18C-164 47 WARBURTON WAY BP-2019-1178
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map Block 18C- 164 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-2019-1178
Proiect# JS-2019-001912
Est.Cost:$6135.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: WINDOW WORLD/ROBERT E BUSHEY JR 57011
Lot Size(sq.ft.), 0.00 Owner: BREZSNYAK MARY LYNN
Zoning URB(100)/ Applicant. WINDOW WORLD/ROBERT E BUSHEY JR
AT. 47 WARBURTON WAY
Applicant Address: Phone: Insurance:
1029 NORTH RD (413) 485-7335 U WC
WESTFIELDMA01085 ISSUED ON:4/242019 0.00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 5 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 q 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:
FeeTYee: Date Paid: Amount:
Building 4/24/2019 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Mynd ows
�CEIVE DIapartmentuseonly
City of No ham Permit
BulldingD part ent Driveway Pemnit
212 Mai Str et tjrbC
ptioAvailapgityRoo 100; APR 2 3 7019 llAvallabdiryNorthampto , M 01060 of Structural Plans
phone 413-587-124 Fes n,, , , 'c [ Plans
„--«nnroN,rnq u,Li cify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION ev 7 /�7U
1.1 Proii Address: / This section to be completed by office
//7 w�('�r,(/�nt✓�y Map \� Lot Unit AAA 0(660 Zone Overlay DlaWct
Elm St Dlatrbl CB District
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGEN
2.1 Owner of Record:
AAO(i INK✓1 (GZSn�Q�
Name(Print) i,\ Current Marg_Aystlrea ,,,,
(See GOnlyac / Telephone I
Signature
2.2 Authorized Apart,
oar 1029 North Rd VJeSSfieltl MA 01085
Name/�(ph t) / Current Mailing Address:
413 4�5 X335
ignatureV Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b permit applicant
1. Building //17� (a)Building Permit Fee
2. Electoral �O (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) Check Number
This Section For Official Use Only
Date
Budding Permit Nu r: Issued:
Signature: y' Z3-Zol q
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacemegt N(indows Alterations) ElRoofing EJQ Doors /®_
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C:3 Siding ill] Other[a
Brief Description of Proposed F /1 L Wn
Work W T
Alteration of existing bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes `No
Plans Attached Roll -Sheet
Sa.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?
It. Type of construction
i. Is construction within 100 R.of wedands?_Yes _No. Is construction within 100 yr. floodplain_Yes_No
I. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank_ CitySewer_ Private well_ City water Supply_
SECTION To-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT 1OR CONTRACTOR APPLIES FOR
R//BUILDING PERMIT
I, r1 Ore-Z-5 K YR/e ,as Owner of the subject
proFeM
hereby authorize V� �'1� l5'�-Y -
to act on my behalf,in all matters relative to work authorized by s bulldimg 61t application.
Sny GOntr t(�)
Signature of Owner 77 1,.,,, Dole
I, h� Yi' Cjl1�'l 1�` as Owner/Authorized
Agent hereby declare that ilia statemen 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.
t
Print N me
Data
Signature fowner/Agent
AFFIDAVIT
In accordance with the provisions of MGL c 40, §54, 1 acknowledge, as a
condition of the Building permit, all debris resulting from construction activity
governed by this Building Permit shall be disposed of at
WASiE A6.4www) /vi CIOC 1
(NAME OF FACILITY)
a properly licensed solid waste facility dFfned bl MGL C 111+§150A.
n,
/g
IS
Date f SIgnat6re of Permit,Applicant
PRINT OR TYPE THE FOLLOWING INFORMATION:
P40KRT E (Std5I5'2
(NAME OF PERMIT APPL ANT)
(TYPE OF MATERIAL TO BE DISPOSED OF)
(PROPERTYADDRESS)
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not
Not Applicable
Name of Ll,,,holder ROIL O
License Number
!2 Dog N Ln SoilthwCY, MR 01ol-1 5-1011
Adtlreas Egsratlon Date
485 335 0 �Zg 11q
51 re �' Telephone
9.RealabspedHo C t c Not Applicable ❑
RObfft l-NS6 -WN Ib5b4'1
Company Name Registration Number
Window ''WC)V' A of WesFern MASS Inc. 3) 14 120
Address Expiration Date
1(32') N Or11n Kra MSt46'P\ d M O)O8Slephone 413•-4Y6S-1335
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 1$2,328C(6p
Workers Compensation Insurance affldav8 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...... ❑
11. -Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwelling 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.
Definitiog 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 f aptly dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit w the Building Official,on a faun acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the b 0d'ne permit.
As acting Construction Supervisor your presence on thejob 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 oftnn
Massachusetts General Laws Aotated.
Homeowner Signature SGG. cc'A rT� CLr—
The Commonwealth of Massachusetts
Department oflndustrialAccidents
00ke of Investigations
1 Congress Street, Suite 100
Boston,MA 02114-2017
u,p www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information `` W( 1 Please Print Legibly
Name (Business/Orgmintion/Individmi): (/k{ 'vk " )HA Q+ WQy t'Crn MR
Address: 10'L9 N OYi1 n Fd
City/State/Zi : YJ bAfi A O S Phone #: fi 1 4`65' 1335
Are you an employer? Check the appropriate box:
general contractor and I Type of project(required):
1.X I am a employer with� 4._ ❑ I am a g
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 subcontractors have g, ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P tY 9. E]Building addition
[No workers' comp. insurance comp. insurance.=
required.] 5. ❑ We are a corporation and its 10.[]Electrical repairs or additions
3.❑ 1 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 ❑Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.�Other Kfp)QCPIYtY'n1"
comp. insurance required.] 1
'My applicant that checks box#1 must also 611 out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they ere doing all work and then hire outside commeons must submit a new affidavit indicating such.
[Connectors that check this box must attached m additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-coMmMors have employees, they must provide their workers'comp.policy another.
I am an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site
information.
Insumnize Company Name: LI['X MU.tucA\ Ins iron Lf p
Policy#or Self-ins./L/ie.#: �[�, -3]s"X11 G41 ' 010 _ Expiration Date: `J -1 �q _
Job Site Address: '17 Uald'" ^ City/State/Zip: fT
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
Suture, Dale'
Phone#' 4-k3- 4 -13-�>S
Oficial 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#:
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CERTIFICATE HOLDER CANCELLATION
City Or mosthampton
212 Wln SUt Nt MWLO AM OF ME ABOVE DESCRIBED POMM BE CANCELLB) BEFORE
THE ErPRATION CAME TNEREOF, Normal WILL BE DBWERCO IN
Northav,pton, W. 01060 ACCORO•HCEWRHTHEPOOCYPROWBIDrm.
Atteation: Building Depastuant
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m 118&2010 ACORO CORPORATION. NI fights rammed.
4CORDU(2410M) Thor ACORD name and logo Are nglarare4 melt of ACORD
A rnes CERTIFICATE OF LIABILITY INSURANCE DAYS
T 502018 TI
8
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATWE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: N the certificate holder Is an ADDITIONAL INSURED,the policy(k a)must have ADDITIONAL INSURED provisions or be endorsed.
N SUBROGATION IS WAIVED,subject to the terms and conditions of the Policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights W the certmcate holder In lieu of such andorsemen s.
PXOOucm FORREST INSURANCE AGENCY
603 NORTH MAIN STREET PHONE F
E LONGMEADOW, MA 01028 w
INSU 9 AFF IW RAGE HNCY
INSURER A: Liberty Mutual Fire Insurance 23035
INSURED INMIRERB:
WINDOW WORLD OF WESTERN
MASSACHUSETTS INC weURSRC:
1029 NORTH ROAD weuREn o:
WESTFIELD MA 01085 IxaURFR e:
INSURERF
COVERAGES CERTIFICATE NUMBER: 41g 5072 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS.
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WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWNS OF THE STATE OF MA
This certificate cancels and supareades all previousty issued cadi5catea,only as may reiste to wodum;Compensation coverage.
CERTIFICATE HOLDER CANCELLATION
CITY OF NORTHHAMPTON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
212 MAIN STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
NORTHHAMPTON MA 01060 ACCORDANCEWITH THE POLICY PROVISIONS,
AIRHORaEOREPREBENTATIVE
Jon Smith
®1988-2013 ACORD CORPORATION. All rights reserved.
ACORD 25(2013/03) The ACORD name and 1090 are registered marks of ACORD
41615872 1 1-377941 118-19 PIC 1 n@54981 15/2/2018 4:39:52 PX i.n l 1 gees 1 of 1
Window World Of Western Massachusetts
'iS �l>(IIO�II{p totsNorthRoad
i5�y 1/'/1VJ 4awmi 3485-7395
ern
'aMeMx.exrn.uu^ wstemass@windowworltlsom
Mary Lynn Brersnyak
mlbrersnyak§comcast.net
Estimate Whole house
Bill Address: install Address: Estimate#E1553709520221
46 Warburton Way,Prospect Woods Cando 46 Warburton Way,Prospect Woods Condo
Northampton,MA Northampton,MA Cate of Esbmato.4.12019
101060 01060 Valid Until,41282019
3 Lite Casement 1 1,824.00 1,824.00
Commas Exterlm, 3 { 185.00 495.00
SotarZone Lcw-E 3 110.00 330.00
tnstafl6NemorlEx"8+6r Stops 8 " �80.fl0 240.00
Mullion Removal 2 WOO 120.00
4000 Series DH ^ 4';
Solisi Low-E 4 1}100.00 440.00
Coaxed Extortor A 115;00 &BpAo
#.
Install inieridr/Extedm Stops 4 60.00 320.00
Permit .,. x3 1i r / ;18R.eP uf1 ^tv : " 15017
AOv
TOTAL AMOUNT $6,135.00
CUSTOMER PAYMENT DETAIL
credit Cards Amount $3,00000
TOTAL PAID $3,000.00
CUSTOMER DUE $3.135.00
'No extra work If not in writing
'Customer Comments:
'Instate,Ndes:Sabrlrp Barnwell property
Customer ID Details
A Type' Drivels Ncanse
kf#' S25y
Id Issue State` Masd
to Expiration Data 23rt
Hales Rep Recommended:
r Interior Stops r Extenor Capping _.. "f ..
Customer Declined:
I u ._