36-023 (4) Window World of Western Massachusetts
1029 North Road-Hampton Ponds Plaza•Westfield, MA 01085
Phone(413)485-7335 • Fax(413)485-7055
www.windowworldofspringfield.com
"Simply the Best for Less"®
Customer: Phone (h)
Install Address: Phone (w)
Bill Address: E-mail
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You the buyer may cancel this transaction at any time prior to midnight of t e 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!
EACH WINDOW WORLD IS INDEPENDENTLY OWNED AND OPERATED
Owner Date
Salesman Date Owner Date
Extra Work 1-07 White Copy-Original Yellow Copy-File Pink Copy-Customer
4 The Commonwealth of MassachuseM
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Ledbty
Name(Business/Organization/Individual): W(N LMW Bung I DE WESTERN AMA SSAC-1414 EE TS
Address: 102a Nv91M RD
City/State/Zip: W)ES`i F 1 F_1-A M Pr D t 0$S Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.(99 I am a employer with z 4. ❑ I am a general contractor and 1 6 ❑New construction
employees(frill and/or part-time)." have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers'comp.insurance comp. insurance..
5. ❑ We are a corporation and its
10. Electrical repairs or additions
required.]
3.0.1 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
instance required)t c. 152,§1(4),and we have no 13 99 Other QIT
employees. (No workers' W 1 N
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 polay andiob site
information.
Insurance Company Name: I-I DE-P-INJ MKINA . IMSUA Ma —
Polic:�#or Self-ins.Lic.#: W I S— 377 Q�7 '���J Expiration Date: 5— •Z.t? _
Job Site Address: I i 0-S _ MI5 Pi"1 �__City/Siaie/Zip: f�(�r ( 1i `� 01 J
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 u the pains and penalties of perjury that the informraden provided above is true and correct
Si � � zh Date:_
Pho a#: t{13 7335
Official use only. Do not write in this area,to be completed by cirty or town oireial
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
b.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
4.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder: 1ROBEERT E d 1}
License Number
12-2 .57011
�oosEvci...i �yF .-
Address Expiration Date
Ft ED i 96 P 1 LLS MA Crt P30 91-3 4 55&6_Ct24
Signature Tetephone 12-<61
i
. Registered Home lmprovement Contractor. Not Applicable ❑
Ro BEP.r BusNf_y S2 1 5 tp 41
Company Name Registration umber
W I AJD� WD-at-1) OV- W F S�2N M ASS i>J L _ 3 T 1 S- ) J (o
Address Expiration Date
102a NpRT:4 QD WES7f�iOLa6 NA DWS5' Telephone 41341&&7336
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------ ❑
C
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 1083.5.1.
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 buildine 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 C 5&
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
'Iris column tote filled in by
Building Depanment
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)
#t of Parking Spaces
Fill:
(volume&Locaaion)
A. Has a Special Permit/Variancelf ding ever been issued for/on the site?
NO O DONT KNO O YES O
IF YES, date issued:
IF YES: Was the permit rec rded at the Registry of Deeds?
NO O ONT KNOW O YES O
IF YES: enter ok Page and/or Document#
B. Does the site contai a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a p it been or need to be obtained from the Conservation Commission?
Needs to be tained 0 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 th4any 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 tilling)over 9 acre or is it part of a common plan
that wilt disturb over 1 acre? YES O NO O
IF YES,omen a Northampton Storm Water Management Permit from the DPW is required.
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
INew House ❑ Addition EJ Replacement Windows Alteration(s) Roofing
Or Doors
I Accessory Bldg. Q Demolition � New Signs [0] Decks Siding Other[Qj
Brief Description,of Proposed
Work: 1lil�t V ( Y r� iY1 1 �j 11 �'<'I(b "Q 7 r,,-n c��` -y ,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes k No
I Plans Attached Roil -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?
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 APPUES FOR BUILDING PERMIT
10 C RAA) I e-0—_ as Owner of the subject
property
hereby authorize _ l� y 127, E
to act on my behalf,in all matters relative to work authorized by this building permit application.
set C n�raCf) q - S , ) 5-
Signature of Owner Date
as Owner/Authorized
Agent hereby declare that the statements 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.
K�BF-2T BIAS 14�
Pyint Name
V /)",,T -5- 4�" q , 9 5
Signature of OwnerlAg n Date
/ Department,use only
City of Northampton ato;Pew
3 r ,
f Building Department
212 Main Street
Room 100
Northamoton, MA 01060
< P v phone 413-587-1240 Fax 413-587-1272 '
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
-`
1 05 bu f tS P it Act • Map Lot Unit
Zero Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Jo\j( e C)D icedifc I IL)s- cbuy t Pi t- Rd
Name(Prin Current Mailins,Add
re
C .See t o rte(-+ ' 15
Telephone'
Signature
2.2 Authorized Agent:
R�D a£P-Y E 8 U 5 H c y 102q N c M 14 W is STE ELD k14 02106—
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Bui.Jing I L. (a)Building Permit Fee
2. Electrical I (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) Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
1105 BURTS PIT RD BP-2016-0345
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-023 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit# BP-2016-0345
Project# JS-2016-000554
Est.Cost: $9405.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT BUSHEY JR 057011
Lot Size(sq. ft.): 12458.16 Owner: CHANDLER JOYCE B
Zoning: Applicant: ROBERT BUSHEY JR
AT.• 1105 BURTS PIT RD
Applicant Address: Phone: Insurance:
1029 NORTH RD (413) 485-7335 O WC
WESTFIELDMA01085 ISSUED ON.911512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING & 3 STORM DOORS
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 9/15/2015 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner