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R enewal DO - ..: ;. RENEWAL BY ANDERSEN MA HIC License # 149601 (expires 1/24/10)
by /� ndersen. , " , Federal Tax 1D# 83- 0404201
WII NN DO W REPLACOMONT an Andersen Company O F , CREAeER•MASSACHUSETTS AND NEW HAMPSHIRE
104 Otis Street • Northborough, Massachusetts 01532
Phone 508.919.0900 • Fax 508.919.0903
SPECIFICATION SHEET
Buyer(s) Name Date of Agreement
— 7 1 /(di ine r P4 /(ki f0 /G -20`
The Buyer(s) listed above hereby jointly and severally agree to purchase the goods and /or services listed below, in accordance with the prices
and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR
REMODELING AGREEMENT, of which this Specification Sheet is a part.
I WINDOW DETAILS , 1
1. Contractor will Install a total of / windows in Owner's home, using the following individual quantities:
I I Double Hung (DB) Qi Equal sash ❑ Cottage sash (1/3 top, 2/3 bottom) ❑ Oriel sash (2/3 top. 1/3 bottom)
Casement (CW) ❑ Hinge right ❑ Hinge left (as viewed from exterior): ❑ Standard handle ❑ Metro handle
Double Casement (CDW) ❑ Standard handle ❑ Metro handle
Casement / Picture / Casement (CPW) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle
(
2 Lite Gliding Window (GW) ' u
Glider / Picture / Glider (GPW) ❑ 1:1:1 or ❑ 1:2:1
Awning Window (AW)
Picture Window (PW)
Bay or Bow Window
Patio Doors (see separate Door Specification Sheet) tf
2. ['Yes ❑ No Qty of Windows to be Custom Fit Replacement: 1
3. ❑ Yes "No Qty of Sills to be replaced by Contractor:
4. ❑ Yes a Qty of Windows to be New Construction Full frame (includes new interior & exterior casings)
Exterior casm s: ❑ Pine ❑ Maintenance -free material ❑ Factory applied 908 Fibrex brickmold
5. Glazing to be: [HP Low -E® SmartSunlM (Tax Credit Eligible) ❑ Other If other, please specify:
6. Exterior color to be: +[ ite ❑ Sand ❑ Canvas ❑ Terratone ❑ Cocoa Bean
7. Interior color to be:ite ❑ Sand ❑ Canvas ❑ Terratone ❑ Pine ❑ Maple ❑ Oak
Note: Inte for color can only be white, wood or same color as exterior. Wood interiors need to finished by Owner.
8. Hardware: ZWhite ❑ Stone ❑ Canvas ❑ Brass Dou}yte Hung:
9. ❑ Yes ❑ No Install Lifts with D uble Hung Windows EIiiti ift(. a;;i S 17 . 6-
10. Screens: windows to have: E Half or ❑ Full screens Screens to be: fiberglass ❑ Aluminum ❑ TruScene
GRILLE DETAILS
11. Windows have v illes: 2 ❑ No If yes: ❑ Grille Between Glass (csc) [Removable Interior Wood ( ❑ Full Divided Light (rnc)
Qtr 7 / Qty: Qty: Qty: Qty: Qty: Qty:
DH DH DH CW/Picture Glider CPW or GPV'i
Draw grille patterns above '"Use additional sheet if needed Owner approved (initials): ( )
ADDITIONAL WORK DETAILS
12. ❑ Yes [/f No Contractor will remove metal frames of windows. Qty of Units:
13. ❑ Yes - No Contractor will install new paint -ready or stain -ready casings.
Interior asing qty of openings: Exterior casings qty of openings: ❑ Pine ❑ Maintenance -free material
14. E] Yes [No Contractor will install new paint -ready or stain -ready inside or outside stops qty of openings:
Interior stops qty of openings: Exterior stops qty of openings: ❑ Pine ❑ Maintenance -free material
15. Owner is ayare that Contractor does not do any painting. ( ) Owner Initials
[] N
16. ❑ Yes o Contractor will wrap exterior casings with aluminum coil stock of color.
Note: Wrapping may be required with storm window removal; removal of storm windows will leave screw holes in casing.
1 7. [,Yes ❑ No Contractor will insulate, caulk and seal windows with 3 -point system to prevent water and air infiltration.
18. 2, ,yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full.
19. [Yes ❑ No Building Permit —Contractor will secure any and all necessary permits. The fee for the permit(s) is not
included in the Contract Price and a,separate check is required at the time of sale for this fee. f
20. Additional job details: t / if S C L t ? F j ( i2i ii, I / / ,i j,, ,t /f2 ( (.,iF ,
21. 2Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment.
No final payment shall be demanded until the contract is completed to the satisfaction of all parties.
It is agreed and understood by and between the parties that this Specification Sheet, along with the CUSTOM WINDOW AND DOOR
REMODELING AGREEMENT, constitutes the entire understantling between the parties, and there are no verbal understandings chan or
modifg,any a terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are
tlhngran¢ signed/0y both the Buyer(s) and Contract hereby acImowledge that Buyer(s) has read this Specification Sheet.
new by i / Andersen of Greater MA and NH Eu_ver(s)7 ) -----7 ,, Buyer(s)
Signature of t Manager .. tu Signature
I I I ,iL ` if if cC -,70,x 'f /,i,/ / � IC /ci/f
Print Name of Product Manager Print Name Print Name
RbA Copy - White Customer Copy - Yellow
R enewal ,,.-- MA HIC License F 149601 )expires 1/24/10)
r
;;, - NEWAL B Y DERSE1\ Federal Tax IDq 83- 0404201 • byAndersen_
WINDOW REPLACEMENT an AndesevCompn, OF GREATER MASSACHUSETTS AND NEW HAMPSHIRE
104 Otis Street • Northborough, MA 01532
Phone 508.919.0900 • Fax 508.919.0903
t r
CUSTOM WINDOW AND DOOR REMODELING AGREEMENT
Buyer(s) Name Date of Agreement
Buyer(s) Street Address, City, State, and Zip Code / �
"2/ k ,4c%�/x/(77 - , W vc �(���fHr��T/%i7 %i )??I Gig -�
E -Mail Address Home Telephone Number Work Telephone Number
'/ / -;Zs- %
Buyer(s) hereby jointly and severally agrees to purchase the products and /or services of J & L Windows, Inc. dba Renewal by Andersen of Greater
Massachusetts and New Hampshire ( "Contractor "), in accordanc4e with the terms and conditions described on the front and the reverse of this '
agreement and on the attached specification sheet(s) (collectively, this 'Agreement "). Buyer(s) hereby agrees to sign a completion certificate after
Contractor has completed all work under this Agreement.
Method of Pymnt: ❑ Cash ❑ Check ❑ Mastercard ❑ VISA
Total Job Amount:/ 5 qVZ _. Estimated Starting Date:
❑ Discover i nanced, App #:
Deposit Received (33 %): ^ EQ f �Kf
Name on Credit Card:
Balance at Start of Job (33%): Estimated Completion Date: Credit Card #:
Balance on Substantial ( `/c_ 9 ,4 t
Completion of Job (33 %): l CC Exp. Date: CC Security Code:
By initialing here, you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion
Buyer Initials of Job cannot be made by credit card and must be made by personal check, bank check, or cash.
Buyer(s) agrees and understands that this Agreement constitutes the entire understanding between the parties, and that
there are no verbal understandings changing or modifying any of the terms of this Agreement. No alteration to or deviation
from this Agreement will be valid without the signed, written consent of both Buyer(s) and Contractor. Buyer(s) hereby
acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a
completed, signed, and dated copy of this Agreement, including the two attached Notices of Cancellation, on the date first
written above and 2) was orally informed of Buyer's right to cancel this Agreement. DO NOT SIGN THIS CONTRACT IF
TH ARE ANY BLANK SPACES.
enewal by n der r.en of Greater MA and NH Buyer ( s) - Buyer(s)
By: / ( i � t �J
M ature of Product Manager . ignature Signature
1 r
ii /2 /2 1' /
Al& f l C Eiie/.
Print Name of Product Manager Print Name Print Name
YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD
BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORMS
FOR AN EXPLANATION OF THIS RIGHT.
NOTICE OF CANCELLATION )f NOTICE OF CANCELLATION x
Date of Transaction {'/ - Zi't +` l
I' . You may cancel Date of Transaction . You may cancel
this transaction, without any penalty or obligation, within this transaction, without any penalty or obligation, within
three business days from the above date. If you cancel, arty three business days from the above date. If you cancel, any
property traded in, any payments made by you under the property traded in, any payments made by you under the
Contract of Sale, and any negotiable instrument executed Contract of Sale, and any negotiable instrument executed
by you will be returned within 10 days following receipt by you will be returned within 10 days following receipt
by the Seller of your cancellation notice, and any security I by the Seller of your cancellation notice, and any security
interest arising out of the transaction will be canceled. I interest arising out of the transaction will be canceled.
If you cancel, you must make available to the Seller at If you cancel, you must make available to the Seller at
your residence, in substantially as good condition as your residence, in substantially as good condition as
when received, any goods delivered to you under this when received, any goods delivered to you under this
Contract or Sale; or you may, if you wish, comply with the I Contract or Sale; or you may, if you wish, comply with the
instructions of the Seller regarding the return shipment of instructions of the Seller regarding the return shipment of
the goods at the Seller's expense and risk. If you do make ' the goods at the Seller's expense and risk. If you do make
the goods available to the Seller and the Seller does not the goods available to the Seller and the Seller does not
pick them up within 20 days of the date of your Notice pick them up within 20 days of the date of your Notice
of Cancellation, you may retain or dispose of the goods I of Cancellation, you may retain or dispose of the goods
without any further obligation. If you fail to make the I without any further obligation. If you fail to make the
goods available to the Seller, or if you agree to return the goods available to the Seller, or if you agree to return the
goods to the Seller and fail to do so, then you remain liable goods to the Seller and fail to do so, then you remain liable `
for performance of all obligations under the Contract. for performance of all obligations under the Contract.
To cancel this transaction, mail or deliver a signed and To cancel this transaction, mail or deliver a signed and
dated copy of this cancellation notice or arty other written dated copy of this cancellation notice or any other written
notice, or send a telegram to Renewal by Andersen I notice, or send a telegram to Renewal by Andersen
of Greater Massachusetts and New Hamsshire, 104 of Greater Massachusetts and New Hampshire, 104 '
Otis Street, Narthbarough, MA 01532, NOT iJER. THAN Otis Street, Narthborough, MA 01532, NOT LATER THAN
MIDNIGHT OF /L' 2 0 - C(7f `1 . (Date) MIDNIGHT OF . (Date)
I HERESY CANCEL THIS TRANSACTION. f HERESY CANCEL THIS TRANSACTION.
I _
Consumer's Signature Date Consumer's Signature Date
t t
RbA Copy - White Customer Copy - Yellow Customer Copy - Fink ■
t
t
The Commonwealth of Massachusetts
—.- Department of Industrial Accidents
` Office of Investigations
G f J 600 Washington Street
Boston, MA 02111
e; zi www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): Re G / y / 94 r3 e., ri
Address: /0 4 Oi l / S 3TYee_.
City /State /Zip: pro, bo 1 °0 X 414 (I 1_K3Z_ Phone #: «�� ?if 0'4o
Are you an employer? Check the appropriate box: Type of project (required):
1. Ef am a employer with 00 4, ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t modeling
ship and have no employees These sub - contractors have 8. Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.E] Electrical repairs or additions
3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions
myself. [No workers' comp, c. 152, § 1(4), and we have no 12. ❑ Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13.0 Other
*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 their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: I ? l (' K o :).e , tic (( f'G ii C e
Policy # or Self -ins. Lic. #:� 1`U I f Expiration Date: / ,/ O
Job Site Address: S {� tt }'v°1'\ City /State /Zip: U s Q 4 utkil Cpl U(o 0
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cer y ur der the pains and penalties, of perjury that the information provided above is true and correct.
1
Signature: ��. .._ �•— Date: 1 v (
Phone #: jr ( (Z) F) CO
Official use only. Do not write in this areg, to be completed by city or town official.
4
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health' 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Sep 1'/ 2UUS 11; lb JI'UflcKeone4ln$ be 81U1 p. 1
ACORD CERTIFICATE OF LEABEE I' EE UE E DATE(MMJODIYI'1'Y1
09/17/2009
" PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF II'/FORMATION
Joseph McKeone ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
JP McKeone ErlsurenceAgency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 333
Ann Arbor, MI 46106 - 0333 INSURERS AFFORDING COVERAGE NAIC #
INSURED Renewal by Anderson INSURER A. Hartford Insurance Company I
J8L Windows, Inc. INSURER B: Hermitage
104 Otis St INSURER C
Northborough, MA 01532 INSURER D:
, INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN tS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR POLICY POLICY EFFECTIVE I POLICY EXPIRATION LIMITS
LTR IIN5RD TYPE OF INSURANCE DATE IMMOD/YY) I MATE IMMPDOD'YP
GENERALUABILITY HCP 507 404 09/07/2009 09/07 /2010 EA.CHOCCURRENCE S 1,000,000
DAMAGE TO RENTED
X_ COMMERCIAL GENERAL LIABILITY PREMISES (Ee cc:urence) $ 100,000
I I CLAIMS MADE r X OCCUR I MED ,:XP (Any one person) $ 5,000
L PERSONAL 8 ADV INJURY $ 1,000.000
I GENERAL AGGREGATE 5 2,000,000
GENT AGGREGATE LIMIT APPLIES PER: PRODU - COMP /OP AGG S 2,000,000
cR0 f L
� POLICY 1 j�CT
CC
A I AUTOMOBILE LIABILITY 35 MCC XD 6390 10/01/2009 10/01/2010 COMBINED SINGLE LIMIT
ANY AUTO
(Ea EOCIdent) 1,000,000
x ALL OWNED AUTOS BODILY INJURY $ I
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY
NON -OWNED AUTOS (Per ecOdent) _
PROPERTY DAMAGE
i ! Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCID ENT I $
OTHER THAN ANY AUTO EA ADC I $
J AUTO ONLY AGG
EXCESS/UMBRELLA LIABILITY I ! I EACH OCCURRENCE
/OCCUR ( CLAMS MADE AGGREGATE $
I5
DEDUCTIBLE
RETENTION $
WORKERS COMPENSATION AND
S OMPENSA WC STATU- OTH.
A WORKE C
S OMPE SA 35 VAC PP 1444 02/17/2009 02/ 17/2010 TORYL:MITS -R
E.L EACH ACCIDENT $ 5
ANY PROPRIETOR. PARTNEVEXECUTIVE OFFICER/MEMBER EXCLUDED? E. L. DISEASE - EA EMPLOYEE $ 500,000
If Yes, aeacnbe under
SPECIAL PROVISIONS �, E.L. DISEASE - POLIOY LIMIT i $ 500,000
OT'H
DESCRIPTION OF OPERA / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
COPY
ANY OF THE ABOVE DESCRIBED POLICIES/ BE CANCELLED BEFORE THE EXPIRATION
INSUp t+OP� DATE THEREOF, THE ISSUING USURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
f � . NOTICE TO THE CERTIFICATE NOLO M NAMED TO THE LEFT, SLIT FAILURE TO DO SO SHALL
IMPOSE NC oeua..t.rioK OR UASILITY OF ANY REID UPON THE INSURER, ITS AEEN'TS DR
REPRESENTATIVES.
t a
AUTHORIZED REPRESENTATIVE `..
ACORD 25 (200110S) J ACORD CORPORATION 1958
i o
i-
d
Board of Building Regulations and Standards . ' I '
� 2 . 'Construction SupervisorLicense ,,,.; ;. ; „
t-� • License; CS • 95707
BirthcTate '91871982
1E)pirat[on 91$12010 Tr# 95707 I
a;
Restriattor 500t •
BRIAN DENNISON;' % I
;:.: �� •
86 CREST CIRCLE "`, -,, 1
WORCESTER, MA 01603` Commissioner;
•
RENEWAL BY ANDERSON
BRIAN DENNISON
104 OTIS STREET
NORTHBOROUGH, MA 01532
DPS -CA1 0 50M- 07/07- PC8490
✓�xe -�o»Unwnurea orudiaaauducaela
Board of Building Regulations and Standards
M1i HOME IMPROVEMENT CONTRACTOR
Registration:, 149601
E Eirrat It 724/2010-
fl ?1 type :uppiement Card
try`
RENEWAL BY ANpERSON. -. 't,'
BRIAN DENNISOfN,`
104 OTIS STREET `';, ;— _;N��
NORTHBOROUGH, MA 01532 Administrator
•
•
4
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 i 1 1 I r
Frontage
Setbacks Front 1
' Side L:1 R:Pi L:E 1 R: ___._..1 1 1
Rear = L___ __I
Building Height = = LJ
Bldg. Square Footage 1 = % = P
Open Space Footage
(Lot area minus bldg & paved I 1 1_1
parking)
# of Parking Spaces
Fill: i ._..... .. -- a - _ ..
(volume & Location) 1 1 1 i
A. Has a Sp ial Permit /Variance /Finding ever been issued for /on the site?
NO O DON'T KNOW 0 YES 0
1
IF YES, date issued:I
IF YES: Was th permit recorded at the Registry of Deeds?
NO DON'T KNOW 0 YES 0
7
IF YES: enter Book Pagel I and /or Document # •
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO er
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 0
IF YES, describe size, type and location: I )
I
E. Will the construction activity disturb (clearing, grading, exc tion, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
n r
Name of License Holder t r I CL E? A 01
License Number
Address Expiration Date
( ' C, 7 7
Signature Telephone
1a. Relastere, Notnerrtiy"r'ouement Gonti actor",_„ , EZ V gy e _ R ' Not Applicable ❑
lv2 -e. � ∎ NNA -C', I R . i V `` { ( LE I
Company Name Registration Number
Address Expiration Date
ti. Telephone ?) % 0 1 I v 7�
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 yy No ❑
1 Ho me Owner enw
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 ❑ Addition L] Replacement W_ irows Alteration(s) LI Roofing E:1 Or Doors [�
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [q Siding [0] Other [CI]
Brief Description .f Proposed j
Work: 0.c , c�Ut , .� .. G n •
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative - Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
o f Nev': ;: ouse •;sir a ii ltion to existll �l housing or piece the fo owincl:
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, , 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 r Ct A ; S cw . , as Owner/ rite
r,$[ hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
an. •elief.
Signed under the pains'and penalties of perjury.
Print Name
Signature of Owner / Date
� %, p gent T"'�z ".lksr, f $ �s 3# {{
City of Northampton atusto e ., q
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---- APPLICATION TO CpNSYRUCT, /ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
hit Th is section t o be compl eted by offi ce
1.1 Property Address: ;,4 -` � � 1 y
Q ( (.1. k.S \∎ ha 1SY, -t._ a�1.. t o ts r , �� o U nit :
r� 0 (-i-`� A vI+� i ter) , �vA f U t o to d Zone al'' ,P� t Overlay Districts ° ` �
Elm St 'P strict to CB District
SECTION 2 - PROPERTY OWN ERSHIP /AU TH RIZED O AG
2.1 Owner of Record: �n 1
A J\ S- � G_ v ( t Y C In ° G In c S (' 1 �rJY1 Pk - ik-t U " 1-L. c:. ( 5 ti m,
,
Name (Print) Current Mailing Addrr ss: J
�1 ) J - J - t - Li t4
Telephone
Signature •
2.2 Authorized Agent: // ll
Name (Print) Current Mailing Address:
Signature Telephone
' SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be I Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fes
2. Electrical (b) Estimated Total Cost of
G Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection .r-►-
6. Total = ( + + + + 5 ) S t'3 C1�{)- Check Number ' 17�
This Section .For Official Use Only
Building Permit Number: i
Signature:
Building Commi r /i
ssionenspector of Buildings Date
*+ 0% 'AYE° BP- 2010 -0448
GIS #: COMMONWEALTH OF MASSACHUSETTS
204 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 -0448
Project to JS- 2010 - 000610
Est. Cost: $13942.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RENEWAL BY ANDERSEN 95707
Lot Size(sq. ft.): 11238.48 Owner: MCEWEN ANN L & DAVID THOMSON
Zoning: URB(100)/ Applicant: RENEWAL BY ANDERSEN
AT: 26 WASHINGTON AVE
Applicant Address: Phone: Insurance:
104 OTIS ST (508) 919 - 0900 WC
NORTHBOROMA01532 ISSUED ON:10/22/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Ins pector 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 10/22/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo