be timely made, then, at Sears' sole discretion, Sears may elect to provide replacement or refund. Service under 11115 Limned Warranty is avaltable by ea1Nng•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. • NOTICE TO BUYER 1. 00 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 TD 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 165 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 SELLS YOU MAY POSSESS. IF YOU WISH, YOU MAY USE THIS PAGE AS NOTIFICATION BY WRITING "1 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 0000S PURCHASED UNDER THIS AGREEMENT. „_. • NOTICE TO MARYLANI,I_IESIDENTS ONLY Notice: All Mme Improvement contractors and subcontractors Must be licensed by the Maryland Home Improvement Commission, Inquiries regard - InA a contractor or subcontractor should be directed to the Home Improvement Commission, telephone: 410 - 230 -6309 or (In- state) 1 -BMB- 218 -5925. •IWIL JEO NEIALHANLIMUSE CUSTOMERS NEW HAMM —SIRE LAW, RSA 359-G, CONTAINS IMPORTANT REQUIREMENTS YOU MUST FOLLOW BEFORE YOU MAY FILE A LAWSUIT OR OTHER ACTial FOR DtFCT)VE CONSTRUCTION AGAINST THE CONTRACTOR WHO CONSTRUCTED, REMODELED, OR REPAIRED YOUR HOME. SIXTY DAYS BEFORE YOU FILE A LAWSUIT OR OTHER ACTION, YOU MUST SERVE ON THE CONTRACTOR A WRITTEN NOTICE OF ANY CONSTRUCTION CONDITIONS YOU ALLEGE ARE DEFECTIVE. UNDER THE LAW. A CONTRACTOR HAS THE OPPORTUNITY TD REPAIR AND /OR PAY FOR THE DEFECTS. THERE ARE STRICT DEADLINES AND PROCEDURES UNDER STATE LAW, AND FAILURE TO FOLLOW THEM MAY AFFECT YOUR ABILITY TO FILE A LAWSUIT OR OTHER ACTION. • r o e slpnature atD a Customer's stgna re Date Accepted by Sears Home Improvement Products, Inc. ( "Sears ") on by' - -� a g em epresentative not a... n■/l1A Ell/ ZZ/ ZE7147 49'3 44 8604665079 PAGE 02 • 1111111111111 la troposel Oatcy ■10/0 1 Job I :52)40 i / � Sears dame Improvemani ProBuvIs, Inc. :ustomer Nam P.O. 0ox 522290 err ..r41,..-. _ _ 1024 Florida Central Parkway :ualomer5 Ho moms Cu . , 'et' Wm* Phone _ Longwood. FL 32752 -2290 , r �♦ d Home Improtremattt Products _Phone (800) 469 -4683 itreer Address ESTIMATE AND PROPOSAL Contractor Llonnae/Foplstrstion Numbor /41 /U4wA0- 24i . .— G ala a Door CT (HIC.0607689); DC (50006423); �' late z,pcode .�._ MD (46542. 87554): RI (27281); /,004V0 W\I .- Is installation within city limits? (WV025882) nstallatlo A ess Count � 'VPs ID No • idling Address (11 tlirrerent from atleve) City -r ate tip Code P ns e & License (N Appllc r _ . / blear +T Dascriptlon o1 the Projec and Description of the ljellICant Materials to be Used nd Elleipmen be Installed the work to be done under this contract includes the lollowing: 1. Remove existing garage door(s) to be replaced. (PLEASE NOTE: The removed garage door(s) are likely to be damaged.) t. Prepare openings as necessary to receive garage door. (No finish work other than normal installation is to be done unless otherwise noted below.) 3. Installation includes the clean up 01 all job - related debris upon completion of the job. 1. Install the products as described below: GARAGE DOOR SIZE a QUANTITY GARAGE DOOR MODEL SIZE (1): X - 0 Sears 1000 0 Preinler 1000 O Wood Carriage House SIZE (2): X ,ears 2000 D Premier 2000 O SIZE (3): X 0 Sears 3100 0 Premier 3000 0 SIZE (4): , X _ Notes; _ DOTE: Special Order Garage Doors require 100% payment arrangements at the time of sale. Returns and cancellations of uninstalled Special Order Garage Doors are subject to a restocking foe equal to fifty percent (50%) of the purchase price. plus applicable freight :barges. However, the 50% restocking fee will not be charged (1) If your order was cancelled in accordance with the Notice to Buyer section of this contract before the described deadline; or (2) if your merchandise does not match your order specifications, has a detect in manu- 'acturing, or is damaged in snlpment or installation performed by Sears or at Sears' direction. PANEL DESIGN: 0 Short Panel ong Panel 0 Flush Panel 0 Ribbed Panel (Flush and Ribbed panel available M 3000 only) COLOR: de litf True White Almond D Sandtone 0 Brown' 0 Hunter Green' D Gray' ('These colors available 3000 only) DECORATIVE 0 WINDOWS Glass Type: 0 Clear 0 Obscure INSERTS: Cathedral 0 Cascade 0 Prairie 0 Five Plece Sunray . 0 Stockton 0 Sunray 0 Full Sunray D Waterford ❑ Wagon Wheel ❑ Moonlite Premier Base Design D A 0 B 0 C D 0 Cop Section nesign 0 Solid Arch 0 Solid Square 0 Double Arch 0 Four Lite Square 0 Quad Arch 0 Plain 0 Ten Lite Arch 0 Ten Lite Square Decorative Hardware ❑ Traditional Handles (Included) 0 Strap Hinges (Included) TRACK & HARDWARE: 0 Std Lift (12` radius) - 015" radius 0 Low Headroom (6 1/2" ext, 9 5/8' torsion) 0 Low Headroom - Front Torsion ❑ Low Headroom - Rear Torsion 0 Extension Spring LOOK: GINo Lock C] Inside Slide Lock (included) 0 Outside Keyed Lock (Sears Traditional) 0 Lever Handle Keyed Lock (Sears Premier) GA DOOR OPENERS Craftsman qty: Rail Length 0 7' ❑ 8' (Extension required) - 0 - 10' ((Extension required) Chain Olive - Model 53985: 2 hp _D Reconnect existing opener (must be equipped with safety photo beams) Belt Drive - Model 53914: 1/2 hp Llltmaster Options: 0 3 Button Remote Qty:. _,_. _ LItiMaster (Chain) - Model 357 : ❑ 3/4 hp _ JM D Wireless Ke lees Entry pry: �, Additional work to be done: ` .. r i - ■ W NOo be done: Painting, treating or caulkinr of an woo. surfaces a ec 'cal work r rounded outlet must be wit n 3 feet o a ; . e door D. ner , mountin . track to concrete ceilin, . .• / . SPECIAL INSTRUCTIO'S: All of the above check boxes and the "Work NOT to be done" section have been reviewed and explained to me. Customer(s y initial APPROXIMATE START DATE and APPROXIMATE COMPLETION DATE The work will start approxlrnately � 4 :'JL (Approximate Start Date) and will be substantially completed by approximately 0/ -S_ (Approximate Completion Date). These dates are subject to change at the time the contract is accepted by Sears Horne 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 including all labor, rnaterial, taxes and any applicable discount i1 $a - 4 5/K. _ CormaCt Price • .,:G Initial Payment (not to exceed 30% of Total Price unless Special Order) $ 3 _ State Sales Tax . . '4 Final Payment (balance payable upon camplelion of Job) �d - Luuil Sales Tax //,V °•) The Initial Payment Is due prior to Sears ordering products. - a �_ _ , Total Amount Due( S j� The form and method by which the Customer(e) will pay le described IIn aeoarate Cash/Credit Card Payment Addendum made a .-rt • a • e corporated Into this contract by reference. - ___ Customer(s) Initial IOTICE 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 OA OLDER) AFTER THE DATE OF THIS ' RANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. Additional provisions of this contract ars slated an the pages lollowing.j Customer(s) initial T. r —• acn.a. lie. enrna s.: : : ,!....1 . ..'; : `:..:1:: 1,.'i : ",;- PAGE 01 .. ,..- :i :. k - . H. C. T 0:1.t: ri S 60-4 6 - ''' 0 ; 5 . ,..__.)) 1 H i C r' i_ 'J c L 9 , Bitildiip. Permit JZegur,t Porn, Date of reytte °t: ta al Its Protected Start Date; ASAP Date Needed: ASAP JOB INFORMATION: Job 4 CASSG Oa Cost of job: '14 . Address of work: Town/City /State: _ F G } Cu.st. Phone 4: Li/ 3'5 -3 (-.- a.. _ ______ . SIDING WINDOWS ENTRY DOORS - ADAGE DOORS Product Brand Name: __ d i_� _ Square feet o. sic ing: Thickness of siding,: . Number of windows, entry doors, garage doors being replaced: 1 . Egress window Size: _ What rooms are windows being installed in: KITCHEN REMODELING New Countertops _ New Cabinets Other • Extra permits needed for: Electrical_ . Plumbing, Other Description of work: r ^ _ ` �� \'✓c hci by authorize hiiluift. Easley and its c nipioyees and agents fn; hliiinic Easley hi apply for and pniaart huilding permits for our compsny's ctmtrentrd %la'k and we alsp +nihMirc Niknle Easley rn pre.sent this lulu or n phorol n py horcnf to any NIildiriz official in nrdrr to dcmon it; .aathorn }'to apply for and prui :urc si "ah permit; no our behalf. to fur her ince or Ili is o,u.horirn no t +t ntt,,c■ cap ir.; cif our eau rent enw:it :tors lie :emir far the several sUitcs in whieh,ae antielpale 1.4ikutc En.si : :y will i c. rt:gttcslyd to apply Dui mtl procure such perrnib for u; We tigiirotni Ohio I is wit familiar with the npriit:a:ions rtir buiHJing px:nnits and relitted!I temmcnt; iv the various lo: alines in which Niknlc i k y will he rcgiicslcd to submit zifil+iieatiort: n n out inihalf. Nil:Mc rr.:tcley is centre sly au thtirizc {t in . ign :ip,piic:ui io :: no nu, hcirtl Nikt ;lc t3;i,1r :y ni her tmployces and ;tgcnt; sluill he drnivicil to he ilic ai nr trip; ut :h igiptic•uauis docu:ncis. +c rrt r;tpruc In hold ;viknic E: +sicy and lir"l ompiti' ' and , 1: cuts: harn•dcss for and initaunify tl cnt m.ain:A and ciaint.i ;wtl u, ;;lr (intaudir.g: my re:i) ;11" �nrn (heir act irilics Cl nit:mp hcr.:invh:t / -:inlc ttf ,A iath,c. , ri/.in_ /1),rnt Jolt. L. _ Sion' tar <:._ ��� / %_._., �tJ,;lc• 0 jt 88/85/2889 12:21 8604665879 __ 8&!85/2889 12 :84 487767$3g SurP PERHST08L.Iw1sE PAGE e1 /81 • CERTIFICATE OF LIABILITY MIRO= °az ggy) ' ` td* 89rvi�8 Ceara, sac. mar IEn SOITED SA.MA'fl MORaea ONLY Chimp a. O fflcp IDDIDDISWODANSISINONIMS C It PRYDE INS ( :_) 3 r1- f • cam.! z t ■ 10011000411900001000WASI 1:23 wilisNalb saxasAs ACEVifsa zfsuraea sears folding, corporation natant& sadewefRy >ltaareade as of North aearlf3 dba Sears Ms AlaprimeastaltMints. Mc fCr 3333 Y 111111111 I Wrenn Wanes 2L ADM ERIIIIIIIMIIIIIIIIIIIIIIIIIEIIIIIII .. . ,.•.. sot L. tamers and _ . an . VIC DO M `" - GIMOURIStCAUSUIDDIWwwarasoilllalaUERmaannstatinualMoISOMMEa 11 naTnapanisserumuscatausamAPAnscutenmertannaRSOCOADITIMMASUSICrilnatarlISSCOMmumossarerISSUBDat MAY ruanstroanomoracanar000tawaannocoaoascamonomansouncrroamtoronsommt AOSAIGATZUSWISSOMMA1VAMINVIVIMUCKCIM OM = AM AS • III Ilfi/ORladt �1►lYl�t� IISILAG Atio tAt!ISSI i;;; ; a %S.Naa. t tauer ❑ , O- 0 sae S AMMO/ {# D011nainosaanUON u.Vwry''... • in MUM A i ■ won) ■ ammeme mnn lOpfLTaaBA9 a is ,a ��« InDOXIRMRY LI Iffafftf�fSSaAMIX pinmemoo 111111111 4 PO ■ contoottarfani. ti•I� •-- i mi ,a,►,aaI tanownLve EAAf II Ocato El fAAPAMPafe II , 111.1111 10111111111 ter. - ,• t • , • u ''" Y 0.-- 7� ( a T F S1,DOO.00Y . A afrofflog ff IKINAV �- • - i t - c� : . :ammo - wwwwir aYlaa neecavaowvrsv R L ....._......... ___, ga CANCIRLAIION COUNICAIERTAISK sac rawt sa ans ooannoo no nomvegosin F'larida t - � tal+: wnot enad fa. 3 trig USA a *arlsMb� woe+camas :; Amf +wea�t�� t s �.� . � � Afaaafmammagaaaas . 07.0• ' g .aa AMID atArtPaSA The AA:fitmaalaaffaA ✓Ifa . t►aete�eoeaRasrtOr.r Received on 8/5/2009 12:04:20 PM 12/12/2008 10:53 8604565079 • :Matnca <htuctts - Departs-own( of PNIN< Safcts Satin! of Building Rcruiatinn:i and Stw dardn Construction Supervisor Specialty License Llicerls CS S1. 100311 Restricted to: WS - VASLLE K(AQIERCHUK ` ' 42 COOPER STREET r ' WEST SPR1NGF1ELD, htA MOB cam' Expiration: =wail .0.mr4e4mwer Trot: 100311 Lf /3-- - ."3 7Z- i5yf 30!2889 10:49 48776785% SH11' r •...- AO , 1 1 1 -', r� _. - = 0 ce o .nsu ner " i : an usiness a t'r - 10 Park Plaza - Suite 5170 ti Boston, sacJusett 02116 Home Improvement CoIIpra ctor Registration Regisbabon: 148607 : - - - Type! Public Corporation . - _ _ - E xpiry 10/11/21111 710# 288268 SEARS HOME IMPROVEMENT ''__,.___"1 .T, ALFRED NYMAN JR. --- 1024 FLORIDA CENTRAL PKWY_ -. -:- • - - • , LONGWOOD, FL 32750 - . Update Address and return card. Mark mason for change- ' --- 0 Address 0 Renewal ❑ Employment ® Lost card CAM 14 50M.041344101Z1B • as Office of C f C � License or Tad 1Or Ind*vidil one only HOME IMPRoVENIENT CONTRACTOR btfbre the expiration dote. If found return to Office of Connener Affairs and B Regulative 1 � . 14 A48847 10 Park Plaza - Suits S110 £xpira . ` ap it2O14 TM 288268 Boston. TL 02116 SEARS HOME ilIPMN t `PROOUGTS NC, - ALFRED n MAM, . f " 1024 FLORIDA t R/IE:f1CWY 4 0 D - LONGWOOD. FL 33'76 = :;".-:/ Uudaucedsry Not valid without sigedintre 1024 Florida Central Parkway, Longwood, FL 32750 PH: 407- 551 -6000 June 2009 LETTER OF AUTHORIZATION I, Alfred W. Nyman, Jr., Assistant Secretary and Connecticut HIC license holder for Sears Home Improvement Products, Inc., grant permission to Nikole Easley to submit permits and licenses, 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 permission to Nikole Easley to purchase permits and /or licenses with a company check, personal check, personal credit card or cash. This authorization is valid through June 30, 2010. I certifiy that the above information is true and correct. Alfred W. Nyman, r., Assistant Secretary and Connecticut HIC License (HIC.0607669) Sears Home Improvement Products, Inc. STATE of Florida COUNTY of Seminole SWORN TO AND SUBSCRIBED BEFORE ME THIS 24th day of June 2009, by Alfred W. Nyman, Jr., Assistant Secretary for Sears Home Improvement Products, Inc. and who is X personally know to me or has producted a valid Drivers License. Seal: DiPrtAX•4 p PI NOTARY PUl1LIC4TATE OF FLORIDA Print Name: Deborah P. P '.I ' ps a te . ' ... . , ,, Deborah P. Phillips _ z Commission #DD689052 Notary Public, State of Florida 1aau�, ar Expires: AUG. 11 2011 Commission #: DD689052 BONDED MINI ATIANTIC MONO CO MY COMMISSION EXPIRES: Aug. 13, 2011 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : v L'.l 5 , IQ__ I..._. , .. k - -I" Q--r,-__ ) t- Imo--- ' C) o 3 1 1 License Number Address Expiration Date SO Q (I C sL,i )-I I '!) (.42 3 Cc -z,3 7 Signature Telephone 9. Re istered Home Improvement Contractor: Not Applicable ❑ d Q (ti j `{ -a»)Q. � prw0 >,1 zit f 1 L,G7 Company Name Registration Number f elCL mt. uS:1___) I40—) i //, Address Expirdtibin Date O cl_ -- 4--- I \ U (.' l.: x,• - _Telephone ' )(c(- - (,^'y 6 r 1O3G - , 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 ❑ No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an indiividual 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 res I onsible for all such work I erformed under the buildin . i ermit. 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 <3G L..�1�(-47cc t— SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) I 1 Roofing ❑ Or Doors Accessory Bldg. ❑ Dem olition t ict ry g. ❑ Newi�ns [D] , Decks ID Siding [p] Other [oIJ Brief Description o ,P roposed Work: i Al) la 4 ' 6L Alteration of existin 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 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 -rt) (cL 1 , as Owner of the subject property hereby authorize -. C:.,/ / ike 1 Me.�57 to act on my behalf, in all matters relative to work authorized by this building perTif application. 4 : - : Signature of Owner Date 1 , r(; k.0 I L a SI e) , as Owner /Authorized Agent hereby declare that the - tatements 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. IA i kcrl4 I cz�1 � Print Name r I 1).7., 110 Signature bf Owner /Age 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 0 DONT KNOW I�✓ ` YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW © ' YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O 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 O 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 Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability ` i, Northampton, MA 01060 Two Sets of Structural Plans 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 1.1 Property Address: This section to be completed by office Map Lot Unit (1? / A cr c . � ..� 1 Zone Overlay District — F ,c _ AACL , h (/` U/ - i Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ry/ ck.17 I =. / GrQ i 76'o ) ' 1 " 1 O/64 Name (Print) ( Current Mailing Address: (! e Telephone Signature 2.2 Authorized Agent: •'KO /e +i tk (.1 cc',i_/`79 Name (Print) Current Mailing Address: / Oi 367c - Signature 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 5 - 2. Electrical (b) Estimated Total Cost of - Construction from (6) �' / 3 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 5 6. Total = (1 + 2 + 3 + 4 + 5) " Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date • 61 NONaivarr .x ,, BP- 2010 -0708 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Bioc 23B • 1E03 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0708 Project # JS- 2010- 001053 Est. Cost: $2443.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEARS HOME IMPROVEMENT PRODUCT 100311 Lot Size(sq. ft.): 16639.92 Owner: HALL SHERYL J & CHRISTINE M NORMANDIN Zoning: URB(100)/ Applicant: SEARS HOME IMPROVEMENT PRODUCT AT: 61 NONOTUCK ST Applicant Address: Phone: Insurance: 51 BELAMOSE AVE (860) 620 -9036 O WC ROCKY H I LLCT06067 ISSUED ON..2/5/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE GARAGE DOOR 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 2/5/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo