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17A-082 • ,"No Substitute for Quality" WORCESTER SPRINGFIELD HARTFORD 459 MAIN STREET-P.O.BOX 51033-SPRINGFIELD,MA 01151 MA.REG# 151711 CT.REG#601525 877-3STURDY FAX 413-543-3200 W W W.STURDYHOME.COM OWNER PERMIT AUTHORIZATION Name: J G-t/ Address: C City/State/Zip: e (owner), of the property located at: 111'a`v h etjhAuthorize Sturdy Home Improvement, fnc. To a 4 s my agent for the construction project taking place at the above address. I also, authorize Sturdy Home Improvement,Inc to obtain a building permit for this project. I understand and accept responsibility to comply with all regulations and required inspections. Signature of Owner Date Signature of Owner Date STURDY HOME IMPROVEMENT, INC. ACCEPTANCE PAGE MA REG. #151711 CT REG. #601525 ANY WORK NOT STATED ON PREVIOUS PAGES IS EXCLUDED The following schedule will be adhered to unless circumstances beyond the contractor's control arise: Work scheduled to begin the week of___/----/ . Expected completion date_____/___/....Weather permitting. The cash price for labor and material as described above is: 1st payment 2nd payment 3rd payment 4th payment Contract Total (u on�sigrnn`g) Mvmrm�,�, �/ ? �,� Roof $ p +rQ1yJ Ventilation $ Other work 32`/0 L 321 q O01� Roofing total $ ' $ �6(� y $ $ 346 b $ QoO Siding $ (0600 ° $ `Lby $ ( yOb $ j6Ybd • $ Windows $ q �t:�0,'p $ �0 6 $ y $ 3c `t 1 $ �(I Special orders $ $ $ --' $ $ Other $ $ $ $ $ Totals $ 2-12, 4:)0 . $-(42-6 Terms: _Cash ,Finance Credit Card:#_ _ ^ _ _ _ _ _ _ — Exp.date____ / ____Code_ Payment schedule: Any balance not paid in full within thirty days, will be charged 1.8%interest per month. In order to meet the completion schedule, the following material/equipment must be SPECIAL ORDERED before the contracted work begins. (Law requires that any deposit or down-payment required by the contractor before work begins,may not exceed the greater of(a.)one-third of the total contract price or(b.)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule) $ to be paid for $-_to be paid for Any additional work orders are to be paid for once accepted and approved by purchaser. Verbal understandings and agreements with representatives shall not be binding. All understandings and agreements must be set forth in writing in this contract. Additional provisions are stated on reverse side and are part of this contract. In witness whereof Purchaser(s)has/have hereunto signed their names this 17 1% day of '1�4, 20.4-1 and acknowledge receipt of a true copy of this contract. UNLESS OTHERWISE SPECIFIED, IT IS UNDERSTOOD THAT THE OWNER IS READY FOR THE WORK TO BEGIN. THE PURCHASE PRICE QUOTED ABOVE WILL BE HONORED ONLY UNTIL (Date). You the Purchaser(s)may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See notice of cancella- tion form for an explanation of this right. Signature affixed below also acts as receipt that Purchaser(s)received separate cancellation forms. The following is a requirement by Massachusetts General Law,Home Improvement Contractor Law MGL c 142A: `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. J /Representative: �Gt°f' Owner: �[, / Owner: 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" Do not sign this contract if there are any blank spaces Submitted /L �® Accepted . � /5 I� 3^0 f� Representative Purchaser Date Accepted Accepted by - by. Purr hacar Date Addendum (A) OTHER WORK yv S l u- �t-� �� 2 �. C a t.., 4 i t I s NcPj CAv � L sub -e. w-c vL JV-��d��Q �1 n-o ytd &A-T1 t C, o C-P- 060 4 /?�? /L-,,< Ze 110 441 (' �_ I°'X l Y A t tec, �!w 41w 1ti &10 4V Q . 3 8 Ue- O Yv�. �j�a mow. �oo►-c..._ � ��- Lt � � K.u�C., --,.-s t T6.Z Initials lnitials_�$Initials Addendum (B) LOW SLOPE ROOFING Scope of work: Yes No ❑ 1. Layover ❑ 2. Strip 1 layer !!?*'�2 layers--2® other (� ❑ 3. Inspect roof deck prior to re-roofing. Renail loose boards. A. Replace rotted or cracked boards at $ a per linear foot. B. Replace boards with same thickness plywood $ per square foot. C. Replace delaminated plywood at $ d per square foot. D. Plywood layover with 1/2 inch CDX at $ 520 per E. Number of sheets of plywood included into this estimate: Quantity C� (see unit cost above for additional sheets) ❑ 4. Install 1/2" recovery board ❑ (K5. Install 1/2" ISO board ❑ 6. Install .060 EPDM rubber roofing. Rubber shall be fully adhered to recovery/ISO board with cement, cold application ❑ l Install Certaineed Flintlastic Color: ❑ 8. Install 3" x 3" aluminum drip edge. Color: White Mill Brown ❑ 9. Penetrations. Quantity < Size �'J! ❑ a-f0. Wall flashing. Linear feet m ❑ Z1,111. Remove and install siding. ❑ @2. Install termination bar. 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Yes No WINDOW SCOPE OF WORK: �❑ 1. Contractor to obtain required building permit(see attached permit authorization form) 1^ 2— 3_ Family home. ❑ 2. Provide certificate of insurance for workers compensation,general liability.(see attached certificates). ❑ 3. Keep job site in a clean and orderly manner in a broom swept condition. ❑ 4. Homeowner to remove all personal contents away from all windows as needed in order to install windows. If additional labor is needed at the time in order to remove personal items, a cost assessment will be made at that time. !� ❑ 5. Provide manufacturers warranty on all windows. ❑ 6. Remove and dispose of (quantity)windows. AQ-' ❑ 7. Remove and dispose of /8 (quantity)storms. ❑ 8. Prepare opening for new replacement windows. Cam-❑ 9. Remove and reinstall stops. Please note:if stops need to be replaced,an additional cost assessment will be made at that time. LJ--❑10. Remove and reinstall trim. Please note:if trim needs to be replaced,an additional cost assessment will be made at that time. Please note: The normal process of removing stops and trim on old windows will disturb paint/stains/wood on windows. Sturdy Home Improvement, Inc. will not be held liable for any paint/stain/wood surrounding the opening of any windows. a," ❑11. Remove weights in pockets and dispose. U2�12. Insulate weight cavities with fiberglass insulation. F&J —❑13.Provide all silicone sealant. ( ❑14. Install aluminum wraps around windows. Quantity _ Color (' ( ❑15. Install new yep a1 cement windows. Quantity _Manufacturer �UX/yalt� Model _1P/t/CK ❑ 16. Install new wood replacement windows, Quantity Manufacturer Model ❑ E t r• Install new construction windows. Quantity Manufacturer Model ❑ . Install bay/bow windows. Vinyl Wood Quantity Manufacturer Model Other y '/ D Lam❑19. Install new glazing on each window: Low-E Low-E with argon af1�>r/ other y •Z l/. L� SK- ❑ 0. Install grids in each window:5/8" Colonial style other ~ GBG Interior Grids SDL Brasstone Brushed Nickel Top Sash Bottom Sash �❑21. Provide screens with windows:half screens �-® full screens aluminum fiberglass ❑22.Owner agrees to meet the installer during the hours of 7 AM to 4 PM for final measurements. All final measurements will be made by the installer. Failure to meet with installer will delay the installation of windows. (3''�❑23. Owner agrees not to hire directly any employee/representative/subcontractor of Sturdy Home Improvement,Inc.for any side work,additional work in relation to this contract or any future work.Owner also agrees not to make payments in any other name other than Sturdy Home Improvement, Inc. unless Sturdy Home Improvement, Inc.gives prior authorization. If so,the employee/representative/subcontractor will be terminated immediately. �❑24.Addendum(A)=OTHER WORK. [G�(❑25.Acceptance Page •y,. ('+ ❑ ❑26. Work not included:1. Final cleaning of windows 2.Any rotted wood(other: ►,1 v�, ''S'C.>ti ��,i �� Initials Initials Initials 459 Main Street Toll Free (877)378-8739 Springfield, MA 01151 Worcester (508)797-6600 E-mail: HRQSturdyHome.com Springfield (413)543-5906 www.SturdyHome.com New Haven (203)848-2118 i HOME IMPROVEMENT, INC.§ Fax (413)543-3200 WINDOWS SIDING • ROOFING • ADDITIONS MA REG.#151711 CT REG.#601525 Name ��� fZ�t��- Home Phone� Business Phone IC11Q t(, G Address Cell Phone Other Town/City Representative resentative Date e:lc-)bt,/ JZ44f&Z-2- I/we the owner(s) of the premises described hereinafter, referred to as Owner,offer to contract with Sturdy Home Improvemilrit, Inc. hereinafter referred to as Contractor,to furnish, deliver and arrange for installation of all materials to improve the premises as described below. Yes No SIDING SCOPE OF WORK: ❑ 1. Contractor to obtain required building permit(see attached permit authorization form) 1- O 5;?_ Family home. [r'❑ 2. Provide certificate of insurance for workers compensation,general liability. (see attached certificates). 3. Keep job site in a clean and orderly manner in a broom swept condition. 4. Provide job site dumpster, set on planks,to remove job related debris only. Please Note: dumpster for contractor's use only. (see dumpster clause). �❑ 5. Provide OSHA approved staging to safely perform work. ['❑ 6. customer to remove all ornamental and personal items away from house,yard and walls outside,etc. �❑ 7. Strip Z- layers of siding off existing house. Wood clapboards 4-f Vinyl Cedar Shakes 0 Stucco o Aluminum Other Q ,2r8 Gutter helmets to be removed and reinstalled by others. ❑ 9. Remove and dispose of gutters attached with spike ferrule. ❑ EKQ Remove and reinstall existing gutters strapped to roof. Install straps under shingle over shingles ❑ 11. Remove and reinstall existing gutters with hidden hangers. Linear feet I �❑12. Furnish and install new gutters linear feet,and downspouts ',K S, (10'lengths). Color ❑ Q'13. Remove Satellite Dish up to 24"in diameter. Alignment and installation by others. ❑14. Remove and reinstall the following items: shutters. (see number 16) 2-9aorbell ❑Storm door Ulareet numbers ❑Power meter(power lines to remain,wrap around anchors) Q-Et hts(see number 15) a'felephone aVater meter (Cable TV lines lep atryer vents �❑14.Install insulation under siding.3/8 fan fold Tyvek Polar Board O High density poly styrene/Green Board a Total Squares 2'=, 15.Install customer provided light fixture on house. Please note additional-wiring is not included. Quantity 16. Install shutters on house.Quantity - _ Color Louvered Panel ❑ [Rf7.Extensions of water faucets on the exterior of home are not included. Please note if d,this will be an additional$150.00 each. a ❑18. Furnish and install. MA 1-) ST siding. Color Total number of squares Wr ❑19. Instal rners. Color 6,c FL,-A .Style Linear feet i�' ❑20.In II Light blocks eio Dryer vents Water blocks. Color ' n ❑ &k2l.Porch ceiling to be covered with soffit siding. Total squares ❑22. Install J channels around windows and doors. Color bK�j� Style / w I��❑23.Install vinyl soffit on overhangs. Vent soffit boards prior to installing vented soffit materials. Color LvL�i'!c Linear feet � 1&- ❑24.Install aluminum coil stock on fascias on front, rear and sides of house. Color 6- 4/7-e Linear feet ga-'-o 25. Install aluminum wraps aroun0deA 164 window andt)ucs. !�&AV door(s). ❑26. Cover Gables End vents with siding to prevent air-flow. (if the roof is vented with soffit and ridge vents,then gable end vents must be closed in order to qualify for warranty coverage). a�--❑27.Owner agrees to cut back or remove any landscaping 18" from house in order for contractor to gain access around perimeter of foundation. ❑ . Addendum (A)=OTHER WORK. wr"❑29. Acceptance Page. ❑30. Work not included: 1. Final cleaning of windows 2.Any rotted wood(other: Ini inle Owl Initials CzInitials Ne�� � Gn ter-- �..sl..��-- �r�►�r�. 459 Main Street Toll Free (877)378-8739 Indian Orchard, MA 01151 W 00 am 00 00000 Worcester (508)797-6600 E-mail: HR @SturdyHome.com Springfield (413)543-5906 www.SturdyHome.com New Haven (203)848-2118 HOME IMPROVEMENT, INC . Fax (413)543-3200 WINDOWS • SIDING ROOFING • ADDITIONS MA REG.#151711 CT REG. #601525 Name HomM Business Phone Address �! Cell Phone Other Town/City y Representative Date I/we the owner(s)of the premises described hereinafter, referred to as Owner,offer to contract with Sturdy Home Improvement, Inc. hereinafter referred to as Contractor,to furnish, deliver and arrange for installation of all materials to improve the premises as described below. Yes NO ROOFING SCOPE OF WORK: L9� U 1. Contractor to obtain required building permit(see attached permit authorization form) 1 4`12_ 3_ Family home. ❑ 2. Provide certificate of insurance for workers compensation, general liability. (see attached certificates). C!r ❑ 3. Provide job site dumpster,set on planks,to remove job related debris only. Please Note: dumpster for contractor's use only. (see dumpster clause). ❑ 4. Prior to stripping roof,tarp sides of house beneath work area,from roof edge to bottom of wall. (see additional protection clause on back). . [� ❑ 5. Keep job site in a clean and orderly manner. Rake work areas at end of job. Use magnetic sweep to pick up nails. (� ❑ 6. Provide OSHA approved staging to safely perform work. [ ❑ 7. Work consecutive days excluding inclement weather. (rain,snow,high winds, high heat,thunder showers,etc). ❑ 8. Staff project with qualified mechanics experienced in residential asphalt roofing. �❑ 9. Strip existing 1_ 2?-3_layers of asphalt roofing see roof plan, page 2). Number of squares A. G one layer cedar removal. Number of squares_. B. .1 one layer slate removal. Number of squares Jkl"Q1410'.Inspect roof deck prior to re-roofing. Renail loose boards: A. Replace rotted or cracked boards at$ per linear foot. B. Install new plywood at$--.JZ�,_'per sheet. C. Number of sheets of plywood included into this estimate:Quantity (see unit cost above for additional sheets). @r-*-❑11. Furnish and install r AALZ1 ZcC-( A-c.-W '4.1 shingles. Color W-f-d*te+.--14 1-d Qi­1❑12. Furnish and install 8"aluminum drip edge around roof perimeter.White !s' Mill Brown ❑ Install cedar drip edge at eaves under aluminum drip edge. Linear ft-. �❑14. Furnish and install ice/water shield at eaves ° 3' �6' o other. Three feet in valleys and around all roof penetrations. 15. Furnish and install underlayment to entire roof.Q_Roofer select /Diamond Deck V16.Furnish and install starter course shingles, eaves&rake. V17.Furnish and install hip and ridge. 18. Furnish and install new neoprene roof boots at soil pipes up to 4"in diameter. Quantity Z Size (boots at electrical mast to be reused). ❑ a-f9. Reuse stove pipe flashing kits. d W40. Reuse existing step flashing at r9of/wall intersections. {�^ ❑21. Furnish and install new '!/ aluminum o copper step flashing at roof/wall intersections. Linear feet 6 y- . If siding work is needed, a cost assessment will be made at that time. ❑ W2. Reuse existing wall flashing at roof/wall intersection. Zr❑23. Furnish and install new aluminum wall flashing at roof/wall intersections. Linear feet If siding work is needed,a cost assessment will be made at that time. 9 X24 Furnish and install new �' aluminum copper step flashing at base of chimney under existing lead counter flashing. ?a--1125. Replace chimney lead counter flashing. 1 flue 2 flues 3 flues other . UV'�❑26. Install new roof hood to vent bathroom(s)with insulated flexible tube. Remove roof deck to gain access into attic. Color: black only. ❑ CID. Gutter Helmets to be removed and reinstalled by others. ❑ [x'28. Remove and dispose of gutters attached with spike and ferrule. ❑ Q-25. Remove and reinstall existing gutters strapped to roof. Install straps under shingle over shingles ❑ ITO. Remove and reinstall existing gutters with hidden hangers. Linear feet �Kl. Reuse skylight flashing kits-!=Replace skylight flashing kits Quantity (Velux models,stock only). ❑ al,42. Remove and dispose of the following:Antenna Snow/Ice Wires Snow Guards/Ice belts Solar panels ❑ tr-,T3'.Remove Satellite Dish up to 24'in diameter. Alignment and installation by others. .}- 34. Page Two=ROOF PLAN. 4 >-� U - ,�,o <Qt���, �,C✓J` 35.Page Three=VENTILATION. 5t4 [� ❑36.Page Four=VENTILATION PLAN. ❑37. Addendum (A)=OTHER WORK. ❑38.Addendum(B)=LOW SLOPE ROOFING. n qG AcceDtance Paoe Initial Initials Initials 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): y % I 0 M-E /m p ro v�m eot Address: #5q m cu n �V - City/State/Zip: In Gl I V l^Gl)Cf l"G� AA Phone #: Are you an employer?Check the appropriate box: Type of project(required):p 1.eI am a employer with 0 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 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. workers' comp.insurance. 9. ❑ Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13T] Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy anti job site information. Insurance Company Name: ran l'le 1 ns ttr .fuen— Policy#or Self-ins.Lic.#: WC, 00 / ' `�',� —''1'S11 Expiration Date:_ 7 a �— Job Site Address: aq e1 6)ar'OFyn J�-reet City/State/Zip: FlDrt.t1ce h"114, Id a 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: L; 14 , Date: 31 d-t, I d­ Phone#• (�I3L 543- )b 0 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 Licensed Construction Supervisor: Not Applicable ❑0 Name of License Holder: Dt a 2z 9,3603 License Number _A 70 7rem c n f rr qfil'ield, M14 Z 7�1� Address Expiration Date 8 -7 902 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Shtr Qrn,P- Irn ro✓ernevI Com a� /�n Name( Registration Number Address 1 Expiration Date bidv ti Orchard, 1411A 0//6/ Telephone` 7/'1 1305/7'3 1al 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. Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[©] Other[dJ Brief Descrip�tigl�of Propose ease Work: ('oW, _ _ GUa , fd 0kys, sue p jy *P lnsfall (ley✓ Al x 4 o whrzn9 cr�-rac Alteration of existing bedroom Yes '� No Adding new bedroom Yes / No Attached Narrative Renovating unfinished basement Yes '�No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following: 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 1, , 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 S ur( / I o me koro�emeg as Owner/Authorized Agent hereby de re that the statements a d 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. David D142- Print Name Signature of Owner/Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L R: L: R: Rear - Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: _ (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW 0 YES IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: 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 IF YES, describe size, type and location: 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 Q NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only Ci y of Northampton Status of Permit: BL ilding Department Curb Cut/Driveway Permit 12 Main Street sewer/Septic.Availability Room 100 WaterJWell Availability DEPT.OF BUILDING INSPECTIONS, NORTHAMPTON,MA01060 Ort ampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office A 3 00-r 0 / n ��. Map Lot Unit yMA O /a Zone Overlay District Elm 3t."District ' CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: r > Doana- lb ro t6n A3 CaxolWn Sf Flo renee'0 MA 0/0cc Name(Print) Current Mail g dr Is- Telephone 3I Telephone Signature 2.2 Authorized Agent: .� (,i / ✓ 1-4 S�ar m P ro vein em� Ina i n S1. /n di&n 6 atd h'lA Name(Prin Current Mailing Address: Sig Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 7,7, 0 O I o0 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= 0 +2+3+4+5) 00 Check Number This Section For Official Use Only Q Building Permit Number:D /� � Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2012-0885 APPLICANT/CONTACT PERSON STURDY HOME IMPROVEMENT ADDRESS/PHONE P O BOX 51033 INDIAN ORCHARD (413)543-5906 PROPERTY LOCATION 23 CAROLYN ST MAP 17A PARCEL 082 001 ZONE RIO 00)/URA(100)/WSP(100 THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUI D DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid l O Off' Typeof Construction:_REPLACE 20 SQ SIDING,10 SO ROOFING,REPLACE 18 WINDOWS,4 X4 OVERHANG W/DECK&RAILS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 093603 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay Signature of Building Official Date Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information.