30B-106 PREPARING FOR YOUR NEW WINDOWS AND DOORS
• Congratulations on your decision to increase the comfort level, value and appearance of your home. To maximize your
investment and enable the installation to take place as smoothly as possible, we have created this handout to acquaint
you with what to expect when our installers arrive.
1. Expected Delivery Time. All of our windows are custom made at one of our manufacturing plants located around the country and
shipped to any of our over 200 Window World locations. The time between when your order is placed and when the windows are ready to
be installed, though not guaranteed is typically 6 to 8 weeks. At that point we will call you to set an installation date. If for some reason you
need to delay your installation for more than a couple of weeks after notification that we are ready to install your order we will be happy
to work with you. We will need to collect the remaining balance before installation if the delay you request is more than three weeks.
2. Access to the Windows and Doors. We will need approximately 2 feet in front of each window, inside your home, so we can place our
drop cloths and tools necessary to perform our work. When the old windows are removed, gusts of wind typically flow through your home.
It is advisable to gather together important papers, and other small items that can be disturbed by the wind and relocate them. Computers
and other electronic equipment should be covered or relocated temporarily. Please move aside any furnishings that are in the way of our
work. If any furniture items are too heavy to move easily, we will gladly assist you.
3. Window Coverings. To gain access to the interior of the windows, we need all mini blinds, vertical blinds, roll -up shades, shutters, drapes
and any other window covering removed prior to our installation. We are not responsible for removing or reinstallation of these items
and are not responsible for damage resulting in the removal and reinstallation. We also are not responsible for any window
covering alterations that may be required to reinstall them.
4. Plants and Bushes. Occasionally we need to work in planters and other landscaped areas of your home that are adjacent to the
windows and doors. Please survey your yard prior to us arriving and look for potential problems. Some trees and vigorous bushes
need to be pruned back to give us access to your windows. Delicate plants and shrubs in areas right below a window should be
temporarily relocated if they cannot survive being stepped on and you want to preserve them. We strive to be careful when working
around vegetation, but our priorities are to focus on our work, your windows and our safety while working on your property. We are not
responsible for any damage to plants, shrubs or landscaped areas.
5. Arrival and Departure Times. We will advise you of the expected arrival time for our crew at the time we set up the installation date with
you. We generally stay till the job is done, unless it will be a 2 or 3 -day job, in which case we may work as long as there is daylight. It is
our policy that our installers get a sign -off form and collect the outstanding balance at the completion of the job. We ask that you
be available to approve the job and make final payment at the time of completion. If this is not convenient for you, we need to
know before we start the job. Inclement weather and other unforeseen hindrances are a fact of life and as such we ask that you
understand if the weather, traffic, etc. cause a delay or cancellation of an installation appointment. We typically do not schedule
more than a day or two in advance to try to avoid such issues.
6. Our Worksite. We like to set up our worksite as close to your windows and doors as possible and generally your driveway is the best
spot. If using the driveway will block a garaged car, please be ready to pull it out upon arrival.
7. Alarm Systems. For those of you who have alarm systems, the alarm company should be notified and advised of our job. They will be
responsible for the disconnection and reconnection of your alarm system.
8. Where do we start? Upon arrival, the crew leader will survey the job and determine where to begin. If you have a preference, feel free to
advise us and we will accommodate to the best of our ability. Because we work in stages (i.e., removal of old windows, setting the new
window, wrapping of exterior, etc.), we don't complete the job one window at a time. The job moves along in a rolling progression where
each operation is done on all windows at the same time. This produces a quality job.
9. If the job takes more than a day, will there be any openings in my house? Of course not. We only remove that which can be reinstalled in the
same day. Although there may not be a complete window, it will be weather -tight and secure for overnight. (Please no critiquing at this time).
10. Pets. We love furry, four - legged creatures; however, we need your help in supervising them. We are not always able to close a gate or
door behind us when carrying a window, so please keep them in a safe place. Our job description does not include scampering down the
street after Fido with new found freedom. Many people say, don't worry, he doesn't bite, but many installers have been bitten. So please
secure dogs that have an aggressive bark towards strangers.
11. Expect some dust, noise and general disruption of your living space. Construction work can sometimes be messy depending upon
the scope of your job. It's an unfortunate reality of remodeling, but we do our best to keep things under control. We appreciate your
patience and understanding during the job and until everything is finished. Even after we have cleaned up, it is advisable to survey the
areas for something we may have overlooked (i.e., kids rooms, baby's room).
12. *Damage to walls and old trim stops. For those of you who have old aluminum and steel windows and are replacing them due to
sweating and damaging of the walls be advised that all water damage plaster will most likely fall out. In addition, all the patch work you
have done over the years will fall out also. This is normal; however, we are not plaster experts, so the repair to those walls would best be
left to the experts. In some cases due to out of square openings, new trim is required to make the window look good. *Unless noted
on the contract new trim will not be provided or installed by us. You can expect to do some touch up painting on the trim after the
installation of your new windows. This is not always necessary and is usually minor if it occurs. If your trim stops around your sashes are
very old, dry, and brittle, they may snap and crack upon removal. If this happens, we can leave them off if you please, or for a small up
charge, replace them with newer ones. Many of the old style stops are no longer available so we would replace the entire window with
newer style stops. Should we discover any hidden damage to the frame or wall area we will advise you before we proceed. Should you
decide to replace or repair anything, the price will be added to your balance.
13. Relax and enjoy the show. After we've been introduced to your home, feel free to run errands, take a walk, or just relax. If a question
should arise; by all means ask the crew leader for clarification. We enjoy people who are interested in what we do, and most customers
are intrigued with the process. We do get nervous, however, when a customer constantly hovers over our shoulder. Like any professional,
we're always happy to answer questions, but we appreciate being able to concentrate on our work without interruptions and distractions.
This ensures a safe and quality installation.
14. Past Due Balances are subject to a service charge of 1.5% per month. In the event that this amount is placed in the hands of an
attorney for collection, the purchaser agrees to pay all costs of collection, including a reasonable attorney fee. Return check fee is $50
(fifty dollars).
Salesperson Home Owner
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 PURCHASER(S) 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.
Window World Owner
Date Date
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."
Agawam) WC 10 -10
M • � 111 Wind w World of Western Massachusetts MA HIC Reg. #
��J 351 W Inut Street Extension • Agawam, MA 01001 165641
044: 11 Phone (413) 786 -9900 • Fax (815) 366 -8039 Construction Supervisors
www. indowworldofspringfield.com License # 57011
"Simply the Best for Less"®
Customer: *gam «i_ �' 4 ' "... r + . t k ''''''' . i Phone (h) , ` - 1 ":F
Install Address: _' ,` , r ;4 Phone (w)
Bill Address: ;' fi ,,. E-mail
r
WINDOW WORLD GLASS OPTIONS
1000 Series DH Mech $180 Stimulus Energy Package* $79
2000 Series DH Mech -Weld $189 • Includes Solarzone ETC Package
— 4000 Series DH All -Weld $200 r ( Solarzone Glass $45 + -
i 6000 Series DH All -Weld $235 Argon Gas $15
2 Lite Slider $329 Triple Glazed TG2 ** (Argon Filled) $155
2 Lite Slider Swing & Clean $389 Triple Glazed TK2 ** (Krypton Filled) $196
3 Lite Slider (1/3, 1/3, 1/3) (1 /4, 1/2, 1 /4) $520 ( *Series 4000 & 6000 Only - Qualifies for Federal Tax Credit)
3 Lite Slider Swing & Clean (1/3, 1/3, 1/3) (1/4, 1/2, 1 /4) $595 (* *Series 6000 Only - Qualifies for Federal Tax Credit)
Picture / Fixed Lite $329 WINDOW OPTIONS
Awning $255
Casement $285 1/2 Screens $9 ;j // ' • 2 Casement $570 Foam Insulation on Jambs and Head $11 -y
3 Lite Casement (1/3, 1/3, 1/3) (1/4, 1/2, 1/4) $855 -./ Double Strength Glass (4000 & 6000 Only) $15 -a,%,
., Double Locks (> 26") $5 f �
Basement Hopper $200
Bay Window $ Full Screens $22
Bow Window $ Colonial Grids (Contoured /Flat) $38
Prairie Grids $44
Garden Window $
Diamond Grids $69
Specialty Window $ Simulated Divided Lite $182
Beige cs $35
Wood Grain Interior (Series 4000 / 6000 only) $95 Tempered DH Sash (BSO) (TSO) $65
Oriel Style Glass (40/ (40/60 (BSO) 60/40) $35
Colored Exterior (Series 4000 / 6000 Only) $138
Oriel Style (40/60 or 60/40) $30
' Foam Enhanced Frame (Series 6000 Only) $25
Window Color • ' ' , / t / ;'
Inside Outside , , . PRE 1978 BUILT HOMES (Federal Lead Containment Law*
r; 1 : With Custom Premium Exterior Trim $50 , ''
Without Custom Premium Exterior Trim $70 '
DOORS MY HOME WAS BUILT IN THE YEAR 1< , . Initial
Vinyl Rolling Patio Door 6ft. $895 MISCELLANEOUS
Vinyl Rolling Patio Door 8ft. $995 Custom Exterior Trim /Wrap Wood Out
Vinyl Rolling Patio Door 9ft. $1095 ❑ Textured $60 ❑ Smooth G - $75 $
Includes Exterior Vinyl Trim
Facing Facing Color
acing Color
Specialty Door Custom Exterior Trim /Wrap Metal Out
Grids Patio Door $100 ❑ Textured $75 ❑ Smooth G -8 $90 $
Solarzone Glass for Patio Door $125 Facing Color
Solarzone Elite Glass for Patio Door* $168 Special Custom Exterior Trim /Wrap $
( *Qualifies for Federal Tax Credit) Mull to Form Multi Unit $30
$ Install Exterior Stops $45
$ Install Interior Casing $45
Storm Door $ Insulate Weight Boxes $30
Repair Sill or Jamb $50
Build Sill or Jamb $75
Door Color / _Remove Mullion $30
Inside Outside Remove Storm Window $15
WINDOW Remove Bay /Bow $250
INDOW WORLD CARES
Roof for Bay /Bow $500
St. Judes Children's Research Hospital $ Remove and Install A/C $100
DISCLAIMER: The information herein related to the Federal Stimulus Package is for informational purposes ONLY. This information is not intended to be legal or I
tax advice. You should contact your accountant or other tax professional for advice related to specific tax benefits of purchasing energy efficient windows.
NO EXTRA WORK IF NOT IN WRITING! Customer agrees to the terms of payment as follows:
r Extra Labor $
r i' Er f ) ) t.- is. 1 -P , . 4 Site Set -Up and Green Environmental Disposal Fee $ $2512:fl'0
Total Amount $ �l i ..
Custom Order Deposit 50% $ . , ‘lacI" ;�
Balance Paid to Installer upon Completion $ G r' i f; 0-r'"
_ Amoun"'tCd',$
WW of W. Massachusetts anticipates starti th work on and being substantially completed in `.,days. Seogrity Interest: Yes No
Any deposit required in advance of the start of the work SHALL NOT exceed 33 1/3% of the total contract price or the 'actual cost of any material or equipment of a
special order or custom made nature, which must be ordered in advance of the start of the work to assure that the project will proceed on schedule. No final payment
shall be demanded until the contract is completed to the satisfaction on all parties. .
All home improvement contractors and subcontractors shall be registered and that any inquires about a contract or subcontractor relating to a registration should be
directed to: Office of Consumer Affairs and Business Regulation, Ten Park Plaza, Suite 5170 Boston, MA 02116. Phone: (617) 973 -8700
No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract.
WW of W. Massachusetts under provision of Chapter 142A of the general laws is required to apply for and obtain all construction - related permits. WW of W. Massa-
chusetts shall not be deemed responsible for delays in the work described in this agreement caused by regulatory, permit granting agencies, authorities or individuals.
Notice: If the PURCHASER(S) obtains his own Construction related permits for the work described under this agreement or deals with unregistered contractors,
the PURCHASER(S) is hereby advised that in the event of a dispute, judgement and nonpayment, the PURCHASER(S) will not be entitled to make a claim or
collection from the guaranty fund established by chapter 142A, M.G.L.
You the buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.
Notice of cancellation must be in writing postmarked no later than midnight of the following third business day.
THIS IS A CUSTOM ORDER NOT FOR RESALE!
Owner Date
a r
alesmar3 Date Owne Date
Agawam WC 10-10 White Copy Original Yellow Copy File Pink Copy - Customer
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation fortheir employes'.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub- contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (J 1.P) with no employees other than the -
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees policy-is required Be advised that this -- affidavit maybe submitted to the Department of - Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retumed to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self - insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
• that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE
Fax # 617 -727 -7749
Revised 4 -24 -07 www.mass.gov /dia
The Commonwealth of Massachusetts
--�— Department of Industrial Accidents
w" l Office of Investigations
1 600 Washington Street
Boston, MA 02111
,.a
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information I Please Print Legibly
vat
Name ( Business / Organization /Individual): LI) „O [, id of WQ►-ttst'1 ,AAtuS&Cttltv4-191 �laL•
Address: 35 ( L, ak (2 S4
City /State /Zip: t.)Arvt MA 0 106 i Phone #: ( -1 13 -- 78‘ q t)0
Are you an employer. Check the appropriate box:
Type of project (required):
1.,1 I am a employer with j 4. 0 I am a general contractor and I 6 New construction
employees (full and/or part- time).* have hired the sub - contractors
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 8. 0 Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. [] 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.] t c. 152, § 1(4), and we have no
— — — -- employees [No workers-'--- 13.� Qther h? �actt rtt,zv�-
comp. insurance required.] L-,`.r.dd
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
tHo meowners who submit this affidavit indicating they are clang all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional shoet showing thename 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: L i L t-t Itault TLvns & rC r CR
Policy # or Self -ins. Lic. #: U )C LS 3 7 (.> 1 Expiration Date: 5/74 2.01 Z
i i a r e . , n M 0 1 0 ( 2 1 —
Job Site Address: tI20 of 1 t\ k n S+ City /State/Zip: C o b t o 6 o
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 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.
I do hereby certify under the pains and penalties o f perjury that the information provided above is true and correct
Si u afore: ��� Date:
•
Phone #: 13" 7 b ° q({ (X)
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 #:
SECTION 8 - CONSTRUCTION SERVICES
n �8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder : r pot ��' _ t+ � Q- \i
\ License Number
Cr? % t A i Fzc .,V(A. l�A 01 030 5
Address Expiration Date
Signature Telephone
/2-e( C f)/t ) 0A
3,
t �
/� Registered Home Improvement Co ctor: Not Applicable ❑
1/ R0 r4 &st r J tf564(
Com.. nv Name r -- Registration Number
60,11, 1 A) LOW Id O f (Ai -tervt /4aL hi. 3(15 f; i
Address Expiration 3(15
.S5J LJCttb1c(-b Si, 74 Te lephone L(3 - 7 Of -, qqj)
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 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
,
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House El Addition D Replacement Win ws Alteration(s) n Roofing El
Or Doors
Accessory Bldg. Ell Demolition 0 New Signs [D] Decks [EJ Siding [01 Other [0]
Airief Description of Proposed
Work:
vi 1° ^N .Y\ w UJ0_s iA
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 budding : 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 stones?
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, , 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, \ \UZek � lxSL , as Owner /Authorized
Agent hereby declare that the 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.
' R LAX f , i.kiLk
ynt Nam I
'46( � ' . 'it
Signature of Owner /A 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 ever been issued for /on the site?
NO 0 DONT KNOW 0 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 O DONT KNOW O 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 O
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 O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
}
w w w
R N ) of Northampton Department use only
City o orthampton Status of Permit:
,`,� 7-6 : uilding Department Curb Cut/Driveway Permit
Jam" / ` 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
-11: orthampton, 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 Property Address: This section to be completed by office
G h h "' \ /� i [ C� Map Lot Unit
o ' CZ D J Zone Overlay District
t .0( , (4._. , IkA A, 003 2--- Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Telephone
Signature
2 Authorized Agent: ��7� sl n 39 wcisik4 .I} pA' ak
Name •nt) Current Mailing Address:
7 V Llk3 - 7 BG - q `k 00
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building MO r � . c ,2\ (a) Building Permit Fee
2. Electrical ✓V (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) \ \Bp. 00 Check Number /7 zt2U
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
6;
60 MILTON ST BP- 2011 -1000
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30B - 106 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit # BP- 2011 -1000
Project # JS- 2011- 001628
Est. Cost: $1180.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT E BUSHEY JR 57011
Lot Size(sq. ft.): 7797.24 Owner: THOMAS THERESA M
Zoning: URB(100)/ Applicant: ROBERT E BUSHEY JR
AT: 60 MILTON ST
Applicant Address: Phone: Insurance:
351 WALNUT ST EXT (413) 786 -9906 WC
AGAWAMMA01001 ISSUED ON:6/2/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 4 REPLACEMENT WINDOWS & TRIM
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 6/2/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner