35-107 (3) ;te W ; '' Window World of Western Massachusetts :,.;7 4FF
f�.(�77A/" `y 10
1029 North Road-Hampton Ponds Plaza, • Westfield MA 01085 ,.f,.. SL, a 7-
r BBB.
,r GLGG Phone (413) 485-7335 • Fax (413) 315-3714 NAT-41779-1 _: ._
"Sim I the Besf for Less" www.WindowWorldofSpringfield.com HIC# 165641 .coon
P y i CSL# 57011 HOUSEKEEPINGCustomer: '64101 cd S �''n-s�"/ Phone (h) 'e
IG — �T'Q,(,'
Install Address: qc, p(e.tilSt-n j,)( :r 07 6IOi. . Phone (w)
Bill Address: E-mail
WINDOW WORLD GLASS OPTIONS ADD U-VALUES
4000 Series DH $295 SolarZone Glass Package* (LE) $79 C3 Z-
6000 Series DH (Triple Pane) $309 (LEE)9 SolarZone Elite Glass Packa e
Picture Window $394 ( ) $89
2 Lite Slider $359 ;' SolarZone Triple Pane Glass Package $99
3 Lite Slider (114.1/2.1/4) 4411110 $716 + a "All SolarZone packages include 1 i2 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 $315 MISCELLANEOUS LABOR
Twin Casement(Requires 2 Value+) (0973)(0979) $630
Three Lite Casement(Requires 3 Value+) $945 Full Exterior White Trim/Wrap (SMOOT-) (PVC; $79 „ 1 ‘.--
Basement
Basement Sliders <55 UI $280 Color Other Than White
Hopper(In existing wood) (Vent+ $150) $250 $10
Specialty Window $ _ Specialty Custom Int./Ext. Trim Wrap S
Bay i Bow(Insulated seat,Int.Casing&Ext.Cap) $3475 Aluminum /Vinyl or Steel Out S50/$150 400
Garden Window(Insuia:ed seat,Int.Casing&Exl.Cap) $1995 Mull Removal $30
Grids/Ext.Color/Int.WoodgrairUColors calculated in WW Upgrades Mull to Form Multi-unit $30
Remove Existing Bay/Bow $400
Reframe&Retrim (stainipaint not included) $400 Customer Provided Stops/Trim $45
Roof for Bay/Bow Window $600 - Install Interior/ Exterior Stops (WHITE VINYL_)$55
Second Floor Installation $500 Woodgrain Interior Stops $75
Window Package $ Install Interior Casing S95
Window Color I1' .t/ lN" Repair! Replace Sill or Brickmould S75
nside Outside Mobile Home Conversion $200
WINDOW WORLD UPGRADES Remove/Re-Install A/C or Awning 5100
Full Screens $45
BEIGE Color charge $50 EXTRA LABOR MUST BE IN WRITING
Exterior Color S165
Woodgrain Interior $95
Contoured/Flat Grids (TOP) (FULL) (ENDS) $49
Prairie Grids (Single)/(Double)-(Flat)/(Contour) $69 �---
Diamond/Brass Grids (TOP) (FULL) $120 ��
Oriel/Cottage Style (40/60) (60/40) $60 '
Obscure Glass Per Sash (BOT) (FULL) $35i$70 (/ U < ,^`
. /
Tempered Glass Per Sash (BOT) (FULL)$60/$120
Catalog Options $
PRE 1978 BUILT HOMES (FEDERAL LEAD CONTAINMENT LAW)
MY HOME WAS BUILT IN THE YEAR INITIAL:
EPA LEAD SAFE (Per Window) $60 Sales RepRecommended: Interior Stops Exterior
EPA LEAD SAFE (Patio Dr/Bay i Bow i Garden) $100 [] p I] Capping:
EPA Lead. third party verification: $475.00 Customer Declined: [] Interior Stop [] Exterior Capping:
I decline third party verification LI (INITIAL): ,'�— Site Setup. Removal, In Home Service, etc.: $250.00
(Initial)I have received a copy of the Lead hazard inforon pamphlet Extra labor (Box above for description)$ .
informing me of the potential risk of the lead hazard exposure from renovation activity to be Total Amount Due$ tr9'U 0
performed in my dwelling unit,the EPA"Renovate Right"brochure. 50% Deposit Amount: S 2 (12 C—)
(initial))have received a copy of the lead test esult(s). [] Cash
Sign: '— `� / % Date:J 6 ,[j Finance () Wells Fargo ( ) Other
,Check made to Window World of WM#' -.3
Name(s)(Print) f] CC# - - -
Exp. Date: V-code
If tenants reside in home, Renovate Right Booklet left with: Final Payment Amount$ 7(-/2 v
To oe paid to the irstalle•upor installation.Thank You.
WINDOW WORLD CARES
or left at: St. Jude Children's Research Hospital $
WW of W.Massachusetts anticipates starting this work on i f i 1(- and being substantially completed in I U days. Security Interest:Yes No
Any deposit required in advance of the start of the work SHALL NOT exceed 33 1/3%of the total contract price OR the 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 Cnnsumer Affairs and Business Regulation,Ten Park Plaza,Suite 5179 Boston,MA 02116.Phone: (617) 973-8700
No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such 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 at 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!
--7
Owner Date
-1 '.- 0/51/( L.IY__Ae__-r_id-ke._, .
Salesman Date Owner Date
This N 9C3V,Wolf' Franchise Is independently owned and operated by Window World of Western Massachusetts.Inc.under license from Window World.Inc.
PREPARING FOR YOUR NEW WINDOWS AND DOORS
Congratulations on your decision to increase the comfort level, value and appearance of your home. To maximize your
investment and enable the installation to take place as smoothly as possible, we have created this handout to acquaint
you with what to expect when our installers arrive.
1. Expected Delivery Time. All of our windows are custom made at one of our manufacturing plants located around the country and
shipped to any of our over 200 Window World locations.The time between when your order is placed and when the windows are ready to
be installed,though not guaranteed is typically 6 to 8 weeks.At that point we will call you to set an installation date.If for some reason you
need to delay your installation for more than a couple of weeks after notification that we are ready to install your order we will be happy
to work with you.We will need to collect the remaining balance before installation if the delay you request is more than three weeks.
2. Access to the Windows and Doors.We will need approximately 2 feet in front of each window, inside your home, so we can place our
drop cloths and tools necessary to perform our work.When the old windows are removed,gusts of wind typically flow through your home.
It is advisable to gather together important papers,and other small items that can be disturbed by the wind and relocate them.Computers
and other electronic equipment should be covered or relocated temporarily. Please move aside any furnishings that are in the way of our
work. If any furniture items are too heavy to move easily, we will gladly assist you.
3. Window Coverings.To gain access to the interior of the windows,we need all mini blinds,vertical blinds, roll-up shades,shutters,drapes
and any other window covering removed prior to our installation.We are not responsible for removing or reinstallation of these items
and are not responsible for damage resulting in the removal and reinstallation. We also are not responsible for any window
covering alterations that may be required to reinstall them.
4. Plants and Bushes. Occasionally we need to work in planters and other landscaped areas of your home that are adjacent to the
windows and doors. Please survey your yard prior to us arriving and look for potential problems. Some trees and vigorous bushes
need to be pruned back to give us access to your windows. Delicate plants and shrubs in areas right below a window should be
temporarily relocated if they cannot survive being stepped on and you want to preserve them.We strive to be careful when working
around vegetation, but our priorities are to focus on our work, your windows and our safety while working on your property. We are not
responsible for any damage to plants, shrubs or landscaped areas.
5. Arrival and Departure Times.We will advise you of the expected arrival time for our crew at the time we set up the installation date with
you.We generally stay till the job is done, unless it will be a 2 or 3-day job, in which case we may work as long as there is daylight. It is
our policy that our installers get a sign-off form and collect the outstanding balance at the completion of the job.We ask that you
be available to approve the job and make final payment at the time of completion. If this is not convenient for you, we need to
know before we start the job. Inclement weather and other unforeseen hindrances are a fact of life and as such we ask that you
understand if the weather,traffic,etc. cause a delay or cancellation of an installation appointment.We typically do not schedule
more than a day or two in advance to try to avoid such issues.
6. Our Worksite. We like to set up our worksite as close to your windows and doors as possible and generally your driveway is the best
spot. If using the driveway will block a garaged car, please be ready to pull it out upon arrival.
7. Alarm Systems. For those of you who have alarm systems, the alarm company should be notified and advised of our job.They will be
responsible for the disconnection and reconnection of your alarm system.
8. Where do we start?Upon arrival.the crew leader will survey the job and determine where to begin. If you have a preference,feel free to
advise us and we will accommodate to the best of our ability. Because we work in stages (i.e., removal of old windows, setting the new
window,wrapping of exterior, etc.),we don't complete the job one window at a time.The job moves along in a rolling progression where
each operation is done on all windows at the same time.This produces a quality job.
9. If the job takes more than a day,will there be any openings in my house?Of course not.We only remove that which can be reinstalled in the
same day.Although there may not be a complete window,it will be weather-tight and secure for overnight. (Please no critiquing at this time).
10. Pets.We love furry, four-legged creatures; however, we need your help in supervising them. We are not always able to close a gate or
door behind us when carrying a window,so please keep them in a safe place.Our job description does not include scampering down the
street after Fido with new found freedom. Many people say, don't worry, he doesn't bite, but many installers have been bitten. So please
secure dogs that have an aggressive bark towards strangers.
11. Expect some dust, noise and general disruption of your living space. Construction work can sometimes be messy depending upon
the scope of your job. It's an unfortunate reality of remodeling, but we do our best to keep things under control. We appreciate your
patience and understanding during the job and until everything is finished. Even after we have cleaned up, it is advisable to survey the
areas for something we may have overlooked (i.e., kids rooms, baby's room).
12. *Damage to walls and old trim stops. For those of you who have old aluminum and steel windows and are replacing them due to
sweating and damaging of the walls be advised that all water damage plaster will most likely fall out. In addition, all the patch work you
have done over the years will fall out also.This is normal; however,we are not plaster experts, so the repair to those walls would best be
left to the experts. In some cases due to out of square openings, new trim is required to make the window look good. *Unless noted
on the contract new trim will not be provided or installed by us. You can expect to do some touch up painting on the trim after the
installation of your new windows.This is not always necessary and is usually minor if it occurs. If your trim stops around your sashes are
very old, dry. and brittle, they may snap and crack upon removal. If this happens, we can leave them off if you please, or for a small up
charge, replace them with newer ones. Many of the old style stops are no longer available so we would replace the entire window with
newer style stops. Should we discover any hidden damage to the frame or wall area we will advise you before we proceed. Should you
decide to replace or repair anything,the price will be added to your balance.
13. Relax and enjoy the show. After we've been introduced to your home. feel free to run errands, take a walk, or just relax. If a question
should arise: by all means ask the crew leader for clarification.We enjoy people who are interested in what we do, and most customers
are intrigued with the process.We do get nervous.however,when a customer constantly hovers over our shoulder. Like any professional,
we're always happy to answer questions, but we appreciate being able to concentrate on our work without interruptions and distractions.
This ensures a safe and quality installation.
14. Past Due Balances are subject to a service charge of 1.5% per month. In the event that this amount is placed in the hands of an
attorney for collection,the purchaser agrees to pay all costs of collection, including a reasonable attorney fee. Return check fee is$50
(fifty dollars).
Salesperson Home Owner
P.S.Now would be a good time to review contract with the salesman to be sure of your order options and work to be done. Only the
items and services on the contract will be done. if you have any questions whatsoever,now is the time to ask.
Window World of Western Massachusetts may not require an acceleration of payments as specified in the payment section (front) for the
reason that he deems himself or the payments to be insecure. However,where the contractor deems himself to be insecure he may require as
a prerequisite to continuing said work that the balance of funds due under the contract,which are in possession of the owner,shall be placed
in a joint escrow account requiring the signatures of the home improvement contractor and the owner for withdrawal.
Arbitration: Window World of Western Massachusetts and the PURCHASER(S) hereby mutually agree in advance that in the event
Window World of Western Massachusetts has a dispute concerning the contract, Window World of Western Massachusetts may
submit such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer
Affairs and Business Regulations and the consumer shall be required to submit to such arbitration in M.G.L. c 142A.
Window World Owner
Date Date
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 dispute resolution even "where this section is not signed separately by the parties."
This Window World°Franchise is independently owned and operated by Window World of Western Massachusetts,Inc.under license from Window World,Inc.
WM WC 08-16
86 DREWSEN DR BP-2017-0608
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35- 107 CITY OF NORTHAMPTON
Lot:-001 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-2017-0608
Project JS-2017-000985
Est.Cost:$5840.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ROBERT BUSHEY JR 057011
Int Size(su.ft.): 9016.92 Owner: SLABINSKI RICHARD P&JOAN B
Zoning: Applicant ROBERT BUSHEY JR
AT: 86 DREWSEN DR
Applicant Address: Phone: Insurance:
1029 NORTH RD (413)485-7335 O WC
WESTFIELDMA01085 ISSUED ON.:11/1/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:8 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 11/1/2016 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit:
�\ Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
% Northampton, MA 01060 Two Sets of Structural Plans
\-c< phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE
�O�RR9DEMOLISH A ONE OR TWO FAMILY DWELLING
�v `W.
SECTION 1 -SITE INFORMATION
-/ 9r "
1.1 Property Address: This section to be completed by office
8(r, 'Drew`aen pr. Map Lot Unit
Nor{Aa r,+pta,", MR O1oG? Zone Overlay District
Elm St.District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Sia b1h-5k: B(c Pre wsc.+. dr. 610(23
Name(Print) Current Mailing Address:
yrs- ¶t'/- 07,36
(4ee c>wtr..41) Telephone
Signature
2.2 Authorized Agent:
Koh ert Sys hey in9 /Vor.'/i gd- L1/estGeWd Mir- 01683--
Name
168--Name(Print) Current Mailing Address:
� ,✓ H/5- I1fS--7335-
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
SFa/b. D d
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) SSHo• co Check Number 353/ 4 50
This Section For Official Use Only
::::r: ig
rmit Number: Date
Issued: ,({
/_/U
ore-
issionadlnspector of Buildings Date
Section 4. ZONING Alt 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 eo
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Fir:ing ever been issued for/on the site?
NO 0 DONT KNO 0 YES 0
IF YES,date issued:
IF YES: Was the permit reco.•-d at the Registry of Deeds?
NO O Dr/NT KNOW O YES O
IF YES: enter Boo Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES O
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 O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is ft part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors a
Accessory Bldg. 0 Demolition ❑ New Signs [O] Decks [0 Siding[p] Other fEft
Brief Description of Proposed
Work: ' V%n Yl Q e9(o,t rM trndow>
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
tic hard .ski kin6ki ,as Owner of the subject
property
hereby authorize k'c Gorf E Xs/w
to act on my behalf, in all matters relative to work authorized bythis building permit application.
(bee C•ortlrw.GF) L 0,2f- /4
Signature of Ower Date
2 btr $&6h y ,as Owner/Authorized
Agent hereby declare that the statemerfts 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.
M10 blPr - /�G} Sys h
Print Name I / /�
to'u -((i
Signature of Owner/A nt Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder R°)9e Y+ f piv6�p, Si o It
License Number
07 K000Qvelh f ve Ogg/ toll
Address Expiration Date
�e
tt4ivv? MILS r hr O/030 CH3f{u5733S—
Sig
9.Registered Home Improvement Contractor: Not Applicable 0
Rcber4 SLiesl .s..r 16_ 41/
Company Name Registration Number
Window Wor1,4 n< Wtz+ern iota&.. Ti.,.e 31 % Olen
Address Expiration Date
/039 Nerd, i[d• Wehtfi.Ad A4/ o/OBS Telephone e//3-4'6.81- 7355
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 $1 No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 buldinp 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 (See (o vHrakk)
City of Northampton
,-;1-1°-. °. .-.s r
J Massachusetts
Lu
- DEPAFtTN6wT OF BUILDING ZN9PECTIDNE
212 Hain street o NuNA 01l auilaing c%
y,.r.� Nortbavpton, MA 01060 bi
SSYv_,yp‘iii i. '`
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 fbefore backfill). sonotube holes jbefore Dour),a rough building inspection
fbefore work is concealedl. insulation inspection lit reaulred) 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 bg
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, (See C'n-fr cr) 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 1 au- /(o
Address of work location gb Dr tst5e-A b C
nAa(i'h^.--erbn 'A 0100_
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office ofInvestigations
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): W lhd of ) 61/o rid of We9F earn AM
Address: /639 North fid.
Cy/State/Zip: kJe5+ fes! mg o/ 1 Phone#: IJ/3-tiFS-7335
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a employer with E, 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp.insurance) 9. ❑Building addition
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 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] ` c. 152, §1(4),and we have no
employees. [No workers' 13.0 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 is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 1/SERYv Mirvnt SN$oRFNGE _
Policy#or Self-ins. Lic. #: tA)C-D-3/S- 37.21q7 014' Expiration Date: 1/0-74 -4.
Job Site Address: C3IP >eJ&ed City/State/Zip: Nrdhar.A{uvi/ O1OG)_
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required wider 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 un•er the q•ains� and penalties ofperjury correct
that the information provided above is true and
Signature: -f/h/I � -tr.- Date: /0. 71-
Phone#:
I-Phone#: H/3- 1/85-- 7-55
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#: