29-143 (7) BAYSTATE WINDOW
87 SHATTUCK RD
HADLEY, MA 01035
(413) 549 -6824
CS 89485 / HIC 125626
CONTRACT
DATE: 5/18/09
PROJECT: DON & CAROL ANDERSON
ITEM DESCRIPTION COST
REPLACE 12 WOOD DH WINDOWS
INSTALL 5 HARVEYS VINYL TRIBUTE DH $2090.00
WINDOWS , FULLY WELDED , TRIPLE GLAZED
INSULATED GLASS W /KRYPTON GAS , WH ,
HALF SCREEN, FOAM FILLED, SUN CLEAN GLASS
INSTALL 7 HARVEYS VINYL CLASSIC DH $2135.00
WINDOW , FULLY WELDED , DOUBLE LOW -E
INSULATED GLASS W /ARGON GAS , WH ,
HALF SCREEN
REPLACE BOW WINDOW $3315.00
INSTALL HARVEYS VINYL 30degree DH
BAY WINDOW , 24" DH FLANKERS , WH ,
TRIBUTE HIGH PERFORMANCE GLASS PKGE,
13" PROJECTION , RETRIM EXTERIOR &
WRAP WITH ALUMINUM REUSE INT TRIM
IF POSSIBLE
HAUL AWAY OLD WINDOWS
PULL PERMIT $75.00
i dS .Audee. i- AnN 'c t Sly, c
TOTAL $ *`13
- DEPOSIT $ Maud
BALANCE $
We hereby agree to furnish labor & materials completed in accordance with
The above specifications, at above stated prices.
OWNER ( L ,Q i DATE °` �- 1
CONTRACTOR ' DATE` (
UNDERLYING DAMAGES WILL BE BILLED SEPERATELY
I..
1
',, The Commonwealth of Massachusetts
Department of Industrial Accidents
:�— - Office of Investigations
_ 600 Washington Street
4 Boston, MA 02111
www. mass. g ov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): (3 5- LA.,) `, j T
Address: N L Q. ck- Rel
City /State /Zip: _ ' - 4'{- C /Zar Phone #: SO 67
Are you an employer? Check t ppropriate box: Type of project (required):
1. am a employer with 2 4. I am a general contractor and I 6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
listed on the attached sheet. 7. Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have g. 111 Demolition
working for me m any capacity. employees au�l have wurkeis'
9 E] Building addition
[No workers' comp. insurance comp. insurance.t
re uired. 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
9 ]
officers have exercised their 11. Plumbing repairs
3. ❑ I am a homeowner doing all work h p irs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
* Any applicant that checks box #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.
{ Contractors 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. e / „/) � �
Insurance Company Name: q i6 ,,u.C.t t
Policy # or Self -ins. Lic. #: 7 .316 4 g f Expiration Date: 7 7 l
0 16 3 L`f►� gd .
Job Site Address: , �- � I Yom • City /State /Zip: rl
A44 ,
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of lip In ,2 50 00 a clay against the violator. Be advised that a copy of this statement may be fonvarded to the Office of
Investigations of the DL& for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
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 #:
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his /her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill)
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction SSupervisor: Not Applicable ❑
Name of License Holder : '�lW4Aae -0 - �Ikw.,tS caLts cl'il
/ License Number
rl 5 kqx-ruc k �s- . (-4a ,iG4- 0 /-0 3 � - FA - 40/4.)
Addr s• ` ' . , Expiration Date
Signa ure Telephone
9. Registered Home, Improvement Contractor Not Applicable ❑
a lJJ c.. `�- /a s6.
Company Name Registration Number
Address Expiration Date
Telephone
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 Exempt
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 Massachusette General Lawo Annotated, you may be liable fui peisuu(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
•
/
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing Ti
Or Doors 527----
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [C] Siding [❑] Other [D]
Brief Descritopa of Pro 4d
Work: i ( 9t Q C9404r Li itf ✓
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes l/ 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
•. 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
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, c?A 04.444e4) , as Owner /A thorizedh
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my�nowrecfge
and belief.
Signed under the pains and nalties of perjury.
Print Nam
Signature of wner /Agent Date
Antommonnommommoommommoungow
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 -- YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO {j DONT KNOW Q YES 0
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 0 NO p_
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
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading,' excava ion, 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.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /SepticAvailabiGt
Room 100 Water/We ua.it i,' e
Northampton, MA 01060 rr. o • St till:
phone 413- 587 -1240 Fax 413- 587 -1272 Sig- - s n Specify %{
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMi? • i NE OR TWO FAM1kY D LLING
SECTION 1 - SITE INFORMATION t n
ti _
1.1 Property Address: \ Thseetion to be completed by office
D -(03 k /JI Map Lot Unit
I Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
t-0D Po Lu'scA r7 511'ic ur-�c l •/ (
Na ri r e Current Mailing Address:
1 ` � / 544-
Signa re Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (c5• q y (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) -7C-79-c4) Check Number '(1L1 3) #3. e (4)
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: i � g 7 (1.3 / Q�
Building Commissioner /Inspector of Buildings Date
263 RYAN RD BP -2010 -0114
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map :Block: 29 - 143 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 -0114
Project # JS -2010- 000130
Est. Cost: $7599.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD PALMISANO 125626
Lot Size(sg. ft.): 12022.56 Owner: ANDERSON DONALD E & CAROL CHAM
Zoning: URA(100) //WSP Applicant: RICHARD PALMISANO
Q T.• 263 RYAN RI)
Applicant Address: Phone: Insurance:
87 SHATTUCK RD (413) 549 -6824
HADLEYMA01035 ISSUED ON: 7/29/2009 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: i"snal: QY F . c 2 - o (7,4
THIS PERMIT MAY BE REVOKED BY THE Y OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL IONS
,00 7--) 7
Certificate of Occupancy
FeeType: Date Paid: Amount:
Building 7/29/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo