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17A-303 (2) City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: The debris will be transported by: _ __ -u�A �Z C The debris will be received by: _ t�L� _ r�S7�CJ -? 9gk44A1"] --- Building permit number: Name of Permit Applicant __—_ J/ � (1�6, --- __- Date Signature of Permit Applicant Repair Rotten Wood MYeS LNo Lead Safe charge ['-Yes 'LAND Amount Yr House Buill/vt Disposal of old Windows IjXe --ONO Yankee Ino, Sealant t-/Yes 01, No Trim Smoc mainframe 91?�e s i-, No Interior casings -.',Yes !.-.INo Grid Pattern Entry Type Color Ext. Color Int Special Instructions ...... Do/Hwt Do ------------------------ (We do not do any paInmngorstaInIng) C:int,� t 1,.E.ga,,,the work or order the materials before the third day following the signing of this Agreeineril, unles.",specoie. 4, ctor will begin the work on or aboLit 11je completed b/, __ __ ate) The Owner hereby acknowledges ag ees t at the �(I led to strikes, Aps of god, shortages of I Barring delay caused by circumstances nevond Contractor's control,it)(,work will an 'at scheduling dates are approximate and that such 'delays that are not avoidable by the Conliaclor ificludin materials,accidents,and all other delays beyond its control,shall not be considered as violations of this Agreement, WARRANTY I 1 he Contractor warrants that thn work furnished hereunder shall be free front defects in materials and workmanship for a period of I__ - following corripletion and shall comply with the requirements of this Agreement.In the event any detect in workmanship or materials,or darnage caused by the Contractor,its-sobcontractors,employees or acients,is discovered after completion of any job, Including cleanup,the Contractor shall,at its own expense,forthwith rernedy,rppav,correct,replace, or cause to be remedied.repaired or replaced,such clarnago or such defect in materials and workmanship.The foregoing warranties shall survive any inspection performed it)corineclion with the agreed-upon work YHI agrees to perform the work,furnish the material and labor specified above for the total sum of: ($ upon signinucontract�0 maximum), Name of Represenia uthorizr�d Signature is upon compi0on u,! J upon compIetion of Notice. No agreernent for nomo,mpF,)vP.men1 Contracting work shall require it down payment(advance, dehros,t;of More than cnL-1hjoJ of the io(al contract price or the total amount of all deposits or parmients shall be made forthwith upon which the contractor most Inake n advanr�e,to order ard,'or otherwise ontain oeirvery of speew order completion of work under this contract InaltmaFs and�quipnivot,whj�,hpryq 1_rf1g_i;qt_r. L Acceptance of Proposal I have read both sides of this document and accept the prices,specifications and conditions stated. I Understand that upon signing,this proposal becornes a binding contract. You are authorized to do the work as specified. Paynteril.will be, made as outlined above. YOU May cancel this agreement it it has been Signed by a party thereto at a place other than an address of the Seller, 'Which may be his main office of- branch thereof,provided you notify the Seller in writing at his main office or branch by ordinary rnail posted,by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. Please refer to the Notice of Cancellation below contents of which are referred to above and incorporated herein by reference. BO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK ' a.un*mm/`~ o/ovum"o / Xf oArsopTRANSACTION YOU MAY CANCEL THIS TRANSACTION,WITHOUT ANY PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE, IF YOU CANCEL, ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENT EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS oA,a poumm/wa RECEIPT oYTHE SELLER op YOUR CANCELLATION mor/us. AmmAwvocoun/Tr Imrsessr xn/s/mo OUT oFTHE rnAmSxoTmm WILL BE oAmCsuso. Tu CANCEL THIS TRANSACTION, MAIL OR DELIVER SIGNED AND DATED Copv OF THIS CANCELLAT104 NOTICE OR ANY OTHER wmrrsw wcx/oc, on aewo ArsLson«w TO, w^wxss onms /spnovsmEwT, INC., mu /mousTnmL on, moR/nAm LATER THAN MIDNIGHT op /HEREBY CANCEL THIS TRANSACTION ______________________ ."=°�=""=p^"""='��,=="� vv,rnso/om^,v^s ums m"y,r(x)acknowledge ooip!,[*mv completely Oo,oin copies vf'hi»^^hoe or)the date first ohv h \ ' uuy, '^s�o" u,, ` Bo/./s��vomm i Window Agreement l {� Thousands of Satisfied Clients! \� (� 82 Industrial Drive MA Lic#160584 1224 Mill Street, BIg B 224 Northampton, MA 01060 CT Lic#0673924 East Berlin, CT 06023 N C 111A k- I ;-"t P P11 III,-) till L N i• 413 341-5259 RI Lic#33382 877 88-YANKEE All home improvement contractors and subcontractors must be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of Consumer.lffairs and Business Regulation Ten Park Plaza,Suite 3170 WWW.YankeeHomelnc.com Boston,MA 02116 Phone:(617)973-8700 Date �r t,� /� �1 I meawner Information ° t , ��i { w Nam C�.t �' — t I'L 1 f-Sreet Addr ss -d C- -- 7 -1( r .,� j �t ° City ' v 1°� Stake " zip ,{,.Z �- - - --- --- - ,"1 Home Phone c- Work Phone _ _.-_ _.._Col! Phone iii " Mailing Address (If different) _ E-Mail •-, The Contractor agrees to do the following work for the Homeowner.° Glass Screens_� Color_ GRIDS Fixtures Qty. Brand Style 2 Pane 3 Pane Option Half Full ___ _ Insi a Exterior layout Style Styl I / i Repair Rotten Wood _,Yes ❑No Lead Safe charge C es ENO Amount$ ' Yr House Buil M j Mull removal #' OYes C.ti O Disposal of old Windows 1 ec ❑No Yankee InO. Sealant L1` es No Insulation around Trim coloml(l �?'1'es L?No PVC �� i Smooth p�a i''`dt ,�c 1,k t4 :t a`, i 1 t mainframe _ es ❑No Interior casings F]Yes DNo U end pattern Doors # Storm ---- Entry ,TYPP Color Ext. _,F' Color lilt. Special instructions Al Do Not Do (We do not do any painting or staining) 9 __ 1 f T WORK SIGHED LE Gout aA)ija of egin the work or order the materials before the third day following the signing of this Agreement,unless specjtie re o tractor will begin the work on or about�, .. _(date), t3arring delay caused by circumstances beyond Contractor's control, fhe vaork will be completed b� te).The Owner hereby acknowledges ag t at the scheduling dates are approximate and that such delays that are not avoidable by the Contractor including but n limited to strikes, of od, shortages of materials,accidents,and ail other delays beyond its control,shall not be considered as violations of this Agreement. . WARRANTY r 4i s1 e The Contractor warrants that the work furnished hereunder shall be free from dolects in materials and workmanship`or a period of t_ 'I following completion and shall comply with the requirements of this Agreement.In the event any defect in workmanship or materials,or damage caused by the contractor,its subcontractors,employees or agents,is discovered after completion of any job, Including cleanup,the Contractor shall,at its own expense,forthwith remedy, repair,correct,replace,or cause to be remedied. repaired or replaced,such damage or such defect in materials and workmanship The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. YHI agrees to perform the work,furnish the material and labor specified above for the total sum of: __..._. �fa t;nt: Name of Representatve L.i'.��i �- ` ' t ✓ c ti. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant,Information Please Print Legibly Name (Business/Organization/Individual): ��t�l '� ye Mai Address: --Drive, uh!! City/State/Zip: N04aUlm ME D 10(o() Phone#: - f -232(2 13- `525'1 Are you an employer? Check t e appropriate box: Type of project(required): 1.VT am a employer with �,� _ 4• ❑ I am a general contractor and 1 employees (full and/or part-time), have hired the sub-contractors 6. []New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7 ❑Remodeling ship and have no employees These sub-contractors have g. F�Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. $ 9. E] Building addition required.] 5. F] 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.R of repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. Other `rins � comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. '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 is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. U 1� j`�-�g-{`f �—�EExxp—iration Date: 5/257Z 257Z 2 0 Ls Job Site Address:_ f�rC2D� ✓ +_Ciry/Statel.Zip: - 1 06 Z- Attach a copy of the workers' cornpe isadon 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 S 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 Oe pains and penalti of perjury that the informationprovr'ded above is true and correct. Signature: -' < - Date: / l 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.CityJTown Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: __ Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable❑ Name of License holder:�QOYrl1r� License Number Address Expiration Date Signature Telephone 9.Registered Home InlDrrovem nt Contractor: Not Applicable ❑ Com an Name r Registration Number 22 ,Adt2; k 714 A�fAocoe�,P yll7/, e Address Expiration Date Telephone1 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 buildi permit. Signed Affidavit Attached Yes....... V 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 WMdows Alteration(s) Roofing F7 Or Doors M Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[p] Other[❑] Brief Description of Proposed / Work: -fi.�Clst C� G1�i;16 0 Alteration of existing bedroom Yes L,/ 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. 1. 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, l[ as Owner of the subject property hereby authorize _Y_d a f DX*4)'tt to act on my behalf, in all matters relative to work @uthorized by thistbuilding permit application. Signature of Owner Date I, Lam t& pbw pi) as Owner/Authorized Agenl hereby declare that the statements a d information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed un r the pains d penalties of perjury. Print Name Signature of Owner/Agent 1 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 Q DONT KNOW Q YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW © YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW U YES Q 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 O NO (D 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 Q 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 Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit NOV 2 4 2014 212 Main Street Sewer/Septic Availability ROOM 100 Water/Well Availability, lorthampton, MA 01060 Two Sets of Structural Plans oePr OF BUILDING INSPE we 13-587-1240 Fax 413-587-1272 Plot/Site Plans NORTHAMPTON,MA Ot Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Properly Address: This section to be completed by office Map Lot Unit Zone Overlay District /0� Ali//G2-ps�7- P, V C--)'l CC Elm St.District CB District SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: A14 Name(Print) _T Cu rre M ilin r s / d P �h �/1�YG7L/ Telephone Signature 2.2 Authorized A ent: Name(Print) Current Mailing Address: l Signature Telephone SECTION 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 [� Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) l/ Check Number �5- This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 107 HILLCREST DR BP-2015-0620 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-303 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-2015-0620 Project# JS-2015-001196 Est. Cost: $4977.00 - Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: YANKEE HOME IMPROVEMENT INC 89442 Lot Size(sq. ft.): 21823.56 Owner: DONNELLY TERRENCE P&GAIL K Zoning: URA(100) Applicant: YANKEE HOME IMPROVEMENT INC AT. 107 HILLCREST DR Applicant Address: Phone: Insurance: 82 INDUSTRIAL DR, UNIT 2 (413) 341-5259 O WC NORTHAMPTON MAO 1060 ISSUED ON:121412014 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 4 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 12/4/2014 0:00:00 $35.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner