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42-135 (3) • • Renewal - : �:,R, byAndersen i, WINDOW• REPLACEMENT *RnndnonComppny ..' Wood/Vinyl Composite IF "at'`go R.r4sr31: r, Dual Argon Low E4 SmartSun tietio carom Double Hung 100-00473518-010 -ENERGY PERFORMANCE RATINGS • U-Factor(U.S)/1-P Solar Heat Gain Coefficient 0 : 29 0 . 19 ADDITIONAL PERFORMANCE RATINGS Visible Transmittance 0 . 42 • Manufacturer m.q uWaa that thaw.ratings conform brm to appina&NFC p procedures for Murm'ring whole product I performance.NFRC ratipr an darennined ben bend an of anvironnranal condition.and a spacdo product aim. NFRC does not reommens any product and dons not warrant the aukabaty of any product for any'pacific ran. • Consul manufacturer's Mermen for ether product patbrmanoe information. WWW.Nfm.oig awur�e�o-nloxm.�w urea. fu11` li< This product mesa Green nave-s .•�,�rk�_."u. �u�,.�,a�.,.<.. i 2 standards governing energy ��r%,r.'R 1',.; �.. > ""*.�,+?,._ r efNCinncy,heavy malt&fa '!•.,,� .ppf r -0' fi.the Name and sash �`� fr_ ••.d• 04Irmateral,packaging,and •': • ag, ,Fl ti�x.r 5 �► consumer adueataal a.»y, • emmtfa&. tut. w+rwN I DESIGN PRESSURE(PSF) WDMA 1IAI,I HARK '' CERTIFIED II LC25 . RbA DB' Sloped Sill DH IN MOM&1N802srAMIAMOMafCSy1f11A&AMOOS. Manufacturer a coonfolrnanna to M s: Die e&rldnds. dew or exceeds M.E.C.,C.E.C,•I.E.C.C.Ai InnilhaMon requirements WDMA Hallmark GnlNatbn('roDram- • • • • • f � efzP Wommozneoeal i o/Ci1Ga4daduae • __ _ ffiice of Consumer Affairs&Business Regulation 11/_ ME IMPROVEMENT CONTRACTOR -(1=1) egistration: 170810 Expiration: 12/23/2013 Supplement(` RENEWAL BY ANDERSON CORPORATION JOSEPH REZZA 104 OTIS STREET — NORTHBOROUGH, MA 01532 Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supenisor License: CS-065272 ` ter I I ` '.. .- � ; JOSEPH P REZZA` 168 KELLEY BLVD N ATTLEBORO 14 IA 1 ; It Expiration Commissioner 04/25/2014 • Rif CERTIFICATE OF LIABILITY INSURANCE ( 0 25/2""'° "Y) 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 POLI W.S 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 polily(les)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 1-612-333-3323 156KrAci Janelle Rargrove or Eric Johnson Nays Companies PHONE x: 612-333-3323 1 ,No1, 612-373-7270 _ SO South 8th Street rate. .MA1►�L Suite 700 Minneapolis, NN 55402 CUITOIrERDE INSURER(*)AFFORDING COVERAGE HNC I INSURED INSURERA: OLD REPUBLIC INS CO 24147 Renewal BY Andersen Corporation INSURERS: NATIONAL ONION FIRE INS CO OP PITTS 19445 104 Otis Street INSURERC: Northborough, NA 01532 INSURER INSURER E: INSURER F: , COVERAGES CERTIFICATE NUMBER: 29229436 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 AU.THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NISR I,-,''. :I-" POLJCYEFF POUCY OP _PR TYPE OF INSURANCE _DISK WI/D_ POLICY NUMBER UNITS A GENERAL LIABILITY NaZT 59828 10/01/12 10/01/13 EACHOCCURRENCE s 1,000,000 X DAMAGE TO RENTED COMMERCIAL GENERALUABILITY PREMISES(Ea occurrence) S 500,000 1 CLAMS-MADE 1 X OCCUR MED EXP(Anyone person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $4,000,000 GEM.AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG $ 3,000,000 X POLICY. PT,. . LOC $ A AUTOMOBILE UASSITY NNTS 21700 10 Ol 1 10 01 13 COMBINED SINGLE UMIT $3,000,000 (Ea sodded) X ANY AUTO • BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per eodderd) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per ) $ X NON-OWNED AUTOS s s B X UMBRELLAUAS IX 1 BUR 13273355 10/01/12 10/01/13 EACH OCCURRENCE $25,000,000 EXCESS 1JAB 1 CLAIMS41ADE AGGREGATE $25,000,000 DEDUCTIBLE $ X -, , . 25,000 $ A WORKERS COMPENSATION IJAS r INC 117948 00 10/01/12 10/01/13 z ANDIMIPLOYER, Y/N ANYPROPRIETORIPARTIERIEXECUTIVE(- N/A E.L.EACH ACCIDENT $ 1,000,000 O�EXCLUDED? ('° I . (Meny/ery In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 Ryes desaee under �_. DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,I mas specs Is required) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE 17e,„(......c..„......... I eric j 01988-2009 ACORD CORPORATION. All rights reserved ACORD 25(20091091 The ACCIRn MIAMI 0...l Iwww avm wammoia....powat..-_.11._ The Commonwealth of Massachusetts Department of Industrial Accidents '; Office of Investigations ■ kiikiL lr.= , 600 Washington Street Boston,MA 02111 � - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Con tractors/Elects icianslPlnmbers A' ,licant i ormation Please Print ,'b • • Name(Business/Organization/Individual): a • a # _ # a . b • . A . Address: k D`-1 .6-k■ s S'r . City/State/Zip:ja n \.--� r 1 S a Phone#: 57 - �3 5 l—c c3 o iJ Are you an employer?Check the appropriate box: Type of project(required): 1.V1 I am a employer with 3 p 4. 0 I am a general contractor and I . employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. ?. p Rwnodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any employees and have workers' Idng Yh' 9. ❑Building addition • [No workers'comp.insurance comp.insurance required.] 5. G We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their , 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t - c. 152,§1(4),and we have no employees,[No workers' 13.0 Other comp.insurance required.] Any applicant that ducks box#1 must also fill out the section below showing their workers'compensation pommy information. t Homeowners who submit this affidavit indicating they are.doing all wok 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 ofthe sub•oouhactors and state whether or not those entities have employees. Here sub-contactors have employees,they.must provide their workers'comp.policy number. I an an encloyez that is providing workers'compensation insurance for my employees. Below is the policy and job site information. . Insurance Company Name:: D 1 c, v.e_Ry■D\� o �n S. C 6 . Policy#or Self-•ins.Lic.#: (1(1 t., c W4 4 C[t-i?O b •Expiration Date: I 0 1- 1 3 rob Site Address: City/State/Zip: 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: . •i one#• *$ . .. - . . • 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): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6:Other • Contact Person: Phone#: . f Renewal snewal by Andersen Corporatic MA]tome Improvement Contractor byAndersen. 104 Otis St.,Northborough,MA 01532 License#170810(Expires 12/23/2013) (508)351-2200*Fax:(651)351-4810 Federal Tax ID#41-1918413 WINDOW REPLACEMENT an Andersen Company WINDOW SPECIFICATION SHEET Buyer(s)Name Date of Agreement 13//4,va' S1/1/4re- s-/b--/1 The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT, of which this Specification Sheet is a part. WINDOW DETAILS 1. Contractor will Install a total of -3, windows in Owner's home,using the following individual quantities: 3 Double Hung(DB) Equal sash Cottage sash(1/3 top,2/3 bottom) Oriel sash(2/3 top.1/3 bottom)__Flat sill (e„st°mer[s°f � aware of Glass loss) Square Check Rail 3 Curve Check Rail Casement(CS) Hinge right Hinge left(as viewed from exterior) Double Casement(CD) 2 Lite Gliding Window(GW) Casement/Picture/Casement(CT) I:1:1 or 1:2:1 Glider/Picture/Glider(GPW) 1:1:1 or 1:2:1 Picture Window Bay or Bow Awning Window #Lights Soffit/Roof Shingle/Copper Specialty Window Patio Doors(See separate door spec sheet) Seat to be Primed/Oak/Pine 2. 3 Qty of Windows to be Custom Fit Replacement: 3. D Qty of Windows to be Custom it Full frame(INCLUDES NEW INTERIOR&EXTERIOR CASINGS) Exterior gasings: Pine Maintenance-free material Factory applied 908 Fibrex brickmoid 4.Glazing to be: HP TM Tempered Other If other,please specify: 5.Exterior color to be: W� Sand Canvas Terratone Cocoa Bean Dark Bronze Forest Green Black 6.Interior color Whi Canvas Pine Maple Oak Same as Exterior Note:Wood interiors need to finished by Owner. 7.Hardware: ,__Stone Canvas Estate Hardware: Style: 8. Install Lifts with Double Hung Wi ws 9. Screens:windows to have: Half or ull scree s Screens to be V Fiberglas _Aluminum TruScene / GRILLE DETAILS 10. Windows have grilles: /Grille Between Glass(GBG) Removable Interior Wood(INTW) Full Divided Light(FDL) (s‘ ,fig )Owner approved(initials) Draw grille patterns below Use additional sheet if needed Qty: Qty: Qty: Qty: Qty: Qty: Qty: I ADDTI1ONAL WORK DETAILS 11. Qty of Sills_Sill noses to be replaced by Contractor 12. '� Contractor will remove metal frames of windows. 13. Contractor will install new paint-ready or stain-ready Interior_Exterior casings in_Pine Maintenance-free material 14. Contractor will install new paint-ready or stain-ready Interior Exterior stops in Pine Maintenance-free material 15.( �t�) )Intls-Owner is aware,contractor does not do any painting or removal/installation of alarm system/hardware. It is the responsibility of the homeowner to have the alarm system/hardware removed prior to installation. 16.• Contractor will wrap exterior casings with coil stock of- color. Note:Wrapping may be required with storm window removal;removal of storm windows will leave screw holes in casing. 17.Contractor will insulate,caulk and seal windows with 3-Point system to prevent water and air infiltration. Removal and disposal of all job related debris,win- dows,storm windows and vacuum nightly included. Upon completion of the job and payment in full,a limited warranty shall be issued. 18.er,fes❑No Building Permit—Contractor will secure any and all necessary permits.The fee for the permit(s)is not ��.// included in the Contract Price and a separate check is required at the time of sale for this fee. Ck#' $ 19.Rcces❑No All discounts have been applied to this agreement price. 20.Additional job details: 21.Yes❑No Owner agrees to be present on the final day of installation for final inspection and to deliver final payment/finance form(s). 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 Andersen Cor oration Buyer(s) Buyer(s) (1M,1/\./ Signature of Product Manager Signature Signature Print Name of Product Manager Print Name Print Name Renewal4. MA Home Improvement Contractor bYA11C�et"Sell. IPi 0, License#170810(Expires 12/23/2013) WINDOW REPLACEMENT an Andersen Company Renewal by Andersen Corporation Federal Tax ID#41-1918413 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 Jr')Aiv NAPe 5 r /3 Buyers)Street Address,City,State,and Zip Code wer E-Mail Address Home Telephone Number Work Telephone Number 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. / p-� Method of Payment: ® Estimated Starting Date: Total Job Amount: Amount Financed ❑Check ❑Cash Deposit Received(33%): OVisa/MC ❑Discover Balance at Start of Job(33%): — 0 financed ❑AMEX Estimated Completion Date: If credit card is selected,please Balance on Substantial ✓ �, 7 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 Andersen C rp Buyer(s) Buyer(s) By: ignature o Product Manager Signaturee Signature (. /r0•�i�l� Sig'e,e i ,A ( P ccVAPE. Print Name of Product Manager Print Name Print Name YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. NOTICE OF CANCELLATION NOTICE OF CANCELLATION Date of Transaction 'S -ISr-17 . You may cancel Date of Transaction J -//-� . You may cancel this transaction,without any pedalty or obligation,within this transaction,without any penalty or obligation,within three business days from the above date.If you cancel,any three business days from the above date.If you cancel,any property traded in,any payments made by you under the I properly traded in,any payments made by you under the Contract of Sale,and any negotiable instrument executed I Contract of Sale,and any negotiable instrument executed by you will be returned within 10 days following receipt I by you will be returned within 10 days following receipt by the Contractor ("Seller") of your cancellation notice, I by the Contractor ("Seller") of your cancellation notice, and any security interest arising out of the transaction will I 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 I as when received,any goods delivered to you under this this Contract or Sale; or you may, if you wish, comply I 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 I pick them up within 20 days of the date of your Notice of your Notice of Cancellation,you may retain or dispose I 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 goods to the Seller and fail to do so,then you remain liable you remain liable for performance of all obligations under I 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 I dated copy of this cancellation notice or any other written other written notice, or send a telegram to Contractor: I notice,or send a telegram to Contractor: Renewal by Andersen Corporation, 104 Otis I Renewal by Andersen Corporation, 104 Otis Street, Street, Northborough, MA 01532, BY NOT LATER THAN Northborough MA 01532,BY NOT LATER THAN MIDNIGHT MIDNIGHT OF S-"2/ -/7 •(Date) OF ..1' -�/ -/3 .(Date) I HEREBY CANCEL THIS TRANSACTION. I HEREBY CANCEL THIS TRANSACTION. Buyer's Signature Print Name Dote Buyer's Signature Print Nome Dote RbA Copy- White Buyer Copy-Yellow Buyer Copy-Pink ©JBLLP2009 RBA-Ph MANN SECTION'8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: 3o SC.�\ 'R e 5c)3-c) (plc ����� License Number l0 - &IVS ► --1Q-L3r� C4);6 0 1-I- s ry \ Expiration Date ,Address Telephone Cfli rsferec' eiii mpWaemeitie6ntractor , TL I ,, .L Not Applicable ❑ n bILL Company Name t Registration Number Ib 1-1 0 ')-L S 1 N I 3-- 1 3 Add‘ess + y Expiration Date l�L.r-\\I" -0'6(`) , VI& D Telephone.51, g-3 C t—c2c)w 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 ❑ i T1 7:� . v xX1. o e O ne Eempti.©n The current exempti.i for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such home. er to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, 'xth Edition Section 108.3.5.1. Definition of Homeowner:Pe on(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 . ily dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs e than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Bui • g Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed un' • the building permit. As acting Construction Supervisor your presenc- .n the job site will be required from time to time,during and upon completion of the work for which this permit is issue.. Also be advised that with reference to Chapter 152(Wor -rs'Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massa 'usetts 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 responsibi ., for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State o Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Wi nd Alteration{s) Roofing 0 Or Doors Accessory Bldg. ❑ Demolition El New Signs [0] Decks [❑ Siding[p] Other[01] Work:Descri do Proposed c _ ( 6 S ('vc TO 2.( C"ke Work: �� <�.c�� :3 LJ t/t ,.JS C . Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet §av ifN a Kiouse nd.oraaddatlo.n 9 ex n>I s�laous nq " vinplefe l e.follow n : a. Use of building : One Family 7 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, f✓rl U n S ntx, , as Owner of the subject property hereby authorize 5e Vt Qe 2- to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, b,Se_ A Q c ,as Owner/Authorized Agent hereby decide 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. -Sds-9L Jee 2 Print Name Avidit i Si. • Owner/Agent Date Section 4. ZONING Ml Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size I 1 I i 1 Frontage 1 14 i 1 Setbacks Front I I ' Side L:= R:1 I L:= R:1.71 -----i Rear = i 1 1 Building Height Bldg. Square Footage = 1 i % = L____- i Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces [173 Fill: x 'I f i _1 (volume&Location) ( ,. I A. Has a Special Permit/Variance/Findin ver been issued for/on the site? NO Q DONT KNOW YES 0 IF YES, date issued: . IF YES: Was the permit recorded at the Regryof Deeds? NO Q DON'T KNOW Q YES 0 1 IF YES: enter Book Page and/or Document #6 • B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: i C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO -Cr IF YES, describe size, type and location: I E. Will the construction activity disturb(clearing,grading, excav ,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. osiy ��� �€ RECEIVED City of Northampton fi ; 3 k Building Department s a -0. 2O 3 212 Main Street JUN Room 100 a - .►. '��' � . J Northampton, MA 01060 D E P T.F 6 � �%SPc o M oNnaon 3-587-1240 Fax 413-587-1272 ,P® "" r .. i 1M APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 11 Property Address. �Tiais section to be � pl�ted by office 7 4 �- s?s i x 6 4 a A ""�1 Q eW U `\ }�} pk. u �+ W i � K.A.I/� � �� P , vIAA D ()(0 zotiier taga 3 erg. vyerii orre efp «i t`s to , tigh«i. f Distnct.-.. ' ` ... ` . GCB District E SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: sl.ck 9Q._ g-9-? �� 41. A e . ` EDiwncc,,. t Name(Print) Current Mailing Address,: � > S-— X 3,3 l Telephone Signature 2.2 Authorized Agent: U e, 11 Q e 104 ()'}l S ��. J�Or� hYJCN2) A&c 01_532. Name(Print Current Mailing Address: (� )—CXD X S5� Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS !: Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fes 2. Electrical (b)Estimated Total Cost ofi Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) 3q. , v� Check Number , This Section For Official Use Only Building Permit Number: Date � ssued: Signature; Building Commissioner/Inspector of Buildings Date 878 WESTHAMPTON RD BP-2013-1211 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:42- 135 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-2013-1211 Project# JS-2013-001983 Est. Cost: $3957.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RENEWAL BY ANDERSEN 065272 Lot Size(sq.ft.): 16727.04 Owner: SNAPE BRIAN&SUSAN GOULET Zoning: Applicant: RENEWAL BY ANDERSEN AT: 878 WESTHAMPTON RD Applicant Address: Phone: Insurance: 104 OTIS ST (508) 919-0900 WC NORTHBOROMA01532 ISSUED ON:6/14/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 3 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 6/14/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner