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32C-106 , ✓/ee eonvinoxcueald a/✓ aaaacieuoe1Z5 Office of Consumer Affairs & Businetis Regulation * " HOME IMPROVEMENT CONTRACTOR aei Registration 147927 ( -- Expiration 8 23 /2011 Tr# 287812 Type fr�dl) dual CHARLA P ABBOTT CHARLES ABBOTT 322 PLYMOUTH ST HOLBROOK, MA 0234 Undersecretary Massachusetts - Department of Public Safet■ Board of Building Regulations and Standards Construction Supervisor License License: CS 80174 Restricted to 00 A ' CHARLES P ABBOTT 322 PLYMOUTH ST y:, " HOLBROOK, MA 02343 ' Expiration: 12/29/2011 ( l,nunissinner Tr#: 10905 g - Ite / 4/ 4 •14 Office of Consumer Affairs and usiness Regulation r_f 10 Park Plaza Suite 5170 Boston, Massacusetts 02116 Home Improvement actor Registration Registration: 120598 f Type: Private Corporation 1' "` t2, Expiration: 2/5/2012 Tr# 293226 RESCOM EXTERIORS, INC ,_r ` , \ SCOTT MERRILL ,. 714A SOUTHBRIDGE STREET ' . i AUBURN, MA 01501 , Update Address and return card. Mark reason for change. 0 Address 0 Renewal 0 Employment 0 Lost Card DPS -CA1 0 50M- 04104- � G1 7 0 / 1216 pp / /J / ✓/te Lr oinmzo7uuea/ /(• , at e1t4 License or registration valid for individul use only *— ft Office of Consumer Affairs & Business Regulation before the expiration date. If found return to _lw- HOME IMPROVEMENT CONTRACTOR 1 Office of Consumer Affairs and Business Regulation Registration,;,. 420598 11 — 10 Park Plaza - Suite 5170 T Expiration t2tf12 Tr# 293226 Boston, MA 02116 Type -± 3, ,Prilte #0,©Tation i RESCOM EXTERIQRI SCOTT MERRILL? 714A SOUTHBRIDGE tf- A6ET`' AUBURN, MA 01501 Undersecretary Not valid without signature -�� "` ;. ,'� !`: ra' i s .�. i - k' - .., - r - -. y Fir- N1 41 -' � r ".. � i-Ti t . 'f .ac fit„- .. 1 ^- 4 .fux 7`e { tiro..y i';' f .1 .,.a 1 ,.. �- '° ENERGY STAR Qual ENERGY STAR Qualified -.,, �` ti- i Highlighted Regions t w in Highlighted Regions in i „LI, . � � \ `� o ff \ a� N. �' ENERGY STA ' ` E NERGY START ®= Qualified In all zones ® = Qualified in all zones n ° WINCHESTER INDUSTRIES ∎ ;, WINCHESTER INDUSTRIES ■■ BRISTOL DOUBLE HUNG NFRC BRISTOL CASEMENT =NF • ■ � •'` �y!k Vinyl -clad aluminum frame, Triple glazed, 1 ! Vi ny l -c aluminum frame, Triple glazed, rnalFation Low E coating (e= 0.035, S2 4), National Fenestration Low E coating (e= 0.035, S2 & 4), Rating Council® Argon /Krypton /air filled + Ra ® Argon /Krypton /air filled CERTIFIED '? CE-- IFIED WCI -K -1 40060 WCI -K 4 .00029 ei ENERGY PERFORMANCE RATINGS - ...... 1,4, *' ENERGY PERFORMANCE RATINGS i U- Factor (U.SJI -P) Solar Heat Gain Coefficient U- Factor (U.S./1 -P) Solar Heat Ga Coeff - ,,,,,. , 0.29 0.23 i ,, 0.30 0.22 ...„ . __„...,.., ADDITIONAL PERFORMANCE RATINGS ` • ? ADDITIONAL PERFORMANCE RATINGS Vis Transm ', ; - Visible Transm 0.41 . ,,,,, •,,, 0 0.41 x .,.,., ,.,,,,,, _.. Manufacturer stipulates that these ratings +> Manufacturer stipulates that these ratings conform to applicable NFRC procedures for determining w determined to applicable NFRC procedures for determining whole 4„, . ,4 product performance. NFRC ratings are determined for a fired set of environmental conditions and Product Performance. NFRC ratings are determined fora fund set of environmental conditions and a ,T, ; specific product size. NFRC does not recommend any product and does not warrant the suitability a -" I specific product size. NFRC does not recommend any product and does not warrant the suitability of any product for any specific use. Consult manufacbnrer s literahnre for other product performance infon, • product for any specific use. Consult manufacturer's literature for other Product performance information www nfrc o vvvvusr.nfrc.or. r SoMkgrsImmugumwwwwwy f" ..: ice- ,r � ^ X 1y o Q! ;�,., a V 1 = 8 �� Y ,, C-- .il- ■ ' A n 0 ~- d O v m m .. ms " d f � `7 {�'' v y , r J � . '` y / 0 / 466 N O. _ if ° is J .Sri` ' ' _ �"°` ' sk �.. !, %ij q��. o _.� oh 1I , t � 2 y . � � .,_ . / � I O a W Q rg ® € Ta i C < ^as �� • �i co 3 .—,, z� ' r °; -4 _ m c, a .x.7R � .. e e L- ® ( ��i xF � ; cc O f tH >✓ ® malt } .. %. y $ { 9 _ Li ® 9*a .Ne C3 I 4. t�� ® v ms s : w _ 2 3/2/2011 2:59 PM FROM: Fax Thomas Woods Insurance Agency TO: 15088328795 PAGE: 001 OF 001 -__"....,,,, OP ID: MM '` 4 - 03102!11 `® CERTIFICATE OF LIABILITY INSURANCE I ° A TE( 02111 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). P RODUCER 508 - 755-5944 O N AME: Thomas J Woods Insurance Agcy 508- 791 -9841 PHO No E sq FAX P.O. Box 2940 E ll_ , I (NC, No): orcester, MA 01613 ADDRESS: Marchand Insurance Agency PRODUCER CUSTOMER ID iF: RESC+O -1 INSURER(S) AFFORDING COVERAGE NAIC # INSURED Rescom Exteriors, Inc. INSURERA: Harleysville Insurance Co. 26182 Scott Merrell INSURER B : 714A Southbridge St INSURER C: Auburn, MA 01501 INSURER D : INSURER E : INSI IRFR F • COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIOOISANB 89NC11TT6A$ OF SUCH POLICIES. v '• • •■ ' • • ' - r• • : -. e _ • • s • INSR TYPE OF INSURANCE ASR SUER POLICY NUMBER I MAW CYE Y FF M (MMMIDDD/WYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00C A X C OMMERCIAL GENERAL LIABILITY X MPA00000038002H 01/01/11 01/01/12 DAMAGE 10 RENTED PREMISES (Ea occurrence) $ 100,00C CLAIMS -MADE I I OCCUR MED EXP (My one person) _ $ 5,00C \ PERSONAL 8 ADV INJURY $ 1,000,00C GENERAL AGGREGATE $ 2,000,00C GEN'L A LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG _ $ 2,000,0 7 POLICY ,__ JFCT __ LOC $ _I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT - --- /— 1,000,00 (Ea accident) A ANY AUTO BA037722H 01/01/11 01/01/12 BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON -OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB I CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION I !TORY LIMITS U- I I O ER AND EMPLOYERS' LIABILITY Y 1 N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ® N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT _ $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) SHOW DATES: 3/26/11 - 3/27/11 THE CAPE ANN CHAMBER OF COMMERCE CAPE ANN HOME SHOW, AND GLOUCESTER HIGH SCHOOL ARE ADDITIONAL INSURED WITH RESPECT TO GENERAL LIABILITY AS REQUIRED BY WRITTEN CONTRACT. CERTIFICATE HOLDER CANCELLATION CAPEANH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CAPE ANN HOME SHOW THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN GLOUCESTER HIGH SCHOOL ACCORDANCE WITH THE POLICY PROVISIONS. FIELD HOUSE 32 LESLIE O'JOHNSON RD AUTHORIZED REPRESENTATIVE GLOUCESTER, MA 01930 (' 1 -- T � ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD DATE (MM /DD/YY) CERTIFICATE OF LIABILITY INSURANCE 06/10/11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Aon Risk Services, Inc of Florida Aon Risk Services, Inc of Florida NAME: PHNE FAX 1001 Brickell Bay Drive, Suite #1100 (A/O No. Ext): 800- 743 -8130 (A/C, No): 800- 522 -751 Miami, FL 33131 -4937 E -MAIL ADDRESS: ADP.COI.Center @Aon.com PRODUCER 10762287 CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: New Hampshire Ins Co 23841 ADP TotalSource FL XVI, Inc. INSURER B: 10200 Sunset Drive Miami, FL 33173 INSURER C: ALTERNATE EMPLOYER INSURER D: Rescom Exteriors Inc. 714A Southbridge St, INSURER E: Auburn, MA 01501 INSURER F: COVERAGES CERTIFICATE NUMBER: 326832 REVISION NUMBER: THIS IS TO CERTIFY THAT 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIMITS SIIOWN ARE AS REQUESTED. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSR V/VD DATE (MMIDDIYYYY) DATE (MMIDDNYYY) GENERAL LIABILITY EACH OCCURRENCE $ ❑ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ ❑ CLAIMS MADE 0 OCCUR PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS — COMP /OP AGG $ ❑ POLICY ❑ PROJECT ❑ LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ❑ ANY AUTO (Ea accident) ❑ ALL OWNED AUTOS BODILY INJURY (Per person) ❑ SCHEDULED AUTOS BODILY INJURY ❑ HIRED AUTOS $ (Per accident) ❑ NON OWNED AUTOS PROPERTY DAMAGE (Per accident) ❑ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB CLAIMS -MADE AGGREGATE $ ❑ DEDUCTIBLE $ ❑ RETENTION $ $ A WORKERS' COMPENSATION AND WC 012438412 MA 07/01/11 07/01/12 x WC STATU- OTHER EMPLOYERS' LIABILITY TORY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 2,000,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L. DISEASE — EA EMPLOYEE $ 2,000,000 It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE — POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) All worksite employees working for the above named client company, paid under ADP TOTALSOURCE, INC.'s payroll, are covered under the above stated policy. The above named client is an alternate employer under this policy. CERTIFICATE HOLDER CANCELLATION Rescom Exteriors Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE 714A Southbridge St THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Auburn, MA 01501 AUTHORIZED REPRESENTATIVE citioa Ciak eetvieee, 'Inc of orlotida ACORD 25 (2009/09) ©1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD RI Reg. #20747 Federal ID #04- 3311838 CT Reg. #573209 .Redeom Ezrotetiu , Corporate Headquorters 714A Southtndpe St.. Auburn, MA 01501 (508) 832.5202 1800. 287.8076 THIS CONTRACT MADE THE i it day of lJill'C 201 between IC ff Gc' *s/ Ly 0. 3, - (-1.%(4 '143 - 1 4 ki•V3 l (Hone bwners) (Home Phone) (Bus. Phone) l ,' of �E `7 g �' fr1rti h i h f+Ve) C7- / : . (Address) (State) (Zip Code) 1 ,...',..t the "Owner" and Rescom Exteriors Inc., "Rescom ". ++' Rescom hereby agrees that it will for the consideration hereinafter mentioned, furnish all labor and material necessary to install the following described work. ___- _ TOTAL Windows Purchased 9 Additional Wont Style Qty TOTAL CASH n Window Color Specify t✓[.l Sliding Glass Door /' PRICE of '/ S - 3 .. Capping Color Specify iivr, Steel Security Door ....- — Double Hung 72.., Insulated Storm Door /* DEPOSIT Picture Window ./* Specialty Windows ./r WITH ORDER — 7 1 00 b Stationary Casement ' Leaded Glass / BALANCE DUE AT q ci C f Casement - Model # Obscure Glass .. Bottom l 7 2 Lite / 3 Lite Slider Screens Half Full INSTALLA ) Bay / Bow Frame /' Bascom does not do any •l g or staining. • S f j ..��, Garden r Balance paid to Awning / Rescom is not responsible for conditions or . circumstances beyond Its control Including ° Other: condensation resulting from or due to pre- FINANCE existing conditions. ank completion form Grids: Colonial igned at instaNation r --... DESCRIBE WORK: — c6, O ite,C fa yde la take fur' dev 4 ("tree,-, 4 - I I t . , - T t l . d t . s C if ) P k P.m( / y 60 1 1 5 o t d4, t< , . "fen /h `�� ' ii' G t.`1 - 4/i r;cr;'1‘N/'vs L t./,Y( -- 4 _N' 4 pr'rv1 _i`'f?f'ft'rtiiS /T ' oiN. ` �C1 Syr Fret 5t,D/ "“ )0i44 j and p• yr- 5r'c pill 7'/I/,7 . ,°',zr- r t F led on P tvr.( f t 9T 7 R re Pleats rt t 11,44- 1r / .) U lvid r g Est. Start Date: 7j,,/ t r Est. Completion Date: 7/ it shag be the obligation of RESCOM to obtain any and all permits necessary under this agreement, es the Owner's Agent. The Owner who secure their own construction-related permits, or deal with unregistered centractois WO be excluded from the guaranty fund provision of MGLC. 142A All home knprasment caaractas and subcontractors shun be by the Director and any inquiries abort a =tractor or subcontractor Mating to a registration should be directed to Director, Home Improvement Registration, One Ashburton Place. Room 1301, Boston, MA 02108, (317) 7274598. If the Owner is obtaining financing by way of a Retail Installment Sales Agreement. such Agreement shall Include a time schedule d to be made under said contract and the all finance amount of each payment stated in dollars. including aroe arges. The Retail Installment Sales shall be incorporated heroin by reference. If the Owner is obtaining a rewlving credit line to pay, in whole or in part, for the contract amount herein, the tams of the rescM g Ilene or credit including Interest rate and payment teens, shell be ciery set out on the credit application. its portion of the credit applIcatIon payment, to be made under this contract, and the smart of each payment stated in dollars, Including all finance charges, shell be ircorporated herein by reference. Rescom represents that It cerise Workmen's Compensation and Public Liabiiity Insurance. it the Owner refuse to permit Rescarm to proceed with the work herein, or in the want of any breech of the Owner of this arpme rev, for any reason Oxbow. shall CUM the owner to pay Regan a sum of money equal tothirty4hros and critHhbd percent d the price agreed to be ped, s toad, liquidated and ascertained damages, and not as a penalty, without further prod of loss or damps. Rowan shall not be held liable in damages for delays in the performance of this contract due to causes beyond Its reasonable control. Owner variants that he it the owner of the property on which the wok is to be performed or that he is Otherwise authorized on behalf of the owners to enter into this agreement. This contract represents that entire agreement between the Owner and Reecom and cannot be changed except by a writing signed by both the Owner and Rscan. You are entitled to a cagy of the Contract et the time you sign. Keep It to protect your legal rights. We, the aforesaid owners, certify that immediately after the signing of the aforesaid agreement, a copy was furnished to us. DO NOT SIGN THIS CONTRACT iF THERE ARE ANY BLANK SPACES. They ,lamas seen "sample' warrantee that will be provided by Rowan Won installation. (_ warranties presided to Owner. (`S +, iN TNESS WHEREOF, the parties have hereunto signed their names this I L t day of ✓a"It 201,/.,_ Signed r ` 2 a.-f. l - Signed / 4ite4..... Sales Representative Owner Signed Accepted: Rescom Exteriors Inc., Owner BY Authorized Signature Title You my cancel this agreement If it has been signed by a early thereto eta place OEhsr then an address of the seller, which may be his main office, or branch thereof, prodded you notify seller in wilting at its nein office or branch by ordinary mail posted, by telegram sent or by delhery, net later than midnight d the third business day foaming the signing of this agreement. (Saturday is a legal business day). YOU MAY CANCEL THiS TRANSACTION, WITHOUT ANY PENALTY OR OBLIGATION, WITHIN THREE BUSINESS DAYS FROM THE DATE BELOW. TO CANCEL. THiS TRANSACTION, MAiL OR DEUVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER WRITTEN NOTICE, OR SEND A TELEGRAM TO: Rescom,, 714A Southbridge St., Auburn, MA 01801 �t NOTICE OF CANCELLATION 6 ` i HEREBY CANCEL THIS TRANSACTION. DATE mx • City of Northampton _ ,<4. y : , s.,-..-, ;` Massachusetts , (,. . 0 y DEPARTMENT OF BUILDING INSPECTIONS y ? 1A . 2 12 Main Street • Municipal Building 0 e o Northampton, MA 01060 aP,, . INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 any 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 • The Commonwealth of Massachusetts - Department of Industrial Accidents , �' Office of Investigations 600 Washington Street r '° WY N Boston, MA 02111 ` � www. mass gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name (Business/ Organization /Individual):'C- - )1E12'lf'- Address: '7 'i J3!to,t't s=': City /State /Zip: .:42N ; r r 015o f Phone #: 5o - 5'31 Z Are you an employer? Check the appropriate box: Type of project (required): 1.1KI am a employer with 4. 0 I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling h b These sub-contractors have ship and have no employees T 8. ❑ Demolition working ca employees and have workers' g for me in any capacity. Y . 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] f c. 152, § 1(4), and we have no (�� employees. [No workers' 13. Other U`d" '—/'1 j'r comp. insurance required.] IAA Ii l'J j *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f 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: 1`' +ifoiP - '� ` r° , Policy # or Self -ins. Lic. #: G 0 I Z q �J 9 I I ! Expiration Date: ?)61 I � - Job Site Address: Jot rf/J- .5-r;r Nc ft City/State /Zip: nj°2 -P, , , 40 - 61060 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 un ' , the pains and penalties of perjury that the information provided above is true and correct. Si gnature: s _ Date: Oti(1 / — .41110 Phone #: l 7 % 2_- fd-(5 1 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): I. 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 Licensed Construction Supervisor: /� �� Not Applicable ❑ Name of License Holder : C It ►3(_L5 ? , tti13�%tl ( ( C3 - 01 ( License Num r Address Expi lion ate S'./ " :hone :9; R s`te -er d.•Homes m rovemen ,UContra"ctor = . . :� Not Applicable ❑ re4 l L- 5 z8 Company Name Registra ion Number Address Ex rat n 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 ❑ 1 mem- wner4Exemption 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 n Addition ❑ Replacement Windows Al • ration(s) ❑ Roofing n Or Doors [� Accessory Bldg. ❑ Demolition ❑ Decks [0 Siding [O] Other [0] Brief Description of Proposed �+ Work: -a .irk a.- CIAPn, icFi.1-E (1'467- vT 1 + bW, Nc' Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa if . ewt;#xouseratad oraddition to eXistiraghous�ng comp e17 he�followcnq: 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 .AU OWNERTHORtZATION„ TO BE COMPLETED, WHEN OWNERS AGENT Ott CONTRACTORAPPLIE 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, - 316 2_0161 , 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. Prin am olk ateAlf Signature of w -r/•it V Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by 'Zoning s This column to be filled in b f Building D4404, . W, g i i I H H i - ±-~.-. Lot Size � Frontage ; Setbacks Front l £ j Side L: R: L:1 , R:` i Rear Building Height € i t Bldg. Square Footage ; I % 1 7 Open Space Footage (Lot area minus bldg & paved t [ f parking) # of Parking Spaces -1 Fill: y (volume & Location) t A. A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW kr4 YES 0 IF YES, date issued:€ IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book I I Page; 1 and /or Document Ad I i r B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW p YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO X 4 IF YES, describe size, type and location: I 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: 1 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 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. t4 3 L3E 1 TtmeAlf •l}E -b01j/ iglA' 1 - 1a . , orthampton tau a ecmtt � � � � E EIVE sin' Department Ct, ® ® a .12 ain Streete t,c aiia•, I , ,', s �� : , f Q 2011 R � om 100 V5lafier 1 a ta Nort am, t on, MA 01060 - # St r u« ,'`� o F:t�,. .�:a— '.7 -1'40 Fax 413- 587 -1272 � -.i„.,::::7,--,--: I` at-'45.7 * ' y- Ma o� oso Other `5c ,fy , ^ 4 `' 4, 3 t APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1' -S INFORMA Th s cfaon to be C ompleted by o 4 w 1.1 Property Address: k { t .,-z(c) ? +'ll�( ° IVlat? , i, 4 t • Lot ,: IJni N f lNf wit �� (0 to e° Zone x OverI District r e f ° , x .,s , ._El S District ,_ C B District SECTION 2 - . PROPERT Y OWNER /AUTHORIZED A 2.1 Owner of Record: K - t L nr `� 2� 5 , 1 -tip "i�► ?(1 2 1 pJ ' Name (Print) Current Mailin Address: 9i -L Z6 Telephone Signature 2.2 Authorized Agent: /Y air ,,..)„,,r.../..-,- � ('.� U� Nam- Tint) Current Mailing Address ip - Sign. / Telephone ;,,SE- ' ON 3 = ESTIMA CON CO Item Estimated Cost ( D) to O ffi c i al Use Only :. completed by perm ollars applicant be '''-.,-,S,,E:-.-,-,::',...-,'''''',;,,:-•:•.1.1„-:,1,.•<';',1;'''',''''':':',';'''''',!-''•=':,-.•.'-'::.'''''' 1. Building (a 2. Electrical (b) E u stimated Total Cos Constr ction from . 3. Plumbing Building Pe rmit 4. Mechanical (HVAC) 5. Fire Protection 6 Total = (1 + 2 + 3 + 4 + 5) C�2 � � Check Number This Section For Official Use Onl , Building Perm Number I sue . I Sig . :Building, C / of Build Date l ' # , 2 26 SMITH ST BP- 2012 -0142 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C - 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- 2012 -0142 Project # JS- 2012- 000208 Est. Cost: Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RESCOM EXTERIORS INC 80174 Lot Size(sq. ft.): 9626.76 Owner: BERESKY MICHAEL A JR & MICHAEL A BERESKY SR & KATHLEEN Zoning: NB(100)/ Applicant: RESCOM EXTERIORS INC AT: 26 SMITH ST Applicant Address: Phone: Insurance: 714A SOUTHBRIDGE ST (508) 832 -5202 WC AUBURNMA01501 ISSUED ON:8/4/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 22 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 8/4/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner