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The Common wealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,4 02111
wi+w.mass.gov dia
Workers' Compensation Insurance Affidavit: Builders.,ConrraLror ?Fiec1
Applicant Information Please Prima bbl
?Name (Business/Organization;Indi,,icu a : Val' ( ,U pf"Vj M-a ss A c i S E T`S
Address: 10 Zit N t 14 fZ Q
City/State/Zip: w F_S1T 1 f t-ij M Pr U t O SS Phone #: L4 i 3
Are you an employer?Check the appropriate box: Type of project(required):
l.Z I am a employer with Z 4. M I am a general contractor and I
employees(full and/or part-time).`
have hired the sub-contractors 6. New construction
❑
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. Demolition
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. Electrical repairs or additions
3.0 M.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 12.0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.[7 Other �i1JT
comp.insurance required.] w t R VOWS
'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.
1 am an employer that is providing workers'comlpensadon insurance for my employees. Below is the policy and job site
information
Insurance Company Name: Li BEQ7V Mtd.TUAL 1AKtk*AN4-r_ —
Policy#or Self-ins.Lic.#: W(!_2— 31 S— 3'7'7 C1 q7__-015 Expiration Date-:
Job Site Address: }1 �i� l l 1 _ City/State/Zip:_I' I ) f`a - L�fo J
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 1
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 a pains and naldes of perjury that the information provided above is true and correct
Sip-nature: GV y e ,,✓- Date:
Phone# 13 406 5 • '7335
Official use only. Do not write in this area,to be completed by city or town of l-ciaL
City or Town: y 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#:
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SECTION 8-CONSTRUCTION SERVICES
Licensed Construction Supervisor_ Not Applicable ❑
Name of License Holder:
License Number
.5 70 1
Address Expiration Date
6)
Signature T e:ephone
/9. Registered Home Improvement Contractor. Not Applicable ❑
Company Name Registration umber
v'! L,� o.
Address Expiration Date
�'J`V-V''TH ebl W f:It- ss wiry C11 C Telephone H I LI J�,�
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...... ❑
1. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellines of one(1) or two(2)families
and to allow such homeowner to en- an individual for hire who
gage does not possess a license,provided that the owner acts
as supervisor.CMR 780. Sixth Edition Section 10835.1.
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 m
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for persom.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,Ci-, a:-
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To incomplete Information
j E)dstins Proposed Required by Zoning
This column to be filled in by
Building Depamnent
Lot Size
Fronta--e
Setbacks Front I
Side L: R L: R:
i s ,
Rear 1 �`
Building Height
Bldg,Square Footage %
Open Space Footage
(Lot area minus bldg&paved
parking)
of Parking Spaces °
j Fill:
(volume&Location) _1
t
A. Has a Special Permit/Variance/Findi ever been issued for/on the site?
NO O DONT KNOW "r YES O
t
IF YES, date issued: /�
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES a
IF YES: enter Book Page and/or Document
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 0 YES U
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES
F YES, describe size, type and location:
E. M l the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part o a __-
:at will disturb over 1 acre? YES O NO O
r YcS,then a Northampton Storm Water Management t Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement endows Alteration(s) Roofing
Or Doors
"accessory Bldg. ❑ Demolition ❑ New Signs ip] Decks [0 Siding[Q] Other[d]
=sc io5on r Pr
- =.-;-Ec,�of existing bedroom Yes No Adding new bedroom Yes No
--»n:=r�Narrative Renovating unfinished basement Yes No
_ --s Attached Roll -Sheet
=a- if New house and or addition to existing housing complete the following-
'.;se of building:One Family Two Family Other
ber of rooms in each family unit: Number of Bathrooms
_ c-:-;ere a garage attached?
_posed Square footage of new construction- Dimensions
',"-Tiber of stories?
=_hod of heating? Fireplaces or Woodstoves Number of each
-:=rgy Conservation Compliance. Masscheck Energy Compliance form attached?
ce of construction
_ o nst action within 100 ft=of wetlands? Yes No- is construction within 100 yr. floodplain Yes No
=_*of basement or cellar floor below finished grade
.*.. building conform to the Building and Zoning regulations? Yes No.
c Tank City Sewer Private well City water Supply ,
SEC"ON 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
aWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�T( 1� fJ �� as Owner of the subject
_ j
in all matters relative to work authorized by this building permit application..,,,
Date J
as OwneriAuthorized
__-.:a:.hat the statements and information on the foregoing application are true and accurate,to the best of my knowledge
-— and.penalties of perjury.
- - - -- Date
REQ Department use only
_._
Ci of Northampton 'Status'd Permit;
B ilding Departments�t
f 1 � 12 Main Street Sewect�ep#icAvaifabil ty
41 Room 100 1fae ArrauabJ#fty
Northamoton, MA 01060 Two Sets of,St tur�t PJarls "
_
_ phone 413-587-1240 Fax 413-587-1272 F31otJSte Plans
OtlterSpecifX�
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
cU ., Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) V Current Mailing Address;
5&a (-G fdYck ct ) Tel— ene—�
Signature
2.2 Authorized Agent: t 1 t� L 1 t t� 4 �i
}11 i i�.-i H i�L el w.0.3 i i:I*:--L D i�/�67 t.r i C;
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmit applicant
1. Bui.Jing — f'U (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) ` °r C-`Z= Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
52 MAIN ST-FLORENCE BP-2016-0692
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A-074 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-2016-0692
Project# JS-2016-001164
Est. Cost: $7828.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT BUSHEY JR 057011
Lot Size(sq. ft.): 16117.20 Owner: GOUGEON ROBERT
zoning: GB(100)/ Applicant: ROBERT BUSHEY JR
AT: 52 MAIN ST - FLORENCE
Applicant Address: Phone: Insurance:
1029 NORTH RD (413) 485-7335 O WC
WESTFIELDMA01085 ISSUED ON:11/18/2015 0:00:00
TO PERFORM THE FOLLOWING WORK:INSSTALL 19 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 11/18/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
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® Window_World of Western Massachusetts
�- �� HOUSEKEEPING
1029 North Road Hampton Ponds Plaza,•Westfield MA 01085 *...^rte
O� Phone(413)485-7335 • Fax(413)-485-7055 NAT-41779-1 BBB
"Simply the Best for Less" www.WindowWorldofSpringfield.com HIC#165641
s r*a�oaeo:,
PY CSL#57011 neard,tlo:pul
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customer: / - l %f Phone(h)
Install Address: C- 'f "' Phone(w) — i!
Bill Address: f° _ E-mail
WINDOW WORLD GLASS OPTIONS ADD U VALUES
t aoo0 Series DH $245 t
6000 Series DH(Triple Pane) $279 SolarZone Glass Package* (LE) $79
i
Picture Window $359 SolarZone Elite Glass Package*(LEE) $89
2 Lite Slider $359 SolarZone TK2 3 Pane Glass/Krypton(6000 Only) $185
3 Lite Slider (im,v2.im) (1/3,t/3,11$1 $605 *ANSolar2one packages include 112 screens,foam Insulation on Jambs and Head,Double
Awning $295 Strength Glass,Double Locks(>29'),Lifetime Glass Breakage and Labor Warranty,Argon Gas
Casement LH RH $295 PRE 1978 BUILT HOMES(FEDERAL LEAD CONTAINMENT LAW)
Twin Casement(Requires 2 Value+)(0973)(0979) $590 MY-HOME WAS BUILT IN THE YEAR r 0 0 INITIAL:'>. ,' r
Three Lite Casement(Requires 3 Value+) $885
Basement Sliders<55 UP $250
EPA LEAD SAFE(Per Window) $60"
Hopper(In existing wood),(Vent+$150) $250 EPA LEAD SAFE(Patio Or I Bay I Bow/Garden) $100
Specialty Window= —<--—tea: $": —EPA Lead,third party verification: 7s QO
Bay/Bow(Insulated seat,Int.Casing,&Ext.Cap) $3375 I decline third party verification I](INITIAL): '
Garden Window Insulated seat,Int.Casing&Ext.Cap) $1995 _1 (Initial)I have received a copy of the Lead hazard information pamphlet
Grids/Ext.Color/int.Woodgrain/Colors calculated in ww upgrades informing me of the potential risk of the lead hazard exposure from renovation activity to be
Remove Existing Bay/Bow $300 performed in my dwelling unit,the EPA"Renovate Right"brochure.
Reframe&Retrim(stain/paint not included) $400 r
Roof for Bay/Bow Window $600 ' `(initial)I have received a copy of the lead test result(s).
Second Floor Installation $500
Window Color to /". / L.,,r', Sign: 4 ,t_i .r ?!-^— Date:
r
Inside Outside
- I Name(s)(Print) .-- �G ����,f �- U, ✓ ��41 r•l
WINDOW WORLD UPGRADES MISCELLANEOUS LABOR _
Full Screens $45 ✓` Full Exterior White Trim/Wrap(SMOOTH)(PVC) $79
BEIGE Color charge $50 Color Other Than White $10 -
Ext.Color(AT)(AB)(DC)(HK)(FG)(ER)(CG) .$165 Specialty Custom Exterior Trim/Wrap $
Woodgrain Interior(LO)(DO)(CH)(Fl0(RM)ISM) $95 Quick Trim(Int) (Ext) $30
Contoured/Flat Grids(TOP)(FULL)(ENDS) $49
Prairie Grids(Single)/(Double)-(Flat)/(Contour) $69 Aluminum/Vinyl or Steel Out $50/$150
Diamond/Brass Grids(TOP)(FULL) $120 Mull Remova! $30
Oriel/Cottage Style(40/60)(60/40) $45
Obscure Glass Per Sash(BOT)(FULL) $35/$70 Mull to Form Multi-unit $30
Tempered Glass Per Sash(BOT)(FULL)$60/$120 Install Interior/Exterior Stops(wwreviNVL>$55
�r Catalog Options $ Customer Provided.Stops/Trim $45
VINYL PATIO DOORS-LH or RH(Outside Looking In) install Interior Casing $95
(Includes:White Interior Casing and Exterior Trim.) Repair/Replace Sill or Brickmould $75
5 Ft./6 Ft.Sliding Patio Door(LH)(RH) $1500 Mobile Home Conversion $200
8 Ft.Sliding Patio Door(LH)(RH) $1800
Patio Door Beige Color $125 Remove/Re Install A/C or Awning $100
Patio Door SolarZone $125
Heat Buster Package Upgrade SolarZone Elite$215 Site Setup,Removal,In Home Service,etc.: $250.00
Patio Door Grids(Regular)(Woodgrain) $100 Extra labor(Box on left for description)$
Woodgrain/Brown(LO)(DO)(CH)(FX) $295 Total Amount Due$ =
.Exterior Colors $395 50%Deposit Amount:$
Patio Door Triple Pane Upgrade $250
Keyed Lock$36 Foot Lock$51 _
Storm Door Model $ []Cash =
[`}-Finance-O Wells Fargo ( )Other
j NO EXTRA WORK IF NOT IN WRITING! CC#k made tVWi-World of WM#
[)
r c _ Z-`3 {f Exp.Date: ---V d
Final Payment Amount$
r To be paid to the installer upon installation.Thank You.
Sales Rep Recommended:[]Interior Stops []Exterior Capping: WINDOW WORLD CARES
Customer Declined: []Interior Stop j]Exterior Capping: St.Jude Children's Research Hospital $
WW of W.Massachusetts anticipates starting this work on i 2 -'- C and being substantially completed in i 4 days.Security Interest:Yes No
-Any depdsRtequired`irradvance of the start of the work-SHALL NOT exceed 33 t/3%°of the total contractpricu orTe`actual cost of any material or equipment of a'
special order or custom made nature,which must be ordered in advance of the start of the work to assure that the project will proceed on schedule.No final payment
shall be demanded until the contract is completed to the satisfaction of all parties.
All home improvement contractors and subcontractors shall be registered and that any inquires about a contract or subcontractor relating to a registration should be
directed to:Office of Consumer Affairs and-Business Regulation,Ten Park Plaza,Suite 5170 Boston,MA 02116 Phone:(617)973-8700
No work shall begin prior to the signing ofihe contract•and transmiflal S the owner of a'eo iy otsuch contract.
WW of W.Massachusetts under provision of Chapter 142A of the general laws is required to apply for and obtain all construction-related permits.WW of W.Massa-
chusetts shall not be deemed responsible for delays in the work described in this agreement caused by regulatory,permit granting agencies,authorities or individuals.
Notice:If the PURCHASER(S)obtains his own construction related permits for the work described under this agreement or deals with unregistered contractors,
the PURCHASER(S)is hereby advised that in the event of a dispute,judgement and nonpayment,the PURCHASER(S)will not be entitled to make a claim or
collection from the guaranty fund established by chapter 142A,M.G.L.
You the buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.
Notice of cancellation must be in.writing postmarked no later than midnight of the following third business day.
THIS IS A CUSTOM ORDER NOT FOR RESALE!
Owner Date
Salesman- Date Owner Date
This Window WoriO Franchise is independently owned and operated by Window World of Western Massachusetts,Inc.under license from Window Word,Inc.
wM WC 0e-15 White Copy-Original Yellow Copy-File Pink Copy-Customer. Hayes Printing 8ee-667-1116