17C-153 „omer: Mary Donovan Quote Name: 739 Architect Series 413 - 586 -4823 Order Number: 739L3IL131
Pocket Install: (sash replacement, existing frame remains)
_ Remove interior or exterior stops, install new window in existing sash opening, re -use existing or replace window stops (interior or exterior). Glass loss will occur.
Lead Paint Discloser:
1. was built prior to 1978, Pre Renovation Form signed and "Protecting Your Family From Lead in Your Home” brochure has been given to the Home Owner.
2._ Are there children under the age of 6 or women who are pregnant?
Pella Will Owner Will
Authorize install of Yard Sign on 1st day of installation and remove 7 days afterward
Finish (paint or stain) product purchased: Trim will be painted by customer
_X_ Ensure someone over age 18 is present at all times while Pella Employees are in the home
_X_ Cut -back or tie trees, bushes, shrubs from exterior wall
_X_ Arrange to have alarm system disconnected and reconnected -
Pelia Products can re -route alarm wires but can not reconnect contacts
_X_ Arrange to have any plumbing or electrical repairs or changes by appropriate licensed contractor -
$500 charge for site unprepared on 1 day job
_X_ Remove and reinstall existing window treatments, wall hangings and air conditioning units -
4 -5 feet in front / 1 foot to side with clear path
_X_ Remove and reposition furniture in work area
_X_ Secure pets in a safe manner
X Remove valuable / breakable items from work area
_X_ Remove snow from area of worksite if necessary
_X Deliver and unload products
_X_ Place drop cloths in work areas
_X_ Remove and reinstall interior and exterior trim if applicable
_X_ Remove and reinstall existing shutters and awnings by contract
_X_ Remove existing product and adjust or modify opening as needed
_X_ Provide all equipment necessary to install products
X Cut all wood and other materials outside of home
_X_ Install all products purchased
_X_ Insulate and caulk around products
_X_ Remove stickers and perform initial cleaning of all glass surfaces
_X_ Demonstrate proper operation of products
_X_ Confirm that all products are in working order
_X_ Remove drop cloths, vacuum and remove all old products from premises
Signature:
Dr;„ +o,+ ,,,, R/91/9(117 Order Verification Page 12 of 12
,per: Mary Donovan Quote Name: 739 Architect Series 413 - 586 -4823 Order Number: 739L31L131
9. An enumeration of such other matters upon which the owner and contractor may lawfully agree.
10. Any other provisions otherwise required by the applicable laws of the Commonwealth
11. Permit Notice: Every contract snail contain a clause informing the owner of the following;
a. and all necessary construction related permits
b. that it shall be the obligation of the contractor to obtain such permits as the owners agent
c. that the owners who secure their own construction related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund.
12. Acceleration of payment: No contract shall contain an acceleration clause under which any part or all of the balance not yet due may be declared due and payable because
the holder deems himself 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
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.
13. No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract.
14. Arbitration: If the contractor determines that in the event of a dispute, the contractor wishes the dispute to be settled by arbitration, this fact must be signified on the contract
and both the contractor and owner shall sign this clause separately. The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor
has a dispute concerning this contract, the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and
Business Regulation and the consumer shall be required to submit to such arbitration as provided in MGL c 142A
Owner:
Contractor:
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
alternative dispute resolution even where this section is not signed separately by the parties.
Site Responsibilities
1. 50% Deposit required at time of order.
2. Final payment is to be made to installation team on the morning of the last day of installation.
3. If the customer will not be present at time of install, payment is to be made prior.
4. Checks returned NSF will be assessed a fee of $50.00 to cover fees incurred by Pella. Failure to pay your final bill will result in finance charges of 1 -1/2% per month (18%
Annual) and legal fees associated in the collection of owed monies.
5. Due to inclement weather or site conditions, it may be necessary to reschedule.
6. We cannot and will not guarantee specific dates or days of the week for installation.
7. Time given to complete a job is an estimate, extension of time is possible.
8. An install appointment will be confirmed at Verification. A courtesy reminder cal will be placed 1 week prior.
9. Unforeseen rot repair will be quoted on site as additional work via a Change Order.
10. Substantial completion is achieved when all available products have been installed and are operational. Items such as missing or broken parts and service adjustments are
covered by Warranty and do not affect the status of a project from being Substantially Complete.
11. In the even that any products are unable to be installed, the final payment will be recalculated. The cost of the products not installed will be subtracted from the balance
due. A subsequent and final payment equal to the cost of products not installed as scheduled will be due upon final completion.
12. Order is not binding until approved by Pella Products management.
13. Pella will secure all necessary Building Permits.
Type of Installation:
New Construction: (tear out installation - existing frame is disposed of)
Remove interior and exterior Trim, remove existing window frame, install new window in rough opening, trim both interior and exterior of window / door.
Printed on 8/21/2012 Order Verification Page 11 of 12
„ner: Mary Donovan Quote Name: 739 Architect Series 413 - 586 -4823 Order Number: 739L3IL131
Line # Quote Qty PO Qty Description
95 1 0 Site Re sponsib !itias ” •
Location:
Rough Opening: 0" X 0"
Frame Size:
Final Wall Depth:
Frame Perimeter (inches):
Assembly Type: Manual Line
Customer Notes: HOMEOWNER - FOR YOUR INFORMATION LEGAL CONTRACT REQUIREMENTS FOR HOME IMPROVEMENT CONTRACTORS IS DETAILED BELOW
THIS SITE RESPONSIBILITIES FORM IS PART OF YOUR CONTRACT WITH PELLA PRODUCTS INC.
155 MAIN STREET, GREENFIELD, MA 01301
HOME IMPROVEMENT CONTRACTOR REGISTRATION # 142279 EXP. 3 -24 -12 FEDERAL TAX ID #: 04- 2303271
The law requires the following fourteen items to be included in any contract between the homeowner and a registered home improvement contractor in all contracts for home
improvement work subject to MGL c 142A
1. The complete agreement between the owner and a clear description of any other documents which are part of the agreement.
2. The full names, federal ID, addresses (not PO box #'s) of the parties, the contractor's registration number, the names(s) of the sales person(s)) involved, if any and the date
the contract was executed by the parties
3. The date on which the work is scheduled to begin and the date the work is scheduled to be substantially complete.
4. A detailed description of the work to be done and the materials to be used.
5. The total amount agreed to be paid for the work to be performed under the contract.
6. A time schedule of payments to be made under the contract and the amount of each payment stated in dollars, including all finance charges, if any. Any deposit required to
be paid in advance of the start of the work shall not exceed one -third 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 of all parties.
7. All parties must sign the contract.
8. There shall be a clear and conspicuous notice stating;
a. That all Home Improvement Contractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to;
Registration Division, Program Coordinator
One Ashburton Place - Room 1301
Boston, MA 02108
617 - 727 -3200 x 25239
b. The contractor's registration number must be on the first page of the contract.
c. The homeowners three day cancellation rights under MGL c93s48; NGK c 140D s 10or MGL c255D s 14 as may be applicable.
d. All warranties on the owners rights under the provisions of 780 CMRR6 and MGL c 142A
e. In ten point bold type or larger, directly above the space provided for the signature, the following statement;
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
f. Whether any lien or security interest is on the residence as a consequence of the contract
Printed on 8/21/2012 Order Verification Page 10 of 12
r: Mary Donovan Quote Name: 739 Architect Series 413 - 586 -4823 Order Number: 739L3IL131
Line # Quote Qty PO Qty Description
90 1 0 INSTALLATION - INSTALLATION
Location: None Assigned
Rough Opening:
Frame Size:
Final Wall Depth:
Frame Perimeter (inches):
Assembly Type: Branch Catalog
Customer Notes: Permit Fee
Printed on 8/21/2012 Order Verification Page 9 of 12
,per: Mary Donovan Quote Name: 739 Architect Series 413- 586 -4823 Order Number: 739L31L131
Line # Quote Qty PO Qty Description
70 1 0 Local Pella Promotion: 15% $557.00 off Expires 8/17/12
Location:
Rough Opening: 0" X 0"
Frame Size:
Final Wall Depth:
Frame Perimeter (inches):
Assembly Type: Manual Line
Line # Quote Qty PO Qty Description
75 1 0 National Pella Promotion: 8% $787.00 off Expires 8/17/12
Location:
Rough Opening: 0" X 0"
Frame Size:
Final Wall Depth:
Frame Perimeter (inches):
Assembly Type: Manual Line
Line # Quote Qty PO Qty Description
80 1 0 Order Now Discount: 5% $453.00 off Expires 8/17/12
Location:
Rough Opening: 0" X 0"
Frame Size:
Final Wall Depth:
Frame Perimeter (inches):
Assembly Type: Manual Line
Line # Quote Qty PO Qty Description
85 1 0 Additional Discount: $500.00 off Expires 8/17/12
Location:
Rough Opening: 0" X 0"
Frame Size:
Final Wall Depth:
Frame Perimeter (inches):
Assembly Type: Manual Line
Printed on 8/21/2012 Order Verification Page 8 of 12
Mary Donovan Quote Name: 739 Architect Series 413 - 586 -4823 Order Number: 739L31L131
Line # Quote Qty PO Qty Description
55 1 1 Architect, Precision Hung Double Hung, 30.5 X 56.5, White
Location: Living Room
Rough Opening: 31" X 57" 1: Non - Standard Size Double Hung, Equal Split
Frame Size: 30 1/2 X 56 1/2
Frame Size: 30.5" X 56.5" General Information: Style Edition, Clad
Final Wall Depth: Exterior Color / Finish: Standard EnduraClad, White
174 Interior Color / Finish: Primed Interior
Frame Perimeter
(inches): Glass: Insulated Low E Advanced Argon Gas
Assembly Type: Branch Finished Hardware Options: Standard Lock, Champagne, Order Sash Lift
Screen: Full Screen, InView
Grille: ILT, No, 7/8 ", Traditional (2W1H / 2W1H)
Wrapping Information: Perimeter Length = 174 ", Glazing Pressure = 95.
* * * PF -1 - Interior Pocket Installation for Precision Fit Qty 1
* * * ITS-EX - Re-use existing stops (replace if broken) Qty 1
* * * LP -2 - Lead safe practices this opening over 1501.11 Qty 1
Line # Quote Qty PO Qty Description !
60 2 2 Architect, Precision Hung Double Hung, 29.5 X 57.5, White
Location: Living Room
Rough Opening: 30" X 58" 1: Non - Standard SizeNon - Standard Size Double Hung, Equal Split
Frame Size: 29 1/2 X 57 1/2
Frame Size: 29.5" X 57.5" General Information: Style Edition, Clad
Final Wall Depth: Exterior Color / Finish: Standard EnduraClad, White
Interior Color / Finish: Primed Interior
Frame Perimeter (inches): 174 Glass: Insulated Low E Advanced Argon Gas
Assembly Type: Branch Finished Hardware Options: Standard Lock, Champagne, Order Sash Lift
Screen: Full Screen, InView
Grille: ILT, No, 7/8 ", Traditional (2W1H / 2W1H)
Wrapping Information: Perimeter Length = 174 ", Glazing Pressure = 95.
* * * PF -1 - Interior Pocket Installation for Precision Fit Qty 1
* * * LP -3 - Lead safe opening within an adjacent Qty 1
containment
* * * ITS -EX - Re-use existing stops (replace if broken) Qty 1
Line # Quote Qty PO Qty Description
65 1 0 Project Volume Discount: 4% $410.00 off Expires 8/17/12
Location:
Rough Opening: 0" X 0"
Frame Size:
Final Wall Depth:
Frame Perimeter (inches):
Assembly Type: Manual Line
Printed on 8/21/2012 Order Verification Page 7 of 12
,ar: Mary Donovan Quote Name: 739 Architect Series 413 -586 -4823 Order Number: 739L31L131
Line # Quote Qty PO Qty Description
r -
45 1 1 Architect, Precision Hung Double Hung, 29.5 X 56.75, White
Location: Dining Room
Rough Opening: 30" X 57.25" 1: Non - Standard Size Double Hung, Equal Split
Frame Size: 29 1/2 X 56 3/4
Frame Size: 29.5" X 56.75" General Information: Style Edition, Clad
Final Wall Depth: Exterior Color / Finish: Standard EnduraClad, White
Frame Perimeter (inches): 173 Interior Color / Finish: Primed Interior
Glass: Insulated Low E Advanced Argon Gas
Assembly Type: Branch Finished Hardware Options: Standard Lock, Champagne, Order Sash Lift
Screen: Full Screen, InView
Grille: ILT, No, 7/8 ", Traditional (2W1 H / 2W1 H)
Wrapping Information: Perimeter Length = 173 ", Glazing Pressure = 100.
* * * PF-1 - Interior Pocket Installation for Precision Fit Qty 1
* * * ITS -EX - Re -use existing stops (replace if broken) Qty 1
* * * LP -2 - Lead safe practices this opening over 150 UI Qty 1
Line # Quote Qty PO Qty Description
50 1 1 Architect, Precision Hung Double Hung, 29.5 X 56.75, White
Location: Dining Room
Rough Opening: 30" X 57.25" 1: Non - Standard Size Double Hung, Equal Split
Frame Size: 29 1/2 X 56 3/4
Frame Size: 29.5" X 56.75" General Information: Style Edition, Clad
Final Wall Depth: Exterior Color / Finish: Standard EnduraClad, White
Interior Color / Finish: Primed Interior
Frame Perimeter (inches): 173 Glass: Insulated Low E Advanced Argon Gas
Assembly Type: Branch Finished Hardware Options: Standard Lock, Champagne, Order Sash Lift
Screen: Full Screen, InView
Grille: ILT, No, 7/8 ", Traditional (2W1 H / 2W1 H)
Wrapping Information: Perimeter Length = 173 ", Glazing Pressure = 100.
* * * LP -3 - Lead safe opening within an adjacent Qty 1
containment
* * * ITS -EX - Re -use existing stops (replace if broken) Qty 1
* * * PF -1- Interior Pocket Installation for Precision Fit Qty 1
Printed on 8/21/2012 Order Verification Page 6 of 12
Mary Donovan Quote Name: 739 Architect Series 413 - 586 -4823 Order Number: 739L31L131
Line # Quote Qty PO Qty Description
35 1 1 Architect, Precision Hung Double Hung, 31.5 X 41, White
Location: Office
Rough Opening: 32" X 41.5" 1: Non - Standard Size Double Hung, Equal Split
Frame Size: 31 1/2 X 41
Frame Size: 31.5" X 41" General Information: Style Edition, Clad
Final Wall Depth: Exterior Color / Finish: Standard EndureClad, White
Interior Color / Finish: Primed Interior
Frame Perimeter (inches): 145 Glass: Insulated Low E Advanced Argon Gas
Assembly Type: Branch Finished Hardware Options: Standard Lock, Champagne, Order Sash Lift
Screen: Full Screen, InView
Grille: !LT, No, 7/8 ", Traditional (2W1H / 2W1H)
Wrapping Information: Perimeter Length = 145 ", Glazing Pressure = 120.
* * * LP -1 - Lead safe practices this opening under 150 Qty 1
UI
* * * PF-1 - Interior Pocket Installation for Precision Fit Qty 1
* * * ITS -EX - Re -use existing stops (replace if broken) Qty 1
Line # Quote Qty PO Qty Description
40 1 1 Architect, Precision Hung Double Hung, 31.5 X 41, White
Location: Office
Rough Opening: 32" X 41.5" 1: Non - Standard Size Double Hung, Equal Split
Frame Size: 31 1/2 X 41
Frame Size: 31.5' X 41" General Information: Style Edition, Clad
Final Wall Depth: Exterior Color / Finish: Standard EnduraClad, White
145 Interior Color / Finish: Primed Interior
Frame Perimeter
(inches): Glass: Insulated Low E Advanced Argon Gas
Assembly Type: Branch Finished Hardware Options: Standard Lock, Champagne, Order Sash Lift
Screen: Full Screen, InView
Grille: ILT, No, 7/8 ", Traditional (2W1H / 2W1H)
Wrapping Information: Perimeter Length = 145 ", Glazing Pressure = 120.
* * * PF -1 - Interior Pocket Installation for Precision Fit Qty 1
* * * ITS -EX - Re -use existing stops (replace if broken) Qty 1
* * * LP - 3 - Lead safe opening within an adjacent Qty 1
containment
Printed on 8/21/2012 Order Verification Page 5 of 12
, Mary Donovan Quote Name: 739 Architect Series 413 - 586 -4823 Order Number: 739L31L131
* * * ITS - EX - Re - use existing stops (replace if broken) Qty 1
Line # Quote Qty PO Qty Description
25 1 1 Architect, Precision Hung Double Hung, 30.5 X 56.75, White
Location: Guest Room
Rough Opening: 31" X 57.25" 1: Non - Standard Size Double Hung, Equal Split
Frame Size: 30 1/2 X 56 3/4
Frame Size: 30.5" X 56.75" General Information: Style Edition, Clad
Final Wall Depth: Exterior Color / Finish: Standard EnduraClad, White
Frame Perimeter (inches): Interior Color / Finish: Primed Interior
( Glass: Insulated Low E Advanced Argon Gas
Assembly Type: Branch Finished Hardware Options: Standard Lock, Champagne, Order Sash Lift
Screen: Full Screen, InView
Grille: ILT, No, 7/8 ", Traditional (2W1H / 2W1H)
Wrapping Information: Perimeter Length = 175 ", Glazing Pressure = 95.
* * * PF -1 - Interior Pocket Installation for Precision Fit Qty 1
* * * LP -2 - Lead safe practices this opening over 150 UI Qty 1
* * * ITS -EX - Re -use existing stops (replace if broken) Qty 1
Line # Quote Qty PO Qty Description
•
30 1 1 Architect, Precision Hung Double Hung, 30.5 X 56.75, White
Location: Guest Room
Rough Opening: 31" X 57.25" 1: Non - Standard Size Double Hung, Equal Split
Frame Size: 30 1/2 X 56 3/4
Frame Size: 30.5" X 56.75" General Information: Style Edition, Clad
Final Wall Depth: Exterior Color / Finish: Standard EnduraClad, White
Interior Color / Finish: Primed Interior
Frame Perimeter (inches): 175 Glass: Insulated Low E Advanced Argon Gas
Assembly Type: Branch Finished Hardware Options: Standard Lock, Champagne, Order Sash Lift
Screen: Full Screen, InView
Grille: ILT, No, 7/8 ", Traditional (2W1 H / 2W1 H)
Wrapping Information: Perimeter Length = 175 ", Glazing Pressure = 95.
* * * LP -3 - Lead safe opening within an adjacent Qty 1
containment
* * * ITS -EX - Re -use existing stops (replace if broken) Qty 1
* * * PF -1 - Interior Pocket Installation for Precision Fit Qty 1
Printed on 8/21/2012 Order Verification Page 4 of 12
tder Number: 739L31L131
1 AS P -FITS, 1 AS MP
b= 2
ig? YES
r parking: • 25'
Ito be altered? NO
3 V-i-t_ NO
None
•
Stagging •
nits : • Wood
n Style: Historic Sill (large)
grip Cap: • MATCH UNIT
n: 1 "X4 "FLAT
ir,r3 : PAINTED
Hissed: NO
squired: • NO
ndows w /pockets? : YES
NO
Hardwood
?: NO
d ?. NO
Clap:
NO
YES
NO
NO
NO
YES
height from the ground to the highest opening: 28'
_ONIAL STYLE HOME, WITH #92 MARKED CLEARLY ON THE HOME
Quote Name: 739 Architect Series 413 - 586 -4823 Order Number: 739L31L131
Order Verification Page 2 of 12 Page 3 of 12
To Whom It May Concern:
I, lctr a Y , as property owner, give
• permission to our contractor, Pella Products, Inc., to
obtain a building permit for the installation of windows
or doors in my home, located at
�'c � ► 3 A Ple ase
accept this letter in place of my signature on the
permit application.
Thank you, •
Please Print Name
Hom.eo4 er's Signature Date
90110 3Ed
NI 51�f1Q0 d C��3d 0EEE9E:LETh E5:T0 ZT0Z /L /80
PELLA PRODUCTS INC
155 MAIN STREET
GREENFIELD, MA 01301
i
Subject: Disposal of Debris
The purpose of this letter is to certify that all the debris resulting from any project undertaken by
Pella Products Inc. in your Town will be transported to a dumpster at our main facility at 155 Main
Street, Greenfield, MA.
Pella Products Inc.is under contract with Waste Management of Massachusetts for the disposal
of the contents of this dumpster.
Very Truly Yours,
PELLA PRODUCTS INC.
John P. Benjamin
Accounting Manager
The Commonwealth of Massachusetts
Department of Industrial Accidents
== "� Office of investigations
600 Washington Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
�-
Name ( Business /Organization/Individual):
Address: / 5 „-� 5 c E
City /State /Zip: 6reed e / >vf9 Q /JQ/ Phone #: / ./,3- 77,
Are you an employer? Check the appropriate box:
C Type of project (required):
1. [ I am a employer with 1 2, 1-
j 1 ❑ " 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. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.: 9. E] Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ 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' 13.0 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. ^
Insurance Company Name: - �,4 V r' f S u G-70 CC` l�-fJ /f'J cm
Policy # or Self -ins. Lic. #: J H// C f 3 7C6" -0 d _ Expiration Date: /— )/- /J
Job Site Address: Z // ", City /State /'Lip: 1_ b`f C',V1 C P (/"i/, (0 6
Attach a copy of the workers' cam i • nsation 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 of perjury that the information provided above is true and correct.
Signature: iv , Date: '%. " / 2 -
Phone #: 7 Lt -7 Z.? /
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
8,1 Llcen s�dl Construction Sunervlsor: Not Apph' able ❑
Name of License Holder 097
License Number
i*y /T-d_z0 (3
Address Expiration Date
`
al
•. C hj9s Z77z -0 /,c:
Sig • re Telephone
B_Reglste ed Nome, iprouemellt Contnaotor. Not Applii;able ❑
at ri)Z , �c 19- Z 2 7 c
Company Name Registration Number
AtidAti , A Expirator Date
0 4 4'
Telephone Z? - - 7 7 2
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 1 o provide this affidavit will result
in the denial of the issuance of the building permit,
Signed Affidavit Attached Yes es NO
11. W Iioime O . ner'Exemption
The current exemption for "homeowners " was extended to include Owner-occupied Dwelltnfts of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess u license, p! ovided that the owner acts
as supervisor. CMS. 780., Sixth Edition Section 1tt .3,S.I.
Definition of Homeowner; Person (s) who own a parcel of land on which he/she resides or intts tds to reside, on which then
is, or is intended to be, a one or two fumily dwelling, attached or detached structures accessory tr i such use and/ or fanu
struetutes. A . erson who cons acts more than the home in a two i riod shall not he t onsiderud a homeowneur.
Such "homeowner" shall submit to • uilding Official, on a form acte. bit; to the Building O: ficial, that he /she shall be
responsible for all such work perform under the buildinglierruitt.
As acting Construction Supervisor your p sense on the job site-Will be required from tune to time, during and upon
completion of the work for which this permit issued.
Also be advised that with reference to Chapter • 2 (Workers' Compensation) at>tt Chapter 153 (Liability of Employers to
Employes for injuries not resulting in Death) of • Massachusetts General Laws Annotated, it a may he liable for person(s)
you hire to perform work for you under this permit. \
The undersigned "homeowner" certifies and assume$ responsibility for compliance with the Statt Building Code, City of
Northampton Ordinances, State and Local Zoning<.aws and State of Massachusetts General Laws Anmotated.
Homeowner Signature ,
l
SO /Er 3DVd ON' S1JriaOdd V1 O5Ec9E, cth E TES Z ,l2Q
.wM
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all apifllcable)
New House ❑ Addition 0 Replacemen 1 p1 dows Alteration(c) fl Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [DJ Decks (q SI ding (p] Other [CO
Brief Cascrhtion o P •po ed
Work: _ •. • r. 4 --` a' 1 ' ' a $ - A.Q.. _
Alteration of existing bedroom _ Yes _____ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement , Yes T _,_No
Plans Attached Roll - Sheet
6a.•If New house and or :additlo to existing houslnp..complete'the tollowingl:,
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. Massoheck Energy Complianoe form at ached? _
h. Type of construction
i. Is construction within 100 ft of wetlands? Yes No, Is construction within 100 yr, floor (plain _ 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, ' i ✓`v O V ] 0 e , as Owner of the subject
property � /� �y °
hereby authorize P'Z f r 1 6t P re, rt � --- 1 C._ - -_
to act on my behalf, in all matters relative , to work authorized by this building permit application.
a� - ve 6 . , _ o2 1 r._ -_
Signs ure of Owner Date
I, . __ , 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 ins and pen sties J rj ry.
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Print Name Id . - -_,
Ki
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Signs ure of Owner /Agent data
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Section 4, ZONING All information Must Be Completed. Permit Can Ele Denied Due To incomple te Information
, -
Existing Proposed Required by Zoning
Thia aohmti to bii filind in by
13ui1dins Depth. ilIcIlt
Lot Size
: 1 1 1 . .. :
p .
. . ..
Fronta I. , 1 • ..I i
. .., t
Setbacks Front , ...,..__,
, . .......
Side
L _ ., R:i. 1 L:, . i lti_ ...... .1, : 1-- !
. ,
Building Fle ight ...... . i
—
.. .
- . —
Bldg. Square Footage ..
. – ' % '
. _
Open Space Footage %
(1..m era minus big at paved 1
_parking)
# of Parking Spaces 1 - , . I
-
Fill:
I 1i 1 i
voila= it Loolitioii
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DoNi KNOW 0 YES 0
IF YES, date issued
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book 1 1 Page i
... i and/or D icurnent # I 1
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commiision?
Needs to be obtained
0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: 1 1
D. Are there any proposed changes to or additions of signs intended for the property '' YES 0 NO (D
. .
IF YES, describe size, type and location:
: .... . .
. MI the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is t part of a caMrnon plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from itie DPW is required.
SO/GCI 39 DNI sionaoad V113d 06EE'RELETV ES:TO Z,'I/2./B3
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' i t y of Northampton sit 4 !C fir,± p '1I ,
u ilding Department O�Ir , (1(Privavi t F�Srriil 1 ,
SEP 1 o me 212 Main Street Psi �rf el�Ue, IIIt 1lli,E �i „< , , ,
Room 100 W.a,r qNl A
°Fem nq ti . N rthampton, MA 01060 'iwl) §0, 41, tak I l,f .4F! .,.,,
• i .. ..u. _ _ 41... ' • 41 587-1240 Fax 413- 587 -1272 ! i P '
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TV fo FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be cl fmpieted in offiCri -
1.1 Property Adddres?:
7 z I i h l) r
'C� M Lot_ Unit
&re,L O t 0 b Z Zone overlay District
Elm S. District GB District _
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
-1 Owner of Record:
M ay 10ono von __22 ► <h �shQ0 � # iv ■ 0lob2
o (Print) /'� /� current Mait�n } ddress s `/ _ - L . J ' 2 3
C t Telephone lJ
` Signature
2.2 Autiorized A t nt
Az
____6_,...,s: Ak2,144 S ( 0A_o_L-G
Name (Print) Current Mailing address:
CfU gig - Cl, , ..._ -
Signatur Telephone
^
SECTION 3 ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost (Dollars) to be Official Use Only
complet'od by permit applicant -
1, Building I ? Ob (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
(� Construction from (6)
3. Plumbing U Building Permit Fee
4. Mechanical (I -IVAC) �^,
5, Fire Protection V
- 6. Total =(1 +2 +3 +4 +5) 1 z Du) •OtO Check Number '' i��,� AIIW�
This Section For Official Use OnIY
Date
Building Permit Number: , Issued:
Signature:
Building Commissioner /Inspector of Buildings - Date ----'
90/3O 3EVd ONI S1JflGO ld 'V1 - 13d OBE99ELETb C9 :TO c,TO? /LZ/90
92 HIGH ST BP- 2013 -0279
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 153 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2013 -0279
Project # JS -2013- 000449
Est. Cost: $12000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 091496
Lot Size(sq. ft.): 16335.00 Owner: KAYE SANFORD & MARY C DONOVAN
Zoning: URB(100)/ Applicant: PELLA PRODUCTS, INC
AT: 92 HIGH ST
Applicant Address: Phone: Insurance:
155 MAIN ST (413) 772 -0153 WC
GREENFIELDMA01301 ISSUED ON:9/10/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 11 REPLACEMENT WINDOWS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 9/10/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner