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44-081 Renewal ir MA Home Improvement Contractor �'� License # 170810 (Expires 12/23/2013) Andersen. Renewal by Andersen Corporation Federal Tax ID #41- 1918413 WINDOW REPLACEMENT an Andersen Company 104 Otis St., Northborough, MA 01532 (508) 351 -2200 • Fax: (651) 351 -4810 SPECIFICATION SHEET Buyer(s) Name Date of Agreement TWA ( I 9 -2 The Buyer(s) listed above hereby jointly aAd 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. PATIO DOOR DETAILS 1. Install total of: Permashield Gliding Patio Door(s) ❑ 5'10" x 6'8" ❑ Other (not available in 8068) Op. panel is ❑ left s 2 right (as viewed from exterior) Interior and Exterior Color to be: White • Canvas❑ S: dstone ❑ Terratone (Color same inside and out on PS) Hardware: Metro: ❑ White ❑ Stone f Bright Brass • - Specify lgai .N7'yL) • Yes ..g-No Gliding Patio ve si. tE7 ' ize: 74121011 No Grilles? If yes: GB INTW ❑ FDL (Pattern is standard as viewed in book for all doors) 2. Insta total of: Narrowline G • • g Patio Door(s) ❑ 6'0" x 6'8" ❑ Other: Op. panel is ❑ left ❑ right (as viewed from exterior) Exterior Color ❑ White ❑ Canvas ❑ Sandtone ❑ Terratone (Interior is WOOD and customer must paint or stain) Hardware: Metro: ❑ White ❑ Canvas ❑ Stone ❑ Bright Brass ❑ Other— Specify: ❑ Yes ❑ No Gliding Patio door to have sidelight? Size: ❑ Yes ❑ No Grilles? If yes: GBG ❑ INTW ❑ FDL (Full Divided Light) 3. Install total of: Frenchwood Gliding Patio Door(s) ❑ 6'0" x 6'8" ❑ Other: Op. panel is ❑ left p right (as viewed from exterior) Exterior Color: ❑ White ❑ Canvas ❑ Sandtone ❑ Terratone Interior Wood: ❑ Pine ❑ Oak ❑ Maple Interior Finish: ❑ Prefinished White (Available only with white exterior) ❑ Unfinished (Paint / stain done by customer) Hardware: Metro: ❑ White ❑ Stone ❑ Bright Brass ❑ Satin Nickel ❑ Yes ❑ No Gliding Patio door to have sidelight? Size: ❑ Yes ❑ No Grilles? If yes: GBG ❑ INTW ❑ FDL (Full Divided Light) 4. Install total of: Frenchwoo Hi nged Patio Doors) ❑ 6'0" x 6'8" ❑ Other: ❑ Yes ❑ No Active / Passive Panel?: ❑ Left ❑ Right (viewed from ext. which is active) OR ❑ Yes ❑ No Active / Stationary Panel ?: ❑ Left ❑ Right Door Swing: ❑ Inswing ❑ Outswing Exterior Color: ❑ White ❑ Canvas ❑ Sandtone El Terratone Interior Wood: ❑ Pine ❑ Oak ❑ Maple Interior Finish: ❑ Prefinished White ❑ Unfinished (Paint / stain done by customer) Hardware: Metro: ❑ White ❑ Stone ❑ Bright Brass ❑ Satin Nickel "NOTE: Canvas hinged screen frame N/A —must choose white or stone if exterior is canvas' ❑ Yes ❑ No Hinged Patio door to have sidelight? Size: ❑ Yes ❑ No Grilles? If yes: GBG ❑ INTW ❑ FDL (Full Divided Light) STORM DOOR DETAILS 5. Install total of: Storm Door(s) 6. ❑ Full View ❑ Mid View 7. Color to be: ❑ White ❑ Canvas ❑ Sandtone ❑ Bronze ❑ Forest Green 8. Size to be: ❑ 32" ❑ 34" (White only) ❑ 36" ❑ Custom (10 week lead time) Size: 9. Hardware to be: ❑ Bright Brass ❑ Nickel /1 10. Additional job details: Jy _ 1 11. Yes ❑ 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 understanding between the parties, and there are no verbal understandings changing or modifying any of the terms. This Specification Sheet may not be changed or its terms modified or varied in any way unless such changes are in writing and signed by both the Buyer(s) and Contractor. Buyer(s) hereby acknowledge that Buyer(s) has read this Specification Sheet. Renewal by'A erse ' o poration Buyer(s) Buyer(s) By: e - w� lr ig ir►t a 1 Y� ir iture of Product Manager Signature Signature Print Name of Product Manager Print Name Print Name Renewal MA Home Improvement Contractor Andersen. I � License #170810 (Expires 12/23/2013) � Federal Tax ID #41- 1918413 WINDOW REPLACEMENT an Andersen Company R enewal by Andersen Corporation 104 Otis St., Northborough, MA 01532 (508) 351 -2200 • Fax: (651) 351 -4810 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s) Name Date of Agreement 64 t2 L ,� — 1 /; Buyer(s) Street Address, City, State, and Zip_Code AT a ir _ - //J 0 • . . E - Mail Address Home Telephone Number - ork Telephone Number //43E 554 --goo Buyer(s) hereby jointly and severally agrees to purchase the products and /or services of Renewal by Andersen Corporation ( "Contractor "), in accordance 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. Total Job Amount: /// Est aced Starting Date: Method of Payment: ) ' Amount Financed ❑Check sh Deposit Received (33 %): /-' _ " " OVisa /MC Discover Balance at Start of Job (33 %): ,3''c:9- 0 ❑Financed °AMEX Esti ated Completion Date: If credit card is selected, please Balance on Substantial 1 3 . _ • _ ( _ see Credit Card Payment Form. Completion of Job (33 %): 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 THERE ARE ANY BLANK SPACES. Renewal by C dersen C • . • or don Buyer(s) Buyer(s) B : .Jim �,f ' " ( ma (( �� yy y� �C �. , ��� ( (52 i\\ G n By: 1L1 k� r L Sit,. .t o f P e .. I. anaer Signtature j Signature ,.L.1,` 1 Print Nam: of Precinct Ma ager 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 gE CANOE TION NOTICE OF CANCELLATION Date of Transaction /7 /7 You may cancel Date of Transaction You may cancel this transaction, without any penalty or obligation, within I this transaction, without any penalty or obligation, within three business days from the above date. If you cancel, any 1 three business days from the above date If you cancel, any property traded in, any payments made by you under the I property traded in, any payments made by you under the Contract of Sale, and any negotiable instrument executed 1 Contract of Sale, and any negotiable instrument executed by you will be returned within 10 days following receipt 1 by you will be retumed within 10 days following receipt by the Contractor ( "Seller") of your cancellation notice, 1 by the Contractor ( "Seller ") of your cancellation notice, and any security interest arising out of the transaction will and any security interest arising out of the transaction will be canceled. If you cancel, you must make available to the be canceled. If you cancel, you must make available to the Seller at your residence, in substantially as good condition Seller at your residence, in substantially as good condition as when received, any goods delivered to you under 1 as when received, any goods delivered to you under this this Contract or Sale; or you may if you wish, comply 1 Contract or Sale; or you may, if you wish, comply with the with the instructions of the Seller regarding the return instructions of the Seller regarding the return shipment of shipment of the goods at the Seller's expense and risk. I the goods at the Seller's expense and risk. If you do make If you do make the goods available to the Seller and the I the goods available to the Seller and the Seller does not Seller does not pick them up within 20 days of the date pick them up within 20 days of the date of your Notice of your Notice of Cancellation, you may retain or dispose of Cancellation, you may retain or dispose of the goods of the goods without any further obligation. If you fail to without any further obligation. If you fail to make the make the goods available to the Seller, or if ou agree I goods available to the Seller, or if you agree to return the to return the goods to the Seller and fail to do so, then 1 goods to the Seller and fail to do so, then you remain liable you remain liable for performance of all obligations under 1 for performance of all obligations under the Contract. the Contract. To cancel this transaction, mail or deliver a I To cancel this transaction, mail or deliver a signed and signed and dated copy of this cancellation notice or any 1 dated copy of this cancellation notice or any other written other written notice, or send a telegram to Contractor: 1 notice, or send a telegram to Contractor. Renewal by Andersen Corporation, 104 Otis 1 Renewal by Andersen Corporation, 104 Otis Street, Street, Northboroyagh MA 01532, BY NOT LATER THAN Northborough, MA 01532, BY NOT LATER THAN MIDNIGHT MIDNIGHT OF 9' O - /Z. (Date) OF . (Date) I HEREBY CANCEL THIS TRANSACTION. 1 HEREBY CANCEL THIS TRANSACTION. Buyer's Signature Print Name Date Buyer's Signature Print Name Date RbA Copy - White Buyer Copy - Yellow Buyer Copy - Pink ©911P2009. Ph.MANH ..._________ rwoos•000ns j ' . Anderseri. w w . , ,, . Andersen NFRC Certified Total Unit Performance (continued) , 1 1 I 1 Andersen;. Product' Glass Type I U- Factor' I SHGC' , VF' I Andersen Product G lass Type U- Factor' J SHGC 1 VT I 400 Serie #' Architectural i •' " ! HP Lnw-E4 . 0.27 035 0.60 - -' -' HP Imr-E4 032 028 0.47 • HP Low -E4 with Grilles 028 031 0.54 F' HP low-E4 with Gilles 032 025 0 42 ' f E 1 HP Low-E4 Sun 027 021 0.33 ® HP Lew-E4 Sun 0.32 0.17 026 Ell E 1 Circle Top Casement Window Casement Window mr HP t-E4 Sun with Grilles 0.29 0.19 0.30 El HP Low-E4 Sun with Galles 0.32 0.16 023 . . i 2 El HP Low-E4 SmartSun 026 023 0.54 I4 c '1® : HP Low-E4 SmartSun 0.31 0.18 0.42. t ; St • `... HP Low-E4 SmartSun w /Grilles 028 011 0.49 '4 !El • ; HP Low-E4 SmartSun w /Grilles 0.31 0.17 038 IT 1141 El 1 HP Inv -E4 0.27 035 0.60 fP HP Low -E4 032 028 0.47 r!?I 3 I HP Low-E4 with Gales 0.28 031 0.54 I HP low-E4 with Galles 032 0.25 0.42 rrif RE . HP Low-E4 Sun 0.27 021 0.33 ltill :'' ® French Casement • ) HP Low-E4 Sun 0.32 0.17 026 "E E Circle & Oval Window) Wi ndow HP Low-E4 Sun with Galles 032 0.16 013 ` HP low-E4 Sun with Grilles 0.29 019 0.30 `' E L.i HP tnw-E4 SmartSun 0.26 023 0.54 ff E • HP Lew-E4 SmartSun 031 018 0.42 - :..j HP law -E4 SmartSun w /Grilles 018 0.21 0.49 1 4 ® . HP Lew -E4 SmartSun w /Grilles 031 017 0.38 "" flPI III HP Low -E4 028 ' 0.33 0.58 f ' HP Low-E4 032 028 0A7 f HP Lnw-E4 with Galles 0.29 0.30 0.52 E 7 HP Low-E4 with Grilles 0.32 025 0.42 .: Fi E HP Low-E4 Sun 0.28 020 031 l IN - _I HP low -E4 Sun 032 0.17 026 DRS! Window . Awning Window ni HP Law-E4 Sun whh Galles 0.29 0.18 0.28 ( r :! E HP L ow-E4 Sun with Galles 0.32 0.16 023 -;' E HP Low-E4 SmartSun 017 023 0.52 El . !: ® : HP Lnw-E4 SmartSun 0.31 018 0.42 ,'• l' E1 1 HP Low-E4 SmartSwi w /Galles 028 021 0.46 0" 1,1E HP Low-64 SmartSun w /Gnites 031 017 038 ?';; El HP Low-E4 027 033 0.58 1 HP Low-E4 0.31 032 0.55 _ . HP Low-E4 with Galles 028 030 0.52 II 1"' HP Law-E4 with Grilles 031 0.29 0.49 ' ' F9 HP Low-E4 Sun 027 020 0.31 Ell f'; ® Casement/Awning HP Low-E4 Sun 0.31 0.20 0.31 E E Flexihame' Window _`{ HP Law-E4 Sun with Gnlles 0.29 0.18 028 n F`1® Pielur Windom HP Low-E4 Sun with Galles 0.31 0.18 0.28 F. MI E HP Low-E4 SmartSun 026 013 0.52 f ? ; !pi , .. HP tow-E4 SmartSun 0.31 021 0.50 i , }_1 E ! HP Low-E4 SmartSun w /Galles 0.28 011 0.46 tI • 1!.: ® -; HP Low-E4 SmartSun w /Galles 031 0.19 0.44 U .:' Er.1 E `1 HP Low-E4 031 033 0.58 HP Low-E4 0.30 037 0.64 i, : 1 HP law-E4 with Grilles 0.32 030 0.52 ''l HP Low-E4 with Grilles 030 033 0.57 E I' _ HP Lew -E4 Sun 0.31 020 0.31 • ^ ® HP Low -E4 Sun 031 022 0.36 r E , Spnngline Window Specialty Window HP Low-E4 Sun with Grilles 0.33 0.18 028 :! ` F HP Lnw-E4 Sun with Grilles 0.31 020 032 F E HP Low-E4 SmartSun 030 0.23 0.52 E : - HP Low -E4 SmartSun 0.30 0.24 0.58 PI ; 1 E ' ! HP tnw-E4 SmartSun w /Gnles 032 021 0.46 Es ., ' ' `' HP low-E4 SmartSun w /Galles 030 022 0.52 E` i ,''! F''. E HP law -E4 0.30 027 0A5 }} i, r ® HP Lnw-E4 032 022 037 'B , �: Er ® HP Low-E4 with Grilles 032 023 039 PI • r' E HP Lmr:E4 with Grilles 033 020 0.33 - Frenchwood' HP low-E4 Sun 031 0.16 0.25 1111 f=l E Hinged Inswing- HP law-E4 Sun 033 014 021 - Gliding . Palo Door '1 HP Low-E4 Sim with Galles 032 0.14 022 E P {:I E French Door' -+ HP Low-E4 Sun with Grilles 0.34 0.13 0.18 - 1 HP Low-E4 SmartSun 030 0.18 0.41 EP 111M HP Lew-E4 SmartSun 032 0.15 033 ET - 1 E . • HP Low-E4 SmartSun w /Galles 0.31 016 035 93 Ill ® 1 HP Low-E4 SmaI1Sun w /Galles 033 0.14 0.30 - vrE 1 HP Low -E4 031 024 0.41 E n E ! HP low-E4 033 025 0.41 • t°,12 HP Low-E4 with Grilles 032 0.21 035 1 i ® HP Lew-E4 with Guiles 034 0.22 036 - • Frenchwood' Hinged'. 1 HP Low-E4 Sun 031 0.15 023 fl i,'.3 ® Hinged Outswing HP Low-E4 Sun 033 0.16 0.23 p Inswing Patio Door HP Low-E4 Sun with Galles 0.32 0.13 0.19 ,'.: ® French Door HP Low-E4 Sun with Galles 0.35 0 0.20 - e6 HP Low-E4 SmartSun 0.30 , 0.16 0.37 I i:' ® HP Low-E4 SmartSun 032 0.17 037 f'.;�. -17 ® 2 z ....±.• • HP Inv-E4 SmartSun w /Gnlies 0.31 0.14 031 Ell - ; ' ® HP Lnw -E4 SmartSun w /Gditrs 034 015 0.32 - °� E HP Law -E4 031 015 0.41 P i' ., ® HP low-E4 0.33 023 038 . - e HP law -E4 with Galles 032 011 0.35 C�s (,.+. ® HP taw-E4 with Grilles 0.33 021 034 - Frenchwoori'. Hinged ,' HP Low-E4 Sun 031 0.15 023 LIE '• ® Fixed French Door HP Low-E4 Sun 0.33 014 0.21 - Dutawing Patio Door (.• HP Low-E4 Sun with Grilles 032 0.13 0.19 f` F ?P p,., Sidelight HP Lnw -E4 Sun with Galles " 0.34 013 019 - HP Low-E4 SmartSun 030 0.17 037 E E • HP Lnw-E4 SmartSun 032 015 0.34 - HP low-E4 SmartSun w /Gnles 0.31 0.15 0.31 fl ', ® HP Low-E4 SmartSun w /Gules 0.33 0.14 030 - HP Lew -E4 0.31 022 037 Fi 11- '1:`. HP Lmv -E4 0.32 0.25 0.41 - '' HP Low -E4 with Galles 0.32 020 0.33 E. t:. ® '1 HP low-E4 with Galles 0.33 0.22 0.37 - Frenchwoori': :.' 1 HP Low -E4 Sun 0.32 0.14 0.21 I1 . f' ® ' Filed Transom ; • HP Low-E4 Sun 0.32 0.15 0.23 - Patin poor Sidelight i HP Low-E4 Sun with Galles 0.32 0.13 0.18 n "l ® french Door ` HP low-E4 Sun with Galles 0.33 0.14 020 - HP Low-E4 SmartSun 0.31 0.15 0.33 ' f 1 (' HP ImwE4 SmartSun 0.32 0.16 0.37 - ' • ! HP Lnw-E4 SmartSun w /Galles 0.32 0.14 0.29 E - !- Ij E . , HP tnw-E4 SmartSun w /Gillis 0.32 0.15 0.33 - HP lew {4 0.30 014 0.40 E rl ® i Low-64 HLow-64 035 0.26 0.44 HP Low-E4 with Gnlles 0.30 021 0.35 t ?. ® HP Low-E4 with Gnhtes 0.36 023 0.38 - Frenchwaod' HP Low -E4 Sun 0.30 0.15 022 ' E Folding Door HP Low-E4 Sun 0.35 0.16 0.24 - Patio Door Transom • HP Low -64 Sun with Galles 0.31 0.13 0.20 PIA .i ® HP Low-E4 Sun with Grilles 0.36 0.14 021 - HP Low -E4 SmartSun 0.29 0.16 0.36 fl '1": ® HP Lnw-E4 SmartSun 0.34 0.17 0.39 - • HP Low-64 SmartSun w /Galles 0.30 ` 0.14 0.32 €7. 11'. ® HP Low-E4 SmartSun w /Gnlies 0.36 0.15 0.34 - • continued an nert page • For NFRC certified total unit performance on units with capillary breather tubes for high altitudes, please visit andersenwindows.com. • •'High- Performance 'Inv- E4 '(HP Low-E4), "High-Performance' low -E4' SmartSun'` (HP Low -E4 SmartSun) and' High- Performance Lnw-E4' Sun (HP Low -E4 Sun) are Andersen trademarks for •Low -E glass. ' U- Factor defines the amount of heat loss through the total unit in 8th /hr sq. ft.°F The lower the value, the less heat is lust through the entire product. Window values represent non- tempered glass. Use of tempered glass can increase U- Factor ratings_ See andersenwindows.com for specific performance values. Door values represent tempered glass. r Solar Heat Gain Coefficient (SHGC) defines the fraction of solar radiation admitted through the glass both directly transmitted and absorbed and subsequently released inward. The lowerthe value, the less heat is transmitted through the product. ' Visible Transmittance (VT) measures how much light comes through a product (glass and frame). The higher the value, from 0 to 1, the mom daylightthe product lets in over the product's total unit area_ Visible Transmittance is measured over the 380 to 760 nanometer portion of the solat spectrum. • NFRC ratings are based on modeling by a third party agency as validated by an independent test lab in compliance with NFRC program and procedural requirements. • This data is accurate as of December 2010. Due to ongoing product changes, updated test results or new industry standards or requirements, this data may change overtime_ Ratings are for saes specified by NFRC for testing and certification_ Ratings may vary depending on use of tempered glass, different grille options, glass for high altitudes, etc . • PassiveSun' glass values are available online at andersenwindows.com. ' 277 • PRODUCT PERFORMANCE Andersen NF RC Certified Total Unit Performance (continued) • Andet Product': Glass Type U- Factor' SHGC Y1 200. Series Gear Dual Pane 145 0.60 163 - ' Clear Dual Pane with Galles 145 054 0.56 - :.: lHt Wosii - Lnw-E 130 0.32 055 2 Dauhlo-Hunel indow Lnw-E with Galles 0.30 029 0.49 P HP LmwE4 SmartSun 030 0.21 049 N - M -: HP Low-E4 SmartSun w /Grilles 031 0.19 0.43 Clear Dual Pane 0.45 0.61 0.64 - Nonskid:: . - Clear Dual Pane with Galles 0.45 054 157 Dauble- HungWindow :_ Lnw-E 030 - 032 0.56 2 _ _.. Lnw-E with Galles 0.31 - 029 OSD .} Clear Dual Pane 0.44 163 0.66 - N aff O M - Clear Dual Pane with Grilles 144 0.57 039 - __ Ty 21150111 Window' _ - Linn{ 0.27 034 158 E Lnw-E with Galles 027 0.30 032 E Clear Dual Pane 0.45 0.60 163 - Clear Dual Pane wthGrilles 145 054 . 056 - Lnw-E 0.30 0.32 0.55 M 68drrrg Window Loty-E with Galles 030 029 0.49 2 LmwE SmartSon 030 021 149 E M lase -E SmartSun with Grilles 0.31 019 0.43 P N Clear Dual Pane 143 051 165 - Gear Dual Pane with Galles 143 OS 0.58 - Inw-E 028 • 0.33 156 g :CSrcle Tap :Window ' Lnw-E with Galles 028 030 0.50 a Law -E SnartSun 027 022 0.51 a 3 NI Lnw-E SmattSun with Guiles 0.27 0.20 0.45 3- . -Oiler Dual Pane 0.44 0.61 0.64 - Clear Dual Pane with Galles 0.45 0.53 0.56 - Lnw-E 0.29 032 0.56 - _ NarreDne _ Lnw-E with Galles 0.30 0.29 0.49 M 2 M =68dingPatio Doors LmwE Sun 0.29 020 0.31 M Lnw-E Sun with 6tiies 0.31 0.18 027■ Inw-E SmartSun 0.28 0.21 150 0 - = - 2" - Low-E SmartSun with Galles 0.30 0.19 0.44 a Clear Dual Pane 0.43 0.61 0.64 - Clear Dual Pane with Galles 143 034 0.56 taw-E 0.28 0.32 0.56 - '�Perma- Shieit;: Inw-E wfh Galles 030 0.2 0.49 g Gliding Patio. Do • Lnw-E Sun 029 019 030 E M Law{ Sun with Grilles 0.30 017 0.27 n 0 NI lnw-E SmartSun 0.27 0.22 0.50 - r I Lnw-E SmartSun with Galles 0.29 019 0.44 E M Clear Dual Pane 0.43 0.45 0.47 - _ Clear Dual Pane with Galles 0.43 0.39 0.40 - tnw.E 0.32 024 0.41 M 3 E Hinged Inswing - Lnw-E with Galles 0.33. 021 0.35 - •Patio.Dooa. ::.'':,'.' taw -E Sun 0.32 025 0.23 M 5 � - _ Loy{ Sun with Grilles 0.34 0.13 0.19 - inw-E SmartSun 032 0.16 037 2 2 Lnw-E SmartSun with Galles 0.33 034 0.31 - I girt • • ;, if/ Department .of I i:& al Accidents' . • - Q, = _ • • Office of btveatagattions • ; • - -,....:-.:1: -4 6 O W�- Street • ' _ = - 'Boston M4 0111 • - • www.miga'n/#ia . . - Worker i' Compensation Insurance Affu3svit 13 rs/Electricianr/Piumbers Applicant Information • Please Print Leah . Name e •t1 e u) a k u n r ecce r\ • • • • s: \ b �', s 3 • • - • • . • • • . City/State p: n n '- \•,QPd i •IMF. D1 C3 Phone #: So ` . - S S 1- (9P • Are you aka employer? Check the appropriafrhom . Type of project (required): ed): . L I em a ea�lopeY with 3 d • 4. ❑ I em n general contractor ®d I 6. El Nay c®swctiam • • eanployeec (fall emd/orpert- time), e • have hired the sub- contrackns - • 2., ❑ I am a vole proprietor or partner- listed on the attached sheet. r 7 ,t -�'� • • ship and brae nn employees These snb-co meters have - R. ❑ Demoltticm • working for me Many. capacity, - work:re oanip. iastromce. P. ❑ gam addition • • . `' No workers' comp, insurance 5. ❑ We are a corporation and its affirms hove main main ore isms • ) af�c hove exercised their • 3 . D I arm a hcaneowner doing all woo of cresagicn per MCA. - . 11 -0 Phmaling TePaiir a &Mitirm • myself (No mss' .onnp. c. 152, ¢ 1(4), and we have no 1.2.0 gy m insurance re ain:4j t • "employees. • y• No workers' . 13.❑ Other • • • comp. iBquhe) • • : 'Vim appiioat tint daces box in meat goo fin omodem ow t ebe mod bel ashowbiz theme as we: bar' pparlay . • t Bo remarma who cobalt this aSdavit indicating they at doing all mama them hire oa0cide mataamo met steal I mar at5davlt ithea di oar. • I.aatro ma•'that cheek this box asst eambest an &radian' thrift thawing the nom ofine• acloa• Rod their atoagr. Imlay information. • . i aai an employer that is poi vidiag wm ors' com,peacealion bwar ante for AV employees Be low is rite po6 y and job cite • �� fit,, {� . , lnaeraoc a C.ampany Name : 0 6 h e p ( \ '� c ...4....,-, . s • a • Policy* or self -ma. Lie. # , W ` \ \ `-I.g 6 - Boration Detz: ) o - i :- 1 3 . Sob bite Address: • a-tJ r.� ✓ 1 • v\ .-1- : gitiStairIET:\A) nvi cs:- . • /VCC\ U 1 Ob d- .Atlarh a copy of the workers coraPearstion policy declaration page (showing the ptdicy number and evirat' 1 dzt4 }. • Faint l e secure coVrrsgt requited melee i e c t i a n 25A o f M G L c. 152' can lead to t h e i m p o s i t i o n of c al penalties tea fee •uP to ;1,500.00 and/or one-year imprisortMent, at ll as civil penalties in the foam of a STOP WORK ORM. and a fine of uF 1a 5250.00 a day against the violainr. Be advised that a copy o -this statement may -be f avarded.ta the Office of as of the DIA for insurance coverage verification. . . n .1 de hereby errtkp • ,' • peachier of pejwy drat the it fiarasat`icn provided-above is true -aced co1T - • Data:. / d 1 r .-1 - • Officiii Fat mcly. Do eorwrate tit dcboreq to be completed is" cit or tawn•o ai . • : • • T Or Town: . - • PerunitiLicense # • • - - 1 Board of sr 2. Siiifrfing Department .3. attpr'T-a rn. 4; Electrical Inspector 5. Plamidug inspector •. t;. -Other. • -Coact Prima: _ Phnne #: • • • • • - • • 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 P. Lot Size 1 a I i P , Frontage 1 Setbacks Front t ' Side L: 1 R:= L:FT R: 1 1 ri Rear = E1 L Building Height Bldg. Square Footage 1 I % L L_j Open Space Footage (Lot area minus bldg & paved 1 CT= = I parking) # of Parking Spaces Fill: .. . — _, — — (volume & Location) a A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW YES 0 1 1 IF YES, date issued: I IF YES: Was the permit recorded at the Re ' ry of Deeds? NO 0 DON'T KNOW YES 0 IF YES: enter Book fi Page and /or Document # ( 1 B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 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:. ----1 D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO .Ey -- IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, ex ion, or filling) over 1 acre or is it part of a common plan 0 that will disturb over 1 acre? YES 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 ❑ Name of License Holder : O ^ vti /1 1 '1 t S License Number 3 L0,04 \ ((�� ) ��it� ` : r^ C, G�� � �t A fti'' t r.S G` 9 -s —1`I Address Expiration Date Signatu Telephone ....^� •,% M -, �s., :r^r � . .vw .> m � »w ,� ar px � 'S -.Registerdd }•lorn mprov menr" vntrac'or .� i , ;, ;�,E �, F „T,.,� Not Applicable ❑ r Af1L cr'5c,A )q010 Com an Name Registration Number ) o' 0 0 S,- c,w ; vlAy v i s 3 . I d '01 3 1 3 Address Expiration Date _ Telephone 5h 3S I 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 S ome O ne r.. Exemption The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families and to . ow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervi .r. CMR 780, Sixth Edition Section 108.3.5.1. Definition of ' eowner: 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, • • e or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who cons is more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the : 'Ming Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed u • the building permit. As acting Construction Supervisor your presence • e 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' • • • ensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts 0- - .1 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 complianc •th 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 Rep ement Win s Alteration(s) ❑ Roofing El Or oors, Accessory Bldg. ❑ Demolition El New Signs [0] Decks [❑ Siding [D] Other [D] Brief Desp iptiorr Proposed Work: i`e ■") 1 - ,) ci;d — TU - ct C �•� Alteration of existing bedroom Yes �o Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes Plans Attached Roll - Sheet f e an ar, di>r t onto eX�st nsa housing co' "irtp ete�he fo iiw ng: 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, SCif, G p (` AAA , as Owner of the subject property hereby authorize ``, {` a 11 J t al dl� to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, 7+ ul DelAvl , as Owner /Authorized Aeejat 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. nil ‘30 Print Name • ,)— Signature of Owner /Agent Date E— _------- q p 111 p {J ,a IM F t h`, 9 De• e t `�R,,gty `,: ,1,, S } '!: -?, 1 R Cit of Northam ton s-t , k Building Department a „ ,��� r ZOIZ 212 Main Street . „ / o ti` i a b ,,:c: �is . * ' : � ,� 3: Room 100 W : ,, DNS � �3 � ���4� 1 ' . � a � eF auiLD∎NG 0 1060 orthampton, MA 01060 t G _ c 5 °14 p 413 - 587 -1240 Fax 413 - 587 -1272 Jb APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION •1 - SITE INFORMATION T his se to be c ompleted "by o f f ice. 1.1 Property Address: i �` �' „ # � a � �3 � d 3 3 fA.,A ✓vv v`v 0 r " la 41� Tar of & �: , , nit ��DJ�.iti C C . I� G. C \(� �. t a rx s '{overlay Districts 4 E', 1�n�zt s,,, t. e�EIm b ti�istrict . r'. OB Districf w SECTION 2 - 'PROPERTY OWNE /AUTHORIZED A G ENT 2.1 Owner of Record: S (�d� f ` ( . 1 0 U : r' 1(,� Current Mailing Address 3 t�v #� � t - v c , vV4 0,0,) Name (Print) : L 1 3 = . — k,, — , t ? h .1.).: Telephone Signature 2.2 Authorized Agent: 2L l 1 k..J � voLvA li)c i k A t 5,'; n lug ( G -..\-,„,_s, J � )..j J i � � n e � . �/12u d i 3 Name (Print) Current Mailing Address: S D`d 3� \- X55 e Signature Telephone SE TION 3 ESTIMATED CO C TION COSTS Item Estimated Cost (Dollars) to be Official, Use On1y completed by permit applicant 1. Building (a) Budding Permit Fe 2. Electrical (b) Estimated T on otal fro Cm ) ofi Con 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = 1 + 2 + 3 + 4 + 5) ( N, lr Check Number f 3 This Section For O fficial Us Only Building Permit Number IIssued: Signature Building Commissioner /Inspector of •Building ! Date 38 AUTUMN DR BP- 2013 -0458 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 44 - 081 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPLACEMENT DOOR BUILDING PERMIT Permit # BP- 2013 -0458 Project # JS- 2013- 000731 Est. Cost: $4164.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RENEWAL BY ANDERSEN 95707 Lot Size(sq. ft.): 10018.80 Owner: GORMELY SANDRA J Zoning: Applicant: RENEWAL BY ANDERSEN AT: 38 AUTUMN DR Applicant Address: Phone: Insurance: 104 OTIS ST (508) 919 -0900 WC NORTHBOROMA01532 ISSUED ON:1 0/1 7/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL REPLACEMENT DOOR 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 10/17/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner