17D-012 REPLACEMENT WINDOW r' City of Northampton 'fx�:Permit: Department use only
Building Department 4p C` '
17
UCif/[ iveway Permit
'( 212 Main Street '_, 6 Sewer/ tic Availability
Room 100 < ter ell Avpttlabili
aty
Northampton, MA 01060'1Two is of truetural Plans
,
phone 413-587-1240 Fax 413-587-121'.2'. Plo ite Pins
er Sp0cify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOVSH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed/by office
Z-/ c' �(L Map I Loty Unit
M/1- U t v L- Z Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Er 1V_ JC Ori
Name(Print) Current Mailing Addr� :
(See c c�r�trc�c � Telephone
- 3 c - G 1
Signature
2.2 Authorized Agent:
Name Pri
102.G n4orfil� �c� "e5k: it',, 6 MA 010165,) i' Current Mailing Address:
t :
x 4t3 4�� �l3
ignature
Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted b ermit a licant
1. Building (a)Building Permit Fee
F3. Plumbing
ical
(b)Estimated Total Cost of
Construction from 6
Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5)
Check Number
This Section For Official Use Only
Building Permit Number:_ 1TQ. a�- ���� Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings
Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aaplicable)
New House ❑ Addition ❑ Replacement W- dows Alteration(s) Roofing E:]Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [Q Siding[I3] Other[a
Brief Description of Proposed
Work: i d('P cCG.MQr(\V '131 f doCU
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
I'__ [ f I V- �P(n (U M as Owner of the subject
property
hereby authorize RODu
to act on my behalf, in all matters relative to work authorized by his building permit application.
confirm( 0 7 j i J 2c 2v
Signature of Owner Date
1�Q Ar A- T-2--) �`�'r 1�� as Owner/Authorized
Agent hereby declare that the statementd 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.
Print
me,
Signature df Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:_ Ro bect - uS Clf y1
License Number
!2 Giro Ln �� �r N1R woy� ��1C�) 1
Address
Expiration Date
LV _-13�aJ`a
Sign /tire / Telephone
X `' _i/' M+"�'T:' ,c.'i;! •�'' if
9.Registered Home lmprbvbment Contractor: Not Applicable ❑
Company Name Registration Number
, +ndnt�l i�r�rlrl of if ) firn Maas lc�c, 3114121
Address y j Expiration Date
2 �10r*1 PA QSY ►t'� G �1OSS lephone 413- 55'1335
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...... ❑
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_ � SC_L'. Conk crur.1)
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street,Suite 100
�< Boston,MA 02114-2017
www mass.gov/dia
Uorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):Window World of Western MA
Address:1029 North Road
City/State/Zip:Westfield, MA 01085 Phone#:413-485-7335
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑✓ I am a employer with 20 employees(full and/or part-time).*
7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8.
any capacity.[No workers'comp.insurance required.] 9. ❑Remodeling
3.❑I am a homeowner doingall work myself. t 9. El Demolition
y [No workers'comp.insurance required.]
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
❑5.5.E]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12. Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurance? 13.❑Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑✓ Other Replacement Window;
152,§1(4),and we have no employees.[No workers'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.
tContractors 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:Liberty Mutual Insurance
Policy#or Self-ins.Lic.#:WC2-31 S-377947-020 Expiration Date:05/07/20
Job Site Address: q91 &I d(4 t_ R (iCity/State/Zip: Elt')(e n a I O 10� 2
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certi'fu der thepain�s andpenalties ofperjury that the information provided above is true and correct
Signature: Date:
Phone#:413-485-7335
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#:
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
e
(NAME OF FACILITY)
a properly licensed solid waste facility, defined by MGL C 111,'§150A.
Z
Date Signature of Permit.Applicant
PRINT OR TYPE THE FOLLOWING INFORMATION:
P-0 K--'l:l Ffit s IWA, 1-`(L.,
(NAME OF PERMIT APPLICANT)
(TYPE OF MATERIAL TO BE DISPOSED OF)
(PROPERTY ADDRES--
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Massachusetts w�S` •�; cfl
DEPARTMENT OF BUILDING INSPECTIONS ' +
t� r 212 Main Street •Municipal Building J�k Cb
l Northampton, MA 01060 rSy .•..., A�
Debris 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.
The debris from construction work being performed at:
I,
(Please print house number and street name)
Is to be disposed of at:
UUQS�e /4MA) 01 O)GO
(Please print name and location soffacility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
Window World Of Western MA
• 1029 North Road
413-485-7335
westernmass@windowworld.com
Erik Jernstrom
ejernstrom@poahcommunities.com
Estimate : New const
Bill Address: Install Address: Estimate#E1584367008455
491 Bridge Rd, 491 Bridge Rd,
Florence,MA Florence,MA Date of Estimate:3/25/2020
101062 01062 Valid Until:4/15/2020
DESCRIPTION CITY UNIT- •
4000-2 Lite Slider 1 1,199.00 1,199.00
Permit&Administrative Fee 1 200.00 200.00
TOTAL AMOUNT $1,399.00
CUSTOMER PAYMENT DETAIL
Cash Amount $1.00
TOTAL PAID $1.00
CUSTOMER DUE $1,398.00
*No extra work if not in writing
*Customer Comments:
*Installer Notes:
Design Consultant-Tim Drost
HIC:165641
FEID#27-1993659
Customer ID Details
Id Type* Driver's license
Id#* S245
Id Issue State* Mass
Id Expiration Date 2456
Sales Rep Recommended:
r Interior Stops r Exterior Capping
Customer Declined:
r Interior Stops r Exterior Capping
Pre1978 built homes:
My home was built in the year 1974 (initial) E - --
(initial)I decline third party verification
(initial)I have received copy of the Lead hazard information pamphlet informing me of the potential risk of the lead hazard exposure from renovation activity to be performed in my