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NFRC Model 8109 Double Hung Operatinb
Alum clad Thermal Frame
314 inch Glazing
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ENERGY PERFORMANCE RATINGS
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DeTartment of lt*.dustri-J Accide,,,t.3
Office of Investigations
_ 600 Was hingron Street
Boston, M.A 02111
www.mass.gov/dia
Workers' Compensation Insurance A.-Mfidavit: Builders/Contractors(Electricians/Plumbers
Applicant Information /_ Please Print Legibly
Name(Business/Organization/Individual): �me— �71 4C)J - _A N i�9 ✓��5
Address
City/State/Zip: 6L-,f1 k�_ 303 Phone #: 17 7
Are you an employer? Check the appropriate lox: Type of project(required):
1.❑ I am a employer with 4. 5 1 am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. E] DemoLtion
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp, insurance comp.insurance.#
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Raof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.6 Other
comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information. [� / �1
Insurance Company Name: //�vew /7 cm
Policy#or Self-ins.Lic.#: W C 0 0 Q g Expiration Date:
Job Site Address: City/State/Zip /6
Attach a copy of the workers'compensation policy declaration page(showing the policy number and iration 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 incur ce over 'e verification.
I do hereby certify under the i a pe alt' =puq a t the information provided above is tr////u'''�e and correct.
Signature: �� Date: —
Phone#: 6
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#:
PLEASE RFAD THIS
r� Sold,Furnished and Installed by:
$ranch Name,Boston Plortlu Nc Soutlo Date 1_l T"D At-Herne Servim,]nc.
dfh/a The Home Depot At-Home Services
Branch Number;31 and 33 908 Boston Tunipike,Unit 1,Shrewsbury,MA 01.945
Toll Free 877-903-3768
Federal II)#75-2699461,Mli.Lic#C 02439:R1 Cont.Lac#16427
�j f� (T Lic#111C.0-965522;MA I tome Inipruvr set of Cunuaetur Rcg.#126893
ess
Installation Addr : "7 !/ 7 1A� $ Q j - ���tl _ /fi(� 016 6 6
City State zip
Purrhawr(s): Work,Mate: Horne Phone: Cell Phone:
pwta_
2 ftA DP_4 S ru11 [ l l yg i
Hone Address:
(If difftxeau from Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates): _.
❑i DO NOT wish to receive any marketing entails t'remn The Home Depot
Project Information: Undersi)mcd("Cushier'),the owners of the property located at the above installation address-agrecs to buy,
and THU At-Horne Services, Inc.("The Iiorne Depot")agrees to lumish,deliver and arrange for the installation("Installation")of
all materials described on the below and on the referenced Spec She:t(s). all of which are incorporated into this Contract by this
reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively,
"Contract"):
Job 4: amvnw aAer i P ucts: _ Spec Sheens)# Project Amuwrt
Roofing LISidiag Al Windows LJ insulation j }
fiultnr</Covmr ❑lintry Dmrs ❑
- �a'/., I RutrfinK Siding Windows insulation R �
+� I [](,iutters((;overt ❑upury ixors ❑__. 1V
R f-. Siding LJ Windows U Insulation
❑Gutters/Covers ❑Entry lours❑
Rcwf)ng Ustelling ❑WmMM U htaulativa
I ❑Guticra/Cuvurs ❑Entry Dotes ❑ I V((
MlrNmum 45%Fk4KvA of Contract Amount t due upon exwutinn of this contract.
Total('arntract Amount
Maine Purchasenc may will deposit more than onMtdt'tl of the CuNraoi Amuurrt.
C:ustumcv 4&FQ0s that,immediately upon completion of the work Iir each Product,Customer will execute a Ccmnpletion Certificate
(inc fcr each Product as defined by an individual Spec Sheet)and pay any halance due. As applicable,c:teh Customer under this
Contract agrees to be jointly and severally obligated and liable hercunder.
The Home Depot reserves the right to issue a Change Order or terrninatc:ibis Contract or arty individual I'roduct(s)included herein.at
its discretion,it The Home Depot or its authorized service provider determines that it cannot pertorrn its obligations due to a structural
problem wilt(the hemnee,environmental hazards such as mold,asbuitos or lead paint,other safety concerns,pricing errors or because
work required to complete the job was not uleluded in the Con act.
'
Payment m ma : The Payment Summary# _ / ��00 included as part of this C'tmtnict, sets forth the total
Contract amount and payments required for the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign u Completion Certificate(note:
there is one Completion Certificate for cash listed Product ac defined by individual Spec Sheets)before work on that Product
IN complete.
in the event of termination of thi4 Contract,Customer agrees to pay The Home Depot the Costs of materials,datum,expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS
01WF.D TO THE IiOME DEPOT FROM TIIE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE. WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF MUCH AMOUNTS.
Acceptance and Au rization: Customer agrees and understands that this Agrtxrnent is the entire agrccment between Customer
rn
and The Hee Depot with regard to the Pr(xhicts and Installation scrviccs and supersedes all prior discussions and almeement's,eldtcr
oral or writtmt,rebuing to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signel
by Cuslorucr and The Home Depot Customer acknowledges and agree~that Customer has read.understands,voluntarily accepts the
terms of and has received a copy of this Agreement.
Acceptca _ Subm, by:
=f+t� R �L 11!tyCa*^ LOi1r����� L ` (
Customer'-.,tii6malure Uatc 'ales Consultant's Signature Date
X
11'cicphtmc.Na.
Customer's Signature Date
I Sales Consultautt License No. —
CANCELLATION: CUSTOMER MAY CANCEL THIS I iesappliieatde)
AGREEMENT WI'THOU'T'PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE To THE IIOME
DEPOT BY MIDNIGHT ON 771k THIRD BUSINESS
DAY AFTER SIGNING TIIIS AGREEMENT. THE l
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE iS
SPECIFICALLY PRESCRIITHD BY LAW iN
CUSTOMER'S STATE,
NO'FI:E.-ADDITIONAL TIKHMS AND CONDITIONS ARE STATkD ON THE REWRSF,SIDE AND ARE PART ON TH1,5 CONTRA[°r
03-07-14 whoa_t9r h coo vet.,,.,_r,
9/L d 96L9£LZ559 << LLUZ95£L't Ma Nd-ZM 0096 hO-LO-�iLOZ
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS ;7j
ivksr 212 Main Street • Municipal Building
Northampton, MA 01060 ss;yY �1
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends to be, a one or two family dwelling, attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in a two-
year period shall not be considered a home owner."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection
(before work is concealed), insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
The Commonwealth of Massachusetts
Department of Industrial Accidents
E
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):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.1
required.]
5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 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.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
Job 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 under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone#:
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 Su ervis�orp: f � Not Applicable £
Name of License Holder:
ZA/1- License Number
Address /^ Expiration Date
4tl
Signature Telephone
9. Re'istered Home ImW hoveme t ontractor:' Not Applicable
Comoanv Name Registration Number
Addre t �j �� �piration Date
L' X77 !s
' Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must beSompleted and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building p
Signed Affidavit Attached Yes..... No...... £
11: Home Qwner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied DweHines 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 buildine 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 W' ows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[O] Other[O]
Brief Description of Pr —
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes C 3
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a,`If New house and or addition to existing h"ousinQ;`complete the foilowinct:
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
as Owner of the subject
property �--- t
hereby authorize
to act on my behal7!1�II ma ters re ative 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 ns an penalties of pequ
Print Name
Date
Sign e of Owner/Agent
r ~
Section 4. ZONING AIL Information Must Be Completed. Permit Can Be Denied Due To Incomptete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
Pt area minus bIdg&paved
of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issuedfor/on the site?
x—� �-�
NO «x~��� DONTKNO0/ v�� YES ��'
IF YES, date issued:' �
IF YES: Was the permit recorded at the Registry of Deeds?
��
NO ��, DDNTKNOYY 0 YES 0
IF YES: enter Book I Page and/or Dncyment#
�� �����
B. Does the site contain a brook, body of water orwet(onds7 NO �_��� UONT KNKNOW �~� YES
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained v,� Obtained �-\ Date�_� �~� ' .
C. Do any signs exist on the property? �� ��y� YE5 �~� 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 0
IF YES, describe ( �
'
E Will the construction activity disturb(clearing, gradingexcavation,or filling)over 1 acre orisi(part ofa common plan
' that will disturb over 1acre? YES ND
~_~
|F YES,then a Northampton Storm Water Management Permit from the DPW inrequired.
^ '-
4 JJepartmeht use only
City of Northampton SfatusofPerrrirt s
614 )/'Building Department Ctrr ,Cut/Driye�ntay Perrrslf
212 Main Street Sewer/SeptleAvairablllty
leck F ..
u
Room 100 UVater/VtreiCAvatlabihty
(_,as!rs
t nro oections orthampton, MA 01060 Twa Sefs of8fructural Plans
phone— -587-1240 Fax 413-587-1272 P[6 'Slte Plans
Oder 5peclfy _
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: Thls section fo 6e completed by office '
-
�/
P/k� � ` Zone Overlay District
l
EIm St-District'
CB
:District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) I_ Current MRiljvg
—' j � ��1 Telephole�'
Signature
2.2 ALdheNzed ent: _
j 440 740 1'j9_
a� ►l �✓��� ' ' �
Name ' t) ` Current Mailing Address:
nature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit 'cant
1. Building )l (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) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/In.spector`of Buildings Date
91 PINES EDGE DR BP-2015-0136
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18 -002 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit# BP-2015-0136
Project# JS-2015-000240
Est. Cost: $2118.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES 99209
Lot Size(sq. ft.): Owner: ANDERSEN RENE
Zoning: Applicant. HOME DEPOT AT HOME SERVICES
AT. 91 PINES EDGE DR
Applicant Address: Phone: Insurance:
24 SUNRISE DR Workers Compensation
PROVIDENCER102908 ISSUED ON.81112014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOW
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 8/1/2014 0:00:00 $35.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner