32C-187 M� REG-1 27893 ENERGY SAVERS OF AMERIC
Fax 413-283-9335 Bondsville, MA 01009 -9933
413-283-6695 P.O. Box 1312'7 ree
This agreement mad day of ween
(Homeowners) (Home Phone) (Business Phone)
of
(Address) . (Tate) (Zip Code)
Hereinafter called the owner and ENERGY SAVERS OF AMERICA INC.of the Town of Bondsville, Massachusetts hereinafter
called the contractor, witnessed:
The said Contractor hereby agrees that it will for the;onsideration hereinafter mentioned,furnished all labor and material
necessary 10 install the following described ises located
(Job Address)
Total Quantity No. of Additional Work Total Total
Windows Purchased Panes Cash Price 3%232'�
Regular Double Hung Casing Covers L" '
Down Payment
Picture Windows Siding Upon Start
3 Lite Sliding Windows Rooting XV' Upon Completion
2 Lite Sliding Windows Bay Window
Casement Windows Bow Window
OTHER- DESCRIBE
�t1AMpT
�0 Oy
� 6 _ �zsazcE(ttsctta
m DEPARTMENT OF BUIL)rNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S CONMENSATION INSURANCE AF1+IDA.Vrr
(Ii censee�permi ttee)
cw.ith a principal place of business/residence at:
(phone#) V! 3 --?P3
(street/city/
do hereby certify, under the pains and penalties of pe-qury, that
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
AZA&C L-4 '��
'(Insurance Company) (Policy Number) (Expiration Date)
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Corupauy/Policy Nuinbcr) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Numb--r) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Lnsurance Commpany/Poticy Number) (Expiration Date)
(attach additi oral r. ei if necc=zfy to inoh iof(xm Co pertaining to all eeertrnc o s)
O I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:pteaae be aware that whilo homcowocn who cmplay persoas to do tnniatcoaact,comtractloo or repair work on a dwelling of
not mote than throe units in wfmch the homoowncr raider or oa the grounds appurtcnnnt thacto arc oot&M-,Mlly cocsidacd to be
employers under the worms.00mpcn 4cci Act(GL152,ss 1(5)),application by a homcowncr for a license a permit may-id--the
legal etatuc of an employer under the Workclz Compom&tioa Act_
I undcntsad that a copy of this a2atcmcut may be forww,1.d to the Dcpartmcc2 of Industrial Accid.&offioo of lmursn-for the
coverage venficaliou and that failure to acutre coverngv under section 25A of MGL 152 can lead to the imposition of criminal penalties
oomistix of a fine of up to S1,500.00 and/oe itnPris�of up to one year and civil pcn.Ma in the form of a Stop W oric Ord--and a
find 100.00 a day agaitui tn�
For dq xt—eal use only
Permit Number
Lot�
S License'rmittee e ---
SECTf.ON 8'-:.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Rigretl Ao�neImprovi:Mt Contr efib _ Not Applicable ❑
COMDany Name Registration Number
v g,x 13-'2 2cOV
Address Expiration Date
Telephone
SECTION 10-WORKERS';COMPENSATION INSURANCE AFFIDAVIT(M.GL. 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�1. f�-Homer:O�vner�E�em.pt�ari°
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
�Epi
SECTION..�DES�CRfPT10NOFPROP( SEDmWbRFG _checkalla litable
770 333 "a*'aw n
Ik163..,sns. Yt<, r. .taSP� +HN .a3 x ,a
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] , Decks [ ] Siding Other [ ]
Brief Description of Proposed Work: �f ��
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet 0
Ifi Ne,Wo*us arid:o °dtlit-or i'We zistin UMMIi , .c0ft1 Wthe f6116W1n :
a. Use of building : One Family Two Family Other 4j",
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. Mascheck 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-QWNER°AUTHORIZATION -TO BE COMPLETED WHEN
01NNERS„AGENT"OR'CONTRACTOR APPLIES 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
, 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 a e � jG
g ture f Owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF 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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO 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 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
„�
C 1 of Northampton Sat fer
I ing Department {0urbtD3' ire a, e
_—.- 2 Main Street Sewer Septicaila �fe
Room 100 Wal,v,qQ i= 9
MAR - 002 Ndr! mpton, MA 01060 Two Sets a Sfructur a s
phone 41 -58 -1240 Fax 413.587-1272 Plot/Site Plans
Other
.Rn
AP�LI'AxfbN T, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION°
1.1 Propert Addre This section to,be completed by office
Map Lot Unit
Zone ''Overlay°District
Elm St. District CB District'
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
a 2_y q o/l am (C ---
Name( int) Current Mailing Address:
-i elephone
Signature
2.2 Authorized Agent: R,
o (]' 13—ac?
Na e(P Current Mailing Address: �I vciof.
S ur Telephone
SECTIO` 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of L�
Construction from 6 1 ,2 3 7 G
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section for Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
;OS PLEASANT ST BP-2002-0746
GIs#: COMMONWEALTH OF MASSACHUSETTS
M;MapBlock:32C 187''' CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:ROOFING/SIDING BUILDING PERMIT
Permit# BP-2002-0746
Project# JS-2002-1232
Est. Cost: $34237.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGY SAVERS OF AMERICA 127893
Lot Size(sq.ft.): 15812.28 Owner: GRYGORCEWICZ FELIX J&JOSEPH P
Zoning GB Applicant: ENERGY SAVERS OF AMERICA
AT. 408 PLEASANT ST
Applicant Address: Phone: Insurance:
P O BOX 1327 (413) 283-6695 Workers
Compensation
BO N D SV I L L E M A ISSUED ON:316102 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL SIDING & STRIP & SHINGLE ROOF
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 3/6/02 0:00:00 1929 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
MA REQ-1 27893
ENERGY SAVERS OF AMERIC tN
413-283-6695 P.O. Box 132-7 Toll Free
Fax 413-283-9335 Bondsville, MA 01009 1��88, -009-9933
This agreement made thea--4 of
day of -.LOtween-
(Homeowner�) (Horne Phone) (Business Phone)
of Cc
(Address) (Itatle) (Zip Code)
Hereinafter called the owner and ENERGY SAVERS OF AMERICA INC.of the Town of Bondsville, Massachusetts hereinafter
called the contractor, witnessed:
The said Contractor hereby agrees that it will for the.,onsideration hereinafter mentioned,furnished all labor and material
necessary to install the following described ises located
(Job Address)
Total Quantity No. of Additional Work Total Total
Windows Purchased Panes Cash Price
Regular Double Hung Casing Covers Down Payment 4 0
Picture Windows iding Upon Start
3 Lite Sliding Windows Roof ing Upon Completion &L-t
2 Lite Sliding Windows Bay Window
Casement Windows Bow Window
OTHER - DESCRIBE
Estimated t�&A �2'-QrQ Estimated Finish Date
Contractor does not perforrr�or assume any iespcnsibility for any Painting, Staining or Wood orWall Finishing on interior or exterior.
And the Contractor dnoa further a0mo with the Owner that(a) he will begin work within e reasonable time after the execution hereof,
and will prosecute it diligently and with duo oa,e, and in ugowj and workmanlike manner; (b) in doing the work, he will comply with all
ata1utea, m|no. regulations and ordinances applicable thereto:
Contractor to procure all permits required by local law. Contractor shall provide public liability insurances.
Due to the custom manufacturing of the product and its restricted use unless installed in its intended opening, if the Owner refuses to
permit the Contractor to proceed with the work horoio, orin the event o( any breach of the Owner ofthis ogmemont, for any reason
whatsoever shall cause the Owner to pay to the Contractor a sum of money equal to fifty percent of the price agreed to be paid. as fixed,
liquidated and ascertained damages, and not una penalty, without further proof of loss ordamage.
SELLER shall be excused for the period of any delay in the performance of any obligations hereunder when prevented from doing so
by cause or causes beyond SELLER's control,which shall include,without limitation,war,fire, or other casualty,governmental regulations
or controls, inability to obtain any of the n^,v,z involved hereunder, or through acts of God.This agreement shall be binding upon and
inure tothe benefit of the executors. admini«trahons, hoins, soc000uo,c and assigns of the parties hereto.
Owner warrants that he is the owner of the Property on which the work is to be performed or that he is otherwise authorized on behalf
of the owners to enter into this agreement.
Owner authorizes the Contractor to enter upon the said premises and Owner agrees to obtain, if necessary consent to enter upon all
adjoining neighbor's premises in order to enable the Contraclor to do and complete the aforementioned work.
This contract represents that entire ogmnmoo", �nu*oen the Owner and the Contractor and no representation or warranty shall be
binding upon either party, un|oao included herein oron reverse side.
This agreement is subject to review by Energy Savers of America Inc.
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the
seller, which may be his main office branch thereof, provided you notify the seller in writing at his main office or
branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day
following the signing of this agreement.
See the attached notice of cancellation form for an explanation of this right. ^
�N WITNESS WHEREOF, i have hereunto signed their names this OIL-_.___ day of rK.,6 2061���_
rp� Signed r/ Owner Pe r Sav rs of America Inc.
'
8igne Signed_
��- Eno,����o,ao�\mo,ioa|no. Owner
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